АкушерствоАнатомияАнестезиологияВакцинопрофилактикаВалеологияВетеринарияГигиенаЗаболеванияИммунологияКардиологияНеврологияНефрологияОнкологияОториноларингологияОфтальмологияПаразитологияПедиатрияПервая помощьПсихиатрияПульмонологияРеанимацияРевматологияСтоматологияТерапияТоксикологияТравматологияУрологияФармакологияФармацевтикаФизиотерапияФтизиатрияХирургияЭндокринологияЭпидемиология

Main consequences of the equitable proportional benefit strategy

Прочитайте:
  1. Computing proportional benefits for each category of individuals
  2. Designing a new treatment strategy
  3. Table 1. Prescription scenarios according to ESH/ESC successive guidelines and the Proportional Benefit strategy.
  4. Table 2. Sensitivity analysis assessing the impact of the 2013 ESH/ESC Guidelines on costs, proportion of benefits and efficiency.

The allocation of a constant relative benefit whatever the age or sex of the individuals is in line with the evidence regarding the effect of BP lowering drugs. Two recent meta-analyses of BP lowering trials stratified by levels of cardiovascular risk [28,29] indicate that the relative reduction of cardiovascular events obtained by BP lowering does not change at different baseline levels of cardiovascular risk and therefore, the absolute benefit increases with increasing risk. The PB strategy maximises gains per categories by allocating drug treatment to the individuals at the highest risk relative to their peers.

The PB strategy increases the therapeutic coverage of people with relatively low risk, i.e. young and women, who have also the greatest life expectancy. As an obvious consequence, the gain in life-years was increased in this subgroup, while the overall number of deaths prevented was reduced compared with the 2007 ESH/ESC guidelines that concentrate prevention efforts on the oldest men (Table 2). Considering the expected age-dependent decrease in QALYs[30] given the lifespan reduction and assuming that utility values per health state decrease with age and co-morbidities, redistributing the number of deaths prevented under the PB strategy would result in greater gains of quality-adjusted life years compared to the ESH/ESC recommendation. Opposite to the results of our equitable treatment rule, Liew and colleagues[14] have suggested that for individuals with different life expectancies but the same short-term CVD risk, treatment makes little difference on health benefits due to the counterbalancing effects of time preferences, case fatality rates and competing risks. It is thus necessary to provide a definition of what benefit is. From a societal perspective, discounting life expectancies by time preference rates implies giving relatively higher value to elders’ lives compared to the remaining lives of younger individuals, as indicated by the reported 40% reduction in life expectancies after discounting at ages 35–39 (from 41.7 to 23.6 years) compared to an 8% reduction at 85 years and over (from 4.87 to 4.47 years). But does the naturally higher vulnerability to death of the individuals that have already lived longer really make worthier treating them than treating younger individuals?

Based on the 2007 ESH/ESC recommendations, the PB strategy considers initiation of antihypertensive treatment when BP is in the high normal range and CVD risk is high compared to the peers’ risk. Drug treatment of high normal BP individuals has proven to be efficacious to reduce the incidence of hypertension with promising substantial public health effect, but the evidence in favour of early interventions is still considered limited. The recommended lifestyle measures for BP control in prehypertension have no demonstrable effect on public health. Assessing how far the benefit of early drug intervention lasts is key to address the issue of treatment eligibility in high normal BP subjects.

Modelling studies have shown that treating hypertension is cost-effective in different populations[31,32], with greater efficiency at increased age of treatment onset[32]. This is not surprising since age increases cardiovascular risk and thus maximises the gains per cost unit. The efficiency, as defined in the present study, was reduced with the PB strategy compared with the 2007 European recommendation, because a greater number of individuals have to be prescribed BP-lowering drugs to extend the benefits to the youngest and especially women. Nevertheless, it has also been shown that for persons treated with hypertension interventions, life extension could be achieved without increasing average lifetime medical spending[31]. Moreover, reducing morbidity as a result of hypertension treatment would still reduce health spending due to the avoided costs of informal care after an event[32].

The PB strategy offers an intermediate point of view between the classical high-risk approach promoted by historical guidelines and the latest hypertension guidelines that introduce new evidence-based recommendations. While the classical approach is the most efficient, the forecasted effectiveness and efficiency of the newest guidelines appear to be hardly competitive against this widely accepted reality. Our original approach has the merit of redistributing the same overall theoretical benefit of the high-risk approach within a population providing the same proportional benefit to every category of individuals, while improving the profile of residual events in younger individuals without elevating costs dramatically. The redistribution of benefit that reduces the residual risk at younger ages is in line with the conclusions of Thomopoulos et al., which promote extending treatment to low-to-moderate risk hypertensive patients in order to prevent the failures due to delayed onset of treatments[28].


Дата добавления: 2015-11-26 | Просмотры: 385 | Нарушение авторских прав







При использовании материала ссылка на сайт medlec.org обязательна! (0.003 сек.)