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(Circulation. 2005;112:3569-3576.)
© 2005 American Heart Association, Inc.

Heart Disease in Africa

Cost-Effectiveness Analysis of Hypertension Guidelines in South Africa

Absolute Risk Versus Blood Pressure Level

Thomas A. Gaziano, MD, MSc; Krisela Steyn, MSc, NED, MD; David J. Cohen, MD, MSc; Milton C. Weinstein, PhD; Lionel H. Opie, MD, DPhil, FRCP

From Cardiovascular Medicine (T.A.G.) and the Division of Social Medicine and Health Inequalities (T.A.G., M.C.W.), Brigham & Women’s Hospital, Harvard Medical School, Boston, Mass; Chronic Diseases of Lifestyle Unit of the Medical Research Council (K.S.), Cape Town, South Africa; Cardiology Division (D.J.C.), Beth Israel Deaconess Medical Center, Boston, Mass; Hatter Institute (L.H.O.), Department of Medicine and Cape Heart Centre, Faculty of Health Sciences, University of Cape Town, South Africa; and Department of Health Policy and Management (M.C.W.), Harvard School of Public Health, Boston, Mass.

Reprint requests to Thomas A. Gaziano, MD, Cardiovascular Medicine, Brigham & Women’s Hospital, 75 Francis St, Boston, MA 02115. E-mail tgaziano{at}partners.org

Received January 12, 2005; revision received May 19, 2005; accepted July 18, 2005.

Background— Hypertension is responsible for more deaths worldwide than any other cardiovascular risk factor. Guidelines based on blood pressure level for initiation of treatment of hypertension may be too costly compared with an approach based on absolute cardiovascular disease (CVD) risk, especially in developing countries.

Methods and Results— Using a Markov CVD model, we compared 6 strategies for initiation of drug treatment—2 different blood pressure levels (160/95 and 140/90 mm Hg) and 4 different levels of absolute CVD risk over 10 years (40%, 30%, 20%, and 15%)—with one of no treatment. We modeled a hypothetical cohort of all adults without CVD in South Africa, a multiethnic developing country, over 10 years. The incremental cost-effectiveness ratios for treating those with 10-year absolute risk for CVD >40%, 30%, 20%, and 15% were $700, $1600, $4900, and $11 000 per quality-adjusted life-year gained, respectively. Strategies based on a target blood pressure level were both more expensive and less effective than treatment decisions based on the strategy that used absolute CVD risk of >15%. Sensitivity analysis of cost of treatments, prevalence estimates of risk factors, and benefits expected from treatment did not change the ranking of the strategies.

Conclusions— In South Africa, current guidelines based on blood pressure levels are both more expensive and less effective than guidelines based on absolute risk of cardiovascular disease. The use of quantitative risk-based guidelines for treatment of hypertension could free up major resources for other pressing needs, especially in developing countries. (Circulation. 2005;112:3569-3576.)

Key Words: cost-benefit analysis • hypertension • prevention • stroke • cardiovascular diseases

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