M Mohsen Ibrahim, MD CARDIOLOGY DEPARTMENT-CAIRO UNIVERSITY

1. MINIMAL vs OPTIMAL MEDICAL CARE M Mohsen Ibrahim, MD CARDIOLOGY DEPARTMENT-CAIRO UNIVERSITY

2. EHS Guidelines - 2003 Minimal Versus Optimal Care • Resources more than science dictate the type of care that can be provided. • Guidelines have to make a compromise between what is possible (minimal care) and what is ideal (optimal care). • No Health Care System Has Unlimited Resources

3. “Where resources are limited it becomes imperative to direct drug treatment to individuals in the high and very high risk before considering their use in the lower risk patients” (WHO-ISH GUIDELINES)

4. Minimal Care Optimal Care Age Family History Past History of ACVD Smoking Body Weight Blood Sugar Total Cholesterol /LDL-C HDL-C Triglycerides S Creatinine ECG Hs-CRP ASSESSMENT OF HIGH RISK STATUS • Age • Family History • Past History of ACVD • Smoking • Body Weight

5. EHS Guidelines - 2003 Evaluation of Hypertensive Patients +++: strongly recommended. +: recommended. - : not done +: done if facilities are available.

6. EHS Guidelines - 2003 Therapy

7. EgyptianHTN Physician & Patient Survey* Ever Stopped Your Antihypertensive Drug Therapy1940 patients Ibrahim - 1998

8. EgyptianHTN Physician & Patient Survey* Reasons of Poor Compliance Doctors Survey % Ibrahim - 1998

9. METHODS TO REDUCE THE COSTS OF HYPEERTENSIVE TREATMENT • Improve Effectiveness of Treatment - Accurate classification of BP - Maximize life style change - Balance benefits vs risks of treatment - Adherence to treatment regimen - Control of other CV risk factors • Reduce Costs - Start treatment with lower cost medications - Limit office visits to clear clinical objective - Limit laboratory test to necessary ones

10. CHANGES IN MEAN BLOOD PRESSURE OVER TIME-Australian Therapeutic Trial in Mild Hypertension* *1119 subjects given placebo and observed for 3 years Lancet:1980

11. EGYPTIAN NHP BLOOD PRESSURE VARIABILITY 54.8%

12. EHS Guidelines - 2003 Diagnosis of Hypertension No TOD TOD / BP > 160/100mmHg Visit 1 Visit 1 Visit 2 Visit 2 >140/90 mmHg Visit 3 Visit 4 Visit 3 Visit 5

13. EHS Guidelines - 2003 Risk Categorization • Hypertensivepatients can be categorized according to their risk profile (adopted from JNC VI): • Group A (low risk): no TOD, no other risk factors and no associated cardiovascular disease. • Group B (intermediate risk): one or more additional risk factors but not diabetes or TOD. • Group C (high risk): diabetes, TOD and/or associated cardiovascular disease.

14. EHS Guidelines - 2003 Drug Initiation BP Monitoring Risk Category BP Threshold A 6-12 month 160/100 mmHg 140/90-150/90 mmHg B 3-6 month 140/85-135/85 mmHg 1-3 month C

15. IMPROVE COST EFFECTIVENESS DRUG COSTS TO PREVENT ONE MI, STROKE OR DEATH(UNCOMPLICATED MILD TO MODERATE HYPERTENSION) Source: Pearce et al. Am J Hypertens , 1998

16. Evaluation of Therapeutic Intervensions • Clinical Effectiveness • Safety • Cost

17. Comparing a New Therapy and a Standard Therapy Clinical Effectiveness -------------------------------------------------------------- Net CostNew>Std New=Std New<Std -----------------------------------------------------------------------------------New>StdCEA needed Standard Rx. cost- saving Use Standard Rx New=Std New Rx. Better Toss-up Standard Rx. better New<StdUse New Rx. New Rx. cost-saving CEA needed ---------------------------------------------------------------------------------------------------------- CEA: Cost-effectiveness analysis Modified After Mark and Hlatky . 2002

18. Cost - Effectiveness Analysis C/new – C/usual care CE = -------------------------------- HB/new – HB/usual care ----------------------------------------------------------------------- CE: cost-effectiveness; C: costs; HB: health benefits

19. Assessment of Health Benefits • Sensible units : -mmHg blood pressure change -No of myocardial infarctions prevented -Minutes of exercise increased • Number of added life-years (LYs) • Primary therapeutic goal is to prolong life expectancy • Quality- adjusted life-year (QALY) • One year of life in excellent health = 1.0 QALY

20. COST ASSESSMENT • Costs of Intervention : -Drugs -Lab tests -Physician • Costs of Morbidity after an Event : - Direct costs (health care costs) - Indirect costs (loss of productivity)

21. MINIMAL vs OPTIMAL MEDICAL CARE M Mohsen Ibrahim, MD CARDIOLOGY DEPARTMENT-CAIRO UNIVERSITY

26. NUMBERS-NEEDED-TO TREAT TO PREVENT CV EVENTS OR DEATH IN PATIENTS WITH MILD-TO- MODERATE HYPERTENSION

27. COST-EFFECTIVENESS OF TREATMENT FOR HYPERTENSION >69 YEARS <45 YEARS Approximate net cost per life-year gained in US dollars Source: Johannesson M,1995

28. PREVENTION PRIORITIESPRIMARY PREVENTION • Population Approach 2% reduction of mean population BP (about 3 mmHg in DBP) Prevent every year by 2020 in Asia Pacific Region : -1.2 million deaths from stroke ( about 15% of all deaths from stroke) -0.6 million deaths from CHD (6% of all deaths from CHD) Reducing Salt Content of Manufactured Food

29. PREVENTION PRIORITIESPRIMARY PREVENTION • Individual Approach • Population Approach

30. Cost-Effectiveness

31. Cost-Effectiveness • <$50.000 per LY is economically acceptable • >$100.00 per LY is economically unacceptable

32. Cost-Effectiveness in Hypertension • Costs of drugs and other medical expenses required to prevent one MI, stroke or death • Medications account for 50% to 90% of the direct costs of hypertension treatment • NNT: number of patients needed to treat for 5 years to prevent one event • Cost-effectiveness of drug therapy = average whole sale price of drug for 5 years of treatment X (5-y NNT)

33. Cost-Effectiveness

34. Cost-Effectiveness • Event Rate = No of events/P-Yof observation • Risk Difference = Control – Treatment event rate • Cost –Effectiveness of Drug (Cost to Prevent an Event) = AWP(5y trt) X 5y NNT -AWP : average whole sale prices -5y NNT : No of patients treated for 5 years to prevent one event

35. Cost-Effectiveness • Cost of QALY gained: - < $40.000 – highly cost-effective - = $60.000 – reasonable cost-effective - > $100.000 – not cost-effective • If society is willing to pay $60.000 to gain a QALY treatment should be started if the 5-year-risk of CHD exceeded -For men -For women 35 y 2.4% 2.0% 50 y 4.6% 3.5% 70 y 10.4% 10.4%