Comparing scale up of status quo hypertension care against dual combination therapy as separate pills or single pill combinations

Abstract

Background International hypertension treatment guidelines recommend initiating pharmacological treatment with combination therapy and using fi xed dose single pill combinations (SPCs) to improve adherence. However, few countries have adopted combination therapy as a form of fi rst-line treatment and SPC uptake in low- and middle- income countries is low due in part to cost and availability. Evidence on costs and cost-effectiveness is needed as health authorities consider incorporating new recommendations into national clinical practice guidelines. Methods Over a 30-year time horizon, we used an Excel-based Markov cohort state-transition model to assess the fi nancial costs (screening, treatment, program, and supply chain costs) and socio-economic outcomes (health outcomes, value of lives saved, productivity losses averted) of three antihypertensive treatment scenarios. A baseline scenario scaled treatment among adults age 30 plus while assuming continuation of the widespread practice of initiating treatment with monotherapy. Scenarios one and two scaled treatment while initiating patients on two antihypertensive medications, either as separate pills or as a SPC. Analysis inputs are informed by country-specific fi c data, meta-analyses of the blood-pressure lowering of antihypertensive medications, and own- studies of medication costs. We compared costs, cost-effectiveness, and net-benefits fi ts across scenarios, and assessed uncertainty in a one-way sensitivity analysis. Findings Using dual combination therapy (with or without SPCs) as fi rst-line treatment would increase costs relative to current practices that largely use monotherapy. Required additional annual resources averaged as much as 3.6, 0.9, and 0.2 percent of government health expenditures in the analysis' lower-middle, and upper-middle income countries. However, across 24 countries, over the next 30 years, combination therapy with separate pills could save 430,000 more lives and combination therapy with SPCs could save 564,000 more lives compared to baseline treatment practices. Administration of two or more medications using SPCs generated higher net benefits fi ts in most countries (16/24) compared to the baseline scenario. Interpretation First line treatment employing SPCs is likely to generate higher net benefits fi ts compared to status quo treatment practices in countries with relatively higher incomes. To improve population health, national health systems would benefit fi t from reducing structural and other barriers to the use of combination therapy and SPCs. Funding This journal article was supported by TEPHINET cooperative agreement number 1NU2HGH000044-01-0 funded by the US Centers for Disease Control and Prevention. Copyright (c) 2024 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).