Screening and Treatment for Subclinical Hypertensive Heart Disease in Emergency Department Patients With Uncontrolled Blood Pressure: A Cost Effectiveness Analysis.

Objectives Poorly controlled hypertension (HTN) is extremely prevalent and if left unchecked, subclinical hypertensive heart disease (SHHD) may ensue leading to conditions such as heart failure (HF). To address this, we designed a multidisciplinary program to detect and treat SHHD in a high-risk, predominantly African American community. The primary objective of this study was to determine the cost effectiveness of our program. Methods Study costs associated with identifying and treating patients with SHHD were calculated and a sensitivity analysis was performed comparing the effect of four parameters on cost estimates. These included prevalence of disease, effectiveness of treatment (regression of SHHD, reversal of left ventricular hypertrophy [LVH], or blood pressure [BP] control as separate measures), echocardiogram costs, and participant time/travel costs. The parent study for this analysis was a single center, randomized controlled trial comparing cardiac effects of standard and intense (<120/80 mm Hg) BP goals at 1 year in patients with uncontrolled HTN and SHHD. A total of 149 patients (94% African American) were enrolled, 133 (89%) had SHHD, 123 (93%) of whom were randomized, with 88 (72%) completing the study. Patients were clinically evaluated and medically managed over the course of one year with repeated echocardiograms. Costs of these interventions were analyzed and, following standard practices, a cost per quality-adjusted life year (QALY) less than $50,000 was defined as cost effective. Results Total costs estimates for the program ranged from $117,044 to $119,319. Cost per QALY was dependent on SHHD prevalence and the measure of effectiveness but not input costs. Cost effectiveness (cost per QALY less than $50,000) was achieved when SHHD prevalence exceeded 11.1% for regression of SHHD, 4.7% for reversal of LVH, and 2.9% for achievement of BP control. Conclusions In this cohort of predominantly African American patients with uncontrolled HTN, SHHD prevalence was high and screening with treatment was cost effective across a range of assumptions. These data suggest that multidisciplinary programs such as this can be a cost effective mechanism to mitigate the cardiovascular consequences of HTN in ED patients with uncontrolled BP. This article is protected by copyright. All rights reserved.