SingHypertension: Primary care intervention for BP control deemed cost-effective

A multicomponent intervention to control elevated blood pressure (BP) levels at the primary care level, SingHypertension, represents good value for money for reducing hypertension-related morbidity and mortality in Singapore, according to a cost-effectiveness study.

“The per‐person cost of SingHypertension was USD 161 in the first year and USD 78 in the second year. SingHypertension was more costly than usual care but resulted in fewer total disability‐adjusted life years (DALYs), cardiovascular disease (CVD) events, and CVD‐related deaths,” the investigators reported in their paper. [J Am Heart Assoc 2024;doi:10.1161/JAHA.123.033631]

Compared with usual care, the intervention cost USD 180 more and averted 0.007 more DALYs over 10 years for an incremental cost-effectiveness ratio (ICER) of USD 24,765 per DALY averted.

SingHypertension was cost‐effective based on a willingness-to-pay threshold of USD 55,500. This result held up even when considering different risk groups (low-risk: ICER USD 27,024; high-risk: ICER USD 22,430) and was robust to the assumption of a delayed linear decline in risk reduction, starting no earlier than year 7 and reaching zero by year 10, the investigators pointed out.

At the willingness-to-pay threshold, SingHypertension had a 78-percent probability of being cost‐effective. The cost-effectiveness depended most on how much the intervention lowered CVD risk, according to the investigators. Specifically, SingHypertension needed to bring down 10-year CVD risk by at least 0.13 percent to 0.16 percent.

“The intervention is good value for the money for reducing CVD risk and related events in the long run,” they said. “It should be considered for broader implementation in Singapore and other high‐income countries.”

Reduced total DALY burden

SingHypertension has four components. First, a tailored BP treatment with single-pill combination and other medications based on individual Framingham Risk Score, pre-existing CVD, comorbidities, cholesterol level, and BP readings. Second, a motivational conversation to empower patients to manage risk factors, set healthy lifestyle goals, use a home BP monitor, and adhere to medication regimens. Third, telephone follow-ups to ensure adherence to treatment and healthy lifestyles. And finally, discounts on single-pill combination antihypertensive medications.

“Although this multicomponent intervention entails more follow‐ups from medical staff, more physician and nurse training, laboratory tests, and switching from current antihypertensive medications to a single-pill combination, our analysis suggests these costs will be balanced by health gains from prevented CVD events and early deaths,” the investigators stated.

About half a million Singaporean adults between 40 and 74 years of age who have hypertension are expected to benefit from SingHypertension. The investigators noted that if implemented nationwide, the intervention has the potential to reduce total DALY burden, which could be another stride towards the United Nations Sustainable Development goal of reducing premature mortality from noncommunicable diseases by a third by 2030. [https://www.moh.gov.sg/resources-statistics/reports/nphs-2020-21]

“In healthcare systems with existing primary care infrastructure, SingHypertension could be easily integrated to address the increasing CVD burden. It can be adapted and tested further for other chronic conditions, and if found cost‐effective, can be further integrated to strengthen primary care networks to manage multiple noncommunicable diseases and their growing burden on healthcare systems worldwide,” they added.

For the cost-effectiveness study, a Markov model was used to simulate CVD events and associated outcomes for a hypothetical cohort of patients with hypertension (average age 65 years) over a 10‐year period. Costs were measured in US dollars, and effectiveness was measured in DALY averted. The patients included those who had no history of stroke, transient ischaemic attack, myocardial infarction, or angina. Of the cohort, 42.6 percent were assumed to be at high risk of CVD (≥20 percent 10‐year CVD risk based on Framingham Risk Score or diabetes or chronic kidney disease).