Anytime I see the words “cost saving” in reference to a public health or medical intervention, my first thought is “Yeah, right!” It just doesn’t happen that often. One can spend more money to get better outcomes (or more care provided), or less money for worse outcomes, but rarely less money AND better outcomes. However, in a new Medical Care article just published ahead of print, Gabriel Tajeu and colleagues concluded just that: using antihypertensive medication was cost saving when compared with no treatment.
The study examined costs of antihypertensive medication treatment in 2012 US dollars and effects in quality-adjusted life years (QALYs) using a state-transition model (STM, also known as a Markov model). It compared antihypertensive medication treatment to a no-treatment alternative for white and black males and females. The study did not consider lifestyle interventions, such as diet and exercise.
Effectiveness of antihypertensive medication was taken from a robust evidence base of previous literature. The authors used data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study to obtain inputs for the model, which included white and black participants aged 45 and older between 2003 and 2007, limited to participants taking antihypertensive medications. Model inputs were also derived from the United States Renal Data System (USRDS), MarketScan data, and the National Center for Health Statistics mortality rate tables.
The costs of drugs, adverse events, and living in a given health state (e.g., post myocardial infarction) were included in the model. The authors discounted future costs at 3%. They conducted the analysis from a third-party payer (e.g., Medicare) perspective. This is important in cost-effectiveness analyses: the perspective must be stated up front, so we know whether we are considering just dollars (direct costs), or — in the case of the societal perspective — both dollars spent and indirect costs, such as unearned income. Using a third-party payer perspective, rather than a societal one, gives limited insights into the real costs of using antihypertensive medication. For example, costs for co-payments, travel, and missed work were not considered in the cost calculation for patients with hypertension and could prove important, especially when considering these costs as barriers to compliance for medication prescriptions.
As the authors mention, this study could be useful for organizations attempting to address health disparities between black and white adults by allocating resources efficiently. The study could also be useful in informing decisions on levels of coverage that Medicare or private insurers choose to provide to various populations and in negotiations of rates and interventions that are covered within healthcare networks.
I highly recommend that interested readers take a look at the supplemental materials (available via a link in the full-text version). The authors provide several tornado diagrams to illustrate the sensitivity analyses, additional tables with model inputs, and cost-effectiveness planes that will help to conceptualize their results. These additional resources also helped to persuade even this skeptic that antihypertensive medication is one of the few examples of a cost-saving intervention.
Nathaniel Taylor