Cost-effectiveness of Chlorthalidone,Amlodipine, and Lisinopril as First-step Treatment for Patients with Hypertension: An Analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) |
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Authors: | Paul A. Heidenreich Barry R. Davis Jeffrey A. Cutler Curt D. Furberg David R. Lairson Michael G. Shlipak Sara L. Pressel Chuke Nwachuku Lee Goldman |
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Affiliation: | (1) VA Palo Alto Health Care System, Palo Alto, CA, USA;(2) Coordinating Center for Clinical Trials, University of Texas Houston School of Public Health, Houston, TX, USA;(3) National Heart, Lung, and Blood Institute, Bethesda, MD, USA;(4) Wake Forest University, Winston-Salem, NC, USA;(5) University of California at San Francisco, San Francisco, CA, USA;(6) College of Physicians and Surgeons, Columbia University, New York, NY, USA |
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Abstract: | Objective To evaluate the cost-effectiveness of first-line treatments for hypertension. Background The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) found that first-line treatment with lisinopril or amlodipine was not significantly superior to chlorthalidone in terms of the primary endpoint, so differences in costs may be critical for optimizing decision-making. Methods Cost-effectiveness analysis was performed using bootstrap resampling to evaluate uncertainty. Results Over a patient’s lifetime, chlorthalidone was always least expensive (mean $4,802 less than amlodipine, $3,700 less than lisinopril). Amlodipine provided more life-years (LYs) than chlorthalidone in 84% of bootstrap samples (mean 37 days) at an incremental cost-effectiveness ratio of $48,400 per LY gained. Lisinopril provided fewer LYs than chlorthalidone in 55% of bootstrap samples (mean 7-day loss) despite a higher cost. At a threshold of $50,000 per LY gained, amlodipine was preferred in 50%, chlorthalidone in 40%, and lisinopril in 10% of bootstrap samples, but these findings were highly sensitive to the cost of amlodipine and the cost-effectiveness threshold chosen. Incorporating quality of life did not appreciably alter the results. Overall, no reasonable combination of assumptions led to 1 treatment being preferred in over 90% of bootstrap samples. Conclusions Initial treatment with chlorthalidone is less expensive than lisinopril or amlodipine, but amlodipine provided a nonsignificantly greater survival benefit and may be a cost-effective alternative. A randomized trial with power to exclude “clinically important” differences in survival will often have inadequate power to determine the most cost-effective treatment. American Society of Health-System Pharmacists (December 2003), American College of Cardiology (March 2006), Society for Clinical Trials (May 2007). ClinicalTrials.gov Identifier: NCT00000542 () |
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Keywords: | hypertension cost-effectiveness diuretic angiotensin-converting enzyme inhibitors calcium channel blockers |
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