Cost-effectiveness of RAMP-HT for Patients With Uncontrolled Hypertension in Hong Kong
Condition: Hypertension; Cost Effectiveness
MeSH terms: Hypertension
Study type: Observational

Summary: 
      Hypertension (HT) is an important risk factor for stroke, coronary heart disease (CHD), heart
      failure and renal diseases, and the leading risk factor of global disease burden. A multitude
      of interventions have proven efficacy in lowering blood pressure and reducing long term HT
      complications, including pharmacologic treatment, DASH diet (Dietary Approaches to Stop
      Hypertension), exercise, weight reduction, smoking cessation, alcohol moderation and
      self-monitoring of blood pressure.

      Objectives:

      To evaluate long-term effectiveness and cost-effectiveness of
      Risk-Assessment-and-Management-Programme-for-Hypertension (RAMP-HT), a multi-disciplinary
      structured service to enhance quality of hypertension care in primary care compared to usual
      care

      Hypotheses:

        1. RAMP-HT is effective in reducing HT complications, based on previous results showing
           RAMP-HT was effective in improving patients' blood pressure

        2. RAMP-HT is cost-effective

      Design and Subjects:

      Retrospective study of 5-year longitudinal data on matched cohorts of public primary care
      patients with uncontrolled HT under RAMP-HT and usual care will be conducted to evaluate
      long-term effectiveness and direct medical costs. Results from the long-term effectiveness
      and costing analyses will be applied to Markov modeling to determine the life time
      cost-effectiveness of RAMP-HT.

      Main outcome measures:

        1. 5-year incidence of cardiovascular complications

        2. Direct medical costs of RAMP-HT and usual care HT patients

        3. Incremental cost-effectiveness ratio (ICER) of cost per quality-adjusted life year
           (QALY) gained by RAMP-HT compared to usual care

      Data analysis:

      Cox regression will be performed to estimate the effect of RAMP-HT on the development of HT
      complication adjusted for baseline covariates. Descriptive statistics will be used to
      calculate costs of RAMP-HT and annual direct medical costs for HT patients. Markov modeling
      will be used to simulate 2 patient cohorts (RAMP-HT versus usual care) to estimate the
      respective lifetime direct medical costs and QALY gained/person. Cost/QALY of RAMP-HT will be
      compared to that of usual care to determine the ICER.

      Expected results:

      The results can provide evidence on the effectiveness and cost-effectiveness of RAMP-HT for
      primary care patients with uncontrolled HT, which can inform health policy and service
      planning.
    

Detailed description: 
      Aim and objectives:

      The aim of this study is to evaluate the cost-effectiveness of the RAMP-HT of the HA in
      primary care patients with uncontrolled hypertension.

      The objectives are to:

        1. Evaluate the long term (5-year) effectiveness of RAMP-HT compared to usual care in
           reducing cardiovascular complications, end-stage renal disease and all-cause mortalities
           in a cohort of primary care patients with uncontrolled hypertension at baseline

        2. Estimate the direct medical cost of RAMP-HT and other health services among primary care
           HT patients with or without complications

        3. Evaluate the cost-effectiveness of RAMP-HT, compared to usual care, in gaining one QALY
           in primary care patients with uncontrolled hypertension

      Hypotheses:

        1. RAMP-HT is more effective in reducing 5-year cardiovascular complications, end stage
           renal disease and all-cause mortality among primary care patients with uncontrolled
           hypertension compared to usual care

        2. The direct medical cost of RAMP-HT patients, for the same disease complication status,
           is not higher than that of usual care except for the RAMP-HT cost

        3. The direct medical cost of HT patients with one or more complications is higher than
           that of HT patients without any complication

        4. RAMP-HT is cost-effective compared to usual care, i.e. ICER per QALY gained is below the
           threshold value of 1 annual GDP (Gross Domestic Product) per capita of Hong Kong, which
           is the benchmark recommended by the World Health Organization
    

Intervention name(s): RAMP-HT
Intervention type(s): Other
Intervention description(s): RAMP-HT was launched since October 2011 by the Hospital Authority with the support from the Food and Health Bureau. Standardized cardiovascular risk factor assessment, hypertensive complication screening and assessment on patient adherence to treatment are carried out on enrolled patients. Patients are stratified into low, medium or high risk groups according to the 10-year cardiovascular disease (CVD) risk calculated from their relevant risk factors by the Joint British Society 2005 Equation. A multidisciplinary team comprised of doctors, nurses, dieticians, physiotherapists and/or occupational therapists would then deliver individualized management targeted to the patient's risk factors according to standardized risk-stratified guidelines.
Observational model: Cohort
Time perspective: Retrospective
Sampling method: Probability Sample
Study population: 
        All patients who have enrolled into the RAMP-HT between 1 October 2011 and 31 March 2012,
        fulfilled the inclusion criteria and without any exclusion criterion will be included in
        the RAMP-HT cohort. The same number of matched patients receiving usual care in general
        outpatient clinics (GOPCs) who have never enrolled into RAMP-HT on or before 31 March 2017,
        fulfilled the inclusion criteria and without any exclusion criterion will be randomly
        selected from the HA clinical management system (CMS) to form the usual care cohort.
      
Keywords: Hypertension; Effectiveness; Cost Effectiveness; Cost; Multi-disciplinary; Risk Stratification