Effectiveness of treat-to-target versus risk-based blood pressure guidelines

描述（由申请人提供）：目前美国有1.65亿成年高血压患者。4随着人口老龄化，高血压患病率持续上升。高血压的医疗费用在2010年估计为7660万美元，在2005年大约有39.5万人死于高血压，或者说六分之一的人死于高血压。传统上，美国的血压指南是基于血压水平和目标的治疗建议——一种“从治疗到目标”的方法。替代方法以心血管事件的短期或长期风险为基础，使用年龄、性别、血压和其他主要风险因素来预测风险——一种基于风险或“量身定制”的方法。美国人口结构的重要变化有可能影响这些策略的相对成本效益。这些人口变化包括人口老龄化，非洲裔美国人和西班牙裔美国人在人口中所占比例的增长，以及超重和肥胖患病率的增加。美国还没有正式的临床效果分析或成本效益分析，比较这两种血压治疗方法，尽管最近有其他国家发表了这样的分析。此外，这些策略在按年龄、性别、种族/民族和肥胖状况定义的人口群体中的比较分析尚未发表。这样的分析有可能以重要的方式为治疗建议提供信息。冠心病（CHD）政策模型是美国成人心血管疾病的流行病学和比较有效性计算机模型。使用经过调整和验证的冠心病政策模型来预测中风、心力衰竭、终末期肾脏疾病以及冠心病，我们建议：根据患者预测的中期（10年）和长期（30年）心血管事件风险，比较“治疗到目标”指南和“量身定制”指南；评估“治疗到目标”和“量身定制”指南在2010-2030年期间对美国成年人的影响：1)人口老龄化；2)非洲裔美国人和墨西哥裔美国人（分别具有较高的高血压患病率和较低的血压治疗率）相对较快的增长；3)各种肥胖和超重趋势情景。这些分析的结果有可能有助于更好地为美国定义最佳的血压控制指南，并确定可能从指南的完全实施中获益最多的人群亚群。一个优化设计的国家BP控制计划有可能大大减轻BP相关发病率和死亡率的负担，同时在未来几十年每年节省数千万美元的医疗保健费用。

DESCRIPTION (provided by applicant): There are presently >65 million adults with hypertension in the United States.4 As the population ages, the prevalence of hypertension continues to increase. The health care costs due to hypertension are estimated at $76.6 million in 20104 and approximately 395,000 deaths, or one in six deaths were attributed to elevated blood pressure in 2005.3 Traditionally, U.S. blood pressure guidelines have based treatment recommendations on blood pressure levels and targets-a "treat-to-target" approach. Alternative approaches base treatment recommendations on short- or long-term risk for cardiovascular events, predicted using age, sex, blood pressure, and other major risk factors to estimate risk-a risk-based or "tailored" approach. Important demographic changes in the U.S. population have the potential to impact the relative cost effectiveness of these strategies. These demographic changes include aging of the population, growth of the proportion of African Americans and Hispanic Americans in the population, and increases in the prevalence of overweight and obesity. No formal clinical effectiveness analysis or cost-effectiveness analysis comparing these two approaches to blood pressure treatment has been published for the U.S., though such analyses have recently been published for other countries. Further, comparative analyses of these strategies in demographic groups defined by age, sex, race/ethnicity and obesity status have not been published. Such analyses have the potential to inform treatment recommendations in important ways. The Coronary Heart Disease (CHD) Policy Model is an epidemiologic and comparative effectiveness computer model of cardiovascular disease in U.S. adults. Using a version of the CHD Policy Model adapted and validated to predict stroke, heart failure and end-stage renal disease as well as CHD, we propose to: Compare "treat-to-target" guidelines to "tailored" guidelines based on patients' predicted medium term (10-year) and long term (30-year) risk for cardiovascular events; Assess the impact of both "treat-to-target" and "tailored" guidelines in U.S. adults during the years 2010-2030 in the context of 1) the aging of the population, 2) the relatively faster growth of African American and Mexican American populations (populations with higher hypertension prevalence and lower blood pressure treatment rates, respectively) and 3) various obesity and overweight trend scenarios. The results of these analyses have the potential to help better define the optimal blood pressure control guidelines for the U.S. and identify population subgroups that may benefit most from complete implementation of guidelines. An optimally designed national BP control program has the potential to greatly alleviate the burden of BP-related morbidity and mortality while saving tens of millions of health care dollars annually in coming decades.