Journal of the American Society of Hypertension 8(10) (2014) 732–738

Research Article

Cost estimation of hypertension management basedon home blood pressure monitoring alone or combinedoffice and ambulatory blood pressure measurements

Nadia Boubouchairopoulou, MSca, Nikos Karpettas, MDb, Kostas Athanasakis, PhDa,Anastasios Kollias, MDb, Athanase D. Protogerou, MDc, Apostolos Achimastos, MDb, and

George S. Stergiou, MD, FRCPb,*aDepartment of Health Economics, National School of Public Health, Athens, Greece;

bHypertension Center, STRIDE Hellas-7, Third University Department of Medicine, Sotiria Hospital, Athens, Greece; andcHypertension Unit and Cardiovascular Research Lab, First Department of Internal and Propaedeutic Medicine, Laiko Hospital,

Athens, Greece

Manuscript received May 5, 2014 and accepted July 9, 2014

Abstract

This study aims at estimating the resources consumed and subsequent costs for hypertension management, using home bloodpressure (BP) monitoring (HBPM) alone versus combined clinic measurements and ambulatory blood pressure monitoring(C/ABPM). One hundred sixteen untreated hypertensive subjects were randomized to use HBPM or C/ABPM for antihyper-tensive treatment initiation and titration. Health resources utilized within 12-months follow-up, their respective costs, andhypertension control were assessed. The total cost of the first year of hypertension management was lower in HBPM thanC/ABPM arm (V1336.0 vs. V1473.5 per subject, respectively; P < .001). Laboratory tests’ cost was identical in both arms.There was no difference in achieved BP control and drug expenditure (HBPM:V233.1 per subject; C/ABPM:V247.6 per sub-ject; P ¼ not significant), whereas the cost of BP measurements and/or visits was higher in C/ABPM arm (V393.9 vs.V516.9,per patient, respectively P < .001). The cost for subsequent years (>1) was V348.9 and V440.2 per subject, respectively forHBPM and C/ABPM arm and V2731.4 versus V3234.3 per subject, respectively (P < .001) for a 5-year projection. HBPMused alone for the first year of hypertension management presents lower cost than C/ABPM, and the same trend is observedin 5-year projection. The results on the resources consumption can be used to make cost estimates for other health-care systems.J Am Soc Hypertens 2014;8(10):732–738. � 2014 American Society of Hypertension. All rights reserved.Keywords: Blood pressure measurement methods; cost effectiveness; economic analysis; hypertension treatment.

Introduction

The diagnosis of hypertension and the evaluation oftreatment-induced effects on blood pressure (BP) andtarget-organ damage have been based for decades on con-ventional office BP measurement. It is now, however, recog-nized that these measurements are often misleading due to

Funding Source: No funding was provided for this project.Conflict of Interest: None for all authors.*Corresponding author: George S. Stergiou, MD, FRCP,

Hypertension Center, STRIDE Hellas-7, Third University Depart-ment of Medicine, Sotiria Hospital, 152 Mesogion Avenue, Athens11527, Greece. Tel: þ302107763117; fax: þ302107719981.

E-mail: gstergi@med.uoa.gr

1933-1711/$ - see front matter � 2014 American Society of Hypertenshttp://dx.doi.org/10.1016/j.jash.2014.07.027

the white-coat and masked hypertension phenomena, thepoor reproducibility of office measurements and observer is-sues such as prejudice and bias.1 Studies have shown thatout-of-office measurements, using 24-hour ambulatory BP(ABP) monitoring (ABPM) or self-monitoring by patientsat home, are more reliable than office measurements, havehigher reproducibility, and higher diagnostic value, andtherefore reflect more accurately preclinical target-organdamage2 and the risk of cardiovascular events.3–6

Both home blood pressure (HBP) monitoring (HBPM)and ABPM record BP in multiple occasions and in the usualenvironment of each subject, away from the office environ-ment.1,5,6 However, ABP records BP data only for 24 hoursbut during all the individual’s kinds of activities includingsleep, whereas HBP provides readings for several days,

ion. All rights reserved.

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weeks, or months, but only in the sitting posture and athome.1,5,6 Although both ABPM and HBPM are endorsedby current European,1,5–7 UK (National Institute for ClinicalExcellence),8 United Sates,9 and Japanese10 guidelines,there is still no agreement on how these methods should beused in clinical practice. Guidelines in Europe, the UnitedStates, and Japan recommend that HBPM should be offeredto all patients with elevated BP, whereas ABPM shouldbe restricted in selected cases.1,5,9,10 In contrary, the UKNational Institute for Clinical Excellence organization rec-ommends ABPM to be offered to all subjects with sus-pected hypertension, whereas HBP should was left as a‘‘suitable alternative’’ for subjects ‘‘unable to tolerate ABPmonitoring’’.8

Recently, a randomized study that compared the useof office BP measurements combined with ABPM (asconfirmatory method) against HBPM alone in terms of hy-pertension diagnosis, treatment initiation, and titration,demonstrated that, after an average of 13.4 months follow-up, the two strategies did not differ in terms of BP decline,hypertension control, and target-organ damage regression.11

Given the major importance of cost-effectiveness analysis ofall medical interventions applied in routine clinical practice,the comparison of different BP measurement methods interms of their requirements for health-care system resourcesand subsequent costs is essential. Moreover, due to the highprevalence of hypertension in the population, even smalldifferences in the cost of applying different strategies is ex-pected to have large impact on the health-care service costs.This article presents a comparative cost analysis of the twoBP monitoring strategies considering the data collected inthe above mentioned prospective study.11

Methods

Overview

This analysis is an estimate of the expenditures attributedto the health resources utilized for hypertension manage-ment by patients using HBPM alone versus patients usingoffice BP measurement and occasionally ABPM as confir-matory test. These data were derived from a published pro-spective randomized study.11 This study compared the BPreduction, the hypertension control rate, and the regressionof target-organ damage achieved after the first 12 months oftreatment based either on HBPM alone or on office BPmeasurement combined with occasional use of ABPM.11

The cost evaluation of resources utilized in this study wasperformed from the private sector’s perspective.

Study Participants

A total of 116 untreated subjects aged >30 years withelevated BP were included in the study after a 2-week run-in period during which the following tests were performed:

(1) BP evaluation using office measurements, HBPM,and ABPM; (2) blood sample for full blood count, glucose,total, low-density lipoprotein and high-density lipoproteincholesterol, triglycerides, serum potassium and sodium,uric acid, creatinine, urine microscopy and dipstick, urinaryalbumin:creatinine ratio (morning spot), and 12-lead elec-trocardiogram. Echocardiography was performed only insuspected white-coat hypertension defined as elevated officeBP and normal HBP or ABP, according to the European hy-pertension guidelines.7

Design

Participants were randomized to use either HBPM alone(arm A) or clinic BP measurements combined with occa-sional use of ABPM as a confirmatory method (arm B) forantihypertensive treatment initiation and titration. In armA treatment decisions for hypertension management wereexclusively based on HBP measurements, whereas in armB on office and ABPM. Each HBPM session was performedusing validated electronic arm devices with automated mem-ory and personal computer link, for 7 days within 2 weekswith duplicate self-measurements in the morning and theevening after 5 minutes of sitting rest and 1 minute-intervals between measurements.5 The average of allHBPM readings was calculated after discarding those ofthe first day.5 In the HBPM arm, the goal of treatment washome BP < 135/85 mm Hg for low- and/or moderate-riskpatients and<125/80 mmHg for high-risk patients, whereasin the ABPM arm clinic BP <140/90 mm Hg and awakeABP<135/85mmHg for low- and/or moderate-risk patientsand <130/80 mm Hg and <125/80 mm Hg, respectively forhigh-risk patients. Details for the study protocol and the BPchanges have been published.1,5,7,11 Participants attendedclinic visits at monthly intervals until BP control wasachieved and then after 6 months. Complete BP and organdamage evaluation was repeated after 12 months follow-upas performed before randomization. A total of 116 subjectswith complete data after 12 months of follow-up wereincluded in the final analysis and were considered in the pre-sent cost analysis. Details on the study selection criteria,design, and procedures have been published.11

Cost Estimation

The analysis was performed from the private sectorperspective and involved all costs related to the first yearof hypertension management. The cost estimation com-prised three main categories of expenditures related to: (1)BP measurements and outpatient visits; (2) laboratory andother tests; and (3) pharmaceutical therapy. To estimatethe indicated cost, the frequency of each treatment or healthservice used was multiplied by the associated charge.All costs were evaluated in Euros and in accordance to thelatest price bulletin in Greece (2013). A 5-year projection

Table 1Costs of each of the expenses and average cost of drug treatment

Type of Expenses Cost (V)

Ambulatory BP monitoring 64.0/24-h applicationHome BP monitoring 2.3/moOffice visit (including office BPmeasurement)

40.0

Full blood count 22.4Routine biochemistry blood test 299.2Urine microscopy 16.512-lead Electrocardiogram 15.2Echocardiogram 24.9

Drug treatment (number of patients) Average Cost (V)

Monotherapy (46) 186.82-drug combination (45) 315.13-drug combination (13) 335.34-drug combination (2) 416.8

BP, blood pressure.

734 N. Boubouchairopoulou et al. / Journal of the American Society of Hypertension 8(10) (2014) 732–738

was also applied by taking into consideration the followingassumptions: (1) in both study arms treatment remained sta-ble as in the end of the first year; (2) a single ABPMwas per-formed per year only in arm B; (3) in arm A, patients had 2outpatient clinic visits/year (to report HBP measurements),whereas in arm B, they had 3 clinic visits/year (becauseonly in the latter arm clinic BP was used for decisionmaking).

The first category of expenditures consisted of outpatientvisits and BP measurements made using different methods.Home BP measurement cost was associated to the meanusual price of the validated electronic arm device as usedin the study. To calculate the respective cost per year, thelife expectancy of the device was taken into account,considering the 5-year guarantee, assuming a 5-year contin-uous use and therefore, the cost of the device was allocatedaccordingly. The cost of office BP measurement was in-cluded in the cost of office visits. The costs of ABPMand office visits were estimated according to the pricesused in the private sector. For the first year of hypertensionmanagement, the data in regard to the number of visits andmeasurements were derived from the above mentioned pro-spective study.11 A 5-year projection was then performed asdescribed previously.

Treatment cost comprised antihypertensive medicationsprescribed during the first year of hypertension manage-ment. As mentioned previously, for the 5-year projection,it was assumed that pharmaceutical treatment remained sta-ble as in the end of the first year. Costs were based on retailprices and were then multiplied by the amount of drugs thatthe patients received.

Laboratory tests included tests that patients were submit-ted to during the 2-week run-in period to participate inthe study and in the end of the follow-up. The laboratoryinvestigation encompassed tests recommended by currentguidelines for the initial evaluation of hypertension andfor 1-year follow-up7 including full blood count, routineblood biochemistry, urine microscopy and dipstick, test formicroalbuminurea, and 12-lead electrocardiogram. Echo-cardiogram was performed only in white-coat hypertensiondetected in a total of 14 subjects. The study’s protocol wasdesigned in such a way that participants were subjected tothe same laboratory tests regardless of the arm in whichthey were allocated, as no significant difference could beattributed to the application of different BP measurements.The cost of laboratory tests was also obtained from the pri-ces applied in the private sector and calculated as cost pertest per patient.

Results

Details on the randomized study results in regard totreatment-induced BP changes, hypertension control, andtarget-organ damage regression have been published.11

There was no difference between the two study arms

in regard to BP decline, hypertension control rate, andtarget-organ damage regression in the end of follow-up(mean, 13.4 � 1.4 months).11

The total cost of the first year of hypertension manage-ment regardless of the BP measurement strategy was esti-mated at V1404.8 per patient. The largest part of expenseswas attributed to the cost of laboratory tests to which pa-tients had been submitted during the 2-week run-in periodand the end of the investigation (50.4%), followed by thecost of applying the office and out-of-office BP measure-ment methods and attending the outpatient visits (32.4%),and finally, the cost of antihypertensive drug therapy(17.1%). The unit costs of each of the expenses consideredin the analysis and the average cost of drug combinationsare presented in Table 1.

Patients in arm B (management based on office and ABPmeasurements) presented higher total average cost (perpatient) compared with subjects in arm A being monitoredwith HBPM alone (V1473.5 and V1336.0, respectively;P < .001). The average cost per patient associated with lab-oratory tests was identical for patients of both arms as theywere submitted to the same tests and computed at V709.0.The costs/patient for BP measurements and office visits washigher in arm B than in arm A, and a similar trend wasobserved for the cost of antihypertensive drug therapy(per patient; Table 2).

For the estimation of a 5-year projection for the costfor hypertension management, the expenditures of the sub-sequent year were first assessed using the assumptionsmentioned in methods. Regardless of the BP monitoringstrategy, the cost for subsequent years (>1) was estimatedat V394.6 per patient. There was a trend toward arm A hav-ing lower total cost than arm B, as in the first year of hyper-tension management (P < .001) (Table 3). In both arms, thecost allocated to antihypertensive therapy was higher than

Table 2Mean costs of the first year of hypertension management

BP Monitoring Strategy Clinic Visits and BP Measurements Antihypertensive Drug Therapy Laboratory Tests Total Costs

Arm A (HBPM alone) 393.9 233.1 709.0 1336.0Arm B (Office þ ABPM) 516.9 247.6 709.0 1473.5P for A vs. B difference <.001 NS NS <.001

ABPM, ambulatory blood pressure monitoring; BP, blood pressure; HBPM, home blood pressure monitoring; NS, not significant.The data are represented as V/patient.

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the cost of BP measurements and visits, nevertheless signif-icant difference between the two arms was observed only inthe costs of BP measurements and office visits with highercost in arm B (Table 3).

For a 5-year projection, the outcomes seemed to followthe same pattern as for the subsequent years, with main dif-ferences noted in BP measurements/outpatient visits costs(lower cost in arm A), contributing to a significantly lowertotal cost (P < .001; Table 4).

Discussion

Hypertension represents a major modifiable risk factorfor cardiovascular diseases worldwide.12 Its precise diag-nosis and adequate management through accurate BP eval-uation is a prerequisite for the effective monitoring ofhypertensive patients. This analysis is based on data froma previously published prospective randomized study11

and aims at evaluating the cost of two strategies for hyper-tension management (treatment initiation and titration) us-ing either HBPM alone (arm A) or office BP measurementscombined with ABPM used as confirmatory method (armB). As aforesaid, the study was designed according to cur-rent guidelines for hypertension management,7 therefore,the outcomes regarding resource use in each study armcan be adapted to other countries to perform further ana-lyses for the cost estimation of both strategies in differenthealth-care systems.

Table 3Expenditures for hypertension management for subsequent year

BP MonitoringStrategy

Clinic Visitsand BPMeasurements

AntihypertensiveDrug Therapy

Total

Arm A (HBPMalone)

107.0 241.9 348.9

Arm B(Office þ ABPM)

184.0 256.2 440.2

P for A vs. Bdifference

<.001 NS <.001

ABPM, ambulatory blood pressure monitoring; BP, blood pres-sure; HBPM, home blood pressure monitoring; NS, not significant.The data are represented as V/patient.

Taking into account the fact that current guidelines re-commend decision making in hypertension to be based onHBPM without requiring confirmation by ABPM, HBPMis considered to be a valid approach.13 In this study, an unbi-ased HBPM was performed by following the current guide-lines5 and usingmonitors with automatedmemory to preventmisreporting.14 Unnecessary treatment in white-coat hyper-tension was also prevented in this study because out-of-office BP measurement was taken into account in thedecision to initiate treatment in both arms (home or ambula-tory). The results suggest that the office BP andABP strategyfor hypertension management presents a higher first yearcost compared with the HBP strategy (Tables 2–4).

It is important to mention that the cost of laboratory testswas identical in the two study arms, given that the patientswere subjected to the same investigations and thereforedid not contribute to cost differences between the twoarms. Also, the level of BP control in the end of follow-up(mean 13.4 months) did not differ in the two arms, and there-fore, there was no need for cost-benefit adjustment due tothis factor to be taken into account in comparing the twostrategies. Thus, any difference in cost between the twoarms is due to differences in the application of BP moni-toring methods, the number of office visits, and the use ofantihypertensive drugs. Although the cost of antihyperten-sive drug therapy did not present statistically significant dif-ferences between the two groups, it contributed to the totalcost which reached statistical significance. In 5-year projec-tion, the same trend toward higher cost of ABPM combinedwith clinic measurements was noticed.

The present findings seem generally to be in line with pre-viously published studies. However, there are several differ-ences between these studies, which are mainly because ofdifferent methodological approaches and variables consid-ered. Evidence on the cost-effectiveness of HBP and ABPmeasurement methods seems to be limited; nevertheless,preliminary data suggest that HBPM is likely to be cost-saving.15–21

Funahashi et al16 studied the economic impact of intro-ducing HBPM in the diagnosis and treatment of hyperten-sion against office BP using a decision tree stemmingfrom data of the Japanese national database and the Oha-sama study. The introduction of HBPM was predicted tobe cost saving as its use for hypertension diagnosis resultedin saving about US $9.30 billion in Japan, because of

Table 4Five-year projection of the cost of hypertension management

BP Monitoring Strategy Clinic Visits and BP Measurements Antihypertensive Drug Therapy Laboratory Tests Total

Arm A (HBPM alone) 821.9 1200.5 709.0 2731.4Arm B (Office þ ABPM) 1252.9 1272.4 709.0 3234.3P for A vs. B difference <.001 NS NS <.001

ABPM, ambulatory blood pressure monitoring; BP, blood pressure; HBPM, home blood pressure monitoring; NS, not significant.The data are represented as V/patient.

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avoidable hypertension-related medical costs and white-coat hypertension.16 Another study in Japan applied a simu-lation model also using data from the Ohasama study andestimated that the introduction of HBP appeared to be costsaving compared with office BP alone. When HBP measure-ment was not used for the diagnosis of hypertension,the medical cost was estimated at US $10.89 million per1000 subjects per 5 years, whereas when integrated to thediagnostic procedure the medical cost was estimated atUS $9.33 million per 1000 subjects per 5 years.17

Furthermore, HBPM was found to obliquely reduce thecosts related to hypertension management. In a randomizedstudy, Verberk et al18 investigated whether antihypertensivedrug treatment based on HBP leads to the use of less medi-cation. A total of 430 hypertensive subjects were random-ized to receive treatment based on HBPM or office BPmeasurements and followed for 1 year.18 Also, the degreeof target-organ damage and pharmaceutical consumptionwere assessed. The findings showed that HBP led to lessmedication use compared with office BP measurements.Medication costs during the whole study were estimated atUS $4147 per 100 patients per month of treatment for sub-jects randomized in the office BP measurement group andUS $3023 for the HBP group.18 However, this study setthe same BP goal for office and home BP (the latter shouldhave been lower), which probably resulted in lesser use ofdrugs in the HBP group and also less effective BP control.18

Ewald & Pekarsky conducted a cost analysis ofABPM based on a model of four alternative strategies:(1) no ABPM, (2) yearly ABPM, (3) two-yearly ABPM,(4) three-yearly ABPM, over a 7-year period and included62 patients newly diagnosed by their GPs as having hyper-tension and requiring drug treatment.19 All monitoring stra-tegies seemed to be more expensive in the first year butbreak even after the third year.19 The emerging tendencydescribed previously was confirmed by Wang et al20, whopursued a review of the evidence on the costs and cost-effectiveness of adding HBPM and ABPM to routine BPscreening. Six of 14 identified studies ascertained thatABPM was cost saving for the diagnosis of hypertensionwhen following an elevated clinic-based BP measurement,whereas three studies found that adding HBPM to clinic-based BP was cost-effective.20 Finally, Lovibond et al21

conducted a cost-effectiveness analysis comparing clinicBP, HBP, or ABP measurement for hypertension diagnosis

using a Markov model including a hypothetical population.ABPM turned out being the most effective strategy forhypertension diagnosis, cost-saving, and resulting in morequality-adjusted life years and consequently, was recom-mended for most patients before antihypertensive drugtreatment initiation.21

The aforementioned studies present some proclivities butalso several variations. The outcomes of these studies denotethat introducing at least one of the two methods, HBPM orABPM, for hypertension diagnosis and monitoring is cost-effective compared with office BPmeasurement alone, espe-cially because of the white-coat phenomenon. However,the cost analyses also present great heterogeneities consist-ing in differences in the nature of the study design, sel-ection criteria, participants’ characteristics, methodologyfollowed, and the components of the cost that were esti-mated. Most of the studies performed a cost-effectivenessanalysis either of ABPM or HBPM, and inadequate resultsfor comparing the two strategies have been provided. Thisis the case of the analyses conducted by Funahashi et al16

and Fukunaga et al17 that evaluated the cost-effectivenessand economic impact of introducing HBPM in hypertensiondiagnosis and management or respectively the study ofEwald and Pekarsky19 using a model to calculate the cost-effectiveness of integrating ABPM in hypertension manage-ment. The findings of the present study cannot be directlycompared with the results of the previously mentionedstudies as we compared the cost of the two methods. More-over, the first strategy considered was HBP alone and thesecond one comprised ABP and office measurements com-bined, which is a sensible approach because HBPM ismore well accepted by hypertensive patients for repeateduse than ABPM.22,23 On the other hand, when all strategieswere assessed simultaneously, the methodology differed tosuch an extent that even in that case no safe comparisonscould be made.21

Possible limitations of the present study could firstlyinclude methodological issues. Potential laboratory teststhat patients could have been submitted to during thefollow-up and pharmaceutical consumption associatedwith other risk factors which might have affected the man-agement of hypertension were not included in the analysis.However, these are expected to occur with same frequencyin the two arms and therefore, the comparison betweenthem was not influenced. Furthermore, the estimation of

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5-year projection took into account a set of assumptionswhich might be considered as rather simplistic.

In summary, the combined use of office BP and ABPmeasurements as a strategy for hypertension managementseems to generally present a higher cost compared withHBPM alone, as a consequence of more health resourcesconsumed. Given that the two BP monitoring strategieshave been proved to lead in the same level of hypertensioncontrol and target-organ damage regression,11 the presentanalysis suggests that the HBPM strategy might be re-garded as more cost-effective. This advantage of the HBPstrategy is attributed to the lower cost of the technique itselfand to a tendency for this strategy to lead to lesser drug use.Compared with other countries, health services in Greececan eventually be regarded as low-cost services. However,the methodology of the present study enables the extrapola-tion of the results to other countries, as the care process ofhypertension management, subsequent health resourcesconsumed, and different types of expenses are based oncurrent guidelines for hypertension management.7 There-fore, the outcomes of the cost analysis performed can becomparable to those of other health-care systems and couldbe also used as a reference for further studies. Estimatingthe costs and resources used in the long-term managementof hypertension is essential for the proper planning ofspecialized health services and the efforts should be moreenhanced in line with using cost-effective methods for earlydiagnosis and optimal long-term control.

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