Dynamic treatment selection and modification for personalised blood pressure therapy using a Markov decision process model: a cost-effectiveness analysis.
BMJ Open
; 7(11): e018374, 2017 Nov 15.
Article
em En
| MEDLINE
| ID: mdl-29146652
ABSTRACT
OBJECTIVE:
Personalised medicine seeks to select and modify treatments based on individual patient characteristics and preferences. We sought to develop an automated strategy to select and modify blood pressure treatments, incorporating the likelihood that patients with different characteristics would benefit from different types of medications and dosages and the potential severity and impact of different side effects among patients with different characteristics. DESIGN, SETTING ANDPARTICIPANTS:
We developed a Markov decision process (MDP) model to incorporate meta-analytic data and estimate the optimal treatment for maximising discounted lifetime quality-adjusted life-years (QALYs) based on individual patient characteristics, incorporating medication adjustment choices when a patient incurs side effects. We compared the MDP to current US blood pressure treatment guidelines (the Eighth Joint National Committee, JNC8) and a variant of current guidelines that incorporates results of a major recent trial of intensive treatment (Intensive JNC8). We used a microsimulation model of patient demographics, cardiovascular disease risk factors and side effect probabilities, sampling from the National Health and Nutrition Examination Survey (2003-2014), to compare the expected population outcomes from adopting the MDP versus guideline-based strategies. MAIN OUTCOMEMEASURES:
Costs and QALYs for the MDP-based treatment (MDPT), JNC8 and Intensive JNC8 strategies.RESULTS:
Compared with the JNC8 guideline, the MDPT strategy would be cost-saving from a societal perspective with discounted savings of US$1187 per capita (95% CI 1178 to 1209) and an estimated discounted gain of 0.06 QALYs per capita (95% CI 0.04 to 0.08) among the US adult population. QALY gains would largely accrue from reductions in severe side effects associated with higher treatment doses later in life. The Intensive JNC8 strategy was dominated by the MDPT strategy.CONCLUSIONS:
An MDP-based approach can aid decision-making by incorporating meta-analytic evidence to personalise blood pressure treatment and improve overall population health compared with current blood pressure treatment guidelines.Palavras-chave
Texto completo:
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Temas:
ECOS
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Aspectos_gerais
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Financiamentos_gastos
Bases de dados:
MEDLINE
Assunto principal:
Cadeias de Markov
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Modelos Econômicos
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Medicina de Precisão
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Hipertensão
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Anti-Hipertensivos
Tipo de estudo:
Guideline
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Health_economic_evaluation
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Prognostic_studies
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Qualitative_research
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Risk_factors_studies
Aspecto:
Patient_preference
Limite:
Adolescent
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Adult
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Aged
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Aged80
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Female
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Humans
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Male
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Middle aged
Idioma:
En
Revista:
BMJ Open
Ano de publicação:
2017
Tipo de documento:
Article
País de afiliação:
Estados Unidos