Association of Sustained Blood Pressure Control with Lower Risk for High-Cost Multimorbidities Among Medicare Beneficiaries in ALLHAT

Abstract

BACKGROUND: Clustering of chronic conditions is associated with high healthcare costs. Sustaining blood pressure (BP) control could be a strategy to prevent high-cost multimorbidity clusters. OBJECTIVE: To determine the association between sustained systolic BP (SBP) control and incident multimorbidity cluster dyads and triads. DESIGN: Cohort study of Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) linked to Medicare claims. PARTICIPANTS: ALLHAT included adults with hypertension and ≥1 coronary heart disease risk factor. This analysis was restricted to 5234 participants with ≥ 8 SBP measurements during a 48-month BP assessment period. MAIN MEASURES: SBP control was defined as <140 mm Hg at <50%, 50 to <75%, 75 to <100%, and 100% of study visits during the BP assessment period. High-cost multimorbidity clusters included dyads (stroke/chronic kidney disease [CKD], stroke/chronic obstructive pulmonary disease [COPD], stroke/heart failure [HF], stroke/ asthma, COPD/CKD) and triads (stroke/CKD/asthma, stroke/CKD/COPD, stroke/CKD/depression, stroke/ CKD/HF, stroke/HF/asthma) identified during followup. KEY RESULTS: Incident dyads occurred in 1334 (26%) participants and triads occurred in 481 (9%) participants over a median follow-up of 9.2 years. Among participants with SBP control at <50%, 50 to <75%, 75 to <100%, and 100% of visits, 32%, 23%, 23%, and 19% of participants developed high-cost dyads, respectively, and 13%, 9%, 8%, and 5% of participants developed high-cost triads, respectively. Compared to those with sustained BP control at <50% of visits, adjusted HRs (95% CI) for incident dyads were 0.66 (0.57, 0.75), 0.67 (0.59, 0.77), and 0.51 (0.42, 0.62) for SBP control at 50 to <75%, 75 to <100%, and 100% of visits, respectively. The corresponding HRs (95% CI) for incident triads were 0.69 (0.55, 0.85), 0.56 (0.44, 0.71), and 0.32 (0.22, 0.47). CONCLUSIONS: Among Medicare beneficiaries in ALLHAT, sustained SBP was associated with a lower risk of developing high-cost multimorbidity dyads and triads.

Sustained SBP control and long-term nursing home admission among Medicare beneficiaries

“…For example, Mancia et al [26,27] reported lower risk for CVD events including MI, heart failure, and stroke associated with BP control at a greater percentage of visits in two separate analyses, from the INVEST (International Verapamil SR-Trandolapril) trial, which enrolled participants with hypertension in addition to coronary artery disease and the VALUE (Valsartan Antihypertensive Long-term use Evaluation) trial, which included those with hypertension and three or more CVD risk factors. A previous analysis using data from the ALLHAT-CMS linkage identified an inverse association between sustained SBP control and progression of multimorbidity defined as the rate of accumulation of chronic conditions over time [9,10]. In that analysis, sustained SBP control at 100% of visits versus less than 50% of visits corresponded to estimated delays in the development of six or more chronic conditions from 68 to 76 years of age.…”

“…We conducted a retrospective cohort study using data from ALLHAT linked to CMS health insurance claims. The details of this ALLHAT-CMS linkage have been previously reported [9,10]. Briefly, ALLHAT is a large simple trial designed to compare the occurrence of major CVD events among participants randomized to receive antihypertensive medications from four different drug classes [11,12].…”

“…Among older adults, antihypertensive medication has been shown to lower the risk for cardiovascular disease (CVD) events including stroke, heart failure, and coronary heart disease (CHD), which are known to be associated with functional decline [7,8]. Sustaining SBP control over time is also associated with a lower risk of multimorbidity, a key factor contributing to frailty [9,10]. For example, achieving SBP control at a greater percentage of visits over a 48-month time period was shown to be associated with a slower rate of accumulation of chronic conditions in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), delaying the onset of six or more concurrent chronic conditions by 8 years [9].…”