title: Cost-effectiveness of chlorthalidone, amlodipine, and lisinopril as first-step treatment for patients with hypertension: an analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).
abstract: OBJECTIVE
  To evaluate the cost-effectiveness of first-line treatments for hypertension.
  
  
  BACKGROUND
  The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) found that first-line treatment with lisinopril or amlodipine was not significantly superior to chlorthalidone in terms of the primary endpoint, so differences in costs may be critical for optimizing decision-making.
  
  
  METHODS
  Cost-effectiveness analysis was performed using bootstrap resampling to evaluate uncertainty.
  
  
  RESULTS
  Over a patient's lifetime, chlorthalidone was always least expensive (mean $4,802 less than amlodipine, $3,700 less than lisinopril). Amlodipine provided more life-years (LYs) than chlorthalidone in 84% of bootstrap samples (mean 37 days) at an incremental cost-effectiveness ratio of $48,400 per LY gained. Lisinopril provided fewer LYs than chlorthalidone in 55% of bootstrap samples (mean 7-day loss) despite a higher cost. At a threshold of $50,000 per LY gained, amlodipine was preferred in 50%, chlorthalidone in 40%, and lisinopril in 10% of bootstrap samples, but these findings were highly sensitive to the cost of amlodipine and the cost-effectiveness threshold chosen. Incorporating quality of life did not appreciably alter the results. Overall, no reasonable combination of assumptions led to 1 treatment being preferred in over 90% of bootstrap samples.
  
  
  CONCLUSIONS
  Initial treatment with chlorthalidone is less expensive than lisinopril or amlodipine, but amlodipine provided a nonsignificantly greater survival benefit and may be a cost-effective alternative. A randomized trial with power to exclude "clinically important" differences in survival will often have inadequate power to determine the most cost-effective treatment.
authors.affiliation: VA Palo Alto Health Care System, Palo Alto, CA, USA.
authors.forename: Paul A
authors.initials: PA
authors.lastname: Heidenreich
authors.forename: Barry R
authors.initials: BR
authors.lastname: Davis
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Cutler
authors.forename: Curt D
authors.initials: CD
authors.lastname: Furberg
authors.forename: David R
authors.initials: DR
authors.lastname: Lairson
authors.forename: Michael G
authors.initials: MG
authors.lastname: Shlipak
authors.forename: Sara L
authors.initials: SL
authors.lastname: Pressel
authors.forename: Chuke
authors.initials: C
authors.lastname: Nwachuku
authors.forename: Lee
authors.initials: L
authors.lastname: Goldman
mesh_terms: D017311:Amlodipine / Q000191:economics / Q000627:therapeutic use; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000191:economics* / Q000627:therapeutic use; D002121:Calcium Channel Blockers / Q000191:economics* / Q000627:therapeutic use; D002752:Chlorthalidone / Q000191:economics / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D004232:Diuretics / Q000191:economics* / Q000627:therapeutic use; D005260:Female; D006801:Humans; D006973:Hypertension / Q000188:drug therapy*; D053208:Kaplan-Meier Estimate; D017706:Lisinopril / Q000191:economics / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000517:prevention & control; D019057:Quality-Adjusted Life Years
chemical_list: D000806:Angiotensin-Converting Enzyme Inhibitors; D002121:Calcium Channel Blockers; D004232:Diuretics; D017311:Amlodipine; D017706:Lisinopril; D002752:Chlorthalidone