title: High Risk versus Proportional Benefit: Modelling Equitable Strategies in Cardiovascular Prevention.
abstract: OBJECTIVE
  To examine the performances of an alternative strategy to decide initiating BP-lowering drugs called Proportional Benefit (PB). It selects candidates addressing the inequity induced by the high-risk approach since it distributes the gains proportionally to the burden of disease by genders and ages.
  
  
  METHODS
  Mild hypertensives from a Realistic Virtual Population by genders and 10-year age classes (range 35-64 years) received simulated treatment over 10 years according to the PB strategy or the 2007 ESH/ESC guidelines (ESH/ESC). Primary outcomes were the relative life-year gain (life-years gained-to-years of potential life lost ratio) and the number needed to treat to gain a life-year. A sensitivity analysis was performed to assess the impact of changes introduced by the ESH/ESC guidelines appeared in 2013 on these outcomes.
  
  
  RESULTS
  The 2007 ESH/ESC relative life-year gains by ages were 2%; 10%; 14% in men, and 0%; 2%; 11% in women, this gradient being abolished by the PB (relative gain in all categories = 10%), while preserving the same overall gain in life-years. The redistribution of benefits improved the profile of residual events in younger individuals compared to the 2007 ESH/ESC guidelines. The PB strategy was more efficient (NNT = 131) than the 2013 ESH/ESC guidelines, whatever the level of evidence of the scenario adopted (NNT = 139 and NNT = 179 with the evidence-based scenario and the opinion-based scenario, respectively), although the 2007 ESH/ESC guidelines remained the most efficient strategy (NNT = 114).
  
  
  CONCLUSIONS
  The Proportional Benefit strategy provides the first response ever proposed against the inequity of resource use when treating highest risk people. It occupies an intermediate position with regards to the efficiency expected from the application of historical and current ESH/ESC hypertension guidelines. Our approach allows adapting recommendations to the risk and resources of a particular country.
authors.affiliation: Escuela de Medicina, Universidad de Valparaíso, Valparaíso, Chile.
authors.forename: Ivanny
authors.initials: I
authors.lastname: Marchant
authors.affiliation: NovaDiscovery, Biomodelling department, Lyon, France.
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Boissel
authors.affiliation: CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Service de Pharmacologie Clinique et Essais Thérapeutiques, Lyon, France.
authors.forename: Patrice
authors.initials: P
authors.lastname: Nony
authors.affiliation: CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Service de Pharmacologie Clinique et Essais Thérapeutiques, Lyon, France; INSERM, CIC 201, EPICIME, Lyon, France; Hop L Pradel, CHU Lyon, Lyon, France.
authors.forename: François
authors.initials: F
authors.lastname: Gueyffier
mesh_terms: D000328:Adult; D000367:Age Factors; D000959:Antihypertensive Agents / Q000494:pharmacology / Q000627:therapeutic use*; D001794:Blood Pressure / Q000187:drug effects; D002318:Cardiovascular Diseases / Q000517:prevention & control*; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D006973:Hypertension / Q000188:drug therapy* / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D012307:Risk Factors; D012737:Sex Factors
chemical_list: D000959:Antihypertensive Agents