| Summary: | 碩士 === 國立臺灣大學 === 流行病學與預防醫學研究所 === 107 === <Background> Although the control for hypertension have widely been accepted as a necessary component for stoke prevention, the heterogeneity regarding the evolution of hypertension in associated with the occurrence of stoke render the elucidation of the effectiveness of each components of prevention strategies intractable. As the primary prevention have gained great attention in current strategies of hypertension management, its contribution to stoke prevention remain not fully addressed. The effectiveness on the application of multiple prevention strategies including the population-based primary prevention and risk-oriented carotid ultrasound screening followed by a series of treatment and therapy for stoke prevention also has not been elaborated. The cost incurred by the multi-step prevention strategies and the attributes of its effectiveness including stroke averted, life-year gained, and quality adjusted life-years gained motivate our research by applying a cost-effectiveness analysis to evaluate the decision on the proposed personalized stroke prevention strategies.
<Aims> This thesis aims
(1) to explore the dynamic of stoke embedded in the evolution of hypertension defined by multiple disease status including normal, prehypertension, stage I hypertension, and stage II hypertension;
(2) to develop a risk-guided individual-tailored stoke prevention strategy incorporating primary and secondary prevention based on (1); and
(3) to assess the cost-effectiveness of (2) applied to Changhua population following the principle of decision analysis.
<Materials and Methods> We calculated the personalized risk score with 4-state hypertension Markov model underpinning in light of definition from JNC 7, normal, pre-hypertension, stage 1 hypertension, stage 2 hypertension. The clinical weights of the risk score were borrowed from literature with Keelung Community-based Screening (KCIS) cohort, and applied to the Changhua Community-based Screening (CHCIS) cohort to stratify the cohort into different risk groups. A Markov decision tree, incorporating the 4-state hypertension model, hemorrhagic stroke, ischemic stroke, three functional outcomes after stroke, and death was built. Finally, the probabilistic cost-effectiveness analysis of personalized prevention of hypertension compared with control group was conducted. The main outcome measures include stroke avoided and quality-adjusted life-year prolonged, incremental cost-utility ratio, and the acceptability curve for personalized prevention against control.
<Results> Among the Changhua population, the incidence of stroke is 16 per 1,000 with 4.2 and 11.8 per 1,000 for hemorrhagic and ischemic type, respectively. The personalized prevention strategy results in stroke risk reduction by 17% (95% CI: 15-18%). Taking into account the stroke events reduction and the functional status after stroke, the personalized prevention program not only results in 0.17 QALY gained per person in a 20-year time horizon, but also leads to an average NTD 161,170 less expenditure per person. Considering the distribution of parameters, the benefit of personalized prevention program over control is still dominant even under the worst case of parameters.
<Conclusion> We developed a framework for the evaluation of individual-tailored hypertension and stroke prevention, which incorporated primary and secondary prevention. As the personalized prevention is cost-effective against control in terms of quality-adjusted life year gained, our results support the personalized prevention as a promising policy for hypertension associated stroke.
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