Download PDF
Am J Perinatol 2021; 38(04): 363-369
DOI: 10.1055/s-0039-1697588
Original Article

The Impact of the New Hypertension Guidelines to Low-Dose Aspirin Prophylaxis Eligibility for the Prevention of Preeclampsia: A Cost-Benefit Analysis

Manesha Putra
1   Department of Reproductive Biology, MetroHealth Medical Center, Cleveland, Ohio
2   Department of Reproductive Biology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
3   Department of Reproductive Biology, Case Western Reserve University, Cleveland, Ohio
,
Madagedara Maduka Balasooriya
4   Department of Industrials and System Engineering, Wayne State University, Detroit, Michigan
,
Alexander L. Boscia
3   Department of Reproductive Biology, Case Western Reserve University, Cleveland, Ohio
,
Evrim Dalkiran
4   Department of Industrials and System Engineering, Wayne State University, Detroit, Michigan
,
Robert J. Sokol
5   Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan
› Author Affiliations Funding None.
› Further Information
Also available at
    Permissions and Reprints

Abstract

Objective American College of Cardiology and American Heart Association (ACC/AHA) published new guidelines which lower the cut-off for hypertension. We sought to evaluate the impact of these guidelines to cost and benefit of various low-dose aspirin prophylaxis approaches.

Study Design Decision tree analysis was created using R software to evaluate four approaches to aspirin prophylaxis in the United States: no aspirin, United States Preventive Service Task Force (USPSTF) with Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) hypertension guidelines, USPSTF with ACC/AHA hypertension guidelines, as well as universal aspirin prophylaxis. This model was executed to simulate a hypothetical cohort of 4 million pregnant women in the United States.

Results The new guidelines would expand the aspirin eligibility by 8% (76,953 women) in the USPSTF guidelines. Even with this increased eligibility, the USPSTF guidelines continue to be the approach with the most cost savings ($386.5 million) when compared with universal aspirin and no aspirin prophylaxis. The new hypertension guidelines are projected to increase the cost savings of the USPSTF approach by $9.4 million.

Conclusion Despite the small change in aspirin prophylaxis, using ACC/AHA definition of hypertension still results in an annual cost-saving of $9.4 million in the United States when compared with JNC7.

Keywords

cost-benefit analysis - low-dose aspirin - preeclampsia prophylaxis - hypertension guidelines

Note

Part of this paper was presented at the Society for Maternal Fetal Medicine Meeting 39th Annual Pregnancy Meeting, February 11 to 16, Las Vegas, NV.


Supplementary Material



Publication History

Received: 24 March 2019

Accepted: 12 August 2019

Article published online:
11 October 2019

© 2019. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Whelton PK, Carey RM, Aronow WS. et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2017; 71 (06) 1269-1324
    PubMedGoogle Scholar
  • 2 Verdecchia P, Angeli F, Gentile G, Reboldi G. More versus less intensive blood pressure-lowering strategy: cumulative evidence and trial sequential analysis. Hypertension 2016; 68 (03) 642-653
    CrossrefPubMedGoogle Scholar
  • 3 Xie X, Atkins E, Lv J. et al. Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis. Lancet 2016; 387 (10017): 435-443
    CrossrefPubMedGoogle Scholar
  • 4 ACOG practice bulletin no. 203: chronic hypertension in pregnancy. Obstet Gynecol 2019; 133 (01) e26-e50
    CrossrefPubMedGoogle Scholar
  • 5 Black MH, Zhou H, Sacks DA. et al. Prehypertension prior to or during early pregnancy is associated with increased risk for hypertensive disorders in pregnancy and gestational diabetes. J Hypertens 2015; 33 (09) 1860-1867
    CrossrefPubMedGoogle Scholar
  • 6 Ohkuchi A, Iwasaki R, Suzuki H. et al. Normal and high-normal blood pressures, but not body mass index, are risk factors for the subsequent occurrence of both preeclampsia and gestational hypertension: a retrospective cohort study. Hypertens Res 2006; 29 (03) 161-167
    CrossrefPubMedGoogle Scholar
  • 7 Rolnik DL, Wright D, Poon LC. et al. Aspirin versus placebo in pregnancies at high risk for preterm preeclampsia. N Engl J Med 2017; 377 (07) 613-622
    CrossrefPubMedGoogle Scholar
  • 8 LeFevre ML, Force USPST. U.S. Preventive Services Task Force. Low-dose aspirin use for the prevention of morbidity and mortality from preeclampsia: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2014; 161 (11) 819-826
    CrossrefPubMedGoogle Scholar
  • 9 Henderson JT. . Low-Dose Aspirin for Prevention of Morbidity and Mortality from Preeclampsia: A Systematic Evidence Review for the U.S Preventive Services Task Force; 2014
  • 10 Werner EF, Hauspurg AK, Rouse DJ. A cost-benefit analysis of low-dose aspirin prophylaxis for the prevention of preeclampsia in the United States. Obstet Gynecol 2015; 126 (06) 1242-1250
    CrossrefPubMedGoogle Scholar
  • 11 Sutton EF, Hauspurg A, Caritis SN, Powers RW, Catov JM. Maternal outcomes associated with lower range stage 1 hypertension. Obstet Gynecol 2018; 132 (04) 843-849
    CrossrefPubMedGoogle Scholar
  • 12 Seely EW, Ecker J. Chronic hypertension in pregnancy. Circulation 2014; 129 (11) 1254-1261
    CrossrefPubMedGoogle Scholar
  • 13 Ananth CV, Keyes KM, Wapner RJ. Pre-eclampsia rates in the United States, 1980-2010: age-period-cohort analysis. BMJ 2013; 347: f6564
    CrossrefPubMedGoogle Scholar
  • 14 Martin JA, Hamilton BE, Osterman MJK, Driscoll AK, Drake P. Births: final data for 2016. Natl Vital Stat Rep 2018; 67 (01) 1-55
    Google Scholar
  • 15 Mullican DR, Lorenzo C, Haffner SM. Is prehypertension a risk factor for the development of type 2 diabetes?. Diabetes Care 2009; 32 (10) 1870-1872
    CrossrefPubMedGoogle Scholar
  • 16 Fink JC, Schwartz SM, Benedetti TJ, Stehman-Breen CO. Increased risk of adverse maternal and infant outcomes among women with renal disease. Paediatr Perinat Epidemiol 1998; 12 (03) 277-287
    CrossrefPubMedGoogle Scholar
  • 17 Bo S, Gruden G, Charbonnier E. et al. High-normal blood pressure and impaired renal function. A prospective study in a population-based cohort. Minerva Med 2014; 105 (03) 211-219
    PubMedGoogle Scholar
  • 18 Xue H, Wang J, Hou J. et al. Prehypertension and chronic kidney disease in Chinese population: four-year follow-up study. PLoS One 2015; 10 (12) e0144438
    CrossrefPubMedGoogle Scholar
  • 19 Cooper GS, Bynum ML, Somers EC. Recent insights in the epidemiology of autoimmune diseases: improved prevalence estimates and understanding of clustering of diseases. J Autoimmun 2009; 33 (3-4): 197-207
    CrossrefPubMedGoogle Scholar
  • 20 Branum AM, Kirmeyer SE, Gregory EC. Prepregnancy body mass index by maternal characteristics and state: data from the birth certificate, 2014. Natl Vital Stat Rep 2016; 65 (06) 1-11
    Google Scholar
  • 21 Booth III JN, Li J, Zhang L, Chen L, Muntner P, Egan B. Trends in prehypertension and hypertension risk factors in US adults: 1999-2012. Hypertension 2017; 70 (02) 275-284
    CrossrefPubMedGoogle Scholar
  • 22 Rotchell YE, Cruickshank JK, Gay MP. et al. Barbados low dose aspirin study in pregnancy (BLASP): a randomised trial for the prevention of pre-eclampsia and its complications. Br J Obstet Gynaecol 1998; 105 (03) 286-292
    CrossrefPubMedGoogle Scholar
  • 23 Roberts JM, Myatt L, Spong CY. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Vitamins C and E to prevent complications of pregnancy-associated hypertension. N Engl J Med 2010; 362 (14) 1282-1291
    CrossrefPubMedGoogle Scholar
  • 24 Leibowitz A, Grossman E. How to define prehypertension in diabetes/metabolic syndrome. Diabetes Care 2009; 32 (Suppl. 02) S275-S279
    CrossrefPubMedGoogle Scholar
  • 25 Masclee GM, Valkhoff VE, Coloma PM. et al. Risk of upper gastrointestinal bleeding from different drug combinations. Gastroenterology 2014; 147 (04) 784-792
    CrossrefPubMedGoogle Scholar
  • 26 Rajan JP, Wineinger NE, Stevenson DD, White AA. Prevalence of aspirin-exacerbated respiratory disease among asthmatic patients: a meta-analysis of the literature. J Allergy Clin Immunol 2015; 135 (03) 676-681
    CrossrefPubMedGoogle Scholar
  • 27 Rolnik DL, Wright D, Poon LCY. et al. ASPRE trial: performance of screening for preterm pre-eclampsia. Ultrasound Obstet Gynecol 2017; 50 (04) 492-495
    CrossrefPubMedGoogle Scholar
  • 28 Smith GN, Pudwell J, Saade GR. Impact of the New American Hypertension Guidelines on the prevalence of postpartum hypertension. Am J Perinatol 2019; 36 (04) 440-442
    Article in Thieme ConnectPubMedGoogle Scholar
  • 29 Network P. Red Book: Pharmacy's Fundamental Reference. Montvale, NJ: PDR Network; 2010
    Google Scholar
  • 30 Research AfH. Quality. HCUP Databases. Healthcare Cost and Utilization Project (HCUP); 2012
    Google Scholar
  • 31 Barton JR, Istwan NB, Rhea D, Collins A, Stanziano GJ. Cost-savings analysis of an outpatient management program for women with pregnancy-related hypertensive conditions. Dis Manag 2006; 9 (04) 236-241
    CrossrefPubMedGoogle Scholar
  • 32 Nicholson WK, Frick KD, Powe NR. Economic burden of hospitalizations for preterm labor in the United States. Obstet Gynecol 2000; 96 (01) 95-101
    PubMedGoogle Scholar
  • 33 Russell RB, Green NS, Steiner CA. et al. Cost of hospitalization for preterm and low birth weight infants in the United States. Pediatrics 2007; 120 (01) e1-e9
    CrossrefPubMedGoogle Scholar
  • 34 James AH, Patel ST, Watson W, Zaidi QR, Mangione A, Goss TF. An assessment of medical resource utilization and hospitalization cost associated with a diagnosis of anemia in women with obstetrical bleeding in the United States. J Womens Health (Larchmt) 2008; 17 (08) 1279-1284
    CrossrefPubMedGoogle Scholar
  • 35 Saltzman JR, Tabak YP, Hyett BH, Sun X, Travis AC, Johannes RS. A simple risk score accurately predicts in-hospital mortality, length of stay, and cost in acute upper GI bleeding. Gastrointest Endosc 2011; 74 (06) 1215-1224
    CrossrefPubMedGoogle Scholar
  • 36 Ivanova JI, Bergman R, Birnbaum HG, Colice GL, Silverman RA, McLaurin K. Effect of asthma exacerbations on health care costs among asthmatic patients with moderate and severe persistent asthma. J Allergy Clin Immunol 2012; 129 (05) 1229-1235
    CrossrefPubMedGoogle Scholar
  • 37 Askie LM, Duley L, Henderson-Smart DJ, Stewart LA. PARIS Collaborative Group. Antiplatelet agents for prevention of pre-eclampsia: a meta-analysis of individual patient data. Lancet 2007; 369 (9575): 1791-1798
    CrossrefPubMedGoogle Scholar
  • 38 Hernández-Díaz S, Toh S, Cnattingius S. Risk of pre-eclampsia in first and subsequent pregnancies: prospective cohort study. BMJ 2009; 338: b2255
    CrossrefPubMedGoogle Scholar
  • 39 Weiss JL, Malone FD, Emig D. et al; FASTER Research Consortium. Obesity, obstetric complications and cesarean delivery rate—a population-based screening study. Am J Obstet Gynecol 2004; 190 (04) 1091-1097
    CrossrefPubMedGoogle Scholar
  • 40 Duley L, Henderson-Smart DJ, Meher S, King JF. Antiplatelet agents for preventing pre-eclampsia and its complications. Cochrane Database Syst Rev 2007; (02) CD004659
    PubMedGoogle Scholar
  • 41 Caritis S, Sibai B, Hauth J. et al; National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. Low-dose aspirin to prevent preeclampsia in women at high risk. N Engl J Med 1998; 338 (11) 701-705
    CrossrefPubMedGoogle Scholar
  • 42 Roberge S, Nicolaides KH, Demers S, Villa P, Bujold E. Prevention of perinatal death and adverse perinatal outcome using low-dose aspirin: a meta-analysis. Ultrasound Obstet Gynecol 2013; 41 (05) 491-499
    CrossrefPubMedGoogle Scholar
  • 43 Bujold E, Roberge S, Lacasse Y. et al. Prevention of preeclampsia and intrauterine growth restriction with aspirin started in early pregnancy: a meta-analysis. Obstet Gynecol 2010; 116 (2 Pt 1): 402-414
    CrossrefPubMedGoogle Scholar
  • 44 van Vliet EO, Askie LA, Mol BW, Oudijk MA. Antiplatelet agents and the prevention of spontaneous preterm birth: a systematic review and meta-analysis. Obstet Gynecol 2017; 129 (02) 327-336
    CrossrefPubMedGoogle Scholar
  • 45 Ananth CV, Wilcox AJ. Placental abruption and perinatal mortality in the United States. Am J Epidemiol 2001; 153 (04) 332-337
    CrossrefPubMedGoogle Scholar
  • 46 Sibai BM, Caritis SN, Thom E. et al; The National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. Prevention of preeclampsia with low-dose aspirin in healthy, nulliparous pregnant women. N Engl J Med 1993; 329 (17) 1213-1218
    CrossrefPubMedGoogle Scholar
  • 47 Feinstein LB, Holman RC, Yorita Christensen KL, Steiner CA, Swerdlow DL. Trends in hospitalizations for peptic ulcer disease, United States, 1998-2005. Emerg Infect Dis 2010; 16 (09) 1410-1418
    CrossrefPubMedGoogle Scholar
  • 48 Pilliod RA, Cheng YW, Snowden JM, Doss AE, Caughey AB. The risk of intrauterine fetal death in the small-for-gestational-age fetus. Am J Obstet Gynecol 2012; 207 (04) 318.e1-318.e6
    CrossrefPubMedGoogle Scholar
  • 49 Matthews TJ, MacDorman MF. Infant mortality statistics from the 2010 period linked birth/infant death data set. Natl Vital Stat Rep 2013; 62 (08) 1-26
    Google Scholar
  • 50 Laopaiboon M, Lumbiganon P, Intarut N. et al; WHO Multicountry Survey on Maternal Newborn Health Research Network. Advanced maternal age and pregnancy outcomes: a multicountry assessment. BJOG 2014; 121 (Suppl. 01) 49-56
    CrossrefPubMedGoogle Scholar
  • 51 Subtil D, Goeusse P, Puech F. et al; Essai Régional Aspirine Mère-Enfant (ERASME) Collaborative Group. Aspirin (100 mg) used for prevention of pre-eclampsia in nulliparous women: the Essai Régional Aspirine Mère-Enfant study (Part 1). BJOG 2003; 110 (05) 475-484
    PubMedGoogle Scholar
  • 52 Hansen C, Joski P, Freiman H. et al. Medication exposure in pregnancy risk evaluation program: the prevalence of asthma medication use during pregnancy. Matern Child Health J 2013; 17 (09) 1611-1621
    CrossrefPubMedGoogle Scholar