OBJECTIVES: Masked hypertension (office blood pressure [BP] <130/80 mmHg, out-of-office BP ≥130/80 mmHg) increases cardiovascular disease (CVD) event risk nearly two-fold compared to sustained normotension (office BP <130/80 mmHg, out-of-office BP <130/80 mmHg) . We compared the lifetime health and economic outcomes of screening for and treating masked hypertension by adding ambulatory or home BP monitoring (i.e., ABPM or HBPM) to standard care (no screening) from a US healthcare sector perspective.

METHODS: The CVD Policy Model, a microsimulation health state transition model, simulates the annual risk of fatal and non-fatal CVD events, treatment-related adverse events, and non-CVD deaths. We simulated screening of 500,000 US adults aged ≥20 years at risk for masked hypertension (office BP 120-129/<80 mmHg, on no antihypertensive medications, without CVD history). Based on published literature, we assumed ABPM had 100% sensitivity and 100% specificity (gold standard), and HBPM had 91.8% sensitivity and 41.4% specificity. We projected total direct health care costs (2020 USD), quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs). Future costs and QALYs were discounted 3% annually. A threshold of <$150,000/QALY gained defined intermediate cost-effectiveness. Primary analyses were performed using 100 probabilistic simulations. Parameter uncertainty was assessed using one-way sensitivity analyses.

RESULTS: Relative to standard care, mean (95%CI) time to first CVD event increased with ABPM 0.232 (0.152-0.326) years and 0.233 (0.149-0.328) years with HBPM masked hypertension screening, but the percent experiencing treatment-related serious adverse events increased 10.9% (9.8%-11.7%) with ABPM and 11.4% (11.1%-11.7%) with HBPM. Compared to standard care, lifetime QALYs increased 0.018 (0.005-0.034) with ABPM and 0.017 (0.003-0.032) with HBPM screening, but neither strategy was cost-effective (ICER: ABPM $433,000/QALY gained, HBPM $428,000/QALY gained). No sensitivity analyses resulted in either ABPM or HBPM becoming cost-effective.

CONCLUSIONS: Screening for masked hypertension with ABPM or HBPM leads to modest health gains but is not cost-effective compared to standard care.