A Systematic Literature Review of Health Economic Modelling Approaches Used to Evaluate Treatment Resistant and Uncontrolled Hypertension: A Critical Appraisal and Considerations for the Design of Future Model Analyses

BACKGROUND AND AIMS: Uncontrolled hypertension (ucHTN) and treatment-resistant hypertension (trHTN) are associated with a substantial increase in the risk of cardiorenal events and mortality compared with well-controlled hypertension. Treatment strategies that can optimise blood pressure management are urgently needed to improve health outcomes in ucHTN and trHTN populations; health economic models play a key role in assessing the economic value of new and existing treatments and supporting resource allocation. This systematic literature review critically assesses the construct and quality of existing health economic modelling used in the evaluation of management approaches for ucHTN and trHTN, to inform the design and development of future health economic models. MATERIALS AND METHODS: This review was conducted and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 checklist. Searches were conducted on Medline, Embase, EconLit, the Cost-effectiveness Analysis and the International HTA database. Searches were run from inception to May 2024 and re-run in February 2026. Although no date limits were placed on the electronic searches, a limit of 2005 and onwards was applied during study selection. Economic model studies were included if they assessed pharmacological or renal denervation (RDN) interventions for treatment of either ucHTN or trHTN in adult populations. Study eligibility, data extraction and quality assessment using the Drummond checklist were conducted independently by two reviewers. RESULTS: After deduplication, a total of 2754 records were identified. Of these, 2556 did not meet the eligibility criteria after title and abstract screening; 198 full texts were reassessed for eligibility. A total of 21 modelling studies were included: 16 economic evaluations (14 cost-utility analyses, 1 cost-effectiveness analysis and 1 cost-minimization analysis), 4 burden-of-illness studies and 1 budget impact analysis. The majority of studies focused on people with ucHTN and employed a healthcare system perspective. Economic evaluations were based on treatment effects on systolic blood pressure estimated from clinical trials. Several models predicted long-term cardiorenal events and mortality on the basis of published, validated risk equations; however, these risk equations were not developed in populations with ucHTN or trHTN. Although models were generally assessed to be of good quality, models incorporated health-related quality of life and cost data from controlled hypertensive or non-hypertensive populations, rather than those with ucHTN and trHTN. CONCLUSIONS: A range of economic models were identified and considered structurally relevant. These models demonstrated that treatment related improvements in blood pressure were cost-effective and robust in scenario analysis. However, important model limitations include their lack of use of population-specific health-related quality-of-life data and risk equations which may result in underestimation of treatment cost effectiveness. To reduce uncertainty and support improved economic modelling that can accurately contextualize emerging therapies for ucHTN and trHTN, future economic model analyses in ucHTN and trHTN need appropriate population health and cost data for these underserved populations.