By Marvin Moser The Cost of Controlling HypertensionCan It Be Reduced?
Hypertension is presently the number one solvable public health problem. Approximately 20 to 25 million Americans have elevated blood pressure. Recent statistics from the National Heart and Lung Institute have shown a definite increase from 50 to approximately 70 percent in the number of people with hypertension who are aware of their disease. Twenty-nine percent of all hypertensives now are receiving adequate th~rapy as compared to only approximately 15 to 16 percent who were appropriately managed five-six years ago-a distinct improvement, but a statistic that suggests a continuing effort to do better. During the past several years efforts of the National High Blood Pressure Education Program, national medical, dental and pharmaceutical organizations, and organizations such as the American Red Cross and Kiwanis Clubs have increased public awareness of the nature and extent of high blood pressure in the United States and the fact that it has been identified as one of the three major risk factors that cause cardiovascular diseases-illnesses that result in over 55 percent of the deaths in the United States. Of the three major risk factors-high blood pressure, smoking and a high fat content in the blood-high blood pressure is the only one where (1) effective treatment is available and (2) where scientific evidence exists that continuous long-term management and blood pressure control will result in a distinct definite decrease in the incidence of strokes, heart and kidney failure, and a reduction in mortality. Until recent years, hypertension was treated by many physicians only when complications occurred; the heart had become enlarged, a stroke, heart attack or kidney failure had occurred. Treatment was given after the crisis. A different approach is to intervene in the treatment of high blood pressure before complications ' occur, before end stage disease, when the patient may be feeling well. A brief review of the economic and social impact of hypertension may serve to highlight the needs for this approach and its benefits. Over 189 billion dollars was spent in direct and indirect costs for medical care in the U.S. in 1972. The figure is obviously much higher now. Twenty-one percent of that or 40 billion dollars was spent for cardiovascular diseases. These costs also have risen significantly since 1972-staggering amounts of money for health care! Table I (page 186) summarizes the approximate costs of various disease entities in 1972. Obviously these numbers are interrelated; hypertension is a
Vol. NS 16, No. 4, April 1976
major risk factor in arteriosclerotic heart disease, strokes, and so forth. In addition, the cost of nursing home and social services involving patients with cardiovascular diseases may add another 10 billion dollars to the above figures. Renal dialysis programs in the U.S. presently involve about 20,000 patients at an annual cost of 400 million dollars. Projections suggest that in 1980, these programs will cost one billion dollars a year. Equally or more important than these impressive numbers in terms of a national problem is the enormous amount of disability and suffering that results from these diseases, many of which result from untreated hypertension and the lack of attention paid to other risk factors at an early stage. Patients with strokes frequently require great efforts to keep them functioning such as rehabilitation units and welfare services. Patients with kidney failure frequently lead only partially productive lives despite the use of dialysis. What can be done to change these numbers? Obviously, additional efforts must be made by all interested groups, including the health professions, lay groups and the pharmaceutical industry, to identify more patients with hypertension and to increase the numbers under effective control. A continuing educational effort is necessary to further increase public awareness that high blood pressure, although usually asymptomatic, can cause serious complications if left untreated. A major problem in the preventive management of cardiovascular diseases relates to the practices of some physiCians. It has been estimated by many studies that approximately 50 percent of all the patients being treated, taking medication, and investing their time, effort and money are still not controlled. This represents a failure of some physiCians to take the data seriously that high blood pressure is a serious disease which requires continuous medication, even though asymptomatic Marvin Moser
and with no evidence of heart, kidney or blood vessel disease. Some physicians have been reluctant to accept the data that effective treatment will decrease the number of complications and increase survival; treatment frequently has not been pursued to an end point, namely, normotensive blood pressure levels. If a patient had pneumonia with a temperature of 104, and tetracycline was given without results (in two to three days · the temperature was still 102), most physicians would either switch to another antibiotic, such as a penicillin derivative, or at least take blood or throat cultures to identify the offending organism. There are still many physicians who do not follow welldefined therapeutic principles when managing patients with hypertension. Drugs are not changed or used appropriately, partially because of the reluctance to cause "side effects." In the treatment of any disease, the risk of therapy must be balanced against benefits of treatment. In most hypertensive patients some risk is clearly justified, and the possibility of some drug side effects should not delay or prevent treatment. Although it has been widely publicized by the National Heart and Lung Institute's Marvin Moser, MD, is senior medical consultant to the National High Blood Pressure Education Program, National Heart and Lung Institute, as well as clinical professor of medicine at New York Medical College in Valhalla, and chief of cardiology at White Plains Hospital. He earned an AB from Cornell University and an MD from State University College of Medicine, New York City. During his career, Dr . Moser has held numerous hospital and teaching appointments and consultantships . He is the co-author of three books and many articles in his field . He is a Fellow of the American College of PhysiCians, American College of Cardiology and the American Heart Association 's Council of Clinical Cardiology, and a member of the Medical Advisory Board of the Council for High Blood Pressure Research .
If we are to prevent runaway costs of a health system which is already under great strain, hypertension is one of the diseases to start with
Economic Cost of Illness in the United States-
1972 Approximate Cos t * A II diseases Cardiol'asclilar diseases Arter iosc le ro tic hea rt d isease Hypertens iun Stroke Cost oI prodllctil'itl' loss Card iovascular d isea scs *Social Securi t y Bureau.
20 Billion (N III estimat e) 3.5 Billion 6.0 Billion
6.5 Billion Adm ini stration In fo n nation
task force on " detection , criteria and the stepped-care system of treatment " that diuretics should form the cornerstone of therapy in practically all hypertensives, recent prescription data demonstrate that about 30 percent of hypertensives still are being treated with another drug first , in many instances , reserpine or alphamethyldopa . In recent months, propranolol has become a " first drug " in treatment. These drugs should be used only with a diuretic and probably only after a diuretic has been proved to be ineffective. If a blood pressure response is not obtained, medications should be added or substituted until either significant side effects occur or satisfactory blood pressure lowering results. The Economics of Treatment Until recent years , most medical colleges and teaching centers advocated a complete workup for every hypertensive patient. Thousands of patients with high blood pressure were hospitalized for as long as seven to 10 days and submitted to exhaustive studies which often cost several thousand dollars . Only approximately one to three percent of all patients with high blood pressure have a specific cause for this disease ; exhaustive studies are clearl y not indicated in the ' majority of patients . A few simple tests performed during one or two visits are necessary. If the patient does not respond appropriately to therapy , treatment can be stopped and more elaborate studies .ouch as X-rays of the kidneys can be performed . Reducing the cost of studying patients is one way that physicians can reduce the total health
care cost of this major disease; this represents cost effective, good medical care . Another way to reduce cost and eliminate one of the reasons why hypertensive patients discontinue a treatment program is to be aware of the cost of medication. For example , it is a mistake to use a drug such as spironolactone, where three or four tablets a day must be taken, as the initial diuretic since this drug is expensive. Instead, one or two tablets a day of a typical thiazide diuretic such as hydrochlorothiazide or chlorthalidone actually may be more effective . Spironolactone may be useful if hypokalemia is present, but there is usually little excuse for this expense when other equally or more effective medication could be used at a lesser cost. Approximately 30 to 40 percent of all hypertensives respond to a diuretic agent alone. In some more complicated cases, cost of treatment might be as much as ten times the cost of using a diuretic agent alonebut these are the exceptions rather than the rule. What Has Treatment Accomplished? Our studies over the past 23 years have demonstrated that (1) over 85 percent of all hypertensive patients followed over a long period of time are controlled, (2) hospitalization is rarely , if ever , necessary and (3) in the vast majority of cases cost can be minimized by utilizing a simple workup and appropriate drugs , such as diuretics , as the first step in therapy . If the " stepped-care approach " advocated by the National Heart and Lung Institute is followed with drug cost kept in mind and treatment pursued to an end point of normotensive blood pressure levels, a sharp reduction in the number of strokes occurs, and the incidence of heart and kidney failure secondary to hypertension is sharply reduced . Data on prevention of heart attacks are less impressive. In a Veterans Administration study , the occurrence of ruptured aneurysms, strokes , heart and kidney failure were dramatically reduced, and mortality was significantly less in the treated patients as compared to controls . The number of heart attacks did not appear to be influenced . Many investigators feel that a study of young men started on treatment for their high blood pressure at an early age and continued on therapy will demonstrate a distinct decrease in the number of heart attacks. How Will Treatment Affect Health Care Costs? Successful treatment of hypertension will have a significant impact on the eco-
nomic and social problems associated with cardiovascular disease. It is estimated, for example, that approximately 10 to 15 percent of all patients on renal dialysis programs would not have gone into kidney failure if their blood pressures had been treated at an early age. Several billions of dollars could be saved by preventing strokes that presently occur. There is no question that a marked decrease in hospital costs could also be effected by adequate long-term management of high blood pressure . A decrease in disability and lost productivity costs alone might save an additional several billion dollars, provided , of course , that the cost of treatment of hypertension can be kept within limits by the approach suggested above . If we are to prevent runaway costs of a health system which is already under great strain , high blood pressure or hypertension is one of the diseases to start with. It requires increasing physician, pharmacist and lay education, but the job can be done . The pharmacist can play a key role in helping with lay education and coordinating contacts between the physician and the patient. A tremendous economic and social saving can be effected on a national level if greater numbers of patients with high blood pressure are brought under continuous effective treatment. •
Silent Disease (Continued from page 184) service education programs for hospital and long-term care facility personnel. APhA also is cooperating with the National High Blood Pressure Education Program to make available to pharmaCists a number of materials to assist in their National High Blood Pressure Month activities, as well as in their regular dealings . with their hypertensive patients . For a description of materials and ordering information , see " Hypertension Materials for Pharmacists " on page 184. It already has been clearly demonstrated that significant progress can be made in alleviating the problem of undetected and uncontrolled hypertension , and pharmacists have already made notable contributions to the effort. National High Blood Pressure Month 1976 is another opportunity to reaffirm and intensify the commitment to continue those contributions . •
Journa l of th e American Pharm aceutica l Assoc iation