The Cost of Treating Hypertension

[Pages:8]AJH 1998;11:120S?127S

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The Cost of Treating Hypertension

Can We Keep it Under Control Without Compromising the Level of Care?

Marvin Moser

The cost of hypertension treatment can be contained without compromising outcome. National recommendations for the routine diagnostic evaluation of hypertensive subjects do not include echocardiograms or ambulatory monitoring. These are expensive procedures, which, if performed in only a fraction of the total hypertensive population, would add several billion dollars to the cost of care. At present there are no data indicating that outcome of treatment would be improved. Costs of labeling before a definitive diagnosis is made, continuing lifestyle modification too long, medication switching, and not treating to goal blood pressures also increase cost without increased benefit. Although there are special indications for the more expensive newer medications, the majority of patients can be

managed, at least initially, with less expensive therapies. Cost should not be a consideration, however, if one therapy has been shown to be more beneficial than another. Finally, the benefits of antihypertensive drug therapy have been underestimated because of the lack of consideration of prevention of left ventricular hypertrophy or progression to more severe disease by early treatment. On the other hand, the cost per quality of life-years saved has been overestimated. Pharmacoeconomic models may serve to mislead practitioners regarding treatment decisions. Am J Hypertens 1998;11:120S?127S ? 1998 American Journal of Hypertension, Ltd.

KEY WORDS: Hypertension, cost, quality of care, clinical trials.

M ost discussions of health care costs in the management of hypertension focus on the cost of medication. There is, however, another aspect of care that must be considered and that may be as important in determining future costs, ie, the increasing use of diagnostic procedures. Hypertension has thus far been managed in a relatively simple manner without the frequent use of high-cost technology. Results have been good because we have medications to lower

From the Yale University School of Medicine, New Haven, Connecticut.

This study was presented at the American Society of Hypertension meeting in San Francisco, California, May 28, 1997.

Address correspondence and reprint requests to Marvin Moser, MD, 13 Murray Hill Road, Scarsdale, NY 10583.

blood pressure and have learned at least a little about changing lifestyles. Results could be better if physicians were more motivated to treat blood pressure to goal levels, and if more effective methods were employed to increase patient adherence to therapy. I do not believe, however, that adding to the complexity and cost of care will increase the percentage of patients with hypertension who are treated to goal levels.

THE COST OF DIAGNOSTIC EVALUATION

Do We Need More Tests Than Recommended by the U.S. Joint National Committees? The Joint National Committees on Detection, Evaluation and Treatment of High Blood Pressure (JNC) have made recommendations for the initial evaluation of hypertension since 1977.1 These committees are convened approximately

? 1998 by the American Journal of Hypertension, Ltd. Published by Elsevier Science, Inc.

0895-7061/98/$19.00 PII S0895-7061(98)00106-X

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every 4 years and are composed of 10 to 15 leading experts; their decisions are reviewed and approved by 50 to 100 consultants and 35 to 40 major medical organizations. The JNC report is not a government document and its recommendations are based on clinical evidence and not on cost of care. In recent years cost has, however, been considered in some aspects of care, ie, if two treatments or procedures produce equal results, cost should be considered; if one treatment is better than another, cost should be a secondary consideration.

All of the JNC reports2?6 suggest a complete history and physical exam, an automated blood chemistry, a urinalysis, and an electrocardiogram (EKG) as part of a routine initial evaluation. Recommendations have not changed significantly in 20 years. The committees have been aware that there were other diagnostic procedures that should be considered. Echocardiography (echo) has been used with increasing frequency over the years to evaluate cardiac size and function. This procedure is clearly more sensitive than an EKG in determining left ventricular mass. But we must ask: are the results of an echo important for treatment decisions? And we must consider the problems with performing a routine echo in a patient with hypertension, primarily the cost of the procedure and the potential for overuse. This would not be a deterrent if the results of this procedure changed patient management.

Echocardiograms: Should They Be Routine in the Diagnostic Evaluation? The JNC reports have not recommended an echo for routine evaluation of the hypertensive patient for a simple overriding reason. In the U.S. the prevailing opinion is that a patient whose blood pressure remains higher than 140/90 mm Hg after 3 to 6 months of nonpharmacologic or lifestyle intervention and repeat blood pressures should be treated regardless of the presence or absence of left ventricular hypertrophy (LVH). The decision to treat can be made without performing an echo. But is the choice of therapy influenced by the presence or absence of LVH? Do medications differ in their ability to cause regression of LVH?

For many years physicians were told that medication X decreases left ventricular mass and medication Y does not; therefore we should use medication X if someone has LVH. There are now abundant data from the V.A. and the Treatment of Mild Hypertension (TOMHS) studies,7,8 as well as long-term clinical trials, to demonstrate that the use of any of the classes of medications suggested as initial or ongoing therapy (except the vasodilators) will result in a regression of LVH if blood pressure is lowered. In most comparative studies, diuretics or angiotensin converting enzyme (ACE) inhibitors are more effective than other

TABLE 1. ESTIMATED COST OF HYPERTENSION CARE IN THE U.S. IN 1995

Billions of Dollars (%)

Physicians, nurses, and other providers

Hospitals, nursing homes Antihypertensive drugs Indirect costs (eg, missed work,

transportation costs) Total

6.6 (35) 5.6 (30) 3.8 (20)

2.7 (15) 18.7 (100)

Source: American Heart Association.

agents.7 An echo is not necessary, therefore, to help in the choice of medication.

What About the Cost of an Echocardiogram? The cost of a two-dimensional (2D) echo at the Cleveland Clinic is $786.00; in New York City it is approximately $375.00. These numbers will differ considerably depending on the area and physician; if Doppler studies are done, they would be much higher. If echos were performed on only five million of the 40 million plus hypertensive subjects each year, the cost would be between two and four billion dollars. The total budget at present for the treatment of hypertension is about 18 billion dollars (Table 1). This includes physician and nursing costs, diagnostic testing, medication, hospitalization, and the cost of disability. Some of this cost probably includes the use of echos in some patients. Studies are ongoing to determine whether outcome would be improved if echos were done in the routine evaluation of a hypertensive patient. There is, as yet, no evidence that this would make an important difference. Some institutions are doing a less expensive limited echo to determine LV mass and left atrial size, but there are no outcome data for this procedure.9

Ambulatory Blood Pressure Monitoring (ABPM) Many investigators advocate including ABPM in the routine evaluation of hypertensive patients.10 The use of ABPM has helped to define the duration of action of drugs and circadian blood pressure patterns (circadian blood pressure changes and the concept of dippers and nondippers were originally described in 1921). Blood pressure levels on ABPM appear to correlate more closely with target organ damage than do casual pressures; people who have high average pressures on ABPM have a greater chance of having LVH than patients who do not. But does this fact make a difference in treatment decisions? I do not believe so, for reasons already reviewed. Patients should be treated whether or not they have LVH if blood pressures remain elevated after lifestyle intervention, especially if they have other risk factors.

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The use of ABPM has helped to define white coat hypertension, but is this of major clinical importance? There are data to demonstrate that individuals with so-called white coat hypertension have increased vascular resistance, some evidence of diastolic dysfunction, and metabolic changes that are often noted in hypertensive patients.11 Follow-up of these patients should not be ignored; they should be treated if their office pressures continue to be elevated.

Ambulatory blood pressure monitoring has not been recommended for routine use by any of the JNC committees. There are good scientific reasons for this decision. Data that estimate risk are based on casual pressures. Blood pressures recorded in the major epidemiologic studies that define levels of risk were taken in an office or clinic.12 Data that estimate benefit of treatment are based on casual pressures.13,14 In all of the clinical trials the lower the blood pressure, taken only two or three times a year, the less the risk of a cardiovascular event. The higher the pressure, the greater the risk. Other than a few studies that are repeatedly quoted,15,16 one of which15 lacks treatment data, there are no long-term data with ABPM to establish its superiority over casual pressures in predicting outcome.

What About the Cost of ABPM? If the results of ABPM contributed greatly to treatment decisions or outcome, cost would not be a consideration. But, at least at present, there are not data to substantiate this. The cost of one 24-h ABPM recording varies from $175 to as much as $400. The potential for abuse is enormous. Many physicians could have three to four of these monitors in constant use. For example, it is not difficult to convince a patient that it is important to know what his or her blood pressure is at home, to get an accurate assessment of blood pressure. It doesn't take much persuasion to convince a patient that a 24-h recording will help to regulate medication dosage. If ABPM were performed on only three million of the 40 million plus hypertensive patients per year, the cost would be 600 million to more than one billion dollars (to repeat, the entire hypertension treatment budget, including hospitalizations, is only 18 billion dollars). A far less costly but probably more helpful way to monitor home blood pressures--if these are thought to be necessary--is with the use of aneroid or electronic blood pressure self-monitoring equipment. Repeat blood pressures can be taken over time at different periods of the day, etc. Cost of the blood pressure machines is between $25.00 and $75.00.

A comparison of the cost of evaluating a new hypertensive patient as recommended by JNC VI at the Cleveland Clinic is approximately $500.00 (Table 2). In an internist's office in New York City it is approximately $350.00. These amounts are high compared to

TABLE 2. EXAMPLES OF COSTS (DOLLARS) FOR EVALUATION OF A NEW HYPERTENSIVE PATIENT, AS RECOMMENDED BY JNC V

Cleveland Clinic*

Internist, Westchester County, NY*

Initial history and Rx SMA-16 Lipids Complete blood count Urinalysis 12-lead ECG Venipuncture Total

140 68 76 32 42 120 18 $496

140?160 45 50 20 20 80 5

$360?380

* Medicare and managed care allowances are considerably less.

charges in other parts of the country and are considerably higher than reimbursement rates for Medicare and managed care organizations. The cost of an initial evaluation, subsequent laboratory procedures, and office visits for the first year in the management of a stage 1 or stage 2 hypertensive subject would be approximately $600.00 if the higher amounts were used. Cost obviously varies a great deal from city to city.

If, however, an echo and possibly one or two ABPM were performed, the difference in cost could be between $525.00 and $975.00/year more per patient, a difference of about three billion dollars a year for only 5 million patients (Table 3). One must question the necessity of these added expenditures.

If echos or ABPM were to be performed more often than at present, resources, of necessity, would have to be shifted from prevention and other social programs. Physicians involved in hypertension care should not yield to the temptation of procedurism, as have many physicians in other disciplines, until data demonstrate the benefits of additional testing.

TABLE 3. COST OF MEDICAL CARE OF A STAGE 1 OR STAGE 2 HYPERTENSIVE PATIENT FOR 1 YEAR*

Diagnostic evaluation plus 2?3 office visits and laboratory studies

If these tests were added: Echocardiogram 24-h ABPM (possibly 2 in 1 year)

Difference in cost/patient Approximate difference in cost if

only 5 million patients had these procedures

$620.00

$375.00 $200?600.00 $575?975.00

3?4.5 billion dollars

ABPM, ambulatory blood pressure monitoring. * If renin determinations, etc., were also done, cost would increase still further. Medicare and managed care allowances are considerably less.

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TABLE 4. REASONS FOR INCURRED COSTS WITHOUT BENEFIT IN THE MANAGEMENT OF

HYPERTENSION

Labeling Ineffective lifestyle modification Medication "switching" Not treating to goal pressures

COSTS OF MANAGING HYPERTENSION (TABLE 4)

Labeling If a diagnosis of hypertension is made after only one examination and a treatment program is instituted that may last a lifetime, a cost is incurred that may not be necessary. Physicians should make certain of the diagnosis with repeated blood pressure readings before labeling.

Lifestyle Modification That Doesn't Work The initial cost of lifestyle intervention is certainly less than medication unless the patient becomes involved in an expensive health club or dietary program. The cost of an unsuccessful lifestyle intervention program, however, may be considerable. How often have physicians persisted in their attempts to achieve a weight loss in patients because they were convinced that this would lower the blood pressure? And it might. But these attempts are often continued without success for many months or years. Blood pressure remains high, weight doesn't change to a great degree, frustration levels rise, and a long-term favorable outcome that might have been achieved with medication is jeopardized. A cost is incurred because of the possible poor outcome and long-term complications. A better approach is to treat elevated blood pressure with medication if lifestyle modifications do not work in 3 to 6 months, and to continue nonpharmacologic interventions.

Changing Medication and Wanting To Be Up to Date Published reports of dropout rates with various medications may have nothing to do with patients' responses, side effects, etc. Medication is often changed, not because of a poor response or side effects but because of the "new drug on the block" syndrome. A television advertisement suggests asking your doctor about a specific drug. A physician attends a symposium and hears about the dramatic effects of a secondor third-generation medication. A change in treatment is made despite a good response from the therapy being used. There is a real cost in switching, not just the cost of medication but office visits, repeated blood tests, etc.

Not Treating to Goal Pressures The fact that only one-quarter of hypertensive patients are being treated

TABLE 5. APPROXIMATE COMPARATIVE COSTS OF DIFFERENT CLASSES OF ANTIHYPERTENSIVE

MEDICATIONS*

Drug

Price

Generic Equivalents (if available)

Diuretics -blockers ACE inhibitors AII receptor antagonists Calcium antagonists -blockers --blockers

$ 4.00?28.00 $15.00?37.00 $15.00?28.00 $34.00?35.00 $26.00?50.00 $13.00?46.00

30.00

$ 1.00?2.50 $ 1.00?8.00 2.00

$11.00?20.00 $ 7.00?8.00

ACE, angiotensin converting enzyme; AII, angiotensin II.

* Average wholesale price for 30-day supply at lowest dose recommended, Red Book, April 1997. Actual price to patients may be considerably higher.

to goal levels of 140/ 90 mm Hg is often attributed to lack of patient adherence.17 But if a football team is performing poorly, the quarterback or the coach is usually blamed. Physicians are the quarterbackcoaches of the treatment team. Many people are being treated, seeing their doctors, purchasing medications, but not being controlled at goal levels. It is quite possible that the person treating the patient is not doing his or her job of titrating or changing medication to achieve goal pressures. Physician adherence is as much a part of the low response rate to therapy as patient adherence.18,19 Blood pressure cannot be reduced to goal levels in 100% of hypertensive individuals, but it certainly could be reduced in a higher percentage of patients than is being achieved at present. If goal levels are not achieved, cost of treatment is incurred but the full benefits of treatment are not manifested.

Thus, labeling, continuing lifestyle modifications too long, switching medication, and treating without benefit because of failure to achieve goal levels are four additional factors that we must consider in our efforts to control costs and improve the level of care.

COST OF MEDICATION

Diuretics are the least expensive medications, -blockers are generally less costly than ACE inhibitors (except for generic brands), and calcium antagonists are the most expensive drugs, especially the long-acting dihydropyridines (Table 5). There is obviously a wide divergence in the cost of medications. The differences in cost for a patient with stage 1 or 2 hypertension may vary from $200.00 to $700.00/year. If 10 million stage 1 or 2 hypertensives were to be treated with the more expensive medications instead of the least expensive, the difference would be between 2 and 7 billion dollars. The more expensive medications may be indicated in special situations, and cost would not be a

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consideration if better results had been demonstrated with them. The majority of patients, however, should probably be started on medications that have proved to be effective and also happen to be the least expensive, ie, diuretics and in some instances -blockers.20 JNC VI again suggests this approach.

A question must be asked: is there any evidence that more expensive medications are more acceptable to the patient, lower blood pressure more effectively, or decrease morbidity or mortality to a greater extent than those suggested by JNC V and VI? The newer medications, ACE inhibitors, angiotensin II (AII) receptor antagonists, and calcium channel blockers, are generally well tolerated. Blood pressure is lowered to as great an extent (in most instances) with these agents as with other medications8; there are some outcome data. ACE inhibitor drugs (and AII receptor antagonists, usually along with a diuretic) are highly effective in diabetic nephropathy and congestive heart failure (CHF) and are suggested for use in these situations.6 The nondihydropyridines (diltiazem and verapamil) reduce reinfarction events in subjects with ischemic heart disease.21 Data suggest that long-acting dihydropyridines reduce strokes in the elderly.22 But we have very limited data regarding the reduction of coronary heart disease (CHD) events in the treatment of hypertensive subjects with these newer agents. If data from ongoing trials conclude that treatment with ACE inhibitor, AII receptor antagonists, or calcium channel blockers produce better results than diuretics and -blockers (used in previous trials), then cost should not be a consideration in the choice of therapy.

Models, Forecasts, and Quality of Life-Years (Q of L) Saved Models are limited by the confidence that can be placed in the assumptions of the models. I believe that we have underestimated the benefit of treatment and overestimated the cost per quality of life-years saved. Several facts from the treatment trials of hypertension have not been included in the estimation models. Certain health benefits of blood pressure control, such as improved quality of life, are difficult to factor in. Avoidance of end-organ damage (not a hard endpoint) is not usually considered in the benefit equation. The benefit of treatment estimates includes consideration of the number of fatal and nonfatal strokes and coronary events, but fails to include many other factors.

Facts Considered in Benefit of Treatment Models These include a significant reduction of 40% in stroke deaths and a significant reduction of 16% in CHD (this updated number has not been used in some analyses).23

Facts That Might Be Considered, But May Not Always Be Possible in an Economic Model In the clinical trials 1493 of 13,342 subjects in the placebo group progressed

from less severe to severe hypertension (defined as systolic pressures of 200 to 210 mm Hg and diastolic pressures of 110 to 130 mm Hg); only 95 of 13,389 in the treated group progressed.24 As clinicians, we should remember this when we are told that the cost of preventing one stroke or one myocardial infarction is x dollars per year. At least some of the subjects who progressed and were then put in a treatment group would have suffered a complication.

The prevention of LVH is also not considered in cost of care or numbers of lives saved per year (NNL) analyses. The regression of LVH, if present before therapy, is an accepted fact in the management of hypertension. But prevention of LVH by early treatment is not often considered when measuring benefit. There has been a highly statistically significant reduction of 35% (with tight confidence intervals) in the occurrence of LVH in the clinical trials (140 of 6150 subjects in the treated groups, compared with 216 of 6098 in the placebo groups).24

Prevention of heart failure, which has been factored in as a cardiovascular event in many of the analyses of the clinical trials, has been reduced by 52% in treated, compared with control or placebo subjects (112 of 6914 compared to 240 of 6923). The significance of this is hard to judge in terms of cost estimates or quality of life improvement.

Thus, benefit may be underestimated by failing to consider prevention of the occurrence of LVH (a major risk factor for cardiovascular events) and progression from less severe to severe hypertension.

There are other factors that tend to underestimate the benefits of hypertension treatment. Recruitment in clinical trials always includes relatively low-risk patients in both treatment and control groups, even in the elderly. Recent myocardial infarction, stroke, or evidence of renal failure are all reasons for clinical trial exclusions. If risk is not great, it may be difficult to demonstrate benefit.

A significant number of patients in the placebo group drop in to the treatment group as a result of exceeding a safe blood pressure limit. A clearcut comparison of treated patients and controls is often impossible because of this fact. Finally, the trials are usually of short duration.

Cholesterol investigators have extrapolated from short-term studies to potential long-term results. They have speculated that if the benefit of a 2- to 3-year trial were to continue for an additional 5 to 6 years, the benefits would be considerably greater. I propose that we do this with the hypertension treatment results. Major reductions in morbid and mortal events have been achieved in 3- to 5-year trials and follow-up data from two large studies, the Hypertension Detection and Follow-up Program (HDFP)25 and Multiple Risk Factor Intervention Trial (MRFIT),26 suggest that be-

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TABLE 6. POSSIBLE BENEFIT PER YEAR OF TREATING LESS SEVERE HYPERTENSION

Reduction After Therapy

Assuming 20 Million Less Severe Hypertensives in the U.S.

Australian Trial (4-year duration)

Over an additional 4 years

2 fatal endpoints* 7.3 fatal and nonfatal events* 10 deaths 20 nonfatal events

40,000 fatal events/year 146,000 fatal and nonfatal events 116,000 fewer deaths 232,000 fewer morbid events

* Per 1000 patient-years. Per 1721 patients.

nefit increases over time. The data, however, from the 8- and 10-year follow-ups in these studies are soft. If results from these and the other trials are extended another 5 or 10 years, a considerably greater benefit of treatment and a much reduced cost per Q of L saved could be demonstrated. Should this be done?

Lack of statistical power in some studies has not been considered in some of the benefit of treatment models. Several major trials whose results are considered in estimating benefits of treatment with regard to reducing CHD events actually lacked the statistical power to demonstrate benefit. Even carefully calculated metaanalyses may not be able to overcome this problem. An equivocal or negative result in these trials has been overemphasized. In the Australian study,27 for example, an extremely low mortality rate of 0.9/1000 patient-years from cerebrovascular disease was noted in the placebo group; a reduction in mortality to 0.4/1000 patient-years occurred in the treated group. Coronary heart disease mortality was 1.6/1000 patient-years in the placebo group and 0.7/1000 patient-years in the active treatment group, a reduction but not a statistically significant one. In the Australian trial, the death rate in the placebo group was less than one-half of the estimate calculated from the Framingham data. It is difficult to demonstrate benefit when the risk in the control group is so low.

On the other hand, in the European Working Party on Hypertension in the Elderly (EWPHE),28 a study with higher risk elderly patients, the numbers of events were considerably higher, for example, 16/ 1000 patient-years in the placebo group for cerebrovascular mortality, compared with 11/1000 patientyears in the treated group. Coronary heart disease rates were 24/1000 patient-years in the placebo group and 15/1000 patient-years in the treated group, demonstrating greater benefit in higher risk individuals. But even in the low-risk or less severe hypertensive subjects in the Australian trial where the placebo cohort did better than expected, the benefits achieved, if results are applied to larger numbers of people and extrapolated beyond the 4 years of the trial, are dramatic (Table 6). For example, there was a reduction of two fatal and 7.3 fatal and nonfatal events per 1000

patient-years at the end of 4 years of therapy. Assuming that there are about 20 million less severe hypertensives in the U.S. (although the number may be higher), approximately 40,000 fewer fatal and 140,000 fewer fatal and nonfatal events would result from therapy. If these results are extended over an additional 4 years, there is a possibility of 116,000 fewer deaths, and about 232,000 fewer morbid events. Unless we begin to consider data over a longer-term basis, especially in low-risk patients, the benefits of care will continue to be underestimated and the cost per life saved overestimated. We will probably never have a 10- to 15-year study of antihypertensive therapy for ethical and economic reasons. It may be reasonable, therefore, to estimate benefit without these types of data.

The pharmacoeconomist models, therefore, tend to underestimate benefit for all of the above reasons. Can softer endpoints, such as lack of disease progression or prevention of LVH, be incorporated into a model? How can we factor in the drop-in effect and the lack of power of many trials? Unless we do this in some way, we will continue to provide economic guidelines for therapy that may not reflect actual results. If physicians pay attention to these estimates and, as they are advised to do by many economists, present the odds of benefit to their patients, many people who should be treated may not be. The quality of life improvement and fewer symptoms as a result of treatment29 are also not considered in most economic models on cost of care.

Strategies to contain costs include limiting the initial evaluation; limiting treatment to patients with persistently elevated blood pressure, thereby avoiding the costs of labeling; limiting visits to medical facilities to two or three times per year, which are adequate in most cases after control is achieved; and emphasizing low-cost but effective medications. There is no evidence at present to suggest that a more complicated or expensive approach would improve outcome. In the 1970s in Westchester County, NY, 6450 low-income hypertensive patients from neighborhood health centers were enrolled in a specific treatment program. At the beginning of the program, 44% were controlled at

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normotensive levels. At the end of 1 year, 6158 were still being treated; more than 68% were controlled. Cost had been reduced by 40%. Visits to doctors were not restricted, but a simple easy-to-follow algorithm was established and followed. Cost was reduced but outcome improved.

There are two ways to reduce cost. The first is to minimize exposure to long-term drug treatment. If we followed the guidelines of the British Medical Society, we would limit treatment to people with blood pressures of 160/100 mm Hg or higher, or evidence of target organ damage, ie, LVH, etc. This would certainly reduce cost. The data, however, support earlier treatment.

The second option is to optimize monetary resources. If money is used for one project, it must be taken away from another. If we increase the cost of treating hypertensive patients, we may have to reduce Head Start programs, etc. We do not have to do this! The vast majority of patients can be evaluated and treated without the use of expensive technology. They can be controlled with available medications alone or in combination. Complications of hypertension can be prevented. New initiatives need not add to the cost of care. Patients can be treated as individuals, level of care can be maintained, and cost contained.

REFERENCES

1. Joint National Committee: Report of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (JNC I). JAMA 1977;237:255?261.

2. Joint National Committee: Report of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (JNC II). Arch Intern Med 1980; 140:1280 ?1285.

3. Joint National Committee: Report of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (JNC III). Arch Intern Med 1984; 144:1045?1057.

4. Joint National Committee: Report of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (JNC IV). Arch Intern Med 1988; 148:1023?1038.

5. Joint National Committee: Report of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (JNC V). Arch Intern Med 1993; 153:154 ?183.

6. Joint National Committee: Report of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (JNC VI): Arch Intern Med 1997; 157:2413?2446.

7. Gottdiener JS, Reda DJ, Massie BM, et al: Effect of single-drug therapy on reduction of left ventricular mass in mild to moderate hypertension: comparison of six antihypertensive agents; the Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents. Circulation 1997;95:2007?2014.

8. Neaton JD, Grimm RH, Prineas RJ, et al: for the Treat-

ment of Mild Hypertension Study Research Group: Treatment of mild hypertension study: final results. JAMA 1993;270:713?724.

9. Sheps SG, Frohlich ED: Limited echocardiography for hypertensive left ventricular hypertrophy. Hypertension 1997;29:560 ?563.

10. Pickering T, for an American Society of Hypertension Ad Hoc Panel: Recommendations for the use of home (self) and ambulatory blood pressure monitoring. Am J Hypertens 1995;9:1?11.

11. Julius S, Mejia A, Jones K, et al: "White coat" versus "sustained" borderline hypertension in Tecumseh, Michigan. Hypertension 1990;16:617? 623.

12. Kannel WB: Blood pressure as a cardiovascular risk factor: prevention and treatment. JAMA 1996;275:1571? 1576.

13. Hypertension Detection and Follow-up Program Cooperative Group: Five-year findings of the Hypertension Detection and Follow-up Program: 1. Reduction in mortality of persons with high blood pressure, including mild hypertension. JAMA 1979;242:2562?2567.

14. SHEP Cooperative Research Group: Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA 1991;265:3255?3264.

15. Perloff D, Sokolow M, Cowan R: The prognostic value of ambulatory blood pressures. JAMA 1983;249:2792? 2798.

16. Verdecchia P, Porcellati C, Schillaci G, et al: Ambulatory blood pressure: an independent predictor of prognosis in essential hypertension. Hypertension 1994;24: 793? 801.

17. Burt VL, Cutler JA, Higgins M, et al: Trends in the prevalence, awareness, treatment, and control of hypertension in the adult US population: data from the health examination surveys, 1960 to 1991. Hypertension 1995;26:60 ? 69.

18. Moser M: Management of hypertension, Part I. Am Family Physician 1996;53:2295?2302.

19. Moser M: Hypertension, in Rakel R (ed): Conn's Curent Therapy. W.B. Saunders Co., Philadelphia, 1995, pp 263?280.

20. Moser M: Management of hypertension, Part II. Am Family Physician 1996;53:2553?2560.

21. Moser M: Angiotensin-converting enzyme inhibitors, angiotensin II receptor antagonists and calcium channel blocking agents: a review of potential benefits and possible adverse reactions. J Am Coll Cardiol 1997;29: 1414 ?1421.

22. Staessen JA, Fagard R, Thijs L, et al, for the Systolic Hypertension Europe (Syst-Eur) Trial Investigators: Morbidity and mortality in the placebo-controlled European Trial on Isolated Systolic Hypertension in the Elderly. Lancet 1997;350:757?764.

23. Hebert PR, Moser M, Mayer J, Hennekens CH: Recent evidence on drug therapy of mild to moderate hypertension and decreased risk of coronary heart disease. Arch Intern Med 1993;153:578 ?581.

24. Moser M, Hebert P: Prevention of disease progression,

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left ventricular hypertrophy and congestive heart failure in hypertension treatment trials. J Am Coll Cardiol 1996;27:1214 ?1218.

25. Hypertension Detection and Follow-up Program Cooperative Group: Persistemce of reduction in blood pressure and mortality of participants in the Hypertension Detection and Follow-up Program. JAMA 1988;259: 2113?2112.

26. The Multiple Risk Factor Intervention Trial Research Group: Mortality rates after 10.5 years for participants in the Multiple Risk Factor Intervention Trial. JAMA 1990;263:1795?1801.

27. Australian National Blood Pressure Management Committee: The Australian therapeutic trial in mild hypertension. Lancet 1980;i:1261?1267.

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29. Grimm RH Jr, Grandits GA, Cutler JA, et al, for the TOMHS Research Group: Relationships of quality-oflife measures to long-term lifestyle and drug treatment in the Treatment of Mild Hypertension Study. Arch Intern Med 1997;157:638 ? 648.

DISCUSSION

Question: If ABPM were to be used more widely, the cost would come down from $200 to $300 per test to $20 to $50 per test, would it not? And aren't there situations where therapy should be targeted to a certain time of day or night based on blood pressure variability?

Dr. Moser: To answer the first question about cost, the cost varies considerably. It is about $200 to $300 per 24-h recording. It is naive to think that if the procedures were used more frequently, prices would decrease. At Yale an attempt was made to do limited echos, but cardiologists would not do this for less than the fee for a standard echo. Whether the fee is $200 or $300, the potential for overuse of ABPM is great.

But the more important question is, is it necessary? There are no long-term controlled data to demonstrate, even in those patients who have circadian fluctuations (where you might choose a drug with a greater action at a certain time of day or night), that outcome will be improved. There are speculations and theories but no data. If 2, 3, or 4 years from now this concept is proved, the use of ABPM should be reexamined. If we want to increase the numbers of patients receiving effective therapy, we must keep treatment programs simple. We should await proof that new technologies are beneficial before accepting them as part of a treatment plan.

Question From Dr. Cushman: Why is a complete blood count (CBC) recommended? I know it is cheap, but polycythemia is so rare that certainly there are other things, such as looking for hypothyroidism, that might be more cost-effective.

Dr. Moser: The JNC I Committee in 19771 was faced with the problem that intravenous pyelograms were being performed routinely in many hypertensive individuals; renin, aldosterone, and 24-h sodium determinations were being done as part of a routine workup. We looked at this very carefully and concluded that these procedures were not necessary as a routine because secondary hypertension is so rare. We argued about CBC; perhaps just a hematocrit was adequate because increased blood viscosity might be associated with an elevated blood pressure level. We eliminated chest X-rays as a routine. Most of us realize that if we were 100 miles from the nearest hospital or facility, we could probably treat the majority of hypertensives with a blood pressure cuff and a dipstick urine. So why do we order glucose and cholesterol levels or an automated chemistry profile (SMAC)? Because it is good medicine in terms of other risk factors.

A CBC is no more costly than a hematocrit and it might provide information about an early leukemia, etc. You are correct; we don't have to do many of these studies simply to treat hypertension, but it is good medicine to screen hypertensive patients for other risk factors, as other risk factors are so prevalent in this population.

Question: At the Mayo Clinic many patients did self-measurements. Today there are simple blood pressure monitors available, so simple that all you have to do is press a button. These are inexpensive and they help to define differences in blood pressures at different times of the day. What about home blood pressures?

Dr. Moser: Home blood pressures make sense and do not add to cost. You can get a 7-day or 2-week profile; you can rule out white coat hypertension or transient hypertension.

There are patients who are hypertensive in the afternoon but not in the morning and there are individuals who have high blood pressures for a short period of time and then become normal. If we don't use some method to distinguish them, many more people will be treated than is necessary. Unless pressures are very high, eg, 165 to 170/105 to 110 mm Hg, patients should not be given medication until pressures are rechecked. A patient with stage 1 or stage 2 hypertension should be followed and have repeated blood pressure readings. Within 3 to 4 months almost everyone whose pressures will normalize are discovered. Having blood pressures taken over time with an inexpensive cuff will help more than if one or even two 24-h recordings were done. An ongoing series of readings taken at different times of the day may be quite helpful in deciding on therapy and guiding the use of medication.

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