“Epidemiological Changes and Economic Burden of Hypertension in Latin America: Evidence from Mexico”

The burden of hypertension was addressed by Arredondo and Zuñiga1 in the current issue of the Journal and in an article published last year by French et al.2 The first report included indirect and direct costs of hypertension in Mexico, whereas the second focused on direct medical cost in the United States. For the estimation of direct cost, the analysis by Arredondo and Zuñiga1 used probabilistic models according to the Box-Jenkins technique, whereas French et al2 used a variety of statistics including multivariate logistic regression adjusting by several factors. The data for Arredondo and Zuñiga came from a time series analysis containing the number of cases in government operated health care systems in Mexico, whereas French et al used multiple sources such as patient interviews, chart reviews, and insurance records. Despite methodologic differences, both studies reported on some similar issues, calling attention to the importance of hypertension for public health. The report by Arredondo and Zuñiga warns about a future increase in the number of cases and expenses for hypertension in the three major health care institutions of Mexico, as well as an increase in indirect cost because of an upward trend in related disability and premature mortality. This situation will tremendously affect the Mexican health system in the near future, calling for new measures to prevent this from occurring. Although Arredondo and Zuñiga did not provide the cost for individual cases; the costs can be calculated with the data shown in the article. The 2007 projection of mean medical cost for hypertension averaged $1117 (between $895 and $1341 depending on the institution) per case. Besides the inclusion of indirect cost, a major strength of the analysis by Arredondo and Zuñiga is that it provides a future projection of the cost for hypertension. Instead French et al examined the current cost of hypertension from the perspective of a large health system, reporting that the annual cost of health care for hypertensive individuals was $4135 and that this represented an estimated differential cost of $724 as compared with costs for individuals without hypertension or diabetes. One of the major strengths of the report by French et al is that it contains a comparison of the cost for medical expenses for persons with and without hypertension or diabetes and also with several other comorbidities, providing a more realistic estimate of the gap of medical cost between persons with and without hypertension. In this analysis it was shown that comorbidities made medical cost much higher. Comparison of estimated direct cost from both articles analyzed may be affected by multiple methodological disparities and the inclusion of dissimilar care components; for example the analysis by French et al included emergency room visits while the one by Arredondo and Zuñiga did not. The known major economic differences between the two countries, and perhaps actual differences in the clinical management of hypertension, may also be relevant. These circumstances make the two study estimates difficult to compare, although they are indeed meaningful in their own context. Nevertheless, according to the results shown in the two articles, the costs for individual cases studied in the US health care system appeared to be much higher than the estimated 2007 projection for the Mexican system. In addition to the increase in the number of cases of hypertension forecasted by Arredondo and Zuñiga, the unaddressed problem of undiagnosed cases and poor control of hypertension make the annotated increase in the future burden conservative. Neither Arredondo and Zuñiga nor French et al reported the cost of different hypertension treatments, which may be useful for future health planning; for example it has been suggested that the adherence to evidence-based prescribing guidelines for hypertension may be cost saving.3 In both articles one of the main recommendations is to prevent obesity, a major risk factor responsible for the rise of hypertension and other chronic diseases. The World Health Organization Global Strategy on Diet, Physical Activity and Health4 provides a framework for multisectoral action in the prevention of obesity. Overall, to address the burgeoning problem of hypertension and other chronic diseases, a multilevel-multisectoral public health approach is recommended. A multisectoral approach should include governments, nongovernmental organizations, general population, academia, research institutions, international organizations, and the private sector. Evidence shows that by implementing better prevention and control of chronic diseases, the related death rates can be reduced by 2% annually, which translates into saving 35 million lives globally by 2015.5