Hypertension Treatment at the Crossroads: A Role for Economics?

See the Original Article on page 1295 and the Original Article on page 1303. An astounding 1 out of 3 adults in the United States—some 78 million people—are afflicted by hypertension (HTN), a leading risk factor of cardiovascular morbidity and premature mortality.1 Older adults and blacks are disproportionately affected. Although there is some evidence that awareness, treatment, and control of HTN have improved over the last decade,2 the disease remains poorly controlled—only half of those with documented cases have their condition under control.3 Moreover, the prevalence of HTN has been rising over the past few decades, as has the economic burden. Estimated costs for 2010 were $90.5 billion, reflecting the combined costs for healthcare services, medications, and missed days of work.4 In this issue, Smith and Campbell5 and Wang et al.6 present 2 perspectives on the economic impact of HTN. Wang et al. frame the impact of HTN solely in terms of medication costs—a staggering $68 billion in 2007 according to their analysis. Given the estimates by Heidenreich and colleagues,4 one is left to conclude that drug costs are increasing beyond their historical share of total treatment costs. This may not be surprising to readers of this journal. Physician practice is largely formulaic and is characterized, according to Olson et al., “by the progressive addition of antihypertensive agents, with the use of specific antihypertensive agents if compelling indications are present.” Additionally, the landmark ALLHAT study revealed that almost one quarter of patients required 3 or more agents to treat their HTN.7 The impact of increasing medication costs provides context for Smith and Campbell’s article, which refocuses clinical practice on a promising treatment strategy for HTN known as plasma renin activity (PRA). The clinical trial that served as the basis for their cost-effectiveness analysis (CEA), although small, demonstrates that a PRA-guided antihypertensive treatment strategy was more effective in reducing blood pressure and achieving HTN control in a group of patients with treated but uncontrolled HTN when compared with the standard of care offered by clinical specialists.8 The incremental cost-effectiveness ratio derived by Smith and Campbell was $14,497 per quality adjusted life year, well within the bounds of other appropriate treatments. More critically, their results indicate that more HTN patients were helped by having their high blood pressure controlled and that lower treatment costs may be achieved with fewer drugs. Other researchers have demonstrated that PRA-guided treatment improves outcomes even for patients who were treated using age/race profiles.9,10 This approach is similar to the British Hypertension Society guidelines, which state, “The theory underpinning the AB/CD algorithm is that hypertension can be broadly classified as high renin or low renin and is therefore best treated initially with one of two categories,” for example, drugs that inhibit renin–angiotensin (AB) or those that do not (CD).11 The guidelines go even further—they suggest that practitioners use the lowest-cost drug available in those categories! PRA-guided treatment is not new. It had largely been discarded due to earlier complexity in testing PRA levels and high costs, but that was before the increased availability of agents and alternative drugs and advances in medical technology. Clinical approaches such as PRA-guided treatment support the integration of evidence-based guidelines and the practice of personalized medicine, which may point the way to the future of medical practice.12 However, if we are concerned with controlling HTN using fewer than 3 agents and if PRA-guided treatments show promise, why aren’t they more widely adapted in practice?13 Let us assume that a PRA-guided treatment strategy is cost effective, as Smith and Campbell have argued. How do we translate this into practice? A good place to start would be to change national treatment guidelines as they have done in Britain. But this alone will be inadequate. Implementing evidence-based recommendations in the community happens slowly and often incompletely.14,15 It has been well established that the pharmaceutical industry exerts a profound influence on physician practice, particularly prescribing patterns16,17 and specifically with regard to anti-HTN medications.18,19 In a recent review of 58 studies examining the influence of pharmaceutical companies on physicians’ prescribing behavior, the authors concluded, “With rare exceptions, studies of exposure to information provided directly by pharmaceutical companies have found associations with higher prescribing frequency, higher costs, or lower prescribing quality or have not found significant associations.”20 After the major findings of the ALLHAT study were released in 2002,21 prescriptions for thiazide diuretics increased temporarily, but thiazide diuretics remain underprescribed despite evidence of their cost effectiveness.22 According to Stafford and colleagues, “the impact of evidence alone can be short-lived unless augmented by efforts that encourage widespread adoption of evidence-based medicine.”23 The literature on changing physician practice styles is rife with poorly designed studies and disappointing results.24 The best opportunity to change practice behavior may be to ensure that insurers and providers adequately reimburse physicians for using a cost-effective strategy such as PRA. Studies have shown that the use of financial incentives does impact physician attitudes and behavior, especially with respect to resource use and improved compliance with guidelines.25,26 Current healthcare reform legislation encourages this approach since insurers and large provider networks contract to serve defined populations and may recoup part of the savings that come from providing more efficient, higher-quality care to that population.27,28 Ironically, reform legislation also provides a significant barrier to the use of cost-effective strategies. The Affordable Care Act established the Patient-Centered Outcomes Research Institute to evaluate the effectiveness of medical treatments. However, the institute is precluded from performing any type of CEA or making recommendations based on costs, quite unlike its counterpart in Britain, the National Institute for Health and Care Excellence. This seems foolish. Should we encourage studies that address costs of care? The articles by Wang et al. and Smith and Campbell illustrate the impact of medical practice on healthcare delivery, costs, and outcomes. They also highlight the importance of refocusing the debate about how to improve outcomes and lower costs. Admittedly, CEA is controversial, in part, because assumptions matter. For example, even small price changes in intervention costs can dramatically change the incremental cost-effectiveness ratio. But policy makers and insurers have failed to capitalize on this, especially where pharmaceutical costs are concerned. Although used to varying degrees in most developed countries, from a national public policy perspective, the intent of CEA is to provide guidance that can be used to restrain prices for technologies and medical practice but also to promote an equitable distribution of care and services. On the other hand, comparative effectiveness research (CER), as authorized under current healthcare reform, makes no such assurances since conducting CEA is expressly forbidden. In fact, as economists, we could argue that the resources we will spend on conducting CER in the United States may garner no savings whatsoever. Put differently, CER may actually encourage the adoption of new technologies that provide diminishing returns on our health dollar investments! CEA should be put to use more widely, but carefully, without industry bias and with full transparency. It may even be used to capitalize on the marketing power of public and private insurers to drive down the costs of medical interventions like the PRA test, making advances in clinical treatment outcomes more affordable and accessible to the American people. The authors declared no conflict of interest.