A Reviewer Critique of Incremental Expenditures of Hypertension Treatment

According to recent studies on health in the Americas, 140 million individuals have hypertension and 50% do not know they have it, as this is a “silent” disease that is not always symptomatic.1 This health problem, with growing and constant trends worldwide, is a determining factor for the presence of cardiovascular diseases. It is also a main cause of high health costs and loss of income as a result of high disability rates and premature mortality. In this sense, the main strength in the Balu and Thomas article2 in this issue of the Journal lies in its methodologic contribution to the analysis of health systems and incremental costs of changes in the demand for health services by hypertensive patients in the United States. Another strength is that the authors propose and use a methodologic approach with a perspective that integrates economic, clinical, organizational, and epidemiologic analyses. This article sets forth evidence on the economic impact of changes in hypertension treatment demand, taking as a central axis the determination of incremental costs for hypertensive patients in the U.S. The evidence presented is relevant because of the undesirable effects of these costs. One of the main methodologic weaknesses of the article is a partial analysis of the problem. The analysis is limited to the direct costs and does not establish the relevance of indirect costs. This limitation partly responds to data limitations in the study survey but also to limitations in the conceptual analysis model used by the investigators. As a consequence of these weaknesses, only the part of the problem relating to the economic impact on the health system is dealt with, whereas the economic impact on the social system is not addressed. All of this is extremely relevant because, according to other studies,3–5 direct hypertension costs negatively affect the health care system, and indirect costs affect society as a whole, having a considerable impact on economic and social development and above all on human capital. When the analysis of both types of costs is performed, it is possible to have more elements for planning and allocation of hypertension resources, which will vary according to the population or country in question. The relative weight of the impact of incremental and total hypertension costs differs depending on the type of country (Table 1). The effects on the health care system and the social system also range in intensity, depending on the country. It is precisely in these effects that we find the relevance and pertinence of economic appraisals of hypertension. Comparative analysis of direct and indirect costs of hypertension in countries with high, middle, and low incomes Comparative analysis of direct and indirect costs of hypertension in countries with high, middle, and low incomes Knowledge of direct and indirect costs is fundamental for a complete analysis of the economic impact of hypertension. These costs allow us to know the economic repercussions of this disease on health services and to understand the need to implement cost-containment mechanisms through programs for the treatment of hypertension. With more effective programs, the economic impact of the disability and premature mortality caused by hypertension will decrease.