Costs of implementing recommendations on hypertension management given in recent guidelines

During the first half of 2003, two major documents concerning the management of arterial hypertension have been published, one prepared by an American committee chosen by the National Institutes of Health, the Joint National Committee report no. 7 (JNC-7) [1], the other prepared by a joint committee named by the European Society of Hypertension and the European Society of Cardiology (2003 ESH–ESC Guidelines) [2]. Both documents have raised interest among experts and clinicians, and some differences have been pointed out and become an object of discussion. Although it is obvious that the discussions mostly verge on discrepancies, it should be emphasized that the similarities between the guidelines are overwhelming, and concern the most important messages, namely the importance of hypertension as a cause of cardiovascular disease worldwide, as indicated by a recent WHO survey [3], the need of early diagnosis and intensive blood pressure lowering therapies, both by lifestyle changes and drugs, and the goal of improving blood pressure control with suitable interventions. Differences between guidelines are likely to attract the attention of primary care physicians, health providers and policy makers primarily for their implications on costs. Furthermore, the overwhelming emphasis recently placed on the cost of drugs, particularly the widely used antihypertensive agents, may lead to the belief that applying the JNC-7 guidelines, and following their recommendation to initiate antihypertensive therapy in stage 1 patients using a cheap thiazide, is going to be less costly than applying the ESH–ESC guidelines that allow a more liberal choice among the major classes of antihypertensive agents. The present editorial aims at demonstrating that this is not so, and that the application of the European guidelines may indeed be less expensive, as well as more effective. However, the reader should be made aware that the author of this editorial was in the Writing Committee of the ESH–ESC guidelines and therefore he may be biased (although he thinks he is not). The cost implications of the major differences in the two sets of guidelines are separately considered in Table 1.Table 1: Cost implications of following JNC-7 or ESH-ESC recommendations.The first major difference focuses on the philosophy behind the two sets of recommendations. The Joint National Committee decided to prepare a very simple document with a set of rather rigid prescriptions to be followed by practitioners and, along this line, chose to prepare an ‘Express’ report with the promise to produce a subsequent, more detailed document discussing the scientific background of their ‘prescriptions'. The ESH–ESC committee took a different attitude, and felt that guidelines that were to be persuasive, and consequently implemented, should be informative and educational rather than prescriptive. Accordingly, the Committee started by preparing an extensive document, 43 pages long, summarizing in detail all the available evidence upon which their recommendations were based [2], and then produced a summary document for primary care physicians, as recently published in the Journal of Hypertension [4]. In agreement with the same philosophy, the European recommendations are much less prescriptive than those in the JNC-7 report, and leave a wide margin of decision to the practising physician. It is obviously difficult to calculate the extent by which the different philosophies of the two sets of guidelines translate into differences in care cost. However, the ESH–ESC committee thought that unsuccessful implementation of all previous guidelines was largely due to their prescriptive character, and that improvement of hypertension management can only result from a better educational and informative approach, leaving the final decisional responsibility to the individual physician treating the individual patient. If these considerations are correct, then the European approach may lead to a much more effective use of available resources. Calculation of relative costs due to other differences between the two sets of recommendations may be easier. The decision of JNC-7 to define all subjects with blood pressure values 120–139/80–89 mmHg as ‘prehypertensives’ independently of the coexistence of additional risk factors, and to advise lifestyle changes for all of them, transforms millions of healthy people into potential patients. It also implies huge costs if lifestyle changes are not paid lip service, and the necessary procedures for education, persuasion and follow-up are implemented. On their part, the ESH–ESC guidelines recommend lifestyle changes for subjects with blood pressures 120–130/80–89 mmHg only if they have additional risk factors, thus sparing the economic costs of any blood pressure-lowering procedures (as well as the psychological costs of medicalization) to a consistent body of individuals (see Table 4 in [4]). The JNC-7 simplified approach of deciding to initiate antihypertensive treatment only on the basis of blood pressure values (an amazing backward turn from JNC-6) obviously requires simple and cheap diagnostic procedures. On the other hand, the ESH–ESC approach of stratifying total cardiovascular risk as a decision basis implies more costly procedures, and indeed the guidelines suggest that, whenever useful, procedures such as cardiac and vascular ultrasound and a search for microalbuminuria be employed. However, these different, and differently costly, diagnostic procedures also reflect differently on therapeutic costs. According to JNC-7, all subjects with consistent blood pressure values 140–159/90–99 mmHg (stage 1 in JNC-7, grade 1 in ESH–ESC guidelines) should receive antihypertensive drug therapy, whereas in the ESH–ESC guidelines for subjects within the same blood pressure range and no other risk factor nor target organ damage (`low added risk'), drug treatment can be deferred for several months and can later be instituted under less stringent pressure, according to patient's preference and the resources available. Therefore, application of a more costly procedure once at the beginning of the diagnostic process may imply a long-term continued saving of therapeutic costs. In addition, the more liberal approach of the European guidelines of choosing between the various classes of antihypertensive agents is only apparently more expensive than the JNC-7 approach of starting with thiazide diuretics in grade 1 (stage 1) hypertensives, because drug treatment is recommended by the European guidelines in a more restricted group of grade 1 hypertensives (i.e. those with additional risk factors). Furthermore, according to the Third National Health and Nutrition Examination Survey, more than one-third of hypertensive patients aged 50 years or more, for whom use of thiazides may be recommended by JNC-7, present the metabolic syndrome [5], thus being more likely to develop diabetes mellitus [6–8], and at least the cost of additional diabetes care should be included in a correct analysis of costs. In conclusion, a detailed analysis of the major differences between the recommendations of the JNC-7 report and the ESH–ESC guidelines indicates that hypertension management according to the JNC-7 is by no means less expensive because it imposes economically and psychologically costly lifestyle changes to a large body of individuals at average cardiovascular risk, who are unlikely to benefit from medicalization, and prescribes drug therapy (albeit a cheap drug) to subjects at an overall low added risk, and whose prospective benefit is also low. The ESH–ESC guidelines, by introducing a patient's preference among the decision criteria for treating low-risk patients, include a factor that is now considered crucial in determining whether treatment is worthwhile [9,10]. More importantly, the ESC–ESC guidelines, although giving due weight to cost of hypertension care, have privileged education and information, and correctly leave any final decision about individual patients to the individual physician. It is hoped that experts’ recommendations will also be shared out by health providers and policy makers, who should help educate and avoid prescriptive constraints, and allow the well informed judgement of physicians.