Should we spend less or control a greater percentage of hypertensive patients?

Abstract

Adherence to hypertension treatment forms a major challenge because, despite the relatively simple and cheap diagnosis combined with efficacious treatments, the majority of patients do not adhere to the treatment and do not present controlled arterial pressure. A large number of factors have been related to low adherence rates. 1When we asked patients in our service (n = 353) regarding the causes of low adherence, we obtained the following results: a) medicines -high cost (89%), taking them several times per day (67%) and collateral effects (54%); b) disease -not knowing how serious it is (50%) and absence of symptoms (36%); c) knowledge and beliefs -only taking the medicine when the pressure is high (83%), not taking care of health (80%), forgetting to take the medicines (75%), not knowing its chronic nature (70%) and complications of the disease (70%); and d) doctor-patient relationship -remaining unconvinced about undertaking treatment (51%) and inadequate relationship (20%).2 Thus, the cost of treatment is a very important cause of low adherence.In a excellent study, through a cross-sectional population-based study in the urban area of Pelotas (southern Brazil), Costa et al. described the healthcare costs for the treatment of hypertension and examined the cost-effectiveness of different classes of antihypertensives. The authors interviewed 1,968 participants in their homes and observed that 23.5% had high pressure (≤ 160/95 mmHg) or were making use of antihypertensives. Although the authors justified the use of these values so as to reduce the potential for bias in pressure measurements due to the phenomenon of regression to the average, the recommendations guide us towards employing values of ≤ 140/90 mmHg.3 Thus, we cannot exclude the possibility that the percentage of hypertensive patients was underestimated in the sample studied.The average monthly cost of caring for hypertension (R$ 89.90) consumed around 23% of the per-capita income. Most of the direct costs associated with hypertension related to the medications. This is an important conclusion that must be disseminated among the medical community. Almost ¼ of earnings were consumed on the medications, confirming our findings that 89% of patients attributed the low adherence to the high cost of the medications. Curiously, however, in a survey that we made among Brazilian doctors, the cost was the fourth item to be considered in the choice of prescriptions of medications, coming after personal experience, patient characteristics and efficacy.

An economic evaluation of antihypertensive therapies based on clinical trials

“…Nevertheless, Brazilian pharmacoeconomic studies related to hypertension have been rare (5). The few studies that have examined antihypertensive treatment costs in Brazil concluded that diuretics and beta-blockers are more cost-effective than other classes of antihypertensive drugs (6).…”