Abstract
Many studies have shown the importance of antihypertensive drug therapy as a factor in reducing the risk of cardiovascular morbidity and mortality, and in containing the cost of managing hypertension and its complications. Nevertheless, the evidence in clinical practice indicates about half of hypertensive patients do not receive pharmacological treatment and about half of treated patients do not achieve blood pressure level control. Undertreating hypertension is the leading cause of failure in drug therapy effectiveness and cost effectiveness.
The pharmacoeconomic burden of undertreating hypertension can be defined as the clinical (number of cardiovascular events) and economic (costs of managing cardiovascular events) consequences that would have been avoided by adequate control of blood pressure levels. In the last few years, the increase in this burden and the restriction of budget constraints has raised the awareness of healthcare providers with regards to the need to achieve better performance and to improve disease management of hypertension.
This review aims to present the current situation regarding the pharmacoeconomic burden of undertreating hypertension by identifying the key issues of this medical condition, defining and measuring the extent of undertreatment, defining and measuring costs associated with undertreatment, and discussing some fundamental aspects of disease management for hypertension.
The pharmacoeconomic burden of undertreating hypertension appears to be an extremely important phenomenon for which there is currently only very limited adequate research. The present dearth of appropriate data can be largely attributed to the lack of epidemiological studies in clinical practice.
Future studies are necessary for a more precise quantification of the therapeutic and economic impact of undertreating arterial hypertension in clinical practice (appropriateness studies) and for more precise selection of antihypertensive drugs on the basis of the different cost-effectiveness profiles detected in ‘real world’ settings (cost-effectiveness studies).
Similar content being viewed by others
References
Burt VL, Whelton PK, Roccella EJ, et al. Prevalence of hypertension in the US adult population: results from the Third National Health and Nutrition Examination Survey, 1988–1991. Hypertension 1995; 25 (3): 305–13
Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure. The sixth report of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (JNC VI). Arch Intern Med 1997; 157 (21): 2413–46
Stamler J. Blood pressure and high blood pressure: aspects of risk. Hypertension 1991; 18 Suppl. I: 95–107
Flack JM, Neaton J, Grimm Jr R, et al. for the Multiple Rick Factor Intervention Trial Research Group. Blood pressure and mortality among men with prior myocardial infarction. Circulation 1995; 92: 2437–45
Psaty BM, Smith NL, Siscovick DS, et al. Health outcomes associated with antihypertensive therapies used as first-line agents: a systematic review and meta-analysis. JAMA 1997; 277: 739–45
Moser M, Hebert PR. Prevention of disease progression, left ventricular hypertrophy and congestive heart failure in hypertension treatment trials. J Am ColI Cardio1 1996; 27: 1214–8
Hodgson TA, Cohen AJ. Medical care expenditures for selected circulatory diseases: opportunities for reducing national expenditures. Med Care 1999; 37: 994–1012
Hodgson TA, Cai L. Medical care expenditure for hypertension, its complications, and its comorbidities. Med Care 2001; 39: 599–615
Croog SR, Levine S, Testa MA, et al. The effects of antihypertensive therapy on the quality of life. N Engl J Med 1986; 314: 1657–64
Mancia G, Giannattasio C. Benefit and costs of anti-hypertensive treatment. Eur Heart J 1995; 17 Suppl. A: 25–8
Burt VL, Cutler JA, Higgins M, et al. Trends in the prevalence, awareness, treatment, and control of hypertension in the adult US population: data from the health examination survey, 1960 to 1991. Hypertension 1995; 26: 60–9
Joffres MR, Hamet P, Maclean DR, et al. Distribution of blood pressure and hypertension in Canada and United States. Am J Hypertens 2001; 14: 1099–105
Marques-Vidal P, Ruidavets JB, Cambou JP, et al. Trends in hypertension prevalence and management in Southwestern France, 1985–1996. J Clin Epidemiol 2000; 53: 1230–5
Banegas JR, Rodriguez-Artalejo F, José de la Cruz Troca J, et al. Blood pressure in Spain: distribution, awareness, control, and benefits of a reduction in average pressure. Hypertension 1998; 32: 998–1002
Whelton PK. Epidemiology of hypertension. Lancet 1994; 344: 101–6
Stamler J, Stamler R, Neaton JD. Blood pressure, systolic and diastolic, and cardiovascular risk: US population data. Arch Intern Med 1993; 153: 598–615
American Heart Association. 2002 heart and stroke statistical update. Dallas (TX): American Heart Association, 2001
MacMahon SW, Cutler JA, Furberg CD, et al. The effect of drug treatment for hypertension on morbidity and mortality from cardiovascular disease: a review of randomized clinical trials. Prog Cardiovasc Dis 1986; 29 Suppl. 1: 99–118
SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension: final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA 1991; 265: 3255–64
Cutler JA, MacMahon SW, Furberg CD. Controlled trials of drug treatment of hypertension: a review. Hypertension 1989; 13 Suppl. I: 136–44
Yusuf S, Thorn T, Abbott RD. Changes in hypertension treatment and in congestive heart failure mortality in the United States. Hypertension 1989; 13: 174–9
Mancia G. Treatment of hypertension and ischemic heart disease. J Cardiovasc Pharmacol 1989; 14 Suppl. 9: S12–9
Guidelines for the management of mild hypertension: memorandum from a World Health Organization/International Society of Hypertension Meeting. J Hypertens 1993; 11: 905–18
Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet 1998; 351: 1755–62
Zanchetti A, Hansson L, Menare J. Risk assessment and treatment benefit in intensively treated hypertensive patients of the Hypertension Optimal Treatment (HOT) study. J Hypertens 2001; 19: 819–25
Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure. The seventh report of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (JNC VII). JAMA 2003; 289: 2560–72
The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomised to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002; 288: 2981–97
Appel LJ. The verdict from ALLHAT: thiazide diuretics are the preferred initial therapy for hypertension. JAMA 2002; 288: 3039–42
Menard J, Cornu P, Day M. Cost of hypertension treatment and the price of health. J Hum Hypertens 1992; 6: 447–58
Elliot WJ. The costs of treating hypertension: what are the longterm realities of cost containment and pharmacoeconomics? Postgrad Med 1996; 99 (4): 241–52
Giles TD. Pharmacoeconomic issues in antihypertensive therapy. Am J Cardiol 1999; 84: 25K-8K
Bernard DB, Townsend RR, Sylvestri MF. Health and disease management: what is it and where is it going? What is the role of health and disease management in hypertension? Am J Hypertens 1998; 11: 103S-8S
Elliott WJ. The economic impact of hypertension. J Clin Hypertens 2003; 5 Suppl. 2: 3–13
American Heart Association. 2003 heart and stroke statistical update. Dallas (TX): American Heart Association, 2002
Manton KG, Corder L, Stallard E. Chronic disability trend in elderly United States population: 1982–1994. Proc Natl Acad Sci USA 1997; 94: 2593–8
Moser M. “Cost containment” in the management of hypertension. Ann Intern Med 1987; 107 (1): 107–9
Fletcher A. Cost effective analyses in the treatment of high blood pressure. J Hum Hypertens 1992; 6: 437–45
Kawachi I, Malcolm LA. The cost-effectiveness of treating mild-to-moderate hypertension: a reappraisal. J Hypertens 1991; 9: 199–208
Jonsson BG. Cost-benefit of treating hypertension. J Hypertens 1994; 12 Suppl. 10: S65–70
Stason WB. Cost and quality trade-offs in the treatment of hypertension. Hypertension 1989; 13 Suppl. I: I145–8
Pardell H, Tresserras R, Armario P, et al. Pharmacoeconomic considerations in management of hypertension. Drugs 2000; 59 Suppl. 2: 13–20
Johannesson M. The cost effectiveness of hypertension treatment in Sweden. Pharmacoeconomics 1995; 7 (3): 242–50
Hughes DA, Bagust A, Haycox A, et al. Accounting for noncompliance in pharmacoeconomic evaluations. Pharmacoeconomics 2001; 19 (12): 1185–97
Urquhart J. Pharmacoeconomic consequences of variable patient compliance with prescribed drug regimens. Pharmacoeconomics 1999; 15 (3): 217-28
Urquhart J. Patient non-compliance with drug regimens: measurement, clinical correlates, economic impact. Eur Heart J 1996; 17 Suppl. A: 8–15
Bloom BS. Daily regimen and compliance with treatment. BMJ 2000; 323 (7314): 64–7
Payne KA, Esmonde-White S. Observational studies of antihypertensive medication use and compliance: is drug choice a factor in treatment adherence? Curr Hypertens Rep 2000; 2: 515–24
Gerth WC. Compliance and persistence with newer antihypertensive agents. Curr Hypertens Rep 2002; 4: 424–33
Degli Esposti L, Degli Esposti E, Valpiani G, et al. A retrospective, population-based analysis on persistence with antihypertensive drug therapy in primary care practice in Italy. Clin Ther 2002; 24 (8): 1347–57
Marentette MA, Gerth WC, Billings DK, et al. Antihypertensive persistence and drug class. Can J Cardiol 2002; 18: 649–56
Conlin PR, Gerth WC, Fox J, et al. Four-year persistence patterns among patients initiating therapy with the angiotensin II receptor antagonist losartan versus other antihypertensive drug classes. Clin Ther 2001; 23: 1999–2010
Caro JJ, Salas M, Speakman JL, et al. Persistence with treatment for hypertension in actual practice. CMAJ 1999; 160: 31–7
Bloom BS. Continuation of initial antihypertensive rredicatlon after 1 year of therapy. Clin Ther 1998; 20 (4): 671–81
Monane M, Bohn RL, Gurwitz JH, et al. The effects of initial drug choice and comorbidity on antihypertensive compliance: results from a population-based study in the elderly. Am J Hypertens 1997; 10: 697–704
Okano GJ, Rascati KL, Wilson JP, et al. Patterns ofhypertensive use among patients in the US Department of Defence database initially prescribed an angiotensin-converting enzyme inhibitor or calcium channel blocker. Clin Ther 1997; 19: 1433–45
Jones JK, Gorkin L, Lian JR, et al. Discontinuation of and changes in the treatment after start of new courses of antihypertensive drugs: a study of a United Kingdom population. BMJ 1995; 311: 293–5
Caro JJ, Speakman JL, Salas M, et al. Effect of initial drug choice on persistence with antihypertensive therapy: the importance of actual practice data. CMAJ 1999; 160: 41–6
Benson S, Vance-Bryan K, Raddatz J. Time to patient discontinuation of antihypertensive drug in difference classes. Am J Health Syst Pharm 2000; 57: 51–4
Degli Esposti E, Sturani A, Di Martino M. Long-term persistence with antihypertensive drugs in new patients. J Hum Hypertens 2002; 16: 439–44
Degli Esposti E, Sturani A, Degli Esposti L, et al. Pharmacoutilization of antihypertensive drugs: a model of analysis. Int J Clin Pharm Ther 2001; 39: 251–8
Monane M, Bohn RL, Gurwitz JH, et al. Compliance with antihypertensive therapy among elderly Medicaid enrollees: the roles of age, gender and race. Am J Public Health 1996; 86: 1805–8
Pham HT, Gause D, Frech FR. Discontinuation, switching and adding among hypertensive drug classes. Am J Hypertens 2001; 14 (Pt 2): 112A
Wogen J, Krejilick CA, Livornese RC, et al. A population-based study of compliance and persistency with cardiovascular agents used in hypertension management. Am J Hypertens 2001; 14 (Pt 2): 12A
Wannemacher AJ, Schepers GP, Townsend KA. Antihypertensive indication compliance in a Veterans Affairs healthcare system. Ann Pharmacother 2002; 36: 986–91
Hasford J, Mimran A, Simon WR. A population-based European cohort study of persistence in newly diagnosed hypertensive patients. J Hum Hypertens 2002; 16: 569–75
Conlin PR, Fox J, Gerth WC, et al. Losartan/angiotensin II antagonists have greater persistence than other antihypertensive agents/classes. Am J Hypertens 2002; 15 (Pt 2): 29A
Caput AJ. Persistency with angiotensin receptor blockers (ARB) versus other antihypertensives (ART) using Saskatchewan Database. Can J Cardiol 2000; 16 Suppl. F: 194F
Mann RD, Mackay F, Pearce G, et al. Losartan: a study of pharmacovigilance data on 14,522 patients. J Hum Hypertens 1999; 13: 551–7
Nelson EC, Stason WE, Neutra RB, et al. Identification of the noncompliant hypertensive patient. Prev Med 1980; 9: 504–17
Caro JJ. Stepped care for hypertension: are the assumptions valid? J Hypertens 1997; 15 Suppl. 7: S35–9
Goldberg AI, Dunlay MC, Sweet CS, et al. Safety and tolerability of losartan potassium, an angiotensin II receptor antagonist, compared to hydrochlorothiazide, atenolol, felodipine ER, and angiotensin-converting enzyme inhibitors for the treatment of systemic hypertension. Am J Cardiol 1995; 75: 793–5
Moore MA, Edelman JM, Gadick LP, et al. Choice of initial antihypertensive medication may influence the extent to which patients stay on therapy: a community-based study oflosartanbased regimen vs usual care. High Blood Press 1998; 7: 156–67
Croog SH, Levine S, Testa MA, et al. The effects of antihypertensive therapy on the quality of life. N Engl J Med 1986; 314: 1657–64
Shulman N, Cutter G, Daugherty R, et al. Correlates of attendance and compliance in the hypertension detection and follow-up program. Control Clin Trials 1982; 3: 13–27
Black DM, Brand RJ, Greenlick M, et al. for the SHEP Pilot Research Group. Compliance to treatment for hypertension in elderly patients: the SHEP pilot study. J Gerontol 1987; 42: 552–7
Neaton JD, Grimm Jr RH, Prineas RJ, et al. for the reatment of Mild Hypertension Study Research Group. Treatment of mild hypertension: final results. JAMA 1993; 270: 713–24
Skaer TL, Sclar DA, Robison LM. Noncompliance with antihypertensive therapy: economic consequences. Pharmacoeconomics 1996; 9 (1): 14
Urquhart J. Some economic consequences of noncompliance. Curr Hypertens Rep 2001; 3: 473–80
Drummond MF, O’Brien BJ, Stoddart JL, et al. Methods for the economic evaluation of health care programmes. New York: Oxford University Press, 1997
Drummond MF, McGuire A. Economic evaluation in health care: merging theory with practice. New York: Oxford University Press, 2001
Degli Esposti L, Baio G, Valpiani G. Cost allocation in antihypertensive drug therapies. Exp Rev Pharmacoeconomics Outcomes Res 2002; 2 (5): 419–26
Paramore LC, Haltern MT, Lapuerta P, et al. Impact of poorly controlled hypertension on healthcare resource utilization and cost. Am J Manag Care 2001; 7: 389–98
Hughes D, McGuire A. The direct costs to the NHS of discontinuing and switching prescriptions for hypertension. J Hum Hypertens 1998; 12: 533–7
Rizzo JA, Simons RW. Variations in compliance among hypertensive patients among drug class: implications for health care costs. Clin Ther 1997; 19: 1446–57
McCombs JS, Nichol ME, Newman CM, et al. The costs of interrupting antihypertensive drug therapy in a Medicaid population. Med Care 1994; 32: 214–26
Stason WB. Effectiveness and costs of veteran affairs hypertension clinics. Med Care 1994; 32 (12): 1197–215
Skaer TL, Sclar DA, Robison LM, et al. Effect of pharmaceutical forrmlation for diltiazem on health care expenditures for hypertension. Clin Tiler 1993; 15 (5): 905–11
Maronde RF, Chan LS, Larsen FJ, et al. Underutilization of antihypertensive drugs and associated hospitalization. Med Care 1989; 27 (12): 1159–66
Lapuerta P, Simon T, Smitten A, et al. Assessment of the association between blood pressure control and health care resource use. Clin Ther 2001; 23 (10): 1773–82
Mar J, Rodriguez-Artalejo F. Which is more important for the efficiency of hypertension treatment: hypertension stage, type of drug or therapeutic compliance? J Hypertens 2001; 19: 149–55
Spence JD, Hurley TC, Spence JD. Actual practice in hypertension: implications for persistence with and effectiveness of therapy. Curr Hypertens Rep 2001; 3: 481–7
Jackson JD, Merat P. Unmet needs in hypertension: challenges and opportunities. Curr Hypertens Rep 1999; 1 (6): 495–501
Epstein RS, Sherwood LM. From outcomes management to disease management: a guide for the perplexed. Ann Intern Med 1996; 124 (9): 832–7
Black N. Developing high quality clinical databases. BMJ 1997; 315 (7119): 1323–4
Black N. Improving the use of clinical databases [letter]. BMJ 2002; 234: 1194
Black N. High-quality clinical databases: breaking down barriers. Lancet 1999; 353: 1205–6
Shortliffe EH, Perrault LE, Wiederhold GIO, et al. Medical informatics. 2nd ed. New York: Springer, 2001
Quam L, Ellis LBM, Venus P, et al. Using claims data for epidemiologic research. Med Care 1993; 31 (6): 498–507
Mitchell JB, Bubolz T, Paul JE, et al. Using Medicare claims for outcome research. Med Care 1994; 32 (7 Suppl.): JS38–51
Birnbaum HG, Cremieux PY, Greenberg PE, et al. Using healthcare claims data for outcome research and pharmacoeconomic analyses. Phannacoeconomics 1999; 16: 1–8
Motheral BR, Fairman KA. The use of claims databases for outcome research: rational challenges and strategies. Clin Ther 1997; 19 (2): 346–66
Black N. Why do we need observational studies to evaluate the effectiveness of health care? BMJ 1996; 312: 1215–8
Revicki DA, Frank L. Phannacoeconomic evaluation in the real world. Pharmacoeconomics 1999; 15 (5): 423–34
Psaty BM, Siscovick DS, Weiss NS, et al. Hypertension and outcomes research: from clinical trials to clinical epidemiology. Am J Hypertens 1996; 9: 178–83
Black N. Evidence-based policy: proceed with care. BMJ 2001; 323: 275–9
Greenberg PE, Almudena A, Birnbaum HG, et al. Pharmacoeconomics and health policy: current applications and prospects for the future. Pharmacoeconomics 1999; 16 (5): 425–32
Baltussen R, Leidl R, Ament A. Real world designs in economic evaluation: bridging the gap between clinical research and policy-making. Pharmacoeconomics 1999; 16 (5): 449–58
Acknowledgements
The authors would like to thank Ezio Degli Esposti and all members of the CliCon team. The authors have provided no information on sources of funding or on conflicts of interest directly relevant to the content of this review.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Degli Esposti, L., Valpiani, G. Pharmacoeconomic Burden of Undertreating Hypertension. PharmacoEconomics 22, 907–928 (2004). https://doi.org/10.2165/00019053-200422140-00002
Published:
Issue Date:
DOI: https://doi.org/10.2165/00019053-200422140-00002