Medical care expenditures for hypertension, its complications, and its comorbidities

Valsartan use in pediatric hypertension

Hypertension affects up to 5% of school-aged children and is defined by an average systolic or diastolic blood pressure greater than the 95th percentile for age, sex and height. In prepubertal children a secondary cause for hypertension including renal disease, coarctation of the aorta or endocrine disease should be excluded by appropriate evaluation. The incidence and prevalence of essential hypertension in adolescents has increased together with the increase in obesity and now accounts for at least 50% of hypertension in this age group. Many children with primary hypertension and most children with secondary causes for hypertension require drug therapy. There are numerous drug classes that are presently used to treat hypertensive pediatric patients, which include β-blockers, peripheral α-blockers, direct vasodilators, ACE inhibitors, calcium channel blockers, diuretics and ARBs. This article will review the pharmacology of the ARB valsartan with respect to its efficacy, tolerability and safe use in hypertensive pediatric patients.

Burden of illness of hypertension among women using menopausal hormone therapy: a US perspective

OBJECTIVE

To estimate the burden of illness (BOI) of hypertension in a cohort of women receiving menopausal hormone therapy (HT).

METHODS

Patients with at least one prescription for menopausal HT were selected from the PharMetrics database during the period July 1, 2003, to June 30, 2005. Hormone therapy patients were divided into those with and without hypertension. The nonhypertensive cohort was propensity score-matched to the hypertensive cohort, controlling for patient demographics, overall comorbidities, and type of HT use. The BOI of hypertension in the menopausal HT cohort was defined as the difference in average annual total healthcare expenditures per person between the cohorts.

RESULTS

The prevalence of menopausal HT use was 9.75% among potentially eligible patients in this commercially insured sample. Hypertension was the most common comorbidity in the menopausal HT cohort, with a prevalence of 34%. Hormone therapy patients with hypertension (n = 106,729) had significantly higher average annual healthcare expenditures compared to matched HT patients without hypertension ($8908 vs. $5960 per person per year; difference of $2948; p < 0.001).

CONCLUSIONS

Hypertension is the most common comorbidity among menopausal HT users in the United States. The annual BOI of hypertension is both substantial and significant when compared to matched patients without hypertension, averaging $2948 per patient per year.

Is newer always better? Re-evaluating the benefits of newer pharmaceuticals

Whether newer pharmaceuticals justify their higher costs by reducing other health expenditures has generated significant debate. We replicate a frequently cited paper by Lichtenberg on drug "offsets" and find the results disappear using a more appropriate model or updated dataset. Further, we test the suitability of similar methods using newer hypertension drugs. We find our observational results run counter to well-established clinical evidence on comparative efficacy and conclude that our model, as well as other studies that do not adequately control for unobserved characteristics that jointly determine drug choice and health expenditures, are likely subject to significant bias.

Long-term social costs of hypertension

According to published studies, much of the cost of hypertension is due to antihypertensive drug treatment. However, the cost of hypertension also includes the cost of an increased frequency of cardiovascular events when hypertension is not controlled. Although conceptually accepted by the scientific community, the achievement of appropriate blood pressure levels is less feasible than expected and studies demonstrate that only 13-27% of hypertensive patients are adequately informed, treated and controlled for their hypertension. This puts a tremendous burden on the healthcare system and society, since uncontrolled hypertension leads to higher rates of cardiovascular events and ultimately death. This paper demonstrates the paucity of reliable cost-of-illness estimates for the long-term consequences of uncontrolled hypertension and suggests that it is understandable that public and private payers focus on the immediate short-term costs of treating hypertension, paying less attention to potential cost savings of fewer cardiovascular events, as these costs are far less well defined. This paper also suggests that hypertension as a disease is an ideal candidate for disease management strategies and programs, as prevention of its long-term consequences should be the focus of medical treatment and could be better achieved through an integrated multispecialist and multisetting approach.

Hypertension and common complications --analysis of the ambulatory treatment cost

AIM

Retrospective analysis of the prescribing practice and cost of ambulatory treatment of hypertension and its common complications--heart failure, sequelae of cerebrovascular disease, and angina pectoris.

METHODS

Analysis of 3,240 reimbursable ambulatory prescriptions for hypertension, heart failure, sequelae of cerebrovascular disease and angina pectoris according to the complexity of the therapy and frequency of the prescribed medicines. Modeling and calculation of the expected monthly cost for outpatient therapy by using the "decision tree model". Sensitivity analysis is performed within the +/- 30% interval.

RESULTS

65% of the prescription were for the hypertension, and 35% for the observed complications. 1,297 prescriptions for hypertension include one medicine, 647 include two medicines, and only 8% of prescriptions were for three medicines. ACE inhibitors have been prescribed in 41% of all hypertension prescriptions, followed by beta-blockers (19%), Ca channel blockers (16%), diuretics (15%) etc. The prescriptions for hypertension complications are more diverse as therapeutic groups. The expected monthly cost of prescribed medicines per patient with hypertension alone is 6.90 Euro and in case of complications it is 10.71 Euro according to the prevalence of the complexity of therapy, and weighted monthly cost of medicines. The overall ambulatory cost is expected to be around 148 million Euro per year for near 1.5 million patients with 44% reimbursement. The cost of the therapy is sensitive more to changes in the medicine's prices than to its complexity.

CONCLUSION

This study is a first step in providing information for evidence-based cost containment measures or policy decisions at ambulatory level in Bulgaria and for the assessment of the share of complications' therapy on the overall hypertension cost.

Recommendations for global hypertension monitoring and prevention

In recent years, cardiovascular diseases (CVDs) have been recognized as the most common cause of death in the world, accounting for 30% of all mortality, with a growing burden in developing countries. In 2000, it was estimated that 26% of the world's adult population (972 million individuals) had prevalent hypertension, a key risk factor for CVD, and this number is expected to increase to 29% (1.56 billion) by 2025. CVDs place a heavy burden on society and overall economic activity; they are ranked third in disability-adjusted life years lost. We now have a comprehensive understanding of the basic lifestyle modifications that decrease risk of hypertension and its associated sequelae, however, and it is clear that only modest lifestyle changes would be required to produce small reductions in population averages that would have a large impact, given the multitude of adverse outcomes attributable to high blood pressure. Hypertension therefore is an important public health issue. Considerably more research and standardization of surveillance methods are required to realize the existing opportunities to reduce the global burden of CVDs.

Hospitalization costs associated with hypertension as a secondary diagnosis among insured patients aged 18-64 years

BACKGROUND

We estimated the hospitalization costs associated with hypertension as a secondary diagnosis among insured adults aged 18-64 years by using data from 2005 MarketScan Commercial Claims and Encounters (CCAE) inpatient admissions.

METHODS

We analyzed costs for four patient groups (N = 455,944): (i) all selected patients; (ii) patients with the primary diagnosis of ischemic heart disease (IHD); (iii) patients with the primary diagnosis of cerebrovascular disease; and (iv) patients with neither IHD nor cerebrovascular disease as the primary diagnosis. We conducted propensity score matching to control possible bias in cost estimates due to sample selections and estimated the costs of hypertension by using a regression model on the matched populations that controlled for subjects' age, sex, length of hospital stay, Charlson comorbidity index (CCI), region of residence, and urbanization of residence.

RESULTS

For all patients with hypertension as a secondary diagnosis, the estimated average annual hospitalization cost per patient was $21,094, of which $2,734 (13%; P < 0.01) was associated with hypertension. The estimated average costs were $31,106 for patients with a primary diagnosis of IHD, $17,298 for those with a primary diagnosis of cerebrovascular disease, and $18,693 for those without a primary diagnosis of IHD or cerebrovascular disease; hypertension-associated costs for these patients were $3,540 (11.4%; P < 0.01), $1,133 (6.5%; P < 0.01), and $2,254 (12.1%; P < 0.01), respectively.

CONCLUSIONS

Hypertension-associated hospitalization costs are substantial among insured US patients aged 18-64 years with hypertension as a secondary diagnosis and suggest a need for cost-effective programs to prevent, manage, and control hypertension.

[Socioeconomic costs of stroke in Korea: estimated from the Korea national health insurance claims database]

OBJECTIVES

To estimate the annual socioeconomic costs of stroke in Korea in 2005 from a societal perspective.

METHODS

We identified those 20 years or older who had at least one national health insurance (NHI) claims record with a primary or a secondary diagnosis of stroke (ICD-10 codes: I60-I69, G45) in 2005. Direct medical costs of the stroke were measured from the NHI claims records. Direct non-medical costs were estimated as transportation costs incurred when visiting the hospitals. Indirect costs were defined as patients' and caregivers' productivity loss associated with office visits or hospitalization. Also, the costs of productivity loss due to premature death from stroke were calculated.

RESULTS

A total of 882,143 stroke patients were identified with prevalence for treatment of stroke at 2.44%. The total cost for the treatment of stroke in the nation was estimated to be 3,737 billion Korean won (KRW) which included direct costs at 1,130 billion KRW and indirect costs at 2,606 billion KRW. The per-capita cost of stroke was 3 million KRW for men and 2 million KRW for women. The total national spending for hemorrhagic and ischemic stroke was 1,323 billion KRW and 1,553 billion KRW, respectively, which together consisted of 77.0% of the total cost for stroke. Costs per patient for hemorrhagic and ischemic stroke were estimated at 6 million KRW and 2 million KRW, respectively.

CONCLUSIONS

Stroke is a leading public health problem in Korea in terms of the economic burden. The indirect costs were identified as the largest component of the overall cost.

Costs of eprosartan versus diuretics for treatment of hypertension in a geriatric population: an observational, open-label, multicentre study

BACKGROUND

Diuretics are considered to be agents of first choice when treating hypertension in the elderly because of their clinical efficacy and, in particular, their low cost. Indeed, the latter consideration has been used by health resource managers to promote the use of diuretics. However, when considering the costs of treating hypertension in a population it is also necessary to assess the adverse effects that diuretics produce, particularly in elderly people.

OBJECTIVE

To compare the overall expenditure associated with the treatment of hypertension (specifically the angiotensin II type 1 receptor antagonist eprosartan vs diuretics) in an elderly population, taking into consideration not only the drug acquisition costs but also the adverse effects of treatment and the costs associated with such adverse effects.

METHODS

This was a prospective, observational, nonrandomized, open-label, multicentre study based in eight community health centres and the Hypertension Unit of the University Hospital of Salamanca, Spain. The study included 220 hypertensive geriatric outpatients (males and females aged >or=65 years) referred from general practitioners and the Hypertension Unit, with a mean age of 71.8 years and distributed into two groups: one (n = 90) treated with diuretics and the other (n = 130) treated with eprosartan. Following an initial clinical assessment of patients at the beginning of the study, monitoring of treatment continued for 1 year with follow-up consultations scheduled for 3, 6 and 12 months. Both the costs relating to acquisition of the drugs and the costs derived from secondary adverse effects of drug treatment were included in the analysis.

RESULTS

The response to the antihypertensive therapy was similar in both groups. In patients taking diuretics, adverse events resulted in increased use of healthcare resources because of urinary incontinence, purchase of adsorbents, hyponatraemia and the need to admit two patients to hospital. The patient/day cost was euro 1.05 for the group treated with diuretics and euro 0.98 for the group treated with eprosartan (year of costing 2006).

CONCLUSION

In the geriatric population, the acquisition cost of the prescribed diuretics is not representative of the actual antihypertensive treatment expenditure. According to the results obtained in our study, the overall costs of eprosartan therapy were no different to those of diuretics, despite the fact that eprosartan had a higher acquisition cost. This is consistent with a more favourable safety profile for eprosartan, which may possibly contribute to improved prescription compliance. This conclusion should be taken into consideration when evaluating economic restrictions on the use of drugs.

Predicted national productivity implications of calorie and sodium reductions in the American diet

PURPOSE

To model the potential long-term national productivity benefits from reduced daily intake of calories and sodium.

DESIGN

Simulation based on secondary data analysis; quantitative research. Measures include absenteeism, presenteeism, disability, and premature mortality under various hypothetical dietary changes.

SETTING

United States.

SUBJECTS

Two hundred twenty-five million adults.

MEASURES

Findings come from a Nutrition Impact Model that combines information from national surveys, peer-reviewed studies, and government reports.

ANALYSIS

We compare current estimates of national productivity loss associated with overweight, obesity, and hypertension to estimates for hypothetical scenarios in which national prevalence of these risk factors is lower. Using the simulation model, we illustrate how modest dietary change can achieve lower national prevalence of excess weight and hypertension.

RESULTS

We estimate that permanent 100-kcal reductions in daily intake among the overweight/obese would eliminate approximately 71.2 million cases of overweight/obesity. In the long term, this could increase national productivity by $45.7 billion annually. Long-term sodium reductions of 400 mg in those with uncontrolled hypertension would eliminate about 1.5 million cases, potentially increasing productivity by $2.5 billion annually. More aggressive diet changes of 500 kcal and 1100 mg of sodium reductions yield potential productivity benefits of $133.3 and $5.8 billion, respectively.

CONCLUSIONS

The potential long-term benefit of reduced calories and sodium, combining medical cost savings with productivity increases, ranges from $108.5 billion for moderate reductions to $255.6 billion for aggressive reductions. These findings help inform public health policy and the business case for improving diet. (AmJ Health Promot 2009;23[6]:423-430.)

Potential health benefits and medical cost savings from calorie, sodium, and saturated fat reductions in the American diet

PURPOSE

Model the potential national health benefits and medical savings from reduced daily intake of calories, sodium, and saturated fat among the U.S. adult population.

DESIGN

Simulation based on secondary data analysis; quantitative research. Measures include the prevalence of overweight/obesity, uncontrolled hypertension, elevated cholesterol, and related chronic conditions under various hypothetical dietary changes.

SETTING

United States.

SUBJECTS

Two hundred twenty-four million adults.

MEASURES

Findings come from a Nutrition Impact Model that combines information from national surveys, peer-reviewed studies, and government reports.

ANALYSIS

The simulation model predicts disease prevalence and medical expenditures under hypothetical dietary change scenarios.

RESULTS

We estimate that permanent 100-kcal reductions in daily intake would eliminate approximately 71.2 million cases of overweight/obesity and save $58 billion annually. Long-term sodium intake reductions of 400 mg/d in those with uncontrolled hypertension would eliminate about 1.5 million cases, saving $2.3 billion annually. Decreasing 5 g/d of saturated fat intake in those with elevated cholesterol would eliminate 3.9 million cases, saving $2.0 billion annually.

CONCLUSIONS

Modest to aggressive changes in diet can improve health and reduce annual national medical expenditures by $60 billion to $120 billion. One use of the model is to estimate the impact of dietary change related to setting public health priorities for dietary guidance. The findings here argue that emphasis on reduction in caloric intake should be the highest priority.

A review of the cost of cardiovascular disease

In Canada, 74,255 deaths (33% of all deaths) in 2003 were due to cardio-vascular disease (CVD). As one of the most costly diseases, CVD represents a major economic burden on health care systems. The purpose of the present study was to review the literature on the economic costs of CVD in Canada and other developed countries (United States, Europe and Australia) published from 1998 to 2006, with a focus on Canada. Of 1656 screened titles and abstracts, 34 articles were reviewed including six Canadian studies and 17 American studies. While considerable variation was observed among studies, all studies indicated that the costs of treating CVD-related conditions are significant, outlining a convincing case for CVD prevention programs.

Asymptomatically elevated blood pressure in the emergency department: a finding deserving of attention by emergency physicians?

The Emergency Department (ED) may be an ideal place to screen and refer patients for blood pressure monitoring in the outpatient setting. Yet, little is known about the public health significance of asymptomatically elevated blood pressure measurements in the ED and what to tell patients when these abnormal vital signs are recorded. Since the prevalence of hypertension and inadequately treated hypertension is so high, the incidental finding of elevated blood pressure in a previously undiagnosed patient may be a pivotal moment in that patient's life. For those patients carrying the diagnosis of hypertension, it is the author's opinion that the observation of elevated blood pressures should trigger advice to see their physicians to consider medication adjustments or changes. Emergency Physicians and their staff are in a unique position to screen and refer large populations of patients to their community physicians and help abort the long-term sequelae of unidentified or inadequately managed hypertension. How best to advise physicians and their patients requires research and innovative methods for transmitting important information to patients that may be unrelated to their primary complaint in the ED.

Aging diseases--do they prevent preventive health care from saving costs?

The potential of preventive health-care services to save costs is intensely debated. On the one hand, a longer life span increases the probability that new and costly diseases occur. On the other hand, a higher life expectancy postpones the expensive last year of life (LYOL), which becomes cheaper with age. Using US expenditure data on survivors and decedents the paper shows that prevention in the general population causes expenditures for additional diseases that are larger than the savings from postponing the LYOL. This result may also hold for prevention in diseased individuals.

The design of an observational study of hypertension management, adherence and pressure control in Blood Pressure Success Zone Program participants

AIMS

The Blood Pressure Success Zone (BPSZ) Program, a nationwide initiative, provides education in addition to a complimentary trial of one of three antihypertensive medications. The BPSZ Longitudinal Observational Study of Success (BPSZ-BLISS) aims to evaluate blood pressure (BP) control, adherence, persistence and patient satisfaction in a representative subset of BPSZ Program participants. The BPSZ-BLISS study design is described here.

METHODS

A total of 20,000 physicians were invited to participate in the study. Using a call centre supported Interactive Voice Response System (IVRS), physicians report BP and other data at enrolment and every usual care visit up to 12 +/- 2 months; subjects self-report BPs, persistence, adherence and treatment satisfaction at 3, 6 and 12 months post-BPSZ Program enrolment. In addition to BPSZ Program enrolment medications, physicians prescribe antihypertensive medications and schedule visits as per usual care. The General Electric Healthcare database will be used as an external reference.

RESULTS

After 18 months, over 700 IRB approved physicians consented and enrolled 10,067 eligible subjects (48% male; mean age 56 years; 27% newly diagnosed); 97% of physicians and 78% of subjects successfully entered IVRS enrolment data. Automated IVRS validations have maintained data quality (< 5% error on key variables). Enrolment was closed 30 April 2007; study completion is scheduled for June 2008.

CONCLUSIONS

The evaluation of large-scale health education programmes requires innovative methodologies and data management and quality control processes. The BPSZ-BLISS design can provide insights into the conceptualisation and planning of similar studies.

The effect of obesity and cardiometabolic risk factors on expenditures and productivity in the United States

OBJECTIVE

To examine the effect of obesity and cardiometabolic risk factors on medical expenditures and missed work days.

METHODS AND PROCEDURES

The 2000 and 2002 Medical Expenditure Panel Survey (MEPS), a nationally representative survey of the US population, was used to estimate the marginal effect of obesity (BMI > or = 30) on annual per-person medical expenditures and missed work days for patients with diabetes, dyslipidemia, or hypertension using multivariate regression methods controlling for age, sex, race, ethnicity, education, income, insurance, and smoking status. Maximum Likelihood Heckman Selection with Smearing retransformation was used to assess medical expenditures, and Negative Binomial regression was used for missed work days.

RESULTS

Normal weight individuals with diabetes, dyslipidemia, or hypertension had significantly greater medical expenditures than those without the respective condition ($6,006 (5,124-6,887), $4,760 (4,102-5,417), $3,911 (3,345-4,476)) and obesity significantly exacerbated this effect ($7,986 (7,397-8,574), $7,636 (7,072-8,200), $6,197 (5,745-6,649); $2007; all P < 0.05). In addition, diabetes, dyslipidemia, and hypertension resulted in greater missed work days (3.1 (0.94-6.21), 3.2 (0.42-7.91), 1.4 (0.0-3.52)) (all P < 0.05 except hypertension), which resulted in greater lost productivity ($433, $451, $199) and obesity significantly exacerbated the deleterious effect on work days (8.7 (4.44-15.2), 5.5 (2.18-10.5), 4.5 (2.92-6.34)) and lost productivity ($1,217, $763, $622) (all P < 0.05). In addition, medical expenditures increased for increasing weight category and increasing number of risk factors.

DISCUSSION

Obesity significantly exacerbates the deleterious effect of diabetes, dyslipidemia, and hypertension on medical expenditures and productivity loss in the United States. Obesity is preventable and public health efforts need to be undertaken to prevent its alarming increase in order to reduce the incidence and effect of cardiometabolic risk factors.

Clinical outcome of hypertension management

OBJECTIVE

This study aimed to investigate the association between inadequately controlled hypertension, medication use pattern and the incidence of cardiovascular events (CVEs) over 5 years. The cost of hospitalisation associated with inadequately controlled hypertension was estimated.

METHODS

This was a retrospective observational study of patients who were diagnosed with hypertension with at least one blood pressure reading recorded at baseline (year 2000), reviewed from 2001-2005. Primary endpoints were the extent, duration and prevalence of blood pressure deviation from treatment goals. Secondary endpoints were incidence of CVEs and the number of days of hospitalisation associated with inadequately controlled hypertension.

RESULTS

In total, the medical records of 210 patients were reviewed. Statistically significant positive associations were found between inadequately controlled systolic blood pressure with the incidence of CVEs (p=0.018) and increased cardiovascular drugs (p<0.001), non-cardiovascular drugs (p=0.019) and total drug usage (p<0.001). Similar observations were observed between inadequately controlled diastolic blood pressure and increased cardiovascular (p<0.05) and total (p=0.007) drug usage. Patients with uncontrolled blood pressure at all times during the study period were associated with a higher incidence of CVEs (p=0.026). The mean cost of hospitalisation due to CVEs was estimated to be HK$42,584.0 +/- 36,670.0 (US$1 = HK$7.8) and it accounted for 3.3% of the total healthcare expenditure during 2005.

CONCLUSION

Inadequately controlled blood pressure is positively associated with an increased incidence of CVEs and polypharmacy in Hong Kong Chinese hypertensive patients.

The medical cost of cardiometabolic risk factor clusters in the United States

OBJECTIVE

Diabetes, hypertension, hyperlipidemia, and overweight/obesity often cluster together. The prevalence of these cardiometabolic risk factor clusters (CMRFCs) is increasing significantly for all sociodemographic groups, but little is known about their economic impact.

RESEARCH METHODS AND PROCEDURES

The nationally representative Medical Expenditure Panel Survey was used (2000 and 2002). The current study estimated the national cost of CMRFCs independent of the cost of cardiovascular disease in the U.S., as well as the cost for all major payers and the marginal cost per individual using a Heckman selection model with Smearing retransformation. CMRFCs included BMI >or= 25 and two of the following three: diabetes, hyperlipidemia, and/or hypertension. All amounts are expressed in 2005 U.S. dollars.

RESULTS

National medical expenditures attributable to CMRFCs in the U.S. totaled 80 billion dollars, of which 27 billion dollars was spent on prescription drugs. Private insurance paid the largest amount of the national bill (28 billion dollars), followed by Medicare (11 billion dollars), Medicaid (6 billion dollars), and the Veterans Administration (4 billion dollars), whereas individuals paid 28 billion dollars out-of-pocket. For each individual with CMRFCs, 5477 dollars in medical expenditures was attributable to CMRFCs, of which 1832 dollars was for prescription drugs. On average, individuals with CMRFCs spent 1668 dollars out-of-pocket, of which 830 dollars was for prescription drugs.

DISCUSSION

The results of this study show that CMRFCs result in significant medical cost in the U.S. independent of the cost of cardiovascular disease. Individuals, private insurers, Medicare, Medicaid, the Veterans Administration, and other payers all share this burden.

Health care charges for patients with ocular hypertension or primary open-angle glaucoma

OBJECTIVES

To determine the total and condition-related direct health care charges of patients with ocular hypertension (OH) or primary open-angle glaucoma (POAG) and identify factors that affect these charges.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients with OH (n = 36 767) and POAG (n = 72 412) with > or =1 year of continuous enrollment during calendar years 1998 through 2005 in a nationally representative, multimanaged health plan database (PharMetrics).

METHODS

First year total health care and condition-related charges were calculated. Subsequently multivariate linear regression models determined the impact of ophthalmic condition (OH or POAG), age, index year, gender, geographic region, payer mix, product type, treatment with glaucoma medication, ocular comorbidities, and systemic comorbidities on these charges.

MAIN OUTCOME MEASURES

Per-person per year first-year total health care and ocular condition-related charges in United States dollars, adjusted for multiple covariates.

RESULTS

Patients with POAG had significantly higher adjusted total and condition-related health care charges during the first year of follow-up than patients with OH in multivariable analysis ($2070 vs. $1990, P<0.0001 and $556 vs. $322 P<0.0001, respectively). Females and older patients had higher total health care charges compared with males and younger patients ($586 or 28.3% more; P<0.0001 and $27 per year or 0.8% per year more; P<0.0001, respectively). However, neither gender nor age were strong determinants of condition-related charges (P = 0.13 and P = 0.052, respectively). Index year, region, payer, and product types significantly dictated both total and disease-related charges. Patients with ocular comorbid conditions, including cataracts, cataract surgery, diabetic retinopathy, and blindness, had significantly higher total and condition-related health care charges than patients without these conditions (P<0.0001).

CONCLUSION

Total and condition-related health care charges are considerable for patients with OH and POAG. These data identify several factors that dictate these charges.

Prevalence of Self‐Reported High Blood Pressure Awareness, Advice Received From Health Professionals, and Actions Taken to Reduce High Blood Pressure Among US Adults—Healthstyles 2002

High blood pressure awareness, advice received from health care providers, and adoption of heart-healthy behaviors were assessed using the Healthstyles 2002 survey. About 20% of respondents reported that they had high blood pressure, and 53% of these were currently taking medications to lower blood pressure. Black men had the highest adjusted prevalence of high blood pressure (32%). Medication use among persons with high blood pressure was lower among Hispanics (45%) than among blacks (54%) and whites (54%). Persons reporting having high blood pressure were five times more likely to report having received advice from a health care professional to go on a diet or change eating habits (p<0.05) and reduce salt or sodium in their diet (p<0.05), but five times less likely to have received advice to exercise (p<0.05) than those reporting not having high blood pressure, after adjustment for differences in sex, race/ethnicity, and age. Persons with self-reported high blood pressure were also more likely to be making these modifications (p<0.05). Among people with high blood pressure, current medication use was associated with both receiving and following advice for diet change and salt reduction (p<0.05). Future initiatives are needed to improve the proportion of Hispanics and blacks taking prescribed medications to improve high blood pressure control and reduce risk for serious sequelae such as heart disease and stroke.

The value of antihypertensive drugs: a perspective on medical innovation

Using national survey data and risk equations from the Framingham Heart Study, we quantify the impact of antihypertensive therapy changes on blood pressures and the number and cost of heart attacks, strokes, and deaths. Antihypertensive therapy has had a major impact on health. Without it, 1999-2000 average blood pressures (at age 40+) would have been 10-13 percent higher, and 86,000 excess premature deaths from cardiovascular disease would have occurred in 2001. Treatment has generated a benefit-to-cost ratio of at least 6:1, but much more can be achieved. More effective use of antihypertensive medication would have an impact on mortality akin to eliminating all deaths from medical errors or accidents.

Comorbid conditions in men with ED before and after ED diagnosis: a retrospective database study

Although erectile dysfunction (ED) has been considered a complication of other medical conditions, clinicians and researchers suggest that ED may serve as a clinical marker of vascular health. This retrospective claims study examined the prevalence of predefined comorbid conditions in men with ED (N=301 994) in the 12 months before and the 6 months following ED diagnosis. Consistent with previous research, comorbid conditions were prevalent among men with ED. Comorbid conditions were most often diagnosed before an ED diagnosis, although new diagnoses in the 6 months following an ED diagnosis were common and occured more frequently than new diagnoses in a matched sample of men without ED during the same period. Differences by age, region and insurance coverage for ED medications were also examined. Findings support previous research that suggests ED may serve as a marker for previously undetected comorbid conditions.

Control of hypertension in patients at high risk of cardiovascular disease

BACKGROUND

Hypertension is a major cardiovascular risk factor, but knowledge about the real magnitude of the problem and its determinants is lacking.

AIM

To assess control of hypertension and evaluate medical resource use, in patients at high risk of cardiovascular disease.

DESIGN

Multicentric cross-sectional study.

METHODS

We collected data for 2205 adult patients from 36 centres, representative of all regions of Spain. Patients had attended out-patient clinics from July 2002 to August 2003, had an absolute cardiovascular risk > or =20% at 10 years (according to the Framingham guidelines), and had a diagnosis of hypertension. Pregnant and terminally ill patients were excluded.

RESULTS

Hypertension was inadequately controlled in 1384 patients (62.8%). LDL cholesterol was higher in patients with uncontrolled hypertension (median 130.2 vs. 120.0 mg/dl, p < 0.001). Haemoglobin A(1c) in diabetic patients was also greater in those with uncontrolled hypertension (median 7.10% vs. 6.90%, p = 0.010). Uncontrolled hypertension was associated with the following variables, in descending strength of association: higher LDL cholesterol, taking antihypertensive medication, living in non-metropolitan areas, and higher body mass index.

DISCUSSION

Hypertension is poorly controlled in most patients with a high risk of cardiovascular disease. Uncontrolled hypertension is frequently associated with poor control of other risk factors.

Maternal protein intake is not associated with infant blood pressure

BACKGROUND

Animal data show that low protein intake in pregnancy programs higher offspring blood pressure, but similar data in humans are limited. We examined the associations of first and second trimester maternal protein intake with offspring blood pressure (BP) at the age of six months.

METHODS

In a prospective US cohort study, called Project Viva, pregnant women completed validated semi-quantitative food-frequency questionnaires (FFQ) to measure gestational protein intake. Among 947 mother-offspring pairs with first trimester dietary data and 910 pairs with second trimester data, we measured systolic blood pressure (SBP) up to five times with an automated device in the offspring at the age of six months. Controlling for blood pressure measurement conditions, maternal and infant characteristics, we examined the effect of energy-adjusted maternal protein intake on infant SBP using multivariable mixed effects models.

RESULTS

Mean daily second trimester maternal protein intake was 17.6% of energy (mean 2111 kcal/day). First trimester nutrient intakes were similar. Mean SBP at age 6 months was 90.0 mm Hg (SD 12.9). Consistent with prior reports, adjusted SBP was 1.94 mm Hg lower [95% confidence interval (CI) -3.45 to -0.42] for each kg increase in birth weight. However, we did not find an association between maternal protein intake and infant SBP. After adjusting for covariates, the effect estimates were 0.14 mm Hg (95% CI 20.12 to 20.40) for a 1% increase in energy from protein during the second trimester, and 20.01 mm Hg (95% CI 20.24 to -0.23) for a 1% increase in energy from protein in the first trimester.

CONCLUSIONS

Variation in maternal total protein intake during pregnancy does not appear to program offspring blood pressure.

The Burden of Adult Hypertension in the United States 1999 to 2000

This study aims to estimate the absolute number of persons with hypertension (the hypertension burden) and time trends using data from the National Health and Nutrition Examination Survey of United States resident adults who had hypertension in 1999 to 2000. This information is vitally important for health policy, medical care, and public health strategy and resource allocation. At least 65 million adults had hypertension in 1999 to 2000. The total hypertension prevalence rate was 31.3%. This value represents adults with elevated systolic or diastolic blood pressure, or using antihypertensive medications (rate of 28.4%; standard error [SE], 1.1), and adults who otherwise by medical history were told at least twice by a physician or other health professional that they had high blood pressure (rate of 2.9%; SE, 0.4). The number of adults with hypertension increased by ≈30% for 1999 to 2000 compared with at least 50 million for 1988 to 1994. The 50 million value was based on a rate of 23.4% for adults with elevated blood pressure or using antihypertensive medications and 5.5% for adults classified as hypertensive by medical history alone (28.9% total; P <0.001). The ≈30% increase in the total number of adults with hypertension was almost 4-times greater than the 8.3% increase in total prevalence rate. These trends were associated with increased obesity and an aging and growing population. Approximately 35 million women and 30 million men had hypertension. At least 48 million non-Hispanic white adults, ≈ 9 million non-Hispanic black adults, 3 million Mexican American, and 5 million other adults had hypertension in 1999 to 2000.

Practice guidelines: role of internists and primary care physicians

This article discusses practice guidelines for internists and primary care physicians who care for patients at risk for heart failure (HF).These guidelines include identifying the risk factors for the development of HF, identifying patients at risk for the development of HF, learning guideline goals for treatment and other recommendations concerning the management of patients at risk for HF, performing serial assessment of how well guideline goals have been met in patients at risk for HF, performing serial assessment of patients at risk for HF to determine possible progression of disease,considering consultation with other health personnel for patients with progressive stages of HF, enlisting hospitals and other care facilities to promote evidence-based management of patients in all stages of HF, and accessing educational materials for patients and other health care personnel.

Failure of computerized treatment suggestions to improve health outcomes of outpatients with uncomplicated hypertension: results of a randomized controlled trial

STUDY OBJECTIVE

To assess the effects of evidence-based treatment suggestions for hypertension made to physicians and pharmacists using a comprehensive electronic medical record system.

DESIGN

Randomized controlled trial with a 2 x 2 factorial design of physician and pharmacist interventions, which resulted in four groups of patients: physician intervention only, pharmacist intervention only, intervention by physician and pharmacist, and intervention by neither physician nor pharmacist (control).

SETTING

Academic primary care internal medicine practice.

SUBJECTS

Seven hundred twelve patients with uncomplicated hypertension.

MEASUREMENTS AND MAIN RESULTS

Suggestions were displayed to physicians on computer workstations used to write outpatient orders and to pharmacists when filling prescriptions. The primary end point was generic health-related quality of life. Secondary end points were symptom profile and side effects from antihypertensive drugs, number of emergency department visits and hospitalizations, blood pressure measurements, patient satisfaction with physicians and pharmacists, drug therapy compliance, and health care charges. In the control group, implementation of care changes in accordance with treatment suggestions was observed in 26% of patients. In the intervention groups, compliance with suggestions was poor, with treatment suggestions implemented in 25% of patients for whom suggestions were displayed only to pharmacists, 29% of those for whom suggestions were displayed only to physicians, and 35% of the group for whom both physicians and pharmacists received suggestions (p=0.13). Intergroup differences were neither statistically significant nor clinically relevant for generic health-related quality of life, symptom and side-effect profiles, number of emergency department visits and hospitalizations, blood pressure measurements, charges, or drug therapy compliance.

CONCLUSION

Computer-based intervention using a sophisticated electronic physician order-entry system failed to improve compliance with treatment suggestions or outcomes of patients with uncomplicated hypertension.

Cost of stress urinary incontinence: a claims data analysis

OBJECTIVES

The primary objectives of this research were to: (i) identify and present methodologies for estimating three types of 'cost-of-illness' measures using healthcare and disability claims data -- specifically 'cost of treatment', 'incremental cost of patient', and 'incremental cost of illness'; and (ii) perform a case-study analysis of these cost measures for women treated for stress urinary incontinence (SUI).

STUDY DESIGN AND METHODS

In this paper, we discuss aspects of cost-of-illness methodologies in the context of SUI. We first distinguish between 'cost of treatment' (i.e. the costs of treating a specific condition), 'incremental cost of patient' (i.e. the additional costs associated with patients with a particular condition, irrespective of any comorbid conditions they may also have), and 'incremental cost of illness' (i.e. the additional costs resulting from a particular illness, as distinct from the costs of other conditions that the patient might have, including conditions which might have caused the illness in question). The latter case is in many ways the most complex to model, requiring controls for related causal conditions. We then applied these three methodologies by analysing the costs associated with SUI. Using data from a large employer claims database (n > 100 000), we estimated a series of regression models that reflected cost of treatment, incremental cost of patient, and incremental cost of illness for SUI.

RESULTS

The three approaches yielded substantially different results. For many purposes the incremental cost-of-illness model provides the most appropriate results, as it controls for comorbid conditions, as well as patient demographics. On a per capita basis using the incremental cost-of-illness model, patients with SUI had direct costs that were 134% more than those for their controls and indirect costs that were 163% more than those for controls. Estimating costs for the average (i.e. mean) person results in dollar-termed estimates of the costs of SUI. In particular, we found that in 1998, the average direct medical cost of SUI was $US5642 and the indirect workplace cost of SUI was $US4208.

CONCLUSIONS

Since the various methods yield substantially different results, it is important that the end user of cost-of-illness analyses of claims data have a clear purpose in mind when reporting the cost of the condition of concern. The incremental cost-of-illness measure for claims data has substantial advantages in terms of enhancing our understanding of the specific cost impact of SUI.

Pharmacoeconomic burden of undertreating hypertension

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).

Inflammation, endothelial dysfunction, and the risk of high blood pressure: epidemiologic and biological evidence

In spite of its high impact on cardiovascular and renal disease, knowledge on risk factors for the development of high blood pressure (HBP) is limited. Mild chronic inflammation may play a significant role in the incidence of HBP. A persistent low-grade inflammation state could be associated with high but within the 'normal range' cytokine plasma concentration. By impairing the capacity of the endothelium to generate vasodilating factors, particularly nitric oxide (NO), elevated cytokines may lead to the development of endothelial dysfunction, chronic impaired vasodilation, and HBP. These alterations in the L-arginine : NO pathway may play a major role in the development of HBP in young subjects, with inflammation-related alterations in the production of cyclo-oxygenase-derived vasoconstrictors becoming more prominent with advanced age. Cross-sectional independent associations between HBP and plasma levels of C-reactive protein, interleukin-6, and tissue necrosis factor alpha have been reported, but no prospective evidence of these associations is currently available.

The economic burden of skin disease in the United States

BACKGROUND

Skin diseases and their complications are a significant burden on the nation, both in terms of acute and chronic morbidities and their related expenditures for care. Because accurately calculating the cost of skin disease has proven difficult in the past, we present here multiple comparative techniques allowing a more expanded approach to estimating the overall economic burden.

OBJECTIVES

Our aims were to (1) determine the economic burden of primary diseases falling within the realm of skin disease, as defined by modern clinical disease classification schemes and (2) identify the specific contribution of each component of costs to the overall expense.

METHODS

Costs were taken as the sum of several factors, divided into direct and indirect health care costs. The direct costs included inpatient hospital costs, ambulatory visit costs (further divided into physician's office visits, outpatient department visits, and emergency department visits), prescription drug costs, and self-care/over-the-counter drug costs. Indirect costs were calculated as the outlay of days of work lost because of skin diseases.

RESULTS

The economic burden of skin disease in the United States is large, estimated at approximately $35.9 billion for 1997, including $19.8 billion (54%) in ambulatory care costs; $7.2 billion (20.2%) in hospital inpatient charges; $3.0 billion (8.2%) in prescription drug costs; $4.3 billion (11.7%) in over-the-counter preparations; and $1.6 billion (6.0%) in indirect costs attributable to lost workdays.

CONCLUSIONS

Our determination of the economic burden of skin care in the United States surpasses past estimates several-fold, and the model presented for calculating cost of illness allows for tracking changes in national expenses for skin care in future studies. The amount of estimated resources devoted to skin disease management is far more than required to treat conditions such as urinary incontinence ($16 billion) and hypertension ($23 billion), but far less than required to treat musculoskeletal conditions ($193 billion).

Compliance and persistence with newer antihypertensive agents

Individuals with hypertension need to stay on therapy with antihypertensive medication to obtain the full benefits of blood pressure reduction. There are important differences in tolerability across antihypertensive drug classes, and these differences influence the extent to which patients are willing to continue taking their drugs. Three separate sources of evidence--postmarket surveillance studies, medical/prescription database studies, and discontinuation of study medication in long-term endpoint clinical trials--support the proposition that angiotensin II antagonists, the newest class of antihypertensives, are well tolerated, and that patients whose initial treatment is an angiotensin II antagonist are more likely to persist with therapy than patients who use other classes of antihypertensives. Recent landmark trials with losartan in hypertensive patients with left ventricular hypertrophy (Losartan Intervention For Endpoint reduction [LIFE]) and in diabetes (Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan [RENAAL]) demonstrated excellent tolerability, a high level of persistence, and clinical benefits exceeding those provided by blood pressure control alone for the prototype angiotensin II antagonist in clinical settings.

Cost of treating hypertension in the elderly

Hypertension is a common disease among the elderly, a population that will continue to grow over the next decade. Untreated hypertension can lead to cardiovascular events and mortality. Given the seriousness of this disease and the increase in the number of elderly with hypertension, this review focuses on the cost of treating hypertension in the elderly as described in recent publications. We found a limited number of articles related to the treatment of hypertension in the elderly. One publication provided insightful information pertaining to expenditures in the United States for hypertension in 1998. This article was the first to examine age distribution among persons 65 years and older. It has been shown that antihypertensive pharmacologic treatment significantly reduces the incidence of cardiovascular events. Without any other medical conditions, thiazide-like diuretics are recommended for the treatment of hypertension in the elderly due to their beneficial effects, low risk for side effects, and low cost. In general, it was found that the elderly have higher expenditures per capita for hypertension and per hypertensive condition.

The global burden of hypertension: good news and bad news

Hypertension is a common disorder and a powerful risk factor for death and disability from heart disease and kidney failure. Worldwide, it affects an estimated 690 million persons and it is the major risk factor for stroke. The good news is that safe and effective treatments are available and in the majority of patients, hypertension can be diagnosed easily and blood pressure can be controlled. Unfortunately, most hypertensive patients have uncontrolled blood pressure. To effectively address this situation, a renewed commitment to refine strategies for controlling blood pressure is necessary. Additional emphasis is also warranted for the prevention of hypertension in the first place.