Cost‐effectiveness of blood pressure measurement and hypertension follow‐up

Hypertension‐attributable cardiovascular mortality amounts to almost 3 million yearly deaths worldwide (5.8% of total deaths), which represents more than 17.5 million years of life lost (YLLs) [1]. There is an urgent need for evaluation of effective treatment options as well as different techniques of blood pressure (BP) control, which may be used to maximize the effectiveness of therapy for patients and minimize costs for society.

When analysing the cost of a disease or a risk factor, two main categories of costs are considered: direct and indirect costs. Direct costs usually involve the screening, diagnosis and lifelong management costs (clinic visits, BP devices and techniques, laboratory tests, acquisition of drugs, adverse effects of medications, and transport/time), and also reduced future healthcare costs due to management of the disease or risk factors and increased healthcare costs due to longer life. Indirect costs mainly include the costs of morbidity/disability and mortality as a result of inadequate or improper medical treatment [2].

In this issue of Blood Pressure, Rodriguez‐Roca and coworkers [3] address a topic that is often overlooked in health economic investigations of hypertension. They have assessed the cost of follow‐up of hypertension in primary care using either conventional clinical BP assessment by sphygmomanometry and ambulatory BP monitoring (ABPM) using validated devices. Their findings are interesting, as they show that ABPM over the years is a more cost‐effective way of patient follow‐up compared with conventional BP measurement by sphygmomanometry. The Rodriguez‐Roca and coworkers [3] study, which was performed in a primary healthcare setting, largely supports the utility of ABPM follow‐up in earlier studies [4], [5].

However, there is a need for additional data since health economic studies commonly have limitations depending on the way the economic analyses were carried out. The main controversial issues in health economic evaluations concern how representative the epidemiological data could be, the effectiveness of the treatment(s) used, the outcome measures employed, the cost concept used, the discounting methods applied, as well as the duration of therapy [2]. To this, we shall also add the mode and costs of BP measurement and assessment in the life‐long follow‐up of therapy.

The fact that the settings in many studies are different justifies the caution when making recommendations based on the results of economic analyses. In spite of current shortcomings, effective hypertension control remains one of the most favourable interventions to maximize effectiveness of therapy for patients and minimize costs for society. In fact, it has been estimated that proper hypertension control remains a leading medical intervention with respect to cost utility (cost per quality‐adjusted life‐year) [6]. However, although the treatment of hypertension is clearly cost effective, additional measures should be taken to increase the cost‐effectiveness ratio, and further studies are needed to optimize policy recommendations regarding the best mode and practice of BP assessment and follow‐up.

The cost effectiveness of home BP follow‐up has not yet been extensively researched. This will be done in the Home versus Office MEasurements, Reduction of Unnecessary treatment Study (HOMERUS) [7], which is a multicentre prospective study by researchers at the Maastricht University, The Netherlands. HOMERUS is primarily designed to examine, in subjects with mild to moderate hypertension, whether treatment decisions based on home BP measurements can lead to reduction in the use of antihypertensive drugs and the associated costs, compared with office BP measurements. In this study, the primary evaluation includes a cost‐minimization analysis from a societal perspective.

The availability of proper health economic evaluations will allow not only comparisons of different treatment options but also of different BP assessment options. This will help the medical decision makers and community to make rational priorities and choices, and allocate health resources more efficiently [8].

It is encouraging that recent and emerging data from health economic assessments suggest not only that the long‐term benefits of antihypertensive treatment for the patients can actually be considerably upgraded, but also, of equal importance, that cost effectiveness and allocation of scarce health resources may be significantly improved to the benefit of society as well as the individual.