Critical aspects in hypertension diagnosis and treatment

Because of the high prevalence of hypertension in most societies, the economic aspects of hypertension diagnosis and treatment becomes critical to modern medicine. In formal health economic assessments, costs and consequences of medical diagnostic and treatment interventions are weighed against outcome benefits and value for patients and society [1,2]. In such assessments, it is clear that the medical, economic and human costs of untreated and inadequately controlled hypertension are enormous [3]. From such a perspective, a rational detection, treatment and follow-up strategy requires that intrinsic outcome values be delivered to the individual at risk as well as to the society.

Since most experts individually or collectively consider that adequate blood pressure control is critical for the achievement of desired outcome benefits for individual patients and for the hypertensive population as a whole [1], procedures and methods for diagnostic assessment as well as guidelines for treatment and follow-up become important in health economic assessments of hypertension. Thus, the standard methods used for diagnosis as well as for non-pharmacological and pharmacological treatment of hypertensive patients clearly impact on the cost and cost/utility of diagnosing and treating hypertension in the population [3].

The assessment of blood pressure has to be reliable, affordable and easy. Compared with classical clinic measurements, patient self-assessment of blood pressure has advantages, i.e. it is affordable and easy. Further, self-measurements may be repeated over time more easily than office measurements, thus providing a better background for proper risk assessment and choice of intervention strategies. Before the emergence of enabling technologies such as microelectronics and information technology, costs for collecting, organizing, processing and storing information for assessment of blood pressure were comparatively high. However, since the price for efficient information processing has fallen considerably, this can now be done on a much larger scale than before. In the light of these developments, the use of patient self-assessment in hypertension diagnosis and treatment has to be re-evaluated. Also of importance is that the increasing use of patient blood pressure self-assessment in hypertension diagnosis and follow-up shifts the costs of the assessment procedure from healthcare providers to the patients.

Previously, the reliability of patient self-assessed blood pressures was questioned based on poor accuracy and reproducibility of the available automated blood pressure monitoring devices. However, modern technology has largely solved such problems, as demonstrated by Germano and coworkers [4] in their assessment of four automatic devices for self-measurement of blood pressure. Clearly, valid technologies have emerged, which enable a wide range of patients to assess correctly their own blood pressures. Important barriers that previously blocked the diffusion and wider dissemination of such techniques to larger groups of patients have largely been removed. However, the healthcare profession has been slow to adopt and incorporate such developments into the routine management of hypertensive patients. This is likely to change, since it is increasingly clear that hypertension experts, health providers, manufacturers and patients share a common interest in working for the wider dissemination and acceptance of validated devices and techniques for patient blood pressure self-assessment.

With respect to lowering costs and optimizing cost-utility, the management of patients with high blood pressure has to provide value to the individual patient as well as to society as a whole. Safe, efficacious and easy to manage antihypertensive therapies, both monotherapies and fixed dose combinations, are currently available. In this issue of Blood Pressure, Hermans et al., in an open-label assessment study [5], demonstrate that the beta-blocker nebivolol interacts with several blood pressure regulating systems and provides a high response rate in patients with or without previous therapy and with or without diabetes. Such data are interesting and may add to the debate about whether hypertension should be treated initially with single agents with highly selective mechanisms of action or with an early combination type of approach with several individual drugs or agents combining multiple mechanisms of actions in one single molecule.

In order to simplify treatment decisions and optimize conditions to achieve marginal benefits, there is a need for cost-effective methods for blood pressure assessment and diagnosis as well as for well documented and easy to manage pharmaceutical regimens. Importantly, treatment of hypertension requires an investment by the patient and the society over many years to prolong disease-free quality years of life. Hypertension management has moved forward from a focus on diagnostic and therapeutic exploration to focus on how to detect, assess, treat and follow-up large high-risk patient cohorts effectively. In order to achieve this, procedures related to diagnosis, treatment and follow-up have to be simplified and made cost effective.