Ir\
National High Blood Pressure Month
National High Blood Pressure Month, which will be observed in May, will mark the third round of an ongoing battle against an awesome opponent-hypertension. Similar observances in 1974 and 1975 have begun to weaken this silent disease that affects about one out of ten Americans, and it is hoped that 1976 will bring it to the mat. The annual national observance is just one of many diversified activities of the National High Blood Pressure Education Program, a unique collaborative association of private and governmental groups which work year-round to help combat uncontrolled hypertension. The American Pharmaceutical Association and its subdivisions-the Academy of Pharmaceutical Sciences, the Academy of Pharmacy Practice and the Student American Pharmaceutical Association-have been actively involved in the National High Blood Pressure Education Program since its inception in 1972, and they are among those organizations sponsoring National High Blood Pressure Month 1976. 1975 Observances Pharmacists and pharmacy organizations played a big part in the success of the 1975 observance last May. During that month, 895 organizations throughout the United States reported activities directed at educating both lay and professional groups, establishing screening and referral programs and participating in community hypertension coordinating councils. Over 1,200 lay and professional publications published articles, features and columns emphasizing some aspect of the high blood pressure problem, and 20 major professional journals, including this Journal, devoted space to hypertension related material. In Texas, each of the 48 component associations of the Texas Pharmaceutical Association was provided a special kit to carry out a statewide media campaign during May 1975. Campaign objectives were to (1) encourage the public to have their blood pressure checked regularly, (2) establish the community pharmacy as a source of information about high blood pressure and (3) provide more information to pharmacists to enable them to more effectively counsel patients concerning hypertension. Members of the Bexar County (Texas) Pharmaceutical Association operated detection centers at several shopping malls during the month, and nine pharmacies in San Antonio are involved in an ongoing
Vol. NS 16, No. 4, April 1976
Combating the Silent Disease program of screening and monitoring patients for high blood pressure. The Michigan Pharmaceutical Association devoted the May 1975 issue of the Michigan Pharmacist to the theme, "Hypertension-The Pharmacist's Expanding Role," and MPA supported various local association projects which included screening programs, and educational lecture series and a patient compliance study project. In Arizona, Pharmacist Tom Samuel is president of the Tucson Breakfast Lions Club which purchased a 36-foot trailer truck and equipped it for vision, hearing and hypertension screening. Ninety Lions, with the help of wives and student volunteers from the University of Arizona school of pharmacy, schedule clinics at schools, parks, libraries, county fairs and shopping centers each week-end. The Illinois Pharmaceutical Association devoted the April issue of its journal to hypertension, and Pharmacist Aaron Goldin was active on the association's hypertension committee and in other activities related to high blood pressure education. In Indiana, a pharmacist-conducted hypertension screening program was developed by the Purdue University school of pharmacy and pharmacal sciences. The program includes a six-hour seminar for participating community pharmacists covering accurate measurement of blood pressure, patient communication techniques and the procedure for efficiently providing hypertension screening in a community pharmacy. In the Indiana program, multiple high readings at least 24 hours apart are required before suspected hypertensive patients are referred to a physician. A follow-up procedure also is a program feature. The Indiana Pharmaceutical Association was instrumental in the formation of a coalition of community health agencies which were concerned about high blood pressure, including the kidney foundation, dental association, medical association, heart association, board of health, Blue Cross/Blue Shield, and nfpresentatives from several public health clinics, centers and hospitals. During National High Blood Pressure Month, coalition members pooled and distributed their various public education material to the media, and also developed a coordinated, communitywide high blood pressure screening, referral, and follow-up system which was standardized and used by the various agencies. Since May 1975, several pharmacists in San Joaquin County, California, have been
participating in a high blood pressure screening program sponsored by the San Joaquin Pharmaceutical Society with the cooperation of the local heart association. Pharmacists obtain certain demographic information from the patient and measure the patient's blood pressure. This data is recorded and referred to the heart association for evaluation by a physician and for identification of those individuals who should receive further study. The actual referral is then accomplished by heart association staff. As a result of this program, 220 patients out of 1,000 were referred for additional evaluation and diagnosis. May 1975 served to provide added visibility to the Virginia Pharmacists' High Blood Pressure Program, a pilot research and demonstration project sponsored by the school of pharmacy of the Virginia Commonwealth University and funded by the Virginia Regional Medical Program. The program seeks to evaluate the effect of community pharmacy services on patients with high blood pressure and hopes to demonstrate that hypertensive patients receiving the pharmacist's services have better controlled blood pressure than a matched group of hypertensive patients not receiving these services. Pharmacists in the program work closely with physicians and are given intensive training 'in hypertension and in methods of interviewing and monitoring patients with high blood pressure. Pharmacists use patient medication profile cards to detect potential drug interactions and to monitor compliance, and they educate patients regarding their disease and the treatment using audio visual programs and brochures developed for the purpose. The Arkansas Pharmaceutical Association, like many of the nation's state pharmaceutical organizations, issued a news release calling the public's attention to the 1975 observance and pointing to the pharmacist as a source of information on the disease and its consequences. The release also cited the Arkansas Heart Asso-
183
Combating the Silent Disease
ciation as an information source and listed a toll-free number which can be used for public inquiries. Although the 1975 observance of National High Blood Pressure Month fell at an inopportune time for many pharmacy students at the end of the school year, support for the observance by students and chapters of the Student American Pharmaceutical Association was outstanding. Provided with many materials from the SAPhA national office, local chapters were active in public education programs and in establishing screening and referral programs. As a result of activities initiated last May, several student-operated high blood pressure screening programs are still underway, notably those at the University of Arkansas college of pharmacy and at Temple University in Philadelphia . Pharmaceutical manufacturing firms also intensified their anti-hypertension efforts during the 1975 observance. For example, the Pharmaceutical Division of Ciba-Geigy estimates that over 225,000 people were screened in May at more than 75 CHEC programs throughout the country, and Searle Laboratories sent a special letter to 50 ,000 physicians encouraging the motivation of patients to adhere to their treatment program and advising physicians of the reduction in insurance costs to patients who have shown a decrease in blood pressure over a stated period of time. The examples stated above are just that, for it would be impossible to relate all
of the activities of the thousands of pharmacists and pharmacy students who helped make the 1975 observance of National High Blood Pressure Month so successful. But the examples certainly demonstrate the commitment of the profession to combat this serious national health problem . It is probably too early to say that we have the problem of undetected and untreated hypertension on the run , but there is little doubt that we have come a long way since the massive national effort was undertaken in 1972. From data recently released by the National Heart and Lung Institute, the effects are apparent. Among a select hypertensive population studied, there is evidence of a change from 50 percent of those affected being aware in 1971 that they had the disease to the point where about 75 percent are now aware. Nationwide, the number of physician visits for hypertension has increased 41 percent over 1971 levels. As impressive as these statistics are, officials of the National High Blood Pressure Education Program estimate that there are still about 7. 1 million persons with undetected hypertension and probably another 4 .3 million persons who know they have the disease but have not had it brought under control. A big job remains to be done. How can pharmaci sts and pharmacy students take part in 1976 National High Blood Pressure Month Activities in May?
The preceding examples should provide many ideas ; the following suggestions also will be helpful 1. Distribute informational materials to patrons. 2. Develop and/or adopt a system for reminding hypertensive patients when prescription renewals are due . 3. Place special emphasis upon the importance of monitoring hypertensive patients' use of prescription and nonprescription drugs. 4. Provide supplementary screenings for borderline and diagnosed hypertension patients, informing both the patient and his physician about the reading . 5. Participate in the presentation of information on hypertension control at lay and professional meetings . 6. Take part in the planning and implementation of a community hypertension control program that can function within the health care system, i.e. , Heart Association; Red Cross; medical , nursing, dental societies; state/county health departments; Blue Cross/Blue Shield, etc . 7. At both the practitioner and student levels, initiate interdisciplinary discussion groups to develop a cooperative approach to hypertension control. 8. In hospitals and long-term care facilities , urge that all admissions receive blood pressure measurement routinely . 9. Include hypertension as a topic for in(Continued on page 186)
Hypertension Materials for Pharmacists
a description of the National High Blood Pressure Education Program, and a series of articles chosen to help the pharmacist in dealing with his patients with high blood pressure.
active part in National High Blood Pressure Month. Besides general background information on the problem of high blood pressure, the handbook contains suggestions for specific activities, samples of public education and public relations materia ls and an order form for hypertension-related materials.
Do you want to know more about hypertension? Would you like some handy tips for providing better pharmaceutical service to your hypertensive patients? Do you need some good suggestions for taking part in National High Blood Pressure Month? APhA is cooperating with the National High Blood Pressure Education Program to make the following materials available• Detecting and Controlling Hypertension-A Source Book for Pharmacists Published by APhA in cooperation with the National High Blood Pressure Education Program, this 48-page publication includes an overview of hypertension and antihypertensive therapy, a summary of the recommendations of the National Pharmacy Symposium on High Blood Pressure,
184
• Special Information Bulletin for Pharmacists Developed by the Nationa l High Blood Pressure Education Program with input from individual pharmacists and pharmacy associations, this publication is designed to describe to pharmaCists in a clear and concise manner many of the roles they can play in combating the problem of undetected and uncontrolled hypertension. • Handbook of National High Blood Pressure Month Activities, Resources and Materials. This 50-page handbook developed by the NHBPEP is a must for pharmacists and pharmacy students who want to take an
A single copy of each of these publications is available without charge . For more than sample copies, a distribution plan must be included which contains- I 1) a description of the program in which the materials would be used , (2) the audience for whom the materials are intended , (3) how they will be disseminated and (4) the objective to be accomplished. Order , by title , from : National High Blood Pressure Education Program, High Blood Pressure Information Center, 120/ 80 National Institute s of Health, Bethesda, MD 20014.
Journal o f the American Pharmaceutica l Association
If we are to prevent runaway costs of a health system which is already under great strain, hypertension is one of the diseases to start with
Table I
Economic Cost of Illness in the United States-
1972 Approximate Cos t * A II diseases Cardiol'asclilar diseases Arter iosc le ro tic hea rt d isease Hypertens iun Stroke Cost oI prodllctil'itl' loss Card iovascular d isea scs *Social Securi t y Bureau.
189
Billion
40
Billion
20 Billion (N III estimat e) 3.5 Billion 6.0 Billion
6.5 Billion Adm ini stration In fo n nation
task force on " detection , criteria and the stepped-care system of treatment " that diuretics should form the cornerstone of therapy in practically all hypertensives, recent prescription data demonstrate that about 30 percent of hypertensives still are being treated with another drug first , in many instances , reserpine or alphamethyldopa . In recent months, propranolol has become a " first drug " in treatment. These drugs should be used only with a diuretic and probably only after a diuretic has been proved to be ineffective. If a blood pressure response is not obtained, medications should be added or substituted until either significant side effects occur or satisfactory blood pressure lowering results. The Economics of Treatment Until recent years , most medical colleges and teaching centers advocated a complete workup for every hypertensive patient. Thousands of patients with high blood pressure were hospitalized for as long as seven to 10 days and submitted to exhaustive studies which often cost several thousand dollars . Only approximately one to three percent of all patients with high blood pressure have a specific cause for this disease ; exhaustive studies are clearl y not indicated in the ' majority of patients . A few simple tests performed during one or two visits are necessary. If the patient does not respond appropriately to therapy , treatment can be stopped and more elaborate studies .ouch as X-rays of the kidneys can be performed . Reducing the cost of studying patients is one way that physicians can reduce the total health
186
care cost of this major disease; this represents cost effective, good medical care . Another way to reduce cost and eliminate one of the reasons why hypertensive patients discontinue a treatment program is to be aware of the cost of medication. For example , it is a mistake to use a drug such as spironolactone, where three or four tablets a day must be taken, as the initial diuretic since this drug is expensive. Instead, one or two tablets a day of a typical thiazide diuretic such as hydrochlorothiazide or chlorthalidone actually may be more effective . Spironolactone may be useful if hypokalemia is present, but there is usually little excuse for this expense when other equally or more effective medication could be used at a lesser cost. Approximately 30 to 40 percent of all hypertensives respond to a diuretic agent alone. In some more complicated cases, cost of treatment might be as much as ten times the cost of using a diuretic agent alonebut these are the exceptions rather than the rule. What Has Treatment Accomplished? Our studies over the past 23 years have demonstrated that (1) over 85 percent of all hypertensive patients followed over a long period of time are controlled, (2) hospitalization is rarely , if ever , necessary and (3) in the vast majority of cases cost can be minimized by utilizing a simple workup and appropriate drugs , such as diuretics , as the first step in therapy . If the " stepped-care approach " advocated by the National Heart and Lung Institute is followed with drug cost kept in mind and treatment pursued to an end point of normotensive blood pressure levels, a sharp reduction in the number of strokes occurs, and the incidence of heart and kidney failure secondary to hypertension is sharply reduced . Data on prevention of heart attacks are less impressive. In a Veterans Administration study , the occurrence of ruptured aneurysms, strokes , heart and kidney failure were dramatically reduced, and mortality was significantly less in the treated patients as compared to controls . The number of heart attacks did not appear to be influenced . Many investigators feel that a study of young men started on treatment for their high blood pressure at an early age and continued on therapy will demonstrate a distinct decrease in the number of heart attacks. How Will Treatment Affect Health Care Costs? Successful treatment of hypertension will have a significant impact on the eco-
nomic and social problems associated with cardiovascular disease. It is estimated, for example, that approximately 10 to 15 percent of all patients on renal dialysis programs would not have gone into kidney failure if their blood pressures had been treated at an early age. Several billions of dollars could be saved by preventing strokes that presently occur. There is no question that a marked decrease in hospital costs could also be effected by adequate long-term management of high blood pressure . A decrease in disability and lost productivity costs alone might save an additional several billion dollars, provided , of course , that the cost of treatment of hypertension can be kept within limits by the approach suggested above . If we are to prevent runaway costs of a health system which is already under great strain , high blood pressure or hypertension is one of the diseases to start with. It requires increasing physician, pharmacist and lay education, but the job can be done . The pharmacist can play a key role in helping with lay education and coordinating contacts between the physician and the patient. A tremendous economic and social saving can be effected on a national level if greater numbers of patients with high blood pressure are brought under continuous effective treatment. •
Silent Disease (Continued from page 184) service education programs for hospital and long-term care facility personnel. APhA also is cooperating with the National High Blood Pressure Education Program to make available to pharmaCists a number of materials to assist in their National High Blood Pressure Month activities, as well as in their regular dealings . with their hypertensive patients . For a description of materials and ordering information , see " Hypertension Materials for Pharmacists " on page 184. It already has been clearly demonstrated that significant progress can be made in alleviating the problem of undetected and uncontrolled hypertension , and pharmacists have already made notable contributions to the effort. National High Blood Pressure Month 1976 is another opportunity to reaffirm and intensify the commitment to continue those contributions . •
Journa l of th e American Pharm aceutica l Assoc iation
National High Blood Pressure Month
National High Blood Pressure Month, which will be observed in May, will mark the third round of an ongoing battle against an awesome opponent-hypertension. Similar observances in 1974 and 1975 have begun to weaken this silent disease that affects about one out of ten Americans, and it is hoped that 1976 will bring it to the mat. The annual national observance is just one of many diversified activities of the National High Blood Pressure Education Program, a unique collaborative association of private and governmental groups which work year-round to help combat uncontrolled hypertension. The American Pharmaceutical Association and its subdivisions-the Academy of Pharmaceutical Sciences, the Academy of Pharmacy Practice and the Student American Pharmaceutical Association-have been actively involved in the National High Blood Pressure Education Program since its inception in 1972, and they are among those organizations sponsoring National High Blood Pressure Month 1976. 1975 Observances Pharmacists and pharmacy organizations played a big part in the success of the 1975 observance last May. During that month, 895 organizations throughout the United States reported activities directed at educating both lay and professional groups, establishing screening and referral programs and participating in community hypertension coordinating councils. Over 1,200 lay and professional publications published articles, features and columns emphasizing some aspect of the high blood pressure problem, and 20 major professional journals, including this Journal, devoted space to hypertension related material. In Texas, each of the 48 component associations of the Texas Pharmaceutical Association was provided a special kit to carry out a statewide media campaign during May 1975. Campaign objectives were to (1) encourage the public to have their blood pressure checked regularly, (2) establish the community pharmacy as a source of information about high blood pressure and (3) provide more information to pharmacists to enable them to more effectively counsel patients concerning hypertension. Members of the Bexar County (Texas) Pharmaceutical Association operated detection centers at several shopping malls during the month, and nine pharmacies in San Antonio are involved in an ongoing
Vol. NS 16, No. 4, April 1976
Combating the Silent Disease program of screening and monitoring patients for high blood pressure. The Michigan Pharmaceutical Association devoted the May 1975 issue of the Michigan Pharmacist to the theme, "Hypertension-The Pharmacist's Expanding Role," and MPA supported various local association projects which included screening programs, and educational lecture series and a patient compliance study project. In Arizona, Pharmacist Tom Samuel is president of the Tucson Breakfast Lions Club which purchased a 36-foot trailer truck and equipped it for vision, hearing and hypertension screening. Ninety Lions, with the help of wives and student volunteers from the University of Arizona school of pharmacy, schedule clinics at schools, parks, libraries, county fairs and shopping centers each week-end. The Illinois Pharmaceutical Association devoted the April issue of its journal to hypertension, and Pharmacist Aaron Goldin was active on the association's hypertension committee and in other activities related to high blood pressure education. In Indiana, a pharmacist-conducted hypertension screening program was developed by the Purdue University school of pharmacy and pharmacal sciences. The program includes a six-hour seminar for participating community pharmacists covering accurate measurement of blood pressure, patient communication techniques and the procedure for efficiently providing hypertension screening in a community pharmacy. In the Indiana program, multiple high readings at least 24 hours apart are required before suspected hypertensive patients are referred to a physician. A follow-up procedure also is a program feature. The Indiana Pharmaceutical Association was instrumental in the formation of a coalition of community health agencies which were concerned about high blood pressure, including the kidney foundation, dental association, medical association, heart association, board of health, Blue Cross/Blue Shield, and nfpresentatives from several public health clinics, centers and hospitals. During National High Blood Pressure Month, coalition members pooled and distributed their various public education material to the media, and also developed a coordinated, communitywide high blood pressure screening, referral, and follow-up system which was standardized and used by the various agencies. Since May 1975, several pharmacists in San Joaquin County, California, have been
participating in a high blood pressure screening program sponsored by the San Joaquin Pharmaceutical Society with the cooperation of the local heart association. Pharmacists obtain certain demographic information from the patient and measure the patient's blood pressure. This data is recorded and referred to the heart association for evaluation by a physician and for identification of those individuals who should receive further study. The actual referral is then accomplished by heart association staff. As a result of this program, 220 patients out of 1,000 were referred for additional evaluation and diagnosis. May 1975 served to provide added visibility to the Virginia Pharmacists' High Blood Pressure Program, a pilot research and demonstration project sponsored by the school of pharmacy of the Virginia Commonwealth University and funded by the Virginia Regional Medical Program. The program seeks to evaluate the effect of community pharmacy services on patients with high blood pressure and hopes to demonstrate that hypertensive patients receiving the pharmacist's services have better controlled blood pressure than a matched group of hypertensive patients not receiving these services. Pharmacists in the program work closely with physicians and are given intensive training 'in hypertension and in methods of interviewing and monitoring patients with high blood pressure. Pharmacists use patient medication profile cards to detect potential drug interactions and to monitor compliance, and they educate patients regarding their disease and the treatment using audio visual programs and brochures developed for the purpose. The Arkansas Pharmaceutical Association, like many of the nation's state pharmaceutical organizations, issued a news release calling the public's attention to the 1975 observance and pointing to the pharmacist as a source of information on the disease and its consequences. The release also cited the Arkansas Heart Asso-
183
Combating the Silent Disease
ciation as an information source and listed a toll-free number which can be used for public inquiries. Although the 1975 observance of National High Blood Pressure Month fell at an inopportune time for many pharmacy students at the end of the school year, support for the observance by students and chapters of the Student American Pharmaceutical Association was outstanding. Provided with many materials from the SAPhA national office, local chapters were active in public education programs and in establishing screening and referral programs. As a result of activities initiated last May, several student-operated high blood pressure screening programs are still underway, notably those at the University of Arkansas college of pharmacy and at Temple University in Philadelphia . Pharmaceutical manufacturing firms also intensified their anti-hypertension efforts during the 1975 observance. For example, the Pharmaceutical Division of Ciba-Geigy estimates that over 225,000 people were screened in May at more than 75 CHEC programs throughout the country, and Searle Laboratories sent a special letter to 50 ,000 physicians encouraging the motivation of patients to adhere to their treatment program and advising physicians of the reduction in insurance costs to patients who have shown a decrease in blood pressure over a stated period of time. The examples stated above are just that, for it would be impossible to relate all
of the activities of the thousands of pharmacists and pharmacy students who helped make the 1975 observance of National High Blood Pressure Month so successful. But the examples certainly demonstrate the commitment of the profession to combat this serious national health problem . It is probably too early to say that we have the problem of undetected and untreated hypertension on the run , but there is little doubt that we have come a long way since the massive national effort was undertaken in 1972. From data recently released by the National Heart and Lung Institute, the effects are apparent. Among a select hypertensive population studied, there is evidence of a change from 50 percent of those affected being aware in 1971 that they had the disease to the point where about 75 percent are now aware. Nationwide, the number of physician visits for hypertension has increased 41 percent over 1971 levels. As impressive as these statistics are, officials of the National High Blood Pressure Education Program estimate that there are still about 7. 1 million persons with undetected hypertension and probably another 4 .3 million persons who know they have the disease but have not had it brought under control. A big job remains to be done. How can pharmaci sts and pharmacy students take part in 1976 National High Blood Pressure Month Activities in May?
The preceding examples should provide many ideas ; the following suggestions also will be helpful 1. Distribute informational materials to patrons. 2. Develop and/or adopt a system for reminding hypertensive patients when prescription renewals are due . 3. Place special emphasis upon the importance of monitoring hypertensive patients' use of prescription and nonprescription drugs. 4. Provide supplementary screenings for borderline and diagnosed hypertension patients, informing both the patient and his physician about the reading . 5. Participate in the presentation of information on hypertension control at lay and professional meetings . 6. Take part in the planning and implementation of a community hypertension control program that can function within the health care system, i.e. , Heart Association; Red Cross; medical , nursing, dental societies; state/county health departments; Blue Cross/Blue Shield, etc . 7. At both the practitioner and student levels, initiate interdisciplinary discussion groups to develop a cooperative approach to hypertension control. 8. In hospitals and long-term care facilities , urge that all admissions receive blood pressure measurement routinely . 9. Include hypertension as a topic for in(Continued on page 186)
Hypertension Materials for Pharmacists
a description of the National High Blood Pressure Education Program, and a series of articles chosen to help the pharmacist in dealing with his patients with high blood pressure.
active part in National High Blood Pressure Month. Besides general background information on the problem of high blood pressure, the handbook contains suggestions for specific activities, samples of public education and public relations materia ls and an order form for hypertension-related materials.
Do you want to know more about hypertension? Would you like some handy tips for providing better pharmaceutical service to your hypertensive patients? Do you need some good suggestions for taking part in National High Blood Pressure Month? APhA is cooperating with the National High Blood Pressure Education Program to make the following materials available• Detecting and Controlling Hypertension-A Source Book for Pharmacists Published by APhA in cooperation with the National High Blood Pressure Education Program, this 48-page publication includes an overview of hypertension and antihypertensive therapy, a summary of the recommendations of the National Pharmacy Symposium on High Blood Pressure,
184
• Special Information Bulletin for Pharmacists Developed by the Nationa l High Blood Pressure Education Program with input from individual pharmacists and pharmacy associations, this publication is designed to describe to pharmaCists in a clear and concise manner many of the roles they can play in combating the problem of undetected and uncontrolled hypertension. • Handbook of National High Blood Pressure Month Activities, Resources and Materials. This 50-page handbook developed by the NHBPEP is a must for pharmacists and pharmacy students who want to take an
A single copy of each of these publications is available without charge . For more than sample copies, a distribution plan must be included which contains- I 1) a description of the program in which the materials would be used , (2) the audience for whom the materials are intended , (3) how they will be disseminated and (4) the objective to be accomplished. Order , by title , from : National High Blood Pressure Education Program, High Blood Pressure Information Center, 120/ 80 National Institute s of Health, Bethesda, MD 20014.
Journal o f the American Pharmaceutica l Association
If we are to prevent runaway costs of a health system which is already under great strain, hypertension is one of the diseases to start with
Table I
Economic Cost of Illness in the United States-
1972 Approximate Cos t * A II diseases Cardiol'asclilar diseases Arter iosc le ro tic hea rt d isease Hypertens iun Stroke Cost oI prodllctil'itl' loss Card iovascular d isea scs *Social Securi t y Bureau.
189
Billion
40
Billion
20 Billion (N III estimat e) 3.5 Billion 6.0 Billion
6.5 Billion Adm ini stration In fo n nation
task force on " detection , criteria and the stepped-care system of treatment " that diuretics should form the cornerstone of therapy in practically all hypertensives, recent prescription data demonstrate that about 30 percent of hypertensives still are being treated with another drug first , in many instances , reserpine or alphamethyldopa . In recent months, propranolol has become a " first drug " in treatment. These drugs should be used only with a diuretic and probably only after a diuretic has been proved to be ineffective. If a blood pressure response is not obtained, medications should be added or substituted until either significant side effects occur or satisfactory blood pressure lowering results. The Economics of Treatment Until recent years , most medical colleges and teaching centers advocated a complete workup for every hypertensive patient. Thousands of patients with high blood pressure were hospitalized for as long as seven to 10 days and submitted to exhaustive studies which often cost several thousand dollars . Only approximately one to three percent of all patients with high blood pressure have a specific cause for this disease ; exhaustive studies are clearl y not indicated in the ' majority of patients . A few simple tests performed during one or two visits are necessary. If the patient does not respond appropriately to therapy , treatment can be stopped and more elaborate studies .ouch as X-rays of the kidneys can be performed . Reducing the cost of studying patients is one way that physicians can reduce the total health
186
care cost of this major disease; this represents cost effective, good medical care . Another way to reduce cost and eliminate one of the reasons why hypertensive patients discontinue a treatment program is to be aware of the cost of medication. For example , it is a mistake to use a drug such as spironolactone, where three or four tablets a day must be taken, as the initial diuretic since this drug is expensive. Instead, one or two tablets a day of a typical thiazide diuretic such as hydrochlorothiazide or chlorthalidone actually may be more effective . Spironolactone may be useful if hypokalemia is present, but there is usually little excuse for this expense when other equally or more effective medication could be used at a lesser cost. Approximately 30 to 40 percent of all hypertensives respond to a diuretic agent alone. In some more complicated cases, cost of treatment might be as much as ten times the cost of using a diuretic agent alonebut these are the exceptions rather than the rule. What Has Treatment Accomplished? Our studies over the past 23 years have demonstrated that (1) over 85 percent of all hypertensive patients followed over a long period of time are controlled, (2) hospitalization is rarely , if ever , necessary and (3) in the vast majority of cases cost can be minimized by utilizing a simple workup and appropriate drugs , such as diuretics , as the first step in therapy . If the " stepped-care approach " advocated by the National Heart and Lung Institute is followed with drug cost kept in mind and treatment pursued to an end point of normotensive blood pressure levels, a sharp reduction in the number of strokes occurs, and the incidence of heart and kidney failure secondary to hypertension is sharply reduced . Data on prevention of heart attacks are less impressive. In a Veterans Administration study , the occurrence of ruptured aneurysms, strokes , heart and kidney failure were dramatically reduced, and mortality was significantly less in the treated patients as compared to controls . The number of heart attacks did not appear to be influenced . Many investigators feel that a study of young men started on treatment for their high blood pressure at an early age and continued on therapy will demonstrate a distinct decrease in the number of heart attacks. How Will Treatment Affect Health Care Costs? Successful treatment of hypertension will have a significant impact on the eco-
nomic and social problems associated with cardiovascular disease. It is estimated, for example, that approximately 10 to 15 percent of all patients on renal dialysis programs would not have gone into kidney failure if their blood pressures had been treated at an early age. Several billions of dollars could be saved by preventing strokes that presently occur. There is no question that a marked decrease in hospital costs could also be effected by adequate long-term management of high blood pressure . A decrease in disability and lost productivity costs alone might save an additional several billion dollars, provided , of course , that the cost of treatment of hypertension can be kept within limits by the approach suggested above . If we are to prevent runaway costs of a health system which is already under great strain , high blood pressure or hypertension is one of the diseases to start with. It requires increasing physician, pharmacist and lay education, but the job can be done . The pharmacist can play a key role in helping with lay education and coordinating contacts between the physician and the patient. A tremendous economic and social saving can be effected on a national level if greater numbers of patients with high blood pressure are brought under continuous effective treatment. •
Silent Disease (Continued from page 184) service education programs for hospital and long-term care facility personnel. APhA also is cooperating with the National High Blood Pressure Education Program to make available to pharmaCists a number of materials to assist in their National High Blood Pressure Month activities, as well as in their regular dealings . with their hypertensive patients . For a description of materials and ordering information , see " Hypertension Materials for Pharmacists " on page 184. It already has been clearly demonstrated that significant progress can be made in alleviating the problem of undetected and uncontrolled hypertension , and pharmacists have already made notable contributions to the effort. National High Blood Pressure Month 1976 is another opportunity to reaffirm and intensify the commitment to continue those contributions . •
Journa l of th e American Pharm aceutica l Assoc iation
