AJH
EDITORIAL
1992; 5:670
What Is the Best Therapy? Lawrence R. Krakoff
T
he differences of opinion clearly expressed in the two preceding letters reflect ongoing efforts to grapple with a most important issue. Are the more recently developed antihypertensive drugs, specifically angiotensin converting enzyme (ACE) inhibitors and calcium channel blockers, truly better therapy (ie, more effective) for prevention of cardiovascular disease, compared to the (now) older agents: thiazide diuretics and ^-blockers? If not, how can one justify the unequivocally higher cost of the newer agents? Goldman and Weinstein have developed a complex model of cost-effectiveness that relies on many assumptions and data inputs for its projections of effectiveness and costs for an entire population of treated patients. Without a detailed analysis of the model and how some of their assumptions were made, clinicians are likely to be suspicious about accepting conclusions emerging from another "black box." Kaplan's views represent an optimism that some of the newer drugs, the ACE inhibitors and calcium channel entry blockers in particular, may well be better than the older agents due to differences in effects on serum lipid levels and perhaps glucose tolerance and insulin resistance as well. 1,2
Dr. Krakoff is Deputy Editor of American Journal of Hypertension.
© 1992 by the American Journal of Hypertension, Inc.
We have, it seems, a clash between two perspectives: that of the epidemiologist/economist concerned for the overall greatest good for the greatest number (including those who pay the bills) and the doctor who wants optimal care for each patient in his practice. What can be done to resolve these differences? More and better long-term studies defining the true effectiveness of alternate drug treatment strategies must be made available. However, the "cost" element is clearly not enough. There needs to be more emphasis on quality of life, since there is no real transformation function which converts dollars to any units that might express such quality, as pointed out by Scheiner and Melmon many years ago. We clinicians face many unknowns in prescribing long-term medication for our patients. However, we do know that if we were the patient, we would gladly pay more for a treatment that lowered our pressure without either symptoms or silent risk. 3
REFERENCES 1.
Goldman L, Weinstein MC: Reply to Kaplan. Am J Hypertens 1992;5:666-668.
2.
Kaplan NM: Response to Goldman and Weinstein. Am J Hypertens 1992;5:668-669.
3.
Scheiner LB, Melmon KL: The utility function of antihypertensive therapy. Ann NY Acad Sci 1978;304:112122.
0895-7061/'92/'$5.00
EDITORIAL
1992; 5:670
What Is the Best Therapy? Lawrence R. Krakoff
T
he differences of opinion clearly expressed in the two preceding letters reflect ongoing efforts to grapple with a most important issue. Are the more recently developed antihypertensive drugs, specifically angiotensin converting enzyme (ACE) inhibitors and calcium channel blockers, truly better therapy (ie, more effective) for prevention of cardiovascular disease, compared to the (now) older agents: thiazide diuretics and ^-blockers? If not, how can one justify the unequivocally higher cost of the newer agents? Goldman and Weinstein have developed a complex model of cost-effectiveness that relies on many assumptions and data inputs for its projections of effectiveness and costs for an entire population of treated patients. Without a detailed analysis of the model and how some of their assumptions were made, clinicians are likely to be suspicious about accepting conclusions emerging from another "black box." Kaplan's views represent an optimism that some of the newer drugs, the ACE inhibitors and calcium channel entry blockers in particular, may well be better than the older agents due to differences in effects on serum lipid levels and perhaps glucose tolerance and insulin resistance as well. 1,2
Dr. Krakoff is Deputy Editor of American Journal of Hypertension.
© 1992 by the American Journal of Hypertension, Inc.
We have, it seems, a clash between two perspectives: that of the epidemiologist/economist concerned for the overall greatest good for the greatest number (including those who pay the bills) and the doctor who wants optimal care for each patient in his practice. What can be done to resolve these differences? More and better long-term studies defining the true effectiveness of alternate drug treatment strategies must be made available. However, the "cost" element is clearly not enough. There needs to be more emphasis on quality of life, since there is no real transformation function which converts dollars to any units that might express such quality, as pointed out by Scheiner and Melmon many years ago. We clinicians face many unknowns in prescribing long-term medication for our patients. However, we do know that if we were the patient, we would gladly pay more for a treatment that lowered our pressure without either symptoms or silent risk. 3
REFERENCES 1.
Goldman L, Weinstein MC: Reply to Kaplan. Am J Hypertens 1992;5:666-668.
2.
Kaplan NM: Response to Goldman and Weinstein. Am J Hypertens 1992;5:668-669.
3.
Scheiner LB, Melmon KL: The utility function of antihypertensive therapy. Ann NY Acad Sci 1978;304:112122.
0895-7061/'92/'$5.00
