Why do we overtreat hypertension?BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e5923 (Published 04 September 2012) Cite this as: BMJ 2012;345:e5923
- Des Spence, general practitioner, Glasgow
“Bloody GPs: sending up this dross!” When medical referrals were received the air was always thick with vitriol, cigarette smoke, and expletives. “Why don’t you send them home if you think the referrals are such rubbish?” I quizzed. The answer: “No one gets sued for admitting patients!” It’s true. No one complains about doctors who are overcautious, overinvestigating, or overtreating. Medicine was once about assessing individual risk, making decisions, and giving a balanced opinion. But in today’s climate it is simpler to intervene early and involve everyone rather than leave yourself open to criticism later.
A recent Cochrane review of hypertension suggests that treating blood pressure of 160/100 is ineffective.1 This means that millions of people in the UK are potentially being overtreated. But the situation may be worse still. Current guidelines from the National Institute for Health and Clinical Excellence recommend treating hypertension only after a risk assessment using the QRisk algorithm (www.qrisk.org) to predict cardiovascular disease.2 But I suspect that many doctors ignore this advice and treat according to blood pressure readings, possibly leading to overtreatment for millions more patients. Why might doctors ignore NICE’s guidance?
Risk is a difficult concept for doctors and patients alike. We tell a patient that he or she has high blood pressure, a dangerous risk factor for stroke and heart attack, the subject of countless initiatives and health campaigns. If, after assessing the so called risk, we decide not to treat, the patient asks why. We explain that he or she lives in the wrong postcode, is of the wrong sex, or isn’t old enough. This normally goes down badly. Risk calculations might make some sense at a population level but are meaningless to most individuals. And for patients (and many doctors) “high blood pressure” is not a moveable concept—you either have it or you don’t. Patients feel that they are being denied treatment, and doctors feel uneasy about not treating. What if the patient has a stroke or heart attack, despite the low risk? What will they and their family—or worse, a coroner—think? The “what if” question haunts clinical care. And few patients are aware that there are financial incentives to diagnose and treat hypertension in general practice.3
The truth is that doctors often treat according to the numbers, not the risk, because no one ever complained, blamed, or sued over overtreatment. This is human nature, not science. Overtreatment of risk factors such as blood pressure, high cholesterol, and osteoporosis is happening everyday and everywhere. And drugs are easy to start but nigh impossible to stop because of the “what if” question. Are millions of patients being overtreated?
Cite this as: BMJ 2012;345:e5923
Follow Des Spence on Twitter @des_spence1