Guidelines do not address marginal cost benefit
The new hypertension guidelines have implications for the NHS beyond
patient care.(1) We have used the guidelines to amend our practice
hypertension protocol but paused to consider the effect this change have
in practice. It seems likely that in order to achieve the more stringent
targets that more frequent visits will be needed and multiple drug
treatment will be necessary. What is the benefit for the patient
(absolute risk reduction) resulting from the change in target blood
pressure from previous guidelines?(2) Furthermore what resource
implications are there for the NHS?
The drug budget is already under pressure from increased generic drug
costs, new drugs and secondary prevention of ischaemic heart disease.
Experience from the UKPDS certainly suggests that there will be additional
drug and consultation costs associated with a strategy of tight blood
pressure control.(3) Extrapolating from their data one may expect an
additional £80 annual drug cost per patient which would consume 10% of the
total practice drug budget for the currently identified hypertensive
patients in our practice.
Whilst the guidelines may represent best practice they should include
some guidance from the health economic point of view. What is the cost of
each additional stroke prevented by moving from the old recommendations to
the new? With cash limited primary care budgets no clinical guidelines
are complete without a consideration of the marginal costs and benefits of
any change in policy.
Three Swans Surgery,
Health Care Research Unit,
Level B South Academic Block,
Southampton General Hospital,
1. Ramsay LE, Williams B, Johnston GD, MacGregor GA, Poston L,
Potter JF, Poulter NR, Russell G. British Hypertension Society guidelines
for hypertension management 1999: summary [see comments]. BMJ
2. Sever P, Beevers G, Bulpitt C, Lever A, Ramsay L, Reid J, Swales
J. Management guidelines in essential hypertension: report of the second
working party of the British Hypertension Society BMJ
3. UK Prospective Diabetes Study Group. Cost effectiveness analysis
of improved blood pressure control in hypertensive patients with type 2
diabetes: UKPDS 40. BMJ 1998;317(7160):720-6.
Competing interests: No competing interests