The Cost of Hypertension Guideline Compliance

The idea of evidence-based guidelines has been around for quite a while.  One of their big problems has been that the “evidence” tends to change, often dramatically, and that population-based guidelines are at odds with our increasing understanding that there is wide biochemical variation across individuals.  (NEJM Article)  High blood pressure is one of the most common chronic conditions and many guidelines regarding its treatment have been promulgated.  The most recent “consensus” guidelines were released in 2014.  The authors attempted to estimate the effects of treating all patients according to this guideline, which focuses more on diastolic rather than systolic blood pressure for adults under 60, has a higher blood pressure goal for adults 60 or older or for patients with diabetes or chronic kidney disease.  (These changes were made because the former “evidence-based” guidelines were causing significant harm to many patients.)  Using a model that attempted to ascertain how many people would be treated under the guideline compared to how many are actually receiving treatment now, and assuming the treatment would be effective, what different outcomes would be achieved.  About 860,000 more people who have been diagnosed with heart disease or high blood pressure would be treated each year from 2014 to 2024 and an additional 8.6 million who have hypertension but not heart disease would also be treated each year.  All this new treatment would prevent about 13,000 deaths a year and 56,000 cardiovascular events a year.  For some groups the treatment was found to be cost-saving; i.e. the costs of treatment would be outweighed by the savings in prevented medical care, but it is not clear that the researchers added all the costs from people living longer.  For other groups, it would be cost-effective, which means it would add to health care spending, but would be worth it in terms of more years of life for the patients.  Treating everyone with high blood pressure who should be treated is a worthy goal, but I am dubious about “modeled” results, and you have to be a little leery of the staying power of any guideline.