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The influence of absolute cardiovascular risk, patient utilities and costs on the decision to treat hypertension: a Markov decision analysis

Two major outstanding questions in the management of hypertension are: (i) why are doctors reluctant to prescribe antihypertensive drugs, and (ii) why are patients reluctant to initiate and continue treatment? Small changes in prescribing practice and concordance have the potential for much greater impact on morbidity and mortality than minor differences in efficacy between drug classes. However, in comparison with the vast resources spent on clinical trials comparing drugs, these practical issues have received scant attention. Although many influences on prescribing and concordance are unknown, the devolution of responsibility for healthcare budgets to frontline doctors has concentrated their minds on value for money, and benefit from drug treatment is a major influence in a patient’s decision of whether or not to take antihypertensive drug treatment [1]. Montgomery et al. [2] attempt to cast light on both these important questions using an analysis of the individual benefits and overall cost-utility of antihypertensive drug treatment. In particular, they challenge the current vogue to base treatment decisions on a patient’s absolute risk of suffering a coronary heart disease (CHD) event in the short term, citing concerns about the tendency of this approach to focus treatment on the elderly. Theirs is one of the few attempts to incorporate all aspects of the patient perspective by inclusion of a directly measured estimate of perceived utility of taking tablets, as well as quality of life in those health states avoided by antihypertensive drug treatment. Inclusion of the personal costs of drug treatment together with its benefits is important because many patients harbour concerns about ongoing sideeffects and the possible long-term effects of drugs, thus influencing their decision to take treatment [3].