MEDICAL MATTERS: Evidence-based cost-cutting can improve care, writes MUIRIS HOUSTON
WE ARE facing even more savage cuts to the health service in coming months as hospitals run out of money. And next year’s budget is likely to see another €1 billion wiped from health spending. Can cuts of this magnitude be managed in a way that doesn’t harm patients?
Given the track record of the Health Service Executive, there is a real and palpable fear that the task is beyond the organisation. Money can be saved effectively but only when the necessary decisions are rational and evidence-based.
An excellent example of how clinical care can be made more cost effective came with last week’s publication by both the Lancet and the National Institute of Clinical Evidence (NICE) of new guidelines on the diagnosis and treatment of high blood pressure. NICE funded research by the University of Birmingham to assess whether the current standard – basically having three separate high BP readings when assessed at a clinic or when self-measuring BP at home – or a new method using mobile 24-hour blood pressure monitors, was the most cost effective way to manage the condition.
Because about a quarter of people find visiting a GP stressful, their blood pressure may seem high when, in fact, it is not. This so-called “white-coat hypertension” leads to over-diagnosis and to the prescription of drugs the patient does not need. Now, NICE has advised doctors in England and Wales to move to the ambulatory diagnosis of patients using a 24-hour monitor that automatically records blood pressure readings every 30 minutes day and at night.
According to the researchers, ambulatory monitoring is “cost saving in the long term as well as more effective and so will be good for patients and doctors alike”. Experts reckon the move could save the National Health Service about £10.5 million (€11.8 million) every year, with a one-off implementation cost of £2.5 million (€2.8 million). This is because of the reduced number of GP visits and reduced drug costs as those who have “white-coat hypertension” no longer receive unnecessary treatment.
High blood pressure is one of the most important preventable causes of premature ill-health and death in Ireland. It is a major risk factor for stroke, heart attack, heart failure, chronic kidney disease and cognitive decline. Hypertension, defined as an average blood-pressure reading of 140/90mmHg or higher, affects about 25 per cent of our adult population. The risk associated with increasing blood pressure is continuous, with each 2mmHg rise in systolic blood pressure (the top reading) associated with a 7 per cent increased risk of mortality from coronary heart disease and a 10 per cent increased risk of death from stroke.
Although the groundbreaking change applies immediately in the UK, doctors here follow the guidelines of the British Hypertension Society closely and so Irish patients can expect the following approach: if your blood pressure in the surgery is 140/90mmHg or higher, the doctor will offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. People under 80 years with an initial clinic systolic blood pressure of 140/90mmHg or higher and subsequent ABPM daytime average of 135/85mmHg or higher, as well as established cardiovascular or renal disease or diabetes, will be offered drug treatment. And anti-hypertensive treatment will be recommended to people of any age with an initial systolic blood pressure exceeding 160mmHg and/or a diastolic blood pressure of 100mmHg or more and subsequent ABPM daytime average of 150/95mmHg or higher.
It’s the first major change in the way high blood pressure is diagnosed in more than a century. But perhaps more importantly for the times we live in, it’s a great example of how to logically rationalise healthcare. A director of the US office of management and budget once said: “That’s the trouble with government: fixing things that aren’t broken and not fixing things that are broken.”
We have a broken health service: can James Reilly fix it in a measured way while at the same time saving money?