I think the most disheartening part of this is: doctors quit reading journals and research when they go into practice. This means that I am usually more informed than my doctor on a lot of drugs and therapy, which is pathetic. I too am a busy person working full time and managing a home. What the hell, can't they even read the abstracts?

You might notice the same result all over when drugs go generic. Generics which perform as well or better than their branded therapeutic equivalents often end up doing worse. Perhaps this is a story of low marginal costs and free-riding between generics, leading no one to promote or run clinical studies on them.

On the point about capitation, it has its own problems. I am wondering how other countries do this. We could equally look to a French model where there are fewer generics but price ceilings and comparative effectiveness studies done by the insurer. But why are they that much more effective than US managed care organizations, despite having having more generous formularies and fewer dollars of cost sharing? Does anyone know if they also have a capitation or other system to incite cost-effective prescribing directly among doctors?

The ACE inhibitor used in the study, lisinopril, has been available as a generic for several years. It's now dirt cheap, so the cost issue is now moot.

It's unfortunate for the Pharmeceutical industry that Newt Gingrich isn't House Speaker anymore. If he was, then he could cut funding the for federal agencies that report these findings as he did in 1990 when attempted to defund the Agency for Health Care Policy and Research when it reported that 90% of back surgeries were unnecesary.

The Pharmeceutical industry has apparently learned nothing from the Banking debacle. When an industry cannot police itself and acts with heedless avarice against the public interest it courts disaster and invites greater regulation and control.

Let's see, this is Tuesday, so Big Pharma is my hate object for the day - Mondays are private Health Insurance companies.

I don't have a solution to how to reign-in the anti-social behavior of the drug companies, except much greater federal regulation and punishments through the tax system. Sometimes I just want them to STOP running these so-called 'educational ads' for their drugs on teevee directed at the consumer. If I hear 'talk to your doctor about....to see if it is right for you' one more time I may go postal.

Bring on the orange jumpsuits for their executives. The rats are in control of the ships.

I prescribe generic diuretics, generic ACE-Is, generic beta blockers, and generic calcium channel blockers every single day. They are all cheap and they are all useful and they are all intolerable for some people. I even prescribe the generic for Cardura for prostatic hypertrophy if not for blood pressure. It's rare to see a patient who isn't taking a diuretic, but certainly, if they aren't, that would be one of the first things to add. Most of the ACE-I and ARBs come in combination pills with hydrochlorthiazide included. If I were very, very careful to make sure that everyone who can tolerate a diuretic is placed on one, the increase in diuretic use would still be very small.

The JNC VI algorithm recommended a beta blocker or an ACE-I first and then a diuretic. The JNC VII recommends a diuretic first for non-diabetics and an ACE-I or ARB for diabetics and people with kidney disease.

The generic for Cardura is usually reserved for men with prostatic hypertrophy.

"The pharmaceutical companies had a skilled team and a lot of money promoting their drugs. No one was promoting the generic diuretics."

DC's actually addressing this issue - under SafeRx, the Department of Health will send academic detailers to doctors' offices to tell them what all of the research really says (as opposed to just focusing on the studies that show the most favorable results, the way drug-company detailers do).

Vermont, Maine, and Pennsylvania apparently have similar academic detailing programs in the works, or, in Pennsylvania's case, already up and running.

As a long-time sufferer of hypertension, I have become something of a mini-expert on these matters. My knowledge is a mile deep and a millimeter wide, unfortunately, meaning any intelligent doctor will quickly figure out what I don't know and then dismiss what I do. But having thus given this caveat, let me say:

Diuretics ARE effective at reducing blood pressure. They are also known to dramatically cut incidence of stroke (by about 45%). Unfortunately, as many enormous and expensive studies in the past have well proven (I'm thinking the Mr. Fit and ALLHAT studies), overall mortality rates for people on diuretics do NOT go down.

This is not to suggest that all the other classes of drugs are somehow superior. The reality is this: taking drugs for hypertension -- except in the 5-10% of cases that aren't primary (essential) hypertension, and/or cases of hypertensive crisis -- is a little like rearranging deck chairs on the Titanic.

Since the late 1970s or early 1980s, the cause of essential hypertension has been absolutely known at the cellular level. It is too much sodium and not enough potassium in the diet. Period. The actual mechanism (involving the sodium-potassium pumps that cover every cell in the body, as well as other mechanisms bodywide) are fairly well understood. If you find a drug that pulls down blood pressure, you are not actually addressing the underlying problem. Instead, it's kind of akin to "fixing" an empty fuel tank on your car by breaking the fuel gauge and forcing the needle to the "full" position.

Moreover, this isn't just hypothetical. We have a powerful real-world example to consider. Finland, in the mid-1980s, mandated that a salt-potassium mixture (called "Pansalt") be used instead of regular table salt in virtually all processed foods in the country. A decade later, a national study there found that stroke and heart attack rates had dropped 60 PERCENT or more for both men and women. This despite increases in smoking among women and greater obesity among men. Researchers attributed about 66% to 75% of the drop to the mandated use of Pansalt which is now in something like 20,000 processed foods, including many restaurant foods.

A more recent study in, I think, Taiwan compared a similar salt substitution in a large retirement home's kitchen to a comparable retirement home with no such change. The same result was seen very quickly.

J. Bean above, a doctor, noted correctly that diuretics and virtually all other anti-hypertensives cause intolerable side effects in a lot of patients. I know personally. What I've suffered over the years has virtually ruined my life (and made much worse by the repeated assurances of my doctors that "oh, that drug doesn't cause THAT side effect," when in fact my own research later showed it most certainly did). Among them is diabetes. My family has a proclivity to it, but only a mild one. I believe had I never been put on a diuretic, I would not now be diabetic (my then-doctor dismissed my concerns. An older and well respected doctor I used to have, when I happened to visit him on a vacation, was appalled and immediately pulled the diuretic, but too late: the diabetes seems irreversible now).

I can scream all day about the sleaziness of the pharmaceutical industry. They do produce occasional miracle drugs, they do save and improve many lives, but they are also monsters in some respects. But it really isn't because they favor expensive new drugs over diuretics. It's because they favor all drugs over urgently-needed dietary changes that are only now -- 25 years too late for me -- gaining traction in the public mind (e.g., Consumer Reports current issue with a story about low-sodium food choices).

To elaborate on what J Bean is getting at, diuretics reduce blood pressure by removing fluid from the body and reducing blood volume. This increases the concentration of the many things dissolved or suspended in the blood, and can be dangerous for some patients, so if there are drugs available that have fewer or less major side effects, there's a real reason to prescribe them. Medicine doesn't mean robotically following the literature because individual patients aren't statistical samples.

To be clear, I don't mean to suggest that it's okay to ignore the literature and just do whatever you feel like, but the results of papers generally mean something more specific than "PRESCRIBE MORE OF THIS DRUG".

I was originally on an angiotensin inhibitor (Avapro) for a while, but recently got put on Avalyde (basically Avapro plus a diuretic). An EMT was shocked I was on a diuretic with no fluid buildup, but my cardiologist was adament about its effectiveness for HBP.
My personal thought is that my diet is causing my issues, as I periodically get leg cramps (low potassium). Even with a low salt intake, the HBP wasn't going down, but adding multivitamins, making a conscious effort to eat potassium-rich foods, and EXERCISE have dropped my BP down to normal levels by evening time much more than the medications did. (I was at 200+/120+ but currently range from 120/75(evening)-150/100 (morning), with dips close to normal after going for mid-day walks at work.

Ezra,

So below are were the points I was hoping you'd make, pointing out that while the policy of benefit guidelines from a indepedent Fed Health board is very attractive, the devil is in the details-- and it is a devil.

From the article:

-- "“all trials have flaws” that leave the results open to interpretation"

-- “You might be answering a question that by the time you are done, no longer feels quite as relevant.”"

-- AHRQ "was now mainly using insurance records to judge how treatments perform. While clinical trials are the gold standard, she said, they are costly and time-consuming."

-- And yes, there will always be a "loser" stakeholder aiming to amplify the imperfections in the data. Even those without profit motives still have career motives, and there are plenty of folks in medicine who aren't balanced in their assessments for this reason as well. If your career has been about research in ACE inhibitors, you don't go away quietly, that's just human nature.

Altogether, the key points are that randomized clinical trials are the "science" in medicine, and that science is very helpful in providing solid evidence to a payor to justify restricting benefits. These trials don't measure everything, however, they are long and expensive, so you'll frequently have studies that provide a definitive answer while the field continues to evolve. Standard of care is a moving target, so its challenging to put a stake in the ground to make definitive assessments. Finally, the cheap and fast way to make these assessments real-time, using medical records (or claims data as AHRQ does) has significant advantages, but with the perils of retrospective analysis. So putting that all together, its very challenging to create an iron-clad case that can be used to restrict patients from accessing medicine for theirdisease. When you're doing this for thousands of treatments/diseases, its very difficult to see how a singular organization like a "Fed Health" could credibly be the authority with what will always be imperfect data, such that Americans would be comfortable with "Fed Health" being the final arbiter on health benefits.

wisewon:

Is your contention that MDs, as a whole, didn't increase their prescription of dieretics vs. other medications because they were making an informed scientific decision about methodological flaws?

It seems to obvious to me that they just weren't paying attention, because they have no reason to.

Maybe Ezra's change in incentives is right, and maybe a Fed Health Board is right... but it's clear that what's going on is a failure.

I prescribe generic diuretics, generic ACE-Is, generic beta blockers, and generic calcium channel blockers...

eat lots of organic bananas everyday,
and thank them.
drink lots of good water.
i think bananas are a wonder food.

sometimes, food can be good,
preventive medicine.

Ezra -

Are you saying that the proposal for a Fed Health Board would include an organization like Britain's NICE, which would do clinical effectiveness studies?

While Liz mentions that counter-detailing exists, most states have stopped their counter-detailing programs, having found them ineffective. In fact, some of the best designed studies on detailing show little effect from detailing (see Mizik and Jacobson; Gonul et al.; Richard and Van Horn).

As someone noted, insurance companies have already tried capitation. It's not what sets Britain apart from the US. It appears the greater effect is in generating the knowledge - the clinical studies, even after approval. If the US government, like NICE, were to perform such studies, we might expect to see greater changes in prescribing behavior.

to the doctors reading this site....
apart from research on medications for high blood pressure, i hope that doctors would also really work hard on encouraging patients to educate themselves about the benefits of good nutrition and sometimes refer patients for nutritional counselling when treating certain illnesses and complaints.
i know that the foods we eat may not be able to cure us, but they certainly can help us greatly.
just the inclusion of large amounts of organic fruits and vegetables into our diets, and taking fresh and healthy water into our systems can do so much to promote our good health.
i know how important medicine is in helping patients, but what we put into our bodies during the course of a day, is so important also.
especially during this holiday season, when people with high blood pressure and high cholesterol are eating so many salted and sweetened foods with additives....it is good to think of cleansing our systems with bananas, apples, vegetables and fresh water.
when people expect medications to do the work for them and we dont take in living food, we disconnect further from the natural processes that support us.
just a reminder, tossed into the mix, with a christmas buffet of diuretics, beta blockers, alcoholic beverages and tiramisu.

1) Change in diet and lifestyle is always the first line of treatment for essential hypertension. Guess what percentage of patients actually follow these recommendations.

2) Diuretics are good at reducing blood pressure for a low monetary cost, but they often have a very high cost in terms of side effects. These side effects can be everything from inconvenience (having to go urinate frequently) which leand to non-compliance, to syncope (feinting) which can lead to an auto accident, or a broken hip, or a head injury.

3.) Pharmaceutical companies should be reigned-in, but they're NOT the main reason patients are prescribed ACE inhibitors, Ca channel blockers, and beta blockers. They push their new drugs based on efficacy as well as improved side-effect profiles.

4.) Pharmaceutical companies also provide me with samples which I can give out FREE to patients who have no way to afford even generic meds out of pocket. When the get Medicare, I'll continue to prescribe the drug they're currently on if it's working well for them.

Actually, with Medicare, I will consider changing their Rx. The drug benefit won't work to cover all expenses for some of my patients. With Medicaid, I'll keep 'em on their current meds as long as they're covered.

It's important to treat patients, not to treat the chart or blindly follow study outcomes. A patient who actually complies with my treatment gets better. (I hope) A patient who is non-compliant because of cost, or side-effects, or even complexity of dosage regimen doesn't get better.

See what I'm saying here?

tweez: I would argue that a change in diet is not always the first line of treatment. I had a temporary high blood pressure condition which I changed by diet, but the first thing my MD did was prescribe a drug. The same for my cholesterol. Not once was diet mentioned. Not once was reducing my stress level at work mentioned. Not once was my weight mentioned.

Although anecdotal, I am sure that many people can tell a similar story.

But I believe that many doctors may shy away from working with a patient on diet since food is such a huge part of our self-description that many people quite literally think they will lose themselves (their manhood, their ethnicity, whatnot). Think of men and their meat and potato cultural fixation. I wonder what the ancient Greeks, Romans and Persians (to mention a few) did without meat and potatoes?

Well, if we're doing dueling anecdotes here, I've never had a doctor who didn't nag me about diet and exercise.

I think you would struggle to find many studies that show that physicians telling people to change their diet actually results in people changing their diet. And if we're talking about getting rid of interventions that cost money but don't give any benefits, you have to seriously question the wisdom of physicians telling people what they already know, but are not motivated to pursue. If every PCP spends 5 minutes counseling each patient with hypertension about lifestyle changes, that's not a small cost.

The only point that hasn't already been hashed out is that the majority of patients who are being treated for hypertension also have comorbid conditions. Aces and Arbs have great data for protecting renal function in diabetics and have protective effects for cardiac remodeling in coronary artery disease. Beta blockers are one of the most cardio-protective drugs we have, due to their ability to reduce cardiac oxygen demand.

Sure, plenty of doctors are guilty of what they are generally being accused of here. But if every doctor were prescribing hypertensives based on the best evidence available, there would still be a whole lot of these other medications prescribed.

ALLHAT is just one trial. Other trials have yielded different outcomes. Clearly, there are also different subgroups that respond better to the various families of drugs and equally clearly some drugs work better for some individuals. That's why I use JNC VII, not the outcome of an individual trial. You talk about the use of "guidelines" in medicine Ezra, but then turn around here and say that doctors are doing something wrong by following a very clear guideline rather than a single study.

I preach diet and exercise until I'm blue in the face. I was really excited today because a have a patient who's lost 51 lbs with diet and exercise. That's one of the few successes that I've had this year.

A lot of good comments here, which I hope other folks are reading as well.

JBean is, as usual, right on the medical aspects of the issue. At the end of the day, hypertension is a topic that is one of the most-studied, discussed, analyzed-- and the JNC guidelines highlighted are well-respected. In practice, this is one of the few practice guidelines that could actually be "forced" upon physicians by payors or Medicare or Fed Health.

The purpose of highlighting this example is showing the complexities involved in developing clear guidelines. Without the work of an expert panel spending years conducting meta-analyses of numberous trials that cost hundreds of millions of dollars-- what you're left with are the rest of the comments in this post-- medical opinions that are scientifically focused and sound robust to lay people (e.g. PupMD), regular people concerned that the focus isn't on the more important issues (e.g. jacqueline) and patients with a variety of experiences that further muddy the waters. All of which is to say, its very, very difficult to see how the credibility of a singular organization charged with defining benefits, could hold up with these varying opinions across thousand of treatments when people's health are at stake. There won't be irrefutable data to "bail out" an organization in most cases. These are judgment calls primarily based on perceived differences in medical benefit.

With our "me first, all-you-can-eat" culture, being told "no" by a quasi-governmental bureaucracy based on a fuzzy set of data is not a solution to our health system issues. Unless financial incentives are aligned. Which is why this always gets back to the same point-- a government-driven system will lead to deficit spending due to health care until the US financial picture nears a breaking point. Politicians aren't going to take the short-term political hit on restricting health care until there is a short-term benefit, i.e. fixing our financial profile. So that's probably an additional $10-20 trillion dollars in unnecessary expenditures. Otherwise, we can figure out how everyone can have some incentive to watch their health care spending in a way that doesn't bankrupt them, so that folks will be receptive to restrictions in benefits. As we've noted previously, the HMO concept of the 90's, which led to flat growth in health care spend, failed because the citizenry rebelled against it. The point I've tried to demonstrate is that the Fed Health proposals are simply going down the same path-- another elegant solution (but less optimal, IMO) to restricting care, but one that society will reject-- because they have no reason to accept it. And Fed Health of the 2010's will be another lesson in failed reform, just as the HMO movement failed in the 90's.

Thanks wisewon.

Actually, I suspect that 40% of all hypertensives is not that terrible a performance. Most diabetics are also hypertensive and with diabetics making up 1/4 to 1/3 of the population, it's clear that the first line choice for probably pretty close to half (or more!) of all hypertensives is an ACE or an ARB. Thiazides don't work for people with chronic kidney disease and creatinine of more than 1.5 mg/dL so there goes another good chunk of your hypertensives. Add in the people with gout (big overlap with the first two groups), allergies, intolerances of various types and you might find it hard to get the total number of thiazide diuretic users up over 50% even with perfect application of the ALLHAT findings. I guess that I'm being overly pedantic again, but neither you nor the NYT writer have provided much illumination here.

Ezra, your final point about diuretic use in England appears to be not so great either, if you look at U.K. hypertension guidelines.

If your intent was to bash doctors, then consider us bashed. I'm afraid that I have to go off now and sit on my yacht and count my money. Either that or spend the next couple of hours wrestling with the EMR to do the day's load of doctorly data entry.

I'm the first to acknowledge that making a decision about a patient's medications requires far more than a cost consideration. If I had to roughly estimate the way I prescribe first line anti-hypertensives, it's probably be about 40% diuretics, 40% ACE inhibitors, and 20% everything else. That's probably because I see a lot of diabetics in Honolulu.

That said, Ezra's broader point about the cooptation of the medical community by drug companies is sound. I think we don't do a good job of acknowledging how corrosive this relationship is in terms of the public trust. For drug companies to have this much say in how a study is interpretted is fairly scandalous. And every doc knows at least a few colleagues who prescribe the expensive brand name stuff first, without any apparent consequences.

It's time we knock it out and get behind legitmate, non-industry funded research.

"I don't have a solution to how to reign-in the anti-social behavior of the drug companies"

I have an almost 100% effecive tried and tested method that works great. We cut out the drug card and make the insured pay for the Rx then submit it to us for reimbursement. It only takes one trip to the pharmacy when they are asked to pay hundreds for a drug before the member calls his doctor and ask what else is available.

We occasionally have to make exceptions for legititmite expensive drugs but clients that do this have Rx cost running 12-15% of total plan cost versus 20%+ for those with drug cards and co-pays.

Apparently simple solutions that work aren't being considered, we need to tear down the whole system and hand it over to politicians to "fix" it.

I would rather have my teeth extracted one by one than submit more payment requests to insurance companies.

In fact, if the solution to this is to have beauracrats who know nothing about healthcare decide what gets payed for and what doesn't, than I say let's all become good socialists right now. At least that way we remove profit as the central motivation.

I, of course, forget that I live in the ideal world of the left coast. The generic thing isn't much of an issue here. When a generic exists, by California law the consumer may choose generic vs. name brand so the doc can write for "Fosamax" and the patient can still have alendronate (that takes me out of the loop -- even if I'm suckered in by the plastic pens). Almost all pharmacy benefit providers use a tiered formulary with generic copays far cheaper than non-generic. In addition, the pharmacies get a slightly higher filling fee for generics than for non-generics. Few, if any of my patients get name-brand meds, even when they need them (inhaled steroids for asthma!) Building some financial incentives into the system for pharmacist and patient works quite well here in the Golden State without being quite as Draconian as Nate suggests.

J Bean,

Funny you consider my solution Draconian then offer your from CA. That's where our company started in 1980, it's also one of the three highest cost states in the country I believe.

CalChoice is a perfect example of the failure of community rating/regualtion/and goverment intervention.

CA insurance market is a failure to a level just short of NY and MA. To claim part of the system works quite well like you say completly ignores the reality of how bad it is in CA.