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Can Better Care Cost Less?

Michael A. Fischer, MD, MS; Jerry Avorn, MD

JAMA. 2004;291:1850-1856.

Context  Deviation from evidence-based guidelines in hypertension treatment is common, but its economic impact has not been rigorously studied. Suboptimal prescribing patterns contribute to the high cost of medications for elderly patients as well as the difficulty in providing affordable prescription drug benefits for older Americans.

Objective  To calculate the potential savings from the perspective of health care payers that would result from increased adherence to evidence-based recommendations for managing hypertension in patients older than 65 years.

Design  Comparative analysis of medications prescribed vs potential regimens suggested by evidence-based guidelines tailored to each patient's medical history, with calculation of the costs of both the actual and the evidence-based regimens.

Setting and Patients  A total of 133 624 patients being treated for hypertension during 2001 who were enrolled in a large state pharmaceutical assistance program that provides prescription drug insurance for elderly persons.

Main Outcome Measure  Cost difference between medications actually prescribed and regimens suggested by evidence-based guidelines.

Results  The patients studied filled more than 2.05 million prescriptions for antihypertensive medications in 2001, at an annual program cost of $48.5 million ($363 per patient). We identified 815 316 prescriptions (40%) for which an alternative regimen appeared more appropriate according to evidence-based recommendations. Such changes would have reduced the costs to payers in 2001 by $11.6 million (nearly a quarter of program spending on antihypertensive medications), as well as being more clinically appropriate overall. Replacement of calcium channel blockers resulted in the largest potential savings. Use of pricing limits similar to those in the Medicaid program would have resulted in even larger potential savings of $20.5 million (42% of program costs).

Conclusions  Adherence to evidence-based prescribing guidelines for hypertension could result in substantial savings in prescription costs for elderly patients with hypertension that would amount to savings of about $1.2 billion nationally. Identification of similar areas in which prescribing can be improved will be critical for the affordability of prescription drug benefit programs.

Author Affiliations: Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.

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