Forces marshalled to spread word of hypertension study
■ Doctors are becoming detailers in promoting ALLHAT results. Some question the wisdom of using research dollars to support these efforts.
By Susan J. Landers — Posted April 12, 2004
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Washington -- Borrowing a successful pharmaceutical firm strategy that employs drug reps to carry study findings to busy physicians, the National Institutes of Health is funding an effort to spread the results of a large federally supported study that compared high blood pressure medications.
The message will be delivered to primary care physicians by a cadre of their colleagues who had been investigators on the large ALLHAT study, or the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial.
If the approximately $4 million effort proves successful, the dissemination method may be duplicated to speed the results of other federally funded trials to clinicians.
The ALLHAT findings were published in the Dec. 18, 2002, Journal of the American Medical Association and served to highlight the role of diuretics as a good starting point for treating some of the 50 million Americans who have high blood pressure and are at increased risk for heart attack, heart failure and stroke.
The study compared a diuretic to a newer calcium channel blocker and an ACE inhibitor and found the treatments to be of equal value in lowering pressure, with the diuretics carrying a lower price tag and often fewer complications and side effects.
While no one questions the importance of encouraging physicians to help patients control their blood pressure, some urge caution before starting down a path that uses valuable NIH research dollars to fund outreach.
"I applaud the efforts of the NIH in doing this, but I raise the question of whether the expenditure might better come from the public health domain," said Edward D. Frohlich, MD, Alton Ochsner distinguished scientist at the Ochsner Medical Foundation in New Orleans. "Even though the NIH budget has grown in recent years, there is still not enough money to fund all the worthy proposals."
Plus the message on medication and hypertension is a complicated one, and treatment must be handled one patient at a time, he noted. While diuretics may be a good starting point for many patients, especially the many who have untreated high blood pressure, there is a still a large role for the other medications.
Michael Weber, MD, editor of the American Journal of Hypertension, charged that the NIH effort could embroil the well-respected Heart, Lung, and Blood Institute in an issue that is "contentious, political and economic and has the potential to weaken the Institute's standing as a source of top quality science."
Since its release, the ALLHAT study itself has stimulated much discussion among hypertension experts, some of it negative.
"In essence [ALLHAT researchers] are trying to persuade physicians to use diuretics as the main treatment for hypertension on the grounds that they are at least as good as other, newer drugs and they are less expensive," said Dr. Weber.
But both of those assertions have been widely criticized. "There is very little in ALLHAT to allow you to say anything other than the drugs they tested seemed to be similar and given the study design -- which favored the diuretic -- you could argue that the possibility still exists that the newer drugs could be superior," he added.
The second assertion, that diuretics are cheaper, also might not be true in the long run, he said. While the diuretics cost only pennies a day initially, when they are used in full dose a physician must check patients' blood frequently, adding the cost of blood tests and office visits to their use.
However, the physicians who took part in ALLHAT stand behind their findings and ask physicians to let the data speak for themselves. They want to ensure that the data are at least widely considered.
"Typically in medicine we conduct a trial, we publish the findings and then we move on to the next research project," said Curt Furberg, MD, chair of the ALLHAT steering committee, and a professor of public health services at Wake Forest University Baptist Medical Center.
"We just assume that people are going to read the article and change their practice if the findings justify that. And that doesn't work."
Clearly, the pharmaceutical industry knows that, he said. And they have an army of representatives visiting physicians and talking to them and trying to influence practice patterns.
Relaying the message
The ALLHAT study was done at taxpayer expense, and its findings should result in benefit to the taxpayer, noted Paul Whelton, MD, a member of the study's steering committee, and professor of epidemiology and Medicine at Tulane University Health Sciences Center in New Orleans.
One of the messages from ALLHAT -- to strive for lower blood pressure -- was strengthened by the release of new clinical practice guidelines last year alerting physicians to the need to pay closer attention to the blood pressure levels of even greater numbers of patients.
The new guidelines feature a "prehypertension" category which includes patients whose blood pressure measures 120-139/80-89 mmHg. While previous guidelines had placed such patients well within the normal range, these readings now should trigger advice to make lifestyle changes that include losing weight and becoming more physically active, according to the new guidelines.
"So what's going forward now," said Dr. Whelton, "is a joint effort between ALLHAT and the National High Blood Pressure Education Program to get more information out" from the "Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure."
The initiative will also include brochures and public service announcements intended to prime patients to ask physicians about blood pressure and medications, and the initiative will spread the word to committees that establish the formularies favored by large insurance companies or organizations such as the Dept. of Veterans Affairs.