PART v. CLINICAL PROBLEMS OF THERAPY ON A NATIONAL SCALE

OPENING REMARKS

Marvin Moser

New York Medical College Valhalla, .New York 10595

For the past two days, we have been struggling with some basic questions and re-emphasizing known facts. We have reaffirmed that elevated blood pres- sure is a significant risk factor for cardiovascular disease; we have reaffirmed that therapy is available to lower it. We have, I believe, agreed that in moder- ately severe to severe disease, this is beneficial; bur, we have been struggling with the possible risks of available therapy and questioning whether or not the benefit to risk or harm ratio is sufficiently positive to warrant long-term therapy of the mild, usually asymptomatic hypertensive patient. We have been ques- tioning methods and procedures.

I am somewhat concerned that we have become too involved with the nega- tives of pharmacotherapy and have perhaps overemphasized other methods of treatment, where proof of efficacy in lowering blood pressure in large numbers of patients has not as yet been forthcoming.

Dr. Blackburn has told us that exercise, although an excellent conditioner and perhaps useful to prevent suddent death, really doesn’t work over a long period of time to lower blood pressure effectively, and Dr. Shapiro has docu- mented the lack of long-term effect of behavior modification on blood pressure lowering.

Management of obesity in specific patients and on a mass scale has always been a difficult problem; it is obviously desirable from an individual and public point of view. Trials in hypertensive patients in the 1940s and early 1950s were not too successful. Newer techniques and greater efforts should be brought to bear in evaluating this approach in mild hypertension. Personally, I am not too optomistic that it will prove effective in large numbers of patients. Modified but practical low-salt diets have also been used in mild hypertension, and some, but not dramatic, blood pressure lowering has been reported. More data are obviously also needed here.

This morning we plan to explore another aspect of the treatment problem: specifically, “Clinical Problems of Mass Treatment with Antihypertensive Drugs.”

Assuming that present studies do prove the efficacy of treating mild hyper- tension and that the benefits of mass treatment programs outweigh the risk or harm, significant problems still present themselves in managing such a common entity in a cost-effective manner over a long period of time.

Clinical approaches to diagnostic studies and treatment programs have, until recent years, been relatively complex and expensive. These approaches have not been conducive to success in large numbers of cases. Do they neces- sarily represent “better” or quality medical care? Can or must a simplified approach be taken to ensure greater success? Can this pragmatic approach be undertaken without compromising the scientific discipline?

The recently released report of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (JAMA 237(2), January 17, 1977) suggests guidelines for management that are relatively simple and repre- sent quality care in the opinion of the major medical organizations that have

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332 Annals New York Academy of Sciences

endorsed the report. The next series of papers will review some of the clinical problems that have been reviewed in the Joint National Report-problems that must be addressed in any consideration of mass treatment programs. The appro- priate diagnostic workup and important problems of adherence to a long-term treatment program will be discussed.

Adherence or compliance has long been considered to be patient-related; yet this clearly represents a physician-patient interaction. Physicians control the complexity of the workup and treatment programs and can regulate cost to a certain extent by choice of therapy and frequency of visits; above all, they provide the incentive and the motivating force for the patient. To do this more effectively, they must expand their role as health educators. The appropriateness of delegating this responsibility to paramedical personnel will also be consid- ered in the next series of papers.