London School of Hygiene & Tropical Medicine

Expanding health insurance coverage and reducing drug costs that are paid by patients (drug co-payments) in countries without universal free healthcare, such as the United States, may improve the treatment and control of high blood pressure according to a study published in PLOS Medicine.

High blood pressure (hypertension) is a condition which affects one billion people worldwide and leads to 7.5 million deaths annually from heart attacks, stroke, other cardiovascular diseases and kidney disease.

Researchers led by the London School of Hygiene & Tropical Medicine reviewed 53 published studies and found an association between reduced co-payments for healthcare, including for medications, and improved hypertension control and treatment adherence in multiple US studies, and in studies from Finland, Israel, and Brazil.

The authors also found that in US settings, health insurance coverage and having a routine physician or place of care were linked to improved hypertension outcomes.

Lead author, Will Maimaris, research fellow at the London School of Hygiene & Tropical Medicine, said: "High blood pressure is one of the biggest contributors to mortality across the globe. Our study suggests that simple steps such as providing blood pressure treatment which is free at the point of use and giving people access to a regular source of medical care may improve levels of blood pressure control and lead to a reduction in deaths from heart attacks and strokes."

Dr Dina Balabanova, Senior Lecturer in Health Systems/Policy at the School, and co-author of the research added: "Our study demonstrated for the first time that successful management of hypertension depends not just on the behaviour of individual physicians and patients, but on a range of health systems factors, such as how health systems are financed, delivered and managed. Any interventions to address hypertension will be likely to require action at multiple levels of the system."

Although the findings are based mainly on US studies, the researchers believe the principal is likely to apply more generally and will have implications for policy makers in other countries like Spain, where co-payments for drugs are being introduced.

Co-author Dr Helena Legido-Quigley, Lecturer in Global Health at the School, said: "This paper suggests that introducing co-payments for medications could reduce uptake of necessary care and influence negatively on health outcomes. This finding has clear implications for policy makers in Spain suggesting that co-payments for pharmaceuticals should be avoided particularly in times of austerity when more than 20% of the Spanish population live below the poverty line and 27% of the labour force are unemployed."

The researchers noted the gap in data in their review, as there were few studies in low-and middle-income countries which bear most of the global burden of hypertension - three-quarters of people with the condition live in these countries. The research also highlighted that there is an urgent need for studies that evaluate how aspects of healthcare systems other than financing (such as delivery and governance mechanisms) and interactions between healthcare system arrangements affect hypertension outcomes. The authors argue that without the results of such studies, governments and national and international organisations will not know the best ways to deal effectively with the global public-health crisis posed by hypertension.

The research was part of the HOPE-4 project. This part of the project was funded by the Canadian Institutes of Health Research with an award number IHR-120389.

Publication:

• Will Maimaris, Jared Paty, Pablo Perel, Helena Legido-Quigley, Dina Balabanova, Robby Nieuwlaat, Martin Mckee, The Influence of Health Systems on Hypertension Awareness, Treatment, and Control: A Systematic Literature Review. PLOS Medicine. Doi:10.1371/journal.pmed.1001490