Resistant Hypertension in Chronic Kidney Disease

2 41

Co-operation and Development (OECD) show a range of public spending on
“prevention and public health” over 2003/2004 as varying from 7.6% of public sec-
tor expenditure in the USA and 8.3% Canada, down to 4.0% in Germany and just
0.8% in Italy [ 41 ]. Much of the spread of these figures can be explained by how the
private sector is proportionately more important to North American health spending
than it is in Europe; this leaves preventative spending greater room within the over-
all scope of public expenditure. The extent of public spending in Europe is also very
likely underreported by the OECD due to official statistics describing state-
sponsored prevention “programs” as health-care “treatments.” A 2002 study con-
ducted in France which incorporated statistics concerning both approaches
concluded that, while spending formally dedicated to prevention was 2.9% of total
health expenditure, a further 3.5% termed as “soins et biens médicaux” [medical
care and goods] was preventative in nature, leading to a more robust total of 6.4%.
This analysis explicitly adds hypertension to the latter group during its discussion of
risk factors and the difficulty of distinguishing between care and prevention: “We
have in effect considered that uncomplicated forms of diabetes, arterial hyperten-
sion and hyperlipidemia are not treated for themselves but rather in order to avoid
the advent of serious cardiovascular illness, which justifies their inclusion in the
area of prevention” [author’s translation of the French original] [ 42 ]. And yet there
is a large imbalance between preventative expenditures and those on treatment even
after this expansion to the scope of prevention, due to the political and economic
pressures on public budgets. Strong and immediate demands for medical treatment
have effectively discouraged investments in prevention which would pay out in the
longer term. In addition to direct public expenditure, policy stakeholders in the pub-
lic sector can take steps either to advance or to retard private sector actions and
spending in the fields of primary and secondary prevention.

Public Policy and Patients’ Organizations

If we are to recognize “prehypertension” as being prognostic of possible illness,
patients’ organizations are natural and committed conduits to reach those people
who could benefit from information and advice regarding lifestyle, medication, and
risk factors as a means of realizing the challenging personal process of behavioral
change. It was for this reason that patient groups organized around cardiovascular
disease and hypertension were advised to expand their focus to encompass “pre-
patient” education and assistance at the special session in St Gallen. To do so
requires a certain, not large, outlay, but patient groups typically rely on outside

Table 15.3 Public policies
for prevention and treatment
of RHT in Europe and the
USA

Patients’ organizations

Pharmaceutical reimbursement

Prevention and financial

incentives for physicians

15 Public Health Efforts for Earlier Resistant Hypertension Diagnosis...