Angiotensin converting enzyme inhibitors v. angiotensin receptor blockers in the management of hypertension: a funder's perspective.

BACKGROUND: Hypertension poses a huge financial risk to any funder/medical aid, including the risk-mitigating strategies provided by the managed care organisations that are required to manage patients with hypertension. The South African Hypertension Guideline states that the choice of therapy--an angiotensin converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB)--should be based on cost and tolerability. OBJECTIVE: To assess the costs of ACEIs v. ARBs in the management of hypertensive patients and the prevention of cardiovascular complications for a private medical aid scheme in South Africa. METHOD: A Phase IV observational, retrospective cohort study of over 480 000 beneficiaries between 2010 and 2011 was undertaken. Hypertensive patients were identified by their chronic medication authorisation and were categorised into three groups: ACEI, ARB and combined groups. A cost-benefit analysis was performed on the claims data, comparing the input costs in rand against the downstream costs using analysis of variance. RESULTS: Data from 28 165 patients were included in the study. Based on the health economic analysis that was performed, there was no statistically significant difference in the input costs between the ACEI and the ARB groups. However, a statistically significant reduction in the downstream costs was observed in the ACEI group v. the ARB and combined groups (p < 0.0001). CONCLUSION: It is more cost beneficial to treat chronic hypertensive patients with an ACEI than ARBs in preventing cardiovascular-related complications. It is recommended that managed care companies continue recommending ACEIs rather than ARBs in the treatment of hypertensive patients.

[Terminal care--a practical guide for the physician]. / Sterwenshulp--'n praktiese benadering vir die geneesheer.

In spite of the tendency to institutionalize the terminally ill patient, the decision as to where he spends his final days nevertheless remains with the patient. Should this be at home or in private surroundings, the responsibility of "death guidance' rests with the doctor/practitioner and involves assisting not only the patient, but also his next of kin. This guidance, if given meaningfully and with understanding, is invaluable to both the patient and his family. The three clinical stages leading up to the death of a patient are the prediagnostic and diagnostic phase, the stage at which the illness is established, and the regression stage. During this process, the patient also undergoes psychological changes, described as awareness, negation, rebellion, remorse, depression and finally, acceptance. When death has occurred, the doctor must indicate this to the family euphemistically and with compassion. Although the doctor's main obligation may end here, further assistance to the family will be of great help; this includes contacting the undertaker, informing the next of kin, contacting a priest if required, offering immediate medical assistance to the next of kin, laying out the deceased and reassuring the family before leaving.