Erik Goldman

WASHINGTON — Price transparency for physician and hospital services is a key element in the Bush administration's vision of “consumer-driven” health care, and the administration is prepared to push for mandatory price-tagging if doctors and hospital administrators won't voluntarily provide the information.

Speaking at a health care congress sponsored by the Wall Street Journal and CNBC, Al Hubbard, assistant to President George W. Bush for economic policy, issued a kind of ultimatum to the clinical community: “Make pricing information available without being forced. We have allies in Congress who are very much inclined to be prescriptive with legislation to impose pricing and quality standards on the health care community.”

Comprehensive and accurate pricing for health care services are essential for the efficacy of health savings accounts (HSAs) and other market-driven solutions to health care spending, said Mr. Hubbard, who is also director of the National Economic Council, at the meeting.

He cited LASIK (laser in situ keratomileusis) surgery as a prime example. “Fifteen years ago, LASIK cost about $2,500 per eye. Because the service is an out-of-pocket expense, now the cost is under $1,000 per eye. That's what would happen in the rest of health care if people were price-sensitive consumers,” he said. “You cannot be a wise consumer if you don't know the prices or the quality of the goods. Right now, providers do not make that information available, and a lot of hospital executives don't believe pricing information should be available.”

Mr. Hubbard's remarks followed a video address by President Bush, in which the President underscored his commitment to HSAs as a key instrument for change. He estimated that more than 3 million Americans will be enrolled in HSAs this year, a number he hopes to see vastly increased over the next few years.

The President underscored the “simple and clear philosophy” that underlies his solution to the health care problem: “The American medical system should be run by doctors, patients, and consumers, not the federal government.”

It was easy for Mr. Hubbard to talk tough at the meeting. According to the conference organizers, physicians represented only 4% of attendees, and there were few doctors in the room during Mr. Hubbard's address.

One physician, an anesthesiologist, did stand up to challenge the administration's fixation on price-tagging. He cited the potential dangers that could arise if “consumers”—that is, patients—began choosing health care services based on price postings. He stressed that the medical community itself is far from having accurate quality measures to determine standards for best practices. Without clear and science-based quality standards, pricing information would have little value because patients would not be able to determine what they would be getting for their money. Further, shopping for health care based on price could encourage substandard care and suboptimal clinical outcomes.

He also pointed out that a higher-priced physician practice or hospital may be incurring those higher costs because they are treating a sicker population. Likewise a practice or hospital with lower outcomes scores may be handling sicker patients. Price tags and raw outcomes data alone would not reflect this, unless accurate risk-stratification measures were also incorporated.

Mr. Hubbard acknowledged that there's much work to be done in developing meaningful outcomes standards and risk assessment tools so that consumers can “compare apples to apples.” At the same time, the administration seems unwilling to wait around indefinitely while practitioners and hospitals figure out how to prove their worth.

Several in the audience pointed out that the “shop-around” approach is likely to break down around episodes of emergency care, critical care, and sudden onset of disease. An individual having a myocardial infarction isn't likely to consult the Internet to find out which area hospital offers the best dollar value.

Mr. Hubbard agreed that emergency situations are an exception to the consumer-driven rule, but he insisted that “there's no reason we should not be able to have bundled pricing from our physicians and hospitals on all nonemergency care. We want you to treat your patients/customers exactly the way you want to be treated when you consume a product or service.”

Whether a mandate for pricing transparency is truly in the offing remains to be seen. What is clear is that the Bush administration views HSAs and other strategies for shifting greater cost and greater health care responsibility onto consumers as the only viable strategy for the nation's health care financing woes.

During a separate session at the meeting, Jack Brennan, CEO of the Vanguard Group, the nation's second largest mutual fund company, and Jim Guest, president of Consumers Union (publisher of Consumer Reports), reviewed the potential strengths and weaknesses of consumer-driven health care plans.

Mr. Brennan said that Vanguard offers its 12,000 employees a consumer-driven health plan option, and has for several years. However, no more than 10% of the company's employees have chosen it. “I'd say there's a bit of a reluctance, but it is a start, and I'd like to see more,” he said.

Consumer Reports' Mr. Guest said his organization supports the general idea of “consumer-informed health care,” but added that it is far too early to tell whether strategies like those advocated by the Bush administration will really deliver on their stated promises.

WASHINGTON — Price transparency for physician and hospital services is a key element in the Bush administration's vision of “consumer-driven” health care, and the administration is prepared to push for mandatory price-tagging if doctors and hospital administrators won't voluntarily provide the information.

Speaking at a health care congress sponsored by the Wall Street Journal and CNBC, Al Hubbard, assistant to President George W. Bush for economic policy, issued a kind of ultimatum to the clinical community: “Make pricing information available without being forced. We have allies in Congress who are very much inclined to be prescriptive with legislation to impose pricing and quality standards on the health care community.”

Comprehensive and accurate pricing for health care services are essential for the efficacy of health savings accounts (HSAs) and other market-driven solutions to health care spending, said Mr. Hubbard, who is also director of the National Economic Council, at the meeting.

He cited LASIK (laser in situ keratomileusis) surgery as a prime example. “Fifteen years ago, LASIK cost about $2,500 per eye. Because the service is an out-of-pocket expense, now the cost is under $1,000 per eye. That's what would happen in the rest of health care if people were price-sensitive consumers,” he said. “You cannot be a wise consumer if you don't know the prices or the quality of the goods. Right now, providers do not make that information available, and a lot of hospital executives don't believe pricing information should be available.”

Mr. Hubbard's remarks followed a video address by President Bush, in which the President underscored his commitment to HSAs as a key instrument for change. He estimated that more than 3 million Americans will be enrolled in HSAs this year, a number he hopes to see vastly increased over the next few years.

The President underscored the “simple and clear philosophy” that underlies his solution to the health care problem: “The American medical system should be run by doctors, patients, and consumers, not the federal government.”

It was easy for Mr. Hubbard to talk tough at the meeting. According to the conference organizers, physicians represented only 4% of attendees, and there were few doctors in the room during Mr. Hubbard's address.

One physician, an anesthesiologist, did stand up to challenge the administration's fixation on price-tagging. He cited the potential dangers that could arise if “consumers”—that is, patients—began choosing health care services based on price postings. He stressed that the medical community itself is far from having accurate quality measures to determine standards for best practices. Without clear and science-based quality standards, pricing information would have little value because patients would not be able to determine what they would be getting for their money. Further, shopping for health care based on price could encourage substandard care and suboptimal clinical outcomes.

He also pointed out that a higher-priced physician practice or hospital may be incurring those higher costs because they are treating a sicker population. Likewise a practice or hospital with lower outcomes scores may be handling sicker patients. Price tags and raw outcomes data alone would not reflect this, unless accurate risk-stratification measures were also incorporated.

Mr. Hubbard acknowledged that there's much work to be done in developing meaningful outcomes standards and risk assessment tools so that consumers can “compare apples to apples.” At the same time, the administration seems unwilling to wait around indefinitely while practitioners and hospitals figure out how to prove their worth.

Several in the audience pointed out that the “shop-around” approach is likely to break down around episodes of emergency care, critical care, and sudden onset of disease. An individual having a myocardial infarction isn't likely to consult the Internet to find out which area hospital offers the best dollar value.

Mr. Hubbard agreed that emergency situations are an exception to the consumer-driven rule, but he insisted that “there's no reason we should not be able to have bundled pricing from our physicians and hospitals on all nonemergency care. We want you to treat your patients/customers exactly the way you want to be treated when you consume a product or service.”

Whether a mandate for pricing transparency is truly in the offing remains to be seen. What is clear is that the Bush administration views HSAs and other strategies for shifting greater cost and greater health care responsibility onto consumers as the only viable strategy for the nation's health care financing woes.

During a separate session at the meeting, Jack Brennan, CEO of the Vanguard Group, the nation's second largest mutual fund company, and Jim Guest, president of Consumers Union (publisher of Consumer Reports), reviewed the potential strengths and weaknesses of consumer-driven health care plans.

Mr. Brennan said that Vanguard offers its 12,000 employees a consumer-driven health plan option, and has for several years. However, no more than 10% of the company's employees have chosen it. “I'd say there's a bit of a reluctance, but it is a start, and I'd like to see more,” he said.

Consumer Reports' Mr. Guest said his organization supports the general idea of “consumer-informed health care,” but added that it is far too early to tell whether strategies like those advocated by the Bush administration will really deliver on their stated promises.

WASHINGTON — Price transparency for physician and hospital services is a key element in the Bush administration's vision of “consumer-driven” health care, and the administration is prepared to push for mandatory price-tagging if doctors and hospital administrators won't voluntarily provide the information.

Speaking at a health care congress sponsored by the Wall Street Journal and CNBC, Al Hubbard, assistant to President George W. Bush for economic policy, issued a kind of ultimatum to the clinical community: “Make pricing information available without being forced. We have allies in Congress who are very much inclined to be prescriptive with legislation to impose pricing and quality standards on the health care community.”

Comprehensive and accurate pricing for health care services are essential for the efficacy of health savings accounts (HSAs) and other market-driven solutions to health care spending, said Mr. Hubbard, who is also director of the National Economic Council, at the meeting.

He cited LASIK (laser in situ keratomileusis) surgery as a prime example. “Fifteen years ago, LASIK cost about $2,500 per eye. Because the service is an out-of-pocket expense, now the cost is under $1,000 per eye. That's what would happen in the rest of health care if people were price-sensitive consumers,” he said. “You cannot be a wise consumer if you don't know the prices or the quality of the goods. Right now, providers do not make that information available, and a lot of hospital executives don't believe pricing information should be available.”

Mr. Hubbard's remarks followed a video address by President Bush, in which the President underscored his commitment to HSAs as a key instrument for change. He estimated that more than 3 million Americans will be enrolled in HSAs this year, a number he hopes to see vastly increased over the next few years.

The President underscored the “simple and clear philosophy” that underlies his solution to the health care problem: “The American medical system should be run by doctors, patients, and consumers, not the federal government.”

It was easy for Mr. Hubbard to talk tough at the meeting. According to the conference organizers, physicians represented only 4% of attendees, and there were few doctors in the room during Mr. Hubbard's address.

One physician, an anesthesiologist, did stand up to challenge the administration's fixation on price-tagging. He cited the potential dangers that could arise if “consumers”—that is, patients—began choosing health care services based on price postings. He stressed that the medical community itself is far from having accurate quality measures to determine standards for best practices. Without clear and science-based quality standards, pricing information would have little value because patients would not be able to determine what they would be getting for their money. Further, shopping for health care based on price could encourage substandard care and suboptimal clinical outcomes.

He also pointed out that a higher-priced physician practice or hospital may be incurring those higher costs because they are treating a sicker population. Likewise a practice or hospital with lower outcomes scores may be handling sicker patients. Price tags and raw outcomes data alone would not reflect this, unless accurate risk-stratification measures were also incorporated.

Mr. Hubbard acknowledged that there's much work to be done in developing meaningful outcomes standards and risk assessment tools so that consumers can “compare apples to apples.” At the same time, the administration seems unwilling to wait around indefinitely while practitioners and hospitals figure out how to prove their worth.

Several in the audience pointed out that the “shop-around” approach is likely to break down around episodes of emergency care, critical care, and sudden onset of disease. An individual having a myocardial infarction isn't likely to consult the Internet to find out which area hospital offers the best dollar value.

Mr. Hubbard agreed that emergency situations are an exception to the consumer-driven rule, but he insisted that “there's no reason we should not be able to have bundled pricing from our physicians and hospitals on all nonemergency care. We want you to treat your patients/customers exactly the way you want to be treated when you consume a product or service.”

Whether a mandate for pricing transparency is truly in the offing remains to be seen. What is clear is that the Bush administration views HSAs and other strategies for shifting greater cost and greater health care responsibility onto consumers as the only viable strategy for the nation's health care financing woes.

During a separate session at the meeting, Jack Brennan, CEO of the Vanguard Group, the nation's second largest mutual fund company, and Jim Guest, president of Consumers Union (publisher of Consumer Reports), reviewed the potential strengths and weaknesses of consumer-driven health care plans.

Mr. Brennan said that Vanguard offers its 12,000 employees a consumer-driven health plan option, and has for several years. However, no more than 10% of the company's employees have chosen it. “I'd say there's a bit of a reluctance, but it is a start, and I'd like to see more,” he said.

Consumer Reports' Mr. Guest said his organization supports the general idea of “consumer-informed health care,” but added that it is far too early to tell whether strategies like those advocated by the Bush administration will really deliver on their stated promises.

MADRID — Fasting blood glucose levels appear to be higher in diabetic patients with poorly controlled blood pressure than in those with well controlled pressure, said Dr. Miroslav Soucek, at the annual meeting of the European Society of Hypertension.

This observation was based on a survey of more than 2,200 patients from 150 primary care practices throughout the Czech Republic. The primary objective of the study was to determine the prevalence of hypertension in the Czech population, and the extent to which physicians there are able to help their patients achieve pressure control targets as outlined in current ESH guidelines, said Dr. Soucek, who presented the findings in a poster.

Each participating physician recorded thorough case data from 15 consecutive patients aged at least 45 years, irrespective of the reason for each patient's visit. The idea was to get a representative sampling of the health status of all comers to primary care offices. The investigators defined hypertension as pressures above 140/90 mm Hg. Dr. Soucek and his colleagues obtained data from 2,211 patients with a mean age of 62 years.

Of the entire cohort, 78% of the patients were defined as hypertensive; of the 403 patients with diabetes, 75% had hypertension. Only 18% of all patients being treated for hypertension were considered well controlled (pressures under 130/80 mm Hg); the rate for diabetics was 6%.

Dr. Soucek noted that blood pressure was uncontrolled in almost 30% of the diabetic patients with hypertension even though they were on at least three antihypertensive drugs.

But the most striking finding of this study, one that surprised the investigators themselves, was the correlation between poor pressure control and increased fasting blood glucose. “The average fasting blood glucose showed a gradual increase, with increasing blood pressure, from 7.98 mmol/L in diabetics with blood pressure under 130/80 mm Hg to 9.44 in diabetic patients with blood pressures greater than 180/110 mm Hg,” reported Dr. Soucek of the department of internal medicine, St. Anne University Hospital, Brno, Czech Republic.

The mechanism underlying this connection is not known, and it is too soon to tell if there is a causal connection.

The clinical implication, however, is clear: Uncontrolled pressure in a diabetic patient may be a signal for uncontrolled glucose as well. These patients need even closer attention than nondiabetic hypertensives or diabetics who are not hypertensive, he said.

MADRID — Fasting blood glucose levels appear to be higher in diabetic patients with poorly controlled blood pressure than in those with well controlled pressure, said Dr. Miroslav Soucek, at the annual meeting of the European Society of Hypertension.

This observation was based on a survey of more than 2,200 patients from 150 primary care practices throughout the Czech Republic. The primary objective of the study was to determine the prevalence of hypertension in the Czech population, and the extent to which physicians there are able to help their patients achieve pressure control targets as outlined in current ESH guidelines, said Dr. Soucek, who presented the findings in a poster.

Each participating physician recorded thorough case data from 15 consecutive patients aged at least 45 years, irrespective of the reason for each patient's visit. The idea was to get a representative sampling of the health status of all comers to primary care offices. The investigators defined hypertension as pressures above 140/90 mm Hg. Dr. Soucek and his colleagues obtained data from 2,211 patients with a mean age of 62 years.

Of the entire cohort, 78% of the patients were defined as hypertensive; of the 403 patients with diabetes, 75% had hypertension. Only 18% of all patients being treated for hypertension were considered well controlled (pressures under 130/80 mm Hg); the rate for diabetics was 6%.

Dr. Soucek noted that blood pressure was uncontrolled in almost 30% of the diabetic patients with hypertension even though they were on at least three antihypertensive drugs.

But the most striking finding of this study, one that surprised the investigators themselves, was the correlation between poor pressure control and increased fasting blood glucose. “The average fasting blood glucose showed a gradual increase, with increasing blood pressure, from 7.98 mmol/L in diabetics with blood pressure under 130/80 mm Hg to 9.44 in diabetic patients with blood pressures greater than 180/110 mm Hg,” reported Dr. Soucek of the department of internal medicine, St. Anne University Hospital, Brno, Czech Republic.

The mechanism underlying this connection is not known, and it is too soon to tell if there is a causal connection.

The clinical implication, however, is clear: Uncontrolled pressure in a diabetic patient may be a signal for uncontrolled glucose as well. These patients need even closer attention than nondiabetic hypertensives or diabetics who are not hypertensive, he said.

MADRID — Fasting blood glucose levels appear to be higher in diabetic patients with poorly controlled blood pressure than in those with well controlled pressure, said Dr. Miroslav Soucek, at the annual meeting of the European Society of Hypertension.

This observation was based on a survey of more than 2,200 patients from 150 primary care practices throughout the Czech Republic. The primary objective of the study was to determine the prevalence of hypertension in the Czech population, and the extent to which physicians there are able to help their patients achieve pressure control targets as outlined in current ESH guidelines, said Dr. Soucek, who presented the findings in a poster.

Each participating physician recorded thorough case data from 15 consecutive patients aged at least 45 years, irrespective of the reason for each patient's visit. The idea was to get a representative sampling of the health status of all comers to primary care offices. The investigators defined hypertension as pressures above 140/90 mm Hg. Dr. Soucek and his colleagues obtained data from 2,211 patients with a mean age of 62 years.

Of the entire cohort, 78% of the patients were defined as hypertensive; of the 403 patients with diabetes, 75% had hypertension. Only 18% of all patients being treated for hypertension were considered well controlled (pressures under 130/80 mm Hg); the rate for diabetics was 6%.

Dr. Soucek noted that blood pressure was uncontrolled in almost 30% of the diabetic patients with hypertension even though they were on at least three antihypertensive drugs.

But the most striking finding of this study, one that surprised the investigators themselves, was the correlation between poor pressure control and increased fasting blood glucose. “The average fasting blood glucose showed a gradual increase, with increasing blood pressure, from 7.98 mmol/L in diabetics with blood pressure under 130/80 mm Hg to 9.44 in diabetic patients with blood pressures greater than 180/110 mm Hg,” reported Dr. Soucek of the department of internal medicine, St. Anne University Hospital, Brno, Czech Republic.

The mechanism underlying this connection is not known, and it is too soon to tell if there is a causal connection.

The clinical implication, however, is clear: Uncontrolled pressure in a diabetic patient may be a signal for uncontrolled glucose as well. These patients need even closer attention than nondiabetic hypertensives or diabetics who are not hypertensive, he said.

MADRID — Aliskiren, the novel renin-blocking drug, improved 24-hour blood pressure control and showed greater systolic pressure reductions, compared with ramipril, in diabetics with uncontrolled hypertension, according to data presented at the annual meeting of the European Society of Hypertension.

Aliskiren also can be safely combined with the ACE inhibitor in this population, the combination giving the greatest degree of pressure reduction.

Aliskiren works by blocking the renin-regulated conversion of circulating angiotensinogen to angiotensin-1. The new drug, also known by the brand name Rasilez, is the first of a new class of renin blockers. It is being considered for approval by regulatory authorities in Europe and the United States.

Dr. Yagiz Uresin, professor of clinical pharmacology at Istanbul (Turkey) University, presented a multicenter international study of 837 patients with diabetes and hypertension. At baseline, the patients had blood pressures of over 155 mm Hg systolic and 98 mm Hg diastolic.

After a washout period and a 2- to 4-week placebo run-in, the patients were randomized to aliskiren monotherapy, 150 mg/day; ramipril monotherapy, 5 mg/day; or a combination of 150 mg aliskiren plus 5 mg ramipril per day. After 4 weeks, the investigators doubled the doses in all study groups.

After 8 weeks, aliskiren gave mean pressure reductions of 14.7 mm Hg systolic and 11.3 mm Hg diastolic. This was significantly better than the 12.0- and 10.7-mm Hg reductions obtained with ramipril alone. In combination, the two drugs gave mean pressure reductions of 16.6 mm Hg systolic and 12.8 mm Hg diastolic.

Using a target pressure of 130/80 mm Hg, slightly over 8% of the patients in the monotherapy arms could be considered well controlled by the end of the study. Combination therapy bumped this up to 13%. The low number of patients who were able to reach target pressures reflects the difficulty of treating longstanding hypertension in diabetic patients.

A separate subgroup analysis drawn from the same international cohort showed that aliskiren alone and in combination with ramipril gave significantly better round-the-clock diastolic pressure control than did ramipril alone.

A total of 173 patients, 55 on ramipril alone, 57 on aliskiren alone, and 61 on the combination, underwent 24-hour ambulatory monitoring. Using the smoothness index, a scale that measures the consistency of pressure control over a 24-hour period, the investigators found that aliskiren alone and in combination with ramipril provides significantly greater consistency over the course of a day. Smoothness index scores correlate with reversal of left ventricular hypertrophy and carotid artery wall thickening.

The difference between renin-blockade and ACE inhibition was greatest in the early morning hours. At 21–24 hours post dose, the renin blocker alone and in combination with ramipril gave significantly better pressure control than did ramipril alone. Systolic pressures remained between 4 and 12 mm Hg below baseline in patients on aliskiren or aliskiren plus ramipril. In the ramipril group, systolic pressure rose to near baseline levels at the end of the 24-hour dosing cycle.

The impact of side effects was low in all treatment groups, said Dr. Uresin. About one-third of the patients in each monotherapy group had some untoward effects, the most common being headache, cough, nasopharyngitis, and diarrhea. These were mild and self-limiting in the vast majority. Just over 2% of the ramipril monotherapy group and just under 3% of the aliskiren group had serious side effects; the incidence was reduced to 1.4% for the combination.

The addition of aliskiren to ramipril can cut the incidence of coughing, which is the most common reason patients quit ACE inhibitor therapy. Dr. Uresin pointed out that incidence of cough was just under 5% in the ramipril-alone group, and just over 2% for aliskiren. The rate was 1.8% among those taking the combination. The difference was statistically significant.

“This was definitely not expected,” said Dr. Uresin.

Though the mechanism underlying the cough attenuation is not clear, it may have to do with reduced bradykinin levels following renin blockade, he said.

MADRID — Aliskiren, the novel renin-blocking drug, improved 24-hour blood pressure control and showed greater systolic pressure reductions, compared with ramipril, in diabetics with uncontrolled hypertension, according to data presented at the annual meeting of the European Society of Hypertension.

Aliskiren also can be safely combined with the ACE inhibitor in this population, the combination giving the greatest degree of pressure reduction.

Aliskiren works by blocking the renin-regulated conversion of circulating angiotensinogen to angiotensin-1. The new drug, also known by the brand name Rasilez, is the first of a new class of renin blockers. It is being considered for approval by regulatory authorities in Europe and the United States.

Dr. Yagiz Uresin, professor of clinical pharmacology at Istanbul (Turkey) University, presented a multicenter international study of 837 patients with diabetes and hypertension. At baseline, the patients had blood pressures of over 155 mm Hg systolic and 98 mm Hg diastolic.

After a washout period and a 2- to 4-week placebo run-in, the patients were randomized to aliskiren monotherapy, 150 mg/day; ramipril monotherapy, 5 mg/day; or a combination of 150 mg aliskiren plus 5 mg ramipril per day. After 4 weeks, the investigators doubled the doses in all study groups.

After 8 weeks, aliskiren gave mean pressure reductions of 14.7 mm Hg systolic and 11.3 mm Hg diastolic. This was significantly better than the 12.0- and 10.7-mm Hg reductions obtained with ramipril alone. In combination, the two drugs gave mean pressure reductions of 16.6 mm Hg systolic and 12.8 mm Hg diastolic.

Using a target pressure of 130/80 mm Hg, slightly over 8% of the patients in the monotherapy arms could be considered well controlled by the end of the study. Combination therapy bumped this up to 13%. The low number of patients who were able to reach target pressures reflects the difficulty of treating longstanding hypertension in diabetic patients.

A separate subgroup analysis drawn from the same international cohort showed that aliskiren alone and in combination with ramipril gave significantly better round-the-clock diastolic pressure control than did ramipril alone.

A total of 173 patients, 55 on ramipril alone, 57 on aliskiren alone, and 61 on the combination, underwent 24-hour ambulatory monitoring. Using the smoothness index, a scale that measures the consistency of pressure control over a 24-hour period, the investigators found that aliskiren alone and in combination with ramipril provides significantly greater consistency over the course of a day. Smoothness index scores correlate with reversal of left ventricular hypertrophy and carotid artery wall thickening.

The difference between renin-blockade and ACE inhibition was greatest in the early morning hours. At 21–24 hours post dose, the renin blocker alone and in combination with ramipril gave significantly better pressure control than did ramipril alone. Systolic pressures remained between 4 and 12 mm Hg below baseline in patients on aliskiren or aliskiren plus ramipril. In the ramipril group, systolic pressure rose to near baseline levels at the end of the 24-hour dosing cycle.

The impact of side effects was low in all treatment groups, said Dr. Uresin. About one-third of the patients in each monotherapy group had some untoward effects, the most common being headache, cough, nasopharyngitis, and diarrhea. These were mild and self-limiting in the vast majority. Just over 2% of the ramipril monotherapy group and just under 3% of the aliskiren group had serious side effects; the incidence was reduced to 1.4% for the combination.

The addition of aliskiren to ramipril can cut the incidence of coughing, which is the most common reason patients quit ACE inhibitor therapy. Dr. Uresin pointed out that incidence of cough was just under 5% in the ramipril-alone group, and just over 2% for aliskiren. The rate was 1.8% among those taking the combination. The difference was statistically significant.

“This was definitely not expected,” said Dr. Uresin.

Though the mechanism underlying the cough attenuation is not clear, it may have to do with reduced bradykinin levels following renin blockade, he said.

MADRID — Aliskiren, the novel renin-blocking drug, improved 24-hour blood pressure control and showed greater systolic pressure reductions, compared with ramipril, in diabetics with uncontrolled hypertension, according to data presented at the annual meeting of the European Society of Hypertension.

Aliskiren also can be safely combined with the ACE inhibitor in this population, the combination giving the greatest degree of pressure reduction.

Aliskiren works by blocking the renin-regulated conversion of circulating angiotensinogen to angiotensin-1. The new drug, also known by the brand name Rasilez, is the first of a new class of renin blockers. It is being considered for approval by regulatory authorities in Europe and the United States.

Dr. Yagiz Uresin, professor of clinical pharmacology at Istanbul (Turkey) University, presented a multicenter international study of 837 patients with diabetes and hypertension. At baseline, the patients had blood pressures of over 155 mm Hg systolic and 98 mm Hg diastolic.

After a washout period and a 2- to 4-week placebo run-in, the patients were randomized to aliskiren monotherapy, 150 mg/day; ramipril monotherapy, 5 mg/day; or a combination of 150 mg aliskiren plus 5 mg ramipril per day. After 4 weeks, the investigators doubled the doses in all study groups.

After 8 weeks, aliskiren gave mean pressure reductions of 14.7 mm Hg systolic and 11.3 mm Hg diastolic. This was significantly better than the 12.0- and 10.7-mm Hg reductions obtained with ramipril alone. In combination, the two drugs gave mean pressure reductions of 16.6 mm Hg systolic and 12.8 mm Hg diastolic.

Using a target pressure of 130/80 mm Hg, slightly over 8% of the patients in the monotherapy arms could be considered well controlled by the end of the study. Combination therapy bumped this up to 13%. The low number of patients who were able to reach target pressures reflects the difficulty of treating longstanding hypertension in diabetic patients.

A separate subgroup analysis drawn from the same international cohort showed that aliskiren alone and in combination with ramipril gave significantly better round-the-clock diastolic pressure control than did ramipril alone.

A total of 173 patients, 55 on ramipril alone, 57 on aliskiren alone, and 61 on the combination, underwent 24-hour ambulatory monitoring. Using the smoothness index, a scale that measures the consistency of pressure control over a 24-hour period, the investigators found that aliskiren alone and in combination with ramipril provides significantly greater consistency over the course of a day. Smoothness index scores correlate with reversal of left ventricular hypertrophy and carotid artery wall thickening.

The difference between renin-blockade and ACE inhibition was greatest in the early morning hours. At 21–24 hours post dose, the renin blocker alone and in combination with ramipril gave significantly better pressure control than did ramipril alone. Systolic pressures remained between 4 and 12 mm Hg below baseline in patients on aliskiren or aliskiren plus ramipril. In the ramipril group, systolic pressure rose to near baseline levels at the end of the 24-hour dosing cycle.

The impact of side effects was low in all treatment groups, said Dr. Uresin. About one-third of the patients in each monotherapy group had some untoward effects, the most common being headache, cough, nasopharyngitis, and diarrhea. These were mild and self-limiting in the vast majority. Just over 2% of the ramipril monotherapy group and just under 3% of the aliskiren group had serious side effects; the incidence was reduced to 1.4% for the combination.

The addition of aliskiren to ramipril can cut the incidence of coughing, which is the most common reason patients quit ACE inhibitor therapy. Dr. Uresin pointed out that incidence of cough was just under 5% in the ramipril-alone group, and just over 2% for aliskiren. The rate was 1.8% among those taking the combination. The difference was statistically significant.

“This was definitely not expected,” said Dr. Uresin.

Though the mechanism underlying the cough attenuation is not clear, it may have to do with reduced bradykinin levels following renin blockade, he said.

WASHINGTON — Price transparency for physician and hospital services is a key element in the Bush administration's vision of “consumer-driven” health care, and the administration is prepared to push for mandatory price-tagging if doctors and hospital administrators won't voluntarily provide the information.

Speaking at a health care congress sponsored by the Wall Street Journal and CNBC, Al Hubbard, assistant to President George W. Bush for Economic Policy, issued a kind of ultimatum to the clinical community: “Make pricing information available without being forced. We have allies in Congress who are very much inclined to be prescriptive with legislation to impose pricing and quality standards on the health care community.”

Comprehensive and accurate pricing for health care services are essential for the efficacy of health savings accounts (HSAs) and other market-driven solutions to health care spending, said Mr. Hubbard, who is also director of the National Economic Council, at the meeting.

He cited LASIK (laser in situ keratomileusis) surgery as a prime example. “Fifteen years ago, LASIK cost about $2,500 per eye. Because the service is an out-of-pocket expense, now the cost is under $1,000 per eye. That's what would happen in the rest of health care if people were price-sensitive consumers,” he said. “You cannot be a wise consumer if you don't know the prices or the quality of the goods. Right now, providers do not make that information available, and a lot of hospital executives don't believe pricing information should be available.”

Mr. Hubbard's remarks followed a video address by President Bush, in which the President underscored his commitment to HSAs as a key instrument for change. He estimated that more than 3 million Americans will be enrolled in HSAs this year, a number he hopes to see vastly increased over the next few years.

The President underscored the “simple and clear philosophy” that underlies his solution to the health care problem: “The American medical system should be run by doctors, patients, and consumers, not the federal government.”

It was easy for Mr. Hubbard to talk tough at the meeting. According to the conference organizers, physicians represented only 4% of attendees, and there were very few doctors in the room during Mr. Hubbard's address.

One physician, an anesthesiologist, did stand up to challenge the administration's fixation on price-tagging. He cited the potential dangers that could arise if “consumers”—that is, patients—began choosing health care services based on price postings. He stressed that the medical community itself is far from having accurate quality measures to determine standards for best practices. Without clear and science-based quality standards, pricing information would have little value because patients would not be able to determine what they would be getting for their money. Further, shopping for health care based on price could encourage substandard care and suboptimal clinical outcomes.

He also pointed out that a higher-priced physician practice or hospital may be incurring those higher costs because they are treating a sicker population. Likewise a practice or hospital with lower outcomes scores may be handling sicker patients. Price tags and raw outcomes data alone would not reflect this, unless accurate risk-stratification measures were also incorporated.

Mr. Hubbard acknowledged that there's much work to be done in developing meaningful outcomes standards and risk assessment tools so that consumers can “compare apples to apples.” At the same time, the administration seems unwilling to wait around indefinitely while practitioners and hospitals figure out how to prove their worth.

Several in the audience pointed out that the “shop-around” approach is likely to break down around episodes of emergency care, critical care, and sudden onset of disease. An individual having a myocardial infarction isn't likely to consult the Internet to find out which area hospital offers the best dollar value.

Mr. Hubbard agreed that emergency situations are an exception to the consumer-driven rule, but he insisted that “there's no reason we should not be able to have bundled pricing from our physicians and hospitals on all nonemergency care. We want you to treat your patients/customers exactly the way you want to be treated when you consume a product or service.”

Whether a mandate for pricing transparency is truly in the offing remains to be seen. What is clear is that the Bush administration views HSAs and other strategies for shifting greater cost and greater health care responsibility onto consumers as the only viable strategy for the nation's health care financing woes.

During a separate session at the meeting, Jack Brennan, CEO of the Vanguard Group, the nation's second largest mutual fund company, and Jim Guest, president of Consumers Union (publisher of Consumer Reports), reviewed the potential strengths and weaknesses of consumer-driven health care plans.

Mr. Brennan, who said that he believes the health care world has a lot to learn by studying the evolution of the 401(k) business, said that Vanguard offers its 12,000 employees a consumer-driven health plan option, and has for several years. However, no more than 10% of the company's employees have chosen it. “I'd say there's a bit of a reluctance, but it is a start, and I'd like to see more,” he said.

Consumer Reports' Mr. Guest said his organization supports the general idea of “consumer-informed health care,” but said it is far too early to tell whether strategies like those advocated by the Bush administration will really deliver on their stated promises.

What's the Lesson From 401(k) Plans?

Health care right now is in a situation somewhat analogous to that facing the employee benefits, pension, and investment world nearly 3 decades ago, when the 401(k) concept was first developed, the Vanguard Group's Mr. Brennan said.

“Twenty-five years ago, the 401(k) industry was very fragmented. It was high cost and poorly understood by the public. Now, it has gotten to the point where 90% or more of all U.S. companies offer them. It is a $2.1 trillion market, and it's basically a story of empowering people to make decisions and choices that are good for them. It is based on one single bedrock idea: that given good information and good tools, the consumer will make smart decisions.”

Effective consumer education based on simple language and clear elucidation of benefits was the fundamental key to winning buy-in from ordinary people. “You can't have overeducated MBAs writing explanations for working people. It all needs to be very simple and straightforward.”

The benefits promised by early advocates of 401(k) investment (greater personal control over investment choices, tailored investment planning, facilitated transactions, and strong returns) were delivered via a vast powerhouse of new interactive technology.

Choice, said Mr. Brennan, is the watchword of the 401(k) industry. Previously, people had few retirement investment options. They got the plans their employers gave them, end of story. They didn't see where their money was going, and for the most part, they didn't care.

The 401(k) put a new range of investment options within reach of ordinary working people, and more important, the industry taught people how to think about investment choices in a way that really spoke to their concerns and needs.

WASHINGTON — Price transparency for physician and hospital services is a key element in the Bush administration's vision of “consumer-driven” health care, and the administration is prepared to push for mandatory price-tagging if doctors and hospital administrators won't voluntarily provide the information.

Speaking at a health care congress sponsored by the Wall Street Journal and CNBC, Al Hubbard, assistant to President George W. Bush for Economic Policy, issued a kind of ultimatum to the clinical community: “Make pricing information available without being forced. We have allies in Congress who are very much inclined to be prescriptive with legislation to impose pricing and quality standards on the health care community.”

Comprehensive and accurate pricing for health care services are essential for the efficacy of health savings accounts (HSAs) and other market-driven solutions to health care spending, said Mr. Hubbard, who is also director of the National Economic Council, at the meeting.

He cited LASIK (laser in situ keratomileusis) surgery as a prime example. “Fifteen years ago, LASIK cost about $2,500 per eye. Because the service is an out-of-pocket expense, now the cost is under $1,000 per eye. That's what would happen in the rest of health care if people were price-sensitive consumers,” he said. “You cannot be a wise consumer if you don't know the prices or the quality of the goods. Right now, providers do not make that information available, and a lot of hospital executives don't believe pricing information should be available.”

Mr. Hubbard's remarks followed a video address by President Bush, in which the President underscored his commitment to HSAs as a key instrument for change. He estimated that more than 3 million Americans will be enrolled in HSAs this year, a number he hopes to see vastly increased over the next few years.

The President underscored the “simple and clear philosophy” that underlies his solution to the health care problem: “The American medical system should be run by doctors, patients, and consumers, not the federal government.”

It was easy for Mr. Hubbard to talk tough at the meeting. According to the conference organizers, physicians represented only 4% of attendees, and there were very few doctors in the room during Mr. Hubbard's address.

One physician, an anesthesiologist, did stand up to challenge the administration's fixation on price-tagging. He cited the potential dangers that could arise if “consumers”—that is, patients—began choosing health care services based on price postings. He stressed that the medical community itself is far from having accurate quality measures to determine standards for best practices. Without clear and science-based quality standards, pricing information would have little value because patients would not be able to determine what they would be getting for their money. Further, shopping for health care based on price could encourage substandard care and suboptimal clinical outcomes.

He also pointed out that a higher-priced physician practice or hospital may be incurring those higher costs because they are treating a sicker population. Likewise a practice or hospital with lower outcomes scores may be handling sicker patients. Price tags and raw outcomes data alone would not reflect this, unless accurate risk-stratification measures were also incorporated.

Mr. Hubbard acknowledged that there's much work to be done in developing meaningful outcomes standards and risk assessment tools so that consumers can “compare apples to apples.” At the same time, the administration seems unwilling to wait around indefinitely while practitioners and hospitals figure out how to prove their worth.

Several in the audience pointed out that the “shop-around” approach is likely to break down around episodes of emergency care, critical care, and sudden onset of disease. An individual having a myocardial infarction isn't likely to consult the Internet to find out which area hospital offers the best dollar value.

Mr. Hubbard agreed that emergency situations are an exception to the consumer-driven rule, but he insisted that “there's no reason we should not be able to have bundled pricing from our physicians and hospitals on all nonemergency care. We want you to treat your patients/customers exactly the way you want to be treated when you consume a product or service.”

Whether a mandate for pricing transparency is truly in the offing remains to be seen. What is clear is that the Bush administration views HSAs and other strategies for shifting greater cost and greater health care responsibility onto consumers as the only viable strategy for the nation's health care financing woes.

During a separate session at the meeting, Jack Brennan, CEO of the Vanguard Group, the nation's second largest mutual fund company, and Jim Guest, president of Consumers Union (publisher of Consumer Reports), reviewed the potential strengths and weaknesses of consumer-driven health care plans.

Mr. Brennan, who said that he believes the health care world has a lot to learn by studying the evolution of the 401(k) business, said that Vanguard offers its 12,000 employees a consumer-driven health plan option, and has for several years. However, no more than 10% of the company's employees have chosen it. “I'd say there's a bit of a reluctance, but it is a start, and I'd like to see more,” he said.

Consumer Reports' Mr. Guest said his organization supports the general idea of “consumer-informed health care,” but said it is far too early to tell whether strategies like those advocated by the Bush administration will really deliver on their stated promises.

What's the Lesson From 401(k) Plans?

Health care right now is in a situation somewhat analogous to that facing the employee benefits, pension, and investment world nearly 3 decades ago, when the 401(k) concept was first developed, the Vanguard Group's Mr. Brennan said.

“Twenty-five years ago, the 401(k) industry was very fragmented. It was high cost and poorly understood by the public. Now, it has gotten to the point where 90% or more of all U.S. companies offer them. It is a $2.1 trillion market, and it's basically a story of empowering people to make decisions and choices that are good for them. It is based on one single bedrock idea: that given good information and good tools, the consumer will make smart decisions.”

Effective consumer education based on simple language and clear elucidation of benefits was the fundamental key to winning buy-in from ordinary people. “You can't have overeducated MBAs writing explanations for working people. It all needs to be very simple and straightforward.”

The benefits promised by early advocates of 401(k) investment (greater personal control over investment choices, tailored investment planning, facilitated transactions, and strong returns) were delivered via a vast powerhouse of new interactive technology.

Choice, said Mr. Brennan, is the watchword of the 401(k) industry. Previously, people had few retirement investment options. They got the plans their employers gave them, end of story. They didn't see where their money was going, and for the most part, they didn't care.

The 401(k) put a new range of investment options within reach of ordinary working people, and more important, the industry taught people how to think about investment choices in a way that really spoke to their concerns and needs.

WASHINGTON — Price transparency for physician and hospital services is a key element in the Bush administration's vision of “consumer-driven” health care, and the administration is prepared to push for mandatory price-tagging if doctors and hospital administrators won't voluntarily provide the information.

Speaking at a health care congress sponsored by the Wall Street Journal and CNBC, Al Hubbard, assistant to President George W. Bush for Economic Policy, issued a kind of ultimatum to the clinical community: “Make pricing information available without being forced. We have allies in Congress who are very much inclined to be prescriptive with legislation to impose pricing and quality standards on the health care community.”

Comprehensive and accurate pricing for health care services are essential for the efficacy of health savings accounts (HSAs) and other market-driven solutions to health care spending, said Mr. Hubbard, who is also director of the National Economic Council, at the meeting.

He cited LASIK (laser in situ keratomileusis) surgery as a prime example. “Fifteen years ago, LASIK cost about $2,500 per eye. Because the service is an out-of-pocket expense, now the cost is under $1,000 per eye. That's what would happen in the rest of health care if people were price-sensitive consumers,” he said. “You cannot be a wise consumer if you don't know the prices or the quality of the goods. Right now, providers do not make that information available, and a lot of hospital executives don't believe pricing information should be available.”

Mr. Hubbard's remarks followed a video address by President Bush, in which the President underscored his commitment to HSAs as a key instrument for change. He estimated that more than 3 million Americans will be enrolled in HSAs this year, a number he hopes to see vastly increased over the next few years.

The President underscored the “simple and clear philosophy” that underlies his solution to the health care problem: “The American medical system should be run by doctors, patients, and consumers, not the federal government.”

It was easy for Mr. Hubbard to talk tough at the meeting. According to the conference organizers, physicians represented only 4% of attendees, and there were very few doctors in the room during Mr. Hubbard's address.

One physician, an anesthesiologist, did stand up to challenge the administration's fixation on price-tagging. He cited the potential dangers that could arise if “consumers”—that is, patients—began choosing health care services based on price postings. He stressed that the medical community itself is far from having accurate quality measures to determine standards for best practices. Without clear and science-based quality standards, pricing information would have little value because patients would not be able to determine what they would be getting for their money. Further, shopping for health care based on price could encourage substandard care and suboptimal clinical outcomes.

He also pointed out that a higher-priced physician practice or hospital may be incurring those higher costs because they are treating a sicker population. Likewise a practice or hospital with lower outcomes scores may be handling sicker patients. Price tags and raw outcomes data alone would not reflect this, unless accurate risk-stratification measures were also incorporated.

Mr. Hubbard acknowledged that there's much work to be done in developing meaningful outcomes standards and risk assessment tools so that consumers can “compare apples to apples.” At the same time, the administration seems unwilling to wait around indefinitely while practitioners and hospitals figure out how to prove their worth.

Several in the audience pointed out that the “shop-around” approach is likely to break down around episodes of emergency care, critical care, and sudden onset of disease. An individual having a myocardial infarction isn't likely to consult the Internet to find out which area hospital offers the best dollar value.

Mr. Hubbard agreed that emergency situations are an exception to the consumer-driven rule, but he insisted that “there's no reason we should not be able to have bundled pricing from our physicians and hospitals on all nonemergency care. We want you to treat your patients/customers exactly the way you want to be treated when you consume a product or service.”

Whether a mandate for pricing transparency is truly in the offing remains to be seen. What is clear is that the Bush administration views HSAs and other strategies for shifting greater cost and greater health care responsibility onto consumers as the only viable strategy for the nation's health care financing woes.

During a separate session at the meeting, Jack Brennan, CEO of the Vanguard Group, the nation's second largest mutual fund company, and Jim Guest, president of Consumers Union (publisher of Consumer Reports), reviewed the potential strengths and weaknesses of consumer-driven health care plans.

Mr. Brennan, who said that he believes the health care world has a lot to learn by studying the evolution of the 401(k) business, said that Vanguard offers its 12,000 employees a consumer-driven health plan option, and has for several years. However, no more than 10% of the company's employees have chosen it. “I'd say there's a bit of a reluctance, but it is a start, and I'd like to see more,” he said.

Consumer Reports' Mr. Guest said his organization supports the general idea of “consumer-informed health care,” but said it is far too early to tell whether strategies like those advocated by the Bush administration will really deliver on their stated promises.

What's the Lesson From 401(k) Plans?

Health care right now is in a situation somewhat analogous to that facing the employee benefits, pension, and investment world nearly 3 decades ago, when the 401(k) concept was first developed, the Vanguard Group's Mr. Brennan said.

“Twenty-five years ago, the 401(k) industry was very fragmented. It was high cost and poorly understood by the public. Now, it has gotten to the point where 90% or more of all U.S. companies offer them. It is a $2.1 trillion market, and it's basically a story of empowering people to make decisions and choices that are good for them. It is based on one single bedrock idea: that given good information and good tools, the consumer will make smart decisions.”

Effective consumer education based on simple language and clear elucidation of benefits was the fundamental key to winning buy-in from ordinary people. “You can't have overeducated MBAs writing explanations for working people. It all needs to be very simple and straightforward.”

The benefits promised by early advocates of 401(k) investment (greater personal control over investment choices, tailored investment planning, facilitated transactions, and strong returns) were delivered via a vast powerhouse of new interactive technology.

Choice, said Mr. Brennan, is the watchword of the 401(k) industry. Previously, people had few retirement investment options. They got the plans their employers gave them, end of story. They didn't see where their money was going, and for the most part, they didn't care.

The 401(k) put a new range of investment options within reach of ordinary working people, and more important, the industry taught people how to think about investment choices in a way that really spoke to their concerns and needs.

WASHINGTON — Price transparency for physician and hospital services is a key element in the Bush administration's vision of “consumer-driven” health care, and the administration is prepared to push for mandatory price-tagging if doctors and hospital administrators won't voluntarily provide the information.

Speaking at a health care congress sponsored by the Wall Street Journal and CNBC, Al Hubbard, assistant to President George W. Bush for Economic Policy, issued a kind of ultimatum to the clinical community:

“Make pricing information available without being forced. If you do not do so, we will force you to. We have allies in Congress who are very much inclined to be prescriptive with legislation to impose pricing and quality standards on the health care community,” he said.

Comprehensive and accurate pricing for health care services is essential for the efficacy of health savings accounts (HSAs) and other market-driven solutions to the health care cost crisis favored by the administration and many business leaders, said Mr. Hubbard, who is also director of the National Economic Council, at the meeting.

“Under a consumer-driven health care system, the consumer is incentivized to become a smart shopper, and a driver to push prices down and quality up,” he said.

He cited LASIK (laser in situ keratomileusis) surgery as a prime example. “Fifteen years ago, LASIK cost about $2,500 per eye. Because the service is an out-of-pocket expense, now the cost is under $1,000 per eye. That's what would happen in the rest of health care if people were price-sensitive consumers.”

According to Mr. Hubbard and others within the Bush camp, there's one major obstruction on the road to a consumer-driven health care utopia: the absence of pricing and quality-rating information for medical services.

“You cannot be a wise consumer if you don't know the prices or the quality of the goods. Right now, providers do not make that information available, and a lot of hospital executives don't believe pricing information should be available,” he said.

Mr. Hubbard's remarks followed a very brief and fast-spoken video address by President Bush, in which the president underscored his commitment to HSAs as a key instrument for change. He estimated that more than 3 million Americans will be enrolled in HSAs this year, a number he hopes to see vastly increased over the next few years.

The president underscored the “simple and clear philosophy” that underlies his solution to the health care problem: “The American medical system should be run by doctors, patients, and consumers, not the federal government.”

It was easy for Mr. Hubbard to talk tough at the meeting. According to the conference organizers, physicians represented only 4% of attendees, and there were very few doctors in the room during Mr. Hubbard's address.

One physician, an anesthesiologist, did stand up to challenge the administration's fixation on price-tagging. He cited the potential dangers that could arise if “consumers”—that is, patients—began choosing health care services based on price postings.

He stressed that the medical community itself is far from having accurate quality measures to determine standards for best practices. Without clear and science-based quality standards, pricing information would have little value because patients would not be able to determine what they would be getting for their money.

Furthermore, shopping for health care based on price could encourage substandard care and suboptimal clinical outcomes.

He also pointed out that a higher-priced physician practice or hospital may be incurring those higher costs because they are treating a sicker population. Likewise a practice or hospital with lower outcomes scores may be handling sicker patients. Price tags and raw outcomes data alone would not reflect this, unless accurate risk-stratification measures were also incorporated.

Mr. Hubbard acknowledged that there's much work to be done in developing meaningful outcomes standards and risk assessment tools so that consumers can “compare apples to apples.” At the same time, the administration seems unwilling to wait around indefinitely while practitioners and hospitals figure out how to prove their worth.

Several in the audience pointed out that the “shop-around” approach is likely to break down around episodes of emergency care, critical care, and sudden onset of disease.

An individual having a myocardial infarction isn't likely to consult the Internet to find out which area hospital offers the best dollar value.

The unflappable Mr. Hubbard agreed that emergency situations are an exception to the consumer-driven rule, but he insisted that “there's no reason we should not be able to have bundled pricing from our physicians and hospitals on all nonemergency care.

“We want you to treat your patients/customers exactly the way you want to be treated when you consume a product or service.”

Whether a mandate for pricing transparency is truly in the offing remains to be seen. What is clear is that the Bush administration views HSAs and other strategies for shifting greater cost and greater health care responsibility onto consumers as the only viable strategy for the nation's health care financing woes.

During a separate session at the meeting, Jack Brennan, CEO of the Vanguard Group, the nation's second largest mutual fund company, and Jim Guest, president of Consumers Union (publisher of Consumer Reports), reviewed the potential strengths and weaknesses of consumer-driven health care plans.

Mr. Brennan, who said that he believes the health care world has a lot to learn by studying the evolution of the 401(k) business, said that Vanguard offers its 12,000 employees a consumer-driven health plan option, and has for several years.

However, no more than 10% of the company's employees have chosen it. “I'd say there's a bit of a reluctance, but it is a start, and I'd like to see more,” Mr. Brennan said.

Asked whether he himself had enrolled in such a plan, Mr. Brennan said he had not.

“I don't use it because I'm still trapped in the belief that if it is more expensive, it must be better,” he joked, but added that one of his family members has a complicated medical situation that would make a consumer-driven plan a less-than-optimal prospect for him.

Consumer Reports' Mr. Guest said his organization supports the general idea of “consumer-informed health care,” but said it is far too early to tell whether strategies like those advocated by the Bush administration will really deliver on their stated promises.

“We're really far away from where we need to be. I don't think the consumer voice has been strongly heard. The movement [toward consumer-driven plans] has been driven more by the industry than by the consumer,” said Mr. Guest.

“Until consumers have full information about what the choices are that they're making, it is not really consumer driven. And right now, most people do not understand what they're deciding between, he added.”

Can 401(k)s Set Health Care Example?

Health care right now is in a situation somewhat analogous to that facing the employee benefits, pension, and investment world nearly 3 decades ago, when the 401(k) concept was first developed, the Vanguard Group's Mr. Brennan said.

“Twenty-five years ago, the 401(k) industry was very fragmented. It was high cost and poorly understood by the public. Now, it has gotten to the point where 90% or more of all U.S. companies offer them. It is a $2.1 trillion market, and it's basically a story of empowering people to make decisions and choices that are good for them. It is based on one single bedrock idea: that given good information and good tools, the consumer will make smart decisions.”

Why did the 401(k) movement succeed? Effective consumer education based on simple language and clear elucidation of benefits was the fundamental key to winning buy-in from ordinary people. “You can't have overeducated MBAs writing explanations for working people. It all needs to be very simple and straightforward.”

The benefits promised by early advocates of 401(k) investment (greater personal control over investment choices, tailored investment planning, facilitated transactions, and strong returns) were delivered via a vast powerhouse of new interactive technology. “Before 401(k) [plans], you were dependent on quarterly statements. The 401(k) industry developed all this real-time transactional information, 800 numbers, and Web sites that offered more consumer interactivity.”

Choice, said Mr. Brennan, is the watchword of the 401(k) industry. Previously, people had few retirement investment options. They got the plans their employers gave them, end of story. They didn't see where their money was going, and for the most part, they didn't care.

The 401(k) put a new range of investment options within reach of ordinary working people, and more important, the industry taught people how to think about investment choices in a way that really spoke to their concerns and needs.

To what extent is health care really similar to retirement investing? Should the health care industry operate more like the investment world? These are open questions, and one could easily tear holes in Mr. Brennan's comparisons. But the issue of how to communicate the relative benefits and downsides of various forms of health care financing to the public is one that physicians, health benefits managers, and policy makers need to face.

Underneath all the policy debate, Mr. Brennan said the real question posed by the consumer-driven health care vision amounts to this: Is the average American worker smart enough to make good decisions about present and future health care needs?

He said he believes, for the most part, that they are.

“I come at my business from the point of view that people are smart. A lot of people, especially in the health care business, come from the point of view that people are not smart and are unable to make intelligent, informed choices. That's a fundamental difference,” he said.

WASHINGTON — Price transparency for physician and hospital services is a key element in the Bush administration's vision of “consumer-driven” health care, and the administration is prepared to push for mandatory price-tagging if doctors and hospital administrators won't voluntarily provide the information.

Speaking at a health care congress sponsored by the Wall Street Journal and CNBC, Al Hubbard, assistant to President George W. Bush for Economic Policy, issued a kind of ultimatum to the clinical community:

“Make pricing information available without being forced. If you do not do so, we will force you to. We have allies in Congress who are very much inclined to be prescriptive with legislation to impose pricing and quality standards on the health care community,” he said.

Comprehensive and accurate pricing for health care services is essential for the efficacy of health savings accounts (HSAs) and other market-driven solutions to the health care cost crisis favored by the administration and many business leaders, said Mr. Hubbard, who is also director of the National Economic Council, at the meeting.

“Under a consumer-driven health care system, the consumer is incentivized to become a smart shopper, and a driver to push prices down and quality up,” he said.

He cited LASIK (laser in situ keratomileusis) surgery as a prime example. “Fifteen years ago, LASIK cost about $2,500 per eye. Because the service is an out-of-pocket expense, now the cost is under $1,000 per eye. That's what would happen in the rest of health care if people were price-sensitive consumers.”

According to Mr. Hubbard and others within the Bush camp, there's one major obstruction on the road to a consumer-driven health care utopia: the absence of pricing and quality-rating information for medical services.

“You cannot be a wise consumer if you don't know the prices or the quality of the goods. Right now, providers do not make that information available, and a lot of hospital executives don't believe pricing information should be available,” he said.

Mr. Hubbard's remarks followed a very brief and fast-spoken video address by President Bush, in which the president underscored his commitment to HSAs as a key instrument for change. He estimated that more than 3 million Americans will be enrolled in HSAs this year, a number he hopes to see vastly increased over the next few years.

The president underscored the “simple and clear philosophy” that underlies his solution to the health care problem: “The American medical system should be run by doctors, patients, and consumers, not the federal government.”

It was easy for Mr. Hubbard to talk tough at the meeting. According to the conference organizers, physicians represented only 4% of attendees, and there were very few doctors in the room during Mr. Hubbard's address.

One physician, an anesthesiologist, did stand up to challenge the administration's fixation on price-tagging. He cited the potential dangers that could arise if “consumers”—that is, patients—began choosing health care services based on price postings.

He stressed that the medical community itself is far from having accurate quality measures to determine standards for best practices. Without clear and science-based quality standards, pricing information would have little value because patients would not be able to determine what they would be getting for their money.

Furthermore, shopping for health care based on price could encourage substandard care and suboptimal clinical outcomes.

He also pointed out that a higher-priced physician practice or hospital may be incurring those higher costs because they are treating a sicker population. Likewise a practice or hospital with lower outcomes scores may be handling sicker patients. Price tags and raw outcomes data alone would not reflect this, unless accurate risk-stratification measures were also incorporated.

Mr. Hubbard acknowledged that there's much work to be done in developing meaningful outcomes standards and risk assessment tools so that consumers can “compare apples to apples.” At the same time, the administration seems unwilling to wait around indefinitely while practitioners and hospitals figure out how to prove their worth.

Several in the audience pointed out that the “shop-around” approach is likely to break down around episodes of emergency care, critical care, and sudden onset of disease.

An individual having a myocardial infarction isn't likely to consult the Internet to find out which area hospital offers the best dollar value.

The unflappable Mr. Hubbard agreed that emergency situations are an exception to the consumer-driven rule, but he insisted that “there's no reason we should not be able to have bundled pricing from our physicians and hospitals on all nonemergency care.

“We want you to treat your patients/customers exactly the way you want to be treated when you consume a product or service.”

Whether a mandate for pricing transparency is truly in the offing remains to be seen. What is clear is that the Bush administration views HSAs and other strategies for shifting greater cost and greater health care responsibility onto consumers as the only viable strategy for the nation's health care financing woes.

During a separate session at the meeting, Jack Brennan, CEO of the Vanguard Group, the nation's second largest mutual fund company, and Jim Guest, president of Consumers Union (publisher of Consumer Reports), reviewed the potential strengths and weaknesses of consumer-driven health care plans.

Mr. Brennan, who said that he believes the health care world has a lot to learn by studying the evolution of the 401(k) business, said that Vanguard offers its 12,000 employees a consumer-driven health plan option, and has for several years.

However, no more than 10% of the company's employees have chosen it. “I'd say there's a bit of a reluctance, but it is a start, and I'd like to see more,” Mr. Brennan said.

Asked whether he himself had enrolled in such a plan, Mr. Brennan said he had not.

“I don't use it because I'm still trapped in the belief that if it is more expensive, it must be better,” he joked, but added that one of his family members has a complicated medical situation that would make a consumer-driven plan a less-than-optimal prospect for him.

Consumer Reports' Mr. Guest said his organization supports the general idea of “consumer-informed health care,” but said it is far too early to tell whether strategies like those advocated by the Bush administration will really deliver on their stated promises.

“We're really far away from where we need to be. I don't think the consumer voice has been strongly heard. The movement [toward consumer-driven plans] has been driven more by the industry than by the consumer,” said Mr. Guest.

“Until consumers have full information about what the choices are that they're making, it is not really consumer driven. And right now, most people do not understand what they're deciding between, he added.”

Can 401(k)s Set Health Care Example?

Health care right now is in a situation somewhat analogous to that facing the employee benefits, pension, and investment world nearly 3 decades ago, when the 401(k) concept was first developed, the Vanguard Group's Mr. Brennan said.

“Twenty-five years ago, the 401(k) industry was very fragmented. It was high cost and poorly understood by the public. Now, it has gotten to the point where 90% or more of all U.S. companies offer them. It is a $2.1 trillion market, and it's basically a story of empowering people to make decisions and choices that are good for them. It is based on one single bedrock idea: that given good information and good tools, the consumer will make smart decisions.”

Why did the 401(k) movement succeed? Effective consumer education based on simple language and clear elucidation of benefits was the fundamental key to winning buy-in from ordinary people. “You can't have overeducated MBAs writing explanations for working people. It all needs to be very simple and straightforward.”

The benefits promised by early advocates of 401(k) investment (greater personal control over investment choices, tailored investment planning, facilitated transactions, and strong returns) were delivered via a vast powerhouse of new interactive technology. “Before 401(k) [plans], you were dependent on quarterly statements. The 401(k) industry developed all this real-time transactional information, 800 numbers, and Web sites that offered more consumer interactivity.”

Choice, said Mr. Brennan, is the watchword of the 401(k) industry. Previously, people had few retirement investment options. They got the plans their employers gave them, end of story. They didn't see where their money was going, and for the most part, they didn't care.

The 401(k) put a new range of investment options within reach of ordinary working people, and more important, the industry taught people how to think about investment choices in a way that really spoke to their concerns and needs.

To what extent is health care really similar to retirement investing? Should the health care industry operate more like the investment world? These are open questions, and one could easily tear holes in Mr. Brennan's comparisons. But the issue of how to communicate the relative benefits and downsides of various forms of health care financing to the public is one that physicians, health benefits managers, and policy makers need to face.

Underneath all the policy debate, Mr. Brennan said the real question posed by the consumer-driven health care vision amounts to this: Is the average American worker smart enough to make good decisions about present and future health care needs?

He said he believes, for the most part, that they are.

“I come at my business from the point of view that people are smart. A lot of people, especially in the health care business, come from the point of view that people are not smart and are unable to make intelligent, informed choices. That's a fundamental difference,” he said.

WASHINGTON — Price transparency for physician and hospital services is a key element in the Bush administration's vision of “consumer-driven” health care, and the administration is prepared to push for mandatory price-tagging if doctors and hospital administrators won't voluntarily provide the information.

Speaking at a health care congress sponsored by the Wall Street Journal and CNBC, Al Hubbard, assistant to President George W. Bush for Economic Policy, issued a kind of ultimatum to the clinical community:

“Make pricing information available without being forced. If you do not do so, we will force you to. We have allies in Congress who are very much inclined to be prescriptive with legislation to impose pricing and quality standards on the health care community,” he said.

Comprehensive and accurate pricing for health care services is essential for the efficacy of health savings accounts (HSAs) and other market-driven solutions to the health care cost crisis favored by the administration and many business leaders, said Mr. Hubbard, who is also director of the National Economic Council, at the meeting.

“Under a consumer-driven health care system, the consumer is incentivized to become a smart shopper, and a driver to push prices down and quality up,” he said.

He cited LASIK (laser in situ keratomileusis) surgery as a prime example. “Fifteen years ago, LASIK cost about $2,500 per eye. Because the service is an out-of-pocket expense, now the cost is under $1,000 per eye. That's what would happen in the rest of health care if people were price-sensitive consumers.”

According to Mr. Hubbard and others within the Bush camp, there's one major obstruction on the road to a consumer-driven health care utopia: the absence of pricing and quality-rating information for medical services.

“You cannot be a wise consumer if you don't know the prices or the quality of the goods. Right now, providers do not make that information available, and a lot of hospital executives don't believe pricing information should be available,” he said.

Mr. Hubbard's remarks followed a very brief and fast-spoken video address by President Bush, in which the president underscored his commitment to HSAs as a key instrument for change. He estimated that more than 3 million Americans will be enrolled in HSAs this year, a number he hopes to see vastly increased over the next few years.

The president underscored the “simple and clear philosophy” that underlies his solution to the health care problem: “The American medical system should be run by doctors, patients, and consumers, not the federal government.”

It was easy for Mr. Hubbard to talk tough at the meeting. According to the conference organizers, physicians represented only 4% of attendees, and there were very few doctors in the room during Mr. Hubbard's address.

One physician, an anesthesiologist, did stand up to challenge the administration's fixation on price-tagging. He cited the potential dangers that could arise if “consumers”—that is, patients—began choosing health care services based on price postings.

He stressed that the medical community itself is far from having accurate quality measures to determine standards for best practices. Without clear and science-based quality standards, pricing information would have little value because patients would not be able to determine what they would be getting for their money.

Furthermore, shopping for health care based on price could encourage substandard care and suboptimal clinical outcomes.

He also pointed out that a higher-priced physician practice or hospital may be incurring those higher costs because they are treating a sicker population. Likewise a practice or hospital with lower outcomes scores may be handling sicker patients. Price tags and raw outcomes data alone would not reflect this, unless accurate risk-stratification measures were also incorporated.

Mr. Hubbard acknowledged that there's much work to be done in developing meaningful outcomes standards and risk assessment tools so that consumers can “compare apples to apples.” At the same time, the administration seems unwilling to wait around indefinitely while practitioners and hospitals figure out how to prove their worth.

Several in the audience pointed out that the “shop-around” approach is likely to break down around episodes of emergency care, critical care, and sudden onset of disease.

An individual having a myocardial infarction isn't likely to consult the Internet to find out which area hospital offers the best dollar value.

The unflappable Mr. Hubbard agreed that emergency situations are an exception to the consumer-driven rule, but he insisted that “there's no reason we should not be able to have bundled pricing from our physicians and hospitals on all nonemergency care.

“We want you to treat your patients/customers exactly the way you want to be treated when you consume a product or service.”

Whether a mandate for pricing transparency is truly in the offing remains to be seen. What is clear is that the Bush administration views HSAs and other strategies for shifting greater cost and greater health care responsibility onto consumers as the only viable strategy for the nation's health care financing woes.

During a separate session at the meeting, Jack Brennan, CEO of the Vanguard Group, the nation's second largest mutual fund company, and Jim Guest, president of Consumers Union (publisher of Consumer Reports), reviewed the potential strengths and weaknesses of consumer-driven health care plans.

Mr. Brennan, who said that he believes the health care world has a lot to learn by studying the evolution of the 401(k) business, said that Vanguard offers its 12,000 employees a consumer-driven health plan option, and has for several years.

However, no more than 10% of the company's employees have chosen it. “I'd say there's a bit of a reluctance, but it is a start, and I'd like to see more,” Mr. Brennan said.

Asked whether he himself had enrolled in such a plan, Mr. Brennan said he had not.

“I don't use it because I'm still trapped in the belief that if it is more expensive, it must be better,” he joked, but added that one of his family members has a complicated medical situation that would make a consumer-driven plan a less-than-optimal prospect for him.

Consumer Reports' Mr. Guest said his organization supports the general idea of “consumer-informed health care,” but said it is far too early to tell whether strategies like those advocated by the Bush administration will really deliver on their stated promises.

“We're really far away from where we need to be. I don't think the consumer voice has been strongly heard. The movement [toward consumer-driven plans] has been driven more by the industry than by the consumer,” said Mr. Guest.

“Until consumers have full information about what the choices are that they're making, it is not really consumer driven. And right now, most people do not understand what they're deciding between, he added.”

Can 401(k)s Set Health Care Example?

Health care right now is in a situation somewhat analogous to that facing the employee benefits, pension, and investment world nearly 3 decades ago, when the 401(k) concept was first developed, the Vanguard Group's Mr. Brennan said.

“Twenty-five years ago, the 401(k) industry was very fragmented. It was high cost and poorly understood by the public. Now, it has gotten to the point where 90% or more of all U.S. companies offer them. It is a $2.1 trillion market, and it's basically a story of empowering people to make decisions and choices that are good for them. It is based on one single bedrock idea: that given good information and good tools, the consumer will make smart decisions.”

Why did the 401(k) movement succeed? Effective consumer education based on simple language and clear elucidation of benefits was the fundamental key to winning buy-in from ordinary people. “You can't have overeducated MBAs writing explanations for working people. It all needs to be very simple and straightforward.”

The benefits promised by early advocates of 401(k) investment (greater personal control over investment choices, tailored investment planning, facilitated transactions, and strong returns) were delivered via a vast powerhouse of new interactive technology. “Before 401(k) [plans], you were dependent on quarterly statements. The 401(k) industry developed all this real-time transactional information, 800 numbers, and Web sites that offered more consumer interactivity.”

Choice, said Mr. Brennan, is the watchword of the 401(k) industry. Previously, people had few retirement investment options. They got the plans their employers gave them, end of story. They didn't see where their money was going, and for the most part, they didn't care.

The 401(k) put a new range of investment options within reach of ordinary working people, and more important, the industry taught people how to think about investment choices in a way that really spoke to their concerns and needs.

To what extent is health care really similar to retirement investing? Should the health care industry operate more like the investment world? These are open questions, and one could easily tear holes in Mr. Brennan's comparisons. But the issue of how to communicate the relative benefits and downsides of various forms of health care financing to the public is one that physicians, health benefits managers, and policy makers need to face.

Underneath all the policy debate, Mr. Brennan said the real question posed by the consumer-driven health care vision amounts to this: Is the average American worker smart enough to make good decisions about present and future health care needs?

He said he believes, for the most part, that they are.

“I come at my business from the point of view that people are smart. A lot of people, especially in the health care business, come from the point of view that people are not smart and are unable to make intelligent, informed choices. That's a fundamental difference,” he said.

MADRID — Rimonabant, the novel cannabinoid type 1 receptor-blocking drug that has been shown to induce weight loss, improve glucose metabolism, raise HDL cholesterol, and lower triglycerides, also appears to lead to small but meaningful reductions in blood pressure in hypertensive obese patients.

That finding comes from a new analysis of pooled data from the four major rimonabant trials involving over 6,600 patients. Among patients with elevated BP at baseline (greater than 143/89 mm Hg for nondiabetics, and greater than 130/85 mm Hg for diabetics), the use of 20 mg/day of rimonabant was associated with a mean systolic pressure reduction of 7.5 mm Hg and a mean diastolic reduction of 5.2 mm Hg. This compares favorably with the mean reductions of 4.7 mm Hg and 3.0 mm Hg, respectively, in patients who received placebo, Dr. Luc Van Gaal reported at the annual meeting of the European Society of Hypertension.

This is the first indication that the cannabinoid receptor blocker may have a role in blood pressure reduction, and it is clearly good news for the treatment of obese or overweight patients who have multiple cardiovascular risk factors.

But the drug should not be misconstrued as being an antihypertensive agent per se. The observed reduction in blood pressure “is mediated by weight loss only, with the drug having no direct effect on blood pressure at this dose level,” stressed Dr. Van Gaal, head of diabetology, metabolism and clinical nutrition at the University Hospital of Antwerp, Belgium.

Rimonabant, which is being developed by Sanofi-Aventis, is under review by the Food and Drug Administration.

The Rimonabant in Obesity and Related Metabolic Disorders (RIO) trial series comprises four distinct international multicenter trials looking at the effects of the drug in nonoverlapping populations.

RIO-North America involved 3,040 obese or overweight patients without comorbidities in the United States and Canada; RIO-Europe looked at a similar population of 1,507 European patients; RIO-Lipids involved 1,033 obese people with untreated dyslipidemia; RIO-Diabetes involved 1,045 obese or overweight patients with type 2 diabetes.

All four studies included hypertensive and nonhypertensive individuals. Across the RIO trials, the percentage of hypertensive subjects ranged from 13% in RIO-North America to 54% in RIO-Diabetes.

The reduction in blood pressure seen in the aggregate RIO population was most pronounced among those with dyslipidemia who were also hypertensive at baseline. In this cohort, the drug was associated with a mean 11.9-mm Hg reduction in systolic pressure and a mean 5.9-mm Hg reduction in diastolic pressure. In contrast, the placebo group had a 6.3-mm Hg drop in systolic and a 2.0-mm Hg drop in diastolic pressure.

In the RIO-Diabetes trial, rimonabant had little apparent effect on blood pressure in those who were normotensive at baseline. But those who were hypertensive at the outset had a 5.5-mm Hg decrease in systolic and a 4.4-mm Hg reduction in diastolic pressure. These differences were statistically significant, and given that nearly 60% of those who were hypertensive were already on antihypertensive medications, these incremental reductions are clinically meaningful, Dr. Van Gaal said.

A linear regression analysis plotting the blood pressure changes against changes in body weight showed nearly identical curves for rimonabant and placebo. The degree of pressure reduction with rimonabant is equivalent to that seen for placebo in patients matched for the same degree of weight loss.

That said, the observed reduction in blood pressure “adds to the other cardiometabolic benefits demonstrated for rimonabant, such as reduced body weight and waist circumference, improved lipid profile, and improved glycemic control,” Dr. Van Gaal said.

Dr. Nick Finer of the Addenbrooke's Hospital, National Health Service Trust, Cambridge, England, commented, “Currently, we use a wide variety of drugs to treat the cardiovascular, inflammatory, endocrine and adipose aspects of the disease of abdominal obesity. Cannabinoid 1 receptor blockade seems to affect all of these areas with one drug. In principle, this could be drug sparing. It is a very exciting development.”

MADRID — Rimonabant, the novel cannabinoid type 1 receptor-blocking drug that has been shown to induce weight loss, improve glucose metabolism, raise HDL cholesterol, and lower triglycerides, also appears to lead to small but meaningful reductions in blood pressure in hypertensive obese patients.

That finding comes from a new analysis of pooled data from the four major rimonabant trials involving over 6,600 patients. Among patients with elevated BP at baseline (greater than 143/89 mm Hg for nondiabetics, and greater than 130/85 mm Hg for diabetics), the use of 20 mg/day of rimonabant was associated with a mean systolic pressure reduction of 7.5 mm Hg and a mean diastolic reduction of 5.2 mm Hg. This compares favorably with the mean reductions of 4.7 mm Hg and 3.0 mm Hg, respectively, in patients who received placebo, Dr. Luc Van Gaal reported at the annual meeting of the European Society of Hypertension.

This is the first indication that the cannabinoid receptor blocker may have a role in blood pressure reduction, and it is clearly good news for the treatment of obese or overweight patients who have multiple cardiovascular risk factors.

But the drug should not be misconstrued as being an antihypertensive agent per se. The observed reduction in blood pressure “is mediated by weight loss only, with the drug having no direct effect on blood pressure at this dose level,” stressed Dr. Van Gaal, head of diabetology, metabolism and clinical nutrition at the University Hospital of Antwerp, Belgium.

Rimonabant, which is being developed by Sanofi-Aventis, is under review by the Food and Drug Administration.

The Rimonabant in Obesity and Related Metabolic Disorders (RIO) trial series comprises four distinct international multicenter trials looking at the effects of the drug in nonoverlapping populations.

RIO-North America involved 3,040 obese or overweight patients without comorbidities in the United States and Canada; RIO-Europe looked at a similar population of 1,507 European patients; RIO-Lipids involved 1,033 obese people with untreated dyslipidemia; RIO-Diabetes involved 1,045 obese or overweight patients with type 2 diabetes.

All four studies included hypertensive and nonhypertensive individuals. Across the RIO trials, the percentage of hypertensive subjects ranged from 13% in RIO-North America to 54% in RIO-Diabetes.

The reduction in blood pressure seen in the aggregate RIO population was most pronounced among those with dyslipidemia who were also hypertensive at baseline. In this cohort, the drug was associated with a mean 11.9-mm Hg reduction in systolic pressure and a mean 5.9-mm Hg reduction in diastolic pressure. In contrast, the placebo group had a 6.3-mm Hg drop in systolic and a 2.0-mm Hg drop in diastolic pressure.

In the RIO-Diabetes trial, rimonabant had little apparent effect on blood pressure in those who were normotensive at baseline. But those who were hypertensive at the outset had a 5.5-mm Hg decrease in systolic and a 4.4-mm Hg reduction in diastolic pressure. These differences were statistically significant, and given that nearly 60% of those who were hypertensive were already on antihypertensive medications, these incremental reductions are clinically meaningful, Dr. Van Gaal said.

A linear regression analysis plotting the blood pressure changes against changes in body weight showed nearly identical curves for rimonabant and placebo. The degree of pressure reduction with rimonabant is equivalent to that seen for placebo in patients matched for the same degree of weight loss.

That said, the observed reduction in blood pressure “adds to the other cardiometabolic benefits demonstrated for rimonabant, such as reduced body weight and waist circumference, improved lipid profile, and improved glycemic control,” Dr. Van Gaal said.

Dr. Nick Finer of the Addenbrooke's Hospital, National Health Service Trust, Cambridge, England, commented, “Currently, we use a wide variety of drugs to treat the cardiovascular, inflammatory, endocrine and adipose aspects of the disease of abdominal obesity. Cannabinoid 1 receptor blockade seems to affect all of these areas with one drug. In principle, this could be drug sparing. It is a very exciting development.”

MADRID — Rimonabant, the novel cannabinoid type 1 receptor-blocking drug that has been shown to induce weight loss, improve glucose metabolism, raise HDL cholesterol, and lower triglycerides, also appears to lead to small but meaningful reductions in blood pressure in hypertensive obese patients.

That finding comes from a new analysis of pooled data from the four major rimonabant trials involving over 6,600 patients. Among patients with elevated BP at baseline (greater than 143/89 mm Hg for nondiabetics, and greater than 130/85 mm Hg for diabetics), the use of 20 mg/day of rimonabant was associated with a mean systolic pressure reduction of 7.5 mm Hg and a mean diastolic reduction of 5.2 mm Hg. This compares favorably with the mean reductions of 4.7 mm Hg and 3.0 mm Hg, respectively, in patients who received placebo, Dr. Luc Van Gaal reported at the annual meeting of the European Society of Hypertension.

This is the first indication that the cannabinoid receptor blocker may have a role in blood pressure reduction, and it is clearly good news for the treatment of obese or overweight patients who have multiple cardiovascular risk factors.

But the drug should not be misconstrued as being an antihypertensive agent per se. The observed reduction in blood pressure “is mediated by weight loss only, with the drug having no direct effect on blood pressure at this dose level,” stressed Dr. Van Gaal, head of diabetology, metabolism and clinical nutrition at the University Hospital of Antwerp, Belgium.

Rimonabant, which is being developed by Sanofi-Aventis, is under review by the Food and Drug Administration.

The Rimonabant in Obesity and Related Metabolic Disorders (RIO) trial series comprises four distinct international multicenter trials looking at the effects of the drug in nonoverlapping populations.

RIO-North America involved 3,040 obese or overweight patients without comorbidities in the United States and Canada; RIO-Europe looked at a similar population of 1,507 European patients; RIO-Lipids involved 1,033 obese people with untreated dyslipidemia; RIO-Diabetes involved 1,045 obese or overweight patients with type 2 diabetes.

All four studies included hypertensive and nonhypertensive individuals. Across the RIO trials, the percentage of hypertensive subjects ranged from 13% in RIO-North America to 54% in RIO-Diabetes.

The reduction in blood pressure seen in the aggregate RIO population was most pronounced among those with dyslipidemia who were also hypertensive at baseline. In this cohort, the drug was associated with a mean 11.9-mm Hg reduction in systolic pressure and a mean 5.9-mm Hg reduction in diastolic pressure. In contrast, the placebo group had a 6.3-mm Hg drop in systolic and a 2.0-mm Hg drop in diastolic pressure.

In the RIO-Diabetes trial, rimonabant had little apparent effect on blood pressure in those who were normotensive at baseline. But those who were hypertensive at the outset had a 5.5-mm Hg decrease in systolic and a 4.4-mm Hg reduction in diastolic pressure. These differences were statistically significant, and given that nearly 60% of those who were hypertensive were already on antihypertensive medications, these incremental reductions are clinically meaningful, Dr. Van Gaal said.

A linear regression analysis plotting the blood pressure changes against changes in body weight showed nearly identical curves for rimonabant and placebo. The degree of pressure reduction with rimonabant is equivalent to that seen for placebo in patients matched for the same degree of weight loss.

That said, the observed reduction in blood pressure “adds to the other cardiometabolic benefits demonstrated for rimonabant, such as reduced body weight and waist circumference, improved lipid profile, and improved glycemic control,” Dr. Van Gaal said.

Dr. Nick Finer of the Addenbrooke's Hospital, National Health Service Trust, Cambridge, England, commented, “Currently, we use a wide variety of drugs to treat the cardiovascular, inflammatory, endocrine and adipose aspects of the disease of abdominal obesity. Cannabinoid 1 receptor blockade seems to affect all of these areas with one drug. In principle, this could be drug sparing. It is a very exciting development.”

MADRID — Aliskiren, the novel renin-blocking drug, improved 24-hour blood pressure control and showed greater systolic pressure reductions, compared with ramipril, in diabetics with uncontrolled hypertension, according to data presented at the annual meeting of the European Society of Hypertension.

Aliskiren also can be safely combined with the ACE inhibitor in this population, the combination giving the greatest degree of pressure.

Aliskiren works by blocking the renin-regulated conversion of circulating angiotensinogen to angiotensin-1. The new drug, also known by the brand name Rasilez, is the first of what may soon be a burgeoning class of renin blockers. It is being considered for approval by regulatory authorities in Europe and the United States.

Dr. Yagiz Uresin, professor of clinical pharmacology at Istanbul (Turkey) University, presented a multicenter international study of 837 patients with diabetes and hypertension. At baseline, the patients had blood pressures of over 155 mm Hg systolic and 98 mm Hg diastolic.

After a washout period and a 2–4 week placebo run-in, the patients were randomized to aliskiren monotherapy, 150 mg/day; ramipril monotherapy, 5 mg/day; or a combination of 150 mg aliskiren plus 5 mg ramipril per day. After 4 weeks, the investigators doubled the doses in all study groups.

After 8 weeks, aliskiren gave mean pressure reductions of 14.7 mm Hg systolic and 11.3 mm Hg diastolic. This was significantly better than the 12.0- and 10.7-mm Hg reductions obtained with ramipril alone. In combination, the two drugs gave mean pressure reductions of 16.6 mm Hg systolic and 12.8 mm Hg diastolic.

Using a target pressure of 130/80 mm Hg, slightly over 8% of the patients in the monotherapy arms could be considered well controlled by the end of the study. Combination therapy bumped this up to 13%. This low rate of response reflects the difficulty of treating longstanding hypertension in diabetic patients, said Dr. Uresin.

A separate subgroup analysis drawn from the same international cohort showed that aliskiren alone and in combination with ramipril gave significantly better round-the-clock diastolic pressure control than did ramipril alone.

A total of 173 patients, 55 on ramipril alone, 57 on aliskiren alone, and 61 on the combination, underwent 24-hour ambulatory monitoring. Using the smoothness index, a scale that measures the consistency of pressure control over a 24-hour period, the investigators found that aliskiren alone and in combination with ramipril provides significantly greater consistency over the course of a day. Smoothness index scores correlate with reversal of left ventricular hypertrophy and carotid artery wall thickening.

The difference between renin blockade and ACE inhibition was greatest in the early morning hours. At 21–24 hours post dose, the renin blocker alone and in combination with ramipril gave significantly better pressure control than did ramipril alone. Systolic pressures remained between 4 and 12 mm Hg below baseline in patients on aliskiren or aliskiren plus ramipril. In the ramipril group, systolic pressure rose to near baseline levels at the end of the 24-hour dosing cycle.

Adverse effects in the new study were similar to those found in earlier trials showing aliskiren as having a low side-effect profile. The impact of side effects was low in all treatment groups, said Dr. Uresin. About one-third of the patients in each monotherapy group had some untoward effects, the most common being headache, cough, nasopharyngitis, and diarrhea. These were mild and self-limiting in the vast majority. Just over 2% of the ramipril monotherapy group and just under 3% of the aliskiren group had serious side effects; the incidence was reduced to 1.4% for the combination.

The addition of aliskiren to ramipril can cut the incidence of coughing, which is the most common reason patients quit ACE inhibitor therapy. Dr. Uresin pointed out that incidence of cough was just under 5% in the ramipril-alone group, and just over 2% for aliskiren. The rate was 1.8% among those taking the combination. The difference was statistically significant.

“This was definitely not expected,” said Dr. Uresin. It may have to do with reduced bradykinin levels following renin blockade, he said.

MADRID — Aliskiren, the novel renin-blocking drug, improved 24-hour blood pressure control and showed greater systolic pressure reductions, compared with ramipril, in diabetics with uncontrolled hypertension, according to data presented at the annual meeting of the European Society of Hypertension.

Aliskiren also can be safely combined with the ACE inhibitor in this population, the combination giving the greatest degree of pressure.

Aliskiren works by blocking the renin-regulated conversion of circulating angiotensinogen to angiotensin-1. The new drug, also known by the brand name Rasilez, is the first of what may soon be a burgeoning class of renin blockers. It is being considered for approval by regulatory authorities in Europe and the United States.

Dr. Yagiz Uresin, professor of clinical pharmacology at Istanbul (Turkey) University, presented a multicenter international study of 837 patients with diabetes and hypertension. At baseline, the patients had blood pressures of over 155 mm Hg systolic and 98 mm Hg diastolic.

After a washout period and a 2–4 week placebo run-in, the patients were randomized to aliskiren monotherapy, 150 mg/day; ramipril monotherapy, 5 mg/day; or a combination of 150 mg aliskiren plus 5 mg ramipril per day. After 4 weeks, the investigators doubled the doses in all study groups.

After 8 weeks, aliskiren gave mean pressure reductions of 14.7 mm Hg systolic and 11.3 mm Hg diastolic. This was significantly better than the 12.0- and 10.7-mm Hg reductions obtained with ramipril alone. In combination, the two drugs gave mean pressure reductions of 16.6 mm Hg systolic and 12.8 mm Hg diastolic.

Using a target pressure of 130/80 mm Hg, slightly over 8% of the patients in the monotherapy arms could be considered well controlled by the end of the study. Combination therapy bumped this up to 13%. This low rate of response reflects the difficulty of treating longstanding hypertension in diabetic patients, said Dr. Uresin.

A separate subgroup analysis drawn from the same international cohort showed that aliskiren alone and in combination with ramipril gave significantly better round-the-clock diastolic pressure control than did ramipril alone.

A total of 173 patients, 55 on ramipril alone, 57 on aliskiren alone, and 61 on the combination, underwent 24-hour ambulatory monitoring. Using the smoothness index, a scale that measures the consistency of pressure control over a 24-hour period, the investigators found that aliskiren alone and in combination with ramipril provides significantly greater consistency over the course of a day. Smoothness index scores correlate with reversal of left ventricular hypertrophy and carotid artery wall thickening.

The difference between renin blockade and ACE inhibition was greatest in the early morning hours. At 21–24 hours post dose, the renin blocker alone and in combination with ramipril gave significantly better pressure control than did ramipril alone. Systolic pressures remained between 4 and 12 mm Hg below baseline in patients on aliskiren or aliskiren plus ramipril. In the ramipril group, systolic pressure rose to near baseline levels at the end of the 24-hour dosing cycle.

Adverse effects in the new study were similar to those found in earlier trials showing aliskiren as having a low side-effect profile. The impact of side effects was low in all treatment groups, said Dr. Uresin. About one-third of the patients in each monotherapy group had some untoward effects, the most common being headache, cough, nasopharyngitis, and diarrhea. These were mild and self-limiting in the vast majority. Just over 2% of the ramipril monotherapy group and just under 3% of the aliskiren group had serious side effects; the incidence was reduced to 1.4% for the combination.

The addition of aliskiren to ramipril can cut the incidence of coughing, which is the most common reason patients quit ACE inhibitor therapy. Dr. Uresin pointed out that incidence of cough was just under 5% in the ramipril-alone group, and just over 2% for aliskiren. The rate was 1.8% among those taking the combination. The difference was statistically significant.

“This was definitely not expected,” said Dr. Uresin. It may have to do with reduced bradykinin levels following renin blockade, he said.

MADRID — Aliskiren, the novel renin-blocking drug, improved 24-hour blood pressure control and showed greater systolic pressure reductions, compared with ramipril, in diabetics with uncontrolled hypertension, according to data presented at the annual meeting of the European Society of Hypertension.

Aliskiren also can be safely combined with the ACE inhibitor in this population, the combination giving the greatest degree of pressure.

Aliskiren works by blocking the renin-regulated conversion of circulating angiotensinogen to angiotensin-1. The new drug, also known by the brand name Rasilez, is the first of what may soon be a burgeoning class of renin blockers. It is being considered for approval by regulatory authorities in Europe and the United States.

Dr. Yagiz Uresin, professor of clinical pharmacology at Istanbul (Turkey) University, presented a multicenter international study of 837 patients with diabetes and hypertension. At baseline, the patients had blood pressures of over 155 mm Hg systolic and 98 mm Hg diastolic.

After a washout period and a 2–4 week placebo run-in, the patients were randomized to aliskiren monotherapy, 150 mg/day; ramipril monotherapy, 5 mg/day; or a combination of 150 mg aliskiren plus 5 mg ramipril per day. After 4 weeks, the investigators doubled the doses in all study groups.

After 8 weeks, aliskiren gave mean pressure reductions of 14.7 mm Hg systolic and 11.3 mm Hg diastolic. This was significantly better than the 12.0- and 10.7-mm Hg reductions obtained with ramipril alone. In combination, the two drugs gave mean pressure reductions of 16.6 mm Hg systolic and 12.8 mm Hg diastolic.

Using a target pressure of 130/80 mm Hg, slightly over 8% of the patients in the monotherapy arms could be considered well controlled by the end of the study. Combination therapy bumped this up to 13%. This low rate of response reflects the difficulty of treating longstanding hypertension in diabetic patients, said Dr. Uresin.

A separate subgroup analysis drawn from the same international cohort showed that aliskiren alone and in combination with ramipril gave significantly better round-the-clock diastolic pressure control than did ramipril alone.

A total of 173 patients, 55 on ramipril alone, 57 on aliskiren alone, and 61 on the combination, underwent 24-hour ambulatory monitoring. Using the smoothness index, a scale that measures the consistency of pressure control over a 24-hour period, the investigators found that aliskiren alone and in combination with ramipril provides significantly greater consistency over the course of a day. Smoothness index scores correlate with reversal of left ventricular hypertrophy and carotid artery wall thickening.

The difference between renin blockade and ACE inhibition was greatest in the early morning hours. At 21–24 hours post dose, the renin blocker alone and in combination with ramipril gave significantly better pressure control than did ramipril alone. Systolic pressures remained between 4 and 12 mm Hg below baseline in patients on aliskiren or aliskiren plus ramipril. In the ramipril group, systolic pressure rose to near baseline levels at the end of the 24-hour dosing cycle.

Adverse effects in the new study were similar to those found in earlier trials showing aliskiren as having a low side-effect profile. The impact of side effects was low in all treatment groups, said Dr. Uresin. About one-third of the patients in each monotherapy group had some untoward effects, the most common being headache, cough, nasopharyngitis, and diarrhea. These were mild and self-limiting in the vast majority. Just over 2% of the ramipril monotherapy group and just under 3% of the aliskiren group had serious side effects; the incidence was reduced to 1.4% for the combination.

The addition of aliskiren to ramipril can cut the incidence of coughing, which is the most common reason patients quit ACE inhibitor therapy. Dr. Uresin pointed out that incidence of cough was just under 5% in the ramipril-alone group, and just over 2% for aliskiren. The rate was 1.8% among those taking the combination. The difference was statistically significant.

“This was definitely not expected,” said Dr. Uresin. It may have to do with reduced bradykinin levels following renin blockade, he said.

PHILADELPHIA—A novel broad-spectrum topical antifungal for the treatment of onychomycosis is now in early-stage clinical trials, and so far the data look favorable. Several papers covering various aspects of the new drug, AN2690, were presented as posters at the annual meeting of the Society for Investigative Dermatology.

AN2690, known also as 5-fluoro-benzoxaborole, belongs to a class of boron-containing compounds and represents an entirely new class of antifungals. The molecule is very small, and is specially designed for optimum nail penetration, said Dr. Stephen J. Baker, a researcher for Anacor Pharmaceuticals Inc., the Palo Alto, Calif., company that is developing AN2690. He noted that the preclinical studies indicate this compound has broad-spectrum activity against a host of fungal pathogens including Candida albicans, C. neoformans, Trichophyton rubrum, and T. mentagrophytes, the latter two being the most common pathogens in human onychomycosis.

Dr. Baker, in collaboration with the dermatology department at the University of California, San Francisco, recently began an open-label clinical study of patients with onychomycosis, treated with a nail lacquer containing either 5% or 7.5% AN2690. Patients were instructed to apply the assigned lacquer daily to all affected toenails for a total of 180 days. All patients had baseline nail involvement of 20%–60%, and potassium hydroxide (KOH)-positive mycology.

Dr. Baker presented the interim 90-day data on the first 24 patients using the 5% AN2690. By day 90, all mycology samples were 100% negative for all dermatophytes, and 70% KOH-negative. The average unaffected nail growth was 2.6 mm, and 13 of the 24 patients had greater than 2.5 mm of new unaffected nail growth.

PHILADELPHIA—A novel broad-spectrum topical antifungal for the treatment of onychomycosis is now in early-stage clinical trials, and so far the data look favorable. Several papers covering various aspects of the new drug, AN2690, were presented as posters at the annual meeting of the Society for Investigative Dermatology.

AN2690, known also as 5-fluoro-benzoxaborole, belongs to a class of boron-containing compounds and represents an entirely new class of antifungals. The molecule is very small, and is specially designed for optimum nail penetration, said Dr. Stephen J. Baker, a researcher for Anacor Pharmaceuticals Inc., the Palo Alto, Calif., company that is developing AN2690. He noted that the preclinical studies indicate this compound has broad-spectrum activity against a host of fungal pathogens including Candida albicans, C. neoformans, Trichophyton rubrum, and T. mentagrophytes, the latter two being the most common pathogens in human onychomycosis.

Dr. Baker, in collaboration with the dermatology department at the University of California, San Francisco, recently began an open-label clinical study of patients with onychomycosis, treated with a nail lacquer containing either 5% or 7.5% AN2690. Patients were instructed to apply the assigned lacquer daily to all affected toenails for a total of 180 days. All patients had baseline nail involvement of 20%–60%, and potassium hydroxide (KOH)-positive mycology.

Dr. Baker presented the interim 90-day data on the first 24 patients using the 5% AN2690. By day 90, all mycology samples were 100% negative for all dermatophytes, and 70% KOH-negative. The average unaffected nail growth was 2.6 mm, and 13 of the 24 patients had greater than 2.5 mm of new unaffected nail growth.

PHILADELPHIA—A novel broad-spectrum topical antifungal for the treatment of onychomycosis is now in early-stage clinical trials, and so far the data look favorable. Several papers covering various aspects of the new drug, AN2690, were presented as posters at the annual meeting of the Society for Investigative Dermatology.

AN2690, known also as 5-fluoro-benzoxaborole, belongs to a class of boron-containing compounds and represents an entirely new class of antifungals. The molecule is very small, and is specially designed for optimum nail penetration, said Dr. Stephen J. Baker, a researcher for Anacor Pharmaceuticals Inc., the Palo Alto, Calif., company that is developing AN2690. He noted that the preclinical studies indicate this compound has broad-spectrum activity against a host of fungal pathogens including Candida albicans, C. neoformans, Trichophyton rubrum, and T. mentagrophytes, the latter two being the most common pathogens in human onychomycosis.

Dr. Baker, in collaboration with the dermatology department at the University of California, San Francisco, recently began an open-label clinical study of patients with onychomycosis, treated with a nail lacquer containing either 5% or 7.5% AN2690. Patients were instructed to apply the assigned lacquer daily to all affected toenails for a total of 180 days. All patients had baseline nail involvement of 20%–60%, and potassium hydroxide (KOH)-positive mycology.

Dr. Baker presented the interim 90-day data on the first 24 patients using the 5% AN2690. By day 90, all mycology samples were 100% negative for all dermatophytes, and 70% KOH-negative. The average unaffected nail growth was 2.6 mm, and 13 of the 24 patients had greater than 2.5 mm of new unaffected nail growth.

MADRID — Fasting blood glucose levels appear to be higher in diabetic patients with poorly controlled blood pressure than in those with well-controlled pressure, Dr. Miroslav Soucek said at the annual meeting of the European Society of Hypertension.

This observation was based on a survey of more than 2,200 patients from 150 primary care practices throughout the Czech Republic. The primary objective of the study was to determine the prevalence of hypertension in the Czech population, and the extent to which physicians there are able to help their patients achieve blood pressure control targets as outlined in current ESH guidelines, Dr. Soucek said in presenting the findings in a poster.

Each participating physician recorded thorough case data from 15 consecutive patients aged at least 45 years, irrespective of the reason for each patient's visit. The idea was to get a representative sampling of the health status of all patients seeking care in primary care offices. The investigators defined hypertension as blood pressures above 140/90 mm Hg.

The pressure measurements were taken from patients in the sitting position, and participants were instructed to take three separate measurements and average the values of the last two measurements. Dr. Soucek and his colleagues obtained data from 2,211 patients with a mean age of 62 years.

Of the entire cohort, 78% of the patients were defined as hypertensive; of the 403 patients with diabetes, 75% had hypertension. Only 18% of all patients being treated for hypertension were considered well controlled (pressures under 130/80 mm Hg); the rate for diabetics was 6%.

Blood pressure was uncontrolled in almost 30% of the diabetic patients with hypertension even though they were on at least three antihypertensive drugs, Dr. Soucek noted.

The most striking finding of this study—one that surprised the investigators themselves—was the correlation between poor pressure control and increased fasting blood glucose. “The average fasting blood glucose showed a gradual increase, with increasing blood pressure, from 7.98 mmol/L in diabetics with blood pressure under 130/80 mm Hg to 9.44 in diabetic patients with blood pressures greater than 180/110 mm Hg,” reported Dr. Soucek of the department of internal medicine, St. Anne University Hospital, Brno, Czech Republic.

The mechanism underlying this connection is not known, and it is too soon to tell if there is a causal connection, or if the elevated pressure and the increased blood glucose are co-occurring manifestations of a deeper metabolic dysregulation.

The clinical implication, however, is clear: Uncontrolled blood pressure in a diabetic patient may be a signal for uncontrolled glucose as well. These patients need even closer attention than nondiabetic hypertensives or diabetics who are not hypertensive, he said.

ELSEVIER GLOBAL MEDICAL NEWS

MADRID — Fasting blood glucose levels appear to be higher in diabetic patients with poorly controlled blood pressure than in those with well-controlled pressure, Dr. Miroslav Soucek said at the annual meeting of the European Society of Hypertension.

This observation was based on a survey of more than 2,200 patients from 150 primary care practices throughout the Czech Republic. The primary objective of the study was to determine the prevalence of hypertension in the Czech population, and the extent to which physicians there are able to help their patients achieve blood pressure control targets as outlined in current ESH guidelines, Dr. Soucek said in presenting the findings in a poster.

Each participating physician recorded thorough case data from 15 consecutive patients aged at least 45 years, irrespective of the reason for each patient's visit. The idea was to get a representative sampling of the health status of all patients seeking care in primary care offices. The investigators defined hypertension as blood pressures above 140/90 mm Hg.

The pressure measurements were taken from patients in the sitting position, and participants were instructed to take three separate measurements and average the values of the last two measurements. Dr. Soucek and his colleagues obtained data from 2,211 patients with a mean age of 62 years.

Of the entire cohort, 78% of the patients were defined as hypertensive; of the 403 patients with diabetes, 75% had hypertension. Only 18% of all patients being treated for hypertension were considered well controlled (pressures under 130/80 mm Hg); the rate for diabetics was 6%.

Blood pressure was uncontrolled in almost 30% of the diabetic patients with hypertension even though they were on at least three antihypertensive drugs, Dr. Soucek noted.

The most striking finding of this study—one that surprised the investigators themselves—was the correlation between poor pressure control and increased fasting blood glucose. “The average fasting blood glucose showed a gradual increase, with increasing blood pressure, from 7.98 mmol/L in diabetics with blood pressure under 130/80 mm Hg to 9.44 in diabetic patients with blood pressures greater than 180/110 mm Hg,” reported Dr. Soucek of the department of internal medicine, St. Anne University Hospital, Brno, Czech Republic.

The mechanism underlying this connection is not known, and it is too soon to tell if there is a causal connection, or if the elevated pressure and the increased blood glucose are co-occurring manifestations of a deeper metabolic dysregulation.

The clinical implication, however, is clear: Uncontrolled blood pressure in a diabetic patient may be a signal for uncontrolled glucose as well. These patients need even closer attention than nondiabetic hypertensives or diabetics who are not hypertensive, he said.

ELSEVIER GLOBAL MEDICAL NEWS

MADRID — Fasting blood glucose levels appear to be higher in diabetic patients with poorly controlled blood pressure than in those with well-controlled pressure, Dr. Miroslav Soucek said at the annual meeting of the European Society of Hypertension.

This observation was based on a survey of more than 2,200 patients from 150 primary care practices throughout the Czech Republic. The primary objective of the study was to determine the prevalence of hypertension in the Czech population, and the extent to which physicians there are able to help their patients achieve blood pressure control targets as outlined in current ESH guidelines, Dr. Soucek said in presenting the findings in a poster.

Each participating physician recorded thorough case data from 15 consecutive patients aged at least 45 years, irrespective of the reason for each patient's visit. The idea was to get a representative sampling of the health status of all patients seeking care in primary care offices. The investigators defined hypertension as blood pressures above 140/90 mm Hg.

The pressure measurements were taken from patients in the sitting position, and participants were instructed to take three separate measurements and average the values of the last two measurements. Dr. Soucek and his colleagues obtained data from 2,211 patients with a mean age of 62 years.

Of the entire cohort, 78% of the patients were defined as hypertensive; of the 403 patients with diabetes, 75% had hypertension. Only 18% of all patients being treated for hypertension were considered well controlled (pressures under 130/80 mm Hg); the rate for diabetics was 6%.

Blood pressure was uncontrolled in almost 30% of the diabetic patients with hypertension even though they were on at least three antihypertensive drugs, Dr. Soucek noted.

The most striking finding of this study—one that surprised the investigators themselves—was the correlation between poor pressure control and increased fasting blood glucose. “The average fasting blood glucose showed a gradual increase, with increasing blood pressure, from 7.98 mmol/L in diabetics with blood pressure under 130/80 mm Hg to 9.44 in diabetic patients with blood pressures greater than 180/110 mm Hg,” reported Dr. Soucek of the department of internal medicine, St. Anne University Hospital, Brno, Czech Republic.

The mechanism underlying this connection is not known, and it is too soon to tell if there is a causal connection, or if the elevated pressure and the increased blood glucose are co-occurring manifestations of a deeper metabolic dysregulation.

The clinical implication, however, is clear: Uncontrolled blood pressure in a diabetic patient may be a signal for uncontrolled glucose as well. These patients need even closer attention than nondiabetic hypertensives or diabetics who are not hypertensive, he said.

ELSEVIER GLOBAL MEDICAL NEWS

WASHINGTON — Price transparency for physician and hospital services is one of the key elements in the Bush administration's vision of "consumer-driven" health care, and the administration is prepared to push for mandatory price-tagging if doctors and hospital administrators won't voluntarily provide the information.

Speaking at a health care congress that was sponsored by the Wall Street Journal and CNBC, Al Hubbard, assistant to President Bush for economic policy, issued something of an ultimatum to the clinical community: "Make pricing information available without being forced. If you do not do so, we will force you to. We have allies in Congress who are very much inclined to be prescriptive with legislation to impose pricing and quality standards on the health care community."

Comprehensive and accurate pricing for health care services are essential for the efficacy of health savings accounts (HSAs) and other market-driven solutions to the health care cost crisis favored by the administration and many business leaders, said Mr. Hubbard, who is also director of the National Economic Council, at the meeting.

"Under a consumer-driven health care system, the consumer is incentivized to become a smart shopper, and a driver to push prices down and quality up," he explained. He cited LASIK (laser in situ keratomileusis) surgery as a prime example. "Fifteen years ago, LASIK cost about $2,500 per eye. Because the service is an out-of-pocket expense, now the cost is under $1,000 per eye. That's what would happen in the rest of health care if people were price-sensitive consumers."

According to Mr. Hubbard and others within the Bush camp, there's one major obstruction on the road to a consumer-driven health care utopia: the absence of pricing and quality-rating information for medical services.

"You cannot be a wise consumer if you don't know the prices or the quality of the goods. Right now, providers do not make that information available, and a lot of hospital executives don't believe pricing information should be available," he said.

Mr. Hubbard's remarks followed a very brief and fast-spoken video address by President Bush, in which the President underscored his commitment to HSAs as a key instrument for change. He estimated that more than 3 million Americans will be enrolled in HSAs this year, a number he hopes to see vastly increased over the next few years.

The President underscored the "simple and clear philosophy" that underlies his solution to the health care problem: "The American medical system should be run by doctors, patients, and consumers, not the federal government."

It was easy for Mr. Hubbard to talk tough at the meeting. According to the conference organizers, physicians represented only 4% of attendees, and there were very few doctors in the room during Mr. Hubbard's address.

One physician, an anesthesiologist, did stand up to challenge the administration's fixation on price-tagging. He cited the potential dangers that could arise if "consumers"—that is, patients—began choosing health care services based on price postings. He stressed that the medical community itself is far from having accurate quality measures to determine standards for best practices. Without clear and science-based quality standards, pricing information would have little value because patients would not be able to determine what they would be getting for their money. Further, shopping for health care based on price could encourage substandard care and suboptimal clinical outcomes.

He also pointed out that a higher-priced physician practice or hospital may be incurring those higher costs because they are treating a sicker population. Likewise a practice or hospital with lower outcomes scores may be handling sicker patients. Price tags and raw outcomes data alone would not reflect this, unless accurate risk-stratification measures were also incorporated.

Mr. Hubbard acknowledged that there's much work to be done in developing meaningful outcomes standards and risk assessment tools so that consumers can "compare apples to apples." At the same time, the administration seems unwilling to wait around indefinitely while practitioners and hospitals figure out how to prove their worth.

Several members of the audience pointed out that the "shop-around" approach is likely to break down around episodes of emergency care, critical care, and sudden onset of disease. An individual having a myocardial infarction isn't likely to consult the Internet to find out which area hospital offers the best dollar value.

The unflappable Mr. Hubbard agreed that emergency situations are an exception to the consumer-driven rule, but he insisted that "there's no reason we should not be able to have bundled pricing from our physicians and hospitals on all nonemergency care. We want you to treat your patients/customers exactly the way you want to be treated when you consume a product or service."

Whether a mandate for pricing transparency is truly in the offing remains to be seen. What is clear is that the Bush administration views HSAs and other strategies for shifting greater cost and greater health care responsibility onto consumers as the only viable strategy for the nation's health care financing woes.

During a separate session at the meeting, Jack Brennan, CEO of the Vanguard Group, the nation's second largest mutual fund company, and Jim Guest, president of Consumers Union (publisher of Consumer Reports), reviewed the potential strengths and weaknesses of consumer-driven health care plans.

Mr. Brennan, who said that he believes the health care world has a lot to learn by studying the evolution of the 401(k) business, said that Vanguard offers its 12,000 employees a consumer-driven health plan option, and has done so for several years. However, no more than 10% of the company's employees have chosen it. "I'd say there's a bit of a reluctance, but it is a start, and I'd like to see more," he said.

Asked whether he himself had enrolled in such a plan, Mr. Brennan said he had not.

"I don't use it because I'm still trapped in the belief that if it is more expensive, it must be better," he joked, but added that one of his family members has a complicated medical situation that would make a consumer-driven plan a less-than-optimal prospect for him.

Consumer Reports' Mr. Guest said his organization supports the general idea of "consumer-informed health care," but said it is far too early to tell whether strategies like those advocated by the Bush administration will really deliver on their stated promises.

"We're really far away from where we need to be. I don't think the consumer voice has been strongly heard. The movement [toward consumer-driven plans] has been driven more by the industry than by the consumer. Until consumers have full information about what the choices are that they're making, it is not really consumer driven. And right now, most people do not understand what they're deciding between."

Can Health Care Learn From 401(k) Plans' Successful Implementation?

Health care right now is in a situation somewhat analogous to that facing the employee benefits, pension, and investment world nearly 3 decades ago, when the 401(k) concept was first developed, the Vanguard Group's Mr. Brennan said.

"Twenty-five years ago, the 401(k) industry was very fragmented. It was high cost and poorly understood by the public. Now, it has gotten to the point where 90% or more of all U.S. companies offer them. It is a $2.1 trillion market, and it's basically a story of empowering people to make decisions and choices that are good for them. It is based on one single bedrock idea: that given good information and good tools, the consumer will make smart decisions."

Why did the 401(k) movement succeed? Effective consumer education based on simple language and clear elucidation of benefits was the fundamental key to winning buy-in from ordinary people. "You can't have overeducated MBAs writing explanations for working people. It all needs to be very simple and straightforward."

The benefits promised by early advocates of 401(k) investment (greater personal control over investment choices, tailored investment planning, facilitated transactions, and strong returns) were delivered via a vast powerhouse of new interactive technology. "Before 401(k) [plans], you were dependent on quarterly statements. The 401(k) industry developed all this real-time transactional information, 800 numbers, and Web sites that offered more consumer interactivity."

Choice, said Mr. Brennan, is the watchword of the 401(k) industry. Previously, people had few retirement investment options. They got the plans their employers gave them, end of story. They didn't see where their money was going, and for the most part, they didn't care. The 401(k) put a new range of investment options within reach of ordinary working people, and more important, the industry taught people how to think about investment choices in a way that really spoke to their concerns and needs.

To what extent is health care really similar to retirement investing? Should the health care industry operate more like the investment world? These are open questions, and one could easily tear holes in Mr. Brennan's comparisons. But the issue of how to communicate the relative benefits and downsides of various forms of health care financing to the public is one that physicians, health benefits managers, and policy makers need to face.

Underneath all the policy debate, Mr. Brennan said the real question posed by the consumer-driven health care vision amounts to this: Is the average American worker smart enough to make good decisions about present and future health care needs?

He said he believes, for the most part, that they are. "I come at my business from the point of view that people are smart. A lot of people, especially in the health care business, come from the point of view that people are not smart and are unable to make intelligent, informed choices. That's a fundamental difference."

WASHINGTON — Price transparency for physician and hospital services is one of the key elements in the Bush administration's vision of "consumer-driven" health care, and the administration is prepared to push for mandatory price-tagging if doctors and hospital administrators won't voluntarily provide the information.

Speaking at a health care congress that was sponsored by the Wall Street Journal and CNBC, Al Hubbard, assistant to President Bush for economic policy, issued something of an ultimatum to the clinical community: "Make pricing information available without being forced. If you do not do so, we will force you to. We have allies in Congress who are very much inclined to be prescriptive with legislation to impose pricing and quality standards on the health care community."

Comprehensive and accurate pricing for health care services are essential for the efficacy of health savings accounts (HSAs) and other market-driven solutions to the health care cost crisis favored by the administration and many business leaders, said Mr. Hubbard, who is also director of the National Economic Council, at the meeting.

"Under a consumer-driven health care system, the consumer is incentivized to become a smart shopper, and a driver to push prices down and quality up," he explained. He cited LASIK (laser in situ keratomileusis) surgery as a prime example. "Fifteen years ago, LASIK cost about $2,500 per eye. Because the service is an out-of-pocket expense, now the cost is under $1,000 per eye. That's what would happen in the rest of health care if people were price-sensitive consumers."

According to Mr. Hubbard and others within the Bush camp, there's one major obstruction on the road to a consumer-driven health care utopia: the absence of pricing and quality-rating information for medical services.

"You cannot be a wise consumer if you don't know the prices or the quality of the goods. Right now, providers do not make that information available, and a lot of hospital executives don't believe pricing information should be available," he said.

Mr. Hubbard's remarks followed a very brief and fast-spoken video address by President Bush, in which the President underscored his commitment to HSAs as a key instrument for change. He estimated that more than 3 million Americans will be enrolled in HSAs this year, a number he hopes to see vastly increased over the next few years.

The President underscored the "simple and clear philosophy" that underlies his solution to the health care problem: "The American medical system should be run by doctors, patients, and consumers, not the federal government."

It was easy for Mr. Hubbard to talk tough at the meeting. According to the conference organizers, physicians represented only 4% of attendees, and there were very few doctors in the room during Mr. Hubbard's address.

One physician, an anesthesiologist, did stand up to challenge the administration's fixation on price-tagging. He cited the potential dangers that could arise if "consumers"—that is, patients—began choosing health care services based on price postings. He stressed that the medical community itself is far from having accurate quality measures to determine standards for best practices. Without clear and science-based quality standards, pricing information would have little value because patients would not be able to determine what they would be getting for their money. Further, shopping for health care based on price could encourage substandard care and suboptimal clinical outcomes.

He also pointed out that a higher-priced physician practice or hospital may be incurring those higher costs because they are treating a sicker population. Likewise a practice or hospital with lower outcomes scores may be handling sicker patients. Price tags and raw outcomes data alone would not reflect this, unless accurate risk-stratification measures were also incorporated.

Mr. Hubbard acknowledged that there's much work to be done in developing meaningful outcomes standards and risk assessment tools so that consumers can "compare apples to apples." At the same time, the administration seems unwilling to wait around indefinitely while practitioners and hospitals figure out how to prove their worth.

Several members of the audience pointed out that the "shop-around" approach is likely to break down around episodes of emergency care, critical care, and sudden onset of disease. An individual having a myocardial infarction isn't likely to consult the Internet to find out which area hospital offers the best dollar value.

The unflappable Mr. Hubbard agreed that emergency situations are an exception to the consumer-driven rule, but he insisted that "there's no reason we should not be able to have bundled pricing from our physicians and hospitals on all nonemergency care. We want you to treat your patients/customers exactly the way you want to be treated when you consume a product or service."

Whether a mandate for pricing transparency is truly in the offing remains to be seen. What is clear is that the Bush administration views HSAs and other strategies for shifting greater cost and greater health care responsibility onto consumers as the only viable strategy for the nation's health care financing woes.

During a separate session at the meeting, Jack Brennan, CEO of the Vanguard Group, the nation's second largest mutual fund company, and Jim Guest, president of Consumers Union (publisher of Consumer Reports), reviewed the potential strengths and weaknesses of consumer-driven health care plans.

Mr. Brennan, who said that he believes the health care world has a lot to learn by studying the evolution of the 401(k) business, said that Vanguard offers its 12,000 employees a consumer-driven health plan option, and has done so for several years. However, no more than 10% of the company's employees have chosen it. "I'd say there's a bit of a reluctance, but it is a start, and I'd like to see more," he said.

Asked whether he himself had enrolled in such a plan, Mr. Brennan said he had not.

"I don't use it because I'm still trapped in the belief that if it is more expensive, it must be better," he joked, but added that one of his family members has a complicated medical situation that would make a consumer-driven plan a less-than-optimal prospect for him.

Consumer Reports' Mr. Guest said his organization supports the general idea of "consumer-informed health care," but said it is far too early to tell whether strategies like those advocated by the Bush administration will really deliver on their stated promises.

"We're really far away from where we need to be. I don't think the consumer voice has been strongly heard. The movement [toward consumer-driven plans] has been driven more by the industry than by the consumer. Until consumers have full information about what the choices are that they're making, it is not really consumer driven. And right now, most people do not understand what they're deciding between."

Can Health Care Learn From 401(k) Plans' Successful Implementation?

Health care right now is in a situation somewhat analogous to that facing the employee benefits, pension, and investment world nearly 3 decades ago, when the 401(k) concept was first developed, the Vanguard Group's Mr. Brennan said.

"Twenty-five years ago, the 401(k) industry was very fragmented. It was high cost and poorly understood by the public. Now, it has gotten to the point where 90% or more of all U.S. companies offer them. It is a $2.1 trillion market, and it's basically a story of empowering people to make decisions and choices that are good for them. It is based on one single bedrock idea: that given good information and good tools, the consumer will make smart decisions."

Why did the 401(k) movement succeed? Effective consumer education based on simple language and clear elucidation of benefits was the fundamental key to winning buy-in from ordinary people. "You can't have overeducated MBAs writing explanations for working people. It all needs to be very simple and straightforward."

The benefits promised by early advocates of 401(k) investment (greater personal control over investment choices, tailored investment planning, facilitated transactions, and strong returns) were delivered via a vast powerhouse of new interactive technology. "Before 401(k) [plans], you were dependent on quarterly statements. The 401(k) industry developed all this real-time transactional information, 800 numbers, and Web sites that offered more consumer interactivity."

Choice, said Mr. Brennan, is the watchword of the 401(k) industry. Previously, people had few retirement investment options. They got the plans their employers gave them, end of story. They didn't see where their money was going, and for the most part, they didn't care. The 401(k) put a new range of investment options within reach of ordinary working people, and more important, the industry taught people how to think about investment choices in a way that really spoke to their concerns and needs.

To what extent is health care really similar to retirement investing? Should the health care industry operate more like the investment world? These are open questions, and one could easily tear holes in Mr. Brennan's comparisons. But the issue of how to communicate the relative benefits and downsides of various forms of health care financing to the public is one that physicians, health benefits managers, and policy makers need to face.

Underneath all the policy debate, Mr. Brennan said the real question posed by the consumer-driven health care vision amounts to this: Is the average American worker smart enough to make good decisions about present and future health care needs?

He said he believes, for the most part, that they are. "I come at my business from the point of view that people are smart. A lot of people, especially in the health care business, come from the point of view that people are not smart and are unable to make intelligent, informed choices. That's a fundamental difference."

WASHINGTON — Price transparency for physician and hospital services is one of the key elements in the Bush administration's vision of "consumer-driven" health care, and the administration is prepared to push for mandatory price-tagging if doctors and hospital administrators won't voluntarily provide the information.

Speaking at a health care congress that was sponsored by the Wall Street Journal and CNBC, Al Hubbard, assistant to President Bush for economic policy, issued something of an ultimatum to the clinical community: "Make pricing information available without being forced. If you do not do so, we will force you to. We have allies in Congress who are very much inclined to be prescriptive with legislation to impose pricing and quality standards on the health care community."

Comprehensive and accurate pricing for health care services are essential for the efficacy of health savings accounts (HSAs) and other market-driven solutions to the health care cost crisis favored by the administration and many business leaders, said Mr. Hubbard, who is also director of the National Economic Council, at the meeting.

"Under a consumer-driven health care system, the consumer is incentivized to become a smart shopper, and a driver to push prices down and quality up," he explained. He cited LASIK (laser in situ keratomileusis) surgery as a prime example. "Fifteen years ago, LASIK cost about $2,500 per eye. Because the service is an out-of-pocket expense, now the cost is under $1,000 per eye. That's what would happen in the rest of health care if people were price-sensitive consumers."

According to Mr. Hubbard and others within the Bush camp, there's one major obstruction on the road to a consumer-driven health care utopia: the absence of pricing and quality-rating information for medical services.

"You cannot be a wise consumer if you don't know the prices or the quality of the goods. Right now, providers do not make that information available, and a lot of hospital executives don't believe pricing information should be available," he said.

Mr. Hubbard's remarks followed a very brief and fast-spoken video address by President Bush, in which the President underscored his commitment to HSAs as a key instrument for change. He estimated that more than 3 million Americans will be enrolled in HSAs this year, a number he hopes to see vastly increased over the next few years.

The President underscored the "simple and clear philosophy" that underlies his solution to the health care problem: "The American medical system should be run by doctors, patients, and consumers, not the federal government."

It was easy for Mr. Hubbard to talk tough at the meeting. According to the conference organizers, physicians represented only 4% of attendees, and there were very few doctors in the room during Mr. Hubbard's address.

One physician, an anesthesiologist, did stand up to challenge the administration's fixation on price-tagging. He cited the potential dangers that could arise if "consumers"—that is, patients—began choosing health care services based on price postings. He stressed that the medical community itself is far from having accurate quality measures to determine standards for best practices. Without clear and science-based quality standards, pricing information would have little value because patients would not be able to determine what they would be getting for their money. Further, shopping for health care based on price could encourage substandard care and suboptimal clinical outcomes.

He also pointed out that a higher-priced physician practice or hospital may be incurring those higher costs because they are treating a sicker population. Likewise a practice or hospital with lower outcomes scores may be handling sicker patients. Price tags and raw outcomes data alone would not reflect this, unless accurate risk-stratification measures were also incorporated.

Mr. Hubbard acknowledged that there's much work to be done in developing meaningful outcomes standards and risk assessment tools so that consumers can "compare apples to apples." At the same time, the administration seems unwilling to wait around indefinitely while practitioners and hospitals figure out how to prove their worth.

Several members of the audience pointed out that the "shop-around" approach is likely to break down around episodes of emergency care, critical care, and sudden onset of disease. An individual having a myocardial infarction isn't likely to consult the Internet to find out which area hospital offers the best dollar value.

The unflappable Mr. Hubbard agreed that emergency situations are an exception to the consumer-driven rule, but he insisted that "there's no reason we should not be able to have bundled pricing from our physicians and hospitals on all nonemergency care. We want you to treat your patients/customers exactly the way you want to be treated when you consume a product or service."

Whether a mandate for pricing transparency is truly in the offing remains to be seen. What is clear is that the Bush administration views HSAs and other strategies for shifting greater cost and greater health care responsibility onto consumers as the only viable strategy for the nation's health care financing woes.

During a separate session at the meeting, Jack Brennan, CEO of the Vanguard Group, the nation's second largest mutual fund company, and Jim Guest, president of Consumers Union (publisher of Consumer Reports), reviewed the potential strengths and weaknesses of consumer-driven health care plans.

Mr. Brennan, who said that he believes the health care world has a lot to learn by studying the evolution of the 401(k) business, said that Vanguard offers its 12,000 employees a consumer-driven health plan option, and has done so for several years. However, no more than 10% of the company's employees have chosen it. "I'd say there's a bit of a reluctance, but it is a start, and I'd like to see more," he said.

Asked whether he himself had enrolled in such a plan, Mr. Brennan said he had not.

"I don't use it because I'm still trapped in the belief that if it is more expensive, it must be better," he joked, but added that one of his family members has a complicated medical situation that would make a consumer-driven plan a less-than-optimal prospect for him.

Consumer Reports' Mr. Guest said his organization supports the general idea of "consumer-informed health care," but said it is far too early to tell whether strategies like those advocated by the Bush administration will really deliver on their stated promises.

"We're really far away from where we need to be. I don't think the consumer voice has been strongly heard. The movement [toward consumer-driven plans] has been driven more by the industry than by the consumer. Until consumers have full information about what the choices are that they're making, it is not really consumer driven. And right now, most people do not understand what they're deciding between."

Can Health Care Learn From 401(k) Plans' Successful Implementation?

Health care right now is in a situation somewhat analogous to that facing the employee benefits, pension, and investment world nearly 3 decades ago, when the 401(k) concept was first developed, the Vanguard Group's Mr. Brennan said.

"Twenty-five years ago, the 401(k) industry was very fragmented. It was high cost and poorly understood by the public. Now, it has gotten to the point where 90% or more of all U.S. companies offer them. It is a $2.1 trillion market, and it's basically a story of empowering people to make decisions and choices that are good for them. It is based on one single bedrock idea: that given good information and good tools, the consumer will make smart decisions."

Why did the 401(k) movement succeed? Effective consumer education based on simple language and clear elucidation of benefits was the fundamental key to winning buy-in from ordinary people. "You can't have overeducated MBAs writing explanations for working people. It all needs to be very simple and straightforward."

The benefits promised by early advocates of 401(k) investment (greater personal control over investment choices, tailored investment planning, facilitated transactions, and strong returns) were delivered via a vast powerhouse of new interactive technology. "Before 401(k) [plans], you were dependent on quarterly statements. The 401(k) industry developed all this real-time transactional information, 800 numbers, and Web sites that offered more consumer interactivity."

Choice, said Mr. Brennan, is the watchword of the 401(k) industry. Previously, people had few retirement investment options. They got the plans their employers gave them, end of story. They didn't see where their money was going, and for the most part, they didn't care. The 401(k) put a new range of investment options within reach of ordinary working people, and more important, the industry taught people how to think about investment choices in a way that really spoke to their concerns and needs.

To what extent is health care really similar to retirement investing? Should the health care industry operate more like the investment world? These are open questions, and one could easily tear holes in Mr. Brennan's comparisons. But the issue of how to communicate the relative benefits and downsides of various forms of health care financing to the public is one that physicians, health benefits managers, and policy makers need to face.

Underneath all the policy debate, Mr. Brennan said the real question posed by the consumer-driven health care vision amounts to this: Is the average American worker smart enough to make good decisions about present and future health care needs?

He said he believes, for the most part, that they are. "I come at my business from the point of view that people are smart. A lot of people, especially in the health care business, come from the point of view that people are not smart and are unable to make intelligent, informed choices. That's a fundamental difference."