I got the right prescription. Then nobody called me back.

About three years ago I noticed something. A high-pitched sound in my ears that never went away. Is this tinnitus, I wondered? And why have I got tinnitus all of a sudden?

Somewhere in the back of my mind I remembered something about high blood pressure causing tinnitus. So I went and bought my own monitor and sat down at my kitchen table. My systolic pressure was well past the point where the guidelines recommend treatment. My god, I thought, how long have I been walking around with this?

As the anxiety started building, I got on the phone to book an appointment with a primary care physician. In all fairness, I did not have to wait long, and a couple of days later I had a prescription for an ARB. But nothing more. No scheduled follow-ups. No nothing.

So I entered a new phase, checking my blood pressure at the kitchen table once a week. The systolic number went down pretty quickly, but I never reached values that are considered controlled. It kept hovering between 130 and 140.

As with most things that are a bit uncomfortable, especially if you’re a man, I eventually almost forgot about it. I kept taking my pill and felt fine. Until my father almost died of a heart attack. That event woke me up and pushed me to do something about my uncontrolled blood pressure.

The 2024 ESC guideline says a patient starting treatment should be seen every one to three months until blood pressure is controlled. In Region Stockholm the recommendation is to evaluate after four weeks and reach target within three months.

These recommendations exist for a reason. They save lives.

The bigger problem

Now, this is not about me, or about how Swedish primary care manages, or mismanages, hypertension. This is part of a much bigger problem that stretches across the entire patient journey across multiple therapeutic areas.

The undiagnosed. In a Swedish population study, 84% of people who met the spirometric criteria for COPD had never been diagnosed with it. One in four of them had already been in contact with healthcare, more often for respiratory symptoms than the general population.

The delayed. In Sweden in 2024, the proportion of patients with head and neck cancer who got from treatment decision to surgery inside the twelve-day national target ranged from 77% in the South-East region to 21% in Stockholm and Gotland.

The lost. In a study of older English patients after emergency admission, 27% of the follow-ups requested in the discharge summary were never arranged.

The not-referred. Pulmonary rehabilitation cuts readmission after a COPD exacerbation by roughly half. In England and Wales, only 13% of patients referred after an exacerbation started it within 30 days, down from 20% the year before.

This is not a knowledge problem

Our modern healthcare systems keep failing a lot of patients. And it is not because they do not know what works, or what they should do to improve patient outcomes. It is about the system itself. How it is constructed.

A really good example can be found in Germany. To identify chronic kidney disease early you measure albumin in urine. A very cheap test. So cheap, in fact, that you would think it was part of a general population screening.

But in Germany, only 4.2% of patients with repeated abnormal kidney results had ever had that urine test.

Why? Because the test costs somewhere around three euros fifty, and a German GP’s entire laboratory budget is three euros thirty-seven per patient. One test, and the budget is gone. A practice that goes over it loses an efficiency bonus worth thousands a year. No clinician designed that. No payer intended it.

Talk about a missed opportunity. Imagine if someone could make that test free and available everywhere. Imagine the reduction in suffering, and the money saved on dialysis every single year.

Okay, some of you may be thinking, there are a lot of strange things going on in our healthcare systems. We know that. We see examples of it every day. What does this have to do with pharma?

Which brings me to last week

Last week I wrote about how fast healthcare has adopted AI. In a seven-country survey reported by eMarketer, 92% of physicians now use it in practice. I argued that this fast and far-reaching change in physician behaviour will push the value of the common information exchange-meeting to zero.

At the same time, the biggest challenge for healthcare is not a lack of information. The biggest challenge is the implementation of knowledge, and that is something AI cannot do.

This gap, I would argue, is what pharma should build its future commercial model to bridge.

What actually closes these gaps

Take home blood pressure monitoring. On its own its impact barely registers - one mmHg, and not even statistically significant. But build a system around it that acts on the numbers, with education, dose titration and someone coming back to the patient, and the same home monitoring lowers systolic pressure by 6.1 mmHg.

A Cochrane review found that an organised system of regular review lowers systolic pressure by 8.0 mmHg. In a large trial that followed patients for years, it also cut five-year mortality. In the same review, education aimed at patients or professionals “appeared unlikely to be associated with large net reductions in blood pressure by themselves.”

In Norway, where 4.5 million people were followed, having the same GP for more than fifteen years rather than one year was associated with 28% fewer acute hospital admissions and 25% lower mortality.

The pattern is clear. Being cared for by a system or someone who knows you, and who comes back to you with your results, works like a clinical intervention in its own right.

Some companies have worked this out

AstraZeneca and Cardiff and Vale University Health Board spent 18 months screening around 1,800 nephrology outpatients remotely against the health board’s own records, then invited roughly 900 of them in for review by specialist renal pharmacists.

AstraZeneca helped a healthcare system close the follow-up loop. Something that this healthcare system would most likely never have done alone.

Boehringer Ingelheim funded extra coordinator capacity at Poole Hospital so GP practices could reach their diabetes targets and worked with Oxfordshire on an integrated respiratory team that won a Health Service Journal Partnership award.

And when the King’s Fund interviewed NHS clinicians and leaders about these partnerships in 2024, what they said they valued was dedicated capacity, and skills ranging from project management to data analysis and health economics.

Not product information. Not clinical education. Pharma providing capacity and skills these organisations lack.

Now, these examples may sound unattainable for most given their large scope. The good news is that initiatives like this work just as well at local account level. One specialist clinic and one cross-functional pharma team, pooling their resources to remove a barrier in the local patient journey, the removal of which will create a win for patients, the account and the company.

Your move

My blood pressure is under control now. And the tinnitus that started the whole thing was not caused by hypertension after all. It turned out I have a hearing loss, caused by bad genes or COVID (I’m not alone it appears to suffer from hearing loss after going through a COVID infection…).

Here’s what I recommend you to do:
Depending on what therapeutic area you are working in, think about one of the patients that’s already on your drug or would be benefitting from getting it.

Imagine this patient at a kitchen table with a monitor and a prescription, wondering what to do with the numbers. There is another person waiting for a spirometry test that someone forgot to order. And there is a third whose early kidney disease would have been caught if a cheap albumin strip had been used at the last check-up.

What can you do to improve on these patients outcomes?
Who should you talk to at the account?

We know what removes these barriers and it was never more information.

/Mats