Patient adherence and the treatment of hypertension
- Brent M Egan, MD
Brent M Egan, MD
- Professor of Medicine
- University of South Carolina School of Medicine-Greenville
- Chief Science Officer, Care Coordination Institute
- Section Editor
- George L Bakris, MD
George L Bakris, MD
- Editor-in-Chief — Nephrology
- Section Editor — Hypertension
- Professor of Medicine
- The University of Chicago
- Deputy Editors
- Daniel J Sullivan, MD, MPH
Daniel J Sullivan, MD, MPH
- Deputy Editor — Primary Care (Adult)
- Assistant Professor of Medicine
- Harvard Medical School
- John P Forman, MD, MSc
John P Forman, MD, MSc
- Senior Deputy Editor — UpToDate
- Deputy Editor — Nephrology
- Assistant Professor of Medicine
- Harvard Medical School
A report using National Health and Nutrition Examination Survey (NHANES) data from 2009 to 2012 found that about 75 percent of hypertensive patients in the United States are being treated, and approximately 70 percent of those being treated have their blood pressure controlled to below 140/90 mmHg (table 1) [1-3]. During this time period, hypertension control among all adults in the United States with hypertension was just over 50 percent. Another study using NHANES data from 2013 to 2014 reported that hypertension was controlled in 54 percent of all hypertensive adults in the United States . (See "The prevalence and control of hypertension in adults".)
Suboptimal adherence with prescribed antihypertensive medication and lifestyle changes contributes to the burden of uncontrolled hypertension [5,6]. This problem persists despite the success that various individual programs have had in attaining high adherence rates with both nondrug  and drug regimens .
This topic will review the major issues related to nonadherence with antihypertensive therapy. A more complete discussion of noncompliance is discussed elsewhere. (See "Compliance with lipid altering medications and recommended lifestyle changes".)
REASON FOR NONADHERENCE
Nonadherence to antihypertensive medication is common. As an example, in a study of 149 hypertensive patients who were monitored with electronic pill boxes, 42 percent were nonadherent, defined as taking less than 80 percent of prescribed antihypertensive medication . In patients with hypertension, many factors have been found to reduce adherence (table 2).
Suboptimal adherence is a major barrier to realizing the benefits of evidence-based pharmacologic therapies for many medical conditions. Thus, adherence is an important topic of longstanding interest and remains a key barrier to better patient outcomes. Adherence is a complex phenomenon, and no single intervention has solved this challenge.
- Egan BM, Zhao Y, Axon RN. US trends in prevalence, awareness, treatment, and control of hypertension, 1988-2008. JAMA 2010; 303:2043.
- Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics--2014 update: a report from the American Heart Association. Circulation 2014; 129:e28.
- Egan BM, Li J, Hutchison FN, Ferdinand KC. Hypertension in the United States, 1999 to 2012: progress toward Healthy People 2020 goals. Circulation 2014; 130:1692.
- Yoon SS, Carroll MD, Fryar CD. Hypertension Prevalence and Control Among Adults: United States, 2011-2014. NCHS Data Brief 2015; :1.
- Mazzaglia G, Ambrosioni E, Alacqua M, et al. Adherence to antihypertensive medications and cardiovascular morbidity among newly diagnosed hypertensive patients. Circulation 2009; 120:1598.
- Matsumura K, Arima H, Tominaga M, et al. Impact of antihypertensive medication adherence on blood pressure control in hypertension: the COMFORT study. QJM 2013; 106:909.
- Beckmann SL, Os I, Kjeldsen SE, et al. Effect of dietary counselling on blood pressure and arterial plasma catecholamines in primary hypertension. Am J Hypertens 1995; 8:704.
- Jaffe MG, Lee GA, Young JD, et al. Improved blood pressure control associated with a large-scale hypertension program. JAMA 2013; 310:699.
- Gallagher BD, Muntner P, Moise N, et al. Are two commonly used self-report questionnaires useful for identifying antihypertensive medication nonadherence? J Hypertens 2015; 33:1108.
- http://amcp.org/uploadedFiles/FMCP/Resources/FMCP_Adherence_Slides.pdf (Accessed on March 29, 2017).
- Arnett DK, Goodman RA, Halperin JL, et al. AHA/ACC/HHS strategies to enhance application of clinical practice guidelines in patients with cardiovascular disease and comorbid conditions: from the American Heart Association, American College of Cardiology, and US Department of Health and Human Services. Circulation 2014; 130:1662.
- Payne KA, Esmonde-White S. Observational studies of antihypertensive medication use and compliance: is drug choice a factor in treatment adherence? Curr Hypertens Rep 2000; 2:515.
- Dimsdale JE. Reflections on the impact of antihypertensive medications on mood, sedation, and neuropsychologic functioning. Arch Intern Med 1992; 152:35.
- Berlowitz DR, Ash AS, Hickey EC, et al. Inadequate management of blood pressure in a hypertensive population. N Engl J Med 1998; 339:1957.
- Daugherty SL, Powers JD, Magid DJ, et al. The association between medication adherence and treatment intensification with blood pressure control in resistant hypertension. Hypertension 2012; 60:303.
- Stephenson BJ, Rowe BH, Haynes RB, et al. The rational clinical examination. Is this patient taking the treatment as prescribed? JAMA 1993; 269:2779.
- Fodor GJ, Kotrec M, Bacskai K, et al. Is interview a reliable method to verify the compliance with antihypertensive therapy? An international central-European study. J Hypertens 2005; 23:1261.
- McHorney CA. The Adherence Estimator: a brief, proximal screener for patient propensity to adhere to prescription medications for chronic disease. Curr Med Res Opin 2009; 25:215.
- Lam WY, Fresco P. Medication Adherence Measures: An Overview. Biomed Res Int 2015; 2015:217047.
- Inui TS, Yourtee EL, Williamson JW. Improved outcomes in hypertension after physician tutorials. A controlled trial. Ann Intern Med 1976; 84:646.
- Tomaszewski M, White C, Patel P, et al. High rates of non-adherence to antihypertensive treatment revealed by high-performance liquid chromatography-tandem mass spectrometry (HP LC-MS/MS) urine analysis. Heart 2014; 100:855.
- Vongpatanasin W. Resistant hypertension: a review of diagnosis and management. JAMA 2014; 311:2216.
- Hafezi H, Robertson TL, Moon GD, et al. An ingestible sensor for measuring medication adherence. IEEE Trans Biomed Eng 2015; 62:99.
- Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005; 353:487.
- Daniels PR, Kardia SL, Hanis CL, et al. Familial aggregation of hypertension treatment and control in the Genetic Epidemiology Network of Arteriopathy (GENOA) study. Am J Med 2004; 116:676.
- Baker D, Roberts DE, Newcombe RG, Fox KA. Evaluation of drug information for cardiology patients. Br J Clin Pharmacol 1991; 31:525.
- Macharia WM, Leon G, Rowe BH, et al. An overview of interventions to improve compliance with appointment keeping for medical services. JAMA 1992; 267:1813.
- Hall JA, Roter DL, Katz NR. Meta-analysis of correlates of provider behavior in medical encounters. Med Care 1988; 26:657.
- Ryan D, Carr A. A study of the differential effects of Tomm's questioning styles on therapeutic alliance. Fam Process 2001; 40:67.
- Fletcher BR, Hartmann-Boyce J, Hinton L, McManus RJ. The Effect of Self-Monitoring of Blood Pressure on Medication Adherence and Lifestyle Factors: A Systematic Review and Meta-Analysis. Am J Hypertens 2015; 28:1209.
- Uhlig K, Patel K, Ip S, et al. Self-measured blood pressure monitoring in the management of hypertension: a systematic review and meta-analysis. Ann Intern Med 2013; 159:185.
- Thakkar J, Kurup R, Laba TL, et al. Mobile Telephone Text Messaging for Medication Adherence in Chronic Disease: A Meta-analysis. JAMA Intern Med 2016; 176:340.
- Eaddy MT, Cook CL, O'Day K, et al. How patient cost-sharing trends affect adherence and outcomes: a literature review. P T 2012; 37:45.
- Gagne JJ, Choudhry NK, Kesselheim AS, et al. Comparative effectiveness of generic and brand-name statins on patient outcomes: a cohort study. Ann Intern Med 2014; 161:400.
- Briesacher BA, Andrade SE, Fouayzi H, Chan KA. Medication adherence and use of generic drug therapies. Am J Manag Care 2009; 15:450.
- Dezii CM. A retrospective study of persistence with single-pill combination therapy vs. concurrent two-pill therapy in patients with hypertension. Manag Care 2000; 9:2.
- Xie L, Frech-Tamas F, Marrett E, Baser O. A medication adherence and persistence comparison of hypertensive patients treated with single-, double- and triple-pill combination therapy. Curr Med Res Opin 2014; 30:2415.
- Egan BM, Bandyopadhyay D, Shaftman SR, et al. Initial monotherapy and combination therapy and hypertension control the first year. Hypertension 2012; 59:1124.
- Feldman RD, Zou GY, Vandervoort MK, et al. A simplified approach to the treatment of uncomplicated hypertension: a cluster randomized, controlled trial. Hypertension 2009; 53:646.
- Choudhry NK, Fischer MA, Avorn J, et al. The implications of therapeutic complexity on adherence to cardiovascular medications. Arch Intern Med 2011; 171:814.
- REASON FOR NONADHERENCE
- Patient and disease characteristics
- Treatment characteristics
- ASSESSMENT OF ADHERENCE
- METHODS TO IMPROVE ADHERENCE
- Educate and communicate
- Encourage home blood pressure self-monitoring
- Use technology acceptable to the patient
- Keep treatment inexpensive and simple
- Consolidate refills
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS