The Role of Health Systems in Promoting Adherence to Hypertension Treatments

Gregory Weiss, MD

Hypertension represents the bedrock of cardiovascular disease. From this well springs the myriad of conditions cardiologists see in the office and in the hospital. Thus far adherence to medications for high blood pressure has been the responsibility of patients with the encouragement and support of their clinicians. However, in a recent scientific statement from the American Heart Association (AHA), the health system itself is called to action in the crucial effort to ensure hypertension medication adherence.

The goal of any therapy is to reduce morbidity and mortality while improving the quality of life for the patient. High blood pressure is implicated in the development of coronary heart disease, myocardial infarction, kidney disease, and stroke. Even in the age of telemedicine and virtual visits patients are not achieving proper blood pressure control. The AHA believes that we, as clinicians, can’t solve this problem alone.

With over 50 million people taking blood pressure medications in the United States, reaching everyone and making sure they are taking their prescribed treatment is daunting to say the least. While adherence campaigns have come and gone the successful management of high blood pressure in the U.S. has actually dropped by 10% in recent years. With some patients only sporadically taking their blood pressure medications and still others never filling their prescriptions at all Niteesh Choudhry, MD, PhD, a professor at Harvard Medical School states,

“To reduce the massive risk for hospitalizations and deaths due to uncontrolled high blood pressure, specific attention is needed to understand why people don’t take their medicine as prescribed. It’s a factor that is highly modifiable.”

Because some factors that hinder medication adherence are beyond the control of the patient, the AHA suggests that clinicians and health systems employ new monitoring modalities that don’t rely on self-reporting. While direct observation is impractical new technologies such as wearable, portable monitors and electronic pill dispensers may increase adherence. The first step in making sure patients take their medications is to understand why they don’t.

The World Health Organization breaks down the barriers to adherence to four categories: Socioeconomic or demographic, therapy-related, health care system-related, and individual and condition-related. Access to care, the cost of medications, and the complexity of the regimen have all been cited as direct causes of poor adherence to blood pressure medication compliance. Once these barriers are identified solutions can be found.

The AHA writing group was able to identify four intervention categories aimed at promoting medication adherence: Patient education and counseling, medication regime management, reminders monitoring and feedback, and lastly, incentives. To these ends, the writing group makes the following suggestions:

• The health systems should develop a robust plan for assessing adherence while offering support for patients. Monitoring a pharmacy medication refill database is a good first step.
• Individual patients should receive real-time counseling making use of visual aids and open-ended discussions. A health diary may help promote adherence.
• Automated reminders and electronic pill devices capable of sending text messages may help patients keep up with their medications with greater regularity.
• Simplification of the medication regimen through single pill therapy or combination preparations can make it easier for patients to stay on track with their blood pressure medications.
• Reductions or elimination of insurance copays for blood pressure medications would make it more likely that lower socioeconomic populations would fill and take their medications.
• Patients should monitor their pressure at home. Readings in a relaxed environment should be more indicative of treatment success or failure.

We know that delaying blood pressure therapy leads to complications. The writing group points out that it is safe and effective to intensify blood pressure treatment even if the patient hasn’t adhered perfectly to the initial plan. Finally, in an effort to reach traditionally underserved communities, the AHA has launched the National Hypertension Control Initiative (NHCI). This initiative brings together all the stakeholders and provides blood pressure management training, technical assistance and resources directly to community health centers. By intervening at the community level, we have a better chance of finally getting a handle on compliance with blood pressure medications and treatment plans.

Medication adherence remains a problem faced by patients and clinicians alike. Blood pressure control is possible for all patients given the right opportunities for success. By bringing the entire health system together we can get at the grassroots of the problem and finally reach those who have slipped through the cracks.