Prevent and Control America's Blood Pressure: MISSION POSSIBLE

Summarized by Robert W. Griffith, MD
May 31, 2007

Summary

Fewer than 40% of hypertensives have their blood pressure under control. Improving adherence to the prescribed therapeutic regimen is a large part of the answer, and strategies to address this are discussed here.

Introduction

May 2007 was National High Blood Pressure Education Month in the USA. The focus of this year's campaign - MISSION POSSIBLE - is a major effort to improve adherence to prescribed antihypertensive medication, which is known to be poor. As part of the campaign the National Heart Lung and Blood Institute website carries an article titled "Improving Adherence to Medical Regimens", which presents a review of the problem, what works, and what doesn't.

The problem

The seriousness of non-adherence to medical regimens was first raised in 1976, when a study showed that 50% of prescribed drugs were not taken as directed. More than 30 years have passed, and published reports state that between 30% and 60% non-adherence is the rule.

High blood pressure is particularly liable to be a focus of non-adherence. This is largely because hypertension has no symptoms, unless it's very severe. Adequate compliance is considered necessary to achieve a desired blood pressure level. It's been shown that patients taking at least 80% of their medications have significantly better control of their blood pressure than those only taking 50% or less of their meds.

Although such statistics are fairly well known amongst health professionals, they are not often made clear to patients. Fewer than 40% of hypertensives have their blood pressure under control, and the blame for this often lies with the physician. Patients who are actively managed by their physician can be shown to have improved control rates.

Why patients are non-adherent

There are three sorts of non-adherence, and they can have different causes:

• Erratic adherence. This may be due to unpredictable factors - running out of meds, problems with refills, being too busy, changed schedules, etc.
• Accidental non-adherence. There can be misunderstanding about the dosage or frequency of medication, language difficulties, or memory problems.
• Purposeful non-adherence. This happens when patients select their dosage based on how they feel - feeling better or experiencing side effects - or when cost is a major factor.

Studies show that a patient's personality and their social circumstances (gender, race, marriage, income, and education) don't predict adherence. Psychological stress, on the other hand, such as anxiety or depression, and substance abuse have more serious effects on good adherence.

The nature of the course of therapy is important. The regimen most likely to be complied with will be simple, easy to follow, of short duration, and without disruption of lifestyle. Above all, it should clearly reduce symptoms or pain, if these are present.

Antihypertensive therapy often fails to fulfill these qualities. Lifestyle changes (low-salt diet, weight control, an exercise program) are usually a part of the first step. Combination therapy, involving two or more drugs, may be required, and adds complexity and cost to the regimen. And the nature of the condition - the absence of symptoms and the long duration of treatment - does not offer immediate 'rewards' to the compliant patient.

The role of interpersonal factors

The most important personal factor is the social support the patient receives from their family, especially their 'significant other'. If the spouse or a near relative is present when therapy is discussed with the doctor, it's more likely that their reinforcement and encouragement will contribute to better adherence.

The doctor (or other health provider) is critical in promoting compliance. Skills in communication, achieving rapport, and understanding the social circumstances of the patient are paramount. It's necessary that the consequences of poor blood pressure control - the increased risks of cardiovascular events such as angina or heart attack, or stroke - are fully explained. The health professional should also be sensitive to possible side effects, and be prepared to change the regimen accordingly.

What works in improving adherence?

The following strategies should be used, where possible:

• Simplify the regimen, involve the patient as a partner, and tailor the regimen to the patient's lifestyle and needs
• Include the spouse and/or family in such discussions
• Give clear written and oral instructions
• Ask about adherence at every patient visit, and if it's poor, find out why, in a non-judgmental way.

The physician can also help the patient learn behavioral strategies to improve compliance. The more strategies that are used, the better the likelihood of good adherence. Here are some successful strategies:

• Reminder systems (e.g. pill organizing boxes)
• Cues - putting meds where the patient will be reminded to take them (e.g. with the toothpaste)
• Self-monitoring - keeping a log of med-taking
• Doctor's feedback (e.g. discussing blood pressure results with the patient)
• Professional's reinforcement - recognizing the patient's efforts to adhere

Jus providing information or guidelines is not enough. But training doctors to offer help with strategies can be very successful.

Newer technologies

In this hyper-connected age it's not surprising that offers abound for phone, texting, or e-mail messages to remind people to take their pills. It's not known yet whether such approaches will be effective. It's possible that messages from pharmacists when a refill is due could be more useful.

Pharmacists and nurses have an important role to play in reinforcing the physician's advice on the need for compliance. Community health workers who make home visits can also assist in looking for, and helping to remove, any obstacles to adherence.

A team effort

The physician, spouse or family, pharmacist, nurse, community health worker - they can all play a part in helping the patient develop appropriate strategies to achieve 100% adherence. This will result in the best outcome for the patient's health, particularly in cases of hypertension, where compliance is such a problem.

Source

• National Heart Lung and Blood Institute. "Improving Adherence to Medical Regimens".

Related Links
NHLBI: Improving Adherence to Medical Regimens
NHLBI: What are High Blood Pressure and Prehypertension?
Not Taking Your Meds Can Be Dangerous to Your Health
Ensuring Control in Type 2 Diabetes