Medication Nonadherence: An Unrecognized Cardiovascular Risk Factor

Mark A. Munger, PharmD; Benjamin W. Van Tassell, PharmD; Joanne LaFleur, PharmD, MSPH


September 19, 2007

Strategies for Promoting Adherence

Researchers have evaluated many strategies for promoting patient adherence to antihypertensive medications efforts to minimize adverse effects, simplification of dosing regimens, interventions to improve patient motivation, and patient education approaches. A recent Cochrane Collaboration review of studies across many chronic conditions concluded that the most effective interventions were complex, including combinations of these individual strategy types.[55] The more successful strategies to improve adherence among patients with hypertension are summarized below.

Although not explicitly evaluated by researchers as a strategy to improve adherence, proper selection of antihypertensive drug therapy plays a key role because the adverse effects of these agents contribute to poor patient adherence. Strategies to improve adherence by minimizing these adverse effects are summarized in Table 2 and generally involve the appropriate selection of antihypertensive agents with a good tolerability profile. Overall, the selection of antihypertensive medication should involve a dynamic interaction between the healthcare practitioner and the patient to encourage patient involvement in treatment decisions that simplify the regimen and improve adherence.[56]

As part of a review of 38 clinical trials testing 58 interventions, 7 of 9 trials demonstrated that the most effective method for improving compliance with antihypertensive regimens was to simplify dosing.[57] Simplified dosing regimens resulted in increasing adherence by between 8% and 19.6%. Longer acting therapeutics can also be used to achieve blood pressure control over a full 24-hour dosing interval.[58,59] This is critical for the prevention of cardiovascular events in patients with hypertension because stroke, myocardial infarction, congestive heart failure, and renal insufficiency are directly linked to elevated blood pressure.[59] Drugs with long half-lives (eg, amlodipine, nadolol, olmesartan, ramipril) stabilize blood pressure over time and minimize the loss of blood pressure control during periods of inconsistent medication compliance.[59]

Patient education alone is a largely unsuccessful strategy to improve adherence.[55] However, patient education combined with strategies aimed at decreasing dose frequency, improving tolerability of the regimen, and motivational approaches have been found to improve adherence as much as 41%.[55] A recent report of a complex intervention involving pharmacy care in a collaborative clinic setting was shown to improve mean adherence rates from 61% at baseline to 97% during 8 months of standardized medication education, regular pharmacist follow-up, and dispensing of medications in multidose blister packs.[60] These findings suggest that a multifaceted approach at improving adherence should be considered.

Psychosocial variables provided by medical support staff can also encourage medication adherence through regular patient contact and individualized educational programs.[16,39] Primary care physicians can contribute to better hypertension control among elderly patients by monitoring treatment, educating patients about the benefits of a healthy lifestyle, and assisting in lifestyle modifications.[61,62] Access to pharmaceutical care by a pharmacist-managed hypertension clinic has also been shown to improve blood pressure management through frequent follow-up care and patient education (81% vs 28% for pharmacist-managed and control groups, respectively; P < .0001).[63] Adherence may also be enhanced by direct communication between the healthcare provider and the patient's pharmacy regarding prescription refill rates. With the patient's approval, prescription refill data can be electronically forwarded from the pharmacy directly to the healthcare practitioner's office to provide constant monitoring of adherence. The practitioner, the pharmacist, or both, could use these data to engage the patient more directly in his or her own care. A multifactorial intervention program assessing the effect of provider and patient interventions showed that neither provider nor patient education alone was sufficient to increase adherence, suggesting the need for a more comprehensive interdisciplinary approach to adherence oversight.[64]

Another strategy, a home blood pressure monitoring program with an electronic monitoring device (monitoring events medication system [MEMS]), was able to improve adherence in patients with hypertension.[65] Use of these monitoring devices is limited by their high cost, but mean adherence rates were significantly increased in comparison with control groups monitored only by physicians (92% vs 74%, respectively; P = .0001). These strategies suggest that multiple methods to facilitate the monitoring and management of hypertension promote patient adherence and that patient education alone is not sufficient.[66]

Based on the prior discussion, increases in adherence may be gained by improving on drug characteristics such as symptom reduction, tolerability, and dosing schedule. Clinicians and researchers should be encouraged to identify and develop new pharmacologic targets for hypertension that meet these criteria. Such research will undoubtedly require large investments of time and resources.


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