ASH Position Paper
Adherence and persistence with taking medication to control high blood pressure

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Abstract

Nonadherence and poor or no persistence with taking antihypertensive medications results in uncontrolled high blood pressure, poor clinical outcomes and preventable health care costs. Factors associated with nonadherence are multilevel and relate not only to the patient, but also to the provider, health care system, health care organization, and community. National guideline committees have called for more aggressive approaches to implement strategies known to improve adherence and technologies known to enable changes at the systems level including improved communication among providers and patients. Improvements in adherence and persistence are likely to be achieved by supporting patient self-management, a team approach to patient care, technology-supported office practice systems, better methods to measure adherence, and less clinical inertia. Integrating high blood pressure control into health care policies that emphasize and improve prevention and management of chronic illness remains a challenge. Four strategies are proposed: focusing on clinical outcomes; empowering informed, activated patients; developing prepared proactive practice teams; and advocating for health care policy reform. With hypertension remaining the most common reason for office visits, the time is now.

Section snippets

The Scope of the Problem

The most recent US survey data, obtained from randomly selected households, show that high BP awareness, treatment, and control rates have improved from 69%, 53%, and 26%, respectively, at the time of the 1988 to 1994 Nutrition Health and Examination Survey to 76%, 65%, and 37% between 2003 to 2004.1 In a recent Harris Interactive survey, more than two thirds of patients with hypertension said they are aware of their high BP and are in care and 90% were on treatment.2 Two major requirements for

Scientific Background

The scientific evidence to support the preceding statement of the problem comes from epidemiology, clinical trials, behavioral science and health services research, and systematic reviews. The original VA trial, the first to show the efficacy of oral medication to lower BP and reduce fatal complications of uncontrolled hypertension, was conducted in a hospital setting where a nursing staff initially directly administered antihypertensive medications to patients. After discharge, compliance was

Practical Considerations and Recommendations

There is clear potential to improve clinical outcomes by improving adherence and persistence with appropriate antihypertensive medications. It is essential that 4 strategies to maintain high BP control be integrated into effective health care policies that emphasize and improve prevention and management of chronic illness. (see Table)

Acknowledgments

This article was reviewed by David J. Hyman, MD, MPH, and Donald E. Morisky, ScD, MSPH, ScM. The American Society of Hypertension Writing Group Steering Committee: Barry J. Materson, MD, MBA, Chair; Henry R. Black, MD; Joseph L. Izzo, Jr., MD; Suzanne Oparil, MD; and Michael A. Weber, MD. Nancy H. Miller is a consultant for Boehringer Ingelheim and AstraZeneca. Martha Hill, RN, PhD and Sabina DeGeest, RN, PhD have nothing to disclose.

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    Reprinted with Permission from the Journal of Clinical Hypertension, Vol. 12, No. 10 October 2010, pgs. 757-764.

    Conflict of interest: MNH: None. NHM—Boerhinger Ingelheim, Consultant, Astra Zeneca, Consultant. SDeG: None.

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