An Electronic Adherence Measurement Intervention to Reduce Clinical Inertia in the Treatment of Uncontrolled Hypertension: The MATCH Cluster Randomized Clinical Trial

Abstract

BACKGROUND: To appropriately manage uncontrolled hypertension, clinicians must decide whether blood pressure (BP) is above goal due to a need for additional medication or to medication nonadherence. Yet, clinicians are poor judges of adherence, and uncertainty about adherence may promote inertia with respect to medication modification. OBJECTIVE: We aimed to determine the effect of sharing electronically-measured adherence data with clinicians on the management of uncontrolled hypertension. DESIGN: This was a cluster randomized trial. PARTICIPANTS: Twenty-four primary care providers (12 intervention, 12 usual care; cluster units) and 100 patients with uncontrolled hypertension (65 intervention, 35 usual care) were included in the study. INTERVENTIONS: At one visit per patient, clinicians in the intervention group received a report summarizing electronically measured adherence to the BP regimen and recommended clinical actions. Clinicians in the control group did not receive a report. MAIN MEASURES: The primary outcome was the proportion of visits with appropriate clinical management (i.e., treatment intensification among adherent patients and adherence counseling among nonadherent patients). Secondary outcomes included patient-rated quality of care and communication during the visit. KEY RESULTS: The proportion of visits with appropriate clinical management was higher in the intervention group than the control group (45 out of 65; 69 %) versus (12 out of 35; 34 %; p = 0.001). A higher proportion of adherent patients in the intervention group had their regimen intensified (p = 0.01), and a higher proportion of nonadherent patients in the intervention group received adherence counseling (p = 0.005). Patients in the intervention group were more likely to give their clinician high ratings on quality of care (p = 0.05), and on measures of patientcentered (p = 0.001) and collaborative communication (p = 0.02).CONCLUSIONS: Providing clinicians with electronicallymeasured antihypertensive adherence reports reduces inertia in the management of uncontrolled hypertension. TRIAL REGISTRATION: NCT01257347; http://clinicaltrials.gov/show/NCT01257347 KEY WORDS: uncontrolled hypertension; medication adherence; clinical inertia; randomized clinical trial.

From the Editors’ Desk: Why Does Not Improvement in Communication Lead to Improvement in “Hard” Outcomes?

“…1-3 This is surprising since improvement in communication can lead to improved adherence to treatment regimens [4][5][6] and adherence has been shown to be critical to improvement in some outcomes, such as blood pressure control. 7 I once attended a BMeet the Professor^session at the annual Society of General Internal Medicine with Shelly Greenfield. The room was full of young researchers, all eager to push the field of patient-provider communication forward and looking forward to his guidance.…”

“…Adherence, for example, can be affected by communication, but there are many factors, often unique to individual patients, that result in the degree of adherence they experience. 7 It is clear from these communication interventions that the impact of communication on adherence may be less than the impact of other factors. If the patient cannot afford to buy their medications, if the patient's health beliefs or social support system is working against improvement in blood pressure or diabetes control, then improving communication will lead to failure.…”

Nonadherence in patients with hypertensive emergency or hypertensive urgency

“…Assessing medication adherence by direct biochemical measurement or electronic pillbox and discussing the results with the patient ("adherence counseling") have been shown to improve adherence to antihypertensive medication and to overcome clinical inertia, that is, a lack of treatment intensification despite uncontrolled hypertension. 6,16 Since subjective estimates of nonadherence by the treating physician are widely inaccurate, and questionnaires overreport adherence, assessing medication adherence by direct biochemical measurement (or electronic pillbox) should become part of daily practice in treating hypertensive patients. 17 6.…”

Using Adherence Information to Improve Care: From Clinic Visits to Populations

“…Kronish and colleagues report a cluster-randomized trial of an intervention that provided clinicians with data from electronic pillbox monitors. 3 The study took place in two hospital-based primary care practices serving vulnerable populations in New York City. Twenty-four clinicians were randomized either to continue usual care or to receive information about recent adherence with antihypertensive medications.…”