The Association Between Medication Adherence and Treatment Intensification With Blood Pressure Control in Resistant Hypertension

Abstract

Patients with resistant hypertension are at risk for poor outcomes. Medication adherence and intensification improve blood pressure control; however, little is known about these processes or their association with outcomes in resistant hypertension. This retrospective study included patients from 2002-2006 with incident hypertension from two health systems who developed resistant hypertension, or uncontrolled blood pressure despite adherence to ≥3 antihypertensive medications. Patterns of hypertension treatment, medication adherence (percentage of days covered) and treatment intensification (increase in medication class or dose) were described in the year after resistant hypertension identification. Then, the association between medication adherence and intensification with 1-year blood pressure control was assessed controlling for patient characteristics. Of the 3,550 patients with resistant hypertension, 49% were male and mean age 60. One year after resistance hypertension determination, fewer patients were taking diuretics (77.7% vs. 92.2%, p<0.01), beta blockers (71.2% vs. 79.4%, p<0.01) and ACE/ARB (64.8% vs. 70.1%, p<0.01) compared to baseline. Rates of blood pressure control improved over 1-year (22% vs. 55%, p=<0.01). During this year, adherence was not associated with 1-year blood pressure control (adjusted OR 1.18, 0.94-1.47). Treatment was intensified in 21.6% of visits with elevated blood pressure. Increasing treatment intensity was associated with 1-year blood pressure control (adjusted OR 1.64; 95% CI 1.58-1.71). In this cohort of patients with resistant hypertension, treatment intensification but not medication adherence was significantly associated with 1-year blood pressure control. These findings highlight the need to investigate why patients with uncontrolled blood pressure do not receive treatment intensification.

Simulating Strategies for Improving Control of Hypertension Among Patients with Usual Source of Care in the United States: The Blood Pressure Control Model

“…11,29,30 Several systematic reviews have shown that protocols that require high visit frequency with vigorous treatment intensification have the greatest impact on BP control. 11,31,32 National initiatives in the U.S aim to disseminate hypertension management protocols that primarily focus on enhancing treatment intensification in patients with BP above targets.…”

An Investigation of Associations Between Clinicians’ Ethnic or Racial Bias and Hypertension Treatment, Medication Adherence and Blood Pressure Control

“…Established procedures were followed to assess treatment intensification on the basis of pharmacy dispensing records. 34,35 A baseline regimen was defined for each patient by the antihypertensive medication fills in a 90-day period, initiated by the first fill following the patient's first visit with the clinician during the observation period.…”

Recent Clinical Trials of Hypertension Management

“…8 Before handing management of resistant hypertension over to the interventionists, however, there is evidence that pharmacological management could be improved with evidence-based regimens. [9][10][11][12] There is a need for rigorous trial design, comparisons with benchmark pharmacotherapy, and better classification of patient groups that will benefit from renal denervation therapy. Extension of indications beyond that supported by trial data should be monitored and generally avoided.…”