michigan hypertension core curriculum - State of Michigan

ecently published RCT investigated the effectiveness of ward-based pharmacist interventions in
reducing morbidity and hospital care among older patients. Investigators demonstrated a 16% reduction
in all hospital visits and a 47% reduction in visits to the emergency department in the pharmacist
intervention group. 12 A similar study in an inner city ambulatory care clinic found greater overall “taking
adherence”(78.8% vs. 67.9%), “scheduling adherence”(53.1% vs. 47.2%), and “refill adherence”(109%
vs. 105%) respectively in the pharmacist intervention group compared to a control group assigned to
usual care. 6 The effects of the intervention dissipated in the post intervention period, highlighting the
importance of continuous engagement of patients in efforts to control HTN.
The responsibility for adherence is shared among the patient, provider and the health care
system. When prescribing medications, providers need to consider not only pharmacologic efficacy
but also simple dosing regimens and inexpensive drugs. Limits on health insurance drug benefits,
expensive co-pays, and lack of drug coverage have a negative impact on patient adherence and
contribute to adverse outcomes. Comparisons of outcomes in Medicare+Choice patients with capped
benefits of $1000 versus unlimited drug benefits demonstrated fewer office visits (RR 0.97) higher
rates of ER visits (RR 1.09), higher non-elective hospitalizations (RR 1.13), and increased death (RR
1.22) in patients with capped benefits. 8 Furthermore, a retrospective cohort study of first-fill adherence
for patients with HTN found a co-pay of less than $10 was associated with greater patient adherence
than co-pays greater than $10 (87% vs. 72% respectively, p< 0.001). Referral to assistance programs,
access to reliable supply systems, and encouraging non-pharmaceutical therapy (low salt diet,
exercise, weight loss) can help ease the cost burden and improve adherence to prescribed therapy.
A large pill burden has been shown to be a major factor contributing to poor patient adherence.
Several Cochrane systematic reviews have recently evaluated the evidence for specific interventions
to improve adherence to antihypertensive or lipid-lowering drugs. 13,14 The review of interventions
to promote antihypertensive drug adherence included 38 studies of 58 different interventions and
concluded that strong evidence supports the value of reducing the number of daily doses. 13 Pill burden
reduction can be achieved not only by limiting the total number of antihypertensive drugs but also by
favoring usage of once-daily formulations over twice-daily and three times daily formulations. Keeping
care simple by using once-daily drugs and using the fewest drugs needed to achieve blood pressure
goal is central to improving patient adherence. The use of combination agents is a good strategy to
reduce pill burden. However, many combination medications are relatively new and newer agents tend
212 Hypertension Core Curriculum