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