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The Importance of Improving Hypertension Management

  1. Top of page
  2. The Importance of Improving Hypertension Management
  3. Behavioral Medicine as a Complement to Pharmaceutical Medicine in Hypertension Management
  4. Previously Suggested Pragmatic Strategies for Improving Adherence
  5. A Call to Action by ASH
  6. Acknowledgment
  7. Disclosures
  8. References

Readers of this journal are well aware of the toll hypertension takes on both human health and financial resources, and will have seen the recent Lancet articles addressing the designation of high blood pressure (BP) as the greatest threat to the global burden of disease.[1-3] When discussing these papers, Dolan and O'Brien[4] observed that “Ischaemic heart disease, ischaemic, nonischaemic and haemorrhagic stroke, hypertensive heart disease, atrial fibrillation and flutter, peripheral vascular disease, aortic aneurysm and chronic renal disease (to which we must now add cognitive impairment and dementia) are all attributed to hypertension,” and also noted the paradox of rampant hypertension in the presence of many pharmacologic agents that, if used appropriately, provide therapeutic benefit. While additional drugs and particularly single-pill combinations with enhanced benefit-safety-value profiles are always welcomed, Nieuwlaat similarly commented that “Learning how to better implement effective therapies for (cardiovascular disease [CVD]) will have a larger effect on patient outcomes than most single new drugs and is a priority for tackling the global burden of CVD.”[5] This commentary therefore focuses on improving both patient and physician adherence towards the goal of better implementation of effective therapies for hypertension.

Behavioral Medicine as a Complement to Pharmaceutical Medicine in Hypertension Management

  1. Top of page
  2. The Importance of Improving Hypertension Management
  3. Behavioral Medicine as a Complement to Pharmaceutical Medicine in Hypertension Management
  4. Previously Suggested Pragmatic Strategies for Improving Adherence
  5. A Call to Action by ASH
  6. Acknowledgment
  7. Disclosures
  8. References

Improving hypertension management requires improvements at the patient level (individual patient education and empowerment, improving patient nonadherence to biopharmaceutical regimens, and lifestyle modifications) and the physician level (improving physicians' knowledge of the cognitive and behavioral factors involved in patients' active engagement in their own care, the manner in which they communicate with patients, and their adherence to prescribing guidelines). I believe that our society, the American Society of Hypertension (ASH), is ideally placed to facilitate these improvements in hypertension management in the United States, and to be a forerunner in related global efforts. Accordingly, in this commentary, I offer some respectful suggestions from a behavioral medicine perspective. Behavioral medicine is an integrative scientific discipline focused on the complex relationships among behavioral activities, psychological processes, sociocultural contexts, and health and disease, and one that is well placed to offer support in adherence enhancement.[6, 7]

Patient Nonadherence

With regard to patients, Howren[8] observed that “Adherence is a term used to describe the extent to which an individual's behavior coincides with health-related instructions or recommendations given by a health care provider in the context of a specific disease or disorder. The term has been used extensively in psychology and medicine in reference to acute, chronic, and preventive treatment regimens (eg, a course of prescribed medication, wound self-care), preventive health screenings, dietary restrictions, exercise recommendations, and other health behaviors.” Of immediate relevance in this quote is the inclusion of both pharmaceutical medicine and behavioral medicine interventions. Pharmaceutical and behavioral medicine are complementary. A perfect example is the inclusion of behavioral modifications in Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), which observes that “Adoption of healthy lifestyles by all persons is critical for the prevention of high BP and is an indispensable part of the management of those with hypertension.”[9]

While the negative effect of patient nonadherence has been known for decades,[8] and authoritative sources such as the World Health Organization put average nonadherence among those with chronic diseases around 50%,[10] the literature still reveals a predominance of discussions of, and further research into, the problem rather than offering immediate action plans. While such research (eg, see Parati and colleagues[11]) will likely be very informative in due course, we need to embrace available strategies right now. An example is Script Your Future, a Medication Adherence Awareness Campaign launched in May 2011 by US Surgeon General Dr Regina Benjamin in conjunction with the National Consumers League. The campaign's Web site[12] contains information concerning diabetes, respiratory diseases, and cardiovascular conditions including hypertension (see further discussion of this initiative in the Table 1).

Table 1. Suggested Items for Initial Consideration
ItemsTask force actions and sample references
1. Engage in Outreach Activities
Society of Behavioral Medicine (SBM)[30]The SBM is a multidisciplinary organization comprising clinicians, scientists, nurses, other healthcare professionals, and educators who are dedicated to promoting the study of the interactions between behavior, biology, and the environment. Knowledge gained is then applied to improve the health and well-being of individuals, families, communities, and populations. SBM's Vision Statement captures its relevance to present discussions: Better Health through Behavior Change. Five peer-reviewed behavioral medicine journals are listed on the society's Web site.[31]
Script Your Future Initiative[12]In May 2011, US Surgeon General Dr Regina Benjamin joined with the National Consumers League to launch the Medication Adherence Awareness Campaign entitled Script Your Future, “a new public education campaign to raise awareness among patients about the consequences of not taking medication as directed.”[32] The initiative is supported by a coalition of more than 100 public and private partners and sponsors, including healthcare professional groups, chronic disease groups, health insurance plans, pharmaceutical companies, business organizations, consumer groups, and researchers. The organizers have indicated that they would welcome the American Society of Hypertension's (ASH's) participation.
Food and Drug Administration (FDA): Safe Use InitiativeThe goal of the FDA's Safe Use Initiative is “to reduce preventable harm by identifying specific, preventable medication risks and developing, implementing and evaluating cross-sector interventions with partners who are committed to safe medication use.”[33] Medication adherence is one of 14 areas in which collaboration by various stakeholders including professional societies is welcomed. (Note: the FDA is supporting the Script Your Future initiative.)
National medical and pharmacy organizationsThe American Medical Association,[34] the American Association of Colleges of Pharmacy,[35] the National Association of Chain Drug Stores Foundation, and the National Community Pharmacists Association are sponsors of Script Your Future's 2012–2013 Medication Adherence Team Challenge in which students of pharmacy and other health professions campaign and raise awareness about adherence.[36] Teaching current students about the importance of adherence is a powerful way to influence the next generation of health professionals in this regard,[34] and ASH is well placed to participate in future events.
2. Engage in Advocacy Activities
Introduction of the flexipill to the US marketFixed-dose combination (FDC) polypills have been marketed for some time. For patients requiring triple therapy, these options offer the possibilities of greater patient adherence, reduced treatment inertia, and better clinical outcomes (including sustained clinical and 24-hour blood pressure [BP] control) compared with multiple tablets.[37-42] The flexipill, available in some European countries, goes an important step further by allowing for flexible-dose combinations within one tablet, hence enabling physicians to increase the dosage of the component parts in a single tablet according to BP response.[43] There now exist flexipill combinations of angiotensin receptor blockers and angiotensin-converting enzyme inhibitors with calcium channel blockers, angiotensin receptor blockers, and angiotensin-converting enzyme inhibitors with thiazide diuretics, and β-blockers and renin inhibitors with thiazide diuretics. The flexipill will likely maintain and perhaps even further enhance improvements in patient adherence and physician adherence to treatment guidelines (decreased treatment inertia).
3. Increase Utilization of In-Office and Community-Based Patient Educators
Nurses

Gindlesberger[44] provided a case study where rooming staff (medical assistants and licensed practice nurses) played an active role in BP control with notable success. The author noted that “a model of care allowing each person on the health care team to function to the highest level of their degree will provide quality, efficient, and low-cost health care.”

Hegney and colleagues[45] reported “the first Australian study investigating the acceptability, feasibility and sustainability of a nurse-led model of chronic disease management in general practice” in which hypertension was included. The authors observed that “Our findings showed that nurses provided chronic disease management that was acceptable, feasible and sustainable.”

Allen and colleagues[46] reported results from a randomized, controlled trial evaluating the effectiveness of “a comprehensive program of cardiovascular disease risk reduction delivered by nurse practitioner/community health worker (NP/CHW) teams vs enhanced usual care (EUC)” to improve control of various parameters including BP. The NP/CHW intervention included “aggressive pharmacological management and tailored educational and behavioral counseling for lifestyle modification and problem-solving to address barriers to adherence and control.” Compared with EUC, patients in the NP/CHW group had significantly greater 12-month improvement in BP.

Additional references are provided.[47-50]

PharmacistsChua and colleagues[51] reported results from “a large controlled trial that evaluated the outcomes of multiprofessional collaboration which involved medical general practitioners, pharmacists, dietitians and nurses in managing diabetes mellitus, hypertension and hyperlipidaemia in primary care settings.” This study demonstrated the importance of pharmacists working in collaboration with other healthcare providers including medical doctors in identifying and resolving pharmaceutical care issues, including nonadherence, to provide optimal care for patients with chronic diseases, including hypertension.
4. Review All Evidence Concerning Financial Incentives for Various Stakeholders
PhysiciansCollate and critically review relevant pay-for-performance (P4P) information from multiple countries, including the United States, appropriately acknowledging differing operating characteristics of healthcare systems across countries.[52-58] Evaluate the national scalability of promising strategies. Also review the role of improvements in processes of care on patient outcomes.[59] From a behavioral perspective, the following quotes are pertinent. Kirschner and colleagues noted that “One may assume that involvement of health care professionals in the goal setting and methods of quality measurement and subsequent payment schemes may enhance their commitment to and motivation for P4P programs and therefore the impact of these programs.”[52] Similarly, Lee and Ferris[53] observed that physicians “should not shy away from payment systems that introduce accountability for clinical outcomes,” since alternatives could be worse. Rather, physicians “should make it our own by adopting it, studying it, correcting its faults, and constantly seeking its improvement.”
PharmacistsKoenigsfeld and colleagues discussed the initiation of a P4P project for clinic-based pharmacists in Iowa and South Dakota by a private insurer in 2009. The project focused on 4 chronic diseases, including hypertension. A high percentage of patients with these diseases achieved goal levels at clinics with clinical pharmacist services: For hypertensives, 86.2% had BP <140/90 mm Hg.[60]
Patients

Long and colleagues commented in 2008 that while physician- and hospital-targeted P4P can change provider behavior when payments are large enough, there are limitations to this approach since it does not directly target patients' health behavior, which is “an extremely important driver of both healthcare costs and outcomes, arguably being responsible for a much higher proportion of premature mortality than is poor quality within the health-care system.”[61] Hence, P4P for patient (P4P4P) programs have been initiated in the United States to directly provide monetary and nonmonetary incentives for healthy behaviors, eg, losing weight, participating in wellness programs, and offering nonsmokers lower health insurance premiums than smokers.

A more recent paper by Wu[62] also advocated for P4P4P, noting that patient rewards could be in the form of discounts towards copayments for doctor's visits, procedures, and medications, thereby potentially reducing costs and improving adherence. The author noted that “A pilot study recruiting patients with diabetes or hypertension, diseases with clear and objective outcome measures, would be useful to examine true costs, savings, and health outcomes of such a reward program.”

Payers

In contrast to the traditional principle that all services must cost the same for all patients, ie, all patients pay the same out-of-pocket costs for health care services whose benefits are nonetheless dependent on individual patient characteristics, value-based insurance design (VBID) “encourages the use of services when the clinical benefits exceed the cost and likewise discourages the use of services when the benefits do not justify the cost,” thus leading to a high-value health system.[63] Farley and colleagues[64] examined whether participation in a population-based VBID program was associated with improved medication adherence to various drugs for several indications including hypertension 2 years after implementation. A pre-post quasi-experimental study design with a retrospective cohort of 75,000 enrollees was employed. VBID was associated with improved medication adherence, with changes being most notable among patients who were less adherent before VBID implementation.

Additional references are provided.[65-70]

Interaction Between Patient and Physician

The interaction between patient and physician is itself important in improving patient adherence. In the context of statin therapy, for example, Schedlbauer and colleagues[13] observed that increased patient-centeredness, ie, placing emphasis on patients' perspectives and engaging in shared decision-making, might be useful. Patient-centered care is included among the quality benchmarks for Accountable Care Organizations as part of the Patient Protection and Affordable Care Act. The importance of communication between doctor and patient has been known for decades,[14, 15] but it is still not optimal. Levinson and colleagues[16] recently observed that patient-centered communication skills enhance patient satisfaction, treatment adherence, and self-management. They also observed that these skills “can be effectively taught at all levels of medical education and to practicing physicians,” yet most physicians receive limited training in these skills.[16]

Physician Nonadherence

As a behavioral and clinical scientist who does not have prescribing responsibilities, it is appropriate for me to acknowledge here that there are many hypertension specialists who are extremely conversant with prescribing guidelines, who communicate very well with their patients, and who sometimes may recommend treatment that differs from the guidelines because, for certain patients, they genuinely believe that such action is warranted. This is certainly within the spirit of guidelines, which acknowledge the role of a physician's expertise and clinical experience. However, the literature reveals that deviation from guideline-recommended treatment is not always as considered, and it is such instances to which this commentary pertains.

Awareness of prescriber nonadherence to hypertension treatment guidelines dates back at least to the 1990s.[17, 18] Balu[19] discussed nonadherence in the United States, with a focus on financial consequences. A retrospective analysis of year 2006 Medical Expenditure Panel Survey data reported substantial costs of inappropriate hypertension management. Using year 2006 US dollars, the author noted that the “overall prevalence of hypertension was estimated at 19.7%, with 36% of identified patients treated inappropriately. The per-person cost for inappropriate treatment was $234.60, and the total national cost was approximately $13 billion.”[19] While harder to quantify, the human cost is no doubt commensurately disturbing.

What information and suggestions for action can we glean from the literature on physician adherence worldwide? Consider the following examples. First, the language used in guidelines can be challenging. Michie and Johnston[20] commented that “Efforts to get doctors to follow guidelines have overlooked the importance of clear and concise recommendations.” Similarly, Rümenapf commented that physicians' time is too limited to read guidelines that are written in a complicated manner, and they often “provide no reading pleasure because the language and style they are written in is too removed from clinical practice.”[21]

Second, Redon and colleagues[22] conducted a survey study in 35 European countries addressing the views of physicians treating hypertension on BP targets recommended by the European Society of Hypertension–European Society of Cardiology guidelines. Overall, 95.0% of physicians felt that patients' systolic BP values needed to be higher than the guideline-recommended goal levels before taking immediate action: the respective figure for diastolic BP was 90.1%. The authors surmised that “Clinical hesitation in relation to reducing elevated BP to goal levels is putting patients at increased cardiovascular risk and contributing to the substantial health and economic burden associated with uncontrolled BP.”[22] The authors discussed various strategies that can combat this problem, citing a cluster randomized trial reported by Luders and colleagues[23] providing evidence that the “delivery of systematic information in connection with a feedback system reduces clinical inertia and improves guideline adherence.” Clinical/physician inertia is also discussed elsewhere in the literature (eg, see Hill and colleagues[24]).

Third, Voogdt-Pruis and colleagues[25] compared adherence with lifestyle intervention aspects of Dutch guidelines on cardiovascular prevention between general practitioners and practice nurses: lifestyle intervention advice was given more frequently by the nurses. Again related to lifestyle advice, Valderrama and colleagues[26] utilized survey data from 5400 respondents and found that only about one quarter had received advice regarding the adoption of specific behavior changes.

Previously Suggested Pragmatic Strategies for Improving Adherence

  1. Top of page
  2. The Importance of Improving Hypertension Management
  3. Behavioral Medicine as a Complement to Pharmaceutical Medicine in Hypertension Management
  4. Previously Suggested Pragmatic Strategies for Improving Adherence
  5. A Call to Action by ASH
  6. Acknowledgment
  7. Disclosures
  8. References

My colleagues and I have previously addressed the global health moral imperative of improving adherence to pharmacologic regimens for cardiodiabesity,[27] a term that has not yet gained traction in the medical lexicon but one that effectively captures 3 chronic and inter-related conditions of clinical concern: diabetes, obesity, and cardiovascular disease.[28, 29] We proposed several pragmatic approaches with the hopes of raising both eyebrows and interest. One was that every biopharmaceutical company with one or more marketed products should consider appointing a Chief Adherence Officer (CAO), and afford this person the same gravitas given to all other occupants of the company's “C-wing” (the CEO, CMO, etc.). This individual should ideally be trained in, or at least be willing to rapidly become immersed in, educational and behavioral sciences as well as biological and pharmaceutical sciences. A second was that schools of medicine, pharmacy, nursing, and allied health professions need to redouble attention to the adherence component of their curricula in novel ways. We readily acknowledge that there are always time pressures in professional training programs, but why not try the following: Devote a 1-hour lecture slot shortly before students interact with patients for the first time to have them write, by hand, the following statement over and over: “I must discuss medication adherence with my patients at every possible opportunity.” We feel that students would not readily forget that experience!

A Call to Action by ASH

  1. Top of page
  2. The Importance of Improving Hypertension Management
  3. Behavioral Medicine as a Complement to Pharmaceutical Medicine in Hypertension Management
  4. Previously Suggested Pragmatic Strategies for Improving Adherence
  5. A Call to Action by ASH
  6. Acknowledgment
  7. Disclosures
  8. References

The challenges of addressing nonadherence must not be underestimated. Attention needs to focus on many facets, including characteristics of the treatment regimen, patient, and physician; patient-physician interaction; sociocultural and socioenvironmental factors; patient and physician education; and cognitive and behavioral factors, eg, having offered educational opportunities, how best to motivate patients to become knowledgeable about their disease, and the consequences of nonadherence to recommended pharmaceutical and behavioral interventions.[8] That said, addressing nonadherence is a global public health moral imperative, and, regardless of the challenges, we must do all we can. I therefore respectfully suggest that ASH consider the creation of an interdisciplinary Patient & Physician Adherence Task Force. The society has already made a meaningful start in this arena with the publication of a position paper addressing patient adherence.[24] With regard to such a task force, meaningful representation from many other branches of science and clinical practice could advantageously be solicited in addition to core members who are hypertension specialists: pharmacists, nurses, health educators and communication specialists, medical psychologists, and other specialists from the field of behavioral medicine are just some possibilities to consider. Representatives from patient advocacy groups would also be valuable contributors, and one would hope that pharmaceutical companies with antihypertensive medications in their portfolios and also payers would like to participate. I hope that this suggestion might be addressed in ASH committee meetings, at our scientific conferences, and in this journal via letters to the editor—I passionately believe that patients will benefit. The timing of such discussions would also be propitious as the Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8) is being prepared. Given that nonadherence is a global concern, creation of such a task force is also an opportunity for ASH to provide a model for other hypertension societies worldwide.

Suggestions for Initial Consideration

The current worlds of regulatory and other governmental agencies, non-for-profit organizations, medical practice settings, and medical reimbursement bear powerful witness to the concept of finite resources. Therefore, whether the word “it” in the following double-barreled question refers to organizational and research work performed by ASH volunteers and staff members, clinical work performed in a physician's office, or any other activity required for successful clinical outcomes from a task force's work, the questions of ultimate salience will become: Who's going to do it, and who's going to pay them for doing so? While such questions must undoubtedly be faced in due course, I respectfully suggest that sufficient initial ASH resources be allocated to consider the items presented in the Table, and to meaningfully assess the viability of expanded action by a task force. Given that motivation and reinforcement are important influences on all successful behavioral changes (including those by a professional society), the Table starts with some outreach and advocacy activities that could easily be implemented, thus initiating a positive feedback loop that would likely generate additional enthusiasm for more challenging pursuits ahead.

References

  1. Top of page
  2. The Importance of Improving Hypertension Management
  3. Behavioral Medicine as a Complement to Pharmaceutical Medicine in Hypertension Management
  4. Previously Suggested Pragmatic Strategies for Improving Adherence
  5. A Call to Action by ASH
  6. Acknowledgment
  7. Disclosures
  8. References
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