Noncompliance with Antihypertensive Therapy

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  • CURRENT OPINION PharmacoEconomics 1996 Jan; 9 (1): 1-4 1170-7690{96{OOOH1OO1{S02.oo{O Adls International limited. All rights reserved.

    Noncompliance with Antihypertensive Therapy Economic Consequences

    Tracy L. Bkaer, David A. Belar and Linda M. Robison College of Pharmacy, Washington State University, Pullman, Washington, USA

    Hypertension is a silent disease state, the full seriousness of which becomes evident only when the sequelae of long-standing high blood pressure are manifest as congestive heart failure, angina, myo-cardial infarction, cerebral vascular accident and/or end-stage renal disease. II-8] An estimated 60 million Americans have elevated blood pressure (systolic blood pressure ~140mrn Hg and/or diastolic blood pressure ~90mm Hg) requiring nonpharmacologi-cal and/or pharmacological treatment.19-11 ] The goal of antihypertensive therapy and/or lifestyle modi-fications is to achieve and maintain a reduced blood pressure 140/90mm Hg) with minimal, if any, ad-verse effects.l'2,13]

    A major barrier to the management of hyperten-sion is the extent to which patients comply with the treatment regimen.114,15] An estimated 30 to 50% of hypertensive patients withdraw from their prescribed regimen within 1 year of diagnosis and, of the re-mainder, nearly 33% administer insufficient medi-cation to facilitate art adequate reduction in blood pressure.l'6,17] Noncompliance with antihypertensive pharmacotherapy has been associated with an in-crease in visits to the physician, hospital admis-sions, length of hospital stay and resulting health service expenditures.l'8,19] Hospital expenditures resulting from an interruption in, or termination of, an antihypertensive regimen have been estimated to exceed $US800 per episode (1988 dollars).120]

    A review of the medical literature reveals that no single intervention strategy will assure compli-

    ance with antihypertensive pharmacotherapy.l21-23] Barriers to compliance include:124-29] the patient's socioeconomic status access to medical care understanding of hypertension and the role of

    pharmacotherapy the patient's locus of control the adverse effect profile and administration

    schedule of the prescribed medication. Recent evidence suggests that a structured long-

    itudinal programme composed of educational modules, specialised prescription packaging, and scheduled consultation with healthcare providers may enhance the probability of long term adher-ence.l3-32] Given the estimated rate of noncompli-ance with antihypertensive pharmacotherapy and the magnitude of resulting health service expendi-tures, pharmaceutical manufacturers, health main-tenance organisations (HMOs) and government agencies have commenced the development and implementation of disease state management pro-gramming.133,34] While holding the promise of en-hanced patient outcomes, commercial sponsorship, whether that of a pharmaceutical firm or health in-surance scheme, may well result in the increased utilisation of either patent-protected medication or inexpensive alternatives, depending on the financial incentive of the benefactor. In either case, individ-ualisation of the treatment regimen may well be sacrificed. Vigilant oversight of programming initia-tives will be required as stakeholders pursue vested interests.

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    Further complicating the prescribing of, and com-pliance with, antihypertensive pharmacotherapy are concerns regarding the magnitude of the patient's direct expenditure for the procurement of medica-tion.l35-37] Cardiovascular medicines are expen-sive.[38,39] As patients often present with more than one cardiovascular disease state, direct expenditures for pharmacotherapy may represent a significant barrier to regimen adherence. For example, an indi-vidual with coronary heart disease, hypertension, renal insufficiency and hypercholesterolaemia may well be prescribed a ~-blocker, an ACE inhib-itor, a diuretic and a cholesterol-lowering agent, thereby yielding a monthly expenditure for pharmaco-therapy in excess of $US150 (1989 dollars).[40]

    The publication of the Joint National Commit-tee's fifth report on the treatment of hypertension has stimulated considerable debate as to the merits of issuing disease state management directives (i.e. guidelines).D 1,41] Many approach the treatment of hypertension as a means to reduce cardiovascular events, with the selection of pharmacotherapy predi-cated on the probability of prolonging both the quality and duration of life, rather than merely the potential to reduce millimetres of mercury.[42-47] Individualised treatment regimens may require in-creased expenditures for antihypertensive pharmaco-therapy; an exacting precursor to noncompliance. However, at present, there are insufficient clinical and/or economic data to assure formulary status for newer, more expensive therapeutic alternatives.[48-49] Randomised controlled trials, such as the Anti-hypertensive and Lipid-Lowering Treatment for Prevention of Heart Attack Trial organised by the US National Heart, Lung and Blood Institute, may assist in determining whether antihypertensive med-ications with demonstrable vasoprotective effects (e.g. ACE inhibitors or calcium antagonists) are to be preferred over diuretics and ~-blockers.l50]

    At odds with scheduled events and outcomes associated with randomised controlled clinical trials are patient behaviours in the natural environ-ment.[51] Quality-of-life considerations are paramount if compliance with antihypertensive pharmaco-therapy is to be achieved.l52-57] Deterioration in

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    Skaer et al.

    quality of life as a result of prescribed medication is often cited by hypertensive patients as the basis for noncompliance with pharmacotherapy.l58] Con-temporary efforts to optimise antihypertensive pharmacotherapy need to focus on individualising treatment in accordance with the patient's age, gen-der and race, the presence of concomitant disease state processes and acceptable outcomes relative to quality of life.[59,60]

    The ultimate value of antihypertensive pharma-cotherapy is its ability to reduce both the morbidity and mortality associated with cardiovascular dis-ease.[61,62] By focusing on expenditures for anti-hypertensive pharmacotherapy rather than expen-ditures for cardiovascular disease, government agencies, medical associations and health insurance schemes inadvertently enhance the probability of noncompliance by advocating the selection of medi-cines that need to be administered more than once per day and that are associated with bothersome adverse effects.l63,64] Where clinical and economic data justify it,first dollar coverage for individualised courses of antihypertensive pharmacotherapy, along with intensive programming on disease state man-agement, need to be considered in order to enhance compliance and reduce health service expendi-tures.l65,66]

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    3. Guidelines Subcommittee of the WHO/ISH Mild Hypertension Liaison Committee. 1993 guidelines for the management of mild hypertension: memorandum from a World Health Orga-nizationllnternational Society of Hypertension meeting. Hy-pertension 1993; 22: 392-403

    4. Myers MG, Carruthers SG, Leenen FHH, et aI. Recommenda-tions from the Canadian Hypertension Society Consensus Conference on the pharmacologic treatment of hypertension. Can Med Assoc 11989; 140: 1141-6

    5. Hypertension Guidelines Committee, South Australian Faculty, Royal Australian College of General Practitioners. Hyperten-sion: diagnosis, treatment, and maintenance. Guidelines en-dorsed by the High Blood Pressure Research Council of Australia. Adelaide: South Australian Faculty, Royal Austra-lian College of General Practitioners, 1991

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    PharmacoEconomics 1996 Jan; 9 (1)

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    50. Oparil S. An...