CURRENT OPINION PharmacoEconomics 1996 Jan; 9 (1): 1-4 1170-7690{96{OOOH1OO1{S02.oo{O

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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, myo­cardial 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 nonpharmacologi­cal and/or pharmacological treatment.19-11 ] The goal of antihypertensive therapy and/or lifestyle modi­fications is to achieve and maintain a reduced blood pressure «140/90mm Hg) with minimal, if any, ad­verse effects.l'2,13]

A major barrier to the management of hyperten­sion 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 re­mainder, nearly 33% administer insufficient medi­cation to facilitate art adequate reduction in blood pressure.l'6,17] Noncompliance with antihypertensive pharmacotherapy has been associated with an in­crease in visits to the physician, hospital admis­sions, 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 adher­ence.l3°-32] Given the estimated rate of noncompli­ance with antihypertensive pharmacotherapy and the magnitude of resulting health service expendi­tures, pharmaceutical manufacturers, health main­tenance organisations (HMOs) and government agencies have commenced the development· and implementation of disease state management pro­gramming.133,34] While holding the promise of en­hanced patient outcomes, commercial sponsorship, whether that of a pharmaceutical firm or health in­surance 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, individ­ualisation of the treatment regimen may well be sacrificed. Vigilant oversight of programming initia­tives will be required as stakeholders pursue vested interests.

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Further complicating the prescribing of, and com­pliance with, antihypertensive pharmacotherapy are concerns regarding the magnitude of the patient's direct expenditure for the procurement of medica­tion.l35-37] Cardiovascular medicines are expen­sive.[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 indi­vidual with coronary heart disease, hypertension, renal insufficiency and hypercholesterolaemia may well be prescribed a ~-blocker, an ACE inhib­itor, a diuretic and a cholesterol-lowering agent, thereby yielding a monthly expenditure for pharmaco­therapy in excess of $US150 (1989 dollars).[40]

The publication of the Joint National Commit­tee'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 predi­cated 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 in­creased expenditures for antihypertensive pharmaco­therapy; 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 Anti­hypertensive 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 med­ications 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 environ­ment.[51] Quality-of-life considerations are paramount if compliance with antihypertensive pharmaco­therapy 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] Con­temporary efforts to optimise antihypertensive pharmacotherapy need to focus on individualising treatment in accordance with the patient's age, gen­der and race, the presence of concomitant disease state processes and acceptable outcomes relative to quality of life.[59,60]

The ultimate value of antihypertensive pharma­cotherapy is its ability to reduce both the morbidity and mortality associated with cardiovascular dis­ease.[61,62] By focusing on expenditures for anti­hypertensive pharmacotherapy rather than expen­ditures for cardiovascular disease, government agencies, medical associations and health insurance schemes inadvertently enhance the probability of noncompliance by advocating the selection of medi­cines 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 man­agement, need to be considered in order to enhance compliance and reduce health service expendi­tures.l65,66]

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5. Hypertension Guidelines Committee, South Australian Faculty, Royal Australian College of General Practitioners. Hyperten­sion: diagnosis, treatment, and maintenance. Guidelines en­dorsed by the High Blood Pressure Research Council of Australia. Adelaide: South Australian Faculty, Royal Austra­lian College of General Practitioners, 1991

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PharmacoEconomics 1996 Jan; 9 (1)

Noncompliance with Antihypertensives

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19. McCombs JS, Nichol MB, Newman CM, et a!. The costs of interrupting antihypertensive drug therapy in a medicaid pop­ulation. Med Care 1994; 32: 214-26

20. Office of National Cost Estimates. National health care expendi­tures, 1988 [summary J. Health Care Financ Rev 1990; II: 125

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Correspondence and reprints: Dr Tracy L. Skaer, College of Pharmacy, Washington State University, Pullman, WA 99164-6510, USA.

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