Prescribers may feel improving adherence should come before increasing doses or giving additional medications, but a new study finds this may not be the case.
Patients who either increased medication adherence or received regimen intensification were no more likely to achieve blood pressure control than those who did neither, researchers have found.
The retrospective cohort study found that only simultaneous intensification and improved adherence led to BP control, with authors suggesting health systems should encourage intensification regardless of adherence status so as not to perpetuate therapeutic inertia.
Intensification was also found to increase adherence in the more than 19,000 US primary care patients with hypertension and uncontrolled BP (at least 130/80mmHg) in 2021.
Those who received intensification at their index visit (their second high BP reading) had greater odds of increasing their adherence (AOR 1.20).
Without intensification or improved adherence, the adjusted probability of achieving BP control was 23%. Intensification alone and improved adherence alone were 24% and 25% respectively, but for patients who did both, the probability of control rose to 31%.
Despite uncontrolled BP at two visits, only 24% of patients had their therapy intensified at their index visit.
Researchers noted a low rate of intensification in patients with low adherence, which they said could be due to providers’ beliefs that improving adherence is necessary before intensification.
“After all, if a patient does not take a medication, it is hard to understand how adding another prescription could improve BP,” they wrote.
“However, our findings do not support this logic. Patients who improved their adherence without intensification did not have better BP control than those who did not improve adherence, so simply encouraging adherence without intensifying medications is unlikely to be sufficient.”
“Failure to intensify medications despite an elevated BP reading is a known barrier to BP control.”
Participants were diagnosed with hypertension on average eight years before their initial uncontrolled reading in the study period.
Adherence and intensification were tracked for the six months before and after the index visit. If multiple readings were taken during this, researchers chose the reading closest to the six-month mark.
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A quarter of participants had low adherence (less than 80%) between their initial and index visits, measured using prescription fills.
Nearly half of nonadherent patients reached the threshold of at least 80% adherence after their index visit. A fifth received intensification.
During the six months before the index visit, 50% of patients had an intensification in their antihypertensive regimen. For those who had an intensification at the index visit, 50% received a higher dose, 47% received a new or additional class and 3% received both.
Median patient age was 68 years, 56% were female and 71% were White. Mean BP at index was 140/79mmHg and they were prescribed an average of 2.1 antihypertensives prior to index.
Patients generally had one visit between the index visit and the outcome time point (the closest reading to six months after).
