New strategies to improve treatment adherence in hypertension

Hypertension, Risk Factors and Heart Failure Unit
Center for Patient Care
Clinique Pasteur
Toulouse, FRANCE

New strategies to improve treatment adherence in hypertension

Interview A. Pathak, France

Despite increasing knowledge about hypertension and its available treatments, blood pressure control remains suboptimal, in part due to poor treatment adherence. Poor treatment adherence in hypertension remains a daily challenge for patients and is of considerable concern given the high number of patients that may be affected. This includes patients who discontinue treatment completely as well as those who take their treatment irregularly or interrupt treatment repeatedly. Health-care systems could make significant savings (financial and in terms of prevention of adverse outcomes) by promoting the benefits of good adherence. An improvement in patient awareness and motivation, and new tools, are required to fight poor treatment adherence in hypertension. Among these tools, the assessment of the psychological status of patients, the transtheoretical model, motivational interviewing, and multidisciplinary health-care team–based approaches could be of interest and should be promoted. All of the above have shown promise in improving treatment adherence in hypertension, and further studies should be undertaken to elucidate how further benefits could be obtained. Ultimately, better blood pressure control for our hypertensive patients will be the reward for these efforts.

Medicographia. 2015;37:449-453 (see French abstract on page 453)

Hypertension is today the leading cause of diseases and death with about 1 billion people affected in the world. Despite efficient ways of detecting it and multiple treatments available, the rate of diagnosis and blood pressure (BP) control remain critically low. This partly contributes to the fact that hypertension was a primary or contributing cause of 9.4 million (95% uncertainty interval [UI], 8.6-10.1 million) deaths in 2010. In addition to death, elevated BP is also associated with major disability, such as that caused by nonfatal strokes and heart attacks. as such, elevated BP is a leading risk factor for global disease burden in terms of global disability- adjusted life years (DaLYs). In 1990, elevated BP was the fourth leading risk factor for global disease burden (5.5% [95% UI, 4.9%-6.0%] of DaLYs), while in 2010, elevated BP was ranked as the number one risk factor for disability and accounted for 7.0% (95% UI, 6.2%-7.7%) of global DaLYs.1

Different hypertension guidelines, eg, the 2013 european Society of Hypertension (eSH)/European Society of Cardiology (eSC) guidelines,2 have been issued by various societies to assess BP goals in different types of patient population. These guidelines have established management tools to control BP by the use of pharmacological or nonpharmacological tools. Despite this, over the last two decades various studies and surveys have shown that the proportion of patients with controlled BP is suboptimal in many European countries and that less than 50% of treated patients attain goal BP. Overall, across all countries in the eURIKa (eURopean study on cardIovascular risK prevention and management in usual daily practice) study,3 the proportion of treated hypertensive patients who had attained goal BP was 34.8%.

How does adherence affect BP control in clinical practice?

The 2013 European Society of Hypertension (eSH)/european Society of Cardiology (eSC) guidelines2 have identified causes for poor BP control in clinical practice:

1. Poor patient adherence to treatment is of considerable concern given the high number of patients who may be affected. This includes “discontinuers” (patients who discontinue treatment completely) and “bad users” (those who take their treatment irregularly or interrupt treatment repeatedly). Healthcare systems need to pay greater attention to the management of chronic diseases and must appreciate that significant savings (financial and prevention of adverse outcomes) can be made by promoting the benefits of adherence.

2. The reluctance or failure of physicians to initiate or intensify treatment in appropriate situations, which has been linked to several factors:
◆ Doubts about the risk represented by high BP (particularly in the elderly).
◆ Fear of morbidity/mortality due to a reduction in vital organ perfusion when BP is reduced too much (the J-curve phenomenon).
◆ Concern about side effects.

Many countries have their own treatment guidelines, and within countries certain regions and even cities with large populations may produce their own treatment guidelines. The existence of different guidelines increases complexity and may be a potential source of confusion for physicians, who may be uncertain over which guidelines to follow.

Hence there is a need to develop new strategies to increase patient adherence, compliance, and persistence4-7 and to overcome clinical inertia.8,9 This suggests that there is a need for physician education, which should include the following topics in educational programs:
◆ The need for BP control to avoid sequelae associated with hypertension such as myocardial infarction, stroke, left ventricular hypertrophy, and microalbuminuria.
◆ Criteria for treatment intensification, particularly for patients receiving combination therapy who may already take other medication for comorbidities.
◆ The benefits of home and nurse BP testing, including obtaining information on diurnal variations in BP and avoidance of “white coat” hypertension.
◆ Information on the potential consequences of even modest elevations in BP.

What factors can influence treatment adherence?

The importance of adherence as a key factor in BP control is demonstrated by the fact that the 2013 ESH/ESC guidelines contains a section dedicated to the improvement of BP control in hypertension, and this section pays considerable attention to adherence and its improvement.2 The 2013 eSH/eSC guidelines not only stress the importance of improving patient adherence in order to improve BP control, but also advise physicians on how they can monitor and attempt to improve patient management on several levels. Some factors that can influence the adherence of patients to treatment (like those related to the health system) may be difficult to address or modify. However, by developing good relationships with patients, physicians and other members of the healthcare team can address “human” factors like motivation (eg, by discussing and raising awareness of the level of cardiovascular risk associated with hypertension), and this can help to improve adherence. Other “human” factors, like emotional state, can also have major effects on adherence/ compliance. Misperception of cardiovascular risk is an issue, since a “perception gap” exists, which can result in patients with an intermediate or high level of cardiovascular risk mistakenly perceiving themselves to be at low risk.6,10-14

A large, prospective, community-based study investigated whether anxiety and five major components of personality could identify individuals likely to present with white coat or masked hypertension.15 There was a significant interaction between anxiety and use of antihypertensive medications in predicting white-coat effect (P=0.0005); in patients treated with antihypertensive medication, anxiety was associated with a 39% higher risk of pseudoresistant hypertension due to white-coat effect (Table I).15 Masked hypertension was not associated with any personality factor, although higher conscientiousness was associated with a lower risk of masked uncontrolled hypertension (odds ratio [OR], 0.70; 95% confidence interval [CI], 0.49-0.99). This study emphasizes that patients’ personalities need to be taken into account when trying to improve management. Beyond an analysis of patients’ personalities, stages of change modeling can be used in the modification of patient behavior. The transtheoretical model (TTM) provides a theoretical framework to guide the design, implementation, and evaluation of population-based interventions for behavioral change.16 TTM has been shown to be effective across various health-related behaviors, including exercise adoption. TTM uses a change-based system, in which patients move between different stages:
◆ Precontemplation (when individuals are not ready to take action in the near future).
◆ Contemplation (when individuals are serious about making a change in the next few months, but have not yet made a commitment to do so).
◆ Preparation (when individuals intend to make a change within the next 30 days or have already taken some small steps towards this aim).
◆ action (the stage at which individuals have made a behavioral change in the last 6 months).
◆ Maintenance (the stage at which individuals have made a behavioral change that has lasted longer than 6 months).

Rather than progressing in a linear fashion, most individuals cycle back to previous stages several times before behavioral change is achieved successfully.

Several studies have looked at what happens when physicians are motivated to work closely with their hypertensive patients and take into account stage of change and patient personality. Pladev all and colleagues used a multifactorial intervention to improve antihypertensive medication adherence and BP control.17 Physicians from hospital-based hypertension clinics and primary care centers across Spain were randomized to provide the intervention to high-risk patients. Physicians randomized to the intervention group counted patients’ pills, designated a family member to support adherence behavior, and provided educational information. at 6 months, intervention patients were: (i) less likely to have uncontrolled systolic BP (OR, 0.62; 95% CI, 0.50-0.78); and (ii) more likely to be adherent (OR, 1.91; 95% CI, 1.19-3.05).

The authors concluded that the multifactorial intervention improved medication adherence and BP control, although it did not influence long-term cardiovascular events. Including the level of motivation of physicians would add value to this approach. Several studies have looked at what happens when physicians are motivated to work closely with their hypertensive patients. In one of these studies, physicians were stratified into one of five groups according to their perception of hypertension.18 Physicians who were more motivated had a more confident and optimistic approach towards hypertension. Importantly, physicians who were more motivated also appeared to be more empathetic and supportive towards patients and were characterised by having higher rates of patients with controlled BP (range 32% to 42%; P=0.01 for trend).18

Finally, research has also shown that a team-based approach to patient management can have a favorable effect on adherence and BP control. Hypertension management teams can comprise primary care physicians, nurses, and others (like pharmacists) who may have an especially important role to play. Some health-care professionals, like nurses, may be able to spend more time with patients than physicians and may also be able to make home visits and develop relationships with significant members of the patient’s social circle (such as relatives, close friends, or neighbors). For this reason, healthcare professionals like nurses may be of particular importance in helping patients to implement important-but-challenging lifestyle changes beyond BP control, like smoking cessation or weight loss, and to adhere to their treatment.2,19 This type of team-based care has been associated with a reduction in systolic BP of ≈10 mm Hg and an increase in BP control of ≈22%. More generally, nurse- and pharmacist-based programs have been shown to reduce cardiovascular disease risk versus usual care.

Does motivational interviewing improve adherent behavior?

Motivational interviewing is a patient-centered, directive therapeutic approach that can be used to help patients embrace change, alter their behavior by exploring feelings and attitudes, and resolve areas of ambivalence. It is more focused and goal-directed than nondirective methods like counseling, in which therapists attempt to influence clients to consider making changes. Motivational interviewing works by enabling and engaging intrinsic motivation within patients to help them change their behavior, and it can be used to help patients improve adherence to medication. Studies have assessed the use of motivational interviewing in the management of hypertensive patients and shown that it is possible to increase patients’ motivation to adhere and comply with their treatment.20,21 Various studies have assessed the use of motivational interviewing in the management of patients with hypertension. For example, in a randomized clinical trial in 190 hypertensive African Americans (88% female; mean age 54 years), practice-based motivational interviewing counseling was compared with usual care, and the primary outcome was adherence measured by electronic pill monitors.22 a steady maintenance of treatment adherence was observed in those receiving motivational interviewing counseling compared with a decline in adherence in those receiving usual care (Figure 1).22 Furthermore, the between-group differences in systolic BP and diastolic BP were –6.1 mm Hg (P=0.065) and –1.4 mm Hg (P=0.465), respectively, in favor of the motivational interviewing group.22

Figure 1
Figure 1. Motivational interviewing counseling resulted in steady
maintenance of medication adherence compared with usual care
after 12 months. Based on data from reference 22.

*P=0.94; **P=0.027 versus usual care group.


In summary, treatment adherence in hypertension remains a daily challenge for patients. Despite increasing knowledge about hypertension and its available treatments, BP control remains suboptimal, in part due to poor adherence. This calls for an improvement in patient awareness and motivation to fight this disease with the use of new tools. Among them, the assessment of the psychological status of patients, motivational interviewing, and transtheoretical modeling could be of interest and should be promoted in the health-care community.

1. Lim SS, Vos T, Flaxman aD, et al. a comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2224-2260.
2. Mancia G, Fargard R, narkiewicz K, et al; Task Force Members. 2013 eSH/eSC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the european Society of Hypertension (eSH) and of the european Society of Cardiology (eSC). J Hypertens. 2013; 31:1281-1357.
3. Banegas JR, López-Garcia e, Dallongeville J, et al. achievement of treatment goals for primary prevention of cardiovascular disease in clinical practice across europe: the eURIKa study. Eur Heart J. 2011;32:2143-2152.
4. Cramer Ja, Roy a, Burrell a, et al. Medication compliance and persistence: terminology and definitions. Value Health. 2008;11:44-47.
5. Corrao G, Parodi a, nicotra F, et al. Better compliance to antihypertensive medications reduces cardiovascular risk. J Hypertens. 2011;29:610-618.
6. World Health Organization. adherence to long-term therapies: evidence for action. pdf. 2003. accessed July 30, 2015.
7. Hill Mn, Miller nH, DeGeest S; american Society of Hypertension Writing Group. aSH position paper: adherence and persistence with taking medication to control high blood pressure. J Clin Hypertens. 2011;12:757-764.
8. Lüders S, Schrader J, Schmieder Re, Smolka W, Wegscheider K, Bestehorn K. Improvement of hypertension management by structured physician education and feedback system: cluster randomized trial. Eur J Cardiovasc Prev Rehabil. 2010;17:271-279.
9. Gil-Guillén V, Orozco-Beltrán D, Márquez-Contreras e, et al. Is there a predictive profile for clinical inertia in hypertensive patients? an observational, crosssectional, multicentre study. Drugs Aging. 2011;28:981-992.
10. Wroe aL. Intentional and unintentional nonadherence: a study of decision making. J Behav Med. 2002;25:355-372.
11. Wang PS, Bohn RL, Knight e, Glynn RJ, Mogun H, avorn J. noncompliance with antihypertensive medications: the impact of depressive symptoms and psychosocial factors. J Gen Intern Med. 2002;17:504-511.
12. Mancia G, Laurent S, agabiti-Rosei e, et al; european Society of Hypertension. Reappraisal of european guidelines on hypertension management: a european Society of Hypertension Task Forcedocument. JHypertens. 2009;27:2121-2158.
13. Redon J, Brunner HR, Ferri C, Hilgers KF, Kolloch R, van Montfrans G. Practical solutions to the challenges of uncontrolled hypertension: a white paper. J Hypertens Suppl. 2008;26:S1-S14.
14. Katz M, Laurinavicius aG, Franco FG, et al. Calculated and perceived cardiovascular risk in asymptomatic subjects submitted to a routine medical evaluation: the perception gap. Eur J Prev Cardiol. 2015;22:1076-1082.
15. Terracciano a, Scuteri a, Strait J, et al. are personality traits associated with white-coat and masked hypertension? J Hypertens. 2014;32:1987-1992.
16. Sarkin Ja, Johnson SS, Prochaska JO, Prochaska JM. applying the transtheoretical model to regular moderate exercise in an overweight population: validation of a stages of change measure. Prev Med. 2001;33:462-469.
17. Pladevall M, Brotons C, Gabriel R, et al; Writing Committee on behalf of the COM99 Study Group. Multicenter cluster-randomized trial of a multifactorial intervention to improve antihypertensive medication adherence and blood pressure control among patients at high cardiovascular risk (the COM99 study). Circulation. 2010;122:1183-1191.
18. Consoli SM, Lemogne C, Levy a, Pouchain D, Laurent S. Physicians’ degree of motivation regarding their perception of hypertension, and blood pressure control. J Hypertens. 2010;28:1330-1339.
19. Walsh JM, McDonald KM, Shojania KG, et al. Quality improvement strategies for hypertension management: a systematic review. Med Care. 2006;44:646-657.
20. Ma C, Zhou Y, Zhou W, Huang C. evaluation of the effect of motivational interviewing counselling on hypertension care. Patient Educ Couns. 2014;95: 231-237.
21. Hettema J, Steele J, Miller WR. Motivational interviewing. Annu Rev Clin Psychol. 2005;1:91-111. 22. Ogedegbe G, Chaplin W, Schoenthaler a, et al. a practice-based trial of motivational interviewing and adherence in hypertensive african americans. Am J Hypertens. 2008;21:1137-1143.

Keywords: treatment adherence; patient compliance; hypertension; motivational interviewing; transtheoretical model; personality