Adherence to Antihypertensive Therapy: A Missing Link Between Treatment and Outcomes

The metric of "adherence" simply captures concordance of patient's self management behavior with mutually agreed health care recommendations. With increasing burden of chronic diseases, adherence to pharmacological, and nonpharmacological measures has emerged as an essential reinforcer to treatment effectiveness. Alarmingly, poor adherence to antihypertensive medication (AHM) is fuelling the public health crisis of unsuccessfully treated hypertension, negatively impacting cardiovascular, cerebrovascular, and renal outcomes.¹ A study carried out in 5 European countries forecasted 6,553 fewer hypertensive complications with cost saving of €36 billion over a decade if 70% of patients take >80% of their AHM.² Indeed, poor adherence to blood pressure (BP) lowering medication cuts across various groups such as gender, race, marital status, comorbidities, and is not driven by one particular demographic or biopsychosocial stereotype. Research over last few decades had aptly dissipated the long held paternalistic belief of "blame the patient" for poor adherence.¹ WHO's multidimensional adherence model has broadly classified reasons for poor adherence into 5 domains—socioeconomic factors, health care team- and system-related factors, condition-related factors, therapy-related factors, and patient-related factors.¹ In this backdrop, study by Fortuna et al. in current issue evaluated the health care team- and system-related dimension highlighting importance of participatory patient provider management with shared decision making in optimizing adherence to AHM therapy.³ Using 8-item Morisky Medication Adherence Scale, 29.7% of patients reported high adherence (score 8), 32.8% reported moderate adherence (score 6–7), and 37.5% (score <6) reported low adherence and there was linear positive correlation between Morisky Medication Adherence Scale score and BP control rate. Notably, quality and not the quantity of time spent by health care provider in the care of hypertensive patient was significant predictor of adherence in their study. However, downside of their study includes an observational design, nonprobability sampling and overfitting the logistic regression model due to higher prevalence of dependent outcome. Moreover, among 3 components of adherence (initiation of therapy, day to day implementation of prescribed dosing, and long-term persistence with therapy), the current study only reported implementation bottlenecks between actual and prescribed antihypertensive therapy. Importantly, it is also reported that 5% of the hypertensive patients fail to initiate treatment after prescribing, nearly 10% skip their scheduled doses on a given day (half of them have "drug holiday" lapses of >3 days) and about 50% default within 1 year of treatment initiation.⁴ The summary of recent meta-analyses of studies evaluating adherence to AHM are tabulated in Table 1.

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