Physician assessments of medication adherence and decisions to intensify medications for patients with uncontrolled blood pressure: still no better than a coin toss.
BACKGROUND
Many patients have uncontrolled blood pressure (BP) because they are not taking medications as prescribed. Providers may have difficulty accurately assessing adherence. Providers need to assess medication adherence to decide whether to address uncontrolled BP by improving adherence to the current prescribed regimen or by intensifying the BP treatment regimen by increasing doses or adding more medications.


METHODS
We examined how provider assessments of adherence with antihypertensive medications compared with refill records, and how providers' assessments were associated with decisions to intensify medications for uncontrolled BP. We studied a cross-sectional cohort of 1169 veterans with diabetes presenting with BP ≥140/90 to 92 primary care providers at 9 Veterans Affairs (VA) facilities from February 2005 to March 2006. Using VA pharmacy records, we utilized a continuous multiple-interval measure of medication gaps (CMG) to assess the proportion of time in prior year that patient did not possess the prescribed medications; CMG ≥20% is considered clinically significant non-adherence. Providers answered post-visit Likert-scale questions regarding their assessment of patient adherence to BP medications. The BP regimen was considered intensified if medication was added or increased without stopping or decreasing another medication.


RESULTS
1064 patients were receiving antihypertensive medication regularly from the VA; the mean CMG was 11.3%. Adherence assessments by providers correlated poorly with refill history. 211 (20%) patients did not have BP medication available for ≥ 20% of days; providers characterized 79 (37%) of these 211 patients as having significant non-adherence, and intensified medications for 97 (46%). Providers intensified BP medications for 451 (42%) patients, similarly whether assessed by provider as having significant non-adherence (44%) or not (43%).


CONCLUSIONS
Providers recognized non-adherence for less than half of patients whose pharmacy records indicated significant refill gaps, and often intensified BP medications even when suspected serious non-adherence. Making an objective measure of adherence such as the CMG available during visits may help providers recognize non-adherence to inform prescribing decisions.
Department of Internal Medicine, University of Michigan, Ann Arbor, USA. meddings@umich.edu
Jennifer
J
Meddings
Eve A
EA
Kerr
Michele
M
Heisler
Timothy P
TP
Hofer
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000959:Antihypertensive Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D003430:Cross-Sectional Studies; D003657:Decision Making; D006801:Humans; D006973:Hypertension / Q000175:diagnosis / Q000188:drug therapy*; D008875:Middle Aged; D010820:Physicians / Q000523:psychology / Q000706:statistics & numerical data; D010818:Practice Patterns, Physicians' / Q000592:standards; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires; D014481:United States; D016903:Drug Monitoring
D000959:Antihypertensive Agents