title: Patterns of treatment modifications among newly treated hypertensive patients: does choice of modification strategy affect likelihood of treatment discontinuation?
abstract: OBJECTIVE
  Treatment modifications--addition, uptitration, switching, and downtitration--are necessary to address issues such as unattained blood pressure goals, adverse drug events, drug cost, or patient dissatisfaction which lead to treatment discontinuation. This study assessed the patterns of treatment modifications, and compared the rates of treatment modification and time-to-treatment modification across five antihypertensive drug classes (ADCs). Additionally, the association between treatment modification strategies and the likelihood of treatment discontinuation was assessed.
  
  
  METHODS
  This is a retrospective cohort study using the BlueCross-BlueShield of Texas commercial claims database (2008-2012). Treatment modifications that occurred within 1 year of starting hypertension treatment were identified. Patients who received treatment modifications were followed for 12 months to determine if and when they discontinued treatment. Cox regression models were used to determine the likelihood of treatment modification and treatment discontinuation.
  
  
  RESULTS
  About 48.5% of patients received treatment modifications within 1 year of treatment initiation. Rates of treatment modification were significantly different across ADCs; angiotensin-converting enzyme inhibitor and angiotensin receptor blocker users were less likely to receive treatment modifications compared with other ADCs. Mean time-to-treatment modification was more than 100 days for adding and uptitrating, and more than 140 days for switching and downtitrating. Patients intensifying treatment by adding medications were about 25% (vs. uptitration) and 50% (vs. switching) less likely to discontinue treatment.
  
  
  CONCLUSIONS
  Treatment modifications are common among newly treated hypertensive patients, and the rates vary significantly across ADCs. In the real world, treatment modifications occur much later than the 30-day timeline recommended by guidelines. Addition of drugs may be a preferred approach for intensifying treatment of patients at a high risk of treatment discontinuation.
authors.affiliation: aHarrison School of Pharmacy, Health Outcomes Research and Policy, 056 James E. Foy HallbHarrison School of Pharmacy, Health Outcomes Research and Policy, 038 James E. Foy HallcHarrison School of Pharmacy, Health Outcomes Research and Policy, 037 James E. Foy Hall, 282WdHarrison School of Pharmacy, Pharmacy Practice, 1202 D Walker Building, Auburn University, AuburneThe University of Alabama at Birmingham, School of Medicine Huntsville Regional Medical Campus, Internal Medicine, HuntsvillefCollege of Sciences and Mathematics, Mathematics and Statistics, 230C Parker Hall, Auburn University, Auburn, AlabamagSchool of Public Health, Management, Policy and Community Health, The University of Texas Health Science Centre at Houston, Houston, TexashHarrison School of Pharmacy, Health Outcomes Research and Policy, 022 James E. Foy Hall, 282W. Auburn University, Auburn, Alabama, USA.
authors.forename: Kalyani B
authors.initials: KB
authors.lastname: Sonawane
authors.forename: Jingjing
authors.initials: J
authors.lastname: Qian
authors.forename: Kimberly B
authors.initials: KB
authors.lastname: Garza
authors.forename: Bradley M
authors.initials: BM
authors.lastname: Wright
authors.forename: Peng
authors.initials: P
authors.lastname: Zeng
authors.forename: Cecilia M
authors.initials: CM
authors.lastname: Ganduglia-Cazaban
authors.forename: Richard A
authors.initials: RA
authors.lastname: Hansen
mesh_terms: D000293:Adolescent; D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D000328:Adult; D057911:Angiotensin Receptor Antagonists / Q000627:therapeutic use*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D000959:Antihypertensive Agents / Q000627:therapeutic use*; D001794:Blood Pressure; D002121:Calcium Channel Blockers / Q000627:therapeutic use*; D015331:Cohort Studies; D016208:Databases, Factual; D004232:Diuretics / Q000627:therapeutic use*; D057915:Drug Substitution; D005260:Female; D006801:Humans; D006973:Hypertension / Q000188:drug therapy*; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D061665:Time-to-Treatment; D055815:Young Adult
chemical_list: D000319:Adrenergic beta-Antagonists; D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D000959:Antihypertensive Agents; D002121:Calcium Channel Blockers; D004232:Diuretics