Compliance and hypertension

Samuel Butler put it in rhyme: He that complies against his will is of his own opinion still.

There isn’t one of us entirely free of the sort of dutiful compliance Butler so poetically invoked. We comply with alarm clocks, taxes and mortgage payments, however unwillingly, because we’re of the opinion that the alternative (arriving late, landing in jail, losing our home) is easily the lesser of two evils.

Similarly, we suffer the interventions of doctors in the opinion that their invasions of our corporeal privacy will defend us from even less welcome intrusions by disease. And we submit to the regimens of drugs they prescribe (imposing schedules on our schedules, side effects on our well being), because we’re of the opinion that, ultimately, they’re for our own good.

Or do we? Innumerable studies have shown that people (as many as 75 per cent of patients in some studies) don’t submit to their physicians’ prescribed therapies closely enough for them to work – for all sorts of reasons: Some people don’t want to take any drug, prescribed or not. Some are afraid to; they see a list of side effects and assume they’ll develop them all. Some people simply forget.

It an issue that keeps popping up because lives often turn on those missed treatments. The matter of compliance, or adherence, surfaced most recently at the American Heart Association’s annual meeting, in Orlando, Fla., this past November. A study titled Adherence to Management of High Blood Pressure: Recommendations of the Canadian Coalition for High Blood Pressure Prevention and Control made several recommendations for improving compliance to the treatment of hypertension, or high blood pressure, with the aim, quite simply, of saving lives.

The Canadian Coalition – comprised of more than 30 professional, volunteer, government and industrial partners, including Health Canada, the Canadian Hypertension Society, Heart and Stroke Canada, the Canadian Cardiovascular Society and the Canadian Medical Association – is an organization set up to reduce the health consequences of hypertension. Also known as high blood pressure, the condition affects more than one in five adult Canadians, including one in two elderly. Left untreated, hypertension can lead to a range of cardiovascular problems, including heart attack, stroke, kidney failure and vascular disease. Together, these vascular diseases are the leading cause of death amongst Canadians.

“Effective treatment largely prevents the damage caused by hypertension,” says Dr. Norman Campbell, Canadian Coalition president and a professor of medicine and adjunct professor of pharmacology and therapeutics at the University of Calgary. “Unfortunately, only one in six Canadians with hypertension is effectively treated. The rest, five out of six, are either unaware that they have hypertension, are aware but not treated, or are ineffectively treated.”

As the Coalition study found, a good deal of the problem is due to non compliance: “The sad reality is that half of all high blood pressure patients stop taking their medication within the first year, in many cases because of drug related side effects,” Campbell observes. “People are dying because of this extraordinary level of non compliance.”

Of those who do continue their therapy (drug and/or non drug), many do not fully adhere, which results in treatment that simply isn’t effective at reducing elevated blood pressure and directly contributes to heart attack, stroke, heart failure and unnecessary death.

There’s also a significant monetary cost, Campbell says: “Lack of adherence wastes limited healthcare resources, estimated to cost society billions of dollars per year. Effective programs to improve patient adherence to blood pressure lowering medication could improve the health of Canadians and also result in a cost saving.”

Thus targeting non adherence or non compliance to therapy is a major priority for the coalition, says Dr. Arun Chockalingam, chairman of the Canadian Working Group on Adherence to the Management of High Blood Pressure and past Coalition president, “since it’s clear that non adherence is the single most important factor contributing to the many unnecessary deaths and complications of high blood pressure.”

With that in mind, the Coalition made four key recommendations:

  • Doctors should provide written and verbal instruction to patients regarding the etiology (the likely cause of the patient’s hypertension, such as a previous family history or a personal history of heart disease, etc.) and prognosis of their condition. Doctors should also explain the benefits of any recommended treatment, making sure patients clearly understand its nature and implications, with follow up appointments.

  • Physicians should simplify medication regimens and provide a combination of behaviour strategies, including tailoring pill taking to patients’ daily habits, with instructions on self monitoring of pills and blood pressure.

  • Doctors, nurses and pharmacists should spend time during patient visits to review adherence to treatment and should try to ensure patients have all the information they need to follow a regimen correctly. Nurses and pharmacists should advise patients on adherence and monitor their progress. Healthcare professionals should assess patient adherence by direct questioning at each visit, and should encourage family support.

  • Whenever possible, patients should have medications prescribed that they can take once a day. (The study found that a significantly greater percentage of patients were still taking losartan – the first in a new class of antihypertensive drugs called angiotensin II receptor antagonists – at 12 months, compared to patients on other medications, which may reflect, Bloom surmises, “losartan’s once a day dosing schedule and good tolerability.”)
  • You can initiate better compliance yourself by, first of all, seeing your doctor to have your blood pressure reconfirmed. With the doctor’s or healthcare provider’s advice, decide whether non drug management (such as exercise, weight loss, reducing sodium intake and other dietary changes) will be effective as a first step in reducing elevated blood pressure, with drug therapy as a second choice. The important point is, whichever route you take, stick to it.

    “It’s currently recommended that every time a patient sees a physician they have their blood pressure assessed,” Dr. Campbell says. “This is being followed reasonably closely but not uniformly. A number of times patients identified with a highish level of blood pressure will not return for a follow up. It’s very important that those with high blood pressure be identified, usually through the routine methods physicians offer.

    “There are recommendations that adults should be seen on a routine basis after age 40 for a variety of preventive measures, including cardiovascular disease. The recommendation on how frequently blood pressure should be measured depends on what the initial measurement is. For someone with a normal blood pressure, a check every two years is adequate. If it’s in a borderline range, not quite hypertensive, then every year. If they’re in the hypertensive range, then they really need a close follow up, not only to assess their blood pressure but also to allow adherence to the blood pressure lowering therapy to be assessed.”

    For the best part of 30 years in most western countries, hypertension has been seen as a public health issue, and to expect physicians to bear full responsibility is probably unrealistic, says Dr. Bernard S. Bloom, a research professor at the University of Pennsylvania. “We really have to think of it more as a population based public health issue, in which physicians have extraordinarily important roles to play, but that the responsibility also devolves onto the public, and in particular patients at large.

    “There are lots of avenues that have been and are being used in terms of capturing the people who have high blood pressure,” Dr. Bloom says, noting the increased accessibility of blood pressure machines in the offices of dentists, nurses, optometrists and other health professionals — even, on occasion, in malls and supermarkets. “It’s then that physicians can come to the fore in terms of education, maintenance, control, along with individuals. But to expect just physicians alone, I think is putting the burden too much on just one group of professionals.”

    Take charge: Seek out the information you need to monitor your own blood pressure and, if it’s elevated, choose to comply with your treatment regimen.