Beyond testing: understanding the patient perspective of medication adherence in hypertension

This invited commentary refers to ‘What happened?: perceptions of patients with hypertension of conflicting results between self-reported medication adherence and chemical adherence testing: a qualitative study’, by S. Soldan et al., https://doi.org/10.1093/eurjcn/zvae104. Hypertension, the silent killer, is the leading risk factor for death, affecting more than one billion people globally.1 For patients with hypertension, taking medications as prescribed is crucial in improving risk profile and avoiding future adverse events. Although great strides have been made towards understanding medication adherence and its importance in clinical practice, adherence rates remain disappointingly low for patients with hypertension.2 Medication non-adherence is therefore a growing concern for patients, clinicians, researchers, and policymakers because failure to adhere to prescribed medications is associated with poor clinical outcomes, higher readmission rates, increased mortality and morbidity, and increased costs.3 To date, there is no consensus on the best approach to improving medication adherence. However, gaining a deeper understanding of the reasons for medication non-adherence is paramount to providing needed support and optimizing adherence in patients with hypertension. In their article, Soldan et al.4 explored the perceptions of patients with hypertension regarding the conflicting results between their self-reported medication adherence and chemical adherence testing. The authors should be commended for ensuring the patient’s voice is heard as this is essential in achieving person-centred care.5 This study reveals the emotional and psychological complexity of medication adherence in patients with hypertension, particularly when self-reported adherence conflicts with chemical testing. The two distinct emotional responses—one group feeling ashamed and disappointed and another feeling falsely accused—points to a fundamental issue of trust and communication between patients and clinicians. Patients who felt wrongly accused highlight the importance of explaining chemical adherence tests and creating a judgement-free dialogue. Clinicians should foster trust by clarifying the test’s purpose and encouraging open discussions about medication habits. Patients want to be heard. However, as reflected in this study, communication with clinicians was difficult and the patients felt like a number rather than a person. Moreover, they were reluctant to share their problems due to limited time and busy consultations. This observation is corroborated by other studies in which clinicians were perceived to have too many patients and too little time, and the encounters with clinicians were too brief and poorly planned. The result is that information about medications, side effects, and the importance of medication adherence was lacking, inadequate, or ad hoc.6,7 Understanding each patient’s unique challenges and incorporate their perspectives into treatment strategies is important as fragmented consultations puts patients at risk for adverse events and early discontinuation of prescribed pharmacotherapy. The study found that both groups, regardless of how they reacted to the test results, shared similar frustrations with taking medications.4 This shared frustration stems from various factors—complex medication regimens, side effects, perceived inefficacy of the treatment, and being ‘fed up with searching for the right medication’. Patients with cardiovascular diseases are particularly vulnerable to side effects due to multiple comorbidities and age-related physiological changes. Given the increased propensity to experiencing side effects from cardiovascular drugs, providing evidence-based information is pivotal for this patient group. Previous studies have also shown that patients who are informed about all aspects of their treatment had a lower incidence of self-reported side effects and fewer concerns about their prescribed pharmacotherapy.8 Thus, information gathered in this study could be used to facilitate shared decision-making between patients and clinicians to promote medication adherence and persistence in patients with hypertension. Simplifying treatment plans (e.g. the use of poly pills), managing side effects (e.g. adjustment of dosage or alternative drugs), and offering regular feedback on progress can help alleviate this burden. Several methods have been developed and validated to assess medication adherence. Subjective methods assess medication adherence based on the perception of either the patient or a healthcare provider, whereas objective methods include direct observation of the patient receiving the medication, use of drug markers with the target medication, and measurement of metabolites in blood or urine.9 However, it is critical to note that no single measurement is perfect, and all measurements of medication adherence have limitations. Self-reported measures have been found to significantly overestimate medication adherence compared with other adherence measures, whereas objective measures are generally labour-intensive, expensive, and not widely available. Chemical adherence testing, as described by Soldan et al.,4 offers strong evidence of the ingestion of the prescribed medications. However, confounding factors including testing time, individual drug metabolism, pharmacokinetics, drug–drug interactions, drug–food interactions, errors, and white coat adherence can lead to false-negative results,10 which might have resulted in the observed discrepancies in the present study. Chemical adherence testing also only provides information on whether a medicine is present and does not provide insights on reasons for non-adherence. Subsequently, overreliance on these tests can erode trust if patients feel wrongly judged. Thus, chemical adherence testing should be used cautiously, alongside empathetic conversations to understand and uncover broader adherence challenges like financial barriers or side effects. Often, patient-related factors are commonly referred to as the sole reason for non-adherence to medication despite substantial evidence to the contrary. This bias reflects a poor understanding of the multifaceted and interrelated factors that affect medication-taking behaviour. According to the World Health Organization, five different dimensions affect medication adherence, including social/economic related, therapy-related, patient-related, condition-related, and healthcare system–related factors.11 As such, reasons for medication non-adherence are frequently context dependent, and a one-size-fits-all approach is unlikely to work. Thus, healthcare systems may need to rethink how they support patients with hypertension. Incorporating behavioural health strategies, peer support systems, and technological interventions such as reminders or digital adherence trackers could provide patients with additional tools to overcome adherence challenges. Importantly, clinicians could benefit from training in understanding the nuances of adherence and the diverse factors that influence it. This study offers valuable insights into the discordance between self-reported and chemically tested medication adherence among patients with hypertension. The findings emphasize the importance of a person-centred, empathetic approach, where clinicians actively listen to and support their patients to meet their individual needs. Effective patient–provider communication and support in navigating patients’ emotional responses to adherence testing is crucial in understanding the emotional and practical barriers to adherence and in developing tailored interventions that promote better treatment outcomes. The key to optimizing hypertension management lies in addressing both the medical and patient perspective of care. Trond Roed Pettersen, PhD (Writing—original draft [equal], Writing—review & editing [equal]) and Dion Candelaria, PhD (Writing—original draft [equal], Writing—review & editing [equal]). None declared. No additional data available.