Improving Medication Routines and Adherence in Hypertensive African Americans: Finding the Needle in the Haystack

C. Everett Koop, the former Surgeon General, famously said “Drugs don't work in patients who don't take them.” In this issue of The Journal of Clinical Hypertension, Solomon and colleagues1 add to our growing body of knowledge regarding medication routines, adherence, and control rates. The setting for their study were two ambulatory care practices affiliated with the Ambulatory Care Network of New York Presbyterian Hospital. Patients were monitored for medication adherence using a well-known research tool, the Medication Event Monitoring System (MEMS; AARDEX Group Ltd, Sion, Switzerland), a pill bottle with an electric chip that allows for real-time tracking of adherence behaviors. The majority (88%) of participants in the study were women, with a mean age of 54 years. They represented a lower socioeconomic cohort based on household income, educational attainment, and insurance status. The investigators found a strong assocition between medication-taking consistency, medication adhererence, and blood pressure control. Younger patients were more likely to have variable medication-taking routines and thus lower adherence to treatment compared with older patients. The results were statistically significant for control of diastolic blood pressure, but nonsignificant for systolic blood pressure. Medication adherence is a vexing problem for clinicians and is not isolated to the disease state of hypertension. Up to 50% of the US population is prescribed medication for chronic conditions, and, of those taking prescribed medication, only 50% are taking it as directed.2 The association between adherence and improved outcomes has been shown in many disease states, including those with cardiovascular disease events,3 survival after a heart attack at 1 year4 and improved glycemic control in diabetics as measured by hemoglobin A1c.5 Some interventions to address adherence are intuitive and effective. In a study by Casebeer and colleagues,6 brief in-office medication counseling after a new statin was prescribed increased 6-month adherence by 17%. Batal and colleagues7 and Schectman and colleagues,8 in separate studies, concluded that prescribing longer-lasting supplies of medications improved adherence. Barriers to adherence can be categorized as patient-centric, provider-centric, and health system–centric. One of the authors (DK) recently coauthored a chapter on this topic focusing on African American hypertensives.9 This study suggests that our message related to adherence needs to start early and be more precise, innovative, and focused toward younger patients. Clinicians need to appreciate that younger, lower-income individuals are likely to be working a second job.10 This, combined with child-care duties for young children, creates additional barriers that can distract someone with an asymptomatic condition to miss their medication. It may not be enough to say “take your medication(s),” but, instead, be precise and say “take your medication every day when you brush your teeth or every evening when you remove your contact lenses.’’ This should be documented in the medical record and reinforced by every provider, nurse, medical assistant, or other staff who interact with the patient. For many patients, we need some creative ideas, which can include text messaging or other automatic reminders, broadly referred to as applications of mobile health (“mHealth”). In a recent metanalysis of randomized controlled trials published between 2005 and 2008, eight of nine interventions for disease prevention and management showed a positive short-term effect utilizing some form of automated reminders.11 These data are consistent with other studies suggesting that mobile phones are a useful tool for interventions seeking improvement in health outcomes.12-14 Not all patients are likely to be poorly adherent, however, even among lower-income minority patients. Are there other ways to predict who is likely to be adherent to target time and energy in counseling? Morisky and colleagues15 proposed an eight-item medication adherence scale that was found to be significantly associated with blood pressure control. Using a cut point of less than six, the sensitivity of the measure to identify patients with poor blood pressure control was estimated to be 93%, with a specificity of 53%. The scale was studied in more than 1300 hypertensive patients, many of whom were low-income minority patients, similar to the patients in the study by Solomon and colleagues. As clinicians we need to spend more time strategizing with our patients about adherence issues, emphasizing maintaining routines, utilizing mobile tools, discussing and addressing belief systems, as well as other barriers that stand between them and effective blood pressure control.