Evaluation of Blood Pressure Control, Medication Adherence, and Therapeutic Inertia in US Patients With Hypertension Prescribed Multiple Antihypertensives

BACKGROUND: Failure to control blood pressure (BP) despite multiple prescribed antihypertensive medications (AHMs) is widespread and leads to worse clinical outcomes. Recent changes to BP targets in US clinical guidelines require an updated evaluation of BP control including evaluations of nonadherence and therapeutic inertia. METHODS: We leveraged clinical and insurance data sourced from >50 US health care organizations to identify >500 000 patients with established hypertension (>15-month history) concurrently prescribed ≥3 AHM classes in 2019. We characterized the prevalence of uncontrolled hypertension and describe patterns of nonadherence (lack of AHM fills covering >80% of days) and therapeutic inertia (failure to escalate AHM for patients persistently out of BP control). We described the associations with factors including race, ethnicity, sex, and insurance. RESULTS: Among 565 737 patients prescribed ≥3 AHMs, 37.7% met the recommended BP target of <130/80 mm Hg. Black race (odds ratio [OR], 0.71 [95% CI, 0.70-0.73]) and uninsured status (OR, 0.81 [95% CI, 0.76-0.86]) were most associated with lack of BP control relative to White or commercially insured patients. In a subset of insured patients, nonadherence occurred in 52.7%, although BP control remained poor among adherent patients (43.0% versus 39.4% for nonadherent). Therapeutic inertia was widespread; 64.5% of patients persistently above the BP target had no medication escalation within 18 months. CONCLUSIONS: An evaluation of a US-based, large, real-world patient cohort demonstrates that most patients prescribed ≥3 AHMs fail to achieve the recommended BP target of <130/80, and both medication nonadherence and therapeutic inertia are widespread.