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SHP 08-187 – HSR Study

SHP 08-187
Evidence Synthesis: Hypertension Medication Adherence & Intensification
Nancy R. Kressin, PhD
VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA
Boston, MA
Funding Period: June 2008 - December 2008
Hypertension affects nearly 50 million Americans [1] and is the most common chronic condition among veterans. Unfortunately, many patients with established hypertension have poorly controlled blood pressure (BP); control rates in the VA are at approximately 70% currently. While clinician failure to aggressively manage hypertension through therapeutic intensification (clinical inertia, or failure to intensify pharmacotherapy appropriately) contributes to poor blood pressure control, even when doctors do intensify therapy, 43-78% of patients fail to adhere to recommended therapies, indicating that adherence remains a central problem in hypertension care. This suggests important opportunities for interventions to improve risk factor control by working through clinicians, their teams, or their delivery systems, as well as with patients, to address both patient adherence and clinical inertia.

Recognizing the importance of understanding and intervening to improve adherence to antihypertensive medications and to address clinical inertia, VA HSR&D has funded numerous studies in the last decade to address these issues, either through interventions or through exploratory studies to better understand the problems. There has been little discussion among investigators and clinical managers as to the comparative effectiveness of such approaches -- which practices are 'best' for use in VA, based on the evidence emerging from these studies. Thus, we conducted an evidence synthesis project to accomplish these aims, in order to summarize the literature and facilitate exchange among investigators and clinicians on the implications of this growing body of VA research.

We sought to catalog and extensively describe all VA funded studies conducted over the past decade focusing on adherence to antihypertensive medications, therapeutic intensification, or both. We also included non-VA funded studies focused on the care of veterans receiving health care in VA. We aimed to describe gaps in current research and identify important areas for future research, synthesize results from the studies, whether published or unpublished, in the form of an evidence synthesis, and to build on these efforts to develop more formal exchange and collaboration among VA researchers and clinicians working on addressing these important issues.

Increased attention to the issue of hypertension through various interventions, whether EMR reminders, counseling, or academic detailing, made a difference, at least in some cases. Adding additional staffing, ranging from clinicians to lay counselors, to do more counseling about BP and BP medications, showed some benefit for BP outcomes. Health IT strategies helped improve prescribing practices, although this did not necessarily translate into improvements in BP outcomes. Interventions targeting patients directly may be more likely to achieve lowering of BP and may be particularly good at improving patient participation in their BP self-management, but may also be more costly and labor-intensive. Provider-oriented interventions may also be necessary to ensure that patients are prescribed correct medications so that they have the opportunity to take them as they improve their self-management regimens.

We initiated the development of a network of collaboration and exchange among VA researchers and clinicians addressing these issues. We are now partnering with Gordon Schectman, MD, Acting Director for Primary Care, Primary Care Program Office, VACO to assist with his programmatic emphasis on improving chronic disease care, with a particular focus on hypertension care. We built a solid foundation for implementation and dissemination of effective strategies to address clinical inertia and improve veterans' adherence to antihypertensive medications, leading to improved clinical outcomes.

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