The benefits of leveraging adherence protocols like Directly Observed Therapy for Treatment-Resistant Hypertension

Approximately a third of adults in the United States—or 75 million people—have high blood pressure, according to the U.S. Centers for Disease Control and Prevention (CDC). Hypertension is a risk factor for cardiovascular disease and a pervasive cause of mortality and morbidity across the globe. While specific medications have been engineered to treat hypertension, resistant hypertension requires a slightly different approach than traditional treatment. Resistant hypertension is generally defined as blood pressure that remains uncontrolled despite the concurrent use of three or more types of blood pressure medications: one of which should be a diuretic.

The Importance of Adherence in Hypertension

Medication nonadherence remains a significant and widespread problem across the entire landscape of healthcare, costing nearly $300 billion in avoidable health care costs annually in the U.S. Beyond the burdensome economic and societal implications, medication nonadherence increases the risks of an adverse cardiac event and death.

Treatment-resistant hypertension poses a unique obstacle, and medication adherence becomes critically important in these situations when the prescribed therapies do not provide the intended or expected results. Having an accurate understanding of the patient’s adherence enables a healthcare provider to monitor patients that may be resistant to one of the many medications they are taking for hypertension treatment.

Caring for Patients with Treatment-Resistant Hypertension

A study recently published in JAMA sought to understand the ways in which Directly Observed Therapy (DOT) affected adherence in patients with treatment-resistant hypertension. Given that nonadherence is a common challenge among patients with treatment-resistant hypertension, researchers wanted to determine the patient’s true and accurate adherence to their medications —beyond proxy measures such as pill counts, refill data, or self-reports. By comparison, DOT—a CDC-endorsed model of care—has been proven to secure rates of adherence greater than 95 percent without the limitations of other modalities.

The study found that even those patients who reported adherence — and had perfect pharmacy refill records and accurate pill counts — demonstrated high nonadherence to their blood-pressure-lowering drug regimens. This finding confirmed that other methods of adherence have inherent constraints. Moreover, most patients with significantly improved blood pressure subsequent to DOT had a sustained improvement in controlled blood pressure one month later.

Although the study included a highly selected group of patients, the author’s findings conclude that strict adherence protocols like DOT should be examined for patients with treatment-resistant hypertension.

Future Efforts to Monitor Treatment-Resistant Hypertension

Hypertension is a ubiquitous problem in the United States, and a major risk factor for global cardiovascular disease and death—with an estimated half of cardiovascular disease events stemming from hypertension. Given the high risk of death among individuals with treatment-resistant hypertension, it is critical that they receive the support needed to ensure medication adherence. Through evidence-based methods like DOT, healthcare providers can more accurately assess adherence and provide the highest level of care to patients, thus leading to enhanced outcomes. New advances in technology like video DOT offer clinicians a potential opportunity to make DOT scalable and reach millions of patients who require more rigorous adherence and medication reconciliation.