Why Are We Doing So Badly with the Control of Hypertension? Poor Compliance Is Only Part of the Story

JOURNAL OF CLINICAL HYPERTENSION 179 Treating hypertension should be a simple matter, but it is not. We know beyond any doubt that lowering blood pressure can substantially reduce the risk of stroke and heart attack. More than 100 different drugs are available for its treatment; all have proven efficacy, most have few side effects, and many are formulated for once-daily dosing. Why, then, are the reported rates of blood pressure control so disappointing, and apparently not getting any better? The official figures are derived from the National Health and Nutrition Examination Surveys (NHANES), conducted at regular intervals in random samples of the population. The latest survey, in 1991–1994,1 revealed that only 27% of hypertensives had blood pressures controlled to below the target level of 140/90 mm Hg; this figure was 29% in 1988–1991. In contrast, figures provided by the American Heart Association show that the expenditure for antihypertensive drugs has increased dramatically over the past few years. What is going on? We in the United States are not alone in this respect: statistics from numerous other countries show that control rates are, if anything, worse overseas: In France and Germany, which by some accounts have health care systems in many ways superior to ours, the rates are even lower.2,3 The easy rationalization is to blame our patients, on the grounds that they refuse to take their pills. While there may be some truth in this, it is by no means the whole story, nor is it necessarily the most important part of the story. One survey found that 70% of doctors attributed treatment failures to poor compliance by their patients, while 81% of patients regarded their compliance as good.4 Two other factors that we must consider are the health care providers (primarily physicians) and the system in which we operate. Given the incontrovertible importance of this problem, surprisingly little is being done to solve it. Compliance, for the purpose of this essay, may be defined as the frequency with which a patient actually takes his or her medication as prescribed. Problems concerning compliance with medical regimens are as old as the history of medical therapy. In fact, Hippocrates complained that “. patients are often lying when they say they have regularly taken the prescribed medicine. ”5 As long as there were practically no pharmacologically effective therapies, poor compliance was a negligible problem. Today, however, with medication available that effectively controls blood pressure, the problem has become a major one. The importance of compliance is underscored by three studies that have documented the association between poor compliance and higher mortality.6–8 This may not seem surprising, but in each of these studies the effect was observed in the placebo group as well as in the active treatment group. All three study populations were high-risk cardiac patients; the study drug was added to the patients’ other medications, so one possible explanation is that the other pills the patients were supposed to be taking may have influenced mortality. Another is that patients with a more positive attitude toward life have a better prognosis. E f f e c t s o f S t r e s s a n d B e h a v i o r a l I n t e r v e n t i o n s i n H y p e r t e n s i o n