dosing, lack of economic resources to access healthcare or purchase medications, and lack of adherence with medications (Table 1) (Egan and Basile 2003; Nelson et al 2003). Hypertension is also frequently complicated by comorbid conditions which makes its treatment more complicated (Meier et al 1999). Poor medication adherence is an important problem in the management of hypertension. Patients with hypertension are often asymptomatic. The disease then lacks a tangible reinforcement factor to foster medication adherence in contrast with what may be seen in other chronic conditions such as diabetes where symptoms of hyperglycemia remind the patient about the need to take medications. The decision to manage the hypertensive patient with medications often results in lifelong therapy. Medications bring along symptoms from side effects enforcing the belief that the cure is worse than the disease. Failure to refill medications as expected occurred in 33% of refill opportunities in one study (Bailey et al 1996). Medication refill patterns have been correlated to blood pressure control and, as would be expected, failure to refill on time corresponds to patients not taking the medication on a regular basis thus losing blood pressure control (Steiner et al 1988). Barriers to effective prescribing practices The prescribing of medication is a complex phenomenon. It is assumed that the skills needed to prescribe medication are acquired during medical training and are sustained during clinical practice by effective continuing medical education (CME). It is hypothesized that scientifically based prescribing patterns are based, at least in part, on the publication, interpretation, and application of results from scientifically sound clinical trials, attendance at CME meetings, or recommendations from expert medical organizations or panels that are then applied to the care of individual patients. There is much evidence that these assumptions are incorrect for the treatment of many cardiovascular conditions including hypertension. There are medical treatments of proven morbidity and mortality benefit for congestive heart failure, atrial fibrillation, dyslipidemias, hypertension, and for patients after myocardial infarction. Current evidence including that cited above indicates that these treatments are underutilized resulting in premature morbidity and mortality (Siegel 2000; Amsterdam et al 2002). Vascular Health and Risk Management 2005:1(1) Methods to improve blood pressure control Why might this be the case? It is unlikely that differences of opinion based on different interpretations of scientific evidence are the primary basis for widespread differences in the use of medications. The use of calcium antagonists for the various manifestations of cardiovascular disease is not only of unproven mortality benefit (Conti 1996), but findings from retrospective noninterventional studies raise concerns that short-acting calcium antagonists are associated with serious adverse effects in hypertensive patients and thus should be avoided except in rare circumstances (Buring et al 1995; Psaty et al 1995). Despite this controversy played out in medical journals and at national meetings, most practitioners from around the world, including the US, were unaware of the calcium antagonist debate, despite widespread media coverage (Hobbs 1997). In the case of hypertension, expert recommendations may have had little impact on antihypertensive prescribing patterns because of the lack of successful dissemination of these recommendations, the effectiveness of pharmaceutical promotion practices, or the attractiveness of using new therapies so that practitioners are considered up-to-date. Of these, the role of pharmaceutical promotion practices, including face-to-face sales activities and pharmaceutical advertisements, has probably had the greatest impact (Soumerai 1988; Soumerai et al 1989; Wilkes et al 1992). Misinformation about the role of drugs may stem from inaccurate drug advertisements and inaccurate statements made by pharmaceutical representatives (Wilkes et al 1992; Ziegler et al 1995). These intense promotional efforts of pharmaceutical companies to influence prescribing patterns for financial reasons may result in the prescribing of medications that are inferior or at best equivalent to other treatments. The end result is that medication use often differs from well developed clinical practice guidelines that are usually based on the best available evidence from clinical trials. Strategies to improve medication use What can be done to improve patterns of medication use (Table 1)? One approach would be to improve how guidelines are formatted, organized, and disseminated (Lenfant 1997), although this is unlikely to have a major impact. A review of 99 studies of methods to change physicians’ practice concluded that educational materials alone and formal CME conferences or activities, without enabling or practice-reinforcing strategies, had relatively 11