Various factors influence whether hypertensive patients take their medicine   

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

What factors influence whether people take their medication to control high blood pressure?

An analysis that included more than 23 million patients gave some answers. Here to explain is Dr. Hani Aiash. He's the assistant dean for interprofessional research at Upstate's College of Health Professions and an associate professor of medicine and cardiac perfusion.

Welcome back to "The Informed Patient," Dr. Aiash.

Hani Aiash, MD, PhD: Hello, how are you, Amber? It's my pleasure to be with you.

Host Amber Smith: Now, before we get into medication adherence, which is what this meta-analysis was about, can you explain a little about high blood pressure and why it's important for people with high blood pressure, or hypertension, to take medication?

Hani Aiash, MD, PhD: Yes. First of all, we must know that hypertension is the leading risk factor for death and disability worldwide, and I think it's the most important disease all over the world. Why? Because about one in three adults in the U.S. has high blood pressure. But many don't realize because high blood pressure is sometimes called "the silent killer," because it usually has no symptoms or signs, yet it can lead to life-threatening conditions like heart attack and stroke.

The good news is that high blood pressure, or hypertension, can often be prevented or treated. Early diagnosis is very important and simple. Healthy changes can keep high blood pressure from seriously damaging our health. Normal blood flow delivers nutrients and oxygen to all our body, including important organs like the heart, brain and kidneys.

Our beating heart helps to push blood through our vast network of blood vessels, both large and small. Our blood vessels in turn consistently adjust to maintain this blood pressure. They become narrow or wider to maintain our blood pressure and keep blood flowing in a healthy rate. It's normal for our blood pressure to go up and down through each day.

Blood pressure is affected by time of the day, exercise, food, eat, stress, sleep and other factors, and some problems can arise. So if our blood pressure stays too high for too long a time, we must take action. High blood pressure can make our heart work too hard, also, and lose strength because you push a lot of power against resistance if our blood pressure is high. This high force of blood can damage our blood vessels, making them weak. Over time, blood pressure can harm several important organs, including, as I told before, heart, kidney, brain and eyes, also. Anyone, even children, can develop high blood pressure, but the risk of hypertension rises with age. Once people are in their 60s, about two-thirds of the population is affected by hypertension.

Other factors also affect this. As you know, there is essential (or primary) hypertension, which we don't know the reason (cause), which about 90% to 95% (of all hypertension cases).

And the others are secondary; we can treat them by the secondary causes. We know that there is a lot of causes. We know that excess weight, having family history of high blood pressure also raise our risk to hypertension. Disease can cause hypertension, hormonal or thyroid or renal problems or a lot of stuff can be involved in this, what we call secondary. If we diagnose the patient early as having secondary, we can deal with this patient, and we can treat him, and sometimes we will not need to give him long-time, or lifetime, medications. So it's very important for screening for young people (with certain diseases). There is a lot of stuff we can diagnose very early and treat it very early, before we have the complication of hypertension.

But because there are no symptoms, the only way to know for sure that we have hypertension is to have a blood pressure test. And this blood pressure test will give us two numbers.

The first number represents the pressure as the heart beats during systole, what we call systolic blood pressure (when the heart contracts and pushes out blood).

The second is the pressure in the heart during the heart relaxation (when it fills with) blood, which we call diastolic blood pressure.

Generally (experts) agree that the safest blood pressure or normal blood pressure is around 120 over 80 or lower, meaning that the systolic blood pressure is 120, and the diastolic is 80.

But if our blood pressure falls between normal and hypertension, we call it sometimes pre-hypertension, and those people are more likely to end up with high blood pressure if they don't take care or do any steps to prevent it. We know we can prevent it, through diet, weight loss, physical activity. This is what we call non-pharmacological treatment.

And then we can go on to pharmacological treatment, with medications. And this is a job of your doctor, and you must be diagnosed first, and the doctor can prescribe the treatment plan. And the goal of this treatment plan is to reduce the blood pressure enough to avoid more serious problems.

But by the way, when we lower the blood pressure to our target, the risk of having cardiovascular complication or heart attack or stroke can be reduced from 25% to 40%, and this is a very high number, and the death rate will be decreased to about 27%, or mortality rate. And this is a very high number, just to control this blood pressure. This is why (high) blood pressure is a very, very important disease.

Host Amber Smith: It sounds like it's something that everyone needs to have checked regularly, at, like you said, their doctor's office, but if a doctor discovers the high blood pressure and prescribes something for the patient to take, it's incumbent upon the patient to actually take it, and that's called adherence, and that's what your meta-analysis looked at. It was published in the Journal of Clinical Hypertension. If I understand correctly, the team looked at 19 different studies representing more than 23 million patients from January of 2022 through December of 2023.

So the focus on adherence, or how well patients take their prescriptions, what did you find? What were your findings?

Hani Aiash, MD, PhD: We have a lot of findings. It's 23 million patients. Why? Because about half of Americans aged from 20 years and up, about 122 million people in the U.S., have high blood pressure. This is according to a 2023 report from American Heart Association.

And, why is this common in the U.S.? Because we have older people. The risk of hypertension increases with age. Also, we have some unhealthy habits here, especially obesity. It's very common in the U.S. And we have very nice and very good systems to discover it early. So we have high diagnostic rate and medication, as we said, to help prevent problems such as heart attack, stroke and other complications of end organ damage.

But, the finding: We found that the racial disparity, insurance status and comorbidities (other health issues) influence the adherence rate among antihypertensive patients. Lower adherence rate were seen among African Americans and uninsured or younger patients. Accordingly, interventions such as fixed-dose combination (two or more drugs in a single dose) should be targeted at susceptible groups.

On the other hand, obesity, overweight, smoking didn't affect adherence to anti-hypertensive treatment.

Host Amber Smith: Did gender matter? Did you see a difference between men and women as to who follows their doctor's orders better?

Hani Aiash, MD, PhD: We conducted a pool analysis based on the sex that also showed no significant association between sex and adherence rate.

Host Amber Smith: What about if a person was married?

Hani Aiash, MD, PhD: We discovered that on analysis, of the adherence rate based on the marital status of anti-hypertensive patients, there was a significant decline in adherence rate among unmarried patients compared to the married ones.

Host Amber Smith: So having a partner to maybe remind you to take your medicine seems to maybe help?

Hani Aiash, MD, PhD: Yes. It's social supportive for them. So the social support is very important in marriage, which make the woman or the man remind their partner to take their medicine.

Host Amber Smith: Did you see a difference among the ages? Did younger people or older people do better?

Hani Aiash, MD, PhD: Yes. Our analysis showed that the older patients have higher adherence rates, especially because the younger patients, you know, that disease is the silent killer; they don't have any symptoms.

The older people have a lot of stuff to remember, that they must take this medication and other medications.

Host Amber Smith: Now, sometimes people, in tough economic times, especially, will forego their prescriptions because they cost a lot of money. Did you see a difference in people who had health insurance that would help pay for the prescription versus those who didn't?

Hani Aiash, MD, PhD: Yes, of course. This is very important because according to our pooled analysis, we found that the insured people are four times more likely to be adherent compared to uninsured individuals. And this is very important because, this is patient factor, doctor factor, health care factors or health system factors -- if you give the patients the insurance, with decreased cost, with good advice, something like this, it'll increase the adherence in this huge sample size.

Host Amber Smith: In looking at this analysis, did anything jump out at you that surprised you, that you maybe weren't expecting?

Hani Aiash, MD, PhD: The health insurance type and the educational type, because we discovered that there is no difference between the educational status

And as we know, educational level and the employment status are sociodemographic factors widely known to contribute to disparities in health and health outcome. It is conceivable that individuals with higher levels of education and better employment are more likely to be insured and, by extension, have better access to hypertension treatment opportunities, which may invariably translate into relatively higher medication adherence.

Our analysis revealed that employment status didn't significantly affect adherence rate, contradicting the finding of cross-sectional studies done before, when employed hypertensive patients reported higher adherence rate. Another study demonstrated that unemployment was associated with higher adherence rate, but was in Saudi Arabia, where all the people have insurance, working or not working. This could be attributed to sociocultural differences and employment status and health insurance status in different countries.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking with Dr. Hani Aiash. He's the assistant dean for interprofessional research at Upstate's College of Health Professions and an associate professor of medicine and cardiac perfusion, and our subject is medication adherence for medication that controls high blood pressure.

Now, I know that the study did not get into the reasons, but do you have your own ideas about why whites were more compliant than African Americans, say?

Hani Aiash, MD, PhD: We found it's plausible that any existing racial and ethnic differences in adherence rate may be partially due to, or explained by, underlying differences in sociocultural factors among the racial groups. And this can explain why they are less compliant or less adherent to treatment.

Host Amber Smith: And also you looked at people with diabetes versus people who don't have diabetes, and you found that people with diabetes had lower adherence than people who did not have diabetes. That seemed a little backward to me. How do you explain that?

Hani Aiash, MD, PhD: I published one paper maybe 15 years ago about the prevalence of depressive disorders in diabetes, and we found that 30% of the people who have diabetes have depressive disorders, and they don't know, by the way.

But depression is one of the key factors for decreasing adherence. And also there are other factors contributing to poor medication adherence in diabetic patients, including that related to the patient, like suboptimal health literacy and lack of involvement in the treatment decision-making process.

All of those are related to physicians, like prescription of a complex drugs regime and communication barriers, and the type; he will take two types of medication, (for) diabetic patients and antihypertensive patients. The more drugs he will take, the less adherence.

Host Amber Smith: Did you and your co-authors talk about ways to improve adherence rates, or do you have ideas yourself?

Hani Aiash, MD, PhD: Yeah, it's a very important subject because if you make the people take medication, you will prevent ischemic heart disease or heart attack by 25%,. stroke by about 40%, heart failure a lot, you will decrease the (hospital) admissions, and it will affect the health economics and also the quality of life and the family quality of life if one member will be affected. So we must focus all our intention now to control this disease because this disease is the most important disease, as I told you, for prevention.

And we want to be proactive, not reactive, for this stuff. We have a lot of, already, guidelines for this stuff, like to do a fixed-dose combination of medication, something related to the patient, something related to the doctor, something related to the healthy policies. For our recommendation we find that fixed-dose combination is great to increase adherence. It should be targeted, especially at susceptible groups.

On the other hand, obesity, overweight? Didn't affect adherence of this anti-hypertensive, so we must increase insurance coverage for those people. And also the five dimensions of medication adherence, like conditions, patients, therapy, health system and socioeconomics as a classification system. But how to increase, or improve adherence rate? We must strengthen the partnership with patients; patient-doctor relationship is very important This is the cornerstone. Communication is very important.

And how to convince the patient to know the patient agenda and not the doctor agenda? We must comply with the patient agenda.

Also help patient understand how and why to take each prescribed medication. You must explain what he will do, the side effects, what he expects. This is very important. He's a partner, not a patient. He's a partner of your plan of management.

So No. 3, simplify the medication regimen. So make it simple, fixed dose. And also use tools to build patient self-efficiency and support adherence. Build a good rapport between you and the patient, and make him independent.

Increase insurance coverage. This is very important, and we have a lot of plans here in the U.S. to do this.

Also target the noncompliant category with health education campaigns and social media, those people who don't understand the benefit of this medication. And they have hidden disease, like depression. They don't know, they don't care about (whether) they take medication or not.

Please, we must go to those patients and direct our attention, our focus in a campaign to help them to do this stuff because they need us. And we need them to decrease that burden of illness.

No. 4, early detection and the screening for all age groups for early intervention. I remember everyone going to the university. We must screen those people because a lot of them has secondary hypertension, and we don't know. I saw a lot of people, like a pregnant woman came with hypertension, and she didn't know before. If we treat her early, she will have babies, and she'll continue to live in a very good quality of life. So, early detection, very important, and screening, especially the secondary hypertension. We can correct those people, and we can control them. As I told you, prevention is better than cure.

Also, we must know why the people not taking medication. A lot of medication has side effects like sexual dysfunction. We must talk to the people about why you are not taking medication.

Also, we increase the health education, about importance of lifestyle modification. Diet: We have, a huge number of obese people. We must do programs to decrease this. Food is medicine. Sleep is medicine. Exercise, medicine. We must put this concept into our people. This is lifestyle modification, which will not cost us anything.

Just make them change their lifestyle, to eat better, to sleep better, to do some exercise, decrease smoking. All of this stuff is negative to our health.

At the end, we need to talk to the patient well to increase the adherence, and we want to talk, from our hearts. and we must understand that they want to know, and this is our mission: to share our knowledge, to share what we have.

Host Amber Smith: Well, it sounds like basic health care, preventive care. People need to check for whether they have high blood pressure and treat it if they do

Hani Aiash, MD, PhD: Yes. And treated well and know why they're not treating well after we give them the medication. We will not give them medication and leave them alone. We must follow up until we make sure that they are, adhered to, or compliant to, our medication and (if) they have any side effects or anything, how can we change it? Because blood pressure is a personalized treatment. We cannot paint all the people with the same brush. Some people need other groups from antihypertensive (drugs). If he cannot comply with one group, I will change to another group. This is the way of personalized treatment, and this is the new model.

This is not against the guidelines, but to choose the guidelines to work with the personalized treatment, or individualized treatment.

Host Amber Smith: Well, Dr. Aiash, I appreciate you making time for this interview. Thank you so much.

Hani Aiash, MD, PhD: You are welcome. Thank you for inviting me.

Host Amber Smith: My guest has been Dr. Hani Aiash. He's the assistant dean for interprofessional research at Upstate's College of Health Professions and an associate professor of medicine and cardiac perfusion.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

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