Annette M. Boyle
ASHEVILLE, NC — Screening, frequent appointments and other interventions enabled the VA by 2010 to bring blood pressure under control in more than three-quarters of patients with hypertension. Helping the remaining one-quarter adhere to medication regimens to reach blood pressure goals might involve a surprisingly simple intervention —pillboxes.
Hypertension affects 37% of veterans, making it the most common condition among VHA patients. In 2000, the VA introduced a range of interventions designed to improve blood pressure control in these veterans. By 2010, the percentage of veterans with diagnosed hypertension who had achieved their goal blood pressure levels had risen from 45.7% to 76.3%.
Active duty servicemembers have lower rates of hypertension but are not immune from the condition. According to a 2008 study, about 13% of active forces have high blood pressure, with the majority of those affected under age 40.
Pharmacists at the Charles George VAMC in Asheville, NC, knew that previous studies had shown that adherence to antiretroviral and anticoagulation regimens improved following the introduction of pillboxes, as did outcomes. In 2010, they initiated a study to see whether veterans with hypertension would also benefit from organizing their blood pressure medications in a pillbox and having the pillbox monitored by pharmacists. The results of the study were published recently in the Journal of Managed Care & Specialty Pharmacy.1
“We know that, if we can improve adherence, we can better assist patients in achieving optimal blood pressure control, thereby decreasing their risk of complications,” said lead author Angela Porter, PharmD, clinical pharmacist.
Because few patients experience symptoms from hypertension, adherence rates are typically low, with more than half of patients discontinuing therapy within a year, and only half of those who remain on therapy being more than 80% adherent to their antihypertensive medications.
“Patient non-adherence to antihypertensive medications has also been linked to adverse effects of antihypertensive medications, complicated drug regimens and misunderstanding of hypertension management,” Porter told U.S. Medicine.
The Charles George team enrolled 60 patients who were taking three or more antihypertensive medications and with a history of three consecutive blood pressure readings above goal as defined by The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7).
At the start of the pill-box clinic, pharmacists provided each patient with two seven-day pillboxes and took baseline blood pressure and adherence history. Patients returned for two follow-up appointments, at two weeks and four weeks, during which pharmacists refilled the pillboxes, took blood pressure measurements and assessed adherence.
The first two appointments were completed by 50 patients, and 45 attended all three. Of those that kept only their first and second appointments, 44% achieved their goal blood pressure and 24% reduced their systolic blood pressure at least 10 mmHg. Of those that made all three appointments, 51% achieved their goal levels, and 31% saw at least a 10 mmHg drop in blood pressure. All participants had more than 80% adherence.
“The percentage of patients achieving goal blood pressure did increase from baseline,” Porter said. “This increase in percentage suggests that in a veteran population, blood pressure goals are more likely to be met when antihypertensive medications are organized in a pillbox, and use of the pillbox is monitored by a pharmacist.”
Even modest reductions in systolic blood pressure can significantly reduce the risk of cardiovascular events, noted the authors. “Reduction of SBP by 5 mmHg decreases mortality due to stroke and coronary heart disease by 14% and 9%, respectively.”
In the trial, 42% of participants reduced systolic blood pressure by at least 5 mmHg, and 22% saw a 12 mmHg or greater drop.
Despite the documented success of the pillbox clinic, the unique characteristics of the study population and the specifics of the JCN7 recommendations might have resulted in an understatement of the effectiveness of the intervention. More than 83% of the participants also had diabetes, and JCN7 established a blood pressure goal of less than 130/80 mmHg for these patients. The remaining 17% had a goal of less than 140/90 mmHg.
The American Diabetes Association Standards of Medical Care in Diabetes 2013 recommended a higher blood pressure goal for diabetic patients, less than 140/80 mmHg. The 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults (JNC8) updated blood pressure goals to 150/90 mmHg for patients age 60 and older and less than 140/90 mmHg for younger patients and patients with diabetes or chronic kidney disease.
The mean age of study participants was 62, with a range from 46 to 76 years.
Because of the changed recommendations, “the goals set in the pillbox trial are not likely to be the same as goals currently used in clinical practice, given the new evidence,” the study authors noted, “but we believe that pillboxes are beneficial in the treatment of hypertension, regardless of the BP goal.”
1 Porter AK, Taylor SR, Yabut AH, Al-Achi A. Impact of a pillbox clinic to improve systolic blood pressure in veterans with uncontrolled hypertension taking 3 or more antihypertensive medications. J Manag Care Pharm. 2014 Sep;20(9):905-11.
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When Terrence O’Neil, MD, retired as chief of nephrology at the James H. Quillen VAMC in Johnson City in December 2016, he left in his wake decades of work treating kidney disease—nearly 35 years in the Air Force and DoD, plus 11 more at VA.