Correspondence

Predisposing Factors for Severe, Uncontrolled Hypertension in an Inner-City Minority Population

N Engl J Med 1993; 328:213-214January 21, 1993

Article

To the Editor:

Shea et al. (Sept. 10 issue)1 identify several factors associated with uncontrolled hypertension, including the lack of a primary care physician, the lack of insurance, and noncompliance, and they note that the cost of medications has been identified as an obstacle to compliance. I think physicians should be cognizant of the part we often play in noncompliance and in the lack of a primary care physician. Patients for whom expensive, proprietary drugs are prescribed for chronic conditions, such as hypertension, may find their medicines unaffordable if they lose their insurance coverage (which is quite common among Medicaid recipients2) or simply do not have insurance coverage for drugs and are not independently wealthy. They may also lose their primary care provider, either through being unable to pay office bills or by ceasing to come for care to avoid incurring bills.

This process, which might be dubbed “iatrogenic noncompliance,” can be avoided at least in part if patients are treated with inexpensive, generic medications that are affordable to almost anyone (e.g., hydrochlorothiazide and propranolol in the case of hypertension). However, patients are more and more frequently treated with expensive, proprietary medications, such as angiotensin-converting-enzyme inhibitors and calcium-channel blockers, despite the general lack of evidence of improved outcomes with these agents. Patients may be given free samples obtained by the physician from a drug detail representative, only to find the drug or drugs unaffordable when the samples run out.

As long as our current nonsystem of health care continues, physicians would do most patients a service by prescribing inexpensive, generic medications instead of expensive, proprietary ones, since the odds of not being able to afford expensive medications and the accompanying risks probably outweigh any unproved risks alleged to accompany some older, inexpensive medications.

Barry G. Saver, M.D., M.P.H.
University of Washington, Seattle, WA 98195

2 References

1. 1

   Shea S, Misra D, Ehrlich MH, Field L, Francis CK. Predisposing factors for severe, uncontrolled hypertension in an inner-city minority population. N Engl J Med 1992;327:776-781
   Full Text | Web of Science | Medline

2. 2

   Wilensky GR, Berk ML. Health care, the poor, and the role of Medicaid. Health Aff (Millwood) 1982;1:93-100
   CrossRef | Medline

To the Editor:

Shea et al. show that noncompliance adversely affects the adequate control of hypertension. Although they point out in their discussion that frequency of dosing can also contribute to noncompliance, this variable was not included in their study and deserves more attention.

Studies by Cramer et al.1 and Eisen et al.2 reveal an inverse relation between compliance with medication and frequency of dosing. With three or more daily doses, compliance is significantly poorer than with one or two doses per day. Greenberg3 reached a similar conclusion after reviewing the literature in 1984.

Neal4 also identified factors that affect compliance: the patient's perception of the physician's level of interest in controlling blood pressure, the selection of a regimen that patients can incorporate into their daily routine, and the physician's willingness to change medication if adverse effects occur.

Since compliance is a critical issue in the successful treatment of hypertension, prescribing medications that can be taken once daily should be emphasized. There are now a variety of antihypertensive agents available that can be given in this manner.

Stan Reents, Pharm.D.
Shands Hospital, Gainesville, FL 32610

4 References

1. 1

   Cramer JA, Mattson RH, Prevey ML, et al. How often is medication taken as prescribed? A novel assessment technique. JAMA 1989;261:3273-3277
   CrossRef | Web of Science | Medline

2. 2

   Eisen SA, Miller DK, Woodward RS, Spitznagel E, Przybeck TR. The effect of prescribed daily dose frequency on patient medication compliance. Arch Intern Med 1990;150:1881-1884
   CrossRef | Web of Science | Medline

3. 3

   Greenberg RN. Overview of patient compliance with medication dosing: a literature review. Clin Ther 1984;6:592-599
   Web of Science | Medline

4. 4

   Neal WW. Reducing costs and improving compliance. Am J Cardiol 1989;63:17B-20B
   CrossRef | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: In our paper, we reported evidence that lack of access to primary care was associated with a poor outcome among patients with hypertension1. We have also reported that lack of access to a primary care physician is associated with noncompliance with antihypertensive treatment2. Patients with hypertension who lack a primary care physician are much more likely to use emergency rooms to obtain prescriptions for antihypertensive medication2. We agree with the comments of Drs. Saver and Reents, which point to specific prescribing practices that contribute to noncompliance. The more general implication of our study is that physicians in primary care settings can prescribe in a fashion that takes into account the specific needs, limitations, and preferences of the individual patient, whereas physicians in emergency rooms cannot.

Steven Shea, M.D.
Columbia University College of Physicians and Surgeons, New York, NY 10032

Martin H. Ehrlich, M.D., M.P.H.
Charles K. Francis, M.D.
Harlem Hospital Center, New York, NY 10037

2 References

1. 1

   Shea S, Misra D, Ehrlich MH, Field L, Francis CK. Predisposing factors for severe, uncontrolled hypertension in an inner-city minority population. N Engl J Med 1992;327:776-781
   Full Text | Web of Science | Medline

2. 2

   Shea S, Misra D, Ehrlich MH, Field L, Francis CK. Correlates of non-adherence to hypertension treatment in an inner city minority population. Am J Public Health (in press).