Adherence to pharmacotherapy is impacted by five categories of factors
Sociodemographic
Health team/system
Therapy-related
Condition-related
Patient-related
Health literacy
Access to and cost of care including co-pays
Adverse effects
Dementia
Alternative therapies
Housing status
Clinician burnout
Complex regimens
Drug/alcohol abuse
Deny diagnosis
Income
Communication
Refill consolidation
Major disability
Fear adverse effects
Minority status
Fail to detect clues
Refill frequency
Mental/behavioral health
Follow-up frequency
Social support
Financial incentives
Time to benefit
Multiple chronic conditions
Forget
Transportation
Knowledge/QI infrastructure
Treatment changes
Quality of life
Future discounting
War/disasters
Patient centeredness
Treatment duration
Symptom severity
Knowledge/understanding
Young, very old
Patient-clinician relationship
Treatment failure
Perception of illness severity/impact
Team-based care
Perception of treatment efficacy
QI: quality improvement
Declarations
Disclaimer
The findings and conclusions in this report are those of the author and do not necessarily represent the official position of the American Medical Association.
Open Exploration maintains a neutral stance on jurisdictional claims in published institutional affiliations and maps. All opinions expressed in this article are the personal views of the author(s) and do not represent the stance of the editorial team or the publisher.
References
Kario K, Okura A, Hoshide S, Mogi M. The WHO Global report 2023 on hypertension warning the emerging hypertension burden in globe and its treatment strategy.Hypertens Res. 2024;47:1099–102. [DOI] [PubMed]
Bellows BK, Ruiz-Negrón N, Bibbins-Domingo K, King JB, Pletcher MJ, Moran AE, et al. Clinic-Based Strategies to Reach United States Million Hearts 2022 Blood Pressure Control Goals: A Simulation Study.Circ Cardiovasc Qual Outcomes. 2019;12:e005624. [DOI] [PubMed] [PMC]
Egan BM, Sutherland SE, Macri CI, Deng Y, Gerelchuluun A, Rakotz MK, et al. Association of Baseline Adherence to Antihypertensive Medications With Adherence After Shelter-in-Place Guidance for COVID-19 Among US Adults.JAMA Netw Open. 2022;5:e2247787. [DOI] [PubMed] [PMC]
Hamdidouche I, Jullien V, Boutouyrie P, Billaud E, Azizi M, Laurent S. Routine urinary detection of antihypertensive drugs for systematic evaluation of adherence to treatment in hypertensive patients.J Hypertens. 2017;35:1891–8. [DOI] [PubMed]
Tomaszewski M, White C, Patel P, Masca N, Damani R, Hepworth J, et al. High rates of non-adherence to antihypertensive treatment revealed by high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) urine analysis.Heart. 2014;100:855–61. [DOI] [PubMed] [PMC]
McNaughton CD, Brown NJ, Rothman RL, Liu D, Kabagambe EK, Levy PD, et al. Systolic Blood Pressure and Biochemical Assessment of Adherence: A Cross-Sectional Analysis in the Emergency Department.Hypertension. 2017;70:307–14. [DOI] [PubMed] [PMC]
Hayes P, Casey M, Glynn LG, Molloy GJ, Durand H, O’Brien E, et al. Measuring adherence to therapy in apparent treatment-resistant hypertension: a feasibility study in Irish primary care.Br J Gen Pract. 2019;69:e621–8. [DOI] [PubMed] [PMC]
Egan BM, Rudisill C. Cost-Utility of an Objective Biochemical Measure to Improve Adherence to Antihypertensive Treatment.Hypertension. 2018;72:1090–2. [DOI] [PubMed]
Manta E, Thomopoulos C, Kariori M, Polyzos D, Mihas C, Konstantinidis D, et al. Revisiting Cardiovascular Benefits of Blood Pressure Reduction in Primary and Secondary Prevention: Focus on Targets and Residual Risk-A Systematic Review and Meta-Analysis.Hypertension. 2024;81:1076–86. [PubMed]
Menditto E, Cahir C, Malo S, Aguilar-Palacio I, Almada M, Costa E, et al. Persistence as a Robust Indicator of Medication Adherence-Related Quality and Performance.Int J Environ Res Public Health. 2021;18:4872. [DOI] [PubMed] [PMC]
Ho PM, Spertus JA, Masoudi FA, Reid KJ, Peterson ED, Magid DJ, et al. Impact of Medication Therapy Discontinuation on Mortality After Myocardial Infarction.Arch Intern Med. 2006;166:1842–7. [DOI] [PubMed]
Yue Z, Cai C, Ai-Fang Y, Feng-Min T, Li C, Bin W. The effect of placebo adherence on reducing cardiovascular mortality: a meta-analysis.Clin Res Cardiol. 2014;103:229–35. [DOI] [PubMed]
Granger BB, Swedberg K, Ekman I, Granger CB, Olofsson B, McMurray JJ, et al.; CHARM investigators. Adherence to candesartan and placebo and outcomes in chronic heart failure in the CHARM programme: double-blind, randomised, controlled clinical trial.Lancet. 2005;366:2005–11. [DOI] [PubMed]
Burnier M. Drug adherence in hypertension.Pharmacol Res. 2017;125:142–9. [DOI] [PubMed]
Simpson SH, Eurich DT, Majumdar SR, Padwal RS, Tsuyuki RT, Varney J, et al. A meta-analysis of the association between adherence to drug therapy and mortality.BMJ. 2006;333:15. [DOI] [PubMed] [PMC]
World Health Organization. Adherence to long-term therapies: Evidence for action. Geneva: World Health Organization; 2003.
Porter J, Boyd C, Skandari MR, Laiteerapong N. Revisiting the Time Needed to Provide Adult Primary Care.J Gen Intern Med. 2023;38:147–55. [DOI] [PubMed] [PMC]
Abdalla M, Bolen SD, Brettler J, Egan BM, Ferdinand KC, Ford CD, et al.; American Heart Association and American Medical Association. Implementation Strategies to Improve Blood Pressure Control in the United States: A Scientific Statement From the American Heart Association and American Medical Association.Hypertension. 2023;80:e143–57. [DOI] [PubMed] [PMC]
Proia KK, Thota AB, Njie GJ, Finnie RK, Hopkins DP, Mukhtar Q, et al.; Community Preventive Services Task Force. Team-Based Care and Improved Blood Pressure Control: A Community Guide Systematic Review.Am J Prev Med. 2014;47:86–99. [DOI] [PubMed] [PMC]
Burnier M, Egan BM. Adherence in Hypertension: A Review of Prevalence, Risk Factors, Impact, and Management.Circ Res. 2019;124:1124–40. [DOI] [PubMed]
Choudhry NK, Kronish IM, Vongpatanasin W, Ferdinand KC, Pavlik VN, Egan BM, et al.; American Heart Association Council on Hypertension. Medication Adherence and Blood Pressure Control: A Scientific Statement From the American Heart Association.Hypertension. 2022;79:e1–14. [DOI] [PubMed] [PMC]
Steiner JF, Ho PM, Beaty BL, Dickinson LM, Hanratty R, Zeng C, et al. Sociodemographic and Clinical Characteristics Are Not Clinically Useful Predictors of Refill Adherence in Patients With Hypertension.Circ Cardiovasc Qual Outcomes. 2009;2:451–7. [DOI] [PubMed] [PMC]
Egan BM, Li J, Small J, Nietert PJ, Sinopoli A. The Growing Gap in Hypertension Control Between Insured and Uninsured Adults: National Health and Nutrition Examination Survey 1988 to 2010.Hypertension. 2014;64:997–1004. [DOI] [PubMed] [PMC]
Muntner P, Hardy ST, Fine LJ, Jaeger BC, Wozniak G, Levitan EB, et al. Trends in Blood Pressure Control Among US Adults With Hypertension, 1999–2000 to 2017–2018.JAMA. 2020;324:1190–200. [DOI] [PubMed] [PMC]
Vaduganathan M, van Meijgaard J, Mehra MR, Joseph J, O’Donnell CJ, Warraich HJ. Prescription Fill Patterns for Commonly Used Drugs During the COVID-19 Pandemic in the United States.JAMA. 2020;323:2524–6. [DOI] [PubMed] [PMC]
Kumamaru H, Lee MP, Choudhry NK, Dong YH, Krumme AA, Khan N, et al. Using Previous Medication Adherence to Predict Future Adherence.J Manag Care Spec Pharm. 2018;24:1146–55. [DOI] [PubMed] [PMC]
Roumie CL, Greevy R, Wallston KA, Elasy TA, Kaltenbach L, Kotter K, et al. Patient centered primary care is associated with patient hypertension medication adherence.J Behav Med. 2011;34:244–53. [DOI] [PubMed]
Ratanawongsa N, Zikmund-Fisher BJ, Couper MP, Van Hoewyk J, Powe NR. Race, Ethnicity, and Shared Decision Making for Hyperlipidemia and Hypertension Treatment: The DECISIONS Survey.Med Decis Making. 2010;30:65S–76S. [DOI] [PubMed]
Commodore-Mensah Y, Loustalot F, Himmelfarb CD, Desvigne-Nickens P, Sachdev V, Bibbins-Domingo K, et al. Proceedings From a National Heart, Lung, and Blood Institute and the Centers for Disease Control and Prevention Workshop to Control Hypertension.Am J Hypertens. 2022;35:232–43. [DOI] [PubMed] [PMC]
Weiner SJ, Schwartz A, Sharma G, Binns-Calvey A, Ashley N, Kelly B, et al. Patient-Centered Decision Making and Health Care Outcomes: An Observational Study.Ann Intern Med. 2013;158:573–9. [DOI] [PubMed]
Eaddy MT, Cook CL, O’Day K, Burch SP, Cantrell CR. How patient cost-sharing trends affect adherence and outcomes: a literature review.P T. 2012;37:45–55. [PubMed] [PMC]
Parati G, Kjeldsen S, Coca A, Cushman WC, Wang J. Adherence to Single-Pill Versus Free-Equivalent Combination Therapy in Hypertension: A Systematic Review and Meta-Analysis.Hypertension. 2021;77:692–705. [DOI] [PubMed]
Egan BM, Kjeldsen SE, Narkiewicz K, Kreutz R, Burnier M. Single-pill combinations, hypertension control and clinical outcomes: potential, pitfalls and solutions.Blood Press. 2022;31:164–8. [DOI] [PubMed]
Hill MN, Miller NH, Degeest S; American Society of Hypertension Writing Group; Materson BJ, Black HR, Izzo JL Jr, Oparil S, Weber MA. Adherence and persistence with taking medication to control high blood pressure.J Am Soc Hypertens. 2011;5:56–63. [DOI] [PubMed]
Mancia G, Parodi A, Merlino L, Corrao G. Heterogeneity in antihypertensive treatment discontinuation between drugs belonging to the same class.J Hypertens. 2011;29:1012–8. [DOI] [PubMed]
Egan BM, Sutherland SE, Tilkemeier PL, Davis RA, Rutledge V, Sinopoli A. A cluster-based approach for integrating clinical management of Medicare beneficiaries with multiple chronic conditions.PLoS One. 2019;14:e0217696. [DOI] [PubMed] [PMC]
Eze-Nliam CM, Thombs BD, Lima BB, Smith CG, Ziegelstein RC. The association of depression with adherence to antihypertensive medications: a systematic review.J Hypertens. 2010;28:1785–95. [DOI] [PubMed] [PMC]
Siegel D, Lopez J, Meier J. AAntihypertensive Medication Adherence in the Department of Veterans Affairs.Am J Med. 2007;120:26–32. [DOI] [PubMed]
McHorney CA, Victor Spain C, Alexander CM, Simmons J. Validity of the adherence estimator in the prediction of 9-month persistence with medications prescribed for chronic diseases: A prospective analysis of data from pharmacy claims.Clin Ther. 2009;31:2584–607. [DOI] [PubMed]
Gwadry-Sridhar FH, Manias E, Lal L, Salas M, Hughes DA, Ratzki-Leewing A, et al. Impact of Interventions on Medication Adherence and Blood Pressure Control in Patients with Essential Hypertension: A Systematic Review by the ISPOR Medication Adherence and Persistence Special Interest Group.Value Health. 2013;16:863–71. [DOI] [PubMed]
Morrison VL, Holmes EA, Parveen S, Plumpton CO, Clyne W, De Geest S, et al. Predictors of self-reported adherence to antihypertensive medicines: a multinational, cross-sectional survey.Value Health. 2015;18:206–16. [DOI] [PubMed]
Krousel-Wood MA, Muntner P, Joyce CJ, Islam T, Stanley E, Holt EW, et al. Adverse Effects of Complementary and Alternative Medicine on Antihypertensive Medication Adherence: Findings from the Cohort Study of Medication Adherence Among Older Adults.J Am Geriatr Soc. 2010;58:54–61. [DOI] [PubMed] [PMC]
Brown CM, Segal R. The effects of health and treatment perceptions on the use of prescribed medication and home remedies among African American and white American hypertensives.Soc Sci Med. 1996;43:903–17. [DOI] [PubMed]
Axon RN, Bradford WD, Egan BM. The role of individual time preferences in health behaviors among hypertensive adults: a pilot study.J Am Soc Hypertens. 2009;3:35–41. [DOI] [PubMed]
Bradford WD. The Association Between Individual Time Preferences and Health Maintenance Habits.Med Decis Making. 2010;30:99–112. [DOI] [PubMed]
Elliott RA, Shinogle JA, Peele P, Bhosle M, Hughes DA. Understanding Medication Compliance and Persistence from an Economics Perspective.Value Health. 2008;11:600–10. [DOI] [PubMed]
Fischer MA, Stedman MR, Lii J, Vogeli C, Shrank WH, Brookhart MA, et al. Primary Medication Non-Adherence: Analysis of 195,930 Electronic Prescriptions.J Gen Intern Med. 2010;25:284–90. [DOI] [PubMed] [PMC]
Corrao G, Conti V, Merlino L, Catapano AL, Mancia G. Results of a retrospective database analysis of adherence to statin therapy and risk of nonfatal ischemic heart disease in daily clinical practice in Italy.Clin Ther. 2010;32:300–10. [DOI] [PubMed]
van Schoonhoven AV, van Asselt ADI, Tomaszewski M, Patel P, Khunti K, Gupta P, et al. Cost-Utility of an Objective Biochemical Measure to Improve Adherence to Antihypertensive Treatment.Hypertension. 2018;72:1117–24. [DOI] [PubMed]
Meddings J, Kerr EA, Heisler M, Hofer TP. Physician assessments of medication adherence and decisions to intensify medications for patients with uncontrolled blood pressure: still no better than a coin toss.BMC Health Serv Res. 2012;12:270. [DOI] [PubMed] [PMC]
Burnier M, Wuerzner G, Struijker-Boudier H, Urquhart J. Measuring, Analyzing, and Managing Drug Adherence in Resistant Hypertension.Hypertension. 2013;62:218–25. [DOI] [PubMed]
Ruzicka M, Leenen FHH, Ramsay T, Bugeja A, Edwards C, McCormick B, et al. Use of Directly Observed Therapy to Assess Treatment Adherence in Patients With Apparent Treatment-Resistant Hypertension.JAMA Intern Med. 2019;179:1433–4. [DOI] [PubMed] [PMC]
Moon SJ, Lee WY, Hwang JS, Hong YP, Morisky DE. Accuracy of a screening tool for medication adherence: A systematic review and meta-analysis of the Morisky Medication Adherence Scale-8.PLoS One. 2017;12:e0187139. [DOI] [PubMed] [PMC]
Hamilton GA. Measuring Adherence in a Hypertension Clinical Trial.Eur J Cardiovasc Nurs. 2003;2:219–28. [DOI] [PubMed]
Halpern MT, Khan ZM, Schmier JK, Burnier M, Caro JJ, Cramer J, et al. Recommendations for Evaluating Compliance and Persistence With Hypertension Therapy Using Retrospective Data.Hypertension. 2006;47:1039–48. [DOI] [PubMed]
Vrijens B, Urquhart J. Methods for Measuring, Enhancing, and Accounting for Medication Adherence in Clinical Trials.Clin Pharmacol Ther. 2014;95:617–26. [DOI] [PubMed]
Strauch B, Petrák O, Zelinka T, Rosa J, Somlóová Z, Indra T, et al. Precise assessment of noncompliance with the antihypertensive therapy in patients with resistant hypertension using toxicological serum analysis.J Hypertens. 2013;31:2455–61. [DOI] [PubMed]
Xie L, Frech-Tamas F, Marrett E, Baser O. A medication adherence and persistence comparison of hypertensive patients treated with single-, double- and triple-pill combination therapy.Curr Med Res Opin. 2014;30:2415–22. [DOI] [PubMed]
Schmieder RE, Wassmann S, Predel H, Weisser B, Blettenberg J, Gillessen A, et al. Improved Persistence to Medication, Decreased Cardiovascular Events and Reduced All-Cause Mortality in Hypertensive Patients With Use of Single-Pill Combinations: Results From the START-Study.Hypertension. 2023;80:1127–35. [DOI] [PubMed] [PMC]
Wong MCS, Tam WWS, Wang HHX, Cheung CSK, Tong ELH, Cheung NT, et al. Duration of initial antihypertensive prescription and medication adherence: a cohort study among 203,259 newly diagnosed hypertensive patients.Int J Cardiol. 2015;182:503–8. [DOI] [PubMed]
Taitel M, Fensterheim L, Kirkham H, Sekula R, Duncan I. Medication days’ supply, adherence, wastage, and cost among chronic patients in Medicaid.Medicare Medicaid Res Rev. 2012;2:mmrr.002.03.a04. [PubMed] [PMC]
Tajeu GS, Kent ST, Huang L, Bress AP, Cuffee Y, Halpern MT, et al. Antihypertensive Medication Nonpersistence and Low Adherence for Adults < 65 Years Initiating Treatment in 2007-2014.Hypertension. 2019;74:35–46. [DOI] [PubMed] [PMC]
Alanaeme CJ, Ghazi L, Akinyelure OP, Wen Y, Christenson A, Poudel B, et al. Trends in the Prevalence of Multiple Chronic Conditions Among US Adults With Hypertension From 1999–2000 Through 2017–2020.Am J Hypertens. 2024;37:493–502. [DOI] [PubMed]
Choudhry NK, Fischer MA, Avorn J, Liberman JN, Schneeweiss S, Pakes J, et al. The Implications of Therapeutic Complexity on Adherence to Cardiovascular Medications.Arch Intern Med. 2011;171:814–22. [DOI] [PubMed]
Ha Dinh TT, Bonner A, Clark R, Ramsbotham J, Hines S. The effectiveness of the teach-back method on adherence and self-management in health education for people with chronic disease: a systematic review.JBI Database System Rev Implement Rep. 2016;14:210–47. [DOI] [PubMed]
Roshan-Nejad M, Hosseini M, Vasli P, Nasiri M, Hejazi S. Effect of health literacy-based teach-back training on quality of life and treatment adherence in type 2 diabetes: an experimental study.Sci Rep. 2025;15:551. [DOI] [PubMed] [PMC]
Egan BM, Li J, Sutherland SE, Rakotz MK, Wozniak GD. Hypertension Control in the United States 2009 to 2018: Factors Underlying Falling Control Rates During 2015 to 2018 Across Age- and Race-Ethnicity Groups.Hypertension. 2021;78:578–87. [DOI] [PubMed]
Behling EM, Garris T, Blankenship V, Wagner S, Ramsey D, Davis R, et al. Improvement in Hypertension Control Among Adults Seen in Federally Qualified Health Center Clinics in the Stroke Belt: Implementing a Program with a Dashboard and Process Metrics.Health Equity. 2023;7:89–99. [DOI] [PubMed] [PMC]
Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.Hypertension. 2018;71:e13–115. [DOI] [PubMed]
Mancia G, Kreutz R, Brunström M, Burnier M, Grassi G, Januszewicz A, et al. 2023 ESH Guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension: Endorsed by the International Society of Hypertension (ISH) and the European Renal Association (ERA).J Hypertens. 2023;41:1874–2071. [DOI] [PubMed]
Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies.BMJ. 2009;338:b1665. [DOI] [PubMed] [PMC]
Feldman RD, Zou GY, Vandervoort MK, Wong CJ, Nelson SA, Feagan BG. A Simplified Approach to the Treatment of Uncomplicated Hypertension: A Cluster Randomized, Controlled Trial.Hypertension. 2009;53:646–53. [DOI] [PubMed]
Webster R, Salam A, de Silva HA, Selak V, Stepien S, Rajapakse S, et al.; TRIUMPH Study Group. Fixed Low-Dose Triple Combination Antihypertensive Medication vs Usual Care for Blood Pressure Control in Patients With Mild to Moderate Hypertension in Sri Lanka: A Randomized Clinical Trial.JAMA. 2018;320:566–79. [DOI] [PubMed] [PMC]
Chow CK, Atkins ER, Hillis GS, Nelson MR, Reid CM, Schlaich MP, et al.; QUARTET Investigators. Initial treatment with a single pill containing quadruple combination of quarter doses of blood pressure medicines versus standard dose monotherapy in patients with hypertension (QUARTET): a phase 3, randomised, double-blind, active-controlled trial.Lancet. 2021;398:1043–52. [DOI] [PubMed]
Carey RM, Calhoun DA, Bakris GL, Brook RD, Daugherty SL, Dennison-Himmelfarb CR, et al.; American Heart Association Professional/Public Education and Publications Committee of the Council on Hypertension; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Genomic and Precision Medicine; Council on Peripheral Vascular Disease. Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association.Hypertension. 2018;72:e53–90. [DOI] [PubMed] [PMC]
Tucker KL, Sheppard JP, Stevens R, Bosworth HB, Bove A, Bray EP, et al. Self-monitoring of blood pressure in hypertension: A systematic review and individual patient data meta-analysis.PLoS Med. 2017;14:e1002389. [DOI] [PubMed] [PMC]
Bosworth HB, Powers BJ, Olsen MK, McCant F, Grubber J, Smith V, et al. Home Blood Pressure Management and Improved Blood Pressure Control: Results From a Randomized Controlled Trial.Arch Intern Med. 2011;171:1173–80. [DOI] [PubMed]
Mikulski BS, Bellei EA, Biduski D, De Marchi ACB. Mobile Health Applications and Medication Adherence of Patients With Hypertension: A Systematic Review and Meta-Analysis.Am J Prev Med. 2022;62:626–34. [DOI] [PubMed]
Hayek MA, Giannouchos T, Lawley M, Kum HC. Economic Evaluation of Blood Pressure Monitoring Techniques in Patients With Hypertension: A Systematic Review.JAMA Netw Open. 2023;6:e2344372. [DOI] [PubMed] [PMC]
Zhang D, Lee JS, Pollack LM, Dong X, Taliano JM, Rajan A, et al. Association of Economic Policies With Hypertension Management and Control: A Systematic Review.JAMA Health Forum. 2024;5:e235231. [DOI] [PubMed] [PMC]
Inui TS, Yourtee EL, Williamson JW. Improved Outcomes in Hypertension After Physician Tutorials: A Controlled Trial.Ann Intern Med. 1976;84:646–51. [DOI] [PubMed]
Jaffe MG, Lee GA, Young JD, Sidney S, Go AS. Improved Blood Pressure Control Associated With a Large-Scale Hypertension Program.JAMA. 2013;310:699–705. [DOI] [PubMed] [PMC]
World Health Organization. Improving hypertension control in 3 million people: country experiences of programme development and implementation. Geneva: World Health Organization; 2020.
