Implementation of Adherence Support for Patients With Hypertension Despite Antihypertensive Therapy in General Practice: A Cluster Randomized Trial

BACKGROUND Uncontrolled hypertension despite treatment is highly prevalent among hypertension patients. Electronic monitoring of medication adherence has been proven to be effective in improving blood pressure. The aim of the study was to compare the effectiveness of intensive support for implementation of this tool in community pharmacies with minimal implementation support. METHODS In a cluster randomized trial, 25 control pharmacies received a manual and 32 experimental pharmacies received intensive support to enhance implementation of electronic monitoring. Primary outcome: the number of patients included for electronic monitoring. Secondary outcomes included mean change in systolic blood pressure (SBP) and percentage of patients with adequate SBP control. RESULTS The experimental group yielded consistently higher scores on all the steps of the implementation process than the control group, but none of these differences were significant. The mean number of patients per pharmacy included for electronic monitoring in a 3-9-months period was 1.6 in the experimental group vs. 1.0 in the control group (difference = 0.7, 95% confidence interval = -0.4; 1.7). The following patient outcomes were pooled because there were no differences between the experimental and the control group. Mean change of SBP/diastolic blood pressure (DBP) was -12 and -6 mm Hg, respectively, SBP dropped <140 mm Hg in 20.9% of all patients. In 13.6% of all patients control of SBP was achieved without treatment intensification. CONCLUSION The intensive implementation program enhanced pharmacist performance, but appeared insufficient to overcome all problems with the implementation of electronic monitoring. The major restrictive factors concerned general practitioner (GP) involvement and the identification of eligible patients.