IMPROVING PATIENTS' MEDICATION ADHERENCE IN PRIMARY HYPERTENSION Josip Čulig1,2, Jelena Bošković3, Marcel Leppée2, Vladimira Lesnikar2 1 School of Medicine, Josip Juraj Strossmayer University, Osijek, Croatia 2 Andrija Stampar Institute of Public Health, Zagreb, Croatia 3 Pharmacy Zagreb, Croatia INTRODUCTION Adherence is the extent to which a person's behaviour-taking medication corresponds with agreed recommendations from a health care provider. There is a strong evidence that many patients with chronic illnesses, including hypertension, have difficulty adhering to their recommended treatment regimen. This leads to reduced control of the illness, reduces patient's quality of life, and increased risk of stroke and myocardial infarction. It has been shown that despite the availability of effective treatment less than 25% of patients treated for hypertension achieve optimum blood pressure. Poor adherence has been identified as the main cause of failure to control hypertension. The determinants of adherence to antihypertensive therapy are related to drug treatment such as drug tolerability and regimen complexity. Other potential determinants of adherence may be related to the demographic factors (age, sex, education), the patient's perception of disease, the health care provider's mode of delivering treatment, the relationship between patients and health care professionals, the socioeconomic factors (price, access, supply). The important factors of the health care providers on the patient's adherence to therapy include: a back of knowledge and inadequate time with patient. The patient-doctor relationship was much more studied then the patient-pharmacist relation. AIM OF THE STUDY The objective of this study was to investigate the adherence to medication in patients with the primary hypertension in Zagreb. The patient-pharmacist relationship was analysed. MATERIAL AND METHODS Patients with diagnosed chronic diseases filled self-reported questionnaire during visit to the pharmacy where they collect their prescribed drugs. The questionnaire was standardized in the previous study on drug use (J.Culig, et al. 9th Congress of EACPT, Edinburgh, 2009.) The extent of adherence to medication was estimated according to the answers on the specific questions. There were 16 reasons offered for not taking medication as agreed. There were 634 self-reported questionnaires collected from the 114 various community pharmacies in Zagreb. The most significant cohort was the primary hypertension patients (357/56,3%). The relationship between patients and pharmacist was evaluated through a part of the questionnaire. RESULTS There were more women than men among the study population. There was no difference between adherent and non-adherent patients according to the sex (Table 1). Also, there was no significant difference according to the age distribution (Figure 1). Patients with primary hypertension (n=357) fulfilled the questionnaire. It was estimated that 39,2% (140) were adherent, and 60,8% (217) were non-adherent (Table 2). The reasons for non-adherence are listed in Table 3. The two leading reasons are patient forgetfullness and „ran out of pills“. The next three are connected with treatment characteristics: drug side-effects, polypharmacy in chronic illness and unconvinent dosing time. The defective supply of local pharmacy is unexpectedly high on the 6th place of the list. In the middle of the list is the frequent changes of prescribed therapy. The patients expected more than they got from the pharmacists (Table 4). Less than half of the patients have got adequate counselling from the pharmacists. DISCUSSION The adherence to long term therapy in the primary hypertension is inadequate. Most of the studies estimated adherence to antihypertensive therapy above 50%. We found it even lower (39,2%). Two of the most important factors contributing to poor adherence are the asymptomatic and lifelong nature of the disease. According to the answers given in our study, two most important factors are that patients simply forgot to take a pill and they forgot to renew supply of drugs. It has been suggested that the interventions should be pointed to a patient behavioural change. The patients should be provided with knowledge of importance to sustain a medication-taking behaviour. Also, a family support might have some influence. The side-effects of therapy, the polipharmacy, the complex dose and time regimen are still pretty high on the list of non-adherent reasons. The health care providers should improve a quality of communication, but also their knowledge on drugs therapy that they prescribe. There are 213 community pharmacies in Zagreb and problem with drug supply should not be the issue. The reason why that was high on the list is probably the bad economic shape of the main Croatian health fund. The most of strategies to improve adherence to drug treatment is dealing with a doctor-patient relationship and with a patient behaviour change. The pharmacist as resource in improving patient's adherence to drugs should be more exploited. According to our results, the patient's expectation were not met. This is obviously the area for improvement. CONCLUSIONS The patient's adherence to antihypertensive medication in Zagreb is low. The strategy for better managemnt should be implemented. The pharmacist-patient relationship is important resource that might be improved in the interventions strategies. ACKNOWLEDGMENT This study was funding by Ministry of Science, Education and Sports, Republic of Croatia. Table 1. Adherent vs. non-adherent patients with chronic diseases according to sex in Zagreb Sex Adherent Non-adherent Total Male 107 151 258 Female 156 220 376 Total 263 371 634 Table 2. A percentage of adherent vs non-adherent patients with a primary hypertension in Zagreb Adherent Non-adherent Total 140 217 357 39,2% 60,8% 100,0% Table 3. The reasons for not taking antihypertensive therapy Reasons N % Forgetfullness „Ran out of pills“ Side-effects Polypharmacy Dosing time Deffective supply Away of home Frequent changes of therapy Well-being Fear of potential toxic effects Symptomatic flu Expensiveness Went asleep Fear of dependancy on drug Depressive mood Public embarrassement 253 251 248 247 247 245 244 243 241 235 234 233 231 231 229 223 70,9 70,3 69,5 69,2 69,2 68,6 68,3 68,1 67,5 65,8 65,5 65,3 64,7 64,7 64,1 62,5 Table 4. The patients view of the patient-pharmacist relationship Pharmacist's advise Pharmacist always check do I take my medication at first visit Pharmacist always informed me how to take a drug Pharmacist always stress the importance of adherence Pharmacist always conselled me on side-effects Pharmacist always check do I miss a dose and why instructions Pharmacist always check do I understand the instructions % 61 57 46 44 42 23 140 Adherent and non-adherent patients according to the age 120 100 80 60 40 20 0 26-35 36-45 46-55 Non-adherent 56-65 Adherent >65 Figure 1. Adherent vs. non-adherent patients with chronic diseases according to the age in Zagreb