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Research Letter
Less Is More
June 17, 2019

Use of Directly Observed Therapy to Assess Treatment Adherence in Patients With Apparent Treatment-Resistant Hypertension

Author Affiliations
  • 1Renal Hypertension Center, Division of Nephrology, University of Ottawa, Ottawa, Ontario, Canada
  • 2Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
  • 3Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
  • 4Kidney Research Center, University of Ottawa, Ottawa, Ontario, Canada
JAMA Intern Med. 2019;179(10):1433-1434. doi:10.1001/jamainternmed.2019.1455

Among patients with apparent treatment-resistant hypertension,1-3 nonadherence to treatment is common. Pharmacy refill data, the Morisky scale, and pill counts are limited tests for determination of nonadherence. In this study, we aimed to assess the contribution of nonadherence to blood pressure (BP)–lowering drugs undetected by these tests by evaluating the association of directly observed therapy (DOT) with treatment adherence in patients with apparent treatment-resistant hypertension.

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    1 Comment for this article
    Use of Directly Observed Therapy to Assess Treatment Adherence in Patients With Apparent Treatment-Resistant Hypertension
    hana morrissey, PhD | University of Wolverhampton
    Dear Editor

    1. The authors are to be congratulated on finding one effective intervention for non-adherence in hypertension which is widely known to be a huge problem. We would take issue however with the opening statement about limited tests for non-adherence. All are effective tools for demonstrating non-adherence, but all the best studies use a combination of checks and clinical reviews/measurements As the authors recognise, the challenge is then to address the non-adherence.
    2. Refill data and pill counts do only demonstrate non-adherence and are open to manipulation by the patient to give a false impression. What steps were taken
    to verify the accuracy of pill count.
    3. We believe the Morisky Widget provides more useful data because non-adherence is not unidimensional. It occurs for a variety of reasons intentional and non-intentional. Detecting a person non-adherent not only allows targeting of interventions but also their knowledge of their non-adherence start the adherence change process, to self-defend or because of their understanding improved or self-responsibility due to the feeling of being part of the problem; the person’s behaviour become ready to be altered or their intention to change is already in the preparation stage to change behaviour.
    4. What are the questions that were asked to determine if the patient was adherent or not? What was the environment where patients were questioned? inpatient, outpatient, resident in an institution or living at home?
    5. The conduct of this study appears to remove self-care responsibility from the patient and force the patient to re-learn new behaviour of adherence (compliance) which is good but not sustainable considering the prevalence of hypertension is very high globally. We believe video DOT in collaboration with Morisky Widget would produce better more sustainable outcomes as the reason of nonadherence can be detected and managed while the new behaviour is developed and observed by practitioners including outside of business hours.
    6. Using the prison system of pill parade where prisoners take most of their treatment as DOT, the health outcome after release remarkably reduced usually due to under recognised or poorly managed patients poor self-care behaviour, understanding of the treatment mechanism of action in relation to the condition and complication with cognitive/learning disability/mental illness and disorders.

    Dr Hana Morrissey