Medication Adherence and Incident Preventable Hospitalizations for Hypertension

Published:October 30, 2015DOI:


      Potentially preventable hospitalizations (PPHs) for hypertension (HTN) is one indicator of possible failed ambulatory care. Rates of PPHs for HTN have remained fairly level since the late 1980s, which may reflect a lack of understanding of the drivers of these hospitalizations. Anti-HTN medication non-adherence has been studied as a potential risk factor for other cardiovascular disease outcomes but not for PPHs for HTN.


      A cohort analysis was conducted during 2005–2012 of people with HTN enrolled in commercial and employee health plans with claims in the MarketScan database. PPH for HTN was defined according to specifications published by the Agency for Healthcare Research and Quality. The proportion of days covered (PDC) algorithm was used to assess adherence to antihypertensives. Crude- and multivariate-adjusted incident PPHs for HTN rates were calculated, as well as third-party payments for selected PPH for HTN–related expenses.


      During 9,344,528 person-years of follow-up (mean=3 years), 6,008 incident PPHs for HTN were identified among 3,099,291 people. The crude rate for good adherence (PDC ≥80%) was 23.2 per 100,000 person-years compared with 102.6 per 100,000 person-years for poor adherence (PDC <40%). Over the 8-year study, PPH for HTN–associated payments equaled $41 million. Payments for those with poor adherence were four times higher than for those with good adherence.


      Poor anti-HTN medication adherence is strongly associated with PPHs for HTN. Improving the percentage of people who achieve good medication adherence is one possible approach to reducing the burden of PPHs for HTN in the U.S.
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        • Billings J.
        • Zeitel L.
        • Lukomnik J.
        • Carey T.S.
        • Blank A.E.
        • Newman L.
        Impact of socioeconomic status on hospital use in New York City.
        Health Aff (Millwood). 1993; 12: 162-173
        • Weissman J.S.
        • Gatsonis C.
        • Epstein A.M.
        Rates of avoidable hospitalization by insurance status in Massachusetts and Maryland.
        JAMA. 1992; 268: 2388-2394
        • Moy E.
        • Chang E.
        • Barrett M.
        Potentially preventable hospitalizations—United States, 2001-2009.
        MMWR Surveill Summ. 2013; 62: 139-143
        • Will J.C.
        • Yoon P.W.
        Preventable hospitalizations for hypertension: establishing a baseline for monitoring racial differences in rates.
        Prev Chronic Dis. 2013; 10: 120165
        • Laditka J.N.
        • Laditka S.B.
        Race, ethnicity and hospitalization for six chronic ambulatory care sensitive conditions in the USA.
        Ethn Health. 2006; 11: 247-263
        • Davis S.K.
        • Liu Y.
        • Gibbons G.H.
        Disparities in trends of hospitalization for potentially preventable chronic conditions among African Americans during the 1990s: implications and benchmarks.
        Am J Public Health. 2003; 93: 447-455
      1. Russo CA, Andrews RM, Coffey RM. Racial and ethnic disparities in potentially preventable hospitalizations, 2003: Statistical brief #10. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville, MD: Agency for Health Care Policy and Research; 2006.

        • Will J.C.
        • Nwaise I.A.
        • Schieb L.
        • Zhong Y.
        Geographic and racial patterns of preventable hospitalizations for hypertension: Medicare beneficiaries, 2004-2009.
        Public Health Rep. 2014; 129: 8-18
        • O’Neil S.S.
        • Lake T.
        • Merrill A.
        • Wilson A.
        • Mann D.A.
        • Bartnyska L.M.
        Racial disparities in hospitalizations for ambulatory care-sensitive conditions.
        Am J Prev Med. 2010; 38: 381-388
        • Kettani F.Z.
        • Dragomir A.
        • Cote R.
        • et al.
        Impact of a better adherence to antihypertensive agents on cerebrovascular disease for primary prevention.
        Stroke. 2009; 40: 213-220
        • Krousel-Wood M.
        • Holt E.
        • Joyce C.
        • et al.
        Differences in cardiovascular disease risk when antihypertensive medication adherence is assessed by pharmacy fill versus self-report: the Cohort Study of Medication Adherence among Older Adults (CoSMO).
        J Hypertens. 2014; 33: 412-420
        • Mazzaglia G.
        • Ambrosioni E.
        • Alacqua M.
        • et al.
        Adherence to antihypertensive medications and cardiovascular morbidity among newly diagnosed hypertensive patients.
        Circulation. 2009; 120: 1598-1605
        • Perreault S.
        • Dragomir A.
        • White M.
        • Lalonde L.
        • Blais L.
        • Berard A.
        Better adherence to antihypertensive agents and risk reduction of chronic heart failure.
        J Intern Med. 2009; 266: 207-218
        • Perreault S.
        • Dragomir A.
        • Roy L.
        • et al.
        Adherence level of antihypertensive agents in coronary artery disease.
        Br J Clin Pharmacol. 2010; 69: 74-84
        • Bailey J.E.
        • Wan J.Y.
        • Tang J.
        • Ghani M.A.
        • Cushman W.C.
        Antihypertensive medication adherence, ambulatory visits, and risk of stroke and death.
        J Gen Intern Med. 2010; 25: 495-503
        • Dragomir A.
        • Cote R.
        • Roy L.
        • et al.
        Impact of adherence to antihypertensive agents on clinical outcomes and hospitalization costs.
        Med Care. 2010; 48: 418-425
        • Sokol M.C.
        • McGuigan K.A.
        • Verbrugge R.R.
        • Epstein R.S.
        Impact of medication adherence on hospitalization risk and healthcare cost.
        Med Care. 2005; 43: 521-530
        • Corrao G.
        • Parodi A.
        • Nicotra F.
        • et al.
        Better compliance to antihypertensive medications reduces cardiovascular risk.
        J Hypertens. 2011; 29: 610-618
        • Esposti L.D.
        • Saragoni S.
        • Benemei S.
        • et al.
        Adherence to antihypertensive medications and health outcomes among newly treated hypertensive patients.
        Clinicoecon Outcomes Res. 2011; 3: 47-54
      2. Danielson E. White paper: Health research data for the real world: the MarketScan Databases. Published January 2014. Accessed March 18, 2015.

      3. Chronic Conditions Warehouse. Centers for Medicare and Medicaid Services. Accessed March 18, 2015.

      4. Medication Management Measures. The National Quality Forum. Accessed March 18, 2015.

        • Nau D.
        Proportion of days covered (PDC) as a preferred measure of medication adherence.
        Pharmacy Quality Alliance. 2015; (Accessed March 18, 2015)
        • Choudhry N.K.
        • Shrank W.H.
        • Levin R.L.
        • et al.
        Measuring concurrent adherence to multiple related medications.
        Am J Manag Care. 2009; 15: 457-464
        • USDHHS HRSA
        Bureau of Health Professions.
        Area Health Resources Files (AHRF). 2015; (Accessed March 18, 2015)
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • MacKenzie C.R.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • Tang J.
        • Wan J.Y.
        • Bailey J.E.
        Performance of comorbidity measures to predict stroke and death in a community-dwelling, hypertensive Medicaid population.
        Stroke. 2008; 39: 1938-1944
      5. Agency for Health Care Research and Quality. Prevention quality indicators technical specifications. Accessed March 18, 2015.

        • Simpson S.H.
        • Eurich D.T.
        • Majumdar S.R.
        • et al.
        A meta-analysis of the association between adherence to drug therapy and mortality.
        BMJ. 2006; 333: 15
      6. Bureau of Economic Analysis. Domestic product and income, Table 1.1.4. Accessed March 18, 2015.

        • Cox D.R.
        Regression models and life-tables.
        J R Stat Soc Series B. 1972; 34: 187-220
        • Nelder J.
        • Wedderburn R.
        Generalized linear models.
        J R Stat Soc Series A. 1972; 135: 370-384
        • Krousel-Wood M.A.
        • Muntner P.
        • Islam T.
        • Morisky D.E.
        • Webber L.S.
        Barriers to and determinants of medication adherence in hypertension management: perspective of the cohort study of medication adherence among older adults.
        Med Clin North Am. 2009; 93: 753-769
        • Nelson M.R.
        • Reid C.M.
        • Ryan P.
        • Willson K.
        • Yelland L.
        Self-reported adherence with medication and cardiovascular disease outcomes in the Second Australian National Blood Pressure Study (ANBP2).
        Med J Aust. 2006; 185: 487-489
        • Breekveldt-Postma N.S.
        • Penning-van Beest F.J.
        • Siiskonen S.J.
        • et al.
        The effect of discontinuation of antihypertensives on the risk of acute myocardial infarction and stroke.
        Curr Med Res Opin. 2008; 24: 121-127
        • Ho P.M.
        • Magid D.J.
        • Shetterly S.M.
        • et al.
        Medication nonadherence is associated with a broad range of adverse outcomes in patients with coronary artery disease.
        Am Heart J. 2008; 155: 772-779
      7. Viswanathan MGC, Jones CD, Ashok M, et al. Medication Adherence Interventions: Comparative Effectiveness. Closing the Quality Gap: Revisiting the State of the Science. Evidence Report No. 208. (Prepared by RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2007-10056-I.) AHRQ Publication No. 12-E010-EF. Rockville, MD: Agency for Healthcare Research and Quality. September 2012. Accessed March 18, 2015.

        • Ogedegbe G.
        • Chaplin W.
        • Schoenthaler A.
        • et al.
        A practice-based trial of motivational interviewing and adherence in hypertensive African Americans.
        Am J Hypertens. 2008; 21: 1137-1143
        • Beckowski M.S.
        • Goyal A.
        • Goetzel R.Z.
        • Rinehart C.L.
        • Darling K.J.
        • Yarborough C.M.
        Developing alternative methods for determining the incidence, prevalence, and cost burden of coronary heart disease in a corporate population.
        J Occup Environ Med. 2012; 54: 1026-1038
        • Hsu C.
        • Lemon J.M.
        • Wong E.S.
        • et al.
        Factors affecting medication adherence: patient perspectives from five veterans affairs facilities.
        BMC Health Serv Res. 2014; 14: 533
        • Iyengar R.
        • Henderson R.
        • Visaria J.
        • Glave Frazee S.
        Dispensing channel and medication adherence: evidence across 3 therapy classes.
        Am J Manag Care. 2013; 19: 798-804