ASHP Midyear: Rural Health Care Barriers Impact Medication Adherence and Hypertension Management

Patients in rural areas face unique challenges that contribute to poor health outcomes, particularly for conditions like hypertension. The distance to health care facilities, lack of transportation, and unaffordable costs of care create significant barriers to accessing regular treatment. These disparities compound the higher prevalence of hypertension in rural communities. Medication adherence is a major issue, as patients often delay picking up prescriptions or avoid follow-up appointments due to the inconvenience and expense. However, there are strategies that can help improve adherence and hypertension management in these underserved areas. Jillian Norris, BSPS, pharmacy student at Cedarville University, discusses strategies to help overcome these barriers.

Pharmacy Times: What are some of the key disparities in health care access that rural communities face compared to urban areas, specifically in hypertension care?

Jillian Norris: So, some of the disparities that affect rural communities a lot more than urban communities are going to be distance to physical health care facility, things are just a lot more spread out in rural areas. And then, the second thing is going to be a lack of transportation is huge, that specifically affects patients who either don't have a car or they share 1 car for the whole family. Another thing to remember is that patients in rural areas are a lot more likely to report that their health care is unaffordable for them areas compared to urban areas, which is a huge barrier to care. So, it's not that these barriers to care are specifically targeting patients with hypertension, but the 2 issues kind of compound each other. Hypertension is more prevalent in rural areas, so that compounded with these barriers to care, lead to poor health outcomes for patients with hypertension living in rural areas.

Pharmacy Times: Can you discuss the challenges rural patients face in adhering to medication regimens for hypertension?

Norris: Patients in rural areas are often only making 1 trip into town every so often, which can hugely impact their adherence in a couple different ways. So, if they come into town and they have any sort of delay at the pharmacy [and] picking up their medication—whether that's just due to low staffing or the pharmacy needs a new prescription from the doctor sent in—they may choose to delay picking up that prescription until the next time they come into town, which may not be for another week or 2. Another thing to remember is that [because] patients in rural areas report that their health care is unaffordable more often, they may be less willing to make an appointment if they're having issues with their medication regimen. So, I've had patients who have come in and said, "Hey, I haven't been taking this medication for months because I had a[n adverse] effect that I couldn't tolerate," but they didn't let anyone know, and they didn't want to make an appointment in the meanwhile, so it had been 3 or 6 months since they had last been seen.

Pharmacy Times: How can pharmacists address medication adherence challenges in rural communities, especially when patients may have limited access to pharmacies or transportation?

Norris: I think that the main thing first is assessing if there is an issue with medication adherence, because there won't be for every patient. But once you have established that there is an issue with medication adherence for your patient, there are a lot of options nowadays to make medication adherence easier for patients. I think the first thing that I would recommend is connecting patients with mail order pharmacies, a lot of insurance companies are now partnering with mail order pharmacies to deliver medications straight to the patient's home, which means they don't have to make a separate trip into town. Another thing is trying to move to 90 day supply fills rather than 30 day supply fills, and that may require a call to the doctor's office to get that switched over, but I think most doctors are amenable to improving medication adherence.

Pharmacy Times: What are some technological tools or resources that pharmacists can utilize to improve hypertension care in rural settings?

Norris: So, telehealth has obviously boomed since COVID 19, but it is important to remember that Internet access can still be a barrier for patients living in rural areas who might have kind of spotty service. In the research that I did during my literature review, I looked at a lot of different telehealth initiative pilot programs, and the ones that tended to be most successful were ones that sat down with the patients prior to initiating a program to see what solutions would be feasible for them with the resources that they had. So, remote patient monitoring programs, in combination with in-person follow-up or over the phone follow-up tended to be the most successful for hypertension. A remote patient monitoring program is when a patient has a device at home—in this case, a blood pressure cuff—they take their measurements at home [so] they can see them for themselves. But they also get transmitted to their health care provider and that allows for aquicker turnaround for medication titration, and ultimately, blood pressure control.