A Cross-Sectional Survey of Fixed-Dose Combination Antihypertensive Medicine Prescribing in Twenty-Four Countries, Including Qualitative Insights

Abstract

Background: Treatment inertia, non-adherence and non-persistence to medical treatment contribute to poor blood pressure (BP) control worldwide. Fixed dose combination (FDC) antihypertensive medicines simplify prescribing patterns and improve adherence. The aim of this study was to identify factors associated with prescribing FDC antihypertensive medicines and to understand if these factors differ among doctors worldwide.

Methods: A cross-sectional survey was conducted online from June 2023 to January 2024 to recruit doctors. We collaborated with an international network of researchers and clinicians identified through institutional connections. A passive snowballing recruitment strategy was employed, where network members forwarded the survey link to their clinical colleagues. The survey instrument, developed through a literature review, interviews with academic and clinical researchers, and pilot testing, assessed participants perspectives on prescribing FDC antihypertensive medicines for hypertension. Participants rated their level of agreement (5-point Likert scale) with statements representing six barriers and four facilitators to FDC use.

Findings: Data from 191 surveys were available for analysis. 25% (n = 47) of participants worked in high-income countries, 38% (n = 73) in upper-middle income, 25% (n = 48) in lower-middle income, 6% (n = 10) in low-income countries. Forty percent (n = 70) of participants were between 36-45 years of age; two thirds were male. Cost was reported as a barrier to prescribing FDC antihypertensive medicines [51% (n = 87) agreeing or strongly agreeing], followed by doctors' confidence in BP measured in clinic [40%, (n = 70)], access [37%, (n = 67)], appointment duration [35%, (n = 61)], concerns about side-effects [(21%, n = 37)], and non-adherence [12%, (n = 21)]. Facilitators to FDC antihypertensive polypills prescribing were clinician facing, such as access to educational supports [79%, (n = 143)], more BP measurement data [67%, (n = 120)], a clinical nudge in health records [61%, (n = 109)] and patient-facing including improved patient health literacy [49%, (n = 88)]. The levels of agreement and strong agreement across all barriers and facilitators were similar for participants working in higher or lower income countries. Across all countries, participants rated FDC antihypertensive medications highly valuable for managing patients with non-adherence, (82% reported high or very high value), for patients with high pill burden (80%).

Interpretation: Cost and access were the most common barriers to prescribing FDCs across high- and low-income countries. While greater educational support for clinicians was perceived as the leading potential facilitator of FDC use, this seems unlikely to be effective without addressing access.

Keywords: antihypertensive medications; fixed dose combinations; global healthcare survey; hypertension; polypills.

Figure 1

Number of participants who completed each block of survey questions.

Figure 2

Map of countries represented. Number of participants per country: Argentina (n = 1), Australia (n = 21), Bahamas (n = 1), Bahrain (n = 2), Belgium (n = 1), Cote d’Ivoire (n = 2), Cameroon (n = 5), Honduras (n = 1), India (n = 34), Jamaica (n = 1), Malaysia (n = 64), Mali (n = 8), Mexico (n = 3), Mozambique (n = 1), New Zealand (n = 6), Peru (n = 5), Saint Kitts (n = 1), Saudi Arabia (n = 4), Singapore (n = 2), Spain (n = 1), Sudan (n = 2), United Kingdom (n = 3), United States of America (n = 5), Viet Nam (n = 5).

Figure 3

Value placed on fixed-dose combination antihypertensive medication in clinical scenarios.

Figure 4

Factors important in the decision to initiate fixed-dose combination medicines.