Noncompliance may cause half of antihypertensive drug "failures"

Association of depression trajectories and subsequent hypertension and cardiovascular disease: findings from the CHARLS cohort

OBJECTIVES

Little evidence regarding the associations of longitudinal trajectories of depressive symptoms and incident hypertension and cardiovascular diseases (CVDs). This study aimed to evaluate the relationships between trajectories of depressive symptoms and new-onset hypertension and CVDs among the Chinese middle-aged and older general population.

METHODS

This prospective cohort study used data from a nationally representative sample aged older than 45 years of Chinese residents recruited for the China Health and Retirement Longitudinal Study (CHARLS). The depressive symptoms were assessed using the 10-item Center for Epidemiologic Studies Depression Scale (CES-D-10). The outcomes of the study were new-onset hypertension and CVDs.

RESULTS

A total of 6071 participants were included in the final analysis and four trajectories of CES-D-10 were identified, including low-stable, medium-decreasing, medium-increasing, and high-stable trajectories. Until 2018, 1668 (27.5%) and 959 (15.8%) participants were newly diagnosed with hypertension and CVDs, respectively. Compared with participants with a low-stable trajectory, individuals with other three trajectories had a significantly higher risk of hypertension and CVDs. The results remained robust in several sensitivity analyses. The restricted cubic spline (RCS) showed an S-shaped relationship between the mean CES-D-10 score and hypertension/CVDs ( P for nonlinear <0.001). Hypertension partially mediated the association between CES-D-10 and CVDs.

CONCLUSION

Among Chinese aged older than 45 years' general adults, depressive symptoms were prevalent and associated with higher risks of incident hypertension and CVDs. Depressive symptoms mediated the development of CVDs by promoting hypertension progression. Immediate efforts are needed to improve depression management in China to further prevent CVDs.

Addressing Hypertension Care in Africa (ADHINCRA): Study protocol for a cluster-randomized controlled pilot trial

BACKGROUND

Uncontrolled hypertension is a major risk factor for cardiovascular disease. Evidence-based interventions to improve hypertension control in high-income countries have not been translated equally in sub-Saharan Africa (SSA). The objective of the Addressing Hypertension Care in Africa (ADHINCRA) Study was to test the feasibility and signal of efficacy of a multilevel, nurse-led, mobile health enhanced intervention in improving hypertension control in Ghana.

METHODS

Using a cluster randomized controlled pilot trial design, four hospitals in Kumasi, Ghana, were randomized to the intervention arm (2 hospitals) and enhanced usual care arm (2 hospitals). A total of 240 patients with uncontrolled hypertension defined as systolic blood pressure (BP) ≥140 mmHg on their most recent visit were included (60 patients per hospital). Patients in the intervention arm received an intervention that consisted of nurse-led task-shifting and a mobile health application (Medtronic® Labs' Empower Health), and home BP monitoring. The enhanced usual care arm received usual care as determined by their providers, plus short text messages on health. The intervention was administered for six months, after which it was withdrawn, and patients were followed for six more months to assess outcomes. Feasibility measures included recruitment and dropout rates of study participants, protocol adherence in both arms. Clinical outcomes included changes in BP control status and systolic BP levels from baseline. Secondary outcomes included change in glycemic control, rates of hypertensive urgencies/emergencies, cardiovascular disease events, and medication adherence.

DISCUSSION

Findings from this study will provide critical pilot data to inform the conduct of a larger scale trial and the development of scalable health system and policy interventions to improve hypertension control in low-resource settings. Trial registration NCT04010344. Registered on July 8, 2019 at ClinicalTrials.govhttps://clinicaltrials.gov/ct2/show/NCT04010344.

A prospective longitudinal study with treated hypertensive patients in Northern Bangladesh (PREDIcT-HTN) to understand uncontrolled hypertension and adverse clinical events: A protocol for 5-years follow-up

Introduction

Uncontrolled hypertension is the most common cause of major adverse clinical events (MACE), such as myocardial infarction, strokes, and death due to CVDs, in both developed and developing countries. Western-led studies found that treated hypertensive adults with uncontrolled hypertension were more at-risk of all-cause and CVD-specific mortality than normotensives. The PRospEctive longituDInal sTudy of Treated HyperTensive patients of Northern-Bangladesh (PREDIcT-HTN) study principally aims to estimate the incidence of MACE in treated hypertensive patients and identify the determinants of MACE. The secondary objective is to find the prevalence of uncontrolled hypertension in treated hypertensive patients and the associated risk factors.

Methods and analysis

The treated hypertensive patients were obtained from the Hypertension and Research Center (H&RC), Rangpur, Bangladesh, from January to December 2020. Based on the eligibility criteria, 2643 patients were included to constitute the PREDIcT-HTN cohort. Baseline data was retrieved from the H&RC registry, and five follow-up waves are planned yearly (2021–2025). A questionnaire will be administered at each follow-up visit on hypertension control status, behavioral factors, quality of life, dietary adherence, and high blood pressure compliance-related variables. The participant will be right censored if the patient develops MACE, death due to any cause, loss to follow-up, or at the end of the study. A proportional hazard model will identify the risk factors of MACE. Multinomial logistic regression analyses will be performed to determine the predictors of the hypertension control status by medication and dietary adherence after adjusting confounders.

Ethics and dissemination

The ethical approval for this study was obtained from the Institutional Review Board, North South University [Ref: 2019/OR-NSU/IRB-No.0902]. The participants will provide written consent to participate. The findings will be disseminated through manuscripts in clinical/academic journals and presentations at professional conferences and stakeholder communication.

Institutional Satisfaction and Anxiety Mediate the Relationship Between Social Support and Depression in Hypertension Patients in Elderly Caring Social Organizations: A Cross-Sectional Study

Background: Depression is a prevalent health condition among hypertension patients in elderly caring social organizations (SOs). Patients with hypertension and depression symptoms have worse health outcomes than those without depression. As the population ages, chronic and mental health issues such as depression of hypertension patients in elderly caring SOs have become prominent. However, the combined effects of social support, institutional satisfaction, and anxiety on depression among hypertension individuals in elderly caring SOs remain unclear. This study aimed to explore the mediating effects of institutional satisfaction and anxiety on the relationship between social support and depression among hypertension patients in elderly caring SOs in Anhui Province, China.

Methods: A cross-sectional study was conducted using a multi-stage stratified random sampling method. A questionnaire was used to collect data on demographic characteristics, the satisfaction of elderly caring SOs, social support, anxiety, and depression. A multiple linear regression model was utilized to investigate depression-related factors, and structural equation modeling (SEM) was employed to examine the relationships between social support, institutional satisfaction, anxiety, and depression among patients with hypertension in elderly caring SOs.

Results: Our results indicated that the mean scores of social support were 20.19 ± 6.98 and 1.92 ± 3.18 for anxiety, and 6.24 ± 5.03 for depression; besides, 33.3% of participants were very satisfied with elderly caring SOs, 48.5% were satisfied, and only 6.0% were dissatisfied or very dissatisfied. Comorbid chronic diseases were significantly associated with depression. Institutional satisfaction was directly negatively related to depression, whereas anxiety was directly positively correlated with depression. Social support had an indirect negative association with depression by the mediating effects of institutional satisfaction and anxiety.

Conclusions: The study highlights the importance of social support in maintaining mental health among hypertension patients residing in elderly caring SOs. To alleviate depression among hypertension patients in elderly caring SOs, strategies that target enhancing social support, institutional satisfaction, and anxiety reduction should be prioritized. More importantly, more attention should be paid to patients with comorbid chronic diseases.

Medical adherence and liver transplantation: a brief review

Liver transplantation remains the only feasible long-term treatment option for patients with end-stage liver disease. Despite significant medical and surgical advances over the decades, liver transplantation remains a complex undertaking with the need for indefinite immunosuppression and avoidance of patient behaviours that may jeopardize the allograft. Adherence (formerly called "compliance") to medical recommendations in terms of anti-rejection medications and-in the case of alcoholic liver disease, abstinence-is considered a key cornerstone to long-term allograft and patient survival. Not surprisingly, a history of habitual non-adherence is considered a contraindication to liver transplantation, especially re-transplantation. It is often assumed that non-adherence policies are "self-evidential" based on "common sense" and "expert opinion." In fact, non-adherence and its negative effects have been well studied in medicine, including in solid organ transplantation. In this review, we present the evidence that non-adherence to medical advice is clearly associated with worse medical outcomes, supporting the concept that efforts to support patient adherence post-transplant need to be optimized at all times.

Social Support and Depression Related to Older Adults' Hypertension Control in Rural China

OBJECTIVE

This study aimed to investigate association between social support and hypertension (HTN) control in rural China older adults, and to what extent depression mediates this relationship. The authors hypothesized that depression severity mediated the relationship between social support and HTN control.

METHODS

Data for the analyses were obtained from baseline data from a randomized controlled clinical trial of a collaborative depression care management intervention conducted in rural villages of China, with older adults with comorbid depression and HTN. Data included baseline assessments of 2,351 subjects aged 60 years and older, whose blood pressure and depression severity were measured using a calibrated manual sphygmomanometer and the 17-item Hamilton Depression Rating Scale (HDRS-17), respectively. Social support was measured using the 20-item Medical Outcomes Study-Social Support Survey.

RESULTS

Uncontrolled HTN was associated with older age (t[df = 2349] = 3.16; p < 0.01), higher HDRS-17 score (t[df = 1488] = 5.89; p < 0.001), and lower social support (t[df = 2349] = 5.37; p < 0.001). A significant indirect effect of social support via depression severity in relation to HTN control (a × b = -0.04[0.01]), bootstrap p = 0.0015, and 95% confidence interval (-0.07, -0.02), accounting for 11% of the effect of social support on HTN control.

CONCLUSION

These findings imply that social support impacts HTN control directly and indirectly through depression. Intervention approaches such as primary care-based collaborative care models should address social support to achieve greater outcomes for depression and HTN management.

Hypertension and Headache: the Effect of Antihypertensive Drugs

Headache is considered to be one of the main symptoms of arterial hypertension (HT). Complaints of headache are presented by many patients with HT: from 44% to 87%. It is obvious that the majority of complaints of headache in patients with HT is not due to headaches due to increased blood pressure (BP), but multimorbidity (polymorbidity) – the presence of coexisting primary headaches, most often, as in the population as a whole, chronic tension headache (57-85%) and migraine (15-30%). On the other hand, the frequency of HT in patients with migraine ranges from 32% to 44%. The relationship between migraine and HT may be due to common exogenous (external) and endogenous (genetic) factors, as well as common pathophysiological mechanisms. External risk factors, which can be associated with both migraine and HT, include the nature of the diet (excessive consumption of table salt with food), low physical activity, chronic stress; both diseases are also associated with the presence of a connection with the metabolic syndrome. The role of hyperactivation of the renin-angiotensin-aldosterone and adrenergic system and endothelial dysfunction are actively discussed. Angiotensin-converting enzyme takes an active part in the BP control and vascular tone; it is known that some angiotensin converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB) have demonstrated efficacy in preventing migraine attacks. The presence of HT can contribute to the chronic course of primary headache, and effective treatment of HT with antihypertensive drugs, on the contrary, can have a positive effect on the course of primary headaches. Antihypertensive drugs reduce the frequency of headaches compared to placebo, but heterogeneity between different classes was revealed. There was a statistically significant decrease in the frequency of headaches compared to placebo during treatment with beta-blockers, ACEI, ARB, diuretics, while calcium antagonists did not reduce the frequency of headaches. According to a number of studies, the frequency of headaches during the treatment with ARB (candesartan) is comparable to that in the placebo group. Some antihypertensive drugs are used to prevent migraine attacks.

Medication regimen complexity and its impact on medication adherence and glycemic control among patients with type 2 diabetes mellitus in an Ethiopian general hospital

BACKGROUND

Different studies reported that higher diabetes-specific Medication Regimen Complexity Index (MRCI) has a negative impact on glycemic control potentially by decreasing medication adherence. However, information about regimen complexity and its association with adherence and glycemic control in Ethiopian patients with diabetes is unknown.

AIM

To evaluate medication regimen complexity and to assess its impact on medication adherence and glycemic control among patients with type 2 diabetes Mellitus (T2DM).

METHODS

A hospital-based cross-sectional design was conducted at Debre Tabor General Hospital from 1 May 2018 to 30 June 2018. Medication regimen complexity was evaluated using the 65-item validated tool called Medication Complexity Index (MRCI). Adherence was measured using Morisky Medication Adherence Scale while patients were classified as having poor or good glycemic control based on the recent record of their fasting blood glucose. Multivariable logistic regression analysis was applied to determine the association between predictive variables and outcome variables.

RESULTS

A total of 275 patients with T2DM who meet the inclusion criteria were included in the final analysis. About 22.2% of the participants were classified as having high diabetes-specific MRCI, whereas 35.6% of the participants were classified as having high patient-level MRCI. The majority (70.5%) of the respondents were adherent to their medications, and 42.9% of the total population were categorized as having good glycemic control. According to the result of the multivariate analysis, patients with low-level and moderate-level MRCI of both diabetes-specific and patient-level MRCI were more adherent to their medication compared with patients with high MRCI. High diabetes medication regimen complexity was associated with poor glycemic control in the adjusted analyses (adjusted OR = 0.276; 95% CI = 0.100 o 0.759).

CONCLUSION

The prevalence of high MRCImedication regimen complexity index is high among patients with T2DM. Patients with low and moderate regimen complexity had improved adherence. High diabetes-specific medication regimen complexity was associated with poor glycemic control. Simplification of a complex medication regimen for patients with diabetes should be sought by physicians and pharmacists to improve medication adherence and subsequent improvement in glycemic control.

The prevalence of depressive symptoms among older patients with hypertension in rural China

OBJECTIVE

The comorbidity of depression and hypertension (HTN) is common and complicates the management of both conditions. This study investigated the prevalence of depressive symptoms among older patients with HTN in rural China and explored the relationship between the two conditions.

METHODS

The baseline data of older patients diagnosed with HTN included in the depression/HTN in Chinese Older Adults-Collaborations for Health Study were used for the analysis. The Chinese Older Adults-Collaborations for Health Study was conducted in rural villages of Tonglu County, Zhejiang Province, China. In all, 10 389 older village residents had HTN (57.2% female, mean age 71.5 ± 8.1 years). Blood pressure was measured by using a calibrated manual sphygmomanometer and stethoscope. Depressive symptom was measured by using the Chinese version of the nine-item Patient Health Questionnaire.

RESULTS

Among 10 389 patients with HTN, 12.8% had significant depressive symptoms (nine-item Patient Health Questionnaire ≥ 10). Rates of significant depressive symptoms were 5.3% and 32.8% among patients with controlled and uncontrolled HTN (systolic blood pressure ≥ 140 and/or diastolic blood pressure ≥ 90), respectively (χ2  = 8.701, p < 0.001). Logistic regression analysis indicated that those in older age group (≥70 years) and with uncontrolled HTN have higher rates of significant depressive symptoms than those who are younger (age 60 to <70) and with controlled HTN.

CONCLUSION

Our findings show high rates of depressive symptoms among patients with HTN in rural China and higher rates of depressive symptoms among patients with uncontrolled HTN. These support the development and dissemination of integrative care approaches for older adults with HTN and depression in rural China. Copyright © 2016 John Wiley & Sons, Ltd.

Impacts of undetected and inadequately treated hypertension on incident stroke in China

OBJECTIVES

China carries the greatest burden of stroke given its largest volume of people with hypertension. This study assessed the impacts of suboptimal controls of hypertension on incident stroke and projected the number of patients with stroke saved after the control of blood pressure improved in population.

SETTING

Anhui, China.

PARTICIPANTS

We examined data from the Anhui cohort of 2001-2011, consisting of 3336 participants aged ≥60 years who were randomly recruited from the urban and rural Anhui. 2852 participants (89.2%) had hypertensive status measured and no stroke at baseline, and were followed up until 2011 in three surveys using a standard method of interview.

RESULTS

At baseline, 1646 participants (57.7%) were identified to have hypertension, among whom 912 (55.4%) were previously undetected, 115 (7.0%) detected but not treated, 452 (27.5%) treated but not controlled and only 127 (7.7%) controlled. During the 10-year follow-up, 211 incident stroke cases (12.8/1000 person-years) occurred. Compared with normotensive individuals at baseline, multivariate adjusted HR for having stroke increased in those with undetected hypertension by 1.63 (95%CI 1.15 to 2.32), untreated by 2.21 (1.26-3.85) and uncontrolled hypertension by 3.34 (2.28-4.88), but did not differ from those with controlled hypertension (1.34; 0.60-2.99). Based on a two-fold increase in the detection and management of current levels of hypertension and algorithms on the current situation in China, approximately 250 000 incident stroke cases could be prevented annually.

CONCLUSIONS

In China, hypertension is frequently undetected or inadequately treated. With appropriate management of hypertension, a substantial number of people could be saved form stroke.

Medication supply, healthcare outcomes and healthcare expenses: longitudinal analyses of patients with type 2 diabetes and hypertension

INTRODUCTION

Patients with chronic conditions largely depend on proper medications to maintain health. This study aims to examine, for patients with diabetes and hypertension, whether the appropriateness of the quantity of drug obtained is associated with favorable healthcare outcomes and lower expenses.

METHODS

This study utilized a longitudinal design with a seven-year follow-up period from 2002 to 2009 under a universal health insurance program in Taiwan. The patients under study were those aged 18 years or older and newly diagnosed with type 2 diabetes or hypertension in 2002. Generalized estimating equations were performed to examine the relationship between medication supply and health outcomes as well as expenses.

RESULTS

The results indicate that while compared with patients with an appropriate medication supply, patients with either an undersupply or an oversupply of medications tended to have poorer healthcare outcomes. The study also found that an excess supply of medications for patients with diabetes or hypertension resulted in higher total healthcare expenses.

CONCLUSION

Either an undersupply or an oversupply of medication was associated with unfavorable healthcare outcomes, and that medication oversupply was associated with the increased consumption of health resources. Our findings suggest that improving appropriate medication supply is beneficial for the healthcare system.

Factors associated with gender differences in medication adherence: a longitudinal study

AIMS

To examine gender differences in the medication adherence of patients with hypertension by applying a longitudinal follow-up.

BACKGROUND

Patient views of illness affect their adherence to therapeutic regimens. However, few studies have explored these issues by using a longitudinal design or from a gender perspective.

DESIGN

This study used a longitudinal, correlational design.

METHODS

A purposive sampling of 118 patients were recruited from cardiovascular clinics of a teaching hospital in Central Taiwan in 2007-2009. Data were collected using the Chinese Illness Perception Questionnaire-Revised and the Medication Adherence Inventory at three time points: at the first clinic visit, 6 and 12 months after the initial survey. Generalized estimating equations were calculated using the STATA software for data analysis.

RESULTS

The findings revealed that male patients adhere more effectively to medications than female patients do. The interaction between systolic blood pressure and gender emerged as a significant predictor of adherence. Factors associated with adherence in male patients included less causal attribution to culture, more attribution to risk factors, fewer symptoms and uncertain symptoms related to high blood pressure, lower scores for timeline-cyclical and higher scores for illness consequences and coherence. Medication adherence for female patients was significantly related to more causal attribution to balance and risk factors, less personal control and enhanced illness coherence.

CONCLUSION

Factors associated with adherence to antihypertensive medication were relatively gender-specific. Awareness of the differences is crucial for health professionals to provide appropriate advice for patients to cope effectively with their health threat.

New models of chronic kidney disease care including pharmacists: improving medication reconciliation and medication management

PURPOSE OF REVIEW

Patients with chronic kidney disease (CKD) are complex, have many medication-related problems (MRPs) and high rates of medication nonadherence, and are less adherent to some medications than patients with higher levels of kidney function. Nonadherence in CKD patients increases the odds of uncontrolled hypertension, which can increase the risk of CKD progression. This review discusses reasons for gaps in medication-related care for CKD patients, pharmacy services to reduce these gaps and successful models that incorporate pharmacist care.

RECENT FINDINGS

Pharmacists are currently being trained to deliver patient-centred care, including identification and management of MRPs and helping patients overcome barriers to improve medication adherence. A growing body of evidence indicates that pharmacist services for CKD patients, including medication reconciliation and medication therapy management, positively affect clinical and cost outcomes, including lower rates of decline in glomerular filtration rates, reduced mortality and fewer hospitalizations and hospital days, but more robust research is needed. Team-based models including pharmacists exist today and are being studied in a wide range of innovative care and reimbursement models.

SUMMARY

Opportunities are growing to include pharmacists as integral members of CKD and dialysis healthcare teams to reduce MRPs, increase medication adherence and improve patient outcomes.

Eliminating the need for fasting with oral administration of bisphosphonates

Bisphosphonates are the major treatment of choice for osteoporosis, given that they are attached preferentially by bone and significantly reduce the risk of fractures. Oral bisphosphonates are poorly absorbed (usually less than 1% for nitrogen-containing bisphosphonates) and when taken with food or beverages create complexes that cannot be absorbed. For this reason, they must be taken on an empty stomach, and a period of up to 2 hours must elapse before the consumption of any food or drink other than plain water. This routine is not only inconvenient but can lead to discontinuation of treatment, and when mistakenly taken with food, may result in misdiagnosis of resistance to or failure of treatment. The development of an enteric-coated delayed-release formulation of risedronate with the addition of the calcium chelator, ethylenediaminetetraacetic acid (EDTA), a widely used food stabilizer, eliminates the need for fasting without affecting the bioavailability of risedronate or its efficacy.

Medication complexity, prescription behaviour and patient adherence at the interface between ambulatory and stationary medical care

PURPOSE

A hospital stay is often accompanied by changes in medication therapy. The purpose of this study was to investigate the impact of a transfer across the interfaces on the complexity of therapeutic regimens and patient adherence as well as the attitudes of patients and general practitioners (GPs) towards pharmacotherapies.

METHODS

This was a prospective observational study that analysed the complexity of medication therapies and the adherence and attitudes of internal medicine and urology patients towards their medication(s) at three time points (hospital admission, discharge and 6 weeks after discharge). GPs of the patients recruited to the study were questioned about the follow-up medication therapy and their opinion on the medication prescribed in hospital.

RESULTS

At the time of hospital admission, 60.2 % of the study population were nonadherent. During hospitalization, the number decreased to 37.6 %, but increased to 61.2 % 6 weeks after discharge. Changes in the overall complexity of the therapy regimens were marginal and not statistically significant. Of the long-term medication regimens, 48.6 % were modified during hospital stay. The patients preferred regimens with a minimum of drug administrations. GPs stated to be willing to continue hospital prescriptions but were restricted by financial budgets.

CONCLUSION

The results of this study confirm that an increase in adherence during a hospital stay is only transient, underlining the need for interventions to ameliorate medication adherence. They also suggest that patients prefer simple regimens. Although GPs are willing to consider their patient's preferences on pharmacotherapy, they state limitations due to financial budgets. Further studies are needed that investigate the extent to which medication therapies can be simplified and the effect of simplification on adherence.

Development and psychometric evaluation of the German version of the Medication Regimen Complexity Index (MRCI-D)

BACKGROUND

Several factors contribute to the complexity of pharmacotherapeutic regimens, like the total number of medications to be taken, the number of dosage units to take at a time, dosage frequency, as well as specific directions concerning the administration. The Medication Regimen Complexity Index (MRCI) is a validated instrument developed in English for the measurement of the complexity of a given pharmacotherapeutic regimen.

OBJECTIVES

Translation of the MRCI into German and evaluation of the translated instrument (MRCI-D) in order to make it more easily accessible for use in German practice and research.

METHODS

The process of validation included the translation of the English version to German, back-translation into English, comparison of the back-translated and the original versions, pre-tests, and pilot-testing of the German version by three raters using 20 medication regimens for inpatients. The subsequent psychometric evaluation included the calculation of inter-rater and test-retest reliability, as well as the assessment of convergent validity.

RESULTS

The number of medications correlated highly and statistically significantly with the MRCI-D score (0.91, P < 0.001), indicating sufficient convergent validity of the instrument. Both inter-rater and test-retest reliability were very high (intraclass correlation coefficients above 0.80 in all cases).

CONCLUSION

Our results demonstrate that the German version of the MRCI reflects the complexity of therapeutic regimens with similar validity and reliability as the established English version. Thus, it may be a valuable tool to analyse therapeutic regimens in both clinical practice and science.

Long-Term Tolerability and Efficacy of Single-Pill Combinations of Telmisartan 40-80 mg Plus Amlodipine 5 or 10 mg in Patients Whose Blood Pressure Was Not Initially Controlled by Amlodipine 5-10 mg: Open-Label, Long-Term Follow-Ups of the TEAMSTA-5 and TEAMSTA-10 Studies

BACKGROUND

Two 8-week, randomized, double-blind, controlled studies previously evaluated the efficacy and tolerability of single-pill combinations of telmisartan 40-80 mg/amlodipine 5-10 mg (T40-80/A5-10) in patients with hypertension not at diastolic blood pressure (DBP) goal (DBP <90 mm Hg) after 6 weeks of amlodipine 5 mg monotherapy (A5) (TEAMSTA-5) or amlodipine 10 mg monotherapy (A10) (TEAMSTA-10). The long-term (≥6 months) tolerability and efficacy of single-pill combinations of T40-T80/A5-A10 have now been evaluated in 2 open-label studies in patients who had successfully completed either TEAMSTA-5 or TEAMSTA-10 (TEAMSTA-5 and TEAMSTA-10 Follow-Ups).

METHODS

In the TEAMSTA-5 Follow-Up, 976 patients whose blood pressure was not initially controlled by taking A5 received T40/A5 for 4 or 8 weeks, with consecutive uptitration to T80/A5 if DBP was ≥90 mm Hg. In TEAMSTA-10 Follow-Up, 838 patients not initially achieving blood pressure control using A10 received T40/A10 for 4 weeks before randomization to T40/A10 or T80/A10; after 4 weeks, patients randomized to T40/A10 with DBP ≥90 mm Hg were uptitrated to T80/A10. In both studies, add-on antihypertensive medication was allowed if DBP was not at goal.

RESULTS

Treatment compliance in both follow-up studies was ≥98.4%. Single-pill combinations of T40-T80/A5-A10 resulted in additional clinically relevant blood pressure reductions and 67% to 93% of patients achieved DBP goal (<90 mm Hg); only 1% to 19% of patients received additional medication for hypertension, of whom 29% to 76% achieved DBP goal. Long-term treatment with T40-T80/A5-A10 was well tolerated, with comparable adverse event profiles for all telmisartan/amlodipine combinations. The most common drug-related adverse events were peripheral edema (1.9%-3.9%) and dizziness (1.5% in the T80/A5 group only); these were consistent with the known tolerability profiles of telmisartan/amlodipine combinations. Overall treatment discontinuation rates due to adverse events were low (0.7%-1.5%).

CONCLUSIONS

In patients not achieving DBP goal with either A5 or A10 monotherapy, the vast majority achieved DBP goal with single-pill combinations of T40-T80/A5-A10. Long-term treatment was well tolerated with high compliance, promoting treatment adherence regardless of telmisartan/amlodipine dose. ClinicalTrials.gov identifiers: NCT00614380 (TEAMSTA-5 Follow-up) and NCT00624052 (TEAMSTA-10 Follow-up).

The influence of locus control on adherence to treatment regimen among hypertensive patients

BACKGROUND

The purpose of this study was to investigate the influence of locus of control on adherence to a treatment regimen among hypertensive patients.

METHODS

The participants were 100 previously diagnosed hypertensive patients drawn from the Ituku-Ozalla University of Nigeria teaching hospital, using a purposive sampling technique. All participants were individually administered the Wallston, Wallston & Devellis (1978), Multidimensional Health Locus of Control (MHLC) scale, and Drug Adherence Questionaire (DAQ) by the researchers. A one-way factorial design and analysis of variance with unequal sample sizes were used to analyze the data.

RESULTS

Internally-oriented patients adhered more to their treatment regimen than externally-oriented patients, F(1.98) = 18.2 (P < 0.01).

CONCLUSION

Locus of control should be taken into consideration in the review of treatment packages for patients. This is because the efficacy of drugs depends to a reasonable extent on adherence to the schedule. If drugs are not taken as prescribed, their potency may be affected or wrongly assessed.

Study protocol: the Adherence and Intensification of Medications (AIM) study--a cluster randomized controlled effectiveness study

Background

Many patients with diabetes have poor blood pressure (BP) control. Pharmacological therapy is the cornerstone of effective BP treatment, yet there are high rates both of poor medication adherence and failure to intensify medications. Successful medication management requires an effective partnership between providers who initiate and increase doses of effective medications and patients who adhere to the regimen.

Methods

In this cluster-randomized controlled effectiveness study, primary care teams within sites were randomized to a program led by a clinical pharmacist trained in motivational interviewing-based behavioral counseling approaches and authorized to make BP medication changes or to usual care. This study involved the collection of data during a 14-month intervention period in three Department of Veterans Affairs facilities and two Kaiser Permanente Northern California facilities. The clinical pharmacist was supported by clinical information systems that enabled proactive identification of, and outreach to, eligible patients identified on the basis of poor BP control and either medication refill gaps or lack of recent medication intensification. The primary outcome is the relative change in systolic blood pressure (SBP) measurements over time. Secondary outcomes are changes in Hemoglobin A1c, low-density lipoprotein cholesterol (LDL), medication adherence determined from pharmacy refill data, and medication intensification rates.

Discussion

Integration of the three intervention elements - proactive identification, adherence counseling and medication intensification - is essential to achieve optimal levels of control for high-risk patients. Testing the effectiveness of this intervention at the team level allows us to study the program as it would typically be implemented within a clinic setting, including how it integrates with other elements of care.

Trial Registration

The ClinicalTrials.gov registration number is NCT00495794.

[Medication adherence of a sample of hypertensive patients in the region of Sfax (Tunisia)]

THE AIM OF THE STUDY

Medication noncompliance is one of the daily problems of the physician. Improving the medication adherence allows better management of hypertension. The aim of this work was to determine the level of compliance for patients with hypertension and to identify factors that determine compliance.

METHODS

A cross-sectional study was carried out among a sample of hypertensive patients attending general and specialist practitioners in public or private clinics of Sfax. Two hundred and seventy-three participants had accepted to be interviewed. Patients were identified as noncompliants using a questionnaire developed by the Comité de lutte contre l'hypertension artérielle (CFLHTA).

RESULTS

Non-compliance rate was 63.4%. The low level of education was associated with a lower adherence. The monotherapy, the once-daily regimen with fewer number of tablets were associated with a better adherence (p<10(-6)). The welcome and the availability of drugs in the public clinic affect positively the adherence of patients (p<0.0002). A patient very satisfied with his consultation and the explanation given by the doctor about his illness and its treatment had a better adherence (p<0.00003).

CONCLUSION

Our study had demonstrated a low compliance with antihypertensive drug therapy. Tunisian health care system should elaborate a management plan which takes into account our particular predictors of compliance to improve adherence to antihypertensive medication.

Improving adherence to medication in stroke survivors (IAMSS): a randomised controlled trial: study protocol

Background

Adherence to therapies is a primary determinant of treatment success, yet the World Health Organisation estimate that only 50% of patients who suffer from chronic diseases adhere to treatment recommendations. In a previous project, we found that 30% of stroke patients reported sub-optimal medication adherence, and this was associated with younger age, greater cognitive impairment, lower perceptions of medication benefits and higher specific concerns about medication. We now wish to pilot a brief intervention aimed at (a) helping patients establish a better medication-taking routine, and (b) eliciting and modifying any erroneous beliefs regarding their medication and their stroke.

Methods/Design

Thirty patients will be allocated to a brief intervention (2 sessions) and 30 to treatment as usual. The primary outcome will be adherence measured over 3 months using Medication Event Monitoring System (MEMS) pill containers which electronically record openings. Secondary outcomes will include self reported adherence and blood pressure.

Discussion

This study shall also assess uptake/attrition, feasibility, ease of understanding and acceptability of this complex intervention.

Trial Registration

Current Controlled Trials ISRCTN38274953

Diabetes and poor disease control: is comorbid depression associated with poor medication adherence or lack of treatment intensification?

OBJECTIVE

To hypothesize that patients with comorbid depression and diabetes and poor disease control will have poorer adherence to disease control medication and less likelihood of physician intensification of treatment. Many patients with diabetes fail to achieve American Diabetes Association Guidelines for glycemic, blood pressure and lipid control. Depression is a common comorbidity and may affect disease control through adverse effects on adherence and physician intensification of treatment.

METHODS

In a cohort of 4117 patients with diabetes, depression was measured at baseline with the Patient Health Questionnaire-9 (PHQ-9). Patient adherence and physician intensification of treatment were measured in those who had evidence of poor disease control (HbA(1c) >or=8.0%, LDL >or=130 mg/dL, systolic blood pressure >or=140 mm Hg) over this 5-year period. Poor adherence was defined as having medication refill gaps for >or=20% of days covered for medications prescribed for each of these conditions. Treatment intensification was defined as an increased medication dosage in a class, an increase in the number of medication classes, or a switch to a different class within 3-month periods before and after notation of above target levels.

RESULTS

Among patients with diabetes and poor disease control, depression was associated with an increased likelihood of poor adherence to diabetes control medications (odds ratio [OR] = 1.98; 95% Confidence Interval [CI] = 1.31, 2.98), antihypertensives (OR = 2.06; 95% CI = 1.47, 2.88), and LDL control medications (OR = 2.43; 95% CI = 1.19, 4.97). In patients with poor disease control who were adherent to medication or not yet started on a medication, depression was not associated with differences in likelihood of physician intensification of treatment.

CONCLUSIONS

In patients with diabetes and poor disease control, depression is an important risk factor for poor patient adherence to medications, but not lack of treatment intensification by physicians.

Impact of supportive measures on drug adherence in patients with essential hypertension treated with valsartan: the randomized, open-label, parallel group study VALIDATE

OBJECTIVE

The majority of treated hypertensive patients do not achieve target blood pressure (BP) levels of less than 140/90 mmHg. One key reason is inadequate adherence with the prescribed drug regimen. Dosing regimens are either not executed as prescribed (noncompliance) or patients stop taking the medication (nonpersistence). It has been demonstrated that adherence with angiotensin receptor antagonists such as valsartan is high due to the tolerability profile of this drug class. The present study was designed to evaluate whether drug adherence could further be improved by the use of supportive measures.

DESIGN AND METHODS

Twenty-eight centers were randomized to provide pharmacological treatment with or without a set of supportive measures (e.g. structured physician-patient interaction, printed information about hypertension, reminder stickers, 24 h timer, and home BP measurement device). Two hundred and two patients with grade 1 hypertension (BP at baseline 149.8 +/- 6.2/93.9 +/- 4.4 mmHg) who were either newly diagnosed or who had not been treated for at least 1 year were included in this trial. All patients entered the 34-week treatment phase with valsartan 160 mg daily. Titration to valsartan 160 mg/hydrochlorothiazide 12.5 mg was allowed if necessary. Drug adherence was assessed by electronic monitors (Medication Event Monitoring System).

RESULTS

Patients treated with a valsartan-based therapy receiving supportive measures as compared with the standard care group demonstrated an initially higher level of adherence with a maximum absolute difference of 7.8% (P = 0.041). This difference did not persist over the observation period but faded with time. In parallel, execution of the dosing regimen (compliance) was also improved in the intervention group during the early months of treatment but this effect also disappeared by the end of the observation period. In contrast, persistence in the two groups slowly but continuously separated over time. Estimated absolute difference in persistence at the end of the 34-weeks study between the two groups was 7.6% (95.9 vs. 88.3%) reflecting a 66% lower hazard of discontinuation in the intervention group (P = 0.073). BP control improved more in patients with the supportive measures.

CONCLUSION

Drug adherence improved initially with the use of supportive measures. However, this effect faded with time mainly because of the short-lived improvement in the quality of execution (compliance) achieved. In contrast, a longer lasting effect of the chosen supportive measures on persistence could be demonstrated, which, however, at least under the conditions of the present study, did not translate into a persistent improvement of medication adherence.

Adherence to osteoporosis treatments: room for improvement

PURPOSE OF REVIEW

Osteoporosis is a growing problem worldwide, with the greatest burden resulting from fractures. Currently available are several treatment options that are effective in reducing fracture risk. Patient adherence to these medications is required for benefit to be seen. Yet, similar to other chronic asymptomatic diseases, adherence to osteoporosis therapies is poor. The reasons for suboptimal adherence are multiple but include fear of possible side effects, dosing requirements, and an unwillingness to take a medication for a 'silent' disease. Poor adherence leads to reduced effectiveness, increased morbidity, and increased medical costs.

RECENT FINDINGS

Efforts to improve adherence to osteoporosis treatments are ongoing. The first obstacle in improving adherence to osteoporosis treatments is determining causes of poor adherence. Despite several identifiable causes, improving adherence is difficult. Passive patient education with printed information alone does not appear very effective. Physician-patient interaction, including discussion of bone mineral density results, discussion of osteoporosis medication benefits, and feedback of treatment effects, may be more effective.

SUMMARY

Improved patient education, better tolerated and less frequently dosed medications, and more healthcare provider-patient interaction may improve adherence and lead to greater fracture reduction.

Practical aspects of treatment discontinuation and adherence

Hypertension control in populations, although improving, remains far from satisfactory, even though effective and inexpensive therapies are available. Among many factors responsible for this situation, poor adherence to treatment appears to be particularly important. Unfortunately, even if its causes have been quite well defined, this problem is still far from being solved in clinical practice. The present paper discusses the key issues related to treatment adherence, and discontinuation in hypertension, in the light of recent evidence coming from the ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) and Telmisartan Randomized AssessmeNt Study in ACE iNtolerant subjects with cardiovascular Disease trial (TRANSCEND).

A cross-national study of the persistence of antihypertensive medication use in the elderly

INTRODUCTION

Little is known about cross-national comparisons of the persistence of antihypertensive medication treatment, trends in persistence, and factors associated with persistence. The aim of this study was to describe and compare patterns of use of antihypertensive drugs in a population of elderly patients in the United States (Pennsylvania), Canada (British Columbia) and the Netherlands.

METHODS

A retrospective cohort study of Medicare enrollees in a state pharmacy assistance programme in Pennsylvania (USA), residents from British Columbia (Canada) and residents from the Netherlands registered in the PHARMO database was conducted. Each population included patients 65 years and older who were initiated on blood pressure-lowering treatment between 1 January 1998 and 31 December 2003 and who had continuous follow-up for at least 365 days. In these populations, the proportion of patients with at least 180 consecutive days without medication available (non-persistence) were identified as were predictors of non-persistence using Cox proportional hazards.

RESULTS

A total of 9664 Medicare enrollees (USA), 25 377 residents from British Columbia and 24 603 residents from the Netherlands were evaluated. During the first year after the initiation of treatment, the percentage of patients with at least 180 days without medication was 23.3% in Pennsylvania, 23.4% in British Columbia and 24.0% in the Netherlands. After 6 years, these percentages increased to 41.1, 36.3 and 38.2%, respectively. Factors associated with non-persistence were different between the three countries.

CONCLUSION

Despite differences in factors associated with persistence, non-persistence patterns are strikingly similar in all three populations. This suggests that the problem of non-persistence transcends international boundaries.

Discontinuation of and changes in drug therapy for hypertension among newly-treated patients: a population-based study in Italy

OBJECTIVES

To assess rates and determinants of treatment discontinuation of or changes in initial antihypertensive drug therapy in a large cohort of patients from Lombardia (Italy).

METHODS

The cohort included 445356 patients aged 40 -80 years who received their first antihypertensive drug prescription (monotherapy) during 1999--2002. Discontinuation was defined by the absence of any antihypertensive prescription during a 90-day period following the end of the latest prescription. If during the same period a drug of a different class was added or replaced the initial prescription, treatment modification was regarded as combination or switching, respectively. Competing risks methodology was used to estimate and compare cause-specific cumulative incidence.

RESULTS

Cumulative incidences of discontinuation, combination and switching were respectively 33, 14 and 15% at 6 months, 41, 18 and 17% at 1 year, and 50, 25 and 19% at 5 years since initial treatment. Compared with patients starting treatment with angiotensin-converting enzyme inhibitors, the rate of discontinuation was less for patients on angiotensin receptor blockers with a hazard ratio of 0.92 (95% confidence interval =0.90-0.94), whereas increased discontinuation was observed for patients starting with other drugs, mainly beta-blockers with a hazard ratio of 1.64 (1.62-1.67); and diuretics with a hazard ratio of 1.83 (1.81-1.85).

CONCLUSION

In the general population of Lombardia, discontinuation of the initial single antihypertensive drug treatment is a common phenomenon, whereas switching to another monotherapy and to combination treatment occur at similarly much lower rates. Blockers of the renin-angiotensin system are associated with the lowest incidence of treatment discontinuation.

Compliance and fixed-dose combination therapy

Despite data on the importance of blood pressure control in preventing cardiovascular and cerebrovascular events, only 34% of hypertensive patients have their blood pressure under control. The National Council on Patient Information and Education has estimated that the compliance rate is just over 30% for chronic conditions like hypertension. Polypharmacy and complex treatment regimens have been identified as important, modifiable risk factors for medication noncompliance. Fixed-dose combination regimens are attractive options because of the improved antihypertensive efficacy resulting from the dual mechanistic action of components targeting different effector mechanisms. One drug in the fixed-dose combination may negate an adverse effect of the other medication. Above all, fixed-dose combination therapy reduces pill burden and improves medication compliance, which can translate into better cardiovascular outcomes. Fixed-dose combinations should be used routinely for the management of hypertension and should also be considered when initiating therapy for patients with newly diagnosed hypertension.

Essential hypertension

Essential hypertension can be defined as a rise in blood pressure of unknown cause that increases risk for cerebral, cardiac, and renal events. In industrialised countries, the risk of becoming hypertensive (blood pressure >140/90 mm Hg) during a lifetime exceeds 90%. Essential hypertension usually clusters with other cardiovascular risk factors such as ageing, being overweight, insulin resistance, diabetes, and hyperlipidaemia. Subtle target-organ damage such as left-ventricular hypertrophy, microalbuminuria, and cognitive dysfunction takes place early in the course of hypertensive cardiovascular disease, although catastrophic events such as stroke, heart attack, renal failure, and dementia usually happen after long periods of uncontrolled hypertension only. All antihypertensive drugs lower blood pressure (by definition) and this decline is the best determinant of cardiovascular risk reduction. However, differences between drugs exist with respect to reduction of target-organ disease and prevention of major cardiovascular events. Most hypertensive patients need two or more drugs for blood-pressure control and concomitant statin treatment for risk factor reduction. Despite the availability of effective and safe antihypertensive drugs, hypertension and its concomitant risk factors remain uncontrolled in most patients.

Preventing cardiovascular disease among Canadians: what are the potential benefits of treating hypertension or dyslipidemia?

BACKGROUND

Treatments for hypertension and dyslipidemia to prevent the development of cardiovascular disease compete for the same finite number of health care dollars. Therefore, the potential benefits of treating Canadians without cardiovascular disease or diabetes who would currently be targeted by the national treatment guidelines were estimated and compared.

STUDY DESIGN

Canadian Heart Health Surveys data were used to estimate the number of Canadians requiring intervention. The Cardiovascular Life Expectancy Model, a previously validated Markov model, was used to calculate the increased life expectancy and decreased morbidity associated with treating risk factors to target.

RESULTS

Among 8.44 million adults 40 to 74 years of age without cardiovascular disease or diabetes, it was estimated that approximately 2.33 million would require treatment for dyslipidemia and 2.34 million for hypertension. The estimated Framingham 10-year coronary risk averaged 12.4% versus 9.6%, respectively. Treating dyslipidemia was associated with an average increased life expectancy of 1.67 years and 1.81 years of life free of cardiovascular disease. Treating hypertension was expected to increase life expectancy by 0.94 years and years of life free of cardiovascular disease by 1.29 years. The population benefits associated with treating dyslipidemia or hypertension would be 2.5 million and 1.4 million person years of life saved, respectively. Overall, the person years of treatment required to save one year of life was estimated to average 20 years for dyslipidemia therapy and 38 years for hypertension.

CONCLUSIONS

The potential benefits associated with treating hypertension or dyslipidemia to prevent cardiovascular disease are substantial. However, compared with hypertension guidelines, dyslipidemia guidelines target higher-risk patients. Accordingly, given the relative efficacy of each treatment, the forecasted benefits associated with treating dyslipidemia are substantially greater than those associated with hypertension therapy.

Gaps in treatment among users of osteoporosis medications: the dynamics of noncompliance

PURPOSE

Cyclical patterns of compliance have been observed with many health-related activities such as dieting and exercise. It is not known whether such patterns of compliance exist among users of chronic medications. We sought to estimate the percentage of patients who restart osteoporosis therapy after a prolonged lapse in medication use and to identify the factors associated with a return to compliance.

METHODS

We studied 26,636 new users of an osteoporosis medication (alendronate, calcitonin, estrogen, raloxifene, or risedronate) who were age 65 or older and had an extended lapse in refill compliance, defined as a period of at least 60 days after the completion of one prescription in which no refill for any osteoporosis medication was obtained. Survival curves were used to estimate the length of time until therapy is resumed. We estimated the association between patient characteristics and the rate of resuming treatment using Cox proportional hazards analysis. We then conducted a case crossover analysis to examine whether certain events occurring during follow-up triggered a return to refill compliance.

RESULTS

Of patients who stopped therapy for at least 60 days, an estimated 30% restarted treatment within 6 months, and 50% restarted within 2 years. Among patients who had at least 6 months of continuous use before their interruption in treatment (n=5863), 42% restarted therapy within 6 months and 59% within 2 years. Younger patients, women, and those with a history of a fracture were more likely to return after a break in medication use. Recent hip fractures, discharges from nursing homes, and bone mineral density testing also predicted a return to treatment.

CONCLUSION

Extended gaps in treatment are common among users of osteoporosis medications. Because the effectiveness of these drugs used in an interrupted way is unknown, compliance interventions should emphasize the need for continuous medication use. Further research is needed to understand why patients often go for months without refilling prescriptions and also whether similar utilization patterns exist for other chronic medications.

Rates and determinants of reinitiating antihypertensive therapy after prolonged stoppage: a population-based study

OBJECTIVE

To assess patterns of restarting antihypertensive drugs after a prolonged period of discontinuation.

METHODS

We conducted a retrospective cohort study among new users of blood pressure-lowering medication in the PHARMO database in The Netherlands, who had a period of at least 180 days without such medication. A multivariable Cox proportional hazard analysis was used to explore the baseline variables associated with reinitiating treatment. Case-crossover analysis was used to evaluate determinants of reinitiating treatment.

RESULTS

We identified 35,714 patients as initiating blood pressure-lowering treatment during the period 1 January 1999 to 30 June 2004. Of the 18,357 (51.4%) patients who discontinued blood pressure-lowering treatment, 19.3% restarted treatment within 1 year and 60.7% restarted within 6 years. With every additional year they had been on therapy, patients were more likely to restart [odds ratio (OR) = 1.38; 95% confidence interval (CI) = 1.34-1.42]. The case-crossover analysis revealed that hospitalization for cardiovascular disease (OR = 2.20; 95% CI = 1.84-2.63), as well as refilling of another cardiovascular medication (OR = 1.25; 95% CI = 1.11-1.40), were each independently associated with reinitiating treatment. Refilling non-cardiovascular medications was not associated with reinitiating treatment (OR = 1.03; 95% CI = 0.97-1.10).

CONCLUSION

Physicians should be aware that many patients have prolonged periods of discontinuation during the use of blood pressure-lowering medication, and that most of these patients will eventually resume therapy. Ongoing refilling other medications is not associated with reinitiating treatment. This suggests that, for some patients, the decision to discontinue may be drug specific rather than a behavioural characteristic applicable to all chronic treatments.

Adherence to medication after liver transplantation in Scotland: a pilot study

This study assessed adherence to medication after liver transplantation and consisted of 2 components: a retrospective audit involving the examination of the Scottish national database, and a preliminary study assessing psychological factors implicated in poor adherence. In order to first establish an idea of the extent of poor adherence within the Scottish liver transplant population, a retrospective audit was carried out on all patients (N = 435) who received transplants before November 2003. Adherence was assessed by attendance at follow-up clinic appointments, blood immunosuppressant levels, and episodes of cellular rejection. It was found that attendance and immunosuppressant levels were often suboptimal and that nonadherence may have contributed to retransplantation and death. Cellular (acute) rejection after 6 months was associated with higher mortality. Explanations as to why liver transplant patients may not take their medication as recommended were then explored in detailed psychological assessments of 33 liver transplant recipients. The results indicated that low self-reported patient adherence was related to greater concerns regarding the potential adverse effects of medication, and a stronger belief that medicines in general are harmful. In addition, the greater the effect the transplantation had on patients' lives and the more it affected them emotionally, the less adherent the patients were likely to be. The results highlight potential areas that, if confirmed in a larger study, might be targeted in a psychological intervention to improve patient adherence and thereby transplantation outcomes.

Factors associated with medication refill adherence in cardiovascular-related diseases: a focus on health literacy

BACKGROUND

The factors influencing medication adherence have not been fully elucidated. Inadequate health literacy skills may impair comprehension of medical care instructions, and thereby reduce medication adherence.

OBJECTIVES

To examine the relationship between health literacy and medication refill adherence among Medicare managed care enrollees with cardiovascular-related conditions.

RESEARCH DESIGN

Prospective cohort study.

SUBJECTS

New Medicare enrollees from 4 managed care plans who completed an in-person survey and were identified through administrative data as having coronary heart disease, hypertension, diabetes mellitus, and/or hyperlipidemia (n=1,549).

MEASURES

Health literacy was determined using the short form of the Test of Functional Health Literacy in Adults (S-TOFHLA). Prospective administrative data were used to calculate the cumulative medication gap (CMG), a valid measure of medication refill adherence, over a 1-year period. Low adherence was defined as CMG> or =20%.

RESULTS

Overall, 40% of the enrollees had low refill adherence. Bivariate analyses indicated that health literacy, race/ethnicity, education, and regimen complexity were each related to medication refill adherence (P<.05). In unadjusted analysis, those with inadequate health literacy skills had increased odds (odds ratio [OR]=1.37, 95% confidence interval [CI]: 1.08 to 1.74) of low refill adherence compared with those with adequate health literacy skills. However, the OR for inadequate health literacy and low refill adherence was not statistically significant in multivariate analyses (OR=1.23, 95% CI: 0.92 to 1.64).

CONCLUSIONS

The present study suggests, but did not conclusively demonstrate, that low health literacy predicts poor refill adherence. Given the prevalence of both conditions, future research should continue to examine this important potential association.

Management of patients with uncontrolled arterial hypertension--the role of electronic compliance monitoring, 24-h ambulatory blood pressure monitoring and Candesartan/HCTZ

Background

Incomplete drug regimen compliance (DRC) and white-coat hypertension are two of several possible causes of uncontrolled hypertension. Therefore the aim of the present study was to compare DRC in hypertensives treated with combination therapy whose blood pressures (BP) were controlled vers. uncontrolled after 4 weeks of self-monitored BP measurement. To observe the consequences in uncontrolled patients of switching one drug of the combination therapy to candesartan/HCTZ (16 mg/12.5 mg) with and without a compliance intervention program.

Methods

Self-and ambulatory-monitoring of BP were done with upper arm oscillometric devices. Patients' dosing histories were compiled electronically (MEMS(c), AARDEX). Patients with office blood pressure (OBP) >140/90 mmHg despite combination therapy were begun on MEMS monitoring and self BP measurement for 4 weeks of run-in. Of 62 such patients, 18 (29%) patients were normotensive according to self BP measurement and ambulatory BP measurement at 4 weeks (Group A); in the remaining 44 still uncontrolled patients, candesartan/HCTZ was substituted for one of the combination therapy drugs, with half these patients receiving passive compliance monitoring (B) and half a DRC intervention program (C). All groups were then followed for 8 weeks.

Results

DRC before week 4 was significantly higher in A than in the uncontrolled patients (B&C). DRC was stable during run-in A, but declined in B and C. DRC after week 4 was not different in the three groups and stayed constant over time. DRC during weekends was lower than during weekdays in all groups.

In group A no significant change in blood pressure was observed with all three methods of BP measurements. In groups B and C significant reductions of systolic and diastolic BP were observed for ABPM and SBPM. After the change to candesartan/HCTZ in B&C ambulatory 24-h-BP (ABPM) was normalized in 39% of patients.

Conclusion

Normalization of BP was associated with superior drug regimen compliance in previously uncontrolled patients treated with a combination drug regimen. Switching still-uncontrolled patients to candesartan/HCTZ significantly improved BP control and stabilized a declining DRC.

Association of Refill Adherence and Health Care Use Among Adults with Hypertension in an Urban Health Care System

STUDY OBJECTIVES

To determine the rates of undersupply, appropriate supply, and oversupply of antihypertensive drugs, as measured by refill adherence, among patients with complicated and uncomplicated hypertension (i.e., patients who have and have not, respectively, experienced hypertension-related target organ damage), and to examine the association of refill adherence with hospitalization and health care costs among these patients.

DESIGN

Retrospective analysis of electronic medical records.

SETTING

An urban, public health care system.

PATIENTS

A total of 15,206 patients aged 18 years or older whose electronic medical records indicated a clinical diagnosis of hypertension based on the International Classification of Diseases, Ninth Revision, Clinical Modification codes, and who had received at least one prescription of an antihypertensive drug from 1995-2001.

MEASUREMENTS AND MAIN RESULTS

We used multivariable analyses to investigate the association of refill adherence with hospitalization and costs. On average, 53% of patients had appropriate supplies (80-120% of supplies needed), 7% had undersupplies, and 40% had oversupplies of drug annually. For patients with complicated hypertension, an undersupply of drug was associated with a 15% greater probability (p=0.009) and an oversupply with a 16% greater probability (p<0.0001) of hospitalization. Among those with uncomplicated hypertension, oversupply was associated with an 11% greater probability (p=0.0002) of hospitalization; undersupply was not associated with greater probability of hospitalization. Total health care costs were lower for patients with undersupplies and higher for those with oversupplies of drug.

CONCLUSION

Among adults in an urban health care system with complicated hypertension, both undersupply and oversupply of drug were associated with increased hospitalization rates. Monitoring refill adherence of patients, particularly those with low income, minority status, and complicated hypertension, may be useful for targeting patients with undersupplies of drug to encourage refill adherence and identifying patients with oversupplies, who are at high risk of hospitalization.

Differences in antihypertensive drug persistence associated with drug class and gender: a PHARMO study

OBJECTIVE

The objective of the study is to investigate factors related to treatment persistence among users of antihypertensive (AHT) drugs in daily practice.

METHODS

Data for this study were obtained from the PHARMO database including pharmacy records and hospitalizations in the Netherlands (n=950,000). Patients who newly received AHT therapy (n=17,113) between 1997 and 2001 were selected. Of these patients, random samples of 500 patients per drug class were drawn. One-year persistence was defined as (1) the percentage of patients using AHTs at least 270 days and receiving AHT in 3 months after the 1-year follow-up period, and (2) Catalan method (Kaplan-Meier curves). Gender specific persistence rates per drug class were adjusted for significant factors including age, use of antidiabetics and lipid lowering drugs, and prior cardiovascular hospitalizations (OR and 95%CI).

RESULTS

Persistence was highest in users of angiotensin II receptor blockers (ARBs) (62.0%), progressively lower in users of angiotensin converting enzyme inhibitors (ACE-inhibitors, 59.7%), betablockers (35.0%), calcium channel blockers (34.7%), and diuretics (33.0%), resulting in the highest OR of 3.4 [95%CI: 2.6-4.5] for ARBs compared to diuretics. The persistence of AHT use in women was substantially lower (40.1% vs. 50.2%, OR 0.7 [95%CI: 0.6-0.8]) and differences between drug classes were larger than in men.

CONCLUSIONS

These results demonstrate marked differences in persistence between AHT classes, with the highest persistence for ARBs and lowest for diuretics. Women were less persistent with their AHT compared to men. This low persistence leads to suboptimal treatment with a potential for substantial clinical consequences. Especially in women, more attention paid to AHT persistence patterns could improve their cardiovascular outcome.

Mothers' attitudes to the randomized controlled trial (RCT): the case of acute lymphoblastic leukaemia (ALL) in children

OBJECTIVES

Survival rates for childhood cancer have improved substantially partly as a result of national and international randomized clinical trials (RCT). However, the decision for families is complex and emotional. Our aim was to describe the views of mothers of children newly diagnosed with ALL regarding consent to randomized controlled trials.

DESIGN

Qualitative interview to explore mothers knowledge, and reasons for involving their child in RCTs. Interviews took place in mothers' homes.

PARTICIPANTS

Fifty mothers of children with newly diagnosed ALL (age 4-16 years; mean = 7.4) recruited through research nurses at outpatient appointments.

RESULTS

All but three families had consented for their child to be treated in the RCT, although there was wide variation in their understanding of the aims, costs and benefits. Most mothers reported the aim of the trial to compare 'old' and 'new' treatments.

CONCLUSION

Despite detailed verbal and written information, mothers were poorly informed about the purpose of the trial, and possibility of side effects. Individual preferences for either standard or new treatment were routinely reported. The data raise questions about the extent to which families give truly informed consent to recruitment of their child to an RCT.