Hypertension and current issues in compliance and patient outcomes

Self-Reported Medication Adherence Measured With Morisky Medication Adherence Scales and Its Determinants in Hypertensive Patients Aged ≥60 Years: A Systematic Review and Meta-Analysis

Background: The aim of this systematic review and meta-analysis was to estimate medication adherence in hypertensive patients aged ≥60 years and to explore potential determinants of adherence with antihypertensive treatment in this age group.

Methods: A systematic search of the PubMed, Scopus, and Google Scholar using the Cochrane guidelines was performed. The analysis included articles published between 1 January 2000 and 30 June 2018. The patients were considered adherent if they scored ≥6 pts. on the Morisky Medication Adherence Scale (MMAS-8) or ≥3 pts. on the Morisky Green Levine Medication Adherence Scale (MGL). If available, also odds ratios (OR) with 95% confidence intervals (95% CI) for determinants of medication adherence were recorded.

Results: Thirteen studies including a total of 5,247 patients were available for the meta-analysis. The pooled percentage of adherence was 68.86% (95% CI: 57.80–79.92%). Subgroup analysis did not demonstrate a significant difference in the adherence measured with the MMAS-8 and the MGL (68.31 vs. 70.39%, P = 0.773). The adherence of patients from Western countries (Europe, United States) turned out to be significantly higher than in other patients (83.87 vs. 54.30%, P = 0.004). The significant determinants of better adherence identified in more than one study were older age, retirement/unemployment, duration of hypertension >10 years, and a lower number of prescribed drugs.

Conclusion: Medication adherence in the oldest old hypertensive patients seems to be higher than in younger persons. Adherence in older persons was associated with age, socioeconomic status, and therapy-related factors.

Using the transtheoretical model's stages of change to predict medication adherence in patients with type 2 diabetes mellitus in a primary health care setting

BACKGROUND

Qatar is currently experiencing a worrying increase in the prevalence of diabetes mellitus (DM). One of the most common reasons for uncontrolled DM is non-adherence to medications. The socio-behavioral intervention has proven effective in some chronic illnesses.

OBJECTIVES

To assess the stages of change (SOC) and medication adherence scores of type 2 diabetes mellitus (T2DM) patients visiting primary healthcare institutions in Qatar, and to evaluate the cause and effect relationship between SOC and adherence to antidiabetic medications.

METHODS

The 8-item Morisky Medication Adherence Scale (MMAS-8) was used to assess medication adherence, and a 2-item SOC questionnaire was utilized to classify the SOC. The analysis to determine if the SOC could predict medication adherence while controlling for demographic characteristics, total number of prescribed medications and disease duration was done using hierarchical multiple regression.

RESULTS

The final analysis included 387 patients. In relation to medication adherence, majority of the patients were in the maintenance stage (76.7%), followed by the preparation stage (14.7%), the action stage (3.9%), the contemplation stage (3.4%) and the precontemplation stage (1.3%). Most of the patients were in high adherence towards antidiabetic medications (50.3%) followed by low level (26.4%) and medium level (23.3%). SOC was significant and positively predicted medication adherence, which accounted for around 58 to 60% (p < 0.001) while controlling for covariates.

CONCLUSIONS

SOC was significant and positively predicted medication adherence. The study recommends that the SOC questionnaire could potentially be used to identify patients at risk for low adherence.

Adherence, risk factors of non-adherence and patient's preferred treatment strategy of mesalazine in ulcerative colitis: multicentric observational study

OBJECTIVES

Compliance to therapy is a key factor in the efficacy of treatment in clinical practice. The aim of our study was to evaluate the rate of compliance with mesalazine in patients with ulcerative colitis (UC), to examine risk factors of noncompliance and especially find ways on how adherence can be improved.

MATERIALS AND METHODS

A total of 198 outpatients with UC completed two anonymous questionnaires including information on basic demographics, details of patient´s disease and the use of mesalazine medication and quality of life.

RESULTS

We found noncompliance (percentage of used medication per day less than 80%) with 5-ASA in 21.2% patients. Our study proved that the education level of patients significantly influenced the compliance of patients using mesalazine. A significant difference (p = .014) was found between the compliance of patients with secondary school education (84.1 ± 16.73) and those with university education (94.1 ± 9.9). The majority of patients preferred mesalazine once daily and are less likely to forget to take medication in the morning. Better quality of life was observed based on our data from WHOQOL-BREF questionnaire in statistically significant way in patients using concomitant therapy of immuosuppressive or biological therapy, lower daily doses and using sachets not tablets.

CONCLUSIONS

Our study proved that compliance with mesalazine in patients with UC was related only to education level. If we target mesalazine therapy based on patient's preferences, we can improve the adherence with mesalazine. Our data could be beneficial for the treatment strategy in clinical practice.

Antihypertensive Medications Adherence Among Nigerian Hypertensive Subjects in a Specialist Clinic Compared to a General Outpatient Clinic

Background:

Poor adherence to antihypertensive medications has been linked with increased cardiovascular risk and mortality in many population. Africans have been shown to have a worse prognosis from hypertension, poorer blood pressure control, and increased risk of complications arising from hypertension compared to Caucasians.

Aim:

The aim was to describe the level of adherence to antihypertensive medications, its determinants and whether any difference exist between those attending specialty clinic or general outpatient department (GOPD) Clinic in a Nigerian University Teaching Hospital.

Subjects and Methods:

An analytical cross-sectional study. The Morisky scale was used to assess for adherence to antihypertensive medications. Clinical and demographic data were taken. Statistical analysis was performed using SPSS 17.0. (Chicago, IL, USA). P < 0.05 was taken as statistically significant.

Results:

A total of 114 hypertensive subjects were recruited for this study. Seventy-nine were from the cardiology clinic whereas 35 were from the GOPD. They consisted of 60 males (52.6%, 60/114) and 54 females (47.4%, 54/110). The mean age was 63.6 (14.1) years. High adherence, low adherence and medium adherence as defined by Morisky scale was found in 36.8% (42/114), 23.9% (27/114) and 39.5% (45/114), respectively. Adherence level was higher among those attending specialty clinic despite shorter duration of hypertension and use of more medications. More than four-fifth of those attending cardiology clinic had at least medium level of adherence compared to a little bit over half of those attending GOPD clinic. Those with good adherence were likely to be older, had a higher level of education and higher average monthly income than those with poor adherence.

Conclusion:

Poor adherence to medications is very common in the hypertensive Nigerians. Hypertensive subjects attending specialty clinic seems to have a better adherence to antihypertensive medications possibly due to the level of health education and information provided to patients. Effective health education and regular screening for compliance and adherence is a potential way to reduce cardiovascular risk associated with uncontrolled hypertension.

Factors influencing the provision of adherence support by community pharmacists: A structural equation modeling approach

BACKGROUND

Non-adherence to medication represents an important barrier to achieving optimum patient outcomes. Community pharmacists are well placed to deliver interventions to support adherence.

AIMS

To investigate community pharmacists' activities in supporting patient adherence; and identify factors influencing pharmacists' provision of adherence support.

METHOD

A random sample of 2020 Australian community pharmacies was mailed a questionnaire investigating their provision of adherence support. The self-completed, structured questionnaire consisted of eight sections, five of which were relevant to this study: strategies used to identify non-adherent patients, strategies used to support patients' adherence to medications, pharmacists' attitudes toward provision of adherence support, perceived barriers to provision of adherence support, and demographics. Structural equation modeling (SEM) was used to determine potential influencing factors.

RESULTS

A response rate of 31% was achieved (n = 627). Pharmacists reported using strategies to identify non-adherent patients for less than half (45%) of the prescriptions dispensed. A mean of 8.4 ± 14.9 (mean ± SD) strategies was used by respondents in the 7 days prior to survey completion. Dose administration aids was the most commonly used strategy (provided by 96.5% of respondents). Time pressure for patients (68%) was perceived by pharmacists as the main barrier to adherence support. SEM identified "stakeholders/skills" and "number of full time equivalent staff" as influencing provision of adherence support strategies.

CONCLUSION

Provision of adherence support by pharmacists was episodic and infrequent, impeded by a number of barriers. By addressing barriers, it is possible to enable pharmacists to become more proactive and effective in supporting patient adherence.

Effects of the fixed combination of manidipine plus delapril in the treatment of hypertension inadequately controlled by monotherapy with either component: a phase III, multicenter, open-label, clinical trial

BACKGROUND

Failure to achieve good blood pressure (BP) control is probably the most important reason for high rates of morbidity and mortality in patients with hypertension. Combination therapy has been shown to increase the percentage of patients in whom BP control is achieved. One combination is a calcium channel blocker (CCB) and an angiotensin-converting enzyme inhibitor (ACE-I).

OBJECTIVE

The aim of this study was to assess the effects of the fixed combination of the CCB manidipine and the ACE-I delapril in the treatment of hypertensive patients already given monotherapy with either component but with poor results (ie, insufficient BP control or adverse events [AEs]).

METHODS

In this Phase III, multicenter, open-label, clinical trial, patients with mild to moderate hypertension were assigned to 1 of 2 groups. Group 1 comprised patients whose diastolic BP (DBP) was >90 mm Hg or who experienced AEs with manidipine 20 mg once daily. Group 2 comprised patients who had a DBP >90 mm Hg or who experienced AEs with delapril 30 mg BID. In both groups, patients aged <65 years were to be treated with a fixed combination of manidipine 10 mg plus delapril 30 mg once daily for 12 weeks, whereas patients aged ≥65 years were to be treated with manidipine 5 mg plus delapril 15 mg once daily for 2 weeks and then manidipine 10 mg plus delapril 30 mg once daily for 10 weeks. Patients were assessed at baseline and at 2, 4, 8, and 12 weeks of treatment. At each visit, systolic blood pressure (SBP), DBP, and heart rate were measured 24 hours after dosing, and AEs were recorded.

RESULTS

Group 1 included 154 patients (80 men, 74 women; mean [SD] age, 55 [6] years); group 2 included 158 patients (79 men, 79 women; mean [SD] age, 56 [5] years). Mean BP decreased significantly in both groups (P<0.01). Compared with baseline values, mean SBP/DBP decreased 16.2 (3.8)/10.1 (1.9) mm Hg in group 1 and 15.8 (3.1)/11.0 (1.5) mm Hg in group 2 at the last visit. The success rate-rate of normalized DBP (≤90 mm Hg) and responder rate (DBP reduction ≥10 mm Hg)-was 79% in group 1 and 82% in group 2. The rates of treatment-related AEs were 11% in group 1 and 8% in group 2. In group 1, heart rate significantly increased from baseline only at 2 weeks (P<0.05); in group 2, at each visit (P<0.05) except at week 12. However, none of these differences were clinically significant.

CONCLUSION

In this study population of patients whose BP was not adequately controlled by monotherapy, the fixed combination of manidipine 10 mg plus delapril 30 mg, once daily, was effective and well tolerated.

Determinants of medication adherence to antihypertensive medications among a Chinese population using Morisky Medication Adherence Scale

BACKGROUND AND OBJECTIVES

Poor adherence to medications is one of the major public health challenges. Only one-third of the population reported successful control of blood pressure, mostly caused by poor drug adherence. However, there are relatively few reports studying the adherence levels and their associated factors among Chinese patients. This study aimed to study the adherence profiles and the factors associated with antihypertensive drug adherence among Chinese patients.

METHODS

A cross-sectional study was conducted in an outpatient clinic located in the New Territories Region of Hong Kong. Adult patients who were currently taking at least one antihypertensive drug were invited to complete a self-administered questionnaire, consisting of basic socio-demographic profile, self-perceived health status, and self-reported medication adherence. The outcome measure was the Morisky Medication Adherence Scale (MMAS-8). Good adherence was defined as MMAS scores greater than 6 points (out of a total score of 8 points).

RESULTS

From 1114 patients, 725 (65.1%) had good adherence to antihypertensive agents. Binary logistic regression analysis was conducted. Younger age, shorter duration of antihypertensive agents used, job status being employed, and poor or very poor self-perceived health status were negatively associated with drug adherence.

CONCLUSION

This study reported a high proportion of poor medication adherence among hypertensive subjects. Patients with factors associated with poor adherence should be more closely monitored to optimize their drug taking behavior.

Bone turnover markers and bone mineral density response with risedronate therapy: relationship with fracture risk and patient adherence

Surrogate markers of fracture risk--bone turnover markers (BTMs) and bone mineral density (BMD)--can be used to monitor treatment response. We assessed whether changes in these markers greater than the least significant change (LSC) were associated with fracture risk reduction and greater adherence. This secondary analysis of the Improving Measurements of Persistence on ACtonel Treatment (IMPACT) study--a multinational prospective, open-label, cluster-randomized study of postmenopausal women on oral risedronate 5 mg/d for 52 weeks-assessed adherence by electronic monitors. Urinary N-terminal cross-linked telopeptide of type 1 collagen (uNTX) and serum C-terminal cross-linked telopeptide of type 1 collagen (sCTX) levels were assessed at baseline and weeks 10 and 22, and BMD at baseline and week 52. Fractures were recorded as adverse events. In 2302 women, responses beyond LSC in BTMs (uNTX and sCTX) and BMD (spine only) were associated with a reduced risk of nonvertebral fractures (NVFs) and all fractures. NVF incidence was about 50% lower in patients with 30% or more of uNTX reduction at week 22 (1.6%) than in those with less than 30% reduction (3.2%, p = .015). NVFs also were reduced in patients with more than 3% spine BMD increase at 52 weeks than those with 3% or less. Responses greater than LSC in BTMs and BMD were associated with greater adherence, but there was no association between adherence and fracture outcomes at 52 weeks. Changes greater than the LSC in BTMs and BMD reflect better treatment adherence, were associated with fracture risk reduction, and identify differences in individual responsiveness to risedronate.

Different aspects of adherence to antihypertensive treatments

This review collects together data concerning the measurement of patient behavior towards antihypertensives, considering all its aspects - adherence, persistence and switching. The wide heterogeneity of terms, outcome definitions and methods of assessment (the multiplicity of approaches did not allow a full meta-analysis, but a qualitative description of the results) are demonstrated. The percentages of adherence/compliance from the studies discussed in this review range from 15 to 99% across different study designs, populations and methods. Large, observational studies are suggested as a reliable method to measure patient behavior. An emerging issue is the relevance of patient motivation and education, which could provide a higher level of compliance to treatment, thus allowing achievement of better clinical outcomes and improved use of resources for the healthcare system.

Assessment of adherence, persistence, and costs among valsartan and hydrochlorothiazide retrospective cohorts in free-and fixed-dose combinations

OBJECTIVES

To assess medication adherence, persistence, and costs between cohorts of patients in managed care settings using a fixed-dose combination (FDC) or individual components (IC) of valsartan and hydrochlorothiazide in an insurance claims database.

METHODS

Medical and prescription claims for hypertensive patients using a combination of valsartan and HCTZ were identified from the IHCIS National Managed Care Benchmark Database via a retrospective cohort analysis. Study subjects had at least 110 days prior to start of study medications during which no other antihypertensive medications were prescribed, and were followed for 12 months. Claims for 8711 adult patients were analyzed for adherence, persistence and costs. General linear regression was conducted to detect differences in adherence among groups. Covariates included age, gender, persistence, number on concomitant cardiovascular drugs, and number of cardiovascular diagnoses.

RESULTS

Most subjects used an FDC product (N=8150, 93.6%) vs. the IC (N=561, 6.4%). The FDC group had a larger portion of males and less concomitant cardiovascular medications or disease. A random sample of 1628 of the FDC subjects had improved values for medication adherence compared to the IC group (62.1 vs. 53.0%, p<0.001) and persistence values were improved at both 180 days (73 vs. 28%, p<0.001) and 365 days (54 vs. 19%, p<0.001). Both prescription drug costs ($1587 vs. $2050, p<0.001) and medical costs ($3343 vs. $3817, p<0.001) were lower in the FDC cohorts.

CONCLUSIONS

The use of fixed-dose therapy in hypertension may lead to increased adherence and persistence with a positive financial impact on both prescription and total medical costs. As with any retrospective claims database analysis, unobserved systematic differences between the two medication groups may exist.

Medication compliance and persistence: terminology and definitions

OBJECTIVE

The aim of the study is to provide guidance regarding the meaning and use of the terms "compliance" and "persistence" as they relate to the study of medication use.

METHODS

A literature review and debate on appropriate terminology and definitions were carried out.

RESULTS

Medication compliance and medication persistence are two different constructs. Medication compliance (synonym: adherence) refers to the degree or extent of conformity to the recommendations about day-to-day treatment by the provider with respect to the timing, dosage, and frequency. It may be defined as "the extent to which a patient acts in accordance with the prescribed interval, and dose of a dosing regimen." Medication persistence refers to the act of continuing the treatment for the prescribed duration. It may be defined as "the duration of time from initiation to discontinuation of therapy." No overarching term combines these two distinct constructs.

CONCLUSIONS

Providing specific definitions for compliance and persistence is important for sound quantitative expressions of patients' drug dosing histories and their explanatory power for clinical and economic events. Adoption of these definitions by health outcomes researchers will provide a consistent framework and lexicon for research.

Importance of medication adherence in cardiovascular disease and the value of once-daily treatment regimens

An estimated 71 million individuals in the United States are currently diagnosed with cardiovascular disease (CVD). If untreated, CVD conditions such as systemic hypertension, coronary artery disease, and heart failure will have potentially serious and often fatal outcomes. Numerous clinical trials have established a variety of evidence-based medications that are efficacious in the treatment of CVD. These drugs will be ineffective, however, if patients have trouble adhering to their prescribed regimens. In patients with hypertension or heart failure, or in those who have suffered a myocardial infarction, poor adherence to therapies has been linked to a variety of problems, including poor blood pressure control, rehospitalization, and increased healthcare resource utilization. Both the asymptomatic nature of some forms of CVD and the high pill burden associated with certain therapies have been linked to poor adherence. Reducing pill burden through the use of once-daily formulations has proven valuable in improving adherence to evidence-based therapies. This review will discuss the impact of adherence to prescribed therapies for CVD, outline common barriers to adherence, and demonstrate the value of once-daily dosing regimens for improved patient adherence.

Effect of monitoring bone turnover markers on persistence with risedronate treatment of postmenopausal osteoporosis

CONTEXT

Persistence with osteoporosis treatment is poor but is important for maximum benefit.

OBJECTIVE

The objective of the study was to assess the impact of physician reinforcement using bone turnover markers (BTMs) on persistence with risedronate treatment.

DESIGN AND SETTING

This was a 1-yr multinational prospective, open-label, blinded study in 171 osteoporosis centers in 21 countries.

PATIENTS

A total of 2382 postmenopausal women (65-80 yr old) with spine/hip T-score -2.5 or less or T-score -1.0 or less with a low-trauma fracture.

INTERVENTION

Intervention included calcium 500 mg/d, vitamin D 400 IU/d, and risedronate 5 mg/d for 1 yr. Centers were randomized to reinforcement (RE+) or no reinforcement (RE-). At 13 and 25 wk, reinforcement based on urinary N-telopeptide of type I collagen change from baseline was provided to the RE+ patients using the following response categories: good (>30% decrease), stable (-30% to +30% change), or poor (>30% increase).

MAIN OUTCOME MEASURES

Persistence assessed with electronic drug monitors was measured.

RESULTS

In the overall efficacy population (n=2302), persistence was unexpectedly high and was similar for both groups (RE-, 77%; RE+, 80%; P=0.160). A significant relationship between the type of message and persistence was observed (P=0.017). Compared with RE-, intervention based on a good BTM response was associated with a significant improvement in persistence [hazard ratio (HR) 0.71; 95% confidence interval (CI) 0.53-0.95]. Persistence was unchanged (HR 1.02; 95% CI 0.74-1.40) or lower (HR 2.22; 95% CI 1.27-3.89) when reinforcement was based on a stable or poor BTM response, respectively. Reinforcement was associated with a lower incidence of new radiologically determined vertebral fractures (odds ratio 0.4; 95% CI, 0.2-1.0).

CONCLUSIONS

Reinforcement using BTMs influences persistence with treatment in postmenopausal women with osteoporosis, depending on the BTM response observed.

Identification of psychosocial factors of noncompliance in hypertensive patients

This cross-sectional study was aimed to identify the predictors of medication noncompliance in hypertensive patients. The study was conducted at the Family Medicine Clinic, Hospital Universiti Sains Malaysia, Kelantan, Malaysia, which is a university-based teaching hospital. All hypertensive patients aged 40 or over-registered from January to June 2004, who had been on treatment for at least 3 months, were screened. Previously validated self-administered questionnaires were used to assess the compliance and psychosocial factors. A total of 240 hypertensive patients were recruited in the study. Of these, 55.8% were noncompliant to medication. Logistic regression showed that age (adjusted odds ratio (OR): 0.96; 95% confidence interval (CI): 0.92-0.997; P: 0.035), patient satisfaction (adjusted OR: 0.97; 95% CI: 0.93-0.998; P: 0.036) and medication barrier (adjusted OR: 0.95; 95% CI: 0.91-0.987; P: 0.009) were significant predictors of medication noncompliance. Therefore, younger age, poor patient satisfaction and medication barrier were identified as independent psychosocial predictors of medication noncompliant in hypertensive patients.

Medication barriers and anti-hypertensive medication adherence: The moderating role of locus of control

Locus of control as a moderator of the relationship between medication barriers (e.g., side-effects, forgetting to take medication, and keeping track of pills) and anti-hypertensive medication adherence was examined. Baseline data were obtained from 588 hypertensive veterans. In general, fewer medication barriers, higher internal locus of control and lower external locus of control was associated with better hypertensive medication adherence. Furthermore, internal locus of control served as a moderator (beta = -.74, p < .01) for the relationship between medication barriers and medication adherence; effect size was large. Decomposition of the interaction revealed that the relationship between medication barriers and medication adherence was strongest when internal control was high (b = -.24, p < .01). Higher internal locus of control was beneficial when barriers to medication adherence are low, but at high perceived barriers, locus of control plays less of a role in medication adherence. Future efforts to improve medication adherence should consider the patient's perceived level of medication barriers in conjunction with their locus of control.

An Open-Label Study Investigating the Efficacy and Safety of 12–96 Weeks of Telmisartan Treatment in Patients with Hypertension

This open-label, multicentre, multinational trial evaluated the efficacy and safety of telmisartan used alone or as add-on therapy in 2121 adults with mild-to-moderate essential hypertension. Patients received telmisartan 40-80 mg once daily for 12 weeks and could participate in the study for up to 96 weeks, or until a marketed supply of telmisartan became available. Mean change from baseline in mean seated trough diastolic blood pressure (DBP) after 12 weeks' treatment, the primary endpoint, was −11.8 mmHg in the intent-to-treat population. The corresponding mean change in mean seated trough systolic blood pressure (SBP) was −20.2 mmHg. Both changes were statistically significant. Mean DBP and SBP reductions were apparent from week 4 and maintained throughout the treatment period. Telmisartan was well tolerated; the most common adverse events were headache (6%) and dizziness (3%), and 10% of adverse events were considered drug-related. In conclusion, telmisartan is an effective and well-tolerated drug when used as monotherapy or add-on treatment in this broad population of patients.

Adherence to Antihypertensive Therapy With Fixed-Dose Amlodipine Besylate/Benazepril HCl Versus Comparable Component-Based Therapy

Adhering to medication regimens has the potential to significantly improve clinical outcomes for persons with high blood pressure. A patient-related factor likely to affect adherence to treatment is the convenience of the prescribed drug regimen. The authors hypothesized that medication adherence would be superior and cost benefits would accrue in subjects who receive a once-daily, single-capsule, fixed-dose combination product for blood pressure control, compared with subjects who receive a similar regimen of separate components. A managed care organization that provides benefits for members enrolled in various health plans provided the data for this retrospective analysis. The database was used to assess medication adherence patterns for two groups of hypertensive subjects. Group 1 included subjects who had been prescribed the single-capsule, fixed-dose combination of amlodipine besylate/benazepril HCl. Group 2 comprised subjects who had been prescribed a regimen including an angiotensin-converting enzyme inhibitor and a dihydropyridine calcium channel blocker as separate drugs. Adherence was measured by the medication possession ratio, and medical resource utilization by the two groups was assessed during the study period. Group 1 (n=2754) and Group 2 (n=2978) were balanced with regard to age (mean, 53 years; range, 18-64 years) and sex (men, 50%; women, 50%). The overall medication possession ratio for Group 1 was significantly higher than that for Group 2 (80.8% vs. 73.8%; p<0.001). The average annual cost of cardiovascular-related care per subject was significantly lower in Group 1 compared with Group 2 (p<0.001). Subjects receiving the once-daily, single-capsule, fixed-dose combination of amlodipine/benazepril HCl demonstrated significantly better medication adherence and required fewer medical resources than did subjects receiving an angiotensin-converting enzyme inhibitor and a dihydropyridine calcium channel blocker as separate components.

Compliance with antihypertensive therapy after renal artery stenting

Hypertension is an important clinical endpoint after renal artery revascularization for renal artery stenosis (RAS). Medication compliance is a critical determinant of blood pressure control. Although factors influencing compliance are known in essential hypertension, they have not been evaluated in studies investigating renal artery revascularization. The aim of this study was to assess the determinants of compliance to antihypertensive therapy in patients with RAS following renal artery stent placement (RASP). A cross-sectional study evaluating blood pressure, antihypertensive medications, quality of life, compliance, and determinants of compliance to antihypertensive therapy was undertaken in 112 patients undergoing RASP. Additionally, cardiovascular risk factors, antihypertensive medications, and cardiovascular history were reported. Self-reported compliance was 79% +/- 24% (scale of 0% [none] to 100% [complete] compliance) in patients after RASP. Determinants of compliance by multivariate analysis included physical symptoms, which correlated negatively to compliance and included loss of appetite (r2 = 0.26, P < 0.0001), dizziness (r2 = 0.06, P < 0.01), and cough (r2 = 0.03, P < 0.05). Systolic blood pressure correlated positively with compliance (r2 = 0.03, P < 0.05). The number or class of antihypertensive medications did not influence compliance. Patients' physical symptoms and level of systolic blood pressure, rather than the number or class of medications, influence compliance in patients with continued hypertension after RASP. Attention to physical symptoms may help to improve blood pressure control in this population.

Validation of the short form of the Spanish Hypertension Quality of Life Questionnaire (MINICHAL)

BACKGROUND

The finding that low health-related quality of life (HRQoL) can be a risk factor for future cardiovascular events in patients with hypertension emphasizes the need for disease-specific HRQoL assessment tools in this population.

OBJECTIVE

This study evaluated the feasibility and psychometric properties of the short form of the Spanish Hypertension Quality of Life Questionnaire (MINICHAL).

METHODS

An observational, prospective, multicenter study was carried out among patients with hypertension, stratified by sex and disease stage. The feasibility and validity of the MINICHAL were evaluated at baseline. Two follow-up visits were conducted at 1 and 6 months after the initial visit, during which the test-retest reliability and responsiveness to change of the MINICHAL were assessed, respectively.

RESULTS

A total of 736 consecutive patients with hypertension were included. Mean (SD) administration time for the MINICHAL was 7.2 (6.5) minutes. In the validation process, factor analysis showed 2 dimensions: "State of mind" (StM) and "Somatic manifestations" (SM). The response level was high, with 94.3% of patients answering all items. Patients with a higher disease stage (ie, stage II/III hypertension) had a worse HRQoL than those with a lower disease stage (P < 0.01). Internal consistency was 0.87 for StM and 0.75 for SM. Test-retest reliability was 0.82 and 0.75 for the StM and SM dimensions, respectively. Among patients who reported experiencing a positive change in their overall health status 6 months after treatment initiation or treatment change, responsiveness to change ranged from 0.52 (better) to 1.14 (much better).

CONCLUSIONS

The MINICHAL questionnaire could be administered in a short time with a high response level and was found to have acceptable psychometric properties. The MINICHAL is a potentially useful tool for the evaluation of HRQoL among patients with hypertension in the routine clinical setting.

Comparison of baseline characteristics and mortality experience of participants and nonparticipants in a randomized clinical trial: the Physicians' Health Study

Although subjects randomized into clinical trials tend to have different mortality experiences from those not randomized, few studies have examined how baseline characteristics may explain these differences. We used the recruitment experience of the Physicians' Health Study (PHS) to describe and compare subgroups of subjects ultimately randomized - or not - into the PHS. A total of 112528 male physicians ages 40-84 years responded to letters of invitation and baseline questionnaires sent to 261248 subjects. Baseline information was collected on eligibility criteria, plus lifestyle and clinical risk factors. Total, cardiovascular, cancer, and other mortality were determined through the National Death Index after a mean follow-up of 5.39 years. Respondents had 19 and 19% lower total and cardiovascular mortality rates than nonrespondents. Similarly, willing respondents were 19 and 16% less likely to die than unwilling respondents. However, much of this difference in mortality was explained by disease and lifestyle factors. Respondents who were eligible for the PHS had significantly lower age-adjusted relative risks (RRs) that were attenuated but remained substantially below 1 upon multivariate adjustment in models for total (RRs from 0.48 to 0.79), cardiovascular (from 0.40 to 0.85), and cancer mortality (from 0.55 to 0.87). Finally, a nearly halving in the age-adjusted risk of total and cause-specific mortality among men completing a run-in and randomized into PHS compared with those not randomized was nominally altered upon adding all covariates into multivariate models. In conclusion, a difference in mortality rates according to willingness to participate in a trial was explained by disease and lifestyle factors. In contrast, diseases and risk factors explain some, but not all, of the lower mortality rates of physicians based on eligibility status and their ability to complete a run-in phase.