Taking antihypertensive medication--controlling or co-operating with patients?

Factors affecting the intention to wear helmets for e-bike riders: the case of Chinese college students

As the popularity of electric bicycles (e-bikes) continues to surge, the number of accidents involving them has commensurately increased. A significant factor contributing to the high fatality rate in these accidents is the low usage of helmets among e-bike riders. Helmets have been proven to reduce the severity of injuries, yet their usage remains unexpectedly low. This issue is particularly pronounced among college students, the primary buyer group for e-bikes. Regrettably, there is a lack of research exploring their intentions to wear helmets. Understanding determinants of their intentions to wear helmets is crucial in promoting safe e-bike travel. Therefore, the present study aims to develop an integrated theoretical model that combines the Theory of Planned Behavior (TPB) and the Health Belief Model (HBM) to examine the factors influencing e-bike riders' helmet-wearing intentions among college students. Additionally, two variables-descriptive norms and law enforcement-are incorporated. The results indicate that the integrated model accounts for 76% of the variance in helmet-wearing intention, surpassing single-theory models. Specifically, the TPB accounts for 65%, while the HBM explains 53%. Notably, law enforcement emerges as the most influential factor, highlighting the crucial role of enforcing regulations and promoting awareness. Other significant factors include subjective and descriptive norms, attitudes, perceived benefits, perceived susceptibility, perceived barriers, and perceived severity. These findings provide valuable insights for policy development and targeted interventions aimed at improving helmet wear rates among e-bike riders, especially among the college student population.

Behavioral and social science research to support accelerated and equitable implementation of long-acting preexposure prophylaxis

PURPOSE OF REVIEW

The sociobehavioral research agenda for HIV prevention urgently needs to progress beyond research on end user preferences to examine how to best support patient access, engagement, and choice in the rollout of long-acting modalities. We outline critical challenges for an era of choice in biomedical prevention that could benefit from the rigorous application of sociobehavioral research methods.

RECENT FINDINGS

Research in three areas could accelerate implementation of long-acting antiretrovirals for prevention: integrating dual process models into research on patient decision-making and behavior; identifying strategies that mitigate against unconscious and implicit biases in provider decision-making and behavior; and developing tools to support patient-centered communication that incorporate research in both of the first two areas.

SUMMARY

We encourage the development of dual process models and measures to better understand patient behavior, including behavior related to initiating biomedical prevention, choice of prevention strategy, switching among strategies, and discontinuation. Second, there is the need to develop intervention research that targets provider behavior. Finally, we call for research to inform patient-centered communication tools that integrate an understanding of affective drivers of preexposure prophylaxis (PrEP) decision-making and protect against implicit bias in provider recommendations related to PrEP.

A patient-centered digital scribe for automatic medical documentation

Objective

We developed a digital scribe for automatic medical documentation by utilizing elements of patient-centered communication. Excessive time spent on medical documentation may contribute to physician burnout. Patient-centered communication may improve patient satisfaction, reduce malpractice rates, and decrease diagnostic testing expenses. We demonstrate that patient-centered communication may allow providers to simultaneously talk to patients and efficiently document relevant information.

Materials and Methods

We utilized two elements of patient-centered communication to document patient history. One element was summarizing, which involved providers recapping information to confirm an accurate understanding of the patient. Another element was signposting, which involved providers using transition questions and statements to guide the conversation. We also utilized text classification to allow providers to simultaneously perform and document the physical exam. We conducted a proof-of-concept study by simulating patient encounters with two medical students.

Results

For history sections, the digital scribe was about 2.7 times faster than both typing and dictation. For physical exam sections, the digital scribe was about 2.17 times faster than typing and about 3.12 times faster than dictation. Results also suggested that providers required minimal training to use the digital scribe, and that they improved at using the system to document history sections.

Conclusion

Compared to typing and dictation, a patient-centered digital scribe may facilitate effective patient communication. It may also be more reliable compared to previous approaches that solely use machine learning. We conclude that a patient-centered digital scribe may be an effective tool for automatic medical documentation.

Self-Reported Prevalence of Hypertension and Antihypertensive Medication Use Among Asian Americans: Behavioral Risk Factor Surveillance System 2013, 2015 and 2017

Asian Americans are one of the fastest growing races in the US. The objectives of this report were to assess self-reported hypertension prevalence and treatment among Asian Americans. Merging 2013, 2015, and 2017 Behavioral Risk Factor Surveillance System data, we estimated self-reported hypertension and antihypertensive medication use among non-Hispanic Asian Americans (NHA) and compared estimates between NHA and non-Hispanic whites (NHW), and by NHA subgroup (Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese/other). The prevalence of hypertension was 20.8% and 33.5%, respectively, for NHAs and NHWs (p < 0.001). Among those with hypertension, the prevalence of antihypertensive medication use was 71.6% and 78.2%, respectively, for NHAs and NHWs (p < 0.001). Among NHA subgroups, a wide range of hypertension prevalence and medication use was found. Overall NHA had a lower reported prevalence of hypertension and use of antihypertensive medication than NHW. Certain NHA subgroups had a burden comparable to high-risk disparate populations.

Patient-Clinician Communication About Pain: A Conceptual Model and Narrative Review

Objective

Productive patient-clinician communication is an important component of effective pain management, but we know little about how patients and clinicians actually talk about pain in clinical settings and how it might be improved to produce better patient outcomes. The objective of this review was to create a conceptual model of patient-clinician communication about noncancer pain, review and synthesize empirical research in this area, and identify priorities for future research.

Methods

A conceptual model was developed that drew on existing pain and health communication research. CINAHL, EMBASE, and PubMed were searched to find studies reporting empirical data on patient-clinician communication about noncancer pain; results were supplemented with manual searches. Studies were categorized and analyzed to identify crosscutting themes and inform model development.

Results

The conceptual model comprised the following components: contextual factors, clinical interaction, attitudes and beliefs, and outcomes. Thirty-nine studies met inclusion criteria and were analyzed based on model components. Studies varied widely in quality, methodology, and sample size. Two provisional conclusions were identified: contrary to what is often reported in the literature, discussions about analgesics are most frequently characterized by patient-clinician agreement, and self-presentation during patient-clinician interactions plays an important role in communication about pain and opioids.

Conclusions

Published studies on patient-clinician communication about noncancer pain are few and diverse. The conceptual model presented here can help to identify knowledge gaps and guide future research on communication about pain. Investigating the links between communication and pain-related outcomes is an important priority for future research.

Variation in Adherence Measures to Imatinib Therapy

PURPOSE

The introduction of tyrosine kinase inhibitors has transformed the care of patients with chronic myeloid leukemia, with survival approaching that of healthy individuals. Current-day challenges in chronic myeloid leukemia care include adherence to tyrosine kinase inhibitor therapy. We studied adherence from resource-constrained settings and tried to analyze the factors responsible for nonadherence in these individuals. We also correlated adherence to current molecular status.

PATIENTS AND METHODS

This was a single-center, cross-sectional, observational study from north India. It consisted of a questionnaire-based survey in which a one-to-one interview technique was used by trained nursing staff administering the Modified Morisky Adherence Scale (MMAS-9) questionnaire. Adherence was also measured on the basis of physician's assessment. JMP 13.0.0 was used for statistical analysis.

RESULTS

A total of 333 patients with a median age of 42 years were included in the study. The median BCR-ABL/ABL ratio (IS) was 0.175 (0.0 to 98.0). The mean MMAS-9 score was 11 ± 2. Adherence was seen in 54.95% on the basis of MMAS-9, whereas physician's assessment reported adherence in 90.39% of patients. Using the χ2 test, no relationship was found between the two assessment techniques. There was a significant relationship between major molecular response status and adherence by physician's assessment and MMAS-9 ( P < .001). Bivariate analysis by logistic fit showed a good relation between the MMAS-9 score and the BCR-ABL/ABL ratio (IS), χ2 (1,220) = 135.45 ( P < .001). On multivariate analysis, enrolment in the Novartis Oncology Access program (a patient assistance program) was significantly associated with adherence ( P = .012).

CONCLUSION

This study highlights the lack of adherence in real-world settings and the various factors responsible. Such studies are important from a public health services perspective in various settings around the world because they may lead to corrective action being taken at the institutional level.

Frequency and predictors of non-adherence to lifestyle modifications and medications after coronary artery bypass grafting: A cross-sectional study

BACKGROUND

Non-adherence to dietary recommendations, exercise and prescribed drug regimens, in coronary heart disease (CHD) patients following coronary artery bypass grafting (CABG), is a major health care issue worldwide.

AIMS AND OBJECTIVES

The primary objective of this study was to investigate the frequency and predictors of non-adherence to lifestyle changes and medication among CHD patients after undergoing CABG surgery.

METHOD

The sample of this cross sectional descriptive study was 265 patients who underwent isolated primary CABG. Participants who met the eligibility criteria were provided with a pre-coded questionnaire 4 weeks or more after surgery. Adherence was assessed on the basis of patient's self-report. Significance of results was analyzed using Chi square test.

RESULTS

Roughly half of the patients were non-adherent to dietary recommendations (n=120, 45.3%) and exercise (n=109, 41.1%) while about one third (n=69, 26%) were non-adherent to prescribed medications. Unwillingness to adopt a new lifestyle and more than one social gathering per week, were found to be statistically significant predictors of non-adherence to diet (p-values<0.001). Reluctance to follow exercise regimen, busy schedule, and fear that exercise will aggravate heart issues were commonly reported as reasons for non-compliance to exercise. As for non-adherence to medication, forgetfulness, affordability of drugs and too many medications to take were important predictors.

CONCLUSION

Non-adherence to lifestyle modifications and medication is an emerging problem worldwide. It is essential for medical health professionals to discuss these predictors and address them individually. Our findings highlight the need for a healthy physician and patient relationship.

Is Adherence to Imatinib Mesylate Treatment Among Patients with Chronic Myeloid Leukemia Associated with Better Clinical Outcomes in Qatar?

BACKGROUND

Despite the revolutionary success of introducing tyrosine kinase inhibitors (TKIs), such as imatinib mesylate (IM), for treating chronic myeloid leukemia (CML), a substantial proportion of patients' treatments fail.

AIM

This study investigates the correlation between patient adherence and failure of TKIs' treatment in a follow-up study.

METHODS

This is a follow-up study of a new cohort of CML patients. Adherence to IM is assessed using the Medication Event Monitoring System (MEMS 6 TrackCap, AARDEX Ltd). The 9-item Morisky Medication Adherence Scale, medication possession ratio (MPR) calculation, and the electronic medical records are used for identifying potential factors that influence adherence. Clinical outcomes are assessed according to the European Leukemia Net 2013 guidelines via reverse transcriptase quantitative polymerase chain reaction measurement of the level of BCR-ABL1 transcripts in peripheral blood. Response is classified at the hematological, cytogenetic, and molecular levels into optimal, suboptimal, or failure.

RESULTS

A total of 36 CML patients (5 citizens and 31 noncitizen residents) consented to participate in the study. The overall mean MEMS score was 89. Of the 36 patients, 22 (61%) were classified as adherent (mean: 95) and 14 (39%) were classified as nonadherent (mean: 80.2). Adherent patients were significantly more likely to obtain optimal response (95%) compared to the nonadherent group (14.3%; P < 0.0001). The rate of poor adherence was as high as 39% using MEMS, which correlates with 37% treatment failure rate. The survey results show that 97% of patients increased the IM dose by themselves when they felt unwell and 31% of them took the missing IM dose when they remembered. Other factors known to influence adherence show that half of patients developed one or more side effects, 65% of patients experienced lack of funds, 13% of patients declared unavailability of the drug in the NCCCR pharmacy, and 72% of patients believed that IM would cure the disease. The MPR results reveal that 16% of patients had poor access to treatment through the hospital pharmacy.

DISCUSSION AND CONCLUSION

This is the first prospective study to evaluate CML patients' adherence and response to IM in Qatar. The high rate of treatment failure observed in Qatar is explained by poor adherence. An economic factor (unaffordable drug prices) is one of the main causes of nonadherence and efforts should be made locally to improve access to medication for cancer diseases. Other risk factors associated with poor adherence could be improved by close monitoring and dose adjustment. Monitoring risk factors for poor adherence and patient education that include direct communication between the health-care teams, doctors, nurses, pharmacists, and patients are essential components for maximizing the benefits of TKI therapy and could rectify this problem. The preliminary results show that patients' response to treatment may be directly linked to patients' adherence to treatment. However, further in-depth and specific analysis may be necessary in a larger cohort.

White coat hypertension: improving the patient-health care practitioner relationship

White coat hypertension is characterized by the variability of a patient’s blood pressure measurements between the physician’s office and the patient’s home environment. A patient with white coat hypertension has high blood pressure levels in the physician’s office and normal blood pressure levels in their typical environment. This condition is likely caused by the patient’s anxiety within the physician’s office and in the presence of the physician. Research has shown that improving the relationship between a patient and their health care provider can decrease the patient’s anxiety, with the implication of decreasing the patient’s likelihood of demonstrating white coat hypertension. This review provides an overview of the previous literature regarding white coat hypertension, its prevalence, and the consequences for those who develop persistent hypertension. Furthermore, this review discusses the implications of improving patient and health care provider interactions through effective communication, empathy, and trust, as well as the implications for future research studies in improving the patient and health care provider’s relationship.

Improving adherence with medication: a selective literature review based on the example of hypertension treatment

BACKGROUND

A common problem among patients with chronic diseases is poor adherence with prescribed medication. Studies have shown that certain interventions can improve adherence and clinical outcomes.

METHOD

We selectively searched the PubMed database for publications on the treatment of hypertension that contained the terms "adherence," "drug," "treatment, "outcome," "hypertension," and "randomized controlled trial."

RESULTS

The interventions studied were highly varied, ranging from the use of calendar blister packs to complex patient education programs. 62% of the studies that we identified documented an improvement in adherence after an intervention (median Cohen's d = 0.52). In 92% of cases, improved adherence was associated with a significant improvement in clinical end points (median Cohen's d = 0.34).

CONCLUSION

The promotion of adherence to prescribed medication is clearly desirable. Studies on the treatment of hypertension have shown that attempts to improve adherence often fail. In most studies, however, improved adherence led to better clinical outcomes. Simplification of drug regimens (e.g., reducing the number of pills taken per day) is the single most effective way to promote adherence. Moreover, the findings of studies on the treatment of hypertension and other diseases suggest that shared decision-making should be the basis of physicianpatient discussions about medication. Suitable medications can also be chosen in order to maximize safety and efficacy even if adherence is incomplete. It would also be desirable for studies on the promotion of adherence to be carried out in Germany, under the specific conditions that prevail in our national health-care system.

"Best practice" for patient-centered communication: a narrative review

BACKGROUND

Communicating with patients has long been identified as an important physician competency. More recently, there is a growing consensus regarding the components that define physician-patient communication. There continues to be emphasis on both the need to teach and to assess the communication skills of physicians.

OBJECTIVE

This narrative review aims to summarize the work that has been conducted in physician-patient communication that supports the efficacy of good communications skills. This work may also help to define the physician-patient communication skills that need to be taught and assessed.

RESULTS

A review of the literature shows it contains impressive evidence supporting positive associations between physician communication behaviors and positive patient outcomes, such as patient recall, patient understanding, and patient adherence to therapy. There is a consensus about what constitutes "best practice" for physician communication in medical encounters: (1) fostering the relationship, (2) gathering information, (3) providing information, (4) making decisions, (5) responding to emotions, and (6) enabling disease- and treatment-related behavior.

CONCLUSIONS

Evidence supports the importance of communication skills as a dimension of physician competence. Effort to enhance teaching of communication skills to medical trainees likely will require significant changes in instruction at undergraduate and graduate levels, as well as changes in assessing the developing communication skills of physicians. An added critical dimension is faculty understanding of the importance of communication skills, and their commitment to helping trainees develop those skills.

Obesity Modifies the Association of Race/Ethnicity with Medication Adherence in the CARDIA Study

OBJECTIVE

To assess associations between race/ethnicity and medication adherence, and the potential modifying effects of weight category (normal, overweight, obese) in a community-based sample.

STUDY DESIGN AND SETTING

We studied 1355 participants from the CARDIA (Coronary Artery Risk Development in Young Adults) study who were taking prescription medications in 2000-1. Medication adherence, as rated on the four-item Morisky medication adherence scale (score of 4 = maximum adherence), was reported for all participants.

RESULTS

The mean age ± SD of participants was 40 ± 3.6 years; 45% were African American and 36% were male. Overall, Whites had a higher proportion of maximum adherence than African Americans (59 vs 41%, respectively; p = 0.001). However, this difference was statistically significant only for participants within the normal weight category, of whom 54% of Whites were maximally adherent versus 35% of African Americans (p < 0.05). After adjustment for possible confounding covariates, race/ethnicity was associated with adherence only in those of normal weight: the odds ratio for maximum adherence in Whites versus African Americans of normal weight was 1.98 (95% CI 1.13, 3.47). Within race/ethnicity subgroups, weight category was associated with adherence in Whites but not in African Americans.

CONCLUSION

Weight category modifies the association of race/ethnicity with medication adherence. The high levels of non-adherence observed among African Americans and obese and overweight Whites bodes poorly for treatment of obesity-associated diseases such as cardiovascular disease or diabetes mellitus.

Under-prescribing and non-adherence to medications after coronary bypass surgery in older adults: strategies to improve adherence

The focus for this clinical review is under-prescribing and non-adherence to medication guidelines in older adults after coronary artery bypass grafting (CABG) surgery. Non-adherence occurs in all age groups, but older adults have a unique set of challenges including difficulty hearing, comprehending, and remembering instructions; acquiring and managing multiple medications; and tolerating drug-drug and drug-disease interactions. Still, non-adherence leads to increased morbidity, mortality, and costs to the healthcare system. Factors contributing to non-adherence include failure to initiate therapy before hospital discharge; poor education about the importance of each medication by hospital staff; poor education about medication side effects; polypharmacy; multiple daily dosing; excessive cost; and the physician's lack of knowledge of clinical indicators for use of medications. To improve adherence, healthcare systems must ensure that (i) all patients are prescribed the appropriate medications at discharge; (ii) patients fill and take these medications post-operatively; and (iii) patients continue long-term use of these medications. Interventions must target central administrative policies within healthcare institutions, the difficulties facing providers, as well as the concerns of patients. Corrective efforts need to be started early during the hospitalization and involve practitioners who can follow patients after the date on which surgical care is no longer needed. A solid, ongoing relationship between patients and their primary-care physicians and cardiologists is essential. This review summarizes the post-operative medication guidelines for CABG surgery, describes barriers that limit the adherence to these guidelines, and suggests possible avenues to improve medication adherence in older cardiac surgery patients.

What determines the duration of patient medication compliance in patients with chronic disease: are we looking in the wrong place?

Objectives: The objective of this study was to do a pilot inquiry, to determine whether physicians with similar practices in the same neighborhood demonstrated any difference in the duration of compliance among their patients.

Methods: Through a cooperating urban community pharmacy, patients with prescriptions for hypertension and type II diabetes were identified for this pilot study. Patients refill medication records were searched to determine the average number of months of drug regimen compliance. The patient data of the four local physicians were separated and compared.

Results: One physician was able to generate refill durations nearly double that of the average duration of medication refills seen in the patients consulting the several other nearby physicians.

Conclusion: In this pilot study, it was determined that there are differences in the compliance behavior of patients attending different physicians. We can conclude that some communication or personality characteristics of some physicians appear to be more successful in achieving higher compliance. Subsequent studies should identify those which may be at least partially responsible for this finding.

Good adherence to imatinib therapy among patients with chronic myeloid leukemia--a single-center observational study

Previous studies have suggested that adherence to imatinib therapy can be an obstacle among patients with chronic myeloid leukemia (CML). We studied adherence to imatinib therapy among CML patients treated at the Sahlgrenska University Hospital. We identified all CML patients that were alive at the 1st of January 2010 (n = 70). Nineteen patients were excluded due to a history of allogenic hematopoietic stem cell transplantation, and nine were excluded due to treatment with other tyrosine kinase inhibitors. Thirty-eight out of 42 patients (90%) treated with imatinib accepted inclusion in the study. The patients were interviewed in a structured way, and adherence was evaluated in a standardized way using the nine-item Morisky Medication Adherence Scale that ranges from 1 to 13. A Morisky score ≤10 indicates nonadherence and ≥11 indicates adherence. In addition, predefined follow-up questions were asked to identify factors known to influence adherence to therapy. In contrast to previous studies, our patients showed good adherence to imatinib therapy with a mean Morisky score of 12.3 out of 13 (range, 9-13). The interviews revealed factors known to predict adherence to therapy, namely being well informed and having frequent contact with a single hematologist. Furthermore, the patients had easy access to the treating clinic and felt that they took part in decisions concerning their disease and treatment. We show that adherence to imatinib can be very good in CML patients, and we suggest that simple measures such as increased patient information and continuity of care will increase adherence in patients with CML.

Determining the difference in medication compliance between the general patient population and patients receiving antihypertensive therapy: a case study

This study addressed the issue of medication compliance in general, compliance with antihypertensive therapy, and the relationship between these two groups. In addition to determining the reasons for noncompliance with therapy prescription, the aim of this study was to also establish whether it was considered feasible by the patients to comply with their physician's instructions and whether the patients believed that the prescribed therapy was beneficial to their health. Hypertensive patients were compared to the total study population according to age groups. The study was designed as a cross-sectional survey with the use of a 33-item self-administered questionnaire. The study included 635 individuals who were collecting or buying drugs for the treatment of chronic diseases, with special reference to subjects taking antihypertensive agents (n = 361). More than half (n = 361; 56.9%) of the 635 study subjects were on therapy for arterial hypertension and possibly for some other diseases. The great majority of study subjects reported forgetfulness as the main reason for skipping drug doses. Comparison between the total study population and the subjects treated for arterial hypertension according to age groups (compliant, noncompliant and all together) yielded no statistically significant difference. We concluded that there was no difference in medication compliance between the general patient population and patients receiving antihypertensive therapy and there was no correlation between medication compliance and age.

Socio-demographic and clinical factors influencing the adherence to treatment in Parkinson's disease: the ADHESON study

BACKGROUND

Symptoms of Parkinson's disease (PD) are usually controlled by a continuous titration of medication and addition of multiple therapies over the course of the disease. Therapeutic complex schemes, polymedication, comorbidities and the number of medications required contribute to non-adherence.

METHODS

This cross-sectional survey was performed in 418 patients with PD on treatment with any antiparkinsonian medication. Patient adherence was assessed through physicians' subjective perception and the Morisky-Green test (MGT). Several social, demographic and clinical features were correlated through bivariate and multivariate analyses.

RESULTS

According to the physician's opinion 93.7%, and according to the MGT 60.4% of patients were adherent to parkinsonian therapy. The bivariate analysis showed greater adherence in patients with a high level of knowledge about the disease (62.8%), good clinical control (63.6%), a spouse or life partner (63%) and higher incomes (66%). Negative correlation with psychiatric symptoms was found. In relation to the MGT, the logistic regression model showed a negative correlation between cognitive deterioration and psychiatric pathology and adherence to therapy.

CONCLUSIONS

The physician's impression overestimated the compliance of patients when compared with an objective evaluation such as the MGT. Cognitive impairment and psychiatric symptoms are the clinical variables associated with a lower level of adherence.

Stroke subtypes and risk factors in patients living in southern Seoul, Korea: the impact of hypertension control on stroke subtypes

BACKGROUND AND PURPOSE

The prevalence of hypertension (HT) does not explain the relatively high incidence of hemorrhagic stroke in Korea and other Asian countries, and whether HT has a greater impact on development of the intracerebral hemorrhage (ICH) than cerebral infarction (CI) remains unclear. It may be speculated that the adequacy of HT control is related to the subtype differences. The present study was aimed to elucidate (1) whether various risk factors exert a different impact on stroke subtypes and (2) whether the adequacy of HT control in patients with a previous history of HT is related to different subtypes in stroke patients from southern Seoul, Korea.

METHODS

We prospectively studied 602 consecutive patients with acute stroke (CI and ICH) admitted to the Asan Medical Center and analyzed their stroke subtypes and risk factors. The mode of HT treatment before the stroke onset was specifically asked. We examined whether various risk factors were related to subtype differences in these patients. We also attempted, in patients with a prior history of HT, to see whether the mode of HT control was related to the subtype differences.

RESULTS

75.8% of the patients had CI (large vessel infarction 33.8%, small vessel infarction 22.1%) and 24.2% had ICH; 75% of the patients had HT of whom the presence of HT was previously unidentified in 8%. Previous treatment of HT was considered adequate in 32.4% and inadequate in the others. On multiple logistic analysis, diabetes mellitus and alcohol drinking were independently related to CI (v ICH), whereas HT did not favor any stroke subtypes. However, in patients with a prior history of HT, previous mode of HT control was a significant factor related to subtype differences in a way that inadequate treatment favored ICH. There were no specific risk factors that independently discriminate large vessel infarction versus small vessel infarction.

CONCLUSIONS

Apparently, HT was not a risk factor that preferentially favors any specific stroke subtypes in patients from southern Seoul. However, in patients with HT, previous mode of HT control was an important factor influencing the subtypes. Inadequate treatment of HT may play a role, at least in part, on the relatively prevalent ICH and hence the greater significance of stroke as a cause of death in Korea compared with Western countries.

Older people and adherence with medication: a review of the literature

BACKGROUND

Older people represent a sizeable population of the UK. Many older people receive drug treatment for long-term conditions. Adherence with medication is therefore an important clinical, financial and resource intensive concern.

OBJECTIVES

This review aimed to examine patient's beliefs, perceptions and views in relation to adherence with medication.

DESIGN

A comprehensive search of the literature was undertaken using numerous approaches. The search of revealed 30 research papers.

FINDINGS

Articles were initially evaluated using Critical Appraisal Skills Programme principles to identify those relevant to the review. Relevant studies were then subjected to a narrative analysis to assist the development of relevant themes. Four themes were identified; experience of adherence; perceptions and attitudes to medication adherence and non-adherence; patients acceptance of their illness and impact on medication taking behaviour and shared decision making.

CONCLUSIONS

The findings of this review imply that there is a need for more emphasis on shared decision making between the older patient and the prescriber. Using this approach, adherence with medication may improve. There is also a need to develop a standardized measure of medication adherence.

How important are individual counselling, expectancy beliefs and autonomy for the maintenance of exercise after cardiac rehabilitation?

Aims: We examined whether autonomy supportive and self-efficacy enhancing individual lifestyle counselling was associated with improved maintenance of exercise and physical capacity compared with group based counselling. We also tested whether self-efficacy beliefs and autonomous motivation was associated with improved maintenance of exercise over time. Methods: Randomised controlled trial and longitudinal study of predictor variables. One hundred and seventy six (38 female) patients mainly with coronary heart disease were randomized to either have standard group based rehabilitation or to additionally receive the intervention. Patients were recruited from a 4-week cardiac rehabilitation programme with two years follow-up at Krokeide Centre in Bergen, Norway. Results: We found no statistically significant between-group differences. The groups showed an overall improvement of their self-evaluated physical capacity during the two years of the study, corresponding 7% change of score (p<0.001). The composite exercise score improved 6% during follow-up (p<0.001). Intensity of exercise activities improved 17% from inclusion to 24 months' follow-up (p<0.001). Self-efficacy for increased exercise, general expectancy and autonomous motivation were significant predictors of increased exercise and physical capacity. Controlled motivation hampered physical capacity improvement. Conclusions: Among this self-selected and motivated group of rehabilitation patients we found no additional effect of adding individual counselling to group-based interventions. Based on longitudinal documentation this cardiac rehabilitation programme improves long-term maintenance of exercise and physical capacity and this maintenance is related to autonomous motivation, general expectancy and self-efficacy.

A connection between medication adherence, patient sense of uniqueness, and the personalization of information

Adherence to treatment regimens is important to achieve optimal disease management. However, nonadherence is evident across numerous clinical contexts, which leads to a higher disease burden on society. Among the various factors associated with patient adherence behavior, patient beliefs are the most influential set of factors. Several cognitive-social models and constructs that incorporate patient belief have been developed to explain patient health behaviors, such as the Health Belief Model, Self-Efficacy Model, Theory of Planned Behavior and so on. However, these models do not explain the formulation of health beliefs. The underlying mechanism accounting for patient variation in information processing that generates beliefs needs to be investigated, which will inform the development of interventions. We propose that patient's sense of uniqueness moderates the self-attribution of statistically-based information. Self-attribution is defined as a person's perceived probability that a statement applies to herself, and is influenced by experience and sense of uniqueness. Sense of uniqueness is a person's general belief regarding how unique she is. Statistically-based information is defined as information derived from or regarding aggregated effects or influences. Basically, the proposed hypothesis is that patients who have a stronger belief that they are unique are less likely to attribute to themselves statistically-based propositions regarding the majority of their group and are more likely to attribute to themselves statistically-based propositions regarding the minority. We further model the relationship between sense of uniqueness and self-attribution of information in terms of an idealized inexperienced person, and then extend the model to include the effect of personal experience. The estimation of hypothesis-specific effect parameters can be achieved by maximum likelihood. In conclusion, the sense of uniqueness hypothesis is general to the formulation of personal beliefs and consequently has implications for deliberate health behavior and indeed personal behavior in general.

Intentional and unintentional medication non-adherence: a comprehensive framework for clinical research and practice? A discussion paper

Non-adherence to medications is a prevalent and persistent healthcare problem, particularly for patients with a chronic disorder. Researchers have endeavoured to address poor adherence for the past five decades resulting in the accumulation of a vast body of literature. Despite the enormity of research conducted, interventions to date have neither been cost-effective nor predictably clinically effective in enhancing medication adherence. Though concerning, such contemporary information serves to refocus attention on the adequacy of knowledge regarding the factors influencing medication non-adherence. Although little consensus exists regarding the optimal categorisation of these influencing factors, increasingly, the broad and 'all encompassing' categorisation of intentional and unintentional factors is being used to account for patient medication-taking behaviours and actions. An extensive review of the related literature provides the basis for a critical discussion on the value and comprehensiveness of this current classification in guiding future adherence research and consequent clinical interventions. An appraisal of this categorisation is important if decisions regarding interventions are not to be made in a vacuum of insufficient understanding, which would result in the continued ineffective use and distribution of valuable resources to combat non-adherence.

How do providers assess antihypertensive medication adherence in medical encounters?

BACKGROUND

Poor adherence to antihypertensives has been shown to be a significant factor in poor blood pressure (BP) control. Providers' communication with patients about their medication-taking behavior may be central to improving adherence.

OBJECTIVE

The goal of this study was to characterize the ways in which providers ask patients about medication taking.

DESIGN

Clinical encounters between primary care providers and hypertensive patients were audiotaped at 3 Department of Veterans' Affairs medical centers.

PARTICIPANTS

Primary care providers (n=9) and African-American and Caucasian patients (n=38) who were diagnosed with hypertension (HTN).

APPROACH

Transcribed audiotapes of clinical encounters were coded by 2 investigators using qualitative analysis based on sociolinguistic techniques to identify ways of asking about medication taking. Electronic medical records were reviewed after the visit to determine the BP measurement for the day of the taped encounter.

RESULTS

Four different aspects of asking about medication were identified: structure, temporality, style and content. Open-ended questions generated the most discussion, while closed-ended declarative statements led to the least discussion. Collaborative style and use of lay language were also seen to facilitate discussions. In 39% of encounters, providers did not ask about medication taking. Among patients with uncontrolled HTN, providers did not ask about medications 33% of the time.

CONCLUSION

Providers often do not ask about medication-taking behavior, and may not use the most effective communication strategies when they do. Focusing on the ways in which providers ask about patients' adherence to medications may improve BP control.

Compliance with risk factor modification: early-onset versus late-onset stroke patients

OBJECTIVES

To study the compliance to risk factor modifications and factors related to it, which may be different between early-onset (15-45 years) and late-onset (>45 years) stroke patients. These issues have not yet been addressed properly.

METHODS

We selected 170 early-onset and 340 late-onset stroke patients from the Asan Stroke Registry. The patients were then followed for 1-5 years (an average of 3.4 years) after the onset of stroke. We used a standardized questionnaire to assess the level of compliance and examine the factors contributing to noncompliance.

RESULTS

Ninety-six early-onset and 160 late-onset patients completed a standardized questionnaire. Early-onset patients were less compliant than late-onset patients in the use of antihypertensive medication (p < 0.01), the cessation of cigarette smoking (p < 0.05) and in regular exercise (p < 0.05). Multivariate analysis showed that factors related to noncompliance in early-onset stroke patients included 'a lack of insurance' (noncompliance with the use of antihypertensive medication) and male gender (noncompliance with participation in regular exercise). Factors related to noncompliance in late-onset stroke patients included a high number of cigarettes consumed before the stroke (noncompliance with the cessation of smoking), the lack of regular exercise and a severe modified Rankin scale (noncompliance with regular exercise).

CONCLUSION

Early-onset stroke patients are generally less compliant than late-onset stroke patients and the factors related to noncompliance in these groups are different. Therefore, strategies should be developed for improving patient compliance, based on these differences.

Teaching communication skills to medical students, a challenge in the curriculum?

INTRODUCTION

As communication skills become more and more important in medical practice, the new medical curriculum at Ghent University (1999) implemented a communication curriculum.

METHOD

Communication training or experiences in 'real life' settings are provided every year of the medical curriculum. The training starts with simple basic skills but gradually slips into medical communication or consultation training and results in communication in different contextual situations or with special groups of patients. Rehearsal is important and seen as inevitable. Poorly performing students get extra training. Several didactical methods are used: the skills are demonstrated by means of videotapes and paper cases of patient stories. Skills are trained in small groups (10-15 students), with focus on role-playing with colleague students or simulated patients (SP). Videotapes of real consultations give an idea of the performance of each student. Every year the students are assessed by means of an OSCE (objective structured clinical examination).

CONCLUSION

After 6 years of experience with the new curriculum, several remarks and questions need to be answered. Small group training gives a huge workload and with different trainers discrepancies between groups can appear. Choosing the most suitable trainer for communication skills is not easy; several options are available: specialists in communication like psychologists with interest in medical practice, GPs with interest in medical communication, medical specialists for communication topics concerning medical problems within their domain. As the most important didactical approach lies in practising the skills, the selection and training of simulated patients remains a challenge.

PRACTICE IMPLICATION

A communication continuum during the whole curriculum seems to be worthwhile. Students with specific communicative problems are detected early, remediation is provided. Rehearsal every year seems to lead to better acquisition. The most positive point is that communication is embedded in a global patient-, student- and community-oriented curriculum and that communication skills are seen as core elements of good doctoring.

Improving control of hypertension by an integrated approach -- results of the 'Manage it well!' programme

BACKGROUND

Patient non-compliance is a significant contributor to poor blood pressure control. Although measures to improve compliance are known, they are not in routine use.

OBJECTIVE

To apply measures based on current recommendations in an integrated approach in the 'Manage it well!' (MIW) programme, and to determine the improvement in blood pressure control.

DESIGN AND SETTING

During the prospective open cohort study, 348 primary and 156 secondary care centres enrolled 6941 hypertensive patients and followed them for 6 months.

INTERVENTIONS

An integrated intervention package also applicable to everyday practice was introduced to improve treatment adherence, including education programmes for patients and physicians, tight follow-up with frequent office visits and regular home blood pressure measurements. Treatment was based on either trandolapril or verapamil SR with dose titration, with added-on therapy if necessary.

MAIN OUTCOME MEASURE

Rates of control of blood pressure to < 140/90 mmHg.

RESULTS

Data were evaluated from 5468 patients, 72% known to have hypertension and 26% newly diagnosed [2% not available (n.a.)]. At baseline only 2.9% of treated patients had their hypertension well controlled (< 140/90 mmHg), but during the programme this increased to 40.9% (P < 0.001). The absolute reduction in office blood pressure was also significant (from 168 +/- 19/97 +/- 11 mmHg to 139 +/- 13/83 +/- 7 mmHg; P < 0.001). No differences in blood pressure control were found between trandolapril and verapamil SR regimens. Office blood pressure was greater than home blood pressure at baseline (168 +/- 19/97 +/- 11 mmHg compared with 151 +/- 17/89 +/- 10 mmHg; P < 0.001), but this difference disappeared at 6 months (139 +/- 13/83 +/- 7 mmHg compared with 140 +/- 13/84 +/- 7 mmHg, respectively).

CONCLUSIONS

The integrated, patient-focused approach used in the MIW programme significantly increases the success of treatment in a 'real-world' setting.

Drug adherence in Parkinson's disease

Physicians modify drug schedules in response to their patients' clinical responses. Failure to relieve patients' symptoms or the emergence of drug-related side effects may reflect nonadherence to a prescribed drug schedule rather than incorrect therapeutic physician decisions. Using a medication questionnaire and a computerized medication event monitoring system (MEMS) to monitor medication use, nonadherence of drug use was examined in subjects with Parkinson's disease (PD). We report that prescription nonadherence in PD subjects was common and approximated that reported in other chronic diseases. During a 28-day observation period, only 4 of 39 subjects had complete schedule adherence, i.e., no missed, extra, or mistimed doses. Using a questionnaire, 24.3% of subjects acknowledged missing any doses but the computerized MEMS recorded that 51.3% of subjects missed at least one dose per week and 20.5% of subjects missed three or more doses per week. Mistiming of doses was admitted by 73% of subjects but 82.1% had recorded mistimed doses. Of multiple sociodemographic and disease-related items examined, only gender and level of education were statistically related to nonadherence.

Factors involved in deciding to start preventive treatment: qualitative study of clinicians' and lay people's attitudes

OBJECTIVES

To explore the views of clinicians and lay people about the minimum benefit needed to justify drug treatment to prevent heart attacks, and to explore the rationale behind treatment decisions.

DESIGN

Qualitative study using semi-structured interviews.

PARTICIPANTS

4 general practitioners, 4 practice nurses, and 18 lay people.

SETTING

8 general practices and 6 community settings across Liverpool.

RESULTS

Participants varied widely in the minimum acceptable benefits chosen. Most people found the concepts difficult initially, and few appreciated that increased length of treatment should increase absolute benefits. Lay people usually wanted to make decisions for themselves, and clinicians supported this. Participants wanted to consider adverse effects and costs of treatment. Dislike of drug taking was common, and many people preferred lifestyle change to an imperfect treatment. Quality of life and personal views were more important than an individual's age.

CONCLUSIONS

Evidence based guidelines make assumptions about people's preferences, and, by using 10 year estimates of risk, inflate the apparent benefits of treatment. It is unlikely that guidelines could incorporate the wide range of people's preferences, and true dialogue is necessary between clinicians and patients before starting long term preventive treatment.

Behavioral medicine in the prevention and treatment of cardiovascular disease

Cardiac behavioral medicine is the application of behavioral and psychosocial principles to the prevention and treatment of heart disease. Most biomedical cardiovascular risk factors (e.g., high blood lipids, high blood pressure, diabetes) require behavioral and medical interventions. Other risks, including obesity, high-fat eating pattern, smoking, and inactivity, clearly require lifestyle change. Behavioral medicine screening and intervention have been applied to psychosocial risk factors such as depression, hostility, and social isolation. Appropriate assessment of risk factors is essential because research has demonstrated successful prevention of heart disease and reduction of morbidity and mortality in patients with existing disease. Behavioral interventions have been beneficial in improving cardiac outcomes by enhancing compliance with medication taking and dietary/exercise recommendations. Future needs include the study of psychosocial factors in women and ethnic minorities with heart disease and the integration of behavioral medicine with newer medical technologies designed to detect subclinical biomarkers of heart disease.

The COMpliance Praxis Survey (COMPASS): a multidimensional instrument to monitor compliance for patients on antihypertensive medication

Low compliance is suspected as a major reason for treatment failure in hypertensive patients. To identify patients with low compliance at the commencement of antihypertensive treatment, the compliance praxis survey (COMPASS) was utilised. A total of 161 physicians identified 2389 hypertensive patients treated by ACE-inhibitor. The physicians rated the compliance of the patients at baseline and at 6-month follow-up prospectively. Standard care was given. The mean age of patients was 64.5 years (54.4% women). The baseline overall score of compliance was medium to high in 97.3% of patients. A quarter of all patients (24.7%) were described as having difficulties to follow lifestyle changes, 22.3% lacked sufficient social support, and 31.0% were unwilling to obtain additional information about illness and treatment. Patients who had received prior treatment for cardiovascular disease were less compliant than those who received first treatment within this study (P=0.05). Younger (P<0.01), male patients (P<0.01), and those without prior cardiovascular disease (P<0.001) were significantly more likely to stop the antihypertensive treatment without a doctor's recommendation. Doctors' rating of compliance at baseline correlated well with ongoing treatment at 6-month follow-up. In conclusion, the COMPASS survey questionnaire is a useful instrument for doctors to differentiate between patients who lack resources and to then counsel patients based on their individual needs.

Patients' decisions about whether or not to take antihypertensive drugs: qualitative study

OBJECTIVE

To describe the ways in which patients taking antihypertensive drugs balance reservations against reasons for taking them.

DESIGN

Qualitative study using detailed interviews.

SETTING

Two urban general practices in the United Kingdom.

PARTICIPANTS

Maximum variety sample of 38 interviewees receiving repeat prescriptions for antihypertensives.

MAIN OUTCOME MEASURES

Interviewees' reservations about drugs and reasons for taking antihypertensives.

RESULTS

Patients had reservations about drugs generally and reservations about antihypertensives specifically. Reasons for taking antihypertensive drugs comprised positive experiences with doctors, perceived benefits of medication, and pragmatic considerations. Patients weighed their reservations against reasons for taking antihypertensives in a way that made sense for them personally. Some individual patients weighed different reservations against different reasons for taking antihypertensives.

CONCLUSIONS

Patients' ideas may derive from considerations unrelated to the drugs' pharmacology. Doctors who want their patients to make well informed choices about antihypertensives and to reach concordant decisions about prescribing should explore how individuals strike this balance, to personalise discussion of drug use.

Validation and feasibility of problem-based learning in rehabilitation of patients with coronary artery disease

A patient education programme applying problem-based learning (PBL) was developed for patients with coronary artery disease (CAD). Groups with 6-8 patients and a tutor from the rehabilitation team met nine times for 1.5h each. The feasibility and validity of the model was evaluated using patient questionnaires, interviews with tutors and video observations of tutorials. The participants were active (69% of all input) and discussions of acquired knowledge and lifestyle changes took place in all groups. A total of 89% of the patients reported implementation of lifestyle changes and over 90% rated their learning and overall experience of the programme as acceptable or high and the demands as acceptable. Shortcomings were the limited use of some of the steps in the problem-solving process and tutors' difficulties in adapting to their new role; their answering of questions was higher than planned (35% of their total input). The programme was feasible in clinical routine.

The nurse--a resource in hypertension care

AIM OF THE STUDY

To explore the content and structure of communication between patient and nurse at follow-up appointments concerning hypertension.

BACKGROUND

Hypertension is a chronic condition and calls for co-operation between health care providers and patients over a long period of time. One important purpose of the follow-up consultations is to transfer knowledge between patients and health care providers in order to empower patients. This is an important determinant of the quality of care.

DESIGN/METHODS

The study was based on 20 audio-recordings of actual follow-up appointments and was approved by ethics committees. The consultations took place at four different health care units for hypertensive patients.

FINDINGS

The average length of consultations was 18 minutes. In the consultations, patients initiated an average of eight new topics and nurses an average of 20. All nurses talked with patients about life style. Compared with previous studies of follow-ups with physicians, consultations with nurses addressed lifestyle factors and adherence to treatment to a higher degree. It was also observed that patients were more actively involved in interaction with nurses compared with the follow-ups with physicians.

CONCLUSIONS

Active patient participation in care is a critical factor in improving adherence to treatment. It would be of value to develop and assess a more patient-centred organization of hypertension care and thereby more individualized hypertension treatment. Nurses may have a pivot role in such care.

Relation between insufficient response to antihypertensive treatment and poor compliance with treatment: a prospective case-control study

OBJECTIVES

To prospectively compare compliance with treatment in patients with hypertension responsive to treatment versus patients with treatment resistant hypertension.

DESIGN

Prospective case-control study.

SETTING

Outpatient department in a large city hospital in Switzerland, providing primary, secondary, and tertiary care.

PARTICIPANTS

110 consecutive medical outpatients with hypertension and taking stable treatment with at least two antihypertensive drugs for at least four weeks.

MAIN OUTCOME MEASURES

Treatment compliance assessed with MEMS devices; blood pressure determined by 12 hour daytime ambulatory monitoring (pressure <135/85 mm Hg in patients aged 60 indicated hypertension responsive to treatment).

RESULTS

Complete data were available for 103 patients, of whom 86 took >/=80% of their prescribed doses ("compliant") and 17 took <80% ("non-compliant"). Of the 49 patients with treatment resistant hypertension, 40 (82%) were compliant, while 46 (85%) of the 54 patients responsive to treatment were compliant.

CONCLUSION

Non-compliance with treatment was not more prevalent in patients with treatment resistant hypertension than in treatment responsive patients.

Factors associated with low compliance with lipid-lowering drugs in hyperlipidemic patients

BACKGROUND

Treatment with lipid-lowering drugs decreases the risk of having a cardiovascular event by 30% according to several large intervention trials. However, both in these trials and in clinical practice the rate of discontinuation of medical treatment and the frequency of low compliance are high.

OBJECTIVE

The purpose of the study was to determine factors associated with poor compliance.

METHODS

We studied 193 hyperlipidemic subjects who had been referred to an out-patient clinic and who were treated with at least one antihyperlipidemic drug. The patients were asked to fill in a questionnaire which explored various factors that could possibly affect compliance. Compliance was evaluated by the percentage of pills missed during the previous month according to patient interview.

RESULTS

Younger subjects and smokers were less compliant. Perception of frequent side-effects to the current antihyperlipidemic treatment and high number of medications were inversely correlated with compliance (P=0.0237 and P=0.0311, respectively). Frequent breaking of appointments with a physician were inversely correlated with compliance (P=0.026). The patient's perception of the time that the physician spent to explain and to discuss the different aspects of cholesterol and cardiovascular disease (CVD) was correlated with a higher compliance (P=0.0125). Patients' perception of the efficacy of antihyperlipidemic therapy to prevent a CVD event in the future was also strongly associated with adherence to treatment (P<0.001).

CONCLUSION

Many factors affect compliance with antihyperlipidemic drug therapy. Good doctor-patient relationship, conviction of the efficacy of treatment and increased age are associated with compliance. Perceived high frequency of side-effects and prescription of numerous drugs negatively affect compliance.

Reasons for adherence with antihypertensive medication

BACKGROUND

Hypertension is often insufficiently controlled in clinical practice, a prominent reason for this being poor patient adherence with therapy. Little is known about the underlying reasons for poor adherence. We set out to investigate hypertensive patients' self-reported reasons for adhering to or ignoring medical advice regarding antihypertensive medication.

METHODS

Qualitative analysis of semi-structured interviews with 33 hypertensive patients in a general-practice centre and a specialist hypertension unit in Southern Sweden. Blood-pressure measurements and laboratory measurements of antihypertensive medication were performed.

RESULTS

Nineteen out of 33 patients were classified as adherent. Adherence was a function of faith in the physician, fear of complications of hypertension, and a desire to control blood pressure. Non-adherence was an active decision, partly based on misunderstandings of the condition and general disapproval of medication, but mostly taken in order to facilitate daily life or minimize adverse effects. Adherent patients gave less evidence of involvement in care than non-adherent patients. There was no obvious relation between reported adherence, laboratory markers of adherence and blood-pressure levels.

CONCLUSIONS

The interview is a powerful tool for ascertaining patients' concepts and behaviour. To optimize treatment of hypertension, it is important to form a therapeutic alliance in which patients' doubts and difficulties with therapy can be detected and addressed. For this, effective patient-physician communication is of vital importance.

Can compliance with nonpharmacologic treatments for cardiovascular disease be improved?

OBJECTIVE

To critically review the literature regarding the effectiveness of interventions aimed at improving cardiovascular patient compliance with nonpharmacologic treatments.

METHODS

We searched Medline, Healthplan, and Psychlit from 1985 to 1996; searched the bibliographies of located studies; contacted Australian government departments and nongovernment organizations; and two experts examined the resulting study list. We selected 27 studies, which randomly allocated patients to groups and were published in English, and we evaluated interventions aimed at increasing compliance with nonpharmacologic treatments for cardiovascular disease. These trials were critically appraised against eight methodologic criteria and, subsequently, classified as of good, fair, or poor quality. Information about target groups, samples, trial intervention strategies and their effectiveness were extracted from the 18 good- and fair-quality trials. Interrater reliability was high on the 20% of references that were double-coded. The 18 studies reviewed described the effectiveness of 27 intervention strategies at improving compliance with dietary, smoking-cessation, exercise, weight-loss, stress-reduction, general lifestyle, relaxation, and blood pressure screening programs.

RESULTS

Tentative recommendations were made for or against most trial strategies: partner-focused and structural strategies showed the most consistent benefits, physician-focused strategies were unanimously unsuccessful, and patient-focused strategies were of mixed benefit.

CONCLUSIONS

The methodologic quality of many of the located trials was less than optimal. Therefore, further good-quality, randomized trials are necessary to clarify the effectiveness of those strategies identified as potentially useful in this review.

A critical review of interventions to increase compliance with medication-taking, obtaining medication refills, and appointment-keeping in the treatment of cardiovascular disease

BACKGROUND

The aim of this study was to critically review the literature regarding interventions to improve cardiovascular patients' compliance with medication-taking, obtaining medication refills, or appointment keeping.

METHODS

The search for relevant randomized trials involved searching the Medline, Healthplan, and Psychlit databases from 1985 to 1996; searching the bibliographies of located studies; contacting Australian government departments, non-government organizations, and pharmaceutical companies; and ultimate review of the resulting list by two field experts. The 33 located trials were critically appraised and classified as being of good, fair, or poor methodological quality. Descriptive and effectiveness data were then extracted from the 20 good and fair quality trials. Interrater reliability was high on the 20% of references double-coded.

RESULTS

The 20 studies reviewed evaluated the effectiveness of 18 intervention strategies. Tentative recommendations were made for many patient-focused and structural strategies across all three target behaviors. Physician-focused strategies, tested only for appointment keeping, were all tentatively recommended against.

CONCLUSIONS

The methodological quality of many of the located trials was less than optimal, prohibiting strong recommendations. Therefore, further good-quality, randomized trials are necessary in order to clarify the effectiveness of those strategies identified as potentially useful in this review.

Risk for hypertension and diminished pain sensitivity in women: autonomic and daily correlates

Research suggests an association between risk for hypertension and decreased pain sensitivity. However, few studies have utilized non-behavioral indices of pain to corroborate subjective reports or sought to generalize these findings to women. Furthermore, it has not been established whether results obtained using well-controlled laboratory pain stimuli extend to naturalistic pain. In Study 1, 80 young adult women with (N = 40) and without (N = 40) a parental history of hypertension and with either normatively low or high resting systolic blood pressure (SBP) were exposed to two experimental pain stimuli, finger pressure and the cold pressor test. In addition to behavioral pain measures, respiratory sinus arrhythmia (RSA) reactions to pain were also assessed. Women with a parental history of hypertension and/or normatively high resting SBP experienced significantly less pain, as assessed by both behavioral and RSA measures. In Study 2, 37 of the participants from Study 1 monitored their behaviors, affect, and physical symptoms, three times a day for 32 days. Laboratory pain sensitivity was significantly correlated with daily reports of pain but not gastrointestinal symptoms. The present results confirm an association between risk for hypertension and hypoalgesia in women and suggest generalizability of this relationship to everyday life.

[Compliance in antihypertensive therapy: analyses in scientific articles]

The aim of this study was to evaluate scientific articles published between 1991-1995, in order to identify the compliance in antihypertensive therapy, One hundred seven scientific articles were evaluated. The results showed that 68% were related to patient, 63% to pharmacological treatment, 62% general, 39% non pharmacological treatment, 34% organizational factors, and 8% related to disease. Compliance with antihypertensive therapy was the major challenge of hypertension management and to know how this aspect was focalized in scientific articles possible reduce non compliance in hypertension.

Antihypertensive medication in clinical encounters

In managing hypertension, patient participation and understanding of the nature and significance of treatment are decisive. We analysed the communication between patient and physician with respect to antihypertensive medication at a follow-up appointment, and assessed patients' knowledge of their medication. The empirical data consist of audio-recordings from 51 hypertensive patients' follow-up appointment with their physicians. Thirty-three of these patients were interviewed in depth immediately after the appointment. The study was performed in primary health care centres and at a specialist clinic for hypertension. When discussing medications, patients mainly talked about experiences of being on medication, whereas physicians generally focused on the pharmacological effect and dosage of the drug. Physicians routinely asked about compliance with drug regimen, but seldom in any depth. Little effort was invested into discussing the effect and goal of therapy. The main finding was that patients had a very fragmentary understanding of the functional nature of their antihypertensive medication. This is unsatisfactory both from the point of view of treatment efficacy and also when considering the legal requirements of involving the patient in the decision making. The follow-up appointments studied gave few possibilities for the patient to learn about their antihypertensive medication.

Designing computer-based frameworks that facilitate doctor--patient collaboration

A current trend in medicine involves establishing collaborative problem solving between patients and physicians in order to involve patients more in their own care. Neither diagnosis nor therapy can be completely successful unless the patient and the doctor understand each other and collaborate with each other in an effort to gauge the other's requests, needs and concerns. This is made even more difficult by the fact that there is often a big difference between the doctors and patients in terms of expectations, vocabulary used, and other factors. For diagnosis of many disorders, a detailed description of the problem and of the patient's history are required. For therapy, patients must understand how and when to take prescribed drugs, what changes to make in diet, exercise, or lifestyle and why they are important. This paper describes a model of asynchronous collaboration between people with very different knowledge of medicine in which a computer framework attempts to mediate between patients and physicians and reduce some of the differences in communication. It allows patients to pace themselves in familiarizing themselves with the relevant domain terms, some of the medical factors underlying the conditions under question, and the justifications and implications of the prescribed treatment plan. It also allows physicians to request more information of patients and gives patients contextual information to help them understand the underlying reasons for the questions. This framework has been partially implemented in the domain of migraines. As described in the paper, not only is the system designed to cooperate with the patient, but using the system also results in better mutual understanding between the doctor and the patient, thus leading to better collaboration between them.