Correlates of nonadherence to hypertension treatment in an inner-city minority population

The Effect of Base Theory Educational Intervention on Health-Promoting Lifestyle in Women Susceptible to Cardiovascular Diseases: Application of the Theory of Planned Behavior

Background

Cardiovascular diseases are the second leading cause of mortality, disability, and reduced productivity in women over 40 years and the first cause of mortality in women over 60 years. Therefore, the present study aimed to determine the effect of educational intervention based on theory of planned behavior (TPB) on health-promoting lifestyle in women susceptible to cardiovascular diseases.

Methods

This quasiexperimental study was conducted on 200 women susceptible to cardiovascular diseases referred to health centers in Fasa city, Fars province, Iran. The available sampling was performed on women who referred to the centers and had a family record. In this study, two health-promoting lifestyle questionnaires consisting of 49 questions and the theory of planned behavior questionnaire consisting of 50 questions were used. The obtained data were analyzed by using the SPSS software version 24 in two stages before and six months after the educational intervention through paired t-test, independent t-test, chi-square test, and McNemar test.

Results

The mean age of women in the experimental and control groups was 38.74 ± 9.22 and 39.14 ± 9.08 years, respectively. The results showed a significant increase in the experimental group after six months of intervention in terms of health-promoting lifestyle and constructs of the theory of planned behavior. Also, mean blood pressure, fasting blood sugar, and smoking of experimental group decreased six months after the educational intervention.

Conclusion

Considering the irreplaceable role of education in adopting healthy behaviors and the role of women in strengthening the family foundation, quality educational programs should be designed and regularly implemented by health care providers for women.

Patient-reported outcome measures to detect intentional, mixed, or unintentional non-adherence to medication: a systematic review

OBJECTIVE

To categorise patient-reported outcome measures (PROMs) into their propensity to detect intentional and/or unintentional non-adherence to medication, and synthesise their psychometric properties.

DESIGN

Systematic review and regression analysis.

ELIGIBILITY

Medication adherence levels studied at primary, secondary and tertiary care settings. Self-reported measures with scoring methods were included. Studies without proxy measures were excluded.

DATA SOURCES

Using detailed searches with key concepts including questionnaires, reliability and validity, and restricted to English, MEDLINE, EMBASE, CINAHL, International Pharmaceutical Abstracts, and Cochrane Library were searched until 01 March 2022. Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 (PRISMA-2020) checklist was used.

DATA ANALYSIS

Risk of bias was assessed via COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN-2018) guidelines. Narrative synthesis aided by graphical figures and statistical analyses.

OUTCOME MEASURES

Process domains [behaviour (e.g., self-efficacy), barrier (e.g., impaired dexterity) or belief (e.g., perception)], and overall outcome domains of either intentional (I), unintentional (UI), or mixed non-adherence.

RESULTS

Paper summarises evidence from 59 studies of PROMs, validated among patients aged 18-88 years in America, the United Kingdom, Europe, Middle East, and Australasia. PROMs detected outcome domains: intentional non-adherence, n=44 (I=491 criterion items), mixed intentionality, n=13 (I=79/UI=50), and unintentional, n=2 (UI=5). Process domains detected include belief (383 criterion items), barrier (192) and behaviour (165). Criterion validity assessment used proxy measures (biomarkers, e-monitors), and scoring was ordinal, dichotomised, or used Visual Analogue Scale. Heterogeneity was revealed across psychometric properties (consistency, construct, reliability, discrimination ability). Intentionality correlated positively with negative beliefs (r(57)=0.88) and barriers (r(57)=0.59). For every belief or barrier criterion-item, PROMs' aptitude to detect intentional non-adherence increased by β=0.79 and β=0.34 units, respectively (R²=0.94). Primary care versus specialised care predicted intentional non-adherence (OR 1.9; CI 1.01 to 2.66).

CONCLUSIONS

Ten PROMs had adequate psychometric properties. Of the ten, eight PROMs were able to detect total, and two PROMs were able to detect partial intentionality to medication default. Fortification of patients' knowledge and illness perception, as opposed to daily reminders alone, is most imperative at primary care levels.

Development and validation of an algorithm using health administrative data to define patient attachment to primary care providers

Purpose

The authors developed and validated an algorithm using health administrative data to identify patients who are attached or uncertainly attached to a primary care provider (PCP) using patient responses to a survey conducted in Ontario, Canada.

Design/methodology/approach

The authors conducted a validation study using as a reference standard respondents to a community-based survey who indicated they did or did not have a PCP. The authors developed and tested health administrative algorithms against this reference standard. The authors calculated the sensitivity, specificity positive predictive value (PPV) and negative predictive value (NPV) on the final patient attachment algorithm. The authors then applied the attachment algorithm to the 2017 Ontario population.

Findings

The patient attachment algorithm had an excellent sensitivity (90.5%) and PPV (96.8%), though modest specificity (46.1%) and a low NPV (21.3%). This means that the algorithm assigned survey respondents as being attached to a PCP and when in fact they said they had a PCP, yet a significant proportion of those found to be uncertainly attached had indicated they did have a PCP. In 2017, most people in Ontario, Canada (85.4%) were attached to a PCP but 14.6% were uncertainly attached.

Research limitations/implications

Administrative data for nurse practitioner's encounters and other interprofessional care providers are not currently available. The authors also cannot separately identify primary care visits conducted in walk in clinics using our health administrative data. Finally, the definition of hospital-based healthcare use did not include outpatient specialty care.

Practical implications

Uncertain attachment to a primary health care provider is a recurrent problem that results in inequitable access in health services delivery. Providing annual reports on uncertainly attached patients can help evaluate primary care system changes developed to improve access. This algorithm can be used by health care planners and policy makers to examine the geographic variability and time trends of the uncertainly attached population to inform the development of programs to improve primary care access.

Social implications

As primary care is an essential component of a person's medical home, identifying regions or high need populations that have higher levels of uncertainly attached patients will help target programs to support their primary care access and needs. Furthermore, this approach will be useful in future research to determine the health impacts of uncertain attachment to primary care, especially in view of a growing body of the literature highlighting the importance of primary care continuity.

Originality/value

This patient attachment algorithm is the first to use existing health administrative data validated with responses from a patient survey. Using patient surveys alone to assess attachment levels is expensive and time consuming to complete. They can also be subject to poor response rates and recall bias. Utilizing existing health administrative data provides more accurate, timely estimates of patient attachment for everyone in the population.

Nonadherence in Home-Based Pulmonary Rehabilitation Program for COPD Patients

Background

The pulmonary rehabilitation (PR) is beneficial for COPD patients. Due to the poor rate of adherence, we evaluate the factors which will predict the nonadherence of PR.

Method

We analyzed the data from a retrospective study of COPD patients who were enrolled to attend the PR program. Patients were classified as the adherence group and the nonadherence group according to completion of over 50% sessions during the 8-week PR program. Demographic characteristics, 6-minute walking distance (6MWD), COPD assessment test (CAT), modified Medical Research Council scale (mMRC), and emotional function were compared between two groups. Univariate and multivariable analyses were performed to determine the factors of poor adherence of PR.

Results

Among 418 patients, 170 patients (40.7%) who completed less than 50% sessions of the PR program were categorized as “nonadherence.” Compared to completers, “nonadherence” patients had more cigarette consumption, higher emotional score, less 6MWD, more exacerbation, using nebulizer frequently, and higher rate of smoking at enrollment. On multivariate analysis, more exacerbation frequency (odds ratio (OR) = 1.434, 95% confidence interval (CI): 1.191∼1.796, P=0.046) and smoking at enrollment (OR = 3.349, 95% CI: 1.194∼6.302, P=0.012) were predict factors associated with nonadherence of PR.

Conclusion

COPD patients with frequent exacerbation and smoking currently were more likely to be nonadherence during PR.

Hypertensive Crisis in Pediatric Patients: An Overview

Hypertensive crisis can be a source of morbidity and mortality in the pediatric population. While the epidemiology has been difficult to pinpoint, it is well-known that secondary causes of pediatric hypertension contribute to a greater incidence of hypertensive crisis in pediatrics. Hypertensive crisis may manifest with non-specific symptoms as well as distinct and acute symptoms in the presence of end-organ damage. Hypertensive emergency, the form of hypertensive crisis with end-organ damage, may present with more severe symptoms and lead to permanent organ damage. Thus, it is crucial to evaluate any pediatric patient suspected of hypertensive emergency with a thorough workup while acutely treating the elevated blood pressure in a gradual manner. Management of hypertensive crisis is chosen based on the presence of end-organ damage and can range from fast-acting intravenous medication to oral medication for less severe cases. Treatment of such demands a careful balance between decreasing blood pressure in a gradual manner while preventing damage end-organ damage. In special situations, protocols have been established for treatment of hypertensive crisis, such as in the presence of endocrinologic neoplasms, monogenic causes of hypertension, renal diseases, and cardiac disease. With the advent of telehealth, clinicians are further able to extend their reach of care to emergency settings and aid emergency medical service (EMS) providers in real time. In addition, further updates on the evolving topic of hypertension in the pediatric population and novel drug development continues to improve outcomes and efficiency in diagnosis and management of hypertension and consequent hypertensive crisis.

Patient Loss to Follow-up After Upper Extremity Surgery: A Review of 2563 Cases

Background: Postoperative care is essential to optimizing patient outcome. We sought to determine the incidence and associated demographic and surgical factors of postoperative patient loss to follow-up following hand and upper extremity surgery. Methods: In all, 2834 surgical cases (2467 patients) were retrospectively reviewed. All surgical cases from July 2014 to June 2015 at a single practice with five surgeons were assessed. Charts were reviewed for compliance with postoperative follow-up. Variables were described with proportions and compared using logistic regression analysis. Results: In total, 2563 cases (2388 patients) met the inclusion criteria. Overall loss to follow-up rate was 26%. Patients lost to follow-up based on insurance type were 13% for worker's compensation, 22% for private insurance, 21% for Medicare, 38% for Medicaid, and 44% for self-pay. Patients with expected short-term follow-up were lost at a 23% rate. Expected mid- and long-term follow-up patients were lost at 34% and 20% rates, respectively. Patients below 30 years old were lost to follow-up at a 42% rate compared to patients 30 to 64 years old (26%) and greater than or equal to 65 years (13%). Males had a higher rate of loss to follow-up, 32%, compared with females (22%). Patients living greater than 50 miles from our surgery center were lost to follow-up at a rate of 31%, compared with those who lived less than 50 miles (25%). Conclusions: We have identified demographic variables associated with patients being lost to follow-up after hand and upper extremity surgery. With this knowledge, we hope to develop methods of either improving in-office follow-up rates or discover new avenues to deliver postoperative care.

Making medications stick: improving medication adherence by highlighting the personal health costs of non-compliance

Poor compliance of prescription medication is an ongoing public health crisis. Nearly half of patients do not take their medication as prescribed, harming their own health while also increasing public health care costs. Despite these detrimental consequences, prior research has struggled to establish cost-effective and scalable interventions to improve adherence rates. We suggest that one reason for the limited success of prior interventions is that they make the personal health costs of non-adherence insufficiently prominent, while a higher saliency of these costs may motivate patients to adhere more. In the current research, we test whether an intervention that makes the personal health costs of non-compliance more salient for patients will increase their medication adherence. To do so, we conducted a randomized controlled trial with 16,191 patients across 278 UK pharmacies over a 9-month time period and manipulated the perceived consequences of medication non-adherence. We find that patients who received a treatment highlighting the personal health costs of non-compliance were significantly more likely to adhere to their medication than three comparison groups (odds ratio = 1.84, 95% confidence interval = 1.37–2.47). Shifting patients’ focus to the personal health costs of non-compliance may thus offer a potentially cost-effective and scalable approach to improving medication adherence.

A systematic literature review comparing methods for the measurement of patient persistence and adherence

OBJECTIVES

A systematic literature review was conducted comparing different approaches estimating persistence and adherence in chronic diseases with polypharmacy of oral and subcutaneous treatments.

METHODS

This work followed published guidance on performing systematic reviews. Twelve electronic databases and grey literature sources were used to identify studies and guidelines for persistence and adherence of oral and subcutaneous therapies in hypercholesterolemia, type 2 diabetes, hypertension, osteoporosis and rheumatoid arthritis. Outcomes of interest of each persistence and adherence data collection and calculation method included pros: accurate, easy to use, inexpensive; and cons: inaccurate, difficult to use, expensive.

RESULTS

A total of 4158 records were retrieved up to March 2017. We included 16 observational studies, 5 systematic reviews and 7 guidelines, in patients with hypercholesterolemia (n = 8), type 2 diabetes (n = 4), hypertension (n = 2), rheumatoid arthritis (n = 1) and mixed patient populations (n = 13). Pharmacy and medical records offer an accurate, easy and inexpensive data collection method. Pill count, medication event monitoring systems (MEMs), self-report questionnaires and observer report are easy to use. MEMS and biochemical monitoring tests can be expensive. Proportion of days covered (PDC) was recommended as a gold standard calculation method for long-term treatments. PDC avoids use of days' supply in calculation, hence is more accurate compared to medication possession ratio (MPR) to assess adherence to treatments in chronic diseases.

CONCLUSIONS

Decisions on what method to use should be based on considerations of the route of medication administration, the resources available, setting and aim of the assessment. Combining different methods may provide wider insights into adherence and persistence, including patient behavior.

Cross-cultural adaptation and validation of a European Portuguese version of the 8-item Morisky medication adherence scale

INTRODUCTION AND OBJECTIVE

The 8-Item Morisky Medication Adherence Scale (MMAS-8) is one of the most widely used instruments to assess medication adherence, but a validated European Portuguese version of MMAS-8 does not exist. Our aim was to develop and validate a European Portuguese version of the MMAS-8.

METHODS

A process of translation and back-translation of the original MMAS-8 was performed. The questionnaire was administered in nine community pharmacies and one public hospital between March 2014 and September 2015. Adult patients taking at least one antihypertensive drug were invited to participate. A confirmatory factor analysis was performed and internal consistency, convergent validity and concurrent validity were examined.

RESULTS

A total of 472 patients were enrolled in the study. The mean MMAS-8 score obtained was 6.74±1.39. One hundred and thirty-two patients were classified as low adherers (28%), 181 (38.3%) as medium adherers and 159 (33.7%) as high adherers. For the factorial structure of the Portuguese version of the MMAS-8, the fit indices of the final model (chi-square [18] 48.465, p<0.001) are suggestive of very good fit, with comparative fit index 0.95, root mean square error of approximation 0.06 (90% confidence interval 0.04-0.08), and standardized root mean square residual 0.04, confirming that the construct tested was unidimensional. The Cronbach's alpha for all items was 0.60, and the translated version presents convergent validity and concurrent validity.

CONCLUSION

A European Portuguese version of the MMAS-8 was created that maintained a similar structure to the original MMAS-8 and good psychometric properties.

Task shifting in the management of hypertension in Kinshasa, Democratic Republic of Congo: a cross-sectional study

Background

The Democratic Republic of the Congo (DRC) is characterized by a high prevalence of hypertension (HTN) and a high proportion of uncontrolled HTN, which is indicative of poor HTN management. Effective management of HTN in the African region is challenging due to limited resources, particularly human resources for health. To address the shortage of health workers, the World Health Organization (WHO) recommends task shifting for better disease management and treatment. Although task shifting from doctors to nurses is being implemented in the DRC, there are no studies, to the best of our knowledge, that document the association between task shifting and HTN control. The aim of this study was to investigate the association between task shifting and HTN control in Kinshasa, DRC.

Methods

We conducted a cross-sectional study in Kinshasa from December 2015 to January 2016 in five general referral hospitals (GRHs) and nine health centers (HCs). A total of 260 hypertensive patients participated in the study. Sociodemographic, clinical, health care costs and perceived health care quality assessment data were collected using a structured questionnaire. To examine the association between task shifting and HTN control, we assessed differences between GRH and HC patients using bivariate and multivariate analyses.

Results

Almost half the patients were female (53.1%), patients’ mean age was 59.5 ± 11.4 years. Over three-fourths of patients had uncontrolled HTN. There was no significant difference in the proportion of GRH and HC patients with uncontrolled HTN (76.2% vs 77.7%, p = 0.771). Uncontrolled HTN was associated with co-morbidity (OR = 10.3; 95% CI: 3.8–28.3) and the type of antihypertensive drug used (OR = 4.6; 95% CI: 1.3–16.1). The mean healthcare costs in the GRHs were significantly higher than costs in the HCs (US$ 34.2 ± US$3.34 versus US$ 7.7 ± US$ 0.6, respectively).

Conclusion

Uncontrolled HTN was not associated with the type of health facility. This finding suggests that the management of HTN at primary healthcare level might be just as effective as at secondary level. However, the high proportion of patients with uncontrolled HTN underscores the need for HTN management guidelines at all healthcare levels.

Prevalence and determinants of use of complementary and alternative medicine by hypertensive patients attending primary health care facilities in Kinshasa, Democratic Republic of the Congo: a cross-sectional study

BACKGROUND

In the Democratic Republic of the Congo the control of hypertension is poor, characterized by an increasing number of reported cases of hypertension related complications. Poor control of hypertension is associated with non-adherence to antihypertensive medication. It is well established that the use of complementary and alternative medicine is one of the main factors of non-adherence to antihypertensive medication. The aim of this study is to determine the prevalence and factors associated with the use of complementary and alternative medicine.

METHODS

A cross-sectional study was carried out at the Kinshasa Primary Health-care (KPHC) facilities network in November 2014. A structured interview questionnaire was administrated to a total of 280hypertensive patients. Complementary and alternative medicine were defined according to the National Institute of Health classification as a group of diverse medical and healthcare systems, practices, and products that are not presently considered to be part of conventional medicine. Data were summarized using proportion and mean (with standard deviation). The student's t test and χ² test were used respectively for mean and proportion comparison. Logistic regression analysis identified determinants of the use of complementary and alternative medicine.

RESULTS

The prevalence of use of complementary and alternative medicine was 26.1% (95% CI: 20.7% - 31.8%).Determinants of use of complementary and alternative medicine included misperception about hypertension curability (OR = 2.1; 95%CI: 1.1-3.7) and experience of medication side effects (OR = 2.9; 95%CI: 1.7-5.1).

CONCLUSION

The use of CAM for hypertensive patients is a major problem; antihypertensives with fewer side effects must be emphasized. Religious leaders must become involved in the communication for behavioral change activities to improve the quality of life for hypertensive patients.

Validity and Reliability of a Self-Reported Measure of Antihypertensive Medication Adherence in Uganda

Background

The Morisky Medication Adherence scale (MMAS-8) is a widely used self-reported measure of adherence to antihypertensive medications that has not been validated in hypertensive patients in sub-Saharan Africa.

Methods

We carried out a cross-sectional study to examine psychometric properties of a translated MMAS-8 (MMAS-U) in a tertiary care hypertension clinic in Uganda. We administered the MMAS-U to consecutively selected hypertensive adults and used principal factor analysis and Cronbach’s alpha to determine its validity and internal consistency respectively. Then we randomly selected one-sixth of participants for a 2-week test-retest telephone interview. Lastly, we used ordinal logistic regression modeling to explore factors associated with levels of medication adherence.

Results

Of the 329 participants, 228 (69%) were females, median age of 55 years [Interquartile range (IQR) (46–66)], and median duration of hypertension of 4 years [IQR (2–8)]. The adherence levels were low (MMAS-U score ≤ 5) in 85%, moderate (MMAS-U score 6–7) in 12% and high (MMAS-U score ≥8) in 3%. The factor analysis of construct validity was good (overall Kaiser’s measure of sampling adequacy for residuals of 0.72) and identified unidimensionality of MMAS-U. The internal consistency of MMAS-U was moderate (Cronbach α = 0.65), and test-retest reliability was low (weighted kappa = 0.36; 95% CI -0.01, 0.73). Age of 40 years or greater was associated with low medication adherence (p = 0.02) whereas a family member buying medication for participants (p = 0.02) and purchasing medication from a private clinic (p = 0.02) were associated with high adherence.

Conclusion

The Ugandan version of the MMAS-8 (MMAS-U) is a valid and reliable measure of adherence to antihypertensive medication among Ugandan outpatients receiving care at a public tertiary facility. Though the limited supply of medication affected adherence, this easy to use tool can be adapted to assess medication adherence among adults with hypertension in Uganda.

Effect of Expectation of Care on Adherence to Antihypertensive Medications Among Hypertensive Blacks: Analysis of the Counseling African Americans to Control Hypertension (CAATCH) Trial

Novel ideas are needed to increase adherence to antihypertensive medication. The current study used data from the Counseling African Americans to Control Hypertension (CAATCH) study, a sample of 442 hypertensive African Americans, to investigate the mediating effects of expectation of hypertension care, social support, hypertension knowledge, and medication adherence, adjusting for age, sex, number of medications, diabetes, education, income, employment, insurance status, and intervention. Sixty-six percent of patients had an income of $20,000 or less and 56% had a high school education or less, with a mean age of 57 years. Greater expectation of care was associated with greater medication adherence (P=.007), and greater social support was also associated with greater medication adherence (P=.046). Analysis also showed that expectation of care mediated the relationship between hypertension knowledge and medication adherence (P<.05). Expectation of care and social support are important factors for developing interventions to increase medication adherence among blacks.

Perspectives on Adherence to Recommended Health Behavior among Low-Income Patients

Although patient nonadherence with health care recommendations is a known barrier to controlling health care costs and improving health outcomes, little is known about variables that affect adherence to recommended health behaviors among low-income patients. Four focus groups were conducted among a sample of low-income patients, to examine their perceptions of adherence with recommendations for appointment keeping, special diets, and medications. Continuity of care and patient fears emerged as common themes contributing to adherence. Continuity of care consisted of having a positive interpersonal relationship with a single primary physician, and a system of coordinated care among multiple specialty physicians. Fear of dying, not living well, getting worse, and feeling bad again were strong promoters of adherence. Among low-income patients and care delivery systems with capitated funding, efforts are needed to improve continuity of care and increase provider awareness of the fears that patients bring to a care encounter.

ADESÃO DE HIPERTENSOS E DIABÉTICOS ANALFABETOS AO USO DE MEDICAMENTO A PARTIR DA PRESCRIÇÃO PICTOGRÁFICA

Resumo A baixa adesão ao tratamento medicamentoso constitui grave entrave para o sucesso do controle de doenças como o diabetes e a hipertensão arterial. Este artigo trata de um estudo que partiu da identificação do analfabetismo como importante causa de não adesão ao tratamento medicamentoso para diabéticos e hipertensos participantes do programa Hiperdia em unidade de saúde do município de Colombo, no estado do Paraná. Teve como objetivo avaliar o impacto de prescrição pictórica na adesão ao tratamento. Analisou-se um grupo de 63 diabéticos e hipertensos que participavam do Hiperdia, para os quais aplicou-se uma entrevista estruturada, com posterior análise do conteúdo, antes e depois da implantação de uma prescrição pictográfica. Como resultado, entre os analfabetos, observou-se a elevação da adesão de 60% para 93,33% em relação ao tratamento medicamentoso. No grupo de alfabetizados não houve mudança na adesão. Conclui-se, no entanto, que esse tipo de intervenção é limitado para a melhora da condição de saúde dos pacientes, pois o aumento da adesão se dá em relação tanto ao tratamento medicamentoso quanto à precariedade.

Determinants of successful completion of pulmonary rehabilitation in COPD

Background

Despite known benefits, a significant proportion of patients with COPD do not complete pulmonary rehabilitation (PR). Little is known regarding which factors promote successful completion of PR.

Methods

We analyzed data from a prospectively maintained database of subjects with COPD who attended a PR program at the University of Alabama at Birmingham, from 1996 to 2013. Subjects were categorized as either completers or non-completers, based on successful completion of at least 8 weeks of PR. Demographics and comorbidities were recorded. Short Form 36 Health Survey, Beck Depression Inventory-II, and San Diego Shortness of Breath Questionnaire were administered to all participants at baseline and on completion of PR to assess participants’ perception of their health status, severity of depression, and dyspnea with performance of activities of daily living. Univariate and multivariable analyses were performed to identify predictors of successful completion of PR.

Results

Four hundred and forty subjects were included, of whom 229 completed PR. Forty-one percent were female, and 17% were African American. Compared with non-completers, completers had greater Short Form 36 Health Survey pain score, lower forced expiratory volume in the first second, and lower Beck Depression Inventory score, and included a lower percentage of current smokers. On multivariate analysis, cigarette smoking at enrollment was associated with lower likelihood of completion of PR (adjusted odds ratio 0.38, 95% confidence interval 0.16–0.90; P=0.02).

Conclusion

Cigarette smoking was the sole independent predictor of PR dropout, and smoking cessation may warrant greater emphasis prior to enrollment.

Social support and adherence to treatment in hypertensive patients: a meta-analysis

BACKGROUND

It is important to examine factors associated with patient adherence to hypertension control strategies.

PURPOSE

A meta-analysis was conducted to examine whether social support was related to adherence to healthy lifestyle and treatment medication in hypertensive patients.

METHODS

Journal articles were searched in medical (CINAHL, MEDLINE), psychological (PsycINFO, PsycARTICLES), and educational (ERIC) electronic databases; in reference lists of selected papers; and in the reference list of a previous review.

RESULTS

Findings of a set of meta-analyses indicated that (a) structural social support was not significantly related to overall adherence, (b) functional social support was significantly and positively related to overall adherence, (c) these findings were further confirmed in meta-analyses conducted on specific types of adherence, and (d) most results were characterized by heterogeneity across studies that was partially explained by moderator analyses.

CONCLUSIONS

Functional social support, but not structural social support, was associated with adherence in hypertensive patients.

Smoking cessation interventions for pulmonary tuberculosis treatment outcomes

BACKGROUND

Active smoking increases the risk of tuberculosis (TB) infection 2 to 2.5 times and is significantly associated with recurrent TB and TB mortality. Observational studies have shown associations between smoking and poor TB treatment outcomes such as increased loss to follow-up rate, severity of disease, drug resistance and slow smear conversion. Since most smoking-related immunologic abnormalities are reversible within six weeks of stopping smoking, smoking cessation may have substantial positive effects on TB treatment outcomes, TB relapse and future lung disease.

OBJECTIVES

To analyse the effect of tobacco smoking cessation interventions (SCIs) on the treatment outcomes of people with adult pulmonary TB.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register using free-text and MeSH terms for TB and antitubercular treatment. We also searched MEDLINE and EMBASE using the same topic-related terms, combined with the search terms used to identify trials of tobacco cessation interventions from the Specialised Register. We also searched reference list of articles and reviews, the Conference Paper Index, clinicaltrials.gov and grey literature. The searches are current to 29th July 2015.

SELECTION CRITERIA

Individual and cluster-randomised controlled trials (RCTs), regardless of date, language and publication status, studies of adults with pulmonary TB on first-line anti-tubercular drugs, with interventions at either an individual or a population level, delivered separately or as part of a larger tobacco control package. This included any type of behavioural or pharmaceutical intervention or both for smoking cessation.

DATA COLLECTION AND ANALYSIS

Using the eligibility criteria, two authors independently checked the abstracts of retrieved studies for relevance, and acquired full trial reports of candidates for inclusion. The authors resolved any disagreements on eligibility by mutual consent, or by recourse to a third author. Two authors intended to independently extract study data from eligible studies into a data extraction form and compare the findings, synthesise data using risk ratios, and assess risk of bias using standard Cochrane methodologies. However, we found no eligible trials.

MAIN RESULTS

There were no randomised controlled trials that met the eligibility criteria. A number of potentially eligible studies are underway, and we will assess them for inclusion in the next update of this review.

AUTHORS' CONCLUSIONS

There is a lack of high-quality evidence, i.e. RCTs, that tests the effectiveness of cessation interventions in improving TB treatment outcomes. There is a need for good-quality randomised controlled trials that assess the effect of SCIs on TB treatment outcomes in both the short and long term. Establishing such an evidence base would be an essential step towards the implementation of SCIs in TB control programmes worldwide.

Predictors of non-adherence to antihypertensive medication in Kinshasa, Democratic Republic of Congo: a cross-sectional study

BACKGROUND

Hypertension remains a public health challenge worldwide. In the Democratic Republic of Congo, its prevalence has increased in the past three decades. Higher prevalence of poor blood pressure control and an increasing number of reported cases of complications due to hypertension have also been observed. It is well established that non-adherence to antihypertensive medication contributes to poor control of blood pressure. The aim of this study is to measure non-adherence to antihypertensive medication and to identify its predictors.

METHODS

A cross-sectional study was conducted at Kinshasa Primary Health-care network facilities from October to November 2013. A total of 395 hypertensive patients were included in the study. A structured interview was used to collect data. Adherence to medication was assessed using the Morisky Medication Scale. Covariates were defined according to the framework of the World Health Organization. Logistic regression was used to identify predictors of non-adherence.

RESULTS

A total of 395 patients participated in this study. The prevalence of non-adherence to antihypertensive medication and blood pressure control was 54.2 % (95 % CI 47.3-61.8) and 15.6 % (95 % CI 12.1-20.0), respectively. Poor knowledge of complications of hypertension (OR = 2.4; 95 % CI 1.4-4.4), unavailability of antihypertensive drugs in the healthcare facilities (OR = 2.8; 95 % CI 1.4-5.5), lack of hypertensive patients education in the healthcare facilities (OR = 1.7; 95 % CI 1.1-2.7), prior experience of medication side effects (OR = 2.2; 95 % CI 1.4-3.3), uncontrolled blood pressure (OR = 2.0; 95 % CI 1.1-3.9), and taking non-prescribed medications (OR = 2.2; 95 % CI 1.2-3.8) were associated with non-adherence to antihypertensive medication.

CONCLUSION

This study identified predictors of non-adherence to antihypertensive medication. All predictors identified were modifiable. Interventional studies targeting these predictors for improving adherence are needed.

Determinants of adherence to treatment in hypertensive patients of African descent and the role of culturally appropriate education

BACKGROUND

In Western countries, better knowledge about patient-related determinants of treatment adherence (medication and lifestyle) is needed to improve treatment adherence and outcomes among hypertensive ethnic minority patients of African descent.

OBJECTIVE

To identify patient-related determinants of adherence to lifestyle and medication recommendations among hypertensive African Surinamese and Ghanaian patients with suboptimal treatment results (SBP≥140) living in the Netherlands and how culturally appropriate hypertension education (CAHE) influenced those determinants.

METHODS

This study analysed data of 139 patients who participated in the CAHE trial. Univariate logistic regression analysis was used to measure the association between patient-related determinants (medication self-efficacy, beliefs about medication and hypertension, social support, and satisfaction with care) and treatment adherence. We also tested whether CAHE influenced the determinants.

RESULTS

Medication self-efficacy and social support were associated with medication adherence at baseline. At six months, more medication self-efficacy and fewer concerns about medication use were associated with improved medication adherence. Self-efficacy was also associated with adherence to lifestyle recommendations at baseline. CAHE influenced patients' illness perceptions by creating more understanding of hypertension, its chronic character, and more concerns about the associated risks.

CONCLUSION

In this high-risk population, health care providers can support medication adherence by paying attention to patients' medication self-efficacy, the concerns they may have about medication use and patients' perceptions on hypertension. The CAHE intervention improved patients' perception on hypertension.

Self-report measures of medication adherence behavior: recommendations on optimal use

Medication adherence plays an important role in optimizing the outcomes of many treatment and preventive regimens in chronic illness. Self-report is the most common method for assessing adherence behavior in research and clinical care, but there are questions about its validity and precision. The NIH Adherence Network assembled a panel of adherence research experts working across various chronic illnesses to review self-report medication adherence measures and research on their validity. Self-report medication adherence measures vary substantially in their question phrasing, recall periods, and response items. Self-reports tend to overestimate adherence behavior compared with other assessment methods and generally have high specificity but low sensitivity. Most evidence indicates that self-report adherence measures show moderate correspondence to other adherence measures and can significantly predict clinical outcomes. The quality of self-report adherence measures may be enhanced through efforts to use validated scales, assess the proper construct, improve estimation, facilitate recall, reduce social desirability bias, and employ technologic delivery. Self-report medication adherence measures can provide actionable information despite their limitations. They are preferred when speed, efficiency, and low-cost measures are required, as is often the case in clinical care.

Medication adherence and visit-to-visit variability of systolic blood pressure in African Americans with chronic kidney disease in the AASK trial

Lower adherence to antihypertensive medications may increase visit-to-visit variability of blood pressure (VVV of BP), a risk factor for cardiovascular events and death. We used data from the African American Study of Kidney Disease and Hypertension (AASK) trial to examine whether lower medication adherence is associated with higher systolic VVV of BP in African Americans with hypertensive chronic kidney disease (CKD). Determinants of VVV of BP were also explored. AASK participants (n=988) were categorized by self-report or pill count as having perfect (100%), moderately high (75-99%), moderately low (50-74%) or low (<50%) proportion of study visits with high medication adherence over a 1-year follow-up period. We used multinomial logistic regression to examine determinants of medication adherence, and multivariable-adjusted linear regression to examine the association between medication adherence and systolic VVV of BP, defined as the coefficient of variation or the average real variability (ARV). Participants with lower self-reported adherence were generally younger and had a higher prevalence of comorbid conditions. Compared with perfect adherence, moderately high, moderately low and low adherence was associated with 0.65% (±0.31%), 0.99% (±0.31%) and 1.29% (±0.32%) higher systolic VVV of BP (defined as the coefficient of variation) in fully adjusted models. Results were qualitatively similar when using ARV or when using pill counts as the measure of adherence. Lower medication adherence is associated with higher systolic VVV of BP in African Americans with hypertensive CKD; efforts to improve medication adherence in this population may reduce systolic VVV of BP.

Patient-related barriers to hypertension control in a Nigerian population

BACKGROUND

Hypertension control is a challenge globally. Barriers to optimal control exist at the patient, physician, and health system levels. Patient-related barriers in our environment are not clear. The aim of this study was to identify patient-related barriers to control of hypertension among adults with hypertension in a semiurban community in South-East Nigeria.

METHODS

This was a cross-sectional descriptive study of patients with a diagnosis of hypertension and on antihypertensive medication.

RESULTS

A total of 252 participants were included in the survey, and comprised 143 males (56.7%) and 109 females (43.3%). The mean age of the participants was 56.6±12.7 years, with a diagnosis of hypertension for a mean duration of 6.1±3.3 years. Among these patients, 32.9% had controlled blood pressure, while 39.3% and 27.8%, respectively, had stage 1 and stage 2 hypertension according to the Seventh Report of the Joint National Committee on Prevention, Detection and Evaluation of High Blood Pressure. Only 23.4% knew the consequences of poor blood pressure control and 64% were expecting a cure from treatment even when the cause of hypertension was not known. Furthermore, 68.7% showed low adherence to medication, the reported reasons for which included forgetfulness (61.2%), financial constraints (56.6%), high pill burden (22.5%), side effects of medication (17.3%), and low measured blood pressure (12.1%). Finally, knowledge and practice of the lifestyle modifications necessary for blood pressure control was inadequate among the participants.

CONCLUSION

Poor knowledge regarding hypertension, unrealistic expectations of treatment, poor adherence with medication, unawareness of lifestyle modification, and failure to apply these were identified as patient-related barriers to blood pressure control in this study.

Perceived discrimination and medication adherence in black hypertensive patients: the role of stress and depression

OBJECTIVE

To examine the relationship between perceived discrimination and medication adherence among black people with hypertension and the role of stress and depressive symptoms in this relationship. Perceived racial discrimination has been associated with poor health outcomes in blacks; its relationship to medication adherence among hypertensive patients remains untested.

METHODS

We measured perceived racial discrimination at baseline, stress and depressive symptoms at 6 months, and medication adherence at 12 months among patients enrolled in a 30-site cluster-randomized controlled trial testing a patient and physician-targeted intervention to improve blood pressure. A mediational method with bootstrapping (stratified by site) confidence intervals was used to estimate the indirect association between perceived discrimination and medication adherence through stress and depression.

RESULTS

Of 1056 patients from 30 sites enrolled in the trial, 463 had complete data on all four measures at 6 and 12 months and were included in the analyses. Adjusting for clustering, perceived discrimination was associated with poor medication adherence (B = 0.138, p = .011) at 12 months, and with stress (B = 2.24, p = .001) and depression (B = 1.47, p = .001) at 6 months. When stress and depression were included in the model, there was a 65% reduction in the total association of perceived discrimination with medication adherence, and the relationship was no longer significant (B = 0.049, p = .35).

CONCLUSIONS

Perceived discrimination is associated with poor medication adherence among hypertensive blacks, and stress and depressive symptoms may account for this relationship.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00233220.

Culturally adapted hypertension education (CAHE) to improve blood pressure control and treatment adherence in patients of African origin with uncontrolled hypertension: cluster-randomized trial

Objectives

To evaluate the effect of a practice-based, culturally appropriate patient education intervention on blood pressure (BP) and treatment adherence among patients of African origin with uncontrolled hypertension.

Methods

Cluster randomised trial involving four Dutch primary care centres and 146 patients (intervention n = 75, control n = 71), who met the following inclusion criteria: self-identified Surinamese or Ghanaian; ≥20 years; treated for hypertension; SBP≥140 mmHg. All patients received usual hypertension care. The intervention-group was also offered three nurse-led, culturally appropriate hypertension education sessions. BP was assessed with Omron 705-IT and treatment adherence with lifestyle- and medication adherence scales.

Results

139 patients (95%) completed the study (intervention n = 71, control n = 68). Baseline characteristics were largely similar for both groups. At six months, we observed a SBP reduction of ≥10 mmHg -primary outcome- in 48% of the intervention group and 43% of the control group. When adjusted for pre-specified covariates age, sex, hypertension duration, education, baseline measurement and clustering effect, the between-group difference was not significant (OR; 0.42; 95% CI: 0.11 to 1.54; P = 0.19). At six months, the mean SBP/DBD had dropped by 10/5.7 (SD 14.3/9.2)mmHg in the intervention group and by 6.3/1.7 (SD 13.4/8.6)mmHg in the control group. After adjustment, between-group differences in SBP and DBP reduction were −1.69 mmHg (95% CI: −6.01 to 2.62, P = 0.44) and −3.01 mmHg (−5.73 to −0.30, P = 0.03) in favour of the intervention group. Mean scores for adherence to lifestyle recommendations increased in the intervention group, but decreased in the control group. Mean medication adherence scores improved slightly in both groups. After adjustment, the between-group difference for adherence to lifestyle recommendations was 0.34 (0.12 to 0.55; P = 0.003). For medication adherence it was −0.09 (−0.65 to 0.46; P = 0.74).

Conclusion

This intervention led to significant improvements in DBP and adherence to lifestyle recommendations, supporting the need for culturally appropriate hypertension care.

Trial Registration

Controlled-Trials.com ISRCTN35675524

Enhancing adherence of antihypertensive regimens in hypertensive African-Americans: current and future prospects

Patient adherence to antihypertensive medication is an important strategy for blood pressure control in hypertensive patients. However, rates of antihypertensive medication adherence among hypertensive African-Americans are unacceptably low. This article examines the current understanding of patient, clinical, provider and healthcare system factors associated with medication adherence in hypertensive African-Americans. Studies demonstrated that patient and clinical factors, such as self-efficacy and depression, are consistently associated with medication adherence in hypertensive African-Americans patients. Provider communication shows promise as a correlate of medication adherence, but more research on provider and healthcare system factors are still needed. The authors recommend that interventions targeted at increasing medication adherence among hypertensive African-Americans focus on self-efficacy. It is also imperative that clinicians screen hypertensive patients for depression and treat, if necessary.

Determinants of tuberculosis treatment default in Morocco: results from a national cohort study

Introduction

Studies have shown an association between smoking and tuberculosis (TB) infection, disease and TB-related mortality. We thus documented the impact of smoking and others factors on TB treatment default.

Methods

A cohort of 1039 new TB cases matched on smoking status was followed between 2004 and 2009 in eight Moroccan regions. Treatment default was defined according to international criteria. Univariate analyses were used to assess associations of treatment default with smoking status and demographic characteristics. Multivariate logistic regression was used to adjust for potential confounding.

Results

Patients’ mean age was 35.0 ±13.2 years. The rate of treatment default was 30.2%. Default was significantly higher among men, smokers, persons living in urban areas and non-religious Muslims. After adjusting for confounding variables, factors that remained significantly associated with treatment default were: being male (OR = 3.2; 95% CI: 1.2-8.7), being a non-religious Muslim (OR = 2.0; 95% CI: 1.4-2.9) and living in an urban area OR = 3.0; 95% CI: 1.8-4.9).

Conclusion

The high rate found for default suggests important program's inadequacies and an urgent need for change. Therefore continued research of predictors of default and strategies to reinforce adherence is recommended.

Solifenacin succinate versus percutaneous tibial nerve stimulation in women with overactive bladder syndrome: results of a randomized controlled crossover study

AIMS

This study compared the effectiveness of solifenacin succinate (SS) versus percutaneous tibial nerve stimulation (PTNS) in women with overactive bladder syndrome (OABS).

METHODS

A randomized controlled crossover study of 40 women with OABS was performed. Patients were randomized into two groups. In group A, patients received SS and then PTNS. In group B, patients underwent PTNS and then SS. Voiding diaries, quality of life surveys and patient perception of intensity of urgency questionnaire were performed before and after each treatment. The global impression of improvement questionnaire was performed at the end of the study.

RESULTS

A reduction in the number of daily micturitions, episodes of nocturia and urge incontinence were found with both SS and PTNS in all groups, but PTNS showed a greater effectiveness than SS. There was an increase in voided volume in all groups with both SS and PTNS, but patients treated with PTNS had a greater increase. PTNS showed greater effectiveness in patient perception of urgency and quality of life.

CONCLUSION

This study demonstrates the effectiveness of SS and PTNS In women with overactive bladder symptoms. However, greater improvements were found with PTNS.

The influence of health systems on hypertension awareness, treatment, and control: a systematic literature review

BACKGROUND

Hypertension (HT) affects an estimated one billion people worldwide, nearly three-quarters of whom live in low- or middle-income countries (LMICs). In both developed and developing countries, only a minority of individuals with HT are adequately treated. The reasons are many but, as with other chronic diseases, they include weaknesses in health systems. We conducted a systematic review of the influence of national or regional health systems on HT awareness, treatment, and control.

METHODS AND FINDINGS

Eligible studies were those that analyzed the impact of health systems arrangements at the regional or national level on HT awareness, treatment, control, or antihypertensive medication adherence. The following databases were searched on 13th May 2013: Medline, Embase, Global Health, LILACS, Africa-Wide Information, IMSEAR, IMEMR, and WPRIM. There were no date or language restrictions. Two authors independently assessed papers for inclusion, extracted data, and assessed risk of bias. A narrative synthesis of the findings was conducted. Meta-analysis was not conducted due to substantial methodological heterogeneity in included studies. 53 studies were included, 11 of which were carried out in LMICs. Most studies evaluated health system financing and only four evaluated the effect of either human, physical, social, or intellectual resources on HT outcomes. Reduced medication co-payments were associated with improved HT control and treatment adherence, mainly evaluated in US settings. On balance, health insurance coverage was associated with improved outcomes of HT care in US settings. Having a routine place of care or physician was associated with improved HT care.

CONCLUSIONS

This review supports the minimization of medication co-payments in health insurance plans, and although studies were largely conducted in the US, the principle is likely to apply more generally. Studies that identify and analyze complexities and links between health systems arrangements and their effects on HT management are required, particularly in LMICs. Please see later in the article for the Editors' Summary.

Fatores associados à adesão ao tratamento de pacientes com diabetes mellitus

OBJETIVO: Investigar associação entre adesão ao tratamento do diabetes mellitus tipo 2 e variáveis sociodemográficas, clínicas e controle metabólico. MÉTODOS: Desenho cross seccional com 423 portadores de diabetes mellitus. Para verificar a associação entre adesão ao tratamento e as variáveis estudadas, utilizou-se teste exato de Fisher e modelos de regressão logística. RESULTADOS: Não houve associação entre adesão ao tratamento do DM2 e variáveis sociodemográficas e clínicas. Verificou-se que o colesterol total e a HbA1c apresentaram associação estatisticamente significativa com a adesão ao plano alimentar (p = 0,036) e de exercício físico (p = 0,006). CONCLUSÃO: A chance do paciente com colesterol dentro do valor recomendado apresentar adesão ao plano alimentar é quase cinco vezes a chance do paciente em mau controle lipídico. A chance dos pacientes com mau controle glicêmico apresentarem adesão ao exercício físico é quase duas vezes a chance daquele sem controle adequado da glicemia.

Factors associated with medication adherence in hypertensive blacks: a review of the literature

BACKGROUND

Rates of medication adherence are low among hypertensive blacks despite numerous interventions to increase their adherence.

PURPOSE

The aim of the study was to conduct a systematic review of the literature to understand the factors associated with medication adherence in hypertensive blacks.

METHODS

A systematic computer search of qualitative and quantitative studies that examined factors associated with medication adherence in hypertensive blacks from 1966 to 2010 was performed. Studies were excluded if medication adherence was not either the primary or secondary outcome variable.

RESULTS

Studies (n = 18) were cross-sectional or qualitative, measured adherence via self-report, and conducted in low-income blacks. Factors that were associated with medication adherence were self-efficacy, depression, patient-provider communication, and healthcare system related.

CONCLUSIONS

Findings from existing studies should be interpreted with caution because of their methodological limitations. Longitudinal studies with heterogeneous samples of hypertensive blacks are imperative so that targeted interventions can be developed for this vulnerable population.

CLINICAL IMPLICATIONS

Even though there are methodological limitations associated with existing studies, clinicians may want to consider some of the factors that were associated with medication adherence in this systematic review as they provide care for hypertensive blacks. Given that self-efficacy and patient-provider communication are modifiable factors, they can be the focus of interventions to increase medication adherence. Finally, clinicians may want to screen their hypertensive patients for depression and treat, if necessary.

A literature review to investigate the link between psychosocial characteristics and treatment adherence in cancer patients

Adherence to medication has been recognized as a key issue in health outcomes and efforts to improve patients' adherence are being made by the pharmaceutical industry, experts, and government bodies alike. This paper presents a review of these issues according to previous descriptive findings. Relevant studies written in English, published in 1976 or later, were identified through Medline, Embase and PsycInfo databases and reviewed. Review articles and clinical trials were excluded; all observational studies and surveys were considered. Articles were reviewed for any discussion of patients' characteristics and psychosocial characteristics affecting adherence to cancer treatment. The search strategy included a combination of key words adherence and cancer in titles. The major findings are summarized and presented under two main headings: i) patients' characteristics; and ii) psychosocial characteristics. In general, factors associated with increased likelihood of adherence to cancer treatment included younger age, higher education, higher income and Caucasian ethnicity. With regards to the psychosocial factors, lower levels of depression and anxiety, optimism as well as social support seemed to have a positive effect on treatment adherence. Studies of patterns of care in cancer treatment can help identify challenges in health care provided to particular subgroups of cancer patients and can aid researchers in designing studies that account for such factors in clinical and outcomes' research.

Nurse-led disease management for hypertension control in a diverse urban community: a randomized trial

BACKGROUND

Treated but uncontrolled hypertension is highly prevalent in African American and Hispanic communities.

OBJECTIVE

To test the effectiveness on blood pressure of home blood pressure monitors alone or in combination with follow-up by a nurse manager.

DESIGN

Randomized controlled effectiveness trial.

PATIENTS

Four hundred and sixteen African American or Hispanic patients with a history of uncontrolled hypertension. Patients with blood pressure ≥150/95, or ≥140/85 for patients with diabetes or renal disease, at enrollment were recruited from one community clinic and four hospital outpatient clinics in East and Central Harlem, New York City.

INTERVENTION

Patients were randomized to receive usual care or a home blood pressure monitor plus one in-person counseling session and 9 months of telephone follow-up with a registered nurse. During the trial, the home monitor alone arm was added.

MAIN MEASURES

Change in systolic and diastolic blood pressure at 9 and 18 months.

KEY RESULTS

Changes from baseline to 9 months in systolic blood pressure relative to usual care was -7.0 mm Hg (Confidence Interval [CI], -13.4 to -0.6) in the nurse management plus home blood pressure monitor arm, and +1.1 mm Hg (95% CI, -5.5 to 7.8) in the home blood pressure monitor only arm. No statistically significant differences in systolic blood pressure were observed among treatment arms at 18 months. No statistically significant improvements in diastolic blood pressure were found across treatment arms at 9 or 18 months. Changes in prescribing practices did not explain the decrease in blood pressure in the nurse management arm.

CONCLUSIONS

A nurse management intervention combining an in-person visit, periodic phone calls, and home blood pressure monitoring over 9 months was associated with a statistically significant reduction in systolic, but not diastolic, blood pressure compared to usual care in a high risk population. Home blood pressure monitoring alone was no more effective than usual care.

Baseline medication adherence and blood pressure in a 24-month longitudinal hypertension study

AIM AND OBJECTIVES

We sought to identify the feasibility and predictive validity of an easy and quick self-reported measure of medication adherence and to identify characteristics of people with hypertension that may warrant increase attentiveness by nurses to address hypertensive self-management needs.

BACKGROUND

Current control rates of hypertension are approximately 50%. Effective blood pressure control can be achieved in most people with hypertension through antihypertensive medication. However, hypertension control can only be achieved if the patient is adherent with their medication regimen. Patients who are non-adherent may be in need of additional intervention.

DESIGN

This secondary analysis evaluated the systolic blood pressure of patients who received usual hypertension management across 24 months at six-month intervals.

METHODS

A longitudinal study of 159 hypertensive patients in two primary care clinics.

RESULTS

In a sample of 159 patients receiving care in a primary care facility, baseline medication non-adherence was associated with a 6·3 mmHg increase in systolic blood pressure (p < 0·05) at baseline, a 8·4 mmHg increase in systolic blood pressure (p < 0·05) at 12 months and a 7·5 increase in systolic blood pressure at 24 months (p < 0·05) compared with adherent patients, respectively. Results also indicate a significant increase in systolic blood pressure across 24 months among people who identified as minority and of low financial status.

CONCLUSIONS

Non-adherence with antihypertensive medication at baseline was predictive of increased systolic blood pressure up to 24 months postbaseline.

RELEVANCE TO CLINICAL PRACTICE

This study demonstrates the use of an easy-to-use questionnaire to identify patients who are non-adherent. We recommend assessing medication adherence to identify patients who are non-adherent with their anti-hypertensive medication and to be especially vigilant with patients who are minority or are considered low income.

Correlates of medication nonadherence among Latinos with type 2 diabetes

PURPOSE

The purpose of this study is to assess factors related to diabetes medication nonadherence in a sample of predominantly Spanish-speaking Mexican-origin adults residing along the US-Mexico border.

METHODS

As part of a randomized controlled trial, 302 patients randomly sampled from a clinic roster completed a baseline interview. Medication nonadherence was assessed with the Morisky Medication Adherence Scale. Consistent with the framework proposed by Venturini et al, four factors were examined: patient-related attributes, drug regimen characteristics and complexity, health status, and patient-provider interaction characteristics.

RESULTS

Sixty percent of the patients were classified as nonadherent. Men, those who engaged in diabetes control behaviors less frequently, and individuals with depression were more likely to be classified as nonadherent. Among those who were Spanish-dominant, education and self-rated health also were significantly and negatively related to medication adherence; patients with a high school education or greater and those who more positively rated their health were more likely to be classified as nonadherent compared to those with less than a high school education and those who rated their health as poor.

CONCLUSIONS

Results reflect potentially higher medication nonadherence rates for Latinos with type 2 diabetes living in rural communities along the US-Mexico border. Additionally, this study supports the need to address strategies to support medication adherence, including addressing depression, for diabetes control. Strategies to promote adherence among Latino men are sorely needed, as are strategies to address forgetfulness and carelessness regarding diabetes medicine taking.

Comparison of hypertension management between cancer survivors and the general public

Proper management of hypertension is important for better survival and quality of life of cancer survivors who have hypertension. We aimed to compare hypertension management between cancer survivors and the general population. A nationwide, multicenter, cross-sectional survey was administered to adult cancer patients, currently receiving treatment or follow-up, who had been diagnosed with hypertension. Comparison group was selected from among participants in the health behavior survey of the third Korean National Health and Nutrition Examination Survey. Self-reported hypertension management was surveyed, including antihypertensive medication adherence, frequency of blood pressure (BP) monitoring and perceived BP control. Multivariate logistic regression analysis was used to evaluate the relationship between cancer survivorship and each outcome measure. Compared with the general population, cancer survivors were more likely to report full adherence (92.7% vs. 73.0%; adjusted odds ratio (aOR)=3.45; 95% confidence interval (CI), 2.08-5.73), more frequent BP measurement (≥ 24 per year: 50.1% vs. 24.7%; aOR=2.51; 95% CI, 1.83-3.46), and very good perceived BP control (60.8% vs. 26.2%; aOR=4.34; 95% CI, 3.13-6.02). Cancer survivors appear to be better with antihypertensive medication adherence and BP monitoring than those without cancer, and as a result, they appear to be under better BP control. However, several methodological limitations of our study prompt further research on this issue.

Emergency management of hypertension in children

Systemic arterial hypertension in children has traditionally been thought to be secondary in origin. Increased incidence of risk factors like obesity, sedentary life-styles, and faulty dietary habits has led to increased prevalence of the primary arterial hypertension (PAH), particularly in adolescent age children. PAH has become a global epidemic worldwide imposing huge economic constraint on health care. Sudden acute increase in systolic and diastolic blood pressure can lead to hypertensive crisis. While it generally pertains to secondary hypertension, occurrence of hypertensive crisis in PAH is however rare in children. Hypertensive crisis has been further subclassified depending on presence or absence of end-organ damage into hypertensive emergency or urgency. Both hypertensive emergencies and urgencies are known to cause significant morbidity and mortality. Increasing awareness among the physicians, targeted at investigation of the pathophysiology of hypertension and its complications, better screening methods, generation, and implementation of novel treatment modalities will impact overall outcomes. In this paper, we discuss the etiology, pathogenesis, and management of hypertensive crisis in children. An extensive database search using keywords was done to obtain the information.

Accuracy of measures of medication adherence in a cholesterol-lowering regimen

This study examined the concordance between multiple measures of adherence, as well as sensitivity to detection of poor adherers, specificity, and predictive validity using a daily cholesterol-lowering regimen. Participants (N = 180) aged 24 to 60 years participated in an adherence ancillary study in a clinical trial. Males constituted 53.9% of this well-educated, community sample. Data on adherence were collected over a 6-month period, using electronic monitoring, self-report, specific recall, and pill counts. Electronically monitored (odds ratio [OR] = 5.348) and Shea self-report (OR = 2.678) predicted cholesterol lowering. Days (78.9%) and intervals (84.2%) adherent and the Shea (73.7%) were sensitive to the detection of poor adherers. Moderate associations were found between measures of the same type. Low correlations were found otherwise. The electronic monitor was the most accurate and informative measure. The Shea self-report was the most accurate brief, global estimate of adherence. Other measures were not associated with clinical outcome or sensitive to poor adherence.

Patient factors, but not provider and health care system factors, predict medication adherence in hypertensive black men

The problem of medication adherence is pronounced in hypertensive black men. However, factors influencing their adherence are not well understood. This secondary analysis of the ongoing Counseling African Americans to Control Hypertension (CAATCH) randomized clinical trial investigated the patient, provider, and health care system factors associated with medication adherence among hypertensive black men. Participants (N=253) were aged 56.6±11.6 years, earned <$20,000 yearly (72.7%), and almost one half were on Medicaid (44%). Mean systolic blood pressure was 148.7±15.8 mm Hg and mean diastolic blood pressure was 92.7±9.8 mm Hg. Over one half of participants (54.9%) were nonadherent. In a hierarchical regression analysis, the patient factors that predicted medication adherence were age, self-efficacy, and depression. The final model accounted for 32.1% of the variance (F=7.80, df 10, 165, P<.001). In conclusion, age, self-efficacy, and depression were associated with antihypertensive medication adherence in black men followed in Community/Migrant Health Centers. Age is a characteristic that may allow clinicians to predict who may be at risk for poor medication adherence. Depression can be screened for and treated. Self-efficacy is modifiable and its implications for practice would be the development of interventions to increase self-efficacy in black men with hypertension.

Cultural Considerations: Pharmacological and Nonpharmacological Means for Improving Blood Pressure Control among Hispanic Patients

Cardiovascular disease is a leading cause of morbidity and mortality in the United States, and its prevention and treatment remain a priority for the medical community. Ethnic variations account for some differences in the prevalence of hypertension and blood pressure (BP) control rates among Hispanics, indicating the need for culturally appropriate management models. Aggressive treatment strategies are key to achieving optimal BP control in high-risk Hispanic patients. Hypertension in this ethnic group continues to be a major health concern. Of note, when provided access to comprehensive care, Hispanics demonstrate similar response rates to treatment as the majority of non-Hispanic whites. This highlights the importance of effective, culturally responsive hypertension management among high-risk Hispanic patients for achieving observable, positive health outcomes.

Association of statin therapy with blood pressure control in hypertensive hypercholesterolemic outpatients in clinical practice

BACKGROUND

Some clinical evidence revealed that statins, apart from lowering cholesterol levels, also have an antihypertensive effect. Our aim was to evaluate the existence of a possible association of statin therapy with blood pressure (BP) control in clinical practice.

MATERIALS AND METHODS

Patients attending a hypertension/dyslipidemia clinic were prospectively evaluated. Those patients with a diagnosis of stage 1 hypertension and hypercholesterolemia who consented to participate were included in the study, either in the statin group (when taking a statin) or in the control group (when not taking a statin). Exclusion criteria included dementia, pregnancy, or breastfeeding, and history or evidence of stage 2 hypertension. Detailed clinical information was prospectively obtained from medical records. A total of 110 hypertensive patients were assigned to the study (82 in the statin group and 28 in the control group).

RESULTS

Although there were no significant differences (P > 0.05) in both groups concerning gender, body mass index, antihypertensive pharmacotherapy, and serum levels of high-density lipoprotein cholesterol and triglycerides, a higher BP control was observed in the statin group (P = 0.002). Significantly lower systolic BP (-6.7 mmHg, P = 0.020) and diastolic BP (-6.4 mmHg, P = 0.002) levels were reported in the statin group. Serum levels of low-density lipoprotein were also significantly lower in the statin group (P < 0.001).

CONCLUSIONS

This observational study detected an association of statin therapy with BP control in hypertensive hypercholesterolemic patients in clinical practice. These findings raise the possibility that statin therapy may be useful for BP control in the studied population.

Factors affecting therapeutic compliance: A review from the patient's perspective

Objective

To explore and evaluate the most common factors causing therapeutic non-compliance.

Methods

A qualitative review was undertaken by a literature search of the Medline database from 1970 to 2005 to identify studies evaluating the factors contributing to therapeutic non-compliance.

Results

A total of 102 articles was retrieved and used in the review from the 2095 articles identified by the literature review process. From the literature review, it would appear that the definition of therapeutic compliance is adequately resolved. The preliminary evaluation revealed a number of factors that contributed to therapeutic non-compliance. These factors could be categorized to patient-centered factors, therapy-related factors, social and economic factors, healthcare system factors, and disease factors. For some of these factors, the impact on compliance was not unequivocal, but for other factors, the impact was inconsistent and contradictory.

Conclusion

There are numerous studies on therapeutic noncompliance over the years. The factors related to compliance may be better categorized as “soft” and “hard” factors as the approach in countering their effects may differ. The review also highlights that the interaction of the various factors has not been studied systematically. Future studies need to address this interaction issue, as this may be crucial to reducing the level of non-compliance in general, and to enhancing the possibility of achieving the desired healthcare outcomes.

Patient-centered culturally sensitive health care: model testing and refinement

OBJECTIVES

This article presents the results of an empirical test of a literature-based Patient-Centered Culturally Sensitive Health Care Model. The model was developed to explain and improve health care for ethnically diverse patients seen in community-based primary care clinics.

DESIGN

Samples of predominantly low-income African American (n = 110) and non-Hispanic White American (n = 119) patients were recruited to complete questionnaires about their perceived health care provider cultural sensitivity and adherence to their provider's treatment regimen recommendations.

MAIN OUTCOME MEASURES

Patients completed written measures of their perceived provider cultural sensitivity, trust in provider, interpersonal control, satisfaction with their health care provider, physical stress, and adherence to provider-recommended treatment regimen variables (i.e., engagement in a health promoting lifestyle, and dietary and medication adherence).

RESULTS

Two-group path analyses revealed significant links between patient-perceived provider cultural sensitivity and adherence to provider treatment regimen recommendations, with some differences in associations emerging by race/ethnicity.

CONCLUSION

The findings provide empirical support for the potential usefulness of the Patient-Centered Culturally Sensitive Health Care Model for explaining the linkage between the provision of patient-centered, culturally sensitive health care, and the health behaviors and outcomes of patients who experience such care.

Pharmacist intervention program to enhance hypertension control: a randomised controlled trial

Objective Studies have demonstrated that hypertension remains inadequately managed throughout the world, with lack of adherence to BP-lowering medication being a major factor. The aim of the present study was to evaluate if a pharmaceutical care program could improve antihypertensive medication adherence and blood pressure control. Setting This study was conducted in a secondary care hypertension/dyslipidemia outpatient clinic in the university teaching hospital of Cova da Beira Hospital Centre, Covilhã, located in the Eastern Central Region of Portugal. Method This report evaluates the pharmacist’s interventions during a prospective randomised controlled trial, from July 2009 to June 2010. Patients with diagnosis of essential hypertension attending the clinic for routine follow-up were randomly allocated either to a control group (no pharmaceutical care) or to an intervention group (quarterly follow-up by a hospital pharmacist during a 9-month period). The pharmacist interventions, aimed to increase medication adherence and blood pressure control, involved educational interventions and counselling tips directed to the patient. Main outcome measure Systolic blood pressure, diastolic blood pressure and blood pressure control (according to JNC 7 guidelines) assessed at the baseline visit and at the end of pharmaceutical care were the main outcome measures. Blood pressure measurements were performed by blinded nurses. Medication adherence was also evaluated, using a validated questionnaire at baseline and at the end of investigation. Results A total of 197 hypertensive patients were randomly assigned to the study (99 in the control group and 98 in the intervention group). Although there were no significant differences (P > 0.05) in both groups concerning mean age, gender, body mass index, and antihypertensive pharmacotherapy, blood pressure control was higher in the intervention group (P = 0.005) at the end of the study. Significant lower systolic blood pressure (−6.8 mmHg, P = 0.006) and diastolic blood pressure (−2.9 mmHg, P = 0.020) levels were observed in the intervention group. Medication adherence was also significantly higher in the intervention group at the end of the study (74.5% vs. 57.6%, P = 0.012).Conclusion Pharmacist intervention can significantly improve medication adherence and blood pressure control in patients treated with antihypertensive agents.

Improving the measurement of self-reported medication nonadherence

OBJECTIVE

Medication nonadherence is a significant clinical problem in chronic disease management. Self-report measures have inadequate reliability and poor distributional properties. We demonstrate how two fundamental measurement issues have limited the usefulness of self-reported medication nonadherence measures and offer recommendations for improving measurement.

STUDY DESIGN AND METHODS

We reviewed existing self-report measures of medication nonadherence in the context of hypertension, one of the most common chronic conditions in which medication nonadherence is a paramount concern. We evaluated these measures with regard to two issues: (1) conflation of causal indicators (which give rise to a latent construct) and effect indicators (which are determined by a latent construct), and (2) a lack of evidence regarding the stability of nonadherence over time.

RESULTS

Nonadherence measurement could be improved by using effect indicators to assess the extent of nonadherence and causal indicators to assess reasons for nonadherence. Moreover, nonadherence should be assessed longitudinally, so that recent developments in statistical modeling can illuminate the extent to which medication nonadherence is transient vs. stable.

CONCLUSION

Attention to these measurement issues can improve the assessment of self-reported nonadherence, thereby allowing more accurate conclusions to be drawn about medication-taking behavior and informing the development of improved interventions that target medication nonadherence.

Short Form (SF-36) Health Survey measures are associated with decreased adherence among urban African Americans with severe, poorly controlled hypertension

The objective of this study was to determine whether an association exists between Short Form (SF-36) Health Survey measures and nonadherence among urban African Americans with poorly controlled hypertension. A total of 158 African Americans were admitted to an urban academic hospital for severe, uncontrolled hypertension. The main outcome measure was self-reported nonadherence to antihypertensive medications using a validated instrument. For every 10-point increase in Physical Component Summary (PCS) score, an individual was almost two times more likely to report being nonadherent (odds ratio, 1.94; 95% confidence interval, 1.30-2.90; P<.01). A significant interaction (P=.05) was observed between the physical functioning and mental health subscales. Individuals with high physical functioning and low mental health scores displayed the lowest adherence rate. These results suggest that high physical functioning, especially if associated with poor mental health, increases the likelihood of nonadherence to antihypertensive regimens among urban African Americans. The SF-36 may serve as an effective clinical tool that identifies patients at risk for nonadherence and, more importantly, may improve clinicians' understanding of nonadherence, allowing for discussions about antihypertensive medications to be tailored to individual patients.

Comparative effectiveness research: evaluating pharmacist interventions and strategies to improve medication adherence

One very effective strategy to achieve good blood pressure (BP) control in primary care is the use of physician/pharmacist collaborative management. Interventions by pharmacists in both community pharmacies and primary care clinics have been shown to significantly reduce BP by both improving medication adherence and intensifying medications. This review will evaluate the strengths and weaknesses of various health services' research study designs that assess various pharmacy interventions to improve BP control. We will also evaluate strategies to measure medication adherence used in research studies, and in some cases, clinical practice. Although poor medication adherence is a major cause of inadequate BP control, suboptimal medication regimens are often more common reasons for poor BP control in typical primary care practice. This review proposes strategies to implement stronger interventions and more robust study designs in comparative effectiveness trials that evaluate team-based care for improving BP control.