Correlation between Usual Source of Care and Medication Adherence in Patients with Hypertension

BACKGROUND

Maintaining a usual source of care (USC), which is crucial for primary healthcare, encompasses initial contact, comprehensive services, coordinated care, and ongoing support. However, limited research exists on the relationship between USC and medication adherence in patients with hypertension. This study aimed to investigate the association between USC and medication adherence among patients with hypertension.

METHODS

Data from the 2nd Korea Health Panel Survey 2020 were analyzed. The final sample consisted of 3,318 participants aged 19 years or older diagnosed with hypertension. USC was categorized into three groups: no USC, place only (without a regular doctor), and regular doctor. Medication adherence was assessed using detailed items (dose, frequency, time, no stop) and a 4-point Likert scale. A logistic regression analysis was conducted with control for relevant variables.

RESULTS

Compared to the no USC group, the regular doctor group had significantly higher odds ratios (ORs) for overall perfect/high medication adherence rates: 1.70 (95% confidence interval [CI], 1.42-2.03) and 1.59 (95% CI, 1.14-2.20). Similar results were observed for each adherence item, including prefect dose (OR, 2.14; 95% CI, 1.73- 2.63), frequency (OR, 1.87; 95% CI, 1.53-2.28), time (OR, 1.72; 95% CI, 1.43-2.07), and no stop (OR, 1.56; 95% CI, 1.09-2.23)/high frequency (OR, 2.47; 95% CI, 1.21-5.01), time (OR, 2.30; 95% CI, 1.19-4.44). However, the place only group showed no significant differences in medication adherence except for perfect adherence to dose (OR, 1.35; 95% CI, 1.06-1.71).

CONCLUSION

These findings provide evidence supporting the need for healthcare policies that encourage having a regular doctor in South Korea, which has a healthcare system with limited primary care.

Factors Influencing Antihypertensive Medication Adherence Among Historically Underrepresented Adults: A Meta-analysis

BACKGROUND

Addressing disparities in blood pressure control must include supporting antihypertensive medication adherence (MA). Developing effective MA interventions requires identifying the most important factors influencing MA.

OBJECTIVE

In this review, the authors aimed to meta-analyze the results of research testing associations between factors potentially influencing antihypertensive MA and assessed antihypertensive MA in historically underrepresented populations. Additional exploratory analyses focused on system-level factors, which have been understudied and may particularly impact disparities in MA.

METHODS

A health sciences librarian assisted with searching across 10 databases. Inclusion criteria included (1) published in English, (2) sample of adults with hypertension, (3) ≥50% of participants having self-identified as a race/ethnicity underrepresented in the country where the study was conducted, and (4) reporting sufficient data to calculate effect size(s).

RESULTS

Fifty-eight studies were eligible for inclusion. Nine factors met criteria for planned analyses. Older age (r = 0.08, P < .01; k = 26 studies) and higher income (r = 0.11, P = .01; k = 15) were significantly correlated with better MA. Having depressive symptoms was significantly correlated with worse MA (r = -0.18, P < .01; k = 11). Effect sizes for sex, education level, marital status, number of medications, comorbidities, and perceived social support were not significant. System-level factors examined included insurance coverage, access to healthcare, perceived barriers, having a primary care provider, perceptions of their healthcare provider, and experiences of discrimination in healthcare.

CONCLUSIONS

Understanding the impact of factors associated with antihypertensive MA in historically underrepresented adults can support development of targeted, culturally relevant MA interventions. Future research should examine the impact of system-level factors on antihypertensive MA among historically underrepresented populations.

The effect of combining therapeutic drug monitoring of antihypertensive drugs with personalised feedback on adherence and resistant hypertension: the (RHYME-RCT) trial protocol of a multi-centre randomised controlled trial

BACKGROUND

Adherence to antihypertensive drugs (AHDs) is important for adequate blood pressure control. Not taking these drugs as prescribed is one of the main underlying causes for resistant hypertension (RH), which in turn leads to an increased risk of cardiovascular events, stroke and kidney damage. Therefore, correct identification of patients that are non-adherent to AHDs is crucial to improve clinical outcome. For this goal, therapeutic drug monitoring is the most reliable method. The primary objective of this trial is to investigate whether monitoring of drug concentrations with a dried blood spot (DBS) sampling method combined with personalised feedback leads to a decrease in prevalence of RH after 12 months due to an increase in adherence. Secondary objectives include the difference over time in the number of required AHDs as well as the defined daily dose (DDD). Lastly, the cost-utility of SoC versus the intervention in RH is determined.

METHODS

This is a multi-centre single-blinded randomised controlled trial (RHYME-RCT). First, at an eligibility visit, DBS sampling, to monitor drug concentrations in blood, and a 24-h ambulatory blood pressure measurement (24-h ABPM) are performed simultaneously. Patients with a daytime systolic blood pressure (SBP) > 135 and/or diastolic blood pressure (DBP) > 85 mmHg are randomised to SoC or intervention + SoC. The intervention is performed by the treating physician and includes information on drug concentrations and a comprehensive personalised feedback conversation with the use of a communication tool. The follow-up period is one year with visits at 3, 6 and 12 months randomisation and includes 24-h ABPM and DBS sampling.

DISCUSSION

This will be the first trial that focusses specifically on patients with RH without taking into account suspicion of non-adherence and it combines monitoring of AHD concentrations to identify non-adherence to AHDs with a comprehensive feedback to improve non-adherence. Furthermore, if this trial shows positive outcomes for the intervention it can be directly implemented in clinical practice, which would be a great improvement in the treatment of RH.

TRIAL REGISTRATION

RHYME-RCT is registered in the Dutch Trial Register on 27/12/2017 (NTR6914) and can be found in the International Clinical Trials Registry Platform.

Predicting population: development and validation of a new predictive nomogram for evaluating medication nonadherence risk in a type 2 diabetes

Background

Diabetes mellitus is a growing global health challenge and affects patients of all ages. Treatment aims to keep blood glucose levels close to normal and to prevent or delay complications. However, adherence to antidiabetic medicines is often unsatisfactory.

Purpose

Here, we established and internally validated a medication nonadherence risk nomogram for use in Chinese type 2 diabetes mellitus (T2DM) patients.

Methods

This cross-sectional study was carried out from July-December 2020 on randomly selected T2DM patients visiting a diabetes clinic and included 753 participants. Adherence was analyzed based on an eight-item Morisky Medication Adherence Scale (MMAS-8). Other data, including patient demographics, treatment, complications, and comorbidities, were also collected on questionnaires. Optimization of feature selection to develop the medication nonadherence risk model was achieved using the least absolute shrinkage and selection operator regression model (LASSO). A prediction model comprising features selected from LASSO model was designed by applying multivariable logistic regression analysis. The decision curve analysis, calibration plot, and C-index were utilized to assess the performance of the model in terms of discrimination, calibration, and clinical usefulness. Bootstrapping validation was applied for internal validation.

Results

The prediction nomogram comprised several factors including sex, marital status, education level, employment, distance, self-monitoringofbloodglucose, disease duration, and dosing frequency of daily hypoglycemics (pills, insulin, or glucagon-like peptide-1). The model exhibited good calibration and good discrimination (C-index = 0.79, 95% CI [0.75-0.83]). In the validation samples, a high C-index (0.75) was achieved. Results of the decision curve analysis revealed that the nonadherence nomogram could be applied in clinical practice in cases where the intervention is decided at a nonadherence possibility threshold of 12%.

Conclusion

The number of patients who adhere to anti-diabetes therapy was small. Being single male, having no formal education, employed, far from hospital, long disease duration, and taking antidiabetics twice or thrice daily, had significant negative correlation with medication adherence. Thus, strategies for improving adherence are urgently needed.

Efficacy and Safety of Chinese Herbal Medicine Compared With Losartan for Mild Essential Hypertension: A Randomized, Multicenter, Double-Blind, Noninferiority Trial

BACKGROUND

Hypertension is one of the most challenging public health problems worldwide. Previous studies suggested that the Songling Xuemaikang capsule (SXC)-a Chinese herbal formula-was effective for essential hypertension. However, the efficacy of SXC monotherapy for hypertension remains unclear. We aimed to compare the blood pressure (BP)-lowering efficacy and safety of SXC versus losartan in patients with essential hypertension.

METHODS

In this multicenter, randomized, double-blind, noninferiority trial in China, patients 18 to 65 years of age with mild essential hypertension were randomly allocated to receive either SXC or losartan for 8 weeks. The primary outcome was the change in sitting diastolic BP from baseline to 8 weeks, with a predefined noninferiority margin of -2.5 mm Hg.

RESULTS

Of the 755 patients who entered a 2-week run-in period, 628 patients (327 women and 301 men; mean [SD] age, 52.6 [9.2] years) were randomly assigned to the SXC (n=314) or losartan (n=314) group. The primary analysis based on the intention-to-treat principle showed that the change in diastolic BP from baseline to 8 weeks was similar between the SXC and losartan groups (-7.9 [8.0] versus -8.1 [7.9]). The lower boundary of 95% CI (mean difference, -0.24 [95% CI, -1.51 to 1.03]) was above the margin of -2.5 mm Hg, showing noninferiority. Results were consistent with per-protocol analysis. SXC produced greater improvements in total hypertension symptom score (-5.7 [4.2] versus -5.0 [4.0]; P=0.020) and total cholesterol (-0.1 [1.0] versus 0.1 [1.2]; P=0.025). There were no differences between groups in the other BP and patient-reported outcomes. Incidence and severity of adverse events were similar between groups.

CONCLUSIONS

SXC was well tolerated and demonstrated noninferior to losartan in BP lowering in patients with mild hypertension. SXC might be an alternative for mild hypertension, particularly for patients with a preference for natural medicine.

REGISTRATION

URL: www.chictr.org.cn; Unique identifier: ChiCTR-IPR-16008108.

Effectiveness of a medication adherence management intervention in a community pharmacy setting: a cluster randomised controlled trial

BACKGROUND

Non-adherence to medications continues to be a burden worldwide, with significant negative consequences. Community pharmacist interventions seem to be effective at improving medication adherence. However, more evidence is needed regarding their impact on disease-specific outcomes. The aim was to evaluate the impact of a community pharmacist-led adherence management intervention on adherence and clinical outcomes in patients with hypertension, asthma and chronic obstructive pulmonary disease (COPD).

METHODS

A 6-month cluster randomised controlled trial was conducted in Spanish community pharmacies. Patients suffering from hypertension, asthma and COPD were recruited. Patients in the intervention group received a medication adherence management intervention and the control group received usual care. The intervention was based on theoretical frameworks for changing patient behaviour. Medication adherence, disease-specific outcomes (Asthma Control Questionnaire (ACQ) scores, Clinical COPD Questionnaire (CCQ) scores and blood pressure levels) and disease control were evaluated. A multilevel regression model was used to analyse the data.

RESULTS

Ninety-eight pharmacies and 1186 patients were recruited, with 1038 patients completing the study. Patients receiving the intervention had an OR of 5.12 (95% CI 3.20 to 8.20, p<0.05) of being adherent after the 6 months. At the end of the study, patients in the intervention group had lower diastolic blood pressure levels (mean difference (MD) -2.88, 95% CI -5.33 to -0.43, p=0.02), lower CCQ scores (MD -0.50, 95% CI -0.82 to -0.18, p<0.05) and lower ACQ scores (MD -0.28, 95% CI -0.56 to 0.00, p<0.05) when compared with the control group.

CONCLUSIONS

A community pharmacist-led medication adherence intervention was effective at improving medication adherence and clinical outcomes in patients suffering from hypertension, asthma and COPD. Future research should explore the implementation of these interventions in routine practice.

TRIAL REGISTRATION NUMBER

ACTRN12618000410257.

Risk Factors for Non-Adherence to Medications That Affect Surgery: A Retrospective Study in Japan

PURPOSE

Data on risk factors for non-adherence to doctors' and pharmacists' instructions to discontinue medications prior to surgery are lacking. This study aimed to identify characteristics and risk factors for such non-adherent patients.

PATIENTS AND METHODS

Data (including patient age, sex, prescription medications, comorbidities, presence of roommate at home, and number of days between receiving instruction and surgery) of 887 patients who used medications affecting surgery at a university hospital from April 2017 to March 2020 were retrospectively evaluated. The primary endpoint was to investigate the rate of non-adherence and to explore independent risk factors for non-adherence (with age categorized as ≥65 [versus <65] years). Secondary endpoints included analysis of limited number of departments subgroup and a sensitivity analysis (with age categorized as ≥75 [versus <75] years) to confirm the robustness of the primary endpoint results. Independent risk factors for non-adherence were identified using logistic regression analysis.

RESULTS

The non-adherence rate was 11.4% (n=101/887), median age (interquartile range) at admission was 73 (70-79) years, and proportion of male patients was 81.2% (n=82). The main analysis adjusted for age ≥65 (versus <65) years showed age as a risk factor for increased non-adherence (adjusted odds ratio: 2.1, 95% confidence interval: 1.09-4.05; p=0.027). However, analyses adjusted for departments (other than urology, gynecology, and breast surgery, with a large sex bias in hospitalized patients) and for age ≥75 (versus <75) years showed no such risk.

CONCLUSION

Age ≥65 years was associated with a higher risk of non-adherence to medications that should be discontinued before surgery. It is important for doctors and pharmacists to ensure that patients at high risk for non-adherence are aware of the importance of adherence. Our findings may help identify patients at high risk for non-adherence to such medications.

The efficacy of cognitive behavioral therapy-based interventions on patients with hypertension: A systematic review and meta-analysis

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CBT-based intervention has a positive effect on health outcomes in patients with hypertension.

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CBT-based intervention might be more effective for blood pressure management in hypertension patients when it is group-based, long term, and cognitive therapy based.

Recently, the benefits of cognitive behavioral therapy (CBT)-based interventions for patients with hypertension have been recognized, but there has been no systematic review that has comprehensively analyzed the efficacy of CBT on health outcomes in this population. We aimed to explore the therapeutic effect of CBT-based interventions on hypertension patients through a meta-analysis.

Relevant randomized controlled trials (RCTs) were obtained by searching electronic databases. The primary outcomes were physiological indicators (blood pressure, blood lipid profile). Secondary outcomes were psychological indicators (anxiety, depression), and the quality of sleep. Stata version 15.0 software was used to analyze the results.

A total of 15 RCTs were included. The main analysis revealed that CBT-based interventions reduced systolic pressure: −8.67 (95% CI: −10.67 to −6.67, P = 0.000); diastolic pressure: −5.82 (95% CI: −7.82 to −3.81, P = 0.000); total cholesterol levels: −0.43 (95% CI: −0.76 to −0.10, P = 0.010); depressive symptoms: −3.13 (95% CI: −4.02 to −2.24, P = 0.000); anxiety symptoms: −3.63 (95% CI: −4.40 to −2.87, P = 0.000); and improved quality of sleep: −2.93 (95% CI: −4.40 to −1.47, P = 0.000). Additionally, the results of subgroup analysis indicated that long-term group-based CBT-based interventions were particularly beneficial for blood pressure management in hypertension patients.

CBT-based interventions are effective in reducing systolic pressure, diastolic pressure, total cholesterol levels, anxiety symptoms, depressive symptoms, and improving quality of sleep in hypertension patients.

The development and validation of the health belief model questionnaire for measuring factors affecting adherence in the elderly with hypertension

OBJECTIVES

This study aimed to validate the questionnaire on the health belief model questionnaire to assess health beliefs that could influence adherence to hypertension in the elderly.

METHODS

The questionnaire was based on a study of the literature and discussion with experts. The questionnaire was then circulated via social media. Participants who met the following criteria were asked to participate in the study: (1) aged 60-79 years of age, (2) had antihypertensive medications in the last three months, and (3) had a mobile phone with an active number. The questionnaire consists of six domains: perceived susceptibility, perceived severity, perceived threat, perceived benefits, perceived barriers, and perceived self efficacy. The findings were grouped by domain and tested for reliability and validity using SPSS ver.24.

RESULTS

Thirty participants completed the questionnaire. Each domain was tested for its reliability and validity at a value of 0.05. The result shows that each domain had a Cronbach's alpha value greater than 0.7, with a total score of 0.89 indicating that all domains in the questionnaire were reliable. Furthermore, of the 49 items in the questionnaire, only two items were invalid while the rest of the items demonstrated their validity based on the Pearson Correlation (>r table 0.361; p<0.05).

CONCLUSIONS

This self administered health belief model questionnaire was a valid and reliable instrument to assess health beliefs in elderly with hypertension.

Drug adherence and psychosocial characteristics of patients presenting with hypertensive urgency at the emergency department

OBJECTIVE

To identify potentially targetable psychosocial factors associated with nonadherence to prescribed antihypertensive medications in patients presenting with hypertensive urgencies at an emergency department.

METHODS

This prospective study included patients treated with antihypertensive drugs who presented with hypertensive urgencies (SBP ≥180 mmHg and/or DBP ≥110 mmHg) at the emergency department of a tertiary referral clinic between April 2018 and April 2019. Health literacy was assessed using the Newest Vital Sign test. The Hospital Anxiety and Depression Scale (HADS) was used to quantify symptoms of anxiety and depression. Patients were classified nonadherent if less than 80% of the prescribed antihypertensive drugs were detectable in urine or plasma using liquid chromatography-high-resolution mass spectrometry.

RESULTS

A total of 104 patients (62% women) presenting with hypertensive urgencies with a median SBP of 200 mmHg (IQR 190-212) and DBP of 97.5 mmHg (IQR 87-104) were included. Twenty-five patients (24%) were nonadherent to their antihypertensive medication. Nonadherent patients were more often men (66 versus 23%, P = 0.039), prescribed higher numbers of antihypertensive drugs (median 3, IQR 3-4 versus 2, IQR 1-3; P < 0.001), and more often treated with calcium channel blockers (76 versus 25%; P < 0.001) and/or diuretics (64 versus 40%; P = 0.030). There was no difference in health literacy (P = 0.904) or the scores on the HADS subscales for depression (P = 0.319) and anxiety (P = 0.529) between adherent and nonadherent patients.

CONCLUSION

Male sex, higher numbers of antihypertensive drugs, and treatment with diuretics and/or calcium channel blockers were associated with nonadherence. We did not identify a specific psychosocial characteristic associated with nonadherence.

A Gap in Post-Stroke Blood Pressure Target Attainment at Entry to Cardiac Rehabilitation

BACKGROUND

Recurrent events account for approximately one-third of all strokes and are associated with greater disability and mortality than first-time strokes. Blood pressure (BP) is the most important modifiable risk factor. Objectives were to determine the proportion of post-stroke patients enrolled in cardiac rehabilitation (CR) meeting systolic and diastolic BP (SBP/DBP) targets and to determine correlates of meeting these targets.

METHODS

A retrospective study of 1,804 consecutively enrolled post-stroke patients in a CR program was conducted. Baseline data (database records 2006-2017) included demographics, anthropometrics, clinical/medication history, and resting BP. Multivariate analyses determined predictors of achieving BP targets.

RESULTS

Mean age was 64.1 ± 12.7 years, median days from stroke 210 (IQR 392), with most patients being male (70.6%; n = 1273), overweight (66.8%; n = 1196), and 64.2% diagnosed with hypertension (n = 1159), and 11.8% (n = 213) with sleep apnea. A mean of 1.69 ± 1.2 antihypertensives were prescribed, with 26% (n = 469) of patients prescribed 3-4 antihypertensives. SBP target was met by 71% (n = 1281) of patients, 83.3% (n = 1502) met DBP target, and 64.3% (n = 1160) met both targets. Correlates of meeting SBP target were not having diabetes, younger age, fewer prescribed antihypertensives, and more recent program entry. Correlates of meeting DBP target were not having diabetes, older age, fewer prescribed antihypertensives, and more recent stroke.

CONCLUSIONS

Up to one-third of patients were not meeting BP targets. Patients with diabetes, and those prescribed multiple antihypertensives are at greater risk for poorly controlled SBP and DBP. Reasons for poor BP control such as untreated sleep apnea and medication non-adherence need to be investigated.

Drug nonadherence is a common but often overlooked cause of hypertensive urgency and emergency at the emergency department

OBJECTIVES

Over 70% of patients who visit the emergency department with a hypertensive emergency or a hypertensive urgency have previously been diagnosed with hypertension. Drug nonadherence is assumed to play an important role in development of hypertensive urgency and hypertensive emergency, but exact numbers are lacking. We aimed to retrospectively compare characteristics of patients with hypertensive urgency and hypertensive emergency and to prospectively quantify the attribution of drug nonadherence.

METHODS

We retrospectively analysed clinical data including information on nonadherence obtained by treating physicians of patients with SBP at least 180 mmHg and DBP at least 110 mmHg visiting the emergency department between 2012 and 2015. We prospectively studied drug adherence among patients admitted to the emergency department with severely elevated BP by measuring plasma drug levels using liquid chromatography tandem mass spectrometry from September 2016 to March 2017.

RESULTS

Of the 1163 patients retrospectively analysed, 257 (22.0%) met the criteria for hypertensive urgency and 356 (30.6%) for hypertensive emergency. Mean SBP (SD) was 203 (19) mmHg and mean DBP 121 (12) mmHg. Mean age was 60.1 (14.6) years; 55.1% were men. In 6.3% of patients with hypertensive urgency or hypertensive emergency, nonadherence was recorded as an attributing factor. Of the 59 patients prospectively analysed, 18 (30.5%) were nonadherent for at least one of the prescribed antihypertensive drugs.

CONCLUSION

Hypertensive urgency and hypertensive emergency are common health problems resulting in frequent emergency department admissions. Workup of patients with a hypertensive urgency or hypertensive emergency should include an assessment of drug adherence to optimize treatment strategy.

[Representations of high blood pressure in France: An exploratory study]

AIM OF THE STUDY

Non-adherence to treatment is one of the problems practitioners face with regard to hypertension. This lack of compliance is often attributed to disease representations. Understanding their nature can therefore help to better target therapeutic education messages and thus, increase compliance.

METHOD

It is in this context that the « groupe infirmiers et acteurs de la SFHTA » initiated a qualitative exploratory study of the representations of arterial hypertension in France. The study covered three sites: Bordeaux, Lyon and Nancy. Interviews with patients were conducted by the members of the group. Questions included the disease definition, its causes and consequences. The interviews were recorded and transcribed verbatim; they were analyzed with Nvivo pro® 11 software.

RESULTS

HTA is discovered accidentally. Patients define the disease according to their experience of symptoms, their perceptions of risks and the disease's consequences. The thresholds of systolic and diastolic blood pressure are unknown; most of the patients ignore their levels of both systolic and diastolic blood pressure. Besides, the fluctuating levels of blood pressure and conflicting messages about "lifestyle" generate confusion. HTA remains associated with stress. Regarding the burden of the disease, having to take a daily medication engendered anxieties, before being integrated into daily routines. The study also showed that patients have the desire to "pay attention" to their diet primarily.

CONCLUSION

This study showed the need to strengthen the training of health professionals and harmonize educational messages, which would allow patients to integrate new recommendations without stress.

Therapeutic Drug Monitoring to Assess Drug Adherence in Assumed Resistant Hypertension: A Comparison With Directly Observed Therapy in 3 Nonadherent Patients

Resistant hypertension is a common health problem leading to suboptimal cardiovascular prevention. A large number of patients with resistant hypertension have poor medication adherence explaining their assumed resistance to therapy. We combined directly observed therapy (DOT) with therapeutic drug monitoring (TDM) in 3 patients at several time points to enable an extensive feedback on blood pressure (BP) and drug levels. BP was measured with an automatic oscillatory device at regular intervals of 5 minutes (directly before and after drug intake) and at 30-minute intervals (at night) during admission. Blood samples were obtained at different time points (t = in hours; t = 0, 2, 4, 6, 12, and 24 hours after drug intake). DOT was performed under supervision of the physician. In 2 of the 3 patients, automated BP decreased directly after DOT, -10/0 and -5/-5 mm Hg, respectively. Plasma drug levels for several drugs or active metabolites were 0 at t = 0, whereas plasma levels were positive at t = 24 hours after observed intake. We recommend a more frequent use of TDM combined with repeated BP measurements in clinical practice because this is a convenient, objective method of measurement and to ensure that actual drug levels reflect the BP at the time of measurement.

Conceptual Model of Medication Adherence in Older Adults with High Blood Pressure-An Integrative Review of the Literature

BACKGROUND

Medication adherence (MA) is the most important controlling factor of high blood pressure (HBP). There are a few MA models, but they have not been successful in predicting MA completely. Thus, this study aimed to expand a conceptual model of MA based on an ecological approach.

METHODS

An integrative review of the literature based on theoretical and empirical studies was completed. Data source comprised: Medline (including PubMed and Ovid), ISI, Embase, Google scholar, and internal databases such as Magiran, Google, SID, and internal magazines. Primary English and Persian language studies were collected from 1940 to 2018. The steps of study included: (a) problem identification, (b) literature review and extracting studies, (c) appraising study quality, (d) gathering data, (e) data analysis using the directed content analysis, (f) concluding.

RESULTS

Thirty-six articles were finally included and analyzed. After analysis, predictors of MA in older adults with hypertension were categorized into personal, interpersonal, organizational, and social factors. Although the personal factors have the most predictors in sub-categories of behavioral, biological, psychological, knowledge, disease, and medication agents, social, organizational and interpersonal factors can have indirect and important effects on elderly MA.

CONCLUSION

There are many factors influencing MA of elderly with HBP. The personal factor has the most predictors. The designed model of MA because of covering all predictor factors, can be considered as a comprehensive MA model. It is suggested that future studies should select factors for study from all levels of the model.

Stress, adherence, and blood pressure control: A baseline examination of Black women with hypertension participating in the SisterTalk II intervention

The prevalence of hypertension is highest among Black women, but treatment adherence is reportedly low. Stress unique to the experiences of Black Americans may be associated with low adherence and poor blood pressure control, but few studies have examined the relationships between stress, adherence, and blood pressure control among hypertensive Black women. This study seeks to fill gaps in research by examining the association between stress, adherence, and blood pressure control. The baseline sample (n = 571) of at-risk or hypertensive Black women from the SisterTalk II RCT (Northeastern USA, 2004-2006) to improve adherence to recommendations for hypertension was analyzed. Participants self-reported stress, pharmacological adherence, non-pharmacological adherence (i.e. lifestyle management such as diet and exercise), and demographics. Blood pressure and anthropometrics (BMI and waist circumference) were measured. Statistical analysis included ANOVA, t-tests, linear regression. Tests of mediation examined if adherence mediated the relationship between stress and blood pressure control. This study found that stress was associated with lower age (p < .001) and being a single parent (p < .001). Stress was also associated with higher systolic blood pressure (p = .029), and poor blood pressure control (p = .043). Participants who reported higher stress also reported lower non-pharmacological adherence (p = .042). Non-pharmacological adherence was found to mediate the association between stress and blood pressure control. Hence, results document a relationship between stress with non-pharmacological adherence and blood pressure control among Black American women. More research is necessary to examine the relationship between stress and treatment adherence.

High-throughput quantification of 8 antihypertensive drugs and active metabolites in human plasma using UPLC-MS/MS

BACKGROUND

To assess drug adherence of patients with hypertension, an analytical method was developed and validated using ultra performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS). The method includes eight frequently prescribed antihypertensive drugs from four classes and their active metabolites: angiotensin converting enzyme inhibitors enalapril and perindopril (active metabolites respectively enalaprilate and perindoprilate), angiotensin II receptor blockers losartan (with the active metabolite losartan carboxylic acid) and valsartan, calcium channel blockers amlodipine and nifedipine and diuretics hydrochlorothiazide and spironolactone (with the active metabolite canrenone).

METHODS

The antihypertensive drugs were analyzed using a simple and fast sample preparation protocol with protein precipitation followed by chromatographic separation using a gradient elution on a reversed phase column. Mass spectrometric detection was conducted by applying both positive and negative electrospray ionization (ESI+/ESI-) and selected reaction monitoring mode (MS/MS). Only 50μl of plasma sample is needed for the simultaneous quantification of all 12 compounds within 6min run-to-run analysis time. Enalapril-d5 was applied as internal standard for all compounds except hydrochlorothiazide (internal standard: Hydrochlorothiazide-13C,d2).

RESULTS

The method was validated according to FDA guidelines. Matrix effects were examined using the method of Matuszewski. Correlation coefficients were higher than 0.995 for all compounds. Intra- and inter-day accuracies were <15% for all analytes except spironolactone (-16.8%) in the established linear range. Intra- and inter-day precision were <15% for all analytes. As a result of the lower sensitivity of hydrochlorothiazide, the lowest three calibration levels were excluded.

DISCUSSION/CONCLUSIONS

The described method is suitable for the simultaneous quantitative analysis of the most commonly used antihypertensive drugs and their corresponding active metabolites. Major advantages are minimal sample volume and clean up and a short runtime. The method is now available to monitor drug adherence of patients with resistant hypertension in our hospital.

Nonadherence to antihypertensive drugs: A systematic review and meta-analysis

BACKGROUND

Hypertension drives the global burden of cardiovascular disease and its prevalence is estimated to increase by 30% by the year 2025. Nonadherence to chronic medication regimens is common; approximately 43% to 65.5% of patients who fail to adhere to prescribed regimens are hypertensive patients. Nonadherence to medications is a potential contributing factor to the occurrence of concomitant diseases.

OBJECTIVE

This systematic review applied a meta-analytic procedure to investigate the medication nonadherence in adult hypertensive patients.

METHODS

Original research studies, conducted on adult hypertensive patients, using the 8-item Morisky medication adherence scale (MMAS-8) to assess the medication adherence between January 2009 and March 2016 were included. Comprehensive search strategies of 3 databases and MeSH keywords were used to locate eligible literature. Study characteristics, participant demographics, and medication adherence outcomes were recorded. Effect sizes for outcomes were calculated as standardized mean differences using random-effect model to estimate overall mean effects.

RESULTS

A total of 28 studies from 15 countries were identified, in total comprising of 13,688 hypertensive patients, were reviewed. Of 25 studies included in the meta-analysis involving 12,603 subjects, a significant number (45.2%) of the hypertensive patients and one-third (31.2%) of the hypertensive patients with comorbidities were nonadherent to medications. However, a higher proportion (83.7%) of medication nonadherence was noticed in uncontrolled blood pressure (BP) patients. Although a higher percentage (54%) of nonadherence to antihypertensive medications was noticed in females (P < 0.001), the risk of nonadherence was 1.3 times higher in males, with a relative risk of 0.883. Overall, nearly two-thirds (62.5%) of the medication nonadherence was noticed in Africans and Asians (43.5%).

CONCLUSION

Nonadherence to antihypertensive medications was noticed in 45% of the subjects studied and a higher proportion of uncontrolled BP (83.7%) was nonadherent to medication. Intervention models aiming to improve adherence should be emphasized.

Blood pressure outcomes of medication adherence interventions: systematic review and meta-analysis

This systematic review applied meta-analytic procedures to integrate primary research that examined blood pressure outcomes of medication adherence interventions. Random-effects model analysis calculated standardized mean difference effect sizes. Exploratory dichotomous and continuous moderator analyses using meta-analytic analogues of ANOVA and regression were performed. Codable data were extracted from 156 reports with 60,876 participants. The overall weighted mean difference systolic effect size was 0.235 across 161 treatment versus control comparisons. The diastolic effect size was 0.189 from 181 comparisons. Effect sizes were significantly heterogeneous. Common risks of bias included lack of allocation concealment, unmasked data collectors, and absent intention-to-treat analyses. Exploratory moderator analyses suggested that habit-based interventions may be most effective. The largest effect sizes were for interventions delivered by pharmacists. The modest magnitude effect sizes suggest future research should explore novel higher dose interventions that might address multiple levels of influence on adherence behavior.

The association between Self-Reported Medication Adherence scores and systolic blood pressure control: a SPRINT baseline data study

We examined baseline data from the Systolic Blood Pressure Intervention Trial (SPRINT) to investigate whether medication adherence, measured by the 8-item Morisky Medication Adherence Scale (MMAS-8), was associated with systolic blood pressure (SBP) and whether MMAS-8 score and number of antihypertensive medications interacted in influencing SBP. A total of 8435 SPRINT participants were included: 21.2% had low adherence (MMAS-8: <6); 40.0% had medium adherence (6 to <8); and 38.8% had high adherence (8). SBP was <140 mm Hg in 54.6%; 140-160 mm Hg in 36.6%; and >160 mm Hg in 8.8%. In multivariable regression, medium vs. low adherence weakly associated with lower SBP (odds ratio: 1.17; confidence interval: 1.04, 1.31). SPRINT eligibility criteria should be considered when interpreting results. Efforts to understand and enhance adherence are crucial to improve population health, and using self-report instruments might be considered for predicting treatment adherence and response in future efficacy trials and for identifying patients for adherence support in clinical practice.

Systematic Review of Clinical Practice Guidelines for the Improvement of Medication Adherence

BACKGROUND

Poor adherence to medications is a significant problem that leads to increased morbidity, mortality, and health care costs. Recommended approaches to address medication adherence vary, and existing practice guidelines are unclear.

PURPOSE

This review evaluated clinical practice guidelines designed to help health care providers address patients' medication adherence.

METHOD

Multiple search methods were used to identify national or international guidelines addressing medication adherence. We included guidelines published in English, as well as guidelines with an English-language summary or translation.

RESULTS

We identified 23 guidelines of varying detail and quality. Recommendations were categorized as assessment strategies (n = 20 guidelines); educational strategies (n = 18); behavioral strategies (n = 17); therapeutic relationship, communication, and provider factors (n = 19); and addressing outside influences/co-morbidities (n = 10).

CONCLUSION

Future guidelines should be more clearly guided by research findings and comparative effectiveness methods. When implemented, guidelines will facilitate health care providers and health systems in supporting optimal adherence and improved health outcomes.

Interventions to Improve Medication Adherence in Hypertensive Patients: Systematic Review and Meta-analysis

This systematic review applied meta-analytic procedures to synthesize medication adherence interventions that focus on adults with hypertension. Comprehensive searching located trials with medication adherence behavior outcomes. Study sample, design, intervention characteristics, and outcomes were coded. Random-effects models were used in calculating standardized mean difference effect sizes. Moderator analyses were conducted using meta-analytic analogues of ANOVA and regression to explore associations between effect sizes and sample, design, and intervention characteristics. Effect sizes were calculated for 112 eligible treatment-vs.-control group outcome comparisons of 34,272 subjects. The overall standardized mean difference effect size between treatment and control subjects was 0.300. Exploratory moderator analyses revealed interventions were most effective among female, older, and moderate- or high-income participants. The most promising intervention components were those linking adherence behavior with habits, giving adherence feedback to patients, self-monitoring of blood pressure, using pill boxes and other special packaging, and motivational interviewing. The most effective interventions employed multiple components and were delivered over many days. Future research should strive for minimizing risks of bias common in this literature, especially avoiding self-report adherence measures.

Adherence to Antihypertensive Medication in Treatment-Resistant Hypertension Undergoing Renal Denervation

BACKGROUND

Adherence to medication has been repeatedly proposed to represent a major cause of treatment-resistant hypertension (TRH); however, treatment decisions such as treating TRH with renal denervation depend on accurate judgment of adherence. We carefully analyzed adherence rates to medication before and after renal denervation and its effect on blood pressure (BP) control.

METHODS AND RESULTS

Eighty patients with TRH were included in 2 prospective observational studies that assessed the difference of potential antihypertensive and nephroprotective effects of renal denervation. To compare prescribed with actual medication intake (representing a measure of adherence), we analyzed urine samples collected at baseline and at 6 months after renal denervation for antihypertensive compounds or metabolites (by liquid chromatography-mass spectrometry). In addition to office BP, 24-hour ambulatory BP and central hemodynamics (central systolic pressure, central pulse pressure) were assessed. Informed consent for analyses of urine metabolites was obtained from 79 of 80 patients. Actual intake of all antihypertensive drugs was detected at baseline and at 6 months after renal denervation in 44 (56%) and 52 (66%) patients, respectively; 1 drug was missing in 22 (28%) and 17 (22%) patients, respectively, and ≥2 drugs were missing in 13 (16%) and 10 (13%) patients, respectively. At baseline, 24-hour ambulatory BP (P=0.049) and central systolic BP (P=0.012) were higher in nonadherent patients. Adherence did not significantly change overall (McNemar-Bowker test, P=0.362). An increase in adherence was observed in 21 patients, and a decrease was observed in 11 patients. The decrease in 24-hour ambulatory BP was not different in those with stable adherence 6 months after renal denervation (n=41, -7±13 mm Hg) compared with those with increased adherence (n=21, -10±13 mm Hg) and decreased adherence (n=11, -7±14 mm Hg) (P>0.20). Our study is limited by the relatively small sample size and potentially by the specific health environment of our university center (Northern Bavaria, Germany).

CONCLUSIONS

Nonadherence to medication among patients with TRH was relatively low: ≈1 of 6 patients with TRH did not take ≥2 of the prescribed drugs. Adherence pattern did not change significantly after renal denervation and had no impact on the overall observed BP changes, supporting the concept that renal denervation is an effective treatment in patients with TRH.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifiers: NCT00888433, NCT01442883 and NCT01687725.

Improving Medication Adherence in Patients with Hypertension: A Randomized Trial

BACKGROUND AND PURPOSE

In patients with hypertension, medication adherence is often suboptimal, thereby increasing the risk of ischemic heart disease and stroke. In a randomized trial, we investigated the effectiveness of a multifaceted pharmacist intervention in a hospital setting to improve medication adherence in hypertensive patients. Motivational interviewing was a key element of the intervention.

METHODS

Patients (n = 532) were recruited from 3 hospital outpatient clinics and randomized to usual care or a 6-month pharmacist intervention comprising collaborative care, medication review, and tailored adherence counseling including motivational interviewing and telephone follow-ups. The primary outcome was composite medication possession ratio (MPR) to antihypertensive and lipid-lowering agents, at 1-year follow-up, assessed by analyzing pharmacy records. Secondary outcomes at 12 months included persistence to medications, blood pressure, hospital admission, and a combined clinical endpoint of cardiovascular death, stroke, or acute myocardial infarction.

RESULTS

At 12 months, 20.3% of the patients in the intervention group (n = 231) were nonadherent (MPR <0.80), compared with 30.2% in the control group (n = 285) (risk difference -9.8; 95% confidence interval [CI], -17.3, -2.4) and median MPR (interquartile range) was 0.93 (0.82-0.99) and 0.91 (0.76-0.98), respectively, P = .02. The combined clinical endpoint was reached by 1.3% in the intervention group and 3.1% in the control group (relative risk 0.41; 95% CI, 0.11-1.50). No significant differences were found for persistence, blood pressure, or hospital admission.

CONCLUSIONS

A multifaceted pharmacist intervention in a hospital setting led to a sustained improvement in medication adherence for patients with hypertension. The intervention had no significant impact on blood pressure and secondary clinical outcomes.