Updates to Adherence to Hypertension Medications

Motivational interviewing intervention for the management of hypertension: a meta-analysis

Background

Improving medication compliance and self-efficacy in hypertensive patients is of significant importance for their prognosis. This meta-analysis aimed to assess the role of motivational interviewing in reducing systolic and diastolic blood pressure, self-efficacy, quality of life and medication adherence in hypertensive patients.

Methods

Two authors searched PubMed, Cochrane Library, Clinicaltrials, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database, Weipu and Wanfang Database up to May 28, 2024 for randomized controlled trials (RCTs) evaluating the role of motivational interviewing on hypertensive patients. The search was restricted to articles published in English and Chinese languages. RevMan 5.4 software was used for meta-analysis.

Results

A total of 16 RCTs were included. The meta-analysis findings demonstrate that motivational interviewing could reduce both systolic pressure [MD = -3.26, 95% CI (-5.16, -1.36), P < 0.001] and diastolic blood pressure [MD = -1.78, 95% CI (-3.48, -0.08), P < 0.001] levels in hypertensive patients, while simultaneously enhancing their self-efficacy [MD = 2.92, 95% CI (1.84, 4.00), P = 0.001], quality of life [MD = 6.99, 95% CI (3.25, 10.74), P = 0.003], and medication compliance [OR = 4.30, 95% CI (1.53, 12.10), P = 0.003]. No significant publication bias across the synthesized outcomes were found by Egger regression analyses (all P > 0.05).

Conclusions

Motivational interviewing has been shown to effectively reduce blood pressure in the short term among individuals with hypertension, while simultaneously enhancing their self-efficacy, quality of life, and adherence to medication regimens.

Analysis of the Effectiveness of Coordinated Care in the Management of Pharmacotherapy of Patients with Hypertension and Comorbidities in Primary Care-Preliminary Reports

Hypertension (HTN) is the dominant cause of cardiovascular disease and premature death worldwide. Also in Poland, the number of people with HTN is steadily increasing. In order to improve care for patients with HTN and other chronic diseases, a pilot of the POZ PLUS coordinated-care model was introduced. The pilot ran from 1 July 2018 to 30 September 2021 at 47 facilities nationwide. The purpose of this study was to conduct a preliminary analysis of the effectiveness of this model of care. The study focused on the management of pharmacotherapy in patients with hypertension and other comorbidities. The study included a group of 90 patients with HTN. Fifty-nine people were in the coordinated-care study group and 31 in the control group. Data were collected from electronic medical records. The analysis showed a trend toward greater blood-pressure reduction in patients under coordinated care (-4 mmHg difference in systolic blood pressure between the second and first visits and -2 mmHg difference in diastolic pressure between the second and first visits, p = 0.180 and p = 0.156). This suggests the preliminary conclusion that coordinated care in the PCP plus model might have positively affected the outcomes of patients with HTN. Further studies on the subject are planned.

Home Blood Pressure Monitoring and Its Association With Blood Pressure Control Among Hypertensive Patients With High Cardiovascular Risk in China

Objective

Home blood pressure monitoring (HBPM) is viewed as a facilitating factor in the initial diagnosis and long-term management of treated hypertension. However, evidence remains scarce about the effectiveness of HBPM use in the real world. This study aimed to examine the associations of HBPM use with blood pressure (BP) control and medication adherence.

Methods

This prospective cohort study included hypertensive patients with high cardiovascular risk who were aged ≥50 years. At baseline, information about types of BP monitor, frequency of HBPM, perception of anti-hypertensive treatment, and measured office BP were collected. During the 1-year follow-up (visits at 1, 2, 3, 6, and 12 months), information on medication adherence was collected at each visit. The 2 major outcomes were BP control at baseline and medication adherence during the 1-year follow-up. A log-binomial regression model was used to examine the association between frequency of HBPM and outcomes, stratified by the perceptions of anti-hypertensive treatment.

Results

A total of 5,363 hypertensive patients were included in the analysis. The age was (64.6 ± 7.2) years, and 41.2% (2,208) were female. Of the total patients, 85.9% (4,606) had a home BP monitor and 47.8% (2,564) had an incorrect perception of anti-hypertensive treatment. Overall, 24.2% (1,299) of patients monitored their BP daily, 37.6% (2,015) weekly, 17.3% (926) monthly, and 20.9% (1,123) less than monthly. At baseline, the systolic BP and diastolic BP were (146.6 ± 10.8) mmHg and (81.9 ± 10.6) mmHg, respectively, and 28.5% (1,527) of patients had their BP controlled. Regardless of whether the patients had correct or incorrect perceptions of anti-hypertensive treatment, there is no significant association between HBPM frequency and BP control at baseline. During the 1-year follow-up, 23.9% (1,280) of patients had non-adherence to medications at least once. In patients with an incorrect perception of anti-hypertensive treatment, those monitoring BP most frequently (daily) had the highest non-adherence rate (29.9%, 175/585). Compared with those monitoring their BP less than monthly, patients who monitored their BP daily were more likely not to adhere to anti-hypertensive medications (adjusted relative risk = 1.38, 95% confidence interval: 1.11-1.72, P = 0.004).

Conclusions

HBPM performance among hypertensive patients in China is, in general, sub-optimal. No association was observed between using HBPM alone and hypertension control, indicating that the effects of HBPM could be conditional. Patients' misconceptions about anti-hypertensive treatment may impair the role of BP monitoring in achieving medication adherence. Fully incorporating the correct perception of hypertension into the management of hypertensive patients is needed.

Systematic review of motivational interventions to improve adherence to medication in patients with hypertension and meta-analysis

INTRODUCTION

Antihypertensive medication non-adherence is an important cause of poor control in hypertension. The role of motivational interventions to increase antihypertensive medication adherence remains unclear.

OBJECTIVE

To systematically review RCTs of motivational interventions for improving medication adherence in hypertension.

METHODS

EMBASE and Pubmed were searched from inception to February 2019 for RCTs of motivational interventions for improving medication adherence in hypertension vs. usual care.

INCLUSION CRITERIA

RCTs with motivational intervention to improve medication adherence in adults with hypertension. A blinded review was conducted by 2 reviewers. Disagreements were resolved by consensus/a third reviewer. Data extraction and quality appraisal was performed using the risk of bias tool from cochrane collaboration. The meta-analyses of blood pressure control used random-effects models to report mean difference and 95% CIs. Primary outcome was medication adherence and second outcome was blood pressure control.

RESULTS

The search methodology yielded 10 studies comprising 1171 participants. Medication adherence improved significantly in 5 studies. We could not perform pool analysis for this outcome due to different measurements of medication adherence. Seven trials reported significant results regarding blood pressure control. On pooled analysis, motivational interventions were not significantly associated with a systolic blood pressure (mean difference, -0.06; 95% CI, -0.05 to 0.18; p=0.63; I2=0.0%) or diastolic blood pressure (mean difference, -0.11; 95% CI, -0.10 to 0.31; p=0.28; I2=23.8%) decrease or blood pressure control.

CONCLUSIONS

Motivational interventions seem to significantly improve medication adherence but not significantly blood pressure control in hypertension, although evidence is still being based on few studies, with unclear risk of bias.

The effects of motivational interviewing on hypertension management: A systematic review and meta-analysis

OBJECTIVE

This systematic review aimed to examine the effects of motivational interviewing-based interventions on hypertension management.

METHODS

Six databases were searched from inception to 25 July, 2022 for randomized controlled trials involving adults diagnosed with hypertension and including motivational interviewing in the treatment interventions.

RESULTS

In total, 11 studies with 2121 participants were included. Compared with no or minimal additional intervention, motivational interviewing-based intervention showed greater reduction in systolic blood pressure (MD: -6.56, 95 % CI: -10.51, -2.62, P = 0.001) and diastolic blood pressure (MD: -3.75, 95 % CI: -4.92, -2.58, P < 0.001). Compared with the lower intensity intervention, motivational interviewing-based intervention produced statistically significant effect on reducing systolic blood pressure (MD: -2.72, 95 % CI: -5.34, -0.10, P = 0.040); while there was no significant effect on reducing diastolic blood pressure (MD: -0.47, 95 % CI: -2.21, 1.28, P = 0.600). Four out of six studies demonstrated medication adherence significantly improved following motivational interviewing-based intervention. Two studies included self-efficacy and quality of life, and inconsistent findings were observed.

CONCLUSION

Motivational interviewing could be effective in improving blood pressure control among patients with hypertension. Future studies with more rigorous study designs should be conducted to confirm the effects of motivational interviewing on medication adherence and psychological well-being.

PRACTICE IMPLICATIONS

Motivational interviewing could be applied as a promising intervention strategy among patients with hypertension.

Using Confocal Microscopy to Generate an Accurate Vascular Model for Use in Patient Education Animation

Hypertension is a condition requiring lifelong medication, where patients often feel well with or without treatment. Uncontrolled hypertension, however, can lead to permanent remodelling processes that occur to the vascular structure, which are seldom understood by the public. As a result, a significant burden is placed on healthcare systems globally as a result of the effects of hypertension and lack of adherence to prescribed treatment.Improving patient education through well-designed interactive applications and animation is a known strategy that can improve adherence rates to medication. In the context of hypertension, little attention has been given to helping patients understand the unseen damage that occurs to vessels exposed to high blood pressure. However, generating an accurate representation of a vessel and the changes that occur can be challenging. Using microscopy data is one way for creating an anatomically correct model, but this often needs careful consideration as data cannot be directly imported. Here we describe methods for creating an accurate 3D model of a small artery using confocal microscopy data. This model can then be animated to demonstrate the substructures and pathological changes that occur in hypertensive conditions to better inform patients about the dangers of uncontrolled blood pressure.

Blood Pressure Control and Adherence to Drug Treatment in Patients with Hypertension Treated at a Specialized Outpatient Clinic: A Cross-Sectional Study

OBJECTIVE

To evaluate and identify variables associated with the control of hypertension and adherence to antihypertensive drug treatment in a group of patients with hypertension monitored in a specialized, highly complex outpatient service.

METHODS

A prospective, cross-sectional study was carried out in the hypertension unit of a tertiary teaching hospital. Patients diagnosed with hypertensive aged 18 years and over and accompanied for at least six months were included in the study. Patients with secondary hypertension and pregnant women were excluded. The sample consisted of 253 patients. Adherence/concordance to antihypertensive treatment was assessed using the Morisky Green Levine Scale. Blood pressure control was set for values less than 140/90 mmHg. Variables with p≤0.20 in univariate analysis were included in multiple logistic regression. The level of significance adopted was p ≤0.05.

RESULTS

Most of patients were white, married and women, with a mean age of 65 (13.3) years old, low income, and education levels. Blood pressure control and adherence were observed in 69.2% and 90.1% of the patients, respectively. Variables that were independently associated with blood pressure control were (OR, odds ratio; CI, 95% confidence interval): married marital status (OR 2.3; CI 1.34-4.28), use of calcium channel blockers (OR 0.4; CI 0.19-0.92) and number of prescribed antihypertensive drugs (OR 0.78; CI 0.66-0.92). Adherence was not associated with any of the variables studied.

CONCLUSION

There was a high frequency of patients with satisfactory adherence to antihypertensive drug treatment. Blood pressure control was less frequent and was associated with social and treatment-related factors.

Adherence to antihypertensive medications among adult hypertensive patients attending chronic follow-up units of Dessie Referral Hospital, Northeastern Ethiopia: A cross-sectional study

Hypertension is the leading cause of increased morbidity and mortality rates worldwide. Despite adherence to therapies is the important determinant of treatment success to reduce apparent resistant hypertension, maintaining good adherence to antihypertensive medications remained the most serious challenge. Thus, this study aimed to assess adherence to antihypertensive medications among adult hypertensive patients in Dessie Referral Hospital.A cross-sectional study design was conducted among hypertensive patients during May and June 2020. The study participants were selected using a systematic random sampling technique. The collected data were entered into EpiData version 4.4 and exported to SPSS version 25.0 software for data cleaning and analysis. Data were analyzed using bivariable and multivariable logistic regression at a 95% confidence interval (CI). A variable that has a P-value < .05 was declared as statistically significant. Hosmer-Lemeshow test was used to test goodness-of-fit and multicollinearity was tested.The overall good adherence to antihypertensive medications was 51.9%; 95% CI: (46.8-58.3%) and poor adherence was 48.1%. Factors associated with good adherence were: sex-female adjusted odd ratio (AOR) = 1.31; 95% CI (1.06-2.52), occupational status-employed AOR = 2.24; 95% CI (1.33-3.72), good knowledge of the disease AOR = 2.20; 95% CI (1.34-3.72) and good self-efficacy AOR = 1.38; 95% CI (1.20-2.13).This study revealed that almost half of the hypertensive patients in Dessie Referral Hospital had good antihypertensive medication adherence. Sex, occupational status, knowledge, and self-efficacy were factors associated with good adherence. Therefore, health education should be given to patients on the importance of complying with medication and patients should be monitored by health extension workers.

Health beliefs and chronic illnesses of refugees: a systematic review

Objective: To evaluate beliefs, and attitudes about health of refugees with chronic conditions such as diabetes mellitus type 2, hypertension, chronic obstructive pulmonary disease, and posttraumatic stress disorder and the consequent effects on self-care in comparison to resident populations.Design: A systematic review methodology was used. PubMed, Embase, PsycINFO and CINAHL databases were searched for relevant articles. The main terms analysed were health beliefs, chronic conditions and refugee populations. From 844 articles, 45 were retained for further assessment, and finally 5 met the inclusion criteria.Results: Differences in the health beliefs, attitudes and self-care management approaches of refugees compared to resident populations were identified in two studies. The remaining three papers did not make comparisons between the refugees and the resident population, nor did they specifically explore the refugees' health beliefs. Of the five studies, three were carried out in Sweden and two in the US. Refugees who have poorer mental and physical health as well as higher prevalence of chronic diseases than the populations among which they resettle seem to lack the knowledge about their illness, symptoms and self-management and thus are less able to control their chronic conditions.Conclusion: The findings highlighted the deficiency in the literature of studies which examine health beliefs and attitudes of minority groups such as refugees who have chronic conditions. The findings also gave insight to the need for a distinctive understanding of refugee health and the management of chronic conditions in comparison to other non-refugee migrant groups. Further research is needed to fully understand the differences between refugees and local populations in terms health beliefs, chronic disease and self-management.

Medication adherence in hypertension

: Suboptimal adherence to antihypertensive medication is a major contributor to poor blood pressure control. Several methods, direct or indirect, are available for measuring adherence, including the recently developed biochemical screening, although there is no gold-standard method routinely used in clinical practice to accurately assess the different facets of adherence. Adherence to treatment is a complex phenomenon and several of the barriers to adherence will need to be addressed at the healthcare system level; however, when looking at adherence from a more practical side and from the practitioner's perspective, the patient-practitioner relationship is a key element both in detecting adherence and in attempting to choose interventions tailored to the patient's profile. The use of single-pill combinations enabling simplification of treatment regimen, the implementation of a collaborative team-based approach and the development of electronic health tools also hold promise for improving adherence, and thus impacting cardiovascular outcomes and healthcare costs.

Pharmacokinetic comparison between a fixed-dose combination of fimasartan/amlodipine/hydrochlorothiazide 60/10/25 mg and a corresponding loose combination of fimasartan/amlodipine 60/25 mg and hydrochlorothiazide 25 mg in healthy subjects

For the treatment of hypertension, fixed-dose combinations (FDCs) of antihypertensive drugs can provide complementary benefits from improved compliance and cost-effectiveness compared with loose combinations of corresponding drugs. A new FDC of fimasartan/amlodipine/hydrochlorothiazide 60/10/25 mg is undergoing clinical development. A randomized, open-label, single-dose, 3-period, 3-sequence, partially replicated crossover phase 1 study was conducted to compare the pharmacokinetics (PKs) between the FDC of fimasartan/amlodipine/hydrochlorothiazide 60/10/25 mg and a loose combination of a dual-combination FDC (fimasartan/amlodipine 60/10 mg) and hydrochlorothiazide 25 mg. Sixty healthy subjects were randomized, and 55 subjects completed the study. Serial blood samples were collected, and plasma concentrations of fimasartan, amlodipine and hydrochlorothiazide were measured to analyze PK parameters. The PK profiles of the FDC were similar to those of the loose combinations. The geometric mean ratios (GMRs) and 90% confidence intervals (CIs) of the FDC to loose combinations for the maximum plasma concentration (C_max) and area under the curve until the last measurable time point (AUC_last) were within the conventional bioequivalent range of 0.80 to 1.25. The GMRs and 90% CIs of fimasartan, amlodipine and hydrochlorothiazide were 1.0163 (0.8681–1.1898), 0.9595 (0.9256–0.9946), and 1.1294 (1.0791–1.1821) for C_max and 1.0167 (0.9347–1.1059), 0.9575 (0.9317–0.9841), and 1.0561 (1.0170–1.0967) for AUC_last, respectively. Both the FDC and loose combinations were well tolerated. In conclusion, the FDC of fimasartan/amlodipine/hydrochlorothiazide 60/10/25 mg showed similar PK profiles to those of the corresponding loose combination, and both treatments were well tolerated.

Association of Perceived Stress and Discrimination on Medication Adherence among Diverse Patients with Uncontrolled Hypertension

Background

Uncontrolled hypertension is a significant risk factor for cardiovascular morbidity and mortality. In the United States, many patients remain uncontrolled, in part, due to poor medication adherence. Efforts to improve hypertension control include not only attending to medical management of the disease but also the social determinants of health, which impact medication adherence, and ultimately blood pressure control.

Purpose

To determine which social determinants - health care access or community and social stressors - explain medication adherence.

Methods

In this cross-sectional analysis, we used baseline data (N=1820, collected August 2017 to October 2019) from a pragmatic trial, which compares the effectiveness of a multi-level intervention including collaborative care and a stepped approach with enhanced standard of care for improving blood pressure. We used logistic regression analyses to examine the association between patient experiences of care and community and social stressors with medication adherence.

Results

The participants represented a diverse sample: mean age of 60 years; 59% female; 57.3% Black, 9.6% Hispanic, and 33.2% White. All participants had a blood pressure reading ≥140/90 mm Hg (mean blood pressure - 152/85 mm Hg). Half of the participants reported some level of non-adherence to medication. Regression analysis showed that, compared with Whites, Blacks (AOR .47; 95% CIs: .37-.60, P<.001) and Hispanics (AOR .48; 95% CIs: .32- .73, P<.001) were less likely to report medication adherence. Also part-time workers (AOR .57; 95% CIs: .38-.86, P<.05), and those who reported greater perceived stress (AOR .94; 95% CIs: .91 - .98, P<.001) and everyday discrimination (AOR .73; 95% CIs: .59 - .89; P<.001) had lower odds of medication adherence. Among Blacks, greater perceived stress (AOR .93; 95% CIs: .88-.98, P<.001) and everyday discrimination (AOR .63; 95% CIs: .49 - .82, P<.005) were negatively associated with medication adherence. Among Hispanics, greater report of everyday discrimination (AOR .36; 95% CIs: .14 - .89, P<.005) was associated with lower odds of medication adherence. Among Whites, the negative effect of perceived stress on medication adherence was attenuated by emotional support.

Conclusions

Using the social determinants of health framework, we identified associations between stress, everyday discrimination and medication adherence among non-Hispanic Blacks and Hispanics that were independent of health status and other social determinants. Programs to enhance self-management for African American and Hispanic patients with uncontrolled blood pressure should include a specific focus on addressing social stressors.

The Role of Medication Beliefs on Medication Adherence in Middle Eastern Refugees and Migrants Diagnosed with Hypertension in Australia

PURPOSE

The study assessed the association between medication beliefs and adherence in Middle Eastern refugees and migrants in Australia, and also examined differences between the two groups regarding beliefs and adherence to medication.

PATIENTS AND METHODS

A total of 319 Middle Eastern refugees and migrants with hypertension were approached via various social groups in Australia and asked to complete Arabic versions of the Beliefs about Medicine Questionnaire (BMQ) and the Medication Adherence Questionnaire. BMQ scores (necessity and concerns scales) were classified as "accepting", "indifferent", "ambivalent" or "skeptical". Multiple mediation modelling was applied to examine the role of necessity and concerns scales as mediators between migration status and medication adherence.

RESULTS

There were significant associations between medication adherence and medication beliefs scores (necessity and concerns scales) (p=0.0001). Necessity and concern were mediators in the relationship between migration status and medication adherence. Significant differences were found between refugees and migrants for medication adherence and medication beliefs. Refugees were likely to have less necessity, and more concern beliefs than migrants, and were also less likely to adhere to medications. Almost 30% of refugees could be classified as skeptical and 40% as ambivalent. In contrast, 50% of migrants had accepting beliefs, and around 35% held ambivalent beliefs. Refugees and migrants with "accepting" beliefs reported the highest adherence to medication and those holding "skeptical" beliefs reported the lowest adherence.

CONCLUSION

Medication beliefs are potentially modifiable and are reasonable targets for clinical interventions designed to improve medication adherence. Understanding these beliefs and the likely differences between refugees and migrants is crucial to provide specific and targeted advice to each group independently in order to improve medication adherence and overall health.

Cost-effectiveness of grass pollen allergen immunotherapy in adults

BACKGROUND

Major scientific societies, such as the EAACI or the AAAAI, do not express any suggestion on which form of allergen immunotherapy (AIT) is to be preferred (subcutaneous immunotherapy, SCIT, vs sublingual immunotherapy, SLIT). This choice could depend on their relative pharmacoeconomic value.

OBJECTIVE

To assess the cost-effectiveness of AIT for grass pollen, administered as SCIT or SLIT.

METHODS

We created a Markovian Model, to evaluate, in a hypothetical cohort of adult patients suffering from moderate-to-severe rhino-conjunctivitis with or without allergic asthma, the cost-effectiveness of SLIT (tablets, Grazax^® and Oralair^® ) or SCIT (various currently available products, plus indirect nonmedical costs, such as travel and productivity costs) in addition to pharmacological therapy, assuming a 9-year horizon to capture AIT long-term effects. The incremental cost-effectiveness ratio (ICER) was calculated assuming pharmacological therapy as the reference comparator.

RESULTS

In the base case, SCIT was slightly more expensive, but more effective than SLIT, being the most cost-effective option (ICER for SCIT, €11 418; ICER for SLIT, €15 212). ICERs greater than €120 000 for both SCIT and SLIT were demonstrated in a scenario assuming that low treatment persistence rates, which are common in real-life, lead to absence of long-term AIT clinical benefit. Considering indirect nonmedical costs SLIT resulted more cost-effective than SCIT (ICER for SCIT, €17 318; ICER for SLIT, €15 212).

CONCLUSION

In daily practice, AIT for grass pollens may be a cost-effective option only in patients with low discontinuation rates. SCIT, which is less affected by this limitation than SLIT, seems the most cost-effective AIT form.

Assessing Providers' Approach to Hypertension Management at a Large, Private Hospital in Kampala, Uganda

Background:

Hypertension is increasingly prevalent in Uganda and its clinical management remains suboptimal across the country. Prior research has elucidated some of the factors contributing to poor control, but little is known about providers’ approaches to hypertension management and perceptions of barriers to care. This is particularly true in private health care settings – despite the fact that the private sector provides a substantial and growing portion of health care in Uganda.

Objective:

Our exploratory, pragmatic qualitative study aimed to examine the factors affecting the quality of hypertension care from the perspective of providers working in an urban, private hospital in Uganda. We focused on the organizational and system-level factors influencing providers’ approaches to management in the outpatient setting.

Methods:

We conducted interviews with 19 health care providers working in the outpatient setting of a 110-bed, private urban hospital in Kampala, Uganda. We then coded the interviews for thematic analysis, using an inductive approach to generate the study’s findings.

Findings:

Several themes emerged around perceived barriers and facilitators to care. Providers cited patient beliefs and behaviors, driven in part by cultural norms, as a key challenge to hypertension control; however, most felt their own approach to hypertension treatment aligned with international guidelines. Providers struggled to collaborate with colleagues in coordinating the joint management of patients. Furthermore, they cited the high cost and limited availability of medication as barriers.

Conclusions:

These findings offer important strategic direction for intervention development specific to this Ugandan context: for example, regarding culturally-adapted patient education initiatives, or programs to improve access to essential medications. Other settings facing similar challenges scaling up management of hypertension may find the results useful for informing intervention development as well.