Long-term persistence with antihypertensive drugs in new patients

Medications adherence post-primary percutaneous coronary intervention in acute myocardial infarction: A population-based cohort study

WHAT IS KNOWN AND OBJECTIVE

The use of medications for secondary prevention is the cornerstone in the treatment of coronary artery disease (CAD). However, adherence to these medications is still suboptimal worldwide. This retrospective observational study aimed to assess the adherence to post-percutaneous coronary intervention (PCI) medications, along with predictors of non-adherence.

METHODS

We conducted a retrospective observational cohort study to assess the adherence to post-PCI medications by determining the rate of prescription refills for 12 months after discharge among STEMI patients, as well as predictors of non-adherence. Adherence was assessed by medication availability 80% of the time monitored by the prescription refills rate for 1 year post-discharge.

RESULTS AND DISCUSSION

A total of 1334 patients who presented with STEMI and underwent primary PCI were included in our retrospective analysis. The majority of patients included were male (96%) with a mean age of 51 ± 10.2 years. The overall adherence rate for all medications was only 28.4%, with an individual adherence rate of 50.5% for aspirin, 49.9% for P₂ Y₁₂ inhibitors, 48.1% for statins, 39.6% for beta-blockers and 42.9% for angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARB). Factors that increased the likelihood of non-adherence were prolonged hospital length of stay and getting the medications with charge (aOR = 1.94, 95% CI 1.1-3.3; p-value = 0.017, aOR = 1.87, 95% CI 1.1-3.3; p-value = 0.029, respectively), while having a regular follow-up after discharge and attending the first clinic appointment were significantly associated with decreased likelihood of non-adherence (aOR = 0.01, 95% CI 0.004-0.04; p-value < 0.001, aOR = 0.06, 95% CI 0.03-0.1; p-value < 0.001, respectively).

WHAT IS NEW AND CONCLUSION

The adherence rate to post-PCI medications among patients with STEMI was relatively low; however, attending the first outpatient clinic appointment and having a regular follow-up reduced the likelihood of non-adherence.

Sex differences in the adherence of antihypertensive drugs: a systematic review with meta-analyses

OBJECTIVES

Poor worldwide rate of blood pressure control is largely due to poor adherence to antihypertensive (AHT) drug treatment. The question of whether sex affects adherence has long been debated but conflicting findings have been reported on this issue. Our objective was to evaluate sex differences in the adherence to AHT therapy.

RESEARCH DESIGN AND METHODS

Studies were identified through a systematic search of PubMed, CINAHL, PsycINFO, Web of Science and Google Scholar (through January 2020) and manual handsearching of relevant articles. Observational studies reporting adherence to AHT drugs measured by self-report or pharmacy refill prescription-based methods among men and women were included. Summarised estimates of OR_s with 95% CIs were calculated using random-effects model and meta-regression models.

RESULTS

From 12 849 potentially relevant publications, 82 studies (15 517 457 men and 18 537 599 women) were included. No significant between-sex differences in adherence to AHT were observed, whether all study-specific estimates were summarised (OR_s 1.04, 95% CI 1.00 to 1.09, p=0.07), nor estimates were pooled according to the method for measuring adherence. Among patients aged 65 years or older, lower self-reported adherence was observed in women (OR_s 0.84, 95% CI 0.72 to 0.97, p=0.02), while the main result remained unchanged according to other subgroup analyses.

CONCLUSIONS

Definitive evidence of sex differences in adherence to AHT therapy cannot be drawn. Our little knowledge about factors affecting adherence, in particular of sex effect among elderly, urgently requires high-quality studies investigating these issues.

Pharmacy-based predictors of non-adherence, non-persistence and reinitiation of antihypertensive drugs among patients on oral diabetes drugs in the Netherlands

Background

Adherence to antihypertensive drugs in patients with diabetes is important. To support adherence, attention should be paid to the dynamic process of implementation, persistence and reinitiation of these drugs. We assessed non-adherence, non-persistence and reinitiation patterns for antihypertensive drugs in patients on oral diabetes drugs and identified pharmacy-based predictors of these processes.

Methods

We conducted a cohort study in patients on oral diabetes drugs who initiated antihypertensive drugs between 1995–2015, as registered in the IADB.nl pharmacy database. Non-adherence was defined as a medication possession ratio < 80% and non-persistence as a gap > 180 days. We defined reinitiation as the dispensing of an antihypertensive drug within one year following discontinuation. We provide descriptive statistics for different time periods and applied logistic and Cox regressions to assess associations with sociodemographic and drug-related factors.

Results

Of 6,669 initiators, non-adherence rates in persistent patients decreased from 11.0% in the first year to 8.5% and 7.7% in the second and third years, respectively. Non-persistence rates decreased from 18.0% in the first year to 3.7% and 2.9% in the second and third years, respectively. Of the 1,201 patients who discontinued in the first year, 22.0% reinitiated treatment within one year. Non-adherence and non-persistence rates were lower in the more recent time period. Predictors of non-adherence were secondary prevention (OR: 1.45; 95% CI: 1.10–1.93) and diuretics as initial drug class (OR: 1.37; 95% CI: 1.08–1.74). Predictors of non-persistence were female gender (HR: 1.18; 95% CI: 1.05–1.32), older age (HR: 1.33; 95% CI: 1.08–1.63) and diuretics, beta-blocking agents or calcium channel blockers as initial drug class. Longer duration of persistence was a predictor of reinitiation.

Conclusions

Adherence to antihypertensive drugs in patients on oral diabetes drugs has improved over time. The first year after initiation is the most crucial with regard to non-adherence and non-persistence, and the risk groups are different for both processes. Early non-persistence is a risk factor for not reinitiating treatment.

Expert consensus on the management of hypertension in the young and middle-aged Chinese population

Hypertension, defined as blood pressure (BP) ≥140/90 mmHg, is one of the most common, yet reversible, risk factors for cardiovascular disease (CVD). Globally, 9.40 million people died from hypertension in 2010, accounting for 17.8% of total deaths; disability-adjusted life years (DALYs) caused by hypertension were 170 million person-years, or 7.0% of the total global DALYs.1 Data from China showed that hypertension accounted for 24.6% of all deaths, and 12.0% of total DALYs,2 and the direct medical cost of hypertension in China has reached 36.6 billion yuan per year.3.

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

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

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

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

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

Fixed Versus Free Combinations Of Antihypertensive Drugs: Analyses Of Real-World Data Of Persistence With Therapy In Italy

PURPOSE

To analyse the pattern of use and cost of antihypertensive drugs in new users in an Italian population, and explore the patient/treatment factors associated with the risk of therapy discontinuation.

PATIENTS AND METHODS

In this retrospective study, information was collected from a population-based electronic primary-care database. Persistence with medication use 1 year from therapy initiation was evaluated for each user using the gap method. Each new user was classified according to his/her pattern of use as: "continuer", "discontinuer" "switching" or "add-on". A Cox regression model was used to analyse the factors influencing therapy discontinuation. Primary-care costs comprised specialists' visits, diagnostic procedures and pharmacologic therapies.

RESULTS

Among 14,999 subjects included in persistence analyses, 55.1% of cases initially started on monotherapy were classified as discontinuers vs 36.5% of cases taking combination therapy (42.3% vs 32.7%, respectively, for free and fixed combinations, P < 0.01). Old age, high cardiovascular risk and being in receipt of fixed-combination therapy were associated with greater persistence. Overall, the primary-care cost/person/year of hypertension management was ~€95.3 (IQR, 144.9). The monotherapy cost was €88 per patient (IQR, 132.9), and that for combination therapy was €151±148.3. The median cost/patient with a fixed combination was lower than that for a free combination (€98.4 (IQR, 155.3) and €154.9 (IQR, 182.6), respectively).

CONCLUSION

The initial type of therapy prescribed influences persistence. Prescribing fixed combinations might be a good choice as initial therapy.

Factors influencing adherence to treatment in older adults with hypertension

PURPOSE

Hypertension (HT) is considered to be the most common disorder in the general population. Demographic data indicate that older adults commonly suffer from HT. Older age is one of the key factors affecting the adherence of patients with HT. The main purpose was to identify demographic, socioeconomic, and clinical factors that affect adherence in older adults with HT.

MATERIALS AND METHODS

This cross-sectional study included 150 patients (84 women and 66 men) with mean age of 72.1 years. The Hill-Bone Compliance to High Blood Pressure Therapy Scale (Hill-Bone CHBPTS) was used to evaluate the adherence to therapeutic recommendations for HT.

RESULTS

The mean score obtained by the patients in the Hill-Bone CHBPTS was 20.19 (SD±4.05). The linear regression model showed the independent predictors of the total score (P<0.05): 1) age, each subsequent year of life raises the total score by an average of 0.2 points; 2) gender, males raise it by an average of 1.34 points compared to females; 3) education, a secondary, higher, or higher professional education lowers it by an average of 1.75 points compared to a primary education or no education; and 4) living with the family, having familial support lowers it by an average of 1.91 points compared to living alone or in an organized institution.

CONCLUSION

Our study has shown that the variables of age, education level, and living with the family were statistically significant in explaining the adherence rates. Health care professionals should pay more attention to older HT patients who have a low level of education and who experience the lack of social support. There is a need for a tailored education among this group of patients to better understand and adhere to medication treatment.

Barriers and facilitators to treatment among patients with newly diagnosed hypertension in Nepal

Objective

Hypertension is a significant and rising burden in Nepal. The disease remains undetected and inadequately managed. However, no studies have been conducted to understand the inhibiting and facilitating factors to hypertension treatment among newly diagnosed cases. This qualitative study aimed to explore barriers and facilitators to treatment among patients with newly diagnosed hypertension aged ≥18 years in Dhulikhel, Nepal.

Methods

We conducted seven focus group discussions with 35 patients with newly diagnosed hypertension identified through community surveillance of the Dhulikhel Heart Study, an observational cohort of Dhulikhel Hospital, Kathmandu University. Audiotaped discussions were transcribed, inductively coded and analysed by the thematic framework method using Atlas.ti V.7.

Results

Hypertension was viewed as a rising problem in the community. Participants had limited knowledge and many misbeliefs regarding hypertension and its treatment. The major barriers included absence of symptoms, reluctance to take medicine, low perceived seriousness of the disease, challenges in behaviour change (diet and exercise), lack of family support, and lack of communication and trust with the provider. The major reported facilitating factors were fear of consequences of the disease, and family support in controlling diet and adhering to treatment.

Conclusions

A number of factors emerged as barriers and facilitators to hypertension treatment. This information can be useful in designing appropriate health interventions to improve hypertension management.

Non-adherence to antihypertensive pharmacotherapy in Buea, Cameroon: a cross-sectional community-based study

Background

Hypertension is a challenging public health problem with a huge burden in the developing countries. Non-adherence to antihypertensive treatment is a big obstacle in blood pressure (BP) control and favours disease progression to complications. Our objectives were to determine the rate of non-adherence to antihypertensive pharmacotherapy, investigate factors associated with non-adherence, and to assess the association between non-adherence and BP control in the Buea Health District (BHD), Cameroon.

Methods

A community-based cross-sectional study using stratified cluster sampling was conducted in the BHD from November 2013 – March 2014. Eligible consenting adult participants had their BP measured and classified using the Joint National Committee VII criteria. The Morisky medication adherence scale was used to assess adherence to BP lowering medication. Multivariable logistic regression models were used to predict non-adherence.

Results

One hundred and eighty-three participants were recruited with mean age of 55.9 years. Overall, 67.7% (95% CI: 59.8–73.6%) of participants were non-adherent to their medications. After adjusting for age, sex and other covariates, forgetfulness (aOR = 7.9, 95%CI: 3.0–20.8), multiple daily doses (aOR = 2.5, 95%CI: 1.2–5.6), financial constraints (aOR = 2.8, 95%CI: 1.1–6.9) and adverse drug effects (aOR = 7.6, 95%CI: 1.7–33.0) independently predicted non-adherence to anti-hypertensive medication. BP was controlled in only 21.3% of participants and was better in those who were adherent to medication (47.5% versus 8.2%, p <  0.01).

Conclusion

At least two of every three hypertensive patients in the Buea Health District are non-adherent to treatment. Forgetfulness, multiple daily doses of medication, financial constraints and medication adverse effects are the major predictors of non-adherence in hypertensive patients. These factors should be targeted to improve adherence and BP control, which will contribute to stem hypertension-related morbidity and mortality.

Prescription patterns of angiotensin-converting enzyme inhibitors for various indications: A UK population-based study

AIM

Angiotensin-converting enzyme inhibitors (ACEIs) are widely prescribed for several cardiovascular indications. This study investigated patterns of ACEI use for various indications.

METHODS

A descriptive, retrospective population-based study was conducted using data from the UK Clinical Practice Research Datalink. Patients starting ACEIs (2007-2014) were selected and ACEI indications were retrieved from electronically recorded medical records. Stratified by indication, we distinguished between persistent and nonpersistent ACEI use, considering a 6-month interval between two prescription periods as a maximum for persistent use. Five-year persistence rates for various indications were calculated using the Kaplan-Meier method and compared in a log-rank test. Nonpersistent users were subdivided into three groups: (i) stop; (ii) restart; and (iii) switch to an angiotensin II-receptor blocker. Patients who received ACEIs for hypertension who switched to other classes of antihypertensive medications were further investigated.

RESULTS

In total, 254 002 ACEI initiators were identified with hypertension (57.6%), myocardial infarction (MI; 4.2%), renal disease (RD; 3.7%), heart failure (HF; 1.5%), combinations of the above (17.2%) or none of the above (15.8%). Five-year persistence rates ranged from 43.2% (RD) to 68.2% (MI; P < 0.0001). RD and HF patients used ACEIs for the shortest time (average 23.6 and 25.0 months, respectively). For the nonpersistent group, the percentage of switchers to angiotensin II-receptor blockers ranged from 27.6% (RD) to 42.2% (MI) and the restarters ranged from 15.0% (HF) to 18.1% (group without indication).

CONCLUSIONS

Depending on the indication, there are various rates of ACEI nonpersistence. Patients with RD are most likely to discontinue treatment.

Adherence to treatment and evaluation of disease and therapy knowledge in Lebanese hypertensive patients

BACKGROUND

Adherence to treatment, healthy lifestyle, physical activities, smoking, diet, and salt intake are important factors to control for an effective decrease in blood pressure (BP) values for patients diagnosed with essential hypertension (HT). The aim of this work was to study the adherence to antihypertensive treatment and factors predicting this behavior in Lebanese patients. In addition, we evaluated the extent of patient's knowledge and perceptions about HT, risk factors, and medication side effects.

METHODS

The cross-sectional study was conducted between May and September 2015 among 249 participants randomly recruited from community and hospital pharmacies (56.6%), private cardiology clinics (37%), and outpatient clinics located in hospitals (6.4%) in Baabda region of Lebanon. The questionnaire was prepared after reviewing published literature. Data were collected by trained and certified interviewers and analyzed by Statistical Package for the Social Sciences program. p-value less than 0.05 was considered to determine the statistical significance.

RESULTS

Among the 249 patients interviewed, 48% were females with a mean age of 62±17.2 years. Overweight and obesity was declared in 42.2% and 35.3%, respectively. Only 52.6% of participants reported visiting their physicians for regular checkups, and 72% claimed checking their BP routinely at home. Awareness of complications related to HT was very high (97%). However, our results showed that 89.2% of the participants were found to be adherent to treatment, and forgetfulness was cited as the main reason for non-adherence to therapy. Only health coverage showed statistical significance (p=0.01) between adherent and non-adherent participants.

CONCLUSION

A better communication between patients and their physicians, the use of a special container for medication packaging, and reminder to refill prescriptions are important parameters to enhance adherence to treatment. HT can be better managed if an educational system is implemented to increase awareness.

Persistence with Medications in Glaucoma Management, Hypertension, and Dyslipidemia

Objective:

To summarize pharmacy database studies of persistence with ocular hypotensives and review the literature of adherence with 2 additional classes of medication—antihypertensives and antihyperlipidemics—comparing methods used to analyze adherence in the 3 treatment areas.

Data Sources:

A search of MEDLINE (1990–2004) was conducted, using search terms designed to identify English-language articles describing adherence or persistence with any of the 3 drug classes of interest.

Study Selection and Data Extraction:

All articles identified through MEDLINE were reviewed and screened for use of an automated pharmacy database as an information source, quantitative results provided, and follow-up duration of at least 90 days. Details of methods used to estimate adherence or persistence and estimates of persistence with ocular hypotensive therapy, antihypertensives, and lipid-lowering agents were extracted.

Data Synthesis:

All studies describing the use of ocular hypotensives, and the majority of studies in the other treatment areas, identified inception cohorts of drug initiators. Use of survival analysis techniques to analyze adherence to medication therapy was less common in the hypertension and hyperlipidemia treatment adherence literature than in literature about glaucoma. In the treatment of hypertension, use of angiotensin II receptor antagonists or angiotensin-converting enzyme inhibitors was associated with higher levels of adherence. Statins in treatment of hyperlipidemia and topical prostaglandins as ocular hypotensive medications were also associated with higher levels of adherence.

Conclusions:

Findings regarding the relative superiority of specific drug classes were consistent within each therapeutic area, with less consistency in identifying other predictors of adherence. Increased use of survival analysis in future studies of persistence might improve comparability of results across studies.

Medication adherence and persistence according to different antihypertensive drug classes: A retrospective cohort study of 255,500 patients

BACKGROUND

Suboptimal adherence to antihypertensives leads to adverse clinical outcomes. This study aims to determine and compare medication adherence and persistence to different first-line antihypertensive drug classes in a large cohort.

METHODS

A cohort study was performed using claims data for prescriptions in the German statutory health insurance scheme that insures approximately 90% of the population. A total of 255,500 patients with a first prescription of an antihypertensive were included and followed for 24months. Persistence was determined based on gaps in continuous dispensation. Adherence was analyzed by calculating the medication possession ratio (MPR).

RESULTS

Within a 2-year period, 79.3% of all incident users of antihypertensive monotherapy met the classification of non-persistence (gap >0.5 times the number of days supplied with medication) and 56.3% of non-adherence (MPR<0.8). Beta-blockers (42.5%) and angiotensin-converting enzyme inhibitors (31.9%) were the most widely prescribed drug classes. Non-persistence and non-adherence were highest for diuretics (85.4%, n=6149 and 66.3%, n=4774) and lowest for beta-blockers (77.6%, n=76,729 and 55.2%, n=54,559). The first gap of antihypertensive medication occurred in median 160-250days after initiation, and the average medication possession ratio for all drug classes was less than 0.8. Fixed combinations with diuretics showed a 19.8% lower chance for non-adherence (OR=0.802, 99.9% CI=[0.715-0.900], p<0.001) and an 8.4% lower hazard for non-persistence (HR 0.916, 99.9% CI=[0.863-0.973], p<0.001) compared with monotherapies.

CONCLUSIONS

This large cohort study reveals important differences in 2-year adherence and persistence between antihypertensives that were lowest for diuretics. Fixed-dose combinations with diuretics may facilitate adherence compared to single substance products. However, effective strategies to improve adherence to antihypertensives are needed regardless of drug class.

Quality of Life in Treatment-Resistant Hypertension

Treatment-resistant hypertension (TRH) is an increasingly common and clinically challenging hypertension phenotype associated with adverse impact on cardiovascular events and death. Recent evidence, although limited, suggests that TRH may also adversely affect health-related quality of life (HrQoL) and other patient-reported outcomes. However, the precise mechanisms for this link remain unknown. A number of recent studies focusing on both the general hypertensive population and those with TRH suggest that patient awareness of difficult-to-control blood pressure, chronically elevated blood pressure levels, and the use of aggressive medication regimens with attendant cumulative adverse effects may play significant roles. This review summarizes the existing literature on HrQoL in persons with TRH, highlights literature from the general hypertensive population with relevance to TRH, and discusses important remaining questions regarding HrQoL in persons with TRH.

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

Background:

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

Aim:

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

Subjects and Methods:

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

Results:

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

Conclusion:

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

Factors involved in the discontinuation of antihypertensive drug therapy: an analysis from real life data

OBJECTIVES

We have previously shown that in Italian region of Lombardy (about 10 million citizens), adherence to antihypertensive treatment is low, and that this is associated with a greater risk of hospitalization for cardiovascular events. In this study, we used a healthcare database to study the factors involved in discontinuation of antihypertensive drug prescriptions in real life.

METHODS AND RESULTS

The analysis was restricted to 493 623 new users of antihypertensive drugs (no prescriptions in the previous 3 years) recruited in 2003, 2006 and 2009. Discontinuation was defined as lack of prescription renewal for at least 3 months. Each patient was followed at most for 1 year. The adjusted risk of treatment discontinuation depended on the type of initial antihypertensive treatment (diuretic monotherapy associated with higher risk) and it was lower in men (-17%) and older (-21 to -29%) patients, in patients with co-treatment with antidiabetic drugs, or hospitalization for cardiovascular or renal disease (-12 to -27%), but greater in patients under co-treatment with antidepressant drugs or hospitalization for concomitant pulmonary, rheumatic, neoplastic or neurological diseases (+9 to +32%). An unexpected relationship between discontinuation of treatment and density of the population of patient's residence, with a much greater discontinuation in metropolitan areas, was observed.

CONCLUSIONS

In a real life setting, discontinuation of antihypertensive treatment is affected in an opposite direction by a large number of factors: type of antihypertensive treatment, co-treatments, clinical conditions and even demographic characteristics of the geographical area where the patient lives. Knowledge of these factors may help the effort to reduce this phenomenon.

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.

Younger females are at greater risk of vasodilation-related adverse symptoms caused by dihydropyridine calcium channel blockers: results of a study of 11,918 Japanese patients

BACKGROUND AND OBJECTIVE

Adequate control of blood pressure in younger females is of crucial importance, because they are at higher risk of hypertensive target organ damage compared with males of similar age. In addition, female sex is a risk factor for adverse effects of antihypertensive drugs, especially dihydropyridines. This study set out to assess the incidence of adverse reactions during dihydropyridine use in a real-life clinical setting, focusing on the influence of female sex and age.

METHODS

The incidence of adverse reactions to dihydropyridine calcium channel blockers were investigated in 11,918 Japanese patients who participated in the Drug Event Monitoring project of the Japan Pharmaceutical Association conducted in Kumamoto prefecture. A multiple logistic regression analysis was used to determine the association between the incidence of adverse symptoms and female sex, with adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs).

RESULTS

Vasodilation-related adverse symptoms occurred significantly more often in females than in males (OR 1.87, 95% CI 1.28-2.71, p=0.001). Furthermore, among females only, the younger age group (<50 years) complained of vasodilation-related symptoms more frequently (OR 2.39, 95% CI 1.02-5.59, p=0.045) and the older age group (≥80 years) complained of vasodilation-related symptoms less frequently (OR 0.56, 95% CI 0.33-0.95, p=0.030) than the middle age group (50-79 years).

CONCLUSION

To the best of our knowledge, this is the first report showing that younger females are at high risk for vasodilation-related adverse symptoms during dihydropyridine use in a real-life clinical setting. These results should be verified in clinical studies using larger samples of young patients and more parameters.

Determinants of medication adherence and blood pressure control among hypertensive patients in Hong Kong: a cross-sectional study

INTRODUCTION

Despite effective treatments, suboptimal medication adherence substantially hinders blood pressure (BP) control among hypertensive patients. This study aimed to evaluate the determinants of medication adherence and BP control among hypertensive patients in Hong Kong.

METHODS

A cross-sectional study was conducted. Adult patients aged>18years taking at least one type of antihypertensive drugs were recruited from four clinics in Hong Kong. Each patient completed a self-administered questionnaire, including socio-demographic variables and items related to knowledge, illness perception and medication adherence. Medication adherence was measured by the eight-item Morisky Medication Adherence Scale (MMAS-8), with a score>6 defined as "good adherence". BP was measured, and optimal control was defined as systolic BP<140mmHg and diastolic BP<90mmHg.

RESULTS

Among 2445 patients, 55.1% and 52.5% had optimal medication adherence and BP control, respectively. Binary logistic regression analyses were conducted with optimal medication adherence and BP control, respectively, as the outcome variables. Advanced age (adjusted odds ratio [aOR] 1.012, 95% CI 1.002-1.022, p=0.014), unemployment (aOR for employed 0.782, 95% CI 0.628-0.975, p=0.029), and good self-perceived health status (aOR 2.155, 95% CI 1.711-2.714, p<0.001) were associated with good adherence; whereas being married (aOR 1.265, 95% CI 1.038-1.542, p=0.020) and having no co-morbidity (aOR for morbidity count 0.713, 95% CI 0.639-0.796, p<0.001) were associated with optimal BP control.

CONCLUSION

Evidence-based, adherence-enhancing interventions should be targeted on younger subjects; employed patients; and those with poor self-perceived health status. Patients who are single and those with comorbidities should be closely monitored for their BP control.

Medication adherence and its associated factors among Chinese community-dwelling older adults with hypertension

OBJECTIVE

To investigate the factors that influence medication adherence in Chinese community-dwelling older adults with hypertension.

METHODS

A cross-sectional study was conducted with a convenience sample of 382 older adults with hypertension recruited from six health centers in Macao, China. Chinese versions of the Morisky 4-Item Self-Report Measure of Medication-Taking Behavior, Fear of Intimacy with Helping Professionals scale and Exercise of Self-care Agency scale were administered to participants.

RESULTS

Participants older than 65 years (β = .118, p = .017), with a low level of education (β = .128, p = .01), who had more than one other common disease (β = .120, p = .015), were on long-term medication (β = .221, p < .001) and who reported higher self-care (β = .188, p = .001), had better medication adherence.

CONCLUSIONS

Health care professionals should consider these factors when planning medication regimens for Chinese older adults with hypertension, to enhance medication adherence and improve patient outcomes.

Proportion and risk indicators of nonadherence to antihypertensive therapy: a meta-analysis

PURPOSE

The World Health Organization (WHO) concluded that poor adherence to treatment is the most important cause of uncontrolled high blood pressure, with approximately 75% of patients not achieving optimum blood pressure control. The WHO estimates that between 20% and 80% of patients receiving treatment for hypertension are adherent. As such, the first objective of our study was to quantify the proportion of nonadherence to antihypertensive therapy in real-world observational study settings. The second objective was to provide estimates of independent risk indicators associated with nonadherence to antihypertensive therapy.

MATERIALS AND METHODS

We performed a systematic literature review and meta-analysis of all studies published between database inception and December 31, 2011 that reviewed adherence, and risk indicators associated with nonadherence, to antihypertensive medications.

RESULTS

In the end, 26 studies met our inclusion and exclusion criteria and passed our methodological quality evaluation. Of the 26 studies, 48.5% (95% confidence interval 47.7%-49.2%) of patients were adherent to antihypertensive medications at 1 year of follow-up. The associations between 114 variables and nonadherence to antihypertensive medications were reviewed. After meta-analysis, nine variables were associated with nonadherence to antihypertensive medications: diuretics in comparison to angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) and calcium channel blockers (CCBs), ACE inhibitors in comparison to ARBs, CCBs in comparison to ARBs, those with depression or using antidepressants, not having diabetes, lower income status, and minority cultural status.

CONCLUSION

This study clarifies the extent of adherence along with determining nine independent risk indicators associated with nonadherence to antihypertensive medications.

Evaluation of a self-management implementation intervention to improve hypertension control among patients in Medicaid

Elevated blood pressure can lead to serious patient morbidity and mortality. The aim of the study was to evaluate the implementation of a tailored multifaceted program, administered by care managers in a Medicaid setting to improve hypertension medication adherence. The program enrolled 558 Medicaid patients. Patients had at least one phone call by care managers. The individually tailored program focused on improving lifestyle and medication adherence. The primary outcome was the medication possession ratio (MPR), calculated using fill history from pharmacy claims. We observed an improvement of medication possession from 55% 9-12 months prior to program enrollment to 77% 9-12 months post initiation of the program. We demonstrated 12 month sustainability and increased MPR. Personal interaction by phone allows the intervention to be tailored to participants' current concerns, health goals, and specific barriers to achieving these goals.

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

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Getting the message across: opportunities and obstacles in effective communication in hypertension care

Effective communication is a prerequisite for any successful encounter between patient and provider. Nevertheless, it is unclear how/where communication can impact/affect adherence to antihypertensive medication, and maintenance of lifestyle changes to control blood pressure targets. Poor physician communication is correlated with a higher risk of treatment nonadherence. Given the high rates of hypertension globally, this review serves to enlighten aspects of the communication exchange from a provider, context, and patient perspective. Relevant articles were analyzed to assess barriers, solutions, and optimizations for communication with hypertensive patients. To support the findings, a model of communication in the context of hypertension treatment is presented, which comprises three phases: comprehension and acceptance, translation into action, and long-term retention. Secondly, an analysis of care providers (bedside manner, verbal/nonverbal communication, empathy and sex, time, knowledge base), context (format and tailoring of the message, and physical environment), and patient-related factors (sex, socio-economic status, language and health literacy, culture, age, psychological factors) were assessed in relation to hypertension. Current literature is limited regarding reciprocal communication, adaptive packaging of messages, and active verification of effective communication. To improve communication, hypertension care programs could benefit from better communication training, more team-based approaches, and flexible tools based on information technology.

Trends in Prescription and Determinants of Persistence to Antihypertensive Therapy : The PAPEETE Study

OBJECTIVES

To assess trends in prescriptions, determinants and timing of treatment discontinuation and/or changes in antihypertensive drug therapy in a cohort of hypertensive patients living in Pavia, a city in the north of Italy.

METHODS

The cohort included 61 493 patients aged ≥18 years who received their first antihypertensive drug prescription (monotherapy, fixed or extemporaneous combination) during the period 2003-6. Patients were classified as 'persistent' if 12 months after the beginning of treatment they were still taking a regular therapy (same drug = 'same therapy users', added one or more drugs = 'add-on therapy users', different drug = 'switchers'). Otherwise, they were classified as 'non-persistent' (stopping therapy after the first prescription = 'occasional users'; stopping treatment early = 'stoppers'; taking medicines in an erratic fashion = 'intermittent users').

RESULTS

ACE inhibitors were the most frequently prescribed drugs (22.8%), followed by β-adrenoceptor antagonists (β-blockers) [14.3%], diuretics (13.9%), Ca(2+) antagonists (11.4%) and angiotensin II type 1 receptor antagonists (angiotensin receptor blockers [ARBs]) [9.3%]. After 12 months, persistent patients were only 11.2% (same therapy users 6.7%, switchers 3.2%, add-on therapy users 1.3%). Non-persistent patients were 88.8% (35.3% occasional users, 20.6% stoppers, 32.8% intermittent users). Patient-related predictors of persistence were older age, male sex, concomitant treatment with antidiabetic and hypolipidaemic drugs and previous hospitalizations for cardiovascular events. Highest level of persistence was seen in patients starting with ARBs (18.8%), followed by ACE inhibitors (11.4%), β-blockers (11.0%), Ca(2+) antagonists (10.8%) and diuretics (3.0%). Among ARBs, considering separately monotherapy and fixed-combination therapy, highest level of persistence was observed in patients starting with candesartan, irbesartan, valsartan and telmisartan given in monotherapy, and with valsartan and telmisartan given in fixed-dose combination.

CONCLUSIONS

Persistence to antihypertensive treatment at 12 months is only 11.2%, being the lowest with diuretics (3.0%) and the highest with ARBs (18.8%).

Updated report on comparative effectiveness of ACE inhibitors, ARBs, and direct renin inhibitors for patients with essential hypertension: much more data, little new information

OBJECTIVES

A 2007 systematic review compared angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) in patients with hypertension. Direct renin inhibitors (DRIs) have since been introduced, and significant new research has been published. We sought to update and expand the 2007 review.

DATA SOURCES

We searched MEDLINE and EMBASE (through December 2010) and selected other sources for relevant English-language trials.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

We included studies that directly compared ACE inhibitors, ARBs, and/or DRIs in at least 20 total adults with essential hypertension; had at least 12 weeks of follow-up; and reported at least one outcome of interest. Ninety-seven (97) studies (36 new since 2007) directly comparing ACE inhibitors versus ARBs and three studies directly comparing DRIs to ACE inhibitor inhibitors or ARBs were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

A standard protocol was used to extract data on study design, interventions, population characteristics, and outcomes; evaluate study quality; and summarize the evidence.

RESULTS

In spite of substantial new evidence, none of the conclusions from the 2007 review changed. The level of evidence remains high for equivalence between ACE inhibitors and ARBs for blood pressure lowering and use as single antihypertensive agents, as well as for superiority of ARBs for short-term adverse events (primarily cough). However, the new evidence was insufficient on long-term cardiovascular outcomes, quality of life, progression of renal disease, medication adherence or persistence, rates of angioedema, and differences in key patient subgroups.

LIMITATIONS

Included studies were limited by follow-up duration, protocol heterogeneity, and infrequent reporting on patient subgroups.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Evidence does not support a meaningful difference between ACE inhibitors and ARBs for any outcome except medication side effects. Few, if any, of the questions that were not answered in the 2007 report have been addressed by the 36 new studies. Future research in this area should consider areas of uncertainty and be prioritized accordingly.

Real-life treatment patterns, compliance, persistence, and medication costs in patients with hypertension in Germany

OBJECTIVE

This retrospective patient data analysis was initiated to describe current treatment patterns of patients in Germany with arterial hypertension, with a special focus on compliance, persistence, and medication costs of fixed-dose and unfixed combinations of angiotensin receptor blockers (ARBs), amlodipine (AML) and hydrochlorothiazide (HCT) in Germany.

METHODS

The study analyzed prescription data collected by general practitioners, using the IMS Disease Analyzer database. The database was searched for patients with the diagnosis hypertension (ICD-10 code I10) and treatment data in the period 09/2009 to 08/2010. Compliance was measured indirectly based on the medication possession ratio (MPR), and persistence was defined as the duration of time from initiation to discontinuation of therapy. Medication costs were assessed from the statutory health insurance perspective in Germany.

RESULTS

In the IMS DA 406,888 observable patients in Germany were encoded with the diagnosis I10 essential hypertension. In total, 88,716 patients received prescriptions including ARBs, monotherapy (18.6%) or unfixed combinations with other anti-hypertensives (19.3%). The compliance with fixed-dose combinations of ARB with HCT, either dual or with one other anti-hypertensive drug, was significantly better, compared to unfixed combinations (mean compliance 78.1% for fixed-dose vs 71.5% for unfixed combinations of ARB with HCT, p < 0.0001; mean compliance 79.4% vs 72.0%, p < 0.0001 if an additional anti-hypertensive medication was added). Fixed-dose combinations of ARB with HCT, ARB with AML, dual only or prescribed with another anti-hypertensive medication resulted in a substantial increase of persistence, especially for patients on fixed-dose dual combinations (225.7 vs 163.6 days for ARB with HCT; 232.9 vs 178.4 days for ARB with AML, respectively). Fixed-dose combinations (varying from €1.38 to €2.20 per patient and day) were on average cheaper than unfixed combinations.

LIMITATIONS

Persistence and compliance could be under- or over-estimated because their assessment was based on prescription information. For two thirds of 69,060 patients, data on compliance and persistence was missing.

CONCLUSION

The study shows considerable variations in ARB treatment patterns among patients, with the majority of patients treated with fixed-dose or semi-fixed combination therapy. Fixed-dose combinations of ARBs with HCT and/or AML seem to result in better compliance and persistence compared to unfixed regimes of these drug classes, leading to reduction in all-cause hospitalizations, emphasizing the benefit and potential cost-savings of using fixed-dose regimes in a real-life general practice setting in Germany.

Persistence with a single pill versus two pills of amlodipine and atorvastatin: the Australian experience, 2006-2010

OBJECTIVE

To study patient persistence on therapy for hypertension and dyslipidaemia using a single-pill combination compared with a two-pill approach.

DESIGN AND SETTING

Post-hoc observational assessment of Pharmaceutical Benefits Scheme claim records covering the period April 2005 to March 2010.

PARTICIPANTS

A 10% random sample of Australian long-term concession card holders was analysed. The patients studied had commenced on either amlodipine and atorvastatin as two individual pills, or a single pill containing both amlodipine and atorvastatin (AA), with neither combined approach having been dispensed to them in the previous 6 months.

MAIN OUTCOME MEASURES

The proportions of patients failing to fill their first repeat prescription after 1 month or failing to persist with treatment at 12 months, and the median persistence time (MPT) were measured.

RESULTS

Of 4146 patients prescribed the AA single pill, 11% failed to fill the first repeat prescription and 33% had ceased treatment by 12 months (MPT, 35 months). Of 6204 patients prescribed amlodipine and atorvastatin as two pills, 23% failed to fill the first repeat prescriptions and 59% had ceased treatment by 12 months (MPT, 7 months). In a multivariate model, cessation of single-pill therapy increased by 165% if there was no prior therapy, but only increased by 48%-55% if there was no prior therapy with a calcium channel blocker or statin. MPT on the single pill was 8 months in those without prior antihypertensive therapy, but was ≥ 37 months in those with any prior antihypertensive therapy.

CONCLUSION

A single-pill combination drug is associated with superior long-term persistence compared with two-pill therapy in the management of hypertension and dyslipidaemia.

Retrospective analysis of real-world efficacy of angiotensin receptor blockers versus other classes of antihypertensive agents in blood pressure management

BACKGROUND

Efficacy of blood pressure (BP) lowering may differ between clinical trials and what is observed in clinical practice. These differences may contribute to poor BP control rates among those at risk.

OBJECTIVE

We conducted an observational study to determine the BP-lowering efficacy of angiotensin receptor blocker (ARB) versus non-ARB-based antihypertensive treatments in a large Canadian primary care database.

METHODS

We analyzed the South Western Ontario database of 170,000 adults (aged >18 years) with hypertension persisting with antihypertensive medication for ≥9 months. Routine standard of care office BP was measured using approved manual aneroid or automated devices. BP <140 mm Hg and/or <90 mm Hg ≤9 months after treatment initiation, persistence (presence of initial antihypertensive prescription at the first, second, third, and fourth year anniversary) with antihypertensive therapy, and the presence of a cardiovascular (CV) event (ie, myocardial infarction) were studied.

RESULTS

After 9 months of monotherapy, 28% (978 of 3490) of patients on ARBs achieved target BP versus 27% (839 of 3110) on angiotensin-converting enzyme inhibitors (ACEIs) (P > 0.05), 26% (265 of 1020) on calcium channel blockers (CCBs) (P > 0.05), 21% (221 of 1050) on β-blockers (P = 0.002), and 19% (276 of 1450) on diuretics (P = 0.001). Attainment rates were significantly higher with irbesartan (38%; 332 of 873) versus losartan (32%; 335 of 1047; P = 0.01), valsartan (19%; 186 of 977; P = 0.001), and candesartan (25%; 148 of 593; P = 0.001). BP goal attainment rates were significantly higher when ARB was compared with non-ARB-based dual therapy (39%; 1007 of 2584 vs 31%; 1109 of 3576; P = 0.004); irbesartan + hydrochlorothiazide (HCTZ) was significantly higher than losartan + HCTZ (36%; 500 of 1390 vs 20%; 252 of 1261; P = 0.001). For patients receiving dual or tri-therapy, 48% (667 of 1390) of patients receiving irbesartan reached target BP versus 41% to 42% for losartan (517 of 1261), valsartan (194 of 462), and candesartan (168 of 401) (P = 0.001 for each). After 4 years, persistence rates were not statistically different among ARB, CCB, and diuretic monotherapies, but appeared somewhat higher with ACEIs and β-blockers (78%, 78%, 79%, 91%, and 84%, respectively). Persistence was not significantly different between irbesartan and losartan monotherapy (76% for both; P > 0.05), but was significantly higher with irbesartan + HCTZ versus losartan + HCTZ (96% vs 73%, respectively; P = 0.001). Patients treated with ARBs reported fewer CV events than those receiving ACEIs or CCBs (4.3% vs 7.0% and 11.0%, respectively; P < 0.001). Within the ARB class, the lowest rate was with irbesartan (3.0% vs 4.6%-5.0% for other ARBs; P < 0.02).

CONCLUSIONS

In this real-world setting, hypertensive adults treated with ARBs versus β-blockers or diuretics were more likely to have evidence-based target BP recorded. In addition, patients using ARBs versus ACEIs or CCBs had fewer reports of CV events.

A review of studies of adherence with antihypertensive drugs using prescription databases

Poor adherence with antihypertensive therapies is a major factor in the low rates of blood pressure control among people with hypertension. Patient adherence is influenced by a large number of interacting factors but their exact impact is not well understood, partly because it is difficult to measure adherence. Longitudinal prescription data can be used as a measure of drug supply and are particularly useful to identify interruptions and changes of treatment. Obtaining a medicine does not ensure its use; however, it has been established that continuous collection of prescription medications is a useful marker of adherence. We found 20 studies published in the last 10 years that used large prescription databases to investigate adherence with antihypertensive therapies. These were assessed in terms of patient selection, the definition of the adherence outcome(s), and statistical modeling. There was large variation between studies, limiting their comparability. Particular methodological problems included: the failure to identify an inception cohort, which ensures baseline comparability, in four studies; the exclusion of patients who could not be followed up, which results in a selection bias, in 17 studies; failure to validate outcome definitions; and failure to model the discrete-time structure of the data in all the studies we examined. Although the data give repeated measurements on patients, none of the studies attempted to model patient-level variability. Studies of such observational data have inherent limitations, but their potential has not been fully realized in the modeling of adherence with antihypertensive drugs. Many of the studies we reviewed found high rates of nonadherence to antihypertensive therapies despite differences in populations and methods used. Adherence rates from one database ranged from 34% to 78% at 1 year. Some studies found women had better adherence than men, while others found the reverse. Novel approaches to analyzing data from such databases are required to use the information available appropriately and avoid the problems of bias.

Better compliance to antihypertensive medications reduces cardiovascular risk. J Hypertens. 2011;29:610-618. [PMID: 21157368 DOI: 10.1097/hjh.0b013e328342ca97]

OBJECTIVE

The effect of compliance with antihypertensive medications on the risk of cardiovascular outcomes in a population without a known history of cardiovascular disease has been addressed by a large population-based prospective, cohort study carried out by linking Italian administrative databases.

METHODS

The cohort of 242 594 patients aged 18 years or older, residents in the Italian Lombardy Region, who were newly treated for hypertension during 2000-2001, was followed from index prescription until 2007. During this period patients who experienced a hospitalization for coronary or cerebrovascular disease were identified (outcome). Exposure to antihypertensive drugs from index prescription until the date of hospitalization or censoring was assessed. Proportional hazards models were fitted to assess the association between persistence on and adherence with antihypertensive drug therapy and outcome. Data were adjusted for several covariates.

RESULTS

During an average follow-up of 6 years, 12 016 members of the cohort experienced the outcome. Compared with patients who experienced at least one episode of treatment discontinuation, those who continued treatment had a 37% reduced risk of cardiovascular outcomes (95% confidence interval 34-40%). Compared with patients who had very low drug coverage (proportion of days covered ≤ 25%), those at intermediate (from 51 to 75%) and high coverage (>75%) had risk reductions of 20% (16-24%) and 25% (20-29%), respectively. Similar effects were observed when coronary and cerebrovascular events were considered separately.

CONCLUSIONS

In the real life setting, fulfillment compliance with antihypertensive medications is effective in the primary prevention of cardiovascular outcomes.

Perceived information needs and non-adherence: evidence from Greek patients with hypertension

BACKGROUND

The role of information on patients' decision to non-adhere is important, yet not well explored.

OBJECTIVE

To identify differences between perceived information needs for hypertension and medication to treat it, to explore the information channels used by patients and to test what type of information is more important to adhere to medication.

DESIGN, SETTING AND PARTICIPANTS

A questionnaire study was designed and conducted by telephone in the Centre for the Treatment of Hypertension in Athens, Greece, among 743 individuals.

MAIN VARIABLES STUDIED

The main variables included perceived information needs, information channels, non-adherence to medication and socio-demographic characteristics.

MAIN OUTCOME MEASURES

Non-adherence to medication was measured using the Morisky scale.

RESULTS

Patients reported feeling better informed about hypertension (90%) than medication to treat it (80%). The doctor remains the dominant information source, while the Media and magazines on health issues were reported more frequently than the family and the pharmacist. Feeling well informed about medication for hypertension was a predictor of better adherence. Other determinants of adherence were the use of the Internet and the Media.

DISCUSSION

The results confirm the importance of patients leaving the consultation feeling well informed about their medication as this improves adherence. They also show that the use of the Internet and the Media can be beneficial for adherence.

CONCLUSIONS

Given the restricted time the doctor can usually spend with the patient, it is important to know that more emphasis on the information regarding medication is important.

Long-term use and tolerability of irbesartan for control of hypertension

In this review, we discuss the pharmacological and clinical properties of irbesartan, a noncompetitive angiotensin II receptor type 1 antagonist, successfully used for more than a decade in the treatment of essential hypertension. Irbesartan exerts its antihypertensive effect through an inhibitory effect on the pressure response to angiotensin II. Irbesartan 150-300 mg once daily confers a lasting effect over 24 hours, and its antihypertensive efficacy is further enhanced by the coadministration of hydrochlorothiazide. Additionally and partially beyond its blood pressure-lowering effect, irbesartan reduces left ventricular hypertrophy, favors right atrial remodeling in atrial fibrillation, and increases the likelihood of maintenance of sinus rhythm after cardioversion in atrial fibrillation. In addition, the renoprotective effects of irbesartan are well documented in the early and later stages of renal disease in type 2 diabetics. Furthermore, both the therapeutic effectiveness and the placebo-like side effect profile contribute to a high adherence rate to the drug. Currently, irbesartan in monotherapy or combination therapy with hydrochlorothiazide represent a rationale pharmacologic approach for arterial hypertension and early-stage and late-stage diabetic nephropathy in hypertensive type II diabetics.

Effect of self-efficacy and social support on adherence to antihypertensive drugs

STUDY OBJECTIVE

To determine the relationship between poor adherence and self-efficacy or social support after a pharmacist intervention.

DESIGN

Post-hoc analysis of data from two randomized controlled trials of physician-pharmacist collaborative interventions (6 and 9 mo, respectively) to improve blood pressure control.

SETTING

Eleven university-affiliated primary care clinics.

PATIENTS

Five hundred eighty-four patients (aged 21-85 yrs) with uncontrolled primary hypertension; 296 were in the intervention group and 288 were in the control group.

INTERVENTION

Pharmacists provided intensified hypertension management and drug adherence counseling to patients in the intervention group.

MEASUREMENTS AND MAIN RESULTS

Social support and self-efficacy questionnaires were administered at baseline and end-of-study visits. Patient adherence was monitored by using the Morisky self-reported adherence questionnaire. Self-reported adherence scores improved significantly in the control group (p=0.0053) but not in the intervention group; however, adherence at baseline in both groups was high. There were small, but significant, improvements in self-efficacy (p<0.04) and social support (p<0.05) scores in the intervention group but not the control group at the end of the study. Social support and, to a lesser extent, self-efficacy improved as a function of duration of study participation (9-mo vs 6-mo intervention), regardless of whether the patient received the intervention. Blood pressure control in both groups improved significantly at the end of the study; however, mean blood pressure was significantly lower in the intervention group (129.7/76.6 mm Hg) compared with the control group (140.8/78.9 mm Hg; p<0.0001 for systolic, p=0.032 for diastolic).

CONCLUSION

Social support and self-efficacy improved significantly in the intervention group at the end of the pharmacist intervention. Drug adherence was correlated with self-efficacy even though drug adherence did not improve significantly in the intervention group. The fact that social support and self-efficacy improved as a function of duration of study participation suggests that participation in a research study may have had a positive influence on these measures. Even though the changes in social support, self-efficacy, and drug adherence were modest, there was significantly better blood pressure control in the intervention group compared with the control group. These findings indicate that changes in drug adherence, self-efficacy, or social support probably played a minor role in the blood pressure outcomes in these studies.

Antihypertensive therapy among newly treated patients: An analysis of adherence and cost of treatment over years

OBJECTIVE

To perform a time-trend analysis of adherence and cost of antihypertensive treatment over four years.

METHODS

A population-based retrospective cohort study was conducted. We included subjects ≥18 years, and newly treated for hypertension with diuretics, beta-blockers, calcium channel blockers, angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers between 01 January 2004 and 31 December 2007. One-year adherence to antihypertensive therapy was calculated and classified as low, low-intermediate, intermediate, high-intermediate, and high. The direct cost of antihypertensive medications was evaluated.

RESULTS

We included data for a total of 105,512 patients. The number of newly treated subjects decreased from 27,334 in 2004 to 23,812 in 2007, as well as antihypertensive drug therapy cost which decreased from €2,654,166 in 2004 to €2,343,221 in 2007. On the other hand, in the same time frame, the percentage of adherent newly treated subjects increased from 22.9% to 28.0%. Compared with subjects initiated on angiotensin receptor blockers (odds ratio [OR] = 1), the risk of nonadherence was higher in those initiated on angiotensin-converting enzyme inhibitors (OR = 1.19), combination therapy (OR = 1.44), beta-blockers (OR = 1.56), calcium channel blockers (OR = 1.67), and diuretics (OR = 4.28).

CONCLUSIONS

The findings of the present study indicate that suboptimal adherence to antihypertensive medication occurs in a substantial proportion of treated patients, and improvements in treatment adherence were obtained but are still unsatisfactory.

Persistence on prostaglandin ocular hypotensive therapy: an assessment using medication possession and days covered on therapy

Background

Prior research has demonstrated that medication persistence (continued acquisition of therapy over time) is far from optimal among patients with glaucoma. The purpose of the present study was to evaluate persistence with prostaglandin analogs among glaucoma patients in the first therapy year using a modification of a previously published technique.

Methods

This retrospective analysis of medical and pharmacy claims database included treatment-naive patients dispensed bimatoprost, latanoprost, or travoprost between 1/1/04-12/31/04. "Index agent" was defined as the first agent filled; "index date" was defined as the fill date. Follow-up continued for 358 days. Persistence measures for first therapy year were: (1) whether last fill had sufficient days supply to achieve medication possession at year's end, and (2) number of days for which the index agent was available (days covered). Associations between index agent and medication possession (logistic regression) and days covered (linear regression) were evaluated. Models were adjusted for gender, age, and previous ocular hypertension diagnosis.

Results

7873 patients met inclusion criteria (bimatoprost, n = 1464; latanoprost, n = 4994; travoprost, n = 1415). Medication possession was 28% and days covered was 131 when using the unadjusted (pharmacy-reported) days supply estimates and rose to 47-48% and days covered to 228-236 days when days supply was imputed. Compared to latanoprost, odds of achieving medication possession at first year's end were 26-34% lower for bimatoprost and 34-36% lower for travoprost (p ≤ 0.001 for all comparisons). Days covered in the first year were 21-29 days lower for bimatoprost and 33-42 days lower for travoprost (p ≤ 0.001 for all comparisons). Failure to refill the index agent within the initial 90 days was a strong predictor of poor persistence.

Conclusions

Persistence with ocular prostaglandin therapy remains a problem. Latanoprost users had greater odds of achieving medication possession and had more days covered during the first therapy year.

Individuals at risk of beta-blocker discontinuation: a cohort study in 19,177 Chinese patients

PURPOSE

This cohort study evaluated the factors associated with discontinuation of antihypertensive pharmacotherapy among Chinese patients who were prescribed beta-blockers. We tested the hypothesis that patients' age, gender, socioeconomic status, clinical settings and the number of comorbidities were significantly associated with the discontinuation of beta-blockers.

METHODS

From a validated clinical database we included all adult patients 18 years or older who were prescribed a beta-blocker in any government primary care clinic in one large territory of Hong Kong during 01 January 2004-30 June 2007. We evaluated the cumulative incidence of drug discontinuation within 180 days of the prescriptions and the factors associated with discontinuation of beta-blockers by multivariable regression analysis.

RESULTS

From a total of 19,177 eligible patients (mean age = 59.1 years), 20.8% discontinued their medication. Younger patients [aged <50 years; adjusted odds ratios (aOR) 0.41-0.52 for patients aged >or=50 years; p < 0.001], female gender (aOR 0.87 for males, p = 0.001), fee-waivers (aOR 0.78 for fee-payers, p < 0.001), attendances in family medicine specialist clinics (FMSC) (aOR 1.49, p < 0.001) and staff clinics (aOR 2.32, p < 0.001), residence in more urbanized areas (aOR 0.80 for North District, p < 0.001), new visits (aOR 0.55 for follow-up visits, p < 0.001) and absence of concomitant comorbidities (aOR 0.60 for one comorbidity, p < 0.001; aOR 0.56 for two comorbidities, p = 0.002) were positively associated with drug discontinuation.

CONCLUSIONS

Patients who were prescribed beta-blockers with these associated factors should be monitored more closely for antihypertensive drug adherence.

Impact of supportive measures on drug adherence in patients with essential hypertension treated with valsartan: the randomized, open-label, parallel group study VALIDATE

OBJECTIVE

The majority of treated hypertensive patients do not achieve target blood pressure (BP) levels of less than 140/90 mmHg. One key reason is inadequate adherence with the prescribed drug regimen. Dosing regimens are either not executed as prescribed (noncompliance) or patients stop taking the medication (nonpersistence). It has been demonstrated that adherence with angiotensin receptor antagonists such as valsartan is high due to the tolerability profile of this drug class. The present study was designed to evaluate whether drug adherence could further be improved by the use of supportive measures.

DESIGN AND METHODS

Twenty-eight centers were randomized to provide pharmacological treatment with or without a set of supportive measures (e.g. structured physician-patient interaction, printed information about hypertension, reminder stickers, 24 h timer, and home BP measurement device). Two hundred and two patients with grade 1 hypertension (BP at baseline 149.8 +/- 6.2/93.9 +/- 4.4 mmHg) who were either newly diagnosed or who had not been treated for at least 1 year were included in this trial. All patients entered the 34-week treatment phase with valsartan 160 mg daily. Titration to valsartan 160 mg/hydrochlorothiazide 12.5 mg was allowed if necessary. Drug adherence was assessed by electronic monitors (Medication Event Monitoring System).

RESULTS

Patients treated with a valsartan-based therapy receiving supportive measures as compared with the standard care group demonstrated an initially higher level of adherence with a maximum absolute difference of 7.8% (P = 0.041). This difference did not persist over the observation period but faded with time. In parallel, execution of the dosing regimen (compliance) was also improved in the intervention group during the early months of treatment but this effect also disappeared by the end of the observation period. In contrast, persistence in the two groups slowly but continuously separated over time. Estimated absolute difference in persistence at the end of the 34-weeks study between the two groups was 7.6% (95.9 vs. 88.3%) reflecting a 66% lower hazard of discontinuation in the intervention group (P = 0.073). BP control improved more in patients with the supportive measures.

CONCLUSION

Drug adherence improved initially with the use of supportive measures. However, this effect faded with time mainly because of the short-lived improvement in the quality of execution (compliance) achieved. In contrast, a longer lasting effect of the chosen supportive measures on persistence could be demonstrated, which, however, at least under the conditions of the present study, did not translate into a persistent improvement of medication adherence.

Factors associated with compliance, discontinuation and switching of calcium channel blockers in 20,156 Chinese patients

BACKGROUND

Noncompliance and nonpersistence to antihypertensive drugs is a recognized worldwide problem. Calcium channel blockers (CCBs) are commonly prescribed among Chinese patients yet few studies have been conducted to study the factors associated with their compliance, discontinuation, and switching profiles.

METHODS

From clinical databases we studied 20,156 patients prescribed a CCB as their antihypertensive monotherapy from January 2004 to June 2007 in a large Territory of Hong Kong. We evaluated their compliance by medication possession ratios (MPRs), cumulative incidences of discontinuation and switching within 180 days after the prescription; and evaluated their associated factors using multivariable logistic regression analyses.

RESULTS

The crude compliance level, discontinuation and switching rates at 180 days were 85.0, 3.1, and 5.0%, respectively. Older patients (aged > or =50 years; adjusted odds ratio (aOR) 1.21-1.34, P < 0.001), female gender (aOR 0.89, 95% confidence interval (CI) 0.82-0.96 for males, P = 0.004), fee payers (aOR 1.09, 95% CI 1.00-1.20, P = 0.050), service settings in family medicine specialist clinic (FMSC) (aOR 1.64, 95% CI 1.33-2.01, P < 0.001), and follow-up visits (aOR 3.24, 95% CI 2.93-3.58, P < 0.001) were positively associated with good compliance. Younger age and new visits were significantly associated with drug discontinuation or switching.

CONCLUSIONS

Younger patients, male subjects, and new visitors were more likely to be noncompliant to CCB among ethnic Chinese. They represent the target subjects where primary care physicians should spend more effort on patient education to improve drug compliance.