Development of explicit criteria to measure adherence to hypertension guidelines

Analysing the context and characteristics of legal abortion and comprehensive post-abortion care among adolescents aged 10-14 in a network of sentinel centres in Latin America: a retrospective cross-sectional study, 2016-2020

Pregnancy-related complications are a substantial source of morbidity and mortality among adolescents in low- and middle-income countries. While the youngest adolescents (those aged 10-14) are considered to be at particularly high risk of adverse outcomes, there is little empirical data available on their sexual and reproductive health. Using a unique dataset of clinical records drawn from a regional network of sentinel centres providing legal abortion and comprehensive post-abortion care in 12 Latin American and Caribbean countries, we described the population of adolescents aged 10-14 seeking legal abortion and post-abortion care and calculated institutional rates of complications, using older adolescents (aged 15-19) and young adults (aged 20-24) as comparator groups. We also assessed the quality of care provided as compared to WHO recommendations. Nearly 17% (89 out of 533) of young adolescents sought care when they were already at 15 or more weeks' gestation. Young adolescents were at higher risk of pre-procedure and intra-operative complications than older adolescents and young adults, though the trend is less clear for the most severe complications. In general, the quality of care provided by centres in the network was aligned with WHO recommendations for safe abortion and comprehensive post-abortion care. Taken together, these findings provide insight into the challenges facing the global health community in assuring the sexual and reproductive health and rights of the youngest adolescents, and outline avenues for future research, advocacy, and evidence-based policymaking.

Blood pressure—lowering medication prescribing, its adherence to guidelines and relationship with blood pressure control at a family medicine department

Background

In many resource‐constrained countries, control of blood pressure (BP) is low. Antihypertensive drug prescribing practices may influence BP control. However, adherence of prescribing to treatment guidelines may not be optimal in resource‐constrained settings. The aim of this study was to evaluate the pattern of blood pressure‐lowering medication prescribing, and how it adheres to treatment guidelines, and to identify the relationship between medication prescriptions and BP control.

Methods

It was a cross‐sectional study of hypertensive outpatients at the Korle Bu Teaching Hospital (KBTH) Family Medicine department (FMD)/Polyclinic. Data was collected with a validated structured form. Adherence of “prescribing” to recommendations of the 2017 Standard Treatment Guidelines of Ghana and 2018 European Society of Cardiology guidelines was assessed using a composite measure. We analyzed data with SPSS.

Results

About 81% (247/304) of patients received two or more antihypertensive drugs. Most patients (41%; 267/651) received calcium channel blockers (CCB), and 21.8% (142/651), 15.7% (102/651) and 12.7% (83/651) were on diuretics, angiotensin‐receptor blockers (ARBs) and angiotensin converting enzyme (ACE) inhibitors respectively. CCB plus RAS inhibitor (50%) was the most prescribed two‐drug combination. Number of BP drugs per patient had a statistically significant inverse relationship with BP control (beta Coefficient = –0.402; 95% Cl: 1.252–2.470; p = 0.015). The composite adherence score was 0.73 (moderate adherence) but Single‐pill combination (SPC) was poor (3.2%; n = 8).

Conclusion

Most patients received multiple‐pill combination treatment, and overall adherence to guidelines was suboptimal, largely owing to complex drug therapy. Number of drugs predicted BP control. Our findings suggest a need to prioritize simplified treatment, and implement other strategies to improve hypertension guideline adherence. Further research on the influence of SPC on BP control may inform future hypertension guidelines in Ghana and elsewhere in Africa.

Concept analysis of adherence

Objective

To explore the concept of adherence in the context of rehabilitation of patients with chronic illnesses. This concept analysis is helpful in predicting health behaviors and intentions including physical activity and dietary behaviors in patients with chronic illnesses.

Methods

The framework of Walker and Avant was used to analyze the concept of adherence.

Results

Adherence is defined as the extent to which a person’s behavior, such as taking medication, following a diet, and/or executing lifestyle changes, corresponds to agreed recommendations from a health-care provider. The antecedents of adherence are the biomedical status of the individual, social support, self-efficacy, and education. Self-report questionnaires and patient self-reporting are the most common measurement tools of adherence. Thus, the reliable and valid instrument of monitoring adherence in the clinical settings is challenging.

Conclusions

Analyzing the concept of adherence is necessary to help understand how best to promote adherence to improve health-related outcomes.

Adherence of doctors to hypertension clinical guidelines in academy charity teaching hospital, Khartoum, Sudan

BACKGROUND

Clinical guidelines are systematically proven statements that help physicians to make healthcare decisions for specific medical conditions. Non-adherence to clinical guidelines is believed to contribute significantly to poor delivery of clinical care, and hence poor clinical outcomes. This study aimed at investigating adherence of doctors to hypertension clinical guidelines in Academy Charity Teaching Hospital, Khartoum, Sudan.

METHODS

A cross-sectional hospital-based study was conducted during the period from January 2017 to October 2017 on a sample of 150 doctors. Adherence of doctors to hypertension guidelines was measured through the modified JNC7 adherence tool. Descriptive statistics was used to summarize the data (mean, standard deviation, median) and analyzed by frequency tables. Chi square test used to determine association among categorized variables. Logistic regression analysis was conducted to determine the relation between adherence to hypertension guidelines and the explanatory variables. All statistical tests were considered statistically significant when p value < 0.05.

RESULTS

Of the 150 participants, 92% (138/150) were aware of the major hypertension treatment guidelines. 71% (98/138) reported the use of guidelines recommendations in their practice. Whereas 52% (78/150) were aware of local Sudanese guidelines. High adherence rate was highly statistically associated with job titles (p = 0.000), and also associated with age of the participants (p = 0.024) and duration of clinical experience (p = 0.012). However, the logistic regression analysis revealed despite all those variables were contributing to adherence to the treatment guidelines, only duration of clinical experience was statistically significant (p = 0.022).

CONCLUSION

The overall adherence of doctors to hypertension treatment guidelines was very low. This study highlights how a gap in clinical governance contributes to low adherence to clinical guidelines. Establishing regular clinical audit, issuing regulations to enforce the use of updated guidelines, along with introducing training programs in hospitals and continuous assessment to the practicing doctors are suggested as crucial interventions. Considerable efforts to build clinical governance in Sudan are required.

CPDI: An Index for measuring deviations in Clinical Pathways

Clinical Pathways (CPs) are evidence-based recommendation for treating a diagnosis and an effective instrument to decrease undesired practice variability and improve clinician performance. Deviations from CPs might just as well reduce quality of care. Moreover they can be associated to possible adverse events. In this perspective, we developed and tested a system for comparing a patient trajectory (PT) with the corresponding CP in order to recognize significant variations. To measure adherence, a Clinical Pathway Deviation Index (CPDI) was constructed as the weighted-sum of five indicators. To build the indicators three different tools for CPs modeling have been tested. Only two of them proved suitable for our system. A preliminary analysis has been carried out using data of 24 real PTs. The aim of this paper is to present the system and to characterize CPDI performances.

Online treatment compliance checking for clinical pathways

Compliance checking for clinical pathways (CPs) is getting increasing attention in health-care organizations due to stricter requirements for cost control and treatment excellence. Many compliance measures have been proposed for treatment behavior inspection in CPs. However, most of them look at aggregated data seen from an external perspective, e.g. length of stay, cost, infection rate, etc., which may provide only a posterior impression of the overall conformance with the established CPs such that in-depth and in near real time checking on the compliance of the essential/critical treatment behaviors of CPs is limited. To provide clinicians real time insights into violations of the established CP specification and support online compliance checking, this article presents a semantic rule-based CP compliance checking system. In detail, we construct a CP ontology (CPO) model to provide a formal grounding of CP compliance checking. Using the proposed CPO, domain treatment constraints are modeled into Semantic Web Rule Language (SWRL) rules to specify the underlying treatment behaviors and their quantified temporal structure in a CP. The established SWRL rules are integrated with the CP workflow such that a series of applicable compliance checking and evaluation can be reminded and recommended during the pathway execution. The proposed approach can, therefore, provides a comprehensive compliance checking service as a paralleling activity to the patient treatment journey of a CP rather than an afterthought. The proposed approach is illustrated with a case study on the unstable angina clinical pathway implemented in the Cardiology Department of a Chinese hospital. The results demonstrate that the approach, as a feasible solution to provide near real time conformance checking of CPs, not only enables clinicians to uncover non-compliant treatment behaviors, but also empowers clinicians with the capability to make informed decisions when dealing with treatment compliance violations in the pathway execution.

Physician-pharmacist co-management and 24-hour blood pressure control

The objectives of this study were to compare indices of 24-hour blood pressure (BP) following a physician-pharmacist collaborative intervention and to describe the associated changes in antihypertensive medications. This was a secondary analysis of a prospective, cluster-randomized clinical trial conducted in 6 family medicine clinics randomized to co-managed (n=3 clinics, 176 patients) or control (n=3 clinics, 198 patients) groups. Mean ambulatory systolic BP (SBP) was significantly lower in the co-managed vs the control group: daytime BP 122.8 mm Hg vs 134.4 mm Hg (P<.001); nighttime SBP 114.8 mm Hg vs 123.7 mm Hg (P<.001); and 24-hour SBP 120.4 mm Hg vs 131.8 mm Hg (P<.001), respectively. Significantly more drug changes were made in the co-managed than in the control group (2.7 vs 1.1 changes per patient, P<.001), and there was greater diuretic use in co-managed patients (79.6% vs 62.6%, P<.001). Ambulatory BPs were significantly lower for the patients who had a diuretic added during the first month compared with those who never had a diuretic added (P<.01). Physician-pharmacist co-management significantly improved ambulatory BP compared with the control group. Antihypertensive drug therapy was intensified much more for patients in the co-managed group.

Cost implications of improving blood pressure management among U.S. adults

OBJECTIVE

To examine the cost-effectiveness of improving blood pressure management from the payer perspective.

DATA SOURCE/STUDY SETTING

Medical record data for 4,500 U.S. adults with hypertension from the Community Quality Index (CQI) study (1996-2002), pharmaceutical claims from four Massachusetts health plans (2004-2006), Medicare fee schedule (2009), and published literature.

STUDY DESIGN

A probability tree depicted blood pressure management over 2 years.

DATA COLLECTION/EXTRACTION METHODS

We determined how frequently CQI study subjects received recommended care processes and attained accepted treatment goals, estimated utilization of visits and medications associated with recommended care, assigned costs based on utilization, and then modeled how hospitalization rates, costs, and goal attainment would change if all recommended care was provided.

PRINCIPAL FINDINGS

Relative to current care, improved care would cost payers U.S.$170 more per hypertensive person annually (2009 dollars). The incremental cost per person newly attaining treatment goals over 2 years would be U.S.$1,696 overall, U.S.$801 for moderate hypertension, and U.S.$850 for severe hypertension. Among people with severe hypertension, blood pressure would decline substantially but seldom reach goal; the incremental cost per person attaining a relaxed goal (≤ stage 1) would be U.S.$185.

CONCLUSIONS

Under the Health Care Effectiveness Data and Information Set program, which monitors the attainment of blood pressure treatment goals, payers will find it slightly more cost-effective to improve care for moderate than severe hypertension. Having a secondary, relaxed goal would substantially increase payers' incentive to improve care for severe hypertension.

[Quality indicators for National Disease Management Guidelines using the example of the National Disease Management Guideline for "Chronic Heart Failure"]

Together with an expert committee a structured approach to determining quality indicators for National Disease Management Guidelines has been developed. The key steps of this approach include: introducing guideline authors to the methodology at an early stage of the process of guideline development, pre-selecting recommendations of the guideline which are potentially measurable by means of quality indicators, assessing the potentially measurable quality indicators in written form using five criteria (including their importance for the health care system and clarity of definitions) and approving them in a formal consensus process. For lack of a database these quality indicators must be regarded as preliminary. For the National Disease Management Guideline "Chronic Heart Failure" nine rate-based indicators have been chosen. The indicators correspond to important strong recommendations (grade of recommendation: A) from the fields of diagnosis (two), general therapeutic strategy (two), specific treatment (three), clinical monitoring (one) and co-ordination of care (one). In a second step, the quality indicators have to be validated within a pilot project. The determination and assessment of the potential quality indicators have revealed room for improvement of guideline development. In particular, there is a need for more health care data and for specification of recommendations.

Sustained blood pressure control following discontinuation of a pharmacist intervention

Team-based care can improve hypertension control. The purpose of the present study was to evaluate blood pressure (BP) control 18 months following the discontinuation of a physician-pharmacist collaborative intervention. This was a retrospective analysis of patients who had previously participated in a prospective, cluster randomized, controlled clinical trial. Six community-based family medicine offices were randomized to control or intervention groups. Research nurses measured BPs using an automated device during the prospective trial. The research nurses then abstracted data from medical records, including BPs, medications, changes in therapy, and laboratory values for 18 months following the discontinuation of the 6-month prospective trial. The study included 228 patients in the control (n = 146) or intervention (n = 82) groups. The control group contained more patients with diabetes or chronic kidney disease (P < .013), were older (P = .047), and had more coexisting conditions (P < .001) than the intervention group. Systolic BP 9 months following discontinuation of the physician-pharmacist intervention was 137.2 ± 18.2 mm Hg and 129.8 ± 13.3 mm Hg in the control and intervention groups, respectively (P = .0015). BP control was maintained in 61 (41.8%) control patients and 55 (67.1%) intervention patients (P = .0003). At 18 months post-intervention, systolic BP was 138.1 ± 20.4 mm Hg and 130.0 ± 16.0 mm Hg in the control and intervention groups, respectively (P = .023). BP control was maintained in 53 (36.3%) control patients and 55 (67.1%) intervention patients at 18 months post-intervention (P < .0001). A sensitivity analysis was conducted to address the uneven distribution of patients with diabetes or chronic kidney disease, and the differences between groups were still significant. BP control rates remained significantly higher following a physician-pharmacist intervention compared with usual care for 18 months after discontinuation of the intervention. This model has the potential value as a useful long-term strategy to benefit patients with hypertension.

A cluster-randomized effectiveness trial of a physician-pharmacist collaborative model to improve blood pressure control

Numerous studies have demonstrated the value of team-based care to improve blood pressure (BP) control, but there is limited information on whether these models would be adopted in diverse populations. The purpose of this study was to evaluate whether a collaborative model between physicians and pharmacists can improve BP control in multiple primary care medical offices with diverse geographic and patient characteristics and whether long-term BP control can be sustained. This study is a randomized prospective trial in 27 primary care offices first stratified by the percentage of underrepresented minorities and the level of clinical pharmacy services within the office. Each office is then randomized to either a 9- or 24-month intervention or a control group. Patients will be enrolled in this study until 2012. The results of this study should provide information on whether this model can be implemented in large numbers of diverse offices, if it is effective in diverse populations, and whether BP control can be sustained long term.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00935077.

ASH position paper: Adherence and persistence with taking medication to control high blood pressure

Nonadherence and poor or no persistence in taking antihypertensive medications results in uncontrolled high blood pressure, poor clinical outcomes, and preventable health care costs. Factors associated with nonadherence are multilevel and relate not only to the patient, but also to the provider, health care system, health care organization, and community. National guideline committees have called for more aggressive approaches to implement strategies known to improve adherence and technologies known to enable changes at the systems level, including improved communication among providers and patients. Improvements in adherence and persistence are likely to be achieved by supporting patient self-management, a team approach to patient care, technology-supported office practice systems, better methods to measure adherence, and less clinical inertia. Integrating high blood pressure control into health care policies that emphasize and improve prevention and management of chronic illness remains a challenge. Four strategies are proposed: focusing on clinical outcomes; empowering informed, activated patients; developing prepared proactive practice teams; and advocating for health care policy reform. With hypertension remaining the most common reason for office visits, the time is now.

A systematic literature review: prescribing indicators related to type 2 diabetes mellitus and cardiovascular risk management

PURPOSE

Valid prescribing indicators (PI) are needed for reliable assessment of prescribing quality. The purpose of this study is to describe the validity of existing PI for type 2 diabetes mellitus and cardiovascular risk management.

METHODS

We conducted a systematic literature search for studies describing the development and assessment of relevant PIs between January 1990 and January 2009. We grouped identified PI as drug- or disease-oriented, and according to the aspects of prescribing addressed and the additional clinical information included. We reviewed the clinimetric characteristics of the different types of PI.

RESULTS

We identified 59 documents describing the clinimetrics of 16 types of PI covering relevant prescribing aspects, including first-choice treatment, safety issues, dosing, costs, sufficient and timely treatment. We identified three types of drug-oriented, and five types of disease-oriented PI with proven face and content validity as well as operational feasibility in different settings. PI focusing on treatment modifications were the only indicators that showed concurrent validity. Several solutions were proposed for dealing with case-mix and sample size problems, but their actual effect on PI scores was insufficiently assessed. Predictive validity of individual PI is not yet known.

CONCLUSION

We identified a range of existing PI that are valid for internal quality assessment as they are evidence-based, accepted by professionals, and reliable. For external use, problems of patient case-mix and sample size per PI should be better addressed. Further research is needed for selecting indicators that predict clinical outcomes.

Deterioration of blood pressure control after discontinuation of a physician-pharmacist collaborative intervention

STUDY OBJECTIVE

To assess blood pressure control after discontinuation of a physician-pharmacist collaborative intervention.

DESIGN

Comparative analysis of data of the patients who received the intervention versus a control group from a prospective, cluster-randomized, 9-month efficacy trial and the same patients' data 18 and 27 months after completion of the trial, abstracted from their medical records.

SETTING

Five primary care medical offices operated by a university health system.

PATIENTS

One hundred four patients with hypertension; 65 were in the intervention group, and 39 were in the control group.

MEASUREMENTS AND MAIN RESULTS

In the prospective study, patients were randomized to receive a physician-pharmacist collaborative intervention to improve blood pressure control or to the control group. Systolic and diastolic blood pressures were measured by a research nurse at baseline and at the end of the study (9 mo later). In the current study, data were abstracted for blood pressure and blood pressure control at 18 and 27 months (9 and 18 mo, respectively, after discontinuation of the study). At baseline, mean +/- SD systolic blood pressure was 152.5 +/- 9.5 and 150.1 +/- 9.6 mm Hg in the intervention and control groups, respectively (p=0.22). At 9 months, systolic blood pressure decreased to 124.5 +/- 10.7 and 132.0 +/- 15.1 mm Hg (p=0.0038 between groups), and blood pressure was controlled in 78.5% and 48.7% (p=0.0017) of patients in the intervention and control groups, respectively. By 18 months, systolic blood pressure had deteriorated to 131.0 +/- 12.2 and 143.3 +/- 17.5 mm Hg (p<0.001), and blood pressure control rates decreased to 53.9% and 30.8% (p=0.02). By 27 months, systolic blood pressure was 131.3 +/- 13.0 and 141.2 +/- 15.8 mm Hg (p=0.0008), and blood pressure control was 55.4% and 35.9% (p=0.05).

CONCLUSION

A sustained positive effect on blood pressure control was noted up to 18 months after discontinuation of a physician-pharmacist collaborative intervention, when compared with a control group. Blood pressure control did deteriorate at a similar rate in both the intervention and control groups, but the percentage of patients with controlled blood pressure remained significantly higher in the intervention group. These results suggest that continued interventions by pharmacists may be necessary to maintain high rates of blood pressure control, especially in those patients whose blood pressure begins to increase.

The cancer pain practice index: a measure of evidence-based practice adherence for cancer pain management in older adults in hospice care

Various clinical practice guidelines addressing pain assessment and management have been available for several years that pertain, at least to some extent, to older patients with cancer. Nonetheless, systematic evaluations or methodologically sound studies of adherence to pain management practice guidelines within Medicare-certified hospice programs are lacking. As part of a larger translating-research-into-practice pain improvement study involving older patients with cancer in hospice programs, we recognized the need to create a valid and reliable tool that can facilitate critical evaluation of hospice medical records for nurse and physician adherence to pain management guidelines to create a consolidated score for comparative and quality improvement purposes. We report the process used to create this tool, named the Cancer Pain Practice Index, and a guide to its use.

Physician and pharmacist collaboration to improve blood pressure control

BACKGROUND

Studies have demonstrated that blood pressure (BP) control can be improved when clinical pharmacists assist with patient management. The objective of this study was to evaluate if a physician and pharmacist collaborative model in community-based medical offices could improve BP control.

METHODS

This was a prospective, cluster randomized, controlled clinical trial with clinics randomized to a control group (n = 3) or to an intervention group (n = 3). The study enrolled 402 patients (mean age, 58.3 years) with uncontrolled hypertension. Clinical pharmacists made drug therapy recommendations to physicians based on national guidelines. Research nurses performed BP measurements and 24-hour BP monitoring.

RESULTS

The mean (SD) guideline adherence scores increased from 49.4 (19.3) at baseline to 53.4 (18.1) at 6 months (8.1% increase) in the control group and from 40.4 (22.6) at baseline to 62.8 (13.5) at 6 months (55.4% increase) in the intervention group (P = .09 for adjusted between-group comparison). The mean BP decreased 6.8/4.5 mm Hg in the control group and 20.7/9.7 mm Hg in the intervention group (P < .05 for between-group systolic BP comparison). The adjusted difference in systolic BP was -12.0 (95% confidence interval [CI], -24.0 to 0.0) mm Hg, while the adjusted difference in diastolic BP was -1.8 (95% CI, -11.9 to 8.3) mm Hg. The 24-hour BP levels showed similar effect sizes. Blood pressure was controlled in 29.9% of patients in the control group and in 63.9% of patients in the intervention group (adjusted odds ratio, 3.2; 95% CI, 2.0-5.1; P < .001).

CONCLUSIONS

A physician and pharmacist collaborative intervention achieved significantly better mean BP and overall BP control rates compared with a control group. Additional research should be conducted to evaluate efficient strategies to implement team-based chronic disease management.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00201019.

A computational framework to identify patients with poor adherence to blood pressure lowering medication

BACKGROUND

Blood pressure (BP) lowering medications have impressive efficacy in reducing cardiovascular and renal events; but low adherence threatens their effectiveness. Analysis of patterns in electronic prescribing from electronic medical records (EMRs) may have the potential to reveal cohorts of patients with significant adherence problems.

METHODS

We developed a computational framework to identify patient cohorts with poor adherence to long-term medication through analysis of electronic prescribing patterns. A range of quality reporting criteria can be specified (as an XML document). We illustrate the framework by application to the EMRs of a New Zealand general practice with a focus on adherence to angiotensin-converting enzyme inhibitors (ACE-inhibitors) and/or angiotensin II receptor blockers (ARBs) in patients classified with hypertension and diabetes. We analyse medication supply based on Medication Possession Ratio (MPR) and duration of lapse in ACE-inhibitors/ARBs over a 12-month evaluation period. We describe graphical tools to assist visualisation of prescribing patterns and relationship of the analysis outputs to controlled blood pressure.

RESULTS

Out of a cohort of 16,504 patient EMRs, 192 patients were found classified with both hypertension and diabetes and under active ACE-inhibitor and/or ARB management. Of these, 107 (56%) patients had an ACE-inhibitor/ARB MPR less than 80% together with a lapse in ACE-inhibitors/ARBs for greater than 30 days. We find non-adherent patients (i.e. MPR <80% or lapse >30 days) are three times more likely to have poor BP than adherent patients (odds ratio=3.055; p=0.012).

CONCLUSIONS

We have developed a generic computational framework that can be used to formulate and query criteria around issues of adherence to long-term medication based on practice EMRs. Within the context of the example we have used, the observed adherence levels indicate that a substantial proportion of patients classified with hypertension and diabetes have poor adherence, associated with poorer rates of blood pressure control, that can be detected through analysis of electronic prescribing. Further work is required to identify effective interventions using the reporting information to reduce non-adherence and improve patient outcomes.

Hypertension guideline adherence among nursing home patients

BACKGROUND

Adherence to hypertension guidelines in the outpatient setting is low.

OBJECTIVE

To evaluate adherence to JNC VII guidelines in nursing home patients.

DESIGN

Data were obtained from the 2004 National Nursing Home Survey (NNHS), a nationally representative sample of US nursing homes. Patients with hypertension were identified using ICD-9 codes. Adherence to JNC VII guidelines was defined as the use of a thiazide diuretic in patients without a compelling indication for a different class of antihypertensive medication, such as diabetes, chronic kidney disease, coronary artery disease, congestive heart failure, or a history of stroke.

PARTICIPANTS

There were 13,507 patients in the 2004 NNHS survey, of whom 7,129 had hypertension.

MAIN RESULTS

Of these 7,129 hypertensive patients, only 12.6% were on a thiazide. Out of the 7,129 hypertensive patients, 3,113 did not have diabetes, chronic kidney disease, coronary artery disease, congestive heart failure, or a history of stroke. Of these 3,113 patients, only 13.9% were on a thiazide. After excluding patients with a potential contraindication to a diuretic, such as hospice care or incontinence, only 18% were prescribed a thiazide. Of the 3,113 patients, 1,148 were on a single class of antihypertensive and more were prescribed a beta blocker, ACE inhibitor, calcium channel blocker, loop diuretic, and ARB than a thiazide diuretic.

CONCLUSIONS

Adherence to hypertension guidelines among nursing home patients is low. The appropriate use of thiazide diuretics could reduce costs and improve blood pressure control and patient outcomes.

Summative index: Acute pain management in older adults

One of the challenges in measuring adoption of complex evidence-based practices (EBPs) such as acute pain management is determining what constitutes adherence to an EBP guideline. Traditionally, individual process indicators extrapolated from an EBP guideline are selected as dependent measures of guideline adoption. When using multiple indicators, the challenge is determining the number of indicators that must be met to define adherence to the EBP guideline. The primary goal of the study reported herein was to develop and test a summative index (SI) of guideline adherence for acute pain management of hospitalized older adults. Steps in formulating the initial index are described as well as refinement of this metric. Techniques used included factor analysis, discriminate validity, and split-half reliability. The resulting SI is composed of 18 indicators each scored as 0 (not present) or 1 (present), with a total SI score of 0 to 18.

Physician adherence to blood pressure guidelines and its effect on seniors

STUDY OBJECTIVE

To compare physician adherence to guidelines from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure for patients younger than 65 years of age with those aged 65 years and older, and to analyze whether factor groupings (subsets of criteria used to determine adherence) were predictive of blood pressure control.

DESIGN

Retrospective medical record review.

SETTING

Five university-affiliated family medicine and internal medicine outpatient clinics.

PATIENTS

One hundred seventy-nine patients (age range 21-85 yrs) with uncontrolled hypertension: 105 patients were younger than 65 years (nonsenior), and 74 patients were 65 years or older (senior).

MEASUREMENTS AND MAIN RESULTS

Data abstracted from each patient's medical record were used to evaluate adherence to 17 process-of-care criteria, identified to assess physician adherence to the guidelines. A computer algorithm generated scores for each criterion as well as an overall adherence score. The relationship between the adherence score and blood pressure control was then examined. Separate factor analyses were conducted to ascertain differences in the way that the criteria were grouped. Factor scores were calculated for each patient, and the scores were evaluated in the context of blood pressure control. Guideline adherence scores were significantly higher for nonsenior patients than for senior patients (59.3% vs 56.1%, p=0.024). Blood pressure control rate was also higher, although not significantly, in nonseniors versus seniors (68.6% vs 56.8%, p=0.063). No factors in the senior group were significantly associated with blood pressure control, but one was significantly correlated in the nonsenior group (p<0.0001). It included diuretic therapy, adjusting a drug when a patient's blood pressure was uncontrolled, documentation of uncontrolled blood pressure in the medical record at the visit, documentation of the correct blood pressure goal, documentation of cardiovascular risk factors, and measurement of urine albumin level.

CONCLUSION

Overall physician adherence to blood pressure guidelines was significantly higher for the nonsenior group than for the senior group. Similarly, control of blood pressure was better in the nonsenior group. However, no significant relationship between overall adherence scores and blood pressure control was found in either group. In nonseniors, one factor grouping was significantly correlated with blood pressure control. Future studies should evaluate the process-of-care criteria to determine if and how they are related to blood pressure control in senior patients.

Validity of four indirect methods to measure adherence in primary care hypertensives

High blood pressure (HBP) is one of the most important risk factors for morbidity and mortality in the world. Non-adherence to medication is associated with the lack of control of HBP. The objective of this study was to assess the validity of four indirect methods for measuring adherence to medication to control HBP in primary health care. A random sample of 120 hypertensive patients who were undergoing treatment for at least 2 months in a primary care unit in Florianópolis (Brazil) were included in the study. The independent variables were four indirect methods to measure adherence to medication: knowledge regarding the HBP medication, the blood pressure level, attitude regarding the medication intake (Morisky-Green test) and self-reported adherence. The classification of HBP was based on criteria established by the Brazilian Ministry of Health. The gold standard used for measuring adherence was the pill count. Logistic regression was used to estimate sensitivity (highest value of 88.2% for self-report), specificity (highest value of 70.7% for HBP control), positive predictive value (highest value of 46.4% for HBP control) and negative predictive value (highest value of 79.1% for Morisky-Green test) for each of the indirect methods. No indirect method of measuring adherence had a good positive predictive value for adherence, which was best predicted by patients' age and whether they managed to control HBP. The results also revealed low treatment adherence (31.2%) and low control of HBP (37.6%). Non-adherence was mainly associated with side effects of the treatment.

Explicit and Implicit Evaluation of Physician Adherence to Hypertension Guidelines

This study evaluated physician adherence to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) hypertension guidelines in 6 community-based clinics. Explicit review of retrospective medical record data for patients with uncontrolled hypertension measured guideline adherence using 22 criteria. Mean overall guideline adherence was 53.5% and did not improve significantly over time. Random-effects models demonstrated significant associations between guideline adherence and various demographic and medical predictors, including age, minority status, comorbid conditions, and number of medications. A subsequent implicit review evaluated the degree to which nonadherence was justifiable and identified factors that might have affected adherence. Nonadherence was rated as justifiable for only 6.6% of the failed explicit criteria. In general, adherence to the JNC 7 guidelines was modest even when barriers that might have affected adherence were taken into consideration.