What are the elements of good treatment for hypertension?

The impact of pharmacy care and motivational interviewing on improving medication adherence in patients with cardiovascular diseases: A systematic review of randomised controlled trials

BACKGROUND

Cardiovascular disease (CVD) is prevalent worldwide, and for many patients, non-adherence to medication remains a problem. Motivational interviewing is a behavioural, communication strategy used as an intervention aimed to improve health outcomes.

AIMS

This systematic review sought to investigate the effect of motivational interviewing delivered as part of pharmacy care on medication adherence, and the effect this has on clinical outcomes. These included systolic and diastolic blood pressure, haemoglobin A1C, lipid profiles and cardiovascular risk scores.

METHOD

A systematic review was conducted in six databases: PubMed Central UK, Cochrane Library, CINAHL (EBSCO), PsycINFO, EMBASE and MEDLINE from the inception of motivational interviewing in 1983 to November 2020. Randomised controlled trials (RCTs) that assessed motivational interviewing as part of pharmacy care interventions were selected. The Cochrane risk of bias tool was used to assess the risk of bias for each included study. This review was registered with PROSPERO (registration number CRD42020222954).

RESULTS

A total of eight RCTs met the inclusion criteria. Five out of eight studies demonstrated medication adherence significantly improved following motivational interviewing interventions. One study showed a significant improvement for systolic blood pressure change by 7.2 mmHg (95% CI 1.6-12.8 mmHg); this reduction was observed in patients whose baseline blood pressure was above their target blood pressure. No statistically significant effect was seen across other clinical outcomes.

CONCLUSION

Motivational interviewing could be an effective behavioural strategy to enhance medication adherence in patients with CVD. Although the evidence is promising thus far, further research is required to explore the impact of motivational interviewing on clinical outcomes as well as the feasibility of implementing motivational interviewing interventions within existing pharmacy care services.

Fixed-Dose Combinations of Renin-Angiotensin System Inhibitors and Calcium Channel Blockers in the Treatment of Hypertension: A Comparison of Angiotensin Receptor Blockers and Angiotensin-Converting Enzyme Inhibitors

Fixed-dose combinations (FDCs) of different regimens are recommended in guidelines for the treatment of hypertension. However, clinical studies comparing FDCs of angiotensin receptor blocker (ARB)/calcium channel blocker (CCB) and angiotensin-converting enzyme inhibitor (ACE inhibitor)/CCB in hypertensive patients are lacking.Using a propensity score matching of 4:1 ratio, this retrospective claims database study compared 2 FDC regimens, ARB/CCB and ACE inhibitor/CCB, in treating hypertensive patients with no known atherosclerotic cardiovascular disease. All patients were followed for at least 3 years or until the development of major adverse cardiovascular events (MACEs) during the study period. In addition, the effect of medication adherence on clinical outcomes was evaluated in subgroup analysis based on different portions of days covered.There was no significant difference in MACE-free survival (hazard ratio [HR]: 1.21; 95% confidence interval [CI]: 0.98-1.50; P = 0.08) and survival free from hospitalization for heart failure (HR: 1.15; 95% CI: 082-1.61; P = 0.431), new diagnosis of chronic kidney disease (HR: 0.98; 95% CI: 071-1.36; P = 0.906), and initiation of dialysis (HR: 0.99; 95% CI: 050-1.92; P = 0.965) between the 2 study groups. The results remained the same within each subgroup of patients with different adherence statuses.ARBs in FDC regimens with CCBs in the present study were shown to be as effective as ACE inhibitors at reducing the risks of MACEs, hospitalization for heart failure, new diagnosis of chronic kidney disease, and new initiation of dialysis in hypertensive patients, regardless of the medication adherence status.

Patients' knowledge about 9 common health conditions: the DECISIONS survey

BACKGROUND

To make informed decisions, patients must have adequate knowledge of key decision-relevant facts.

OBJECTIVE

To determine adults' knowledge about information relevant to common types of medication, screening, or surgery decisions they recently made.

SETTING

National sample of US adults identified by random-digit dialing.

DESIGN

Cross-sectional survey conducted between November 2006 and May 2007.

PARTICIPANTS

A total of 2575 English-speaking adults aged 40 y or older who reported having discussed the following medical decisions with a health care provider within the previous 2 y: prescription medications for hypertension, hypercholesterolemia, or depression; screening tests for colorectal, breast, or prostate cancer; or surgeries for knee/hip replacement, cataracts, or lower back pain.

MEASUREMENTS

Participants answered knowledge questions and rated the importance of their health care provider, family/friends, and the media as sources of information.

RESULTS

Accuracy rates varied widely across questions and decision contexts. For example, patients considering cataract surgery were more likely to correctly estimate recovery time than those patients considering lower back pain or knee/hip replacement (78% v. 29% and 39%, P < 0.001). Similarly, participants were more knowledgeable of facts about colorectal cancer screening than those who were asked about breast or prostate cancer. Finally, respondents were consistently more knowledgeable on comparable questions about blood pressure medication than cholesterol medication or antidepressants. The impact of demographic characteristics and sources of information also varied substantially. For example, blacks had lower knowledge than whites about cancer screening decisions (odds ratio [OR] = 0.57; 95% confidence interval [CI] = 0.43, 0.75; P = 0.001) and medication (OR = 0.77; 95% CI = 0.60, 0.97; P = 0.03) even after we controlled for other demographic factors. The same was not true for surgical decisions.

LIMITATIONS

The questions did not measure all knowledge relevant to informed decision making, were subject to recall biases, and may have assessed numeracy more than knowledge.

CONCLUSIONS

Patient knowledge of key facts relevant to recently made medical decisions is often poor and varies systematically by decision type and patient characteristics. Improving patient knowledge about risks, benefits, and characteristics of medical procedures is essential to support informed decision making.

Race, Ethnicity, and Shared Decision Making for Hyperlipidemia and Hypertension Treatment: The DECISIONS Survey

Background

Racial/ethnic differences in shared decision making about cardiovascular risk-reduction therapy could affect health disparities.

Objective

To investigate whether patient race/ethnicity is associated with experiences discussing cardiovascular risk-reduction therapy with health care providers.

Setting

National sample of US adults identified by random-digit dialing.

Design

Cross-sectional survey conducted in November 2006 to May 2007.

Participants

Among participants in the National Survey of Medical Decisions (DECISIONS), a nationally representative sample of English-speaking US adults aged 40 and older, the authors analyzed respondents who reported discussing hyperlipidemia or hypertension medications with a health care provider in the previous 2 years.

Measurements

In multivariate linear and logistic regressions adjusting for age, gender, income, insurance status, perceived health, and current therapy, they assessed the relation between race/ethnicity (black/Hispanic v. white) and decision making: knowledge, discussion of pros and cons of therapy, discussion of patient preference, who made the final decision, preferred involvement, and confidence in the decision.

Results

Of respondents who discussed high cholesterol (N = 738) or hypertension (N = 745) medications, 88% were white, 9% black, and 4% Hispanic. Minorities had lower knowledge scores than whites for hyperlipidemia (42% v. 52%, difference –10% [95% confidence interval (CI): 15, –5], P < 0.001), but not for hypertension. For hyperlipidemia, minorities were more likely than whites to report that the health care provider made the final decision for treatment (31.7% v. 12.3% whites, difference 19.4% [95% CI: 6.9, 33.1%], P < 0.01); this was not true for hypertension.

Limitations

Possible limitations include the small percentage of minorities in the sample and potential recall bias.

Conclusions

Minorities considering hyperlipidemia therapy may be less informed about and less involved in the final decision-making process.

Treatment of hypertension in athletes: an evidence-based review

Hypertension is the most common cardiovascular condition in adults. It is also very common in athletes. When lifestyle changes fail, medications may be needed for the treatment of hypertension. When choosing a drug for antihypertensive therapy, providers should choose an agent that has favorable effects on blood pressure and minimal detrimental hemodynamic change during exercise. Evidence supports that the medications with the most favorable effects are angiotensin-converting enzyme inhibitors, calcium channel blockers, alpha-blockers, and cardiac-selective beta-blockers. The effects of diuretics are less desirable, and nonselective beta-blockers should be a last choice for hypertensive patients who are physically active.

Managing hypertension in cardiology practice according to risk profile

Cardiologists play a central role in managing hypertensive patients, although recent surveys reveal a marked discrepancy between cardiologists' appreciation of their patients' risk status and the measures taken to reduce that risk. The diagnosis and the management of hypertension, in fact, must be viewed today not in isolation, but as part of a patients' global cardiovascular (CV) risk, resulting from the concomitant presence of a variety of risk factors, organ damage (left ventricular hypertrophy, carotid or peripheral atherosclerosis, microalbuminuria or impaired glomerular filtration rate), and hypertension-related clinical conditions. The choice of timing and the intensity of antihypertensive treatment should be based on blood pressure (BP)-lowering efficacy and the propensity to favourably impact patient's individual absolute CV disease risk profile. As part of this paradigm shift in CV disease prevention strategy, cardiologists can take several key steps to help improve standards of hypertension control: (i) increase the awareness of total risk management; (ii) initiate an integrated management strategy tailored to the individual patient's global CV risk (e.g. hypertension, hypercholesterolaemia, diabetes, age, smoking and gender); (iii) use any elevation in BP as a gateway to begin total risk management and (iv) utilise combination therapies (particularly fixed-dose combinations) to achieve more rapid and persistent BP control and improve patient compliance/persistence with therapy. To help improve standards of hypertension control in the cardiology setting, this review examines the concept of treating hypertension using a global risk assessment approach and proposes effective hypertensive therapy as part of global risk management in patients typically seen in cardiology practice.

Making sense of blood pressure values in follow-up appointments for hypertension

BACKGROUND

Although there are effective ways of treating hypertension, only a minority of all hypertensive people reach target blood pressure levels. This may be a function of how patients and physicians put measured values into context when they decide if the blood pressure is well controlled or too high.

METHODOLOGY

Qualitative analysis of audio-taped follow-up appointments for hypertension between 51 outpatients and their 11 physicians. All patients came for routine follow-up appointments for hypertension. The setting was primary and a specialist outpatient care in the south of Sweden.

PRINCIPAL FINDINGS

Borderline blood pressure values led to more deliberation. Common ways of contextualising the blood pressure were by comparing it to previous values and by explaining it in terms of stress or lack of rest. The net effect of this was that the representativity and severity of the measured blood pressure value were downplayed by both patients and physicians. In some instances, physicians (but not patients) worked in the opposite direction. Patients were less actively engaged in interpreting the blood pressure values, stated their views about therapy less often, and were careful not to express views that were overly critical of the drug treatment.

CONCLUSIONS

Patients and physicians make sense of the blood pressure through a contextualisation process which tends to normalise the face values towards the reference values. The resulting (processed) value is the one acted upon. Discursive handling of the blood pressure therefore makes up an important part of the decision-making.

Impact on hypertension control of a patient-held guideline: a randomised controlled trial

BACKGROUND

Hypertension is generally poorly controlled in primary care. One possible intervention for improving control is the harnessing of patient expertise through education and encouragement to challenge their care.

AIM

To determine whether encouraging patients to manage their hypertension in an 'expert' manner, by providing them with information in a clear clinical guideline, coupled with an explicit exhortation to become involved in and to challenge their own care if appropriate, would improve their care.

DESIGN OF STUDY

Single blind randomised controlled trial of detailed guideline versus standard information.

SETTING

Single urban general practice over 1 year.

METHOD

Patient-held guideline with written explicit exhortation to challenge care when appropriate. Two hundred and ninety-four of 536 eligible patients on the practice hypertension register were recruited, all of whom were randomised into one of two groups. Two hundred and thirty-six patients completed the study.

RESULTS

PRIMARY OUTCOME

average systolic blood pressure.

SECONDARY OUTCOMES

proportion of patients with blood pressure < 150 mmHg systolic and < 90 mmHg diastolic, average cholesterol, proportion of patients prescribed statins and aspirin according to guideline, hospital anxiety and depression score. No clinically, or statistically significant differences were found between intervention and control with respect to all parameters or in anxiety and depression levels. Statin and aspirin use improved throughout the course of the study in both groups. Statin use showed a trend (P = 0.02) in favour of control.

CONCLUSION

In this study there was no clinically significant perceived benefit to patients as a result of providing them with a hypertension guideline. Patient guidelines are currently planned for many chronic illnesses. It is important to determine the utility of such interventions before scarce resources are applied to them.

Prospective cohort study of retinal vessel diameters and risk of hypertension

OBJECTIVE

To examine the relation between diameters of the retinal arterioles and 10 year incidence of hypertension.

DESIGN

Population based prospective cohort study.

SETTING

Beaver Dam eye study.

PARTICIPANTS

2451 normotensive people aged 43 to 84 years.

MAIN OUTCOME MEASURES

Diameters of retinal arterioles and venules measured from digitised photographs of the retina taken at baseline. Measurements summarised as the arteriole:venule ratio, with a lower ratio indicating smaller arteriolar diameters. Incident hypertension, defined as systolic blood pressure > or =140 mm Hg, diastolic blood pressure > or =90 mm Hg, or use of antihypertensive drugs during follow up.

RESULTS

721 participants developed hypertension over a 10 year period. Those with lower arteriole:venule ratio had a higher cumulative incidence of hypertension (incidences of 17.4%, 24.1%, 31.0%, and 45.1%, respectively, for decreasing quarters of distribution of arteriole:venule ratio). After adjustment for age and sex, participants with arteriole:venule ratios in the lowest quarter had a threefold higher risk of hypertension (odds ratio 2.95, 95% confidence interval 2.77 to 3.88) than those with ratios in the highest quarter. This association remained significant after further adjustment for baseline systolic and diastolic blood pressure and other risk factors (1.82, 1.39 to 2.40, for lowest versus highest ratio quarters).

CONCLUSIONS

Narrowed retinal arterioles are associated with long term risk of hypertension, suggesting that structural alterations of the microvasculature may be linked to the development of hypertension.

Adverse events and patients' perceptions of antihypertensive drug effectiveness

Adverse events that patients attribute to their drug treatment are generally considered to reduce adherence to medication. However, some patients interpret such symptoms as indicating drug effectiveness. If perceivedly effective drugs are more likely to be taken then adverse events may increase adherence. The extent to which patients interpret adverse events as indicating drug effectiveness is not well known. We investigated this in a cross-sectional questionnaire study of 1013 drug-treated hypertensive patients from 55 primary health-care centres and 11 internal medicine clinics in Sweden. We hypothesized that estimates of future risk of complications of hypertension made by hypertensive patients who had adverse events would be lower than estimates made by patients who did not have adverse events, and that these estimates would only differ when patients were estimating their risks in a setting where they continued taking antihypertensive drugs. Patients' risk estimates were measured with visual analogue scales and adverse events were detected by an open question. Contrary to our hypothesis, patients with adverse events (25.7%) gave higher estimates of future risk in the continuing medication setting. This association persisted in a multivariate analysis, where a number of factors related to adverse events and risk were controlled for (OR 1.76 (95% CI, 1.26-2.45), P=0.001 for the most highly correlated risk measure), but risk estimates did not differ between patients with and without adverse events in the setting of not continuing medication. Possible explanations for these findings are pre-existing differences in attitude towards drugs and level of fear of complications.

The association between protein-energy malnutrition, malaria morbidity and all-cause mortality in West African children

Both malaria and protein-energy malnutrition (PEM) are highly prevalent in young children of sub-Saharan Africa, and the association between PEM and malaria continues to be discussed controversially. We analysed the association between PEM, malaria morbidity and all-cause mortality in a cohort of 709 children aged 6-30 months in a malaria holoendemic rural area of Burkina Faso. Study children were followed over the main malaria transmission period (June-December) in 1999 through longitudinal malaria surveillance complemented by three cross-sectional clinical surveys. There was no association between PEM and malaria morbidity, but malnourished children had a more than two-fold higher risk of dying than non-malnourished children.

Inappropriate prescriptions for the aging population of the United States: an analysis of the National Ambulatory Medical Care Survey, 1997

PURPOSE

Generally, elderly patients in the United States tend to consume more prescriptions than younger adults. The purpose of the study is to examine nationwide prescription patterns for elderly patients who visited physicians' offices in 1997.

METHODS

The database of a nationwide sample survey of practicing physicians participating in the National Ambulatory Medical Care Survey, 1997 was used. Inappropriate medicines for the elderly were identified using previously published and widely accepted criteria.

RESULTS

During 1997, patients aged 65 years or older made more than 191 million visits to physicians' offices in the United States. Four or more prescriptions per visit were issued with the following frequencies: 17.7% for females; 16.4% for males; 17.0% for Whites, 22.7% for Blacks, and 6.1% for other minorities including American Asians, Indians, Eskimos, Aleuts and Pacific Islanders. The frequencies with which at least one inappropriate medication per visit was prescribed were: 10.8% for females; 8.9% for males; 10.3% for Whites; 9.7% for Blacks; and 1.9% for other minorities.

DISCUSSION

Four or more prescriptions issued per visit and inappropriate prescriptions for the elderly in the United States were evident, and may put a vulnerable aging population at risk of adverse drug events.

Community factors associated with malaria prevention by mosquito nets: an exploratory study in rural Burkina Faso

Malaria-related knowledge, attitudes and practices (KAP) were examined in a rural and partly urban multiethnic population of Kossi province in north-western Burkina Faso prior to the establishment of a local insecticide-treated bednet (ITN) programme. Various individual and group interviews were conducted, and a structured questionnaire was administered to a random sample of 210 heads of households in selected villages and the provincial capital of Nouna. Soumaya, the local illness concept closest to the biomedical term malaria, covers a broad range of recognized signs and symptoms. Aetiologically, soumaya is associated with mosquito bites but also with a number of other perceived causes. The disease entity is perceived as a major burden to the community and is usually treated by both traditional and western methods. Malaria preventive practices are restricted to limited chloroquine prophylaxis in pregnant women. Protective measures against mosquitoes are, however, widespread through the use of mosquito nets, mosquito coils, insecticide sprays and traditional repellents. Mosquito nets are mainly used during the rainy season and most of the existing nets are used by adults, particularly heads of households. Mosquito nets treated with insecticide (ITN) are known to the population through various information channels. People are willing to treat existing nets and to buy ITNs, but only if such services would be offered at reduced prices and in closer proximity to the households. These findings have practical implications for the design of ITN programmes in rural areas of sub-Saharan Africa (SSA).