Recommendations for Evaluating Compliance and Persistence With Hypertension Therapy Using Retrospective Data

Subarachnoid haemorrhage and intracranial aneurysms in Greenland in the period 2018-2021: incidence, outcome and familial disposition

Subarachnoid haemorrhages (SAH) caused by rupture of intracranial aneurysms (IA) are a severe condition. Earlier studies found a higher incidence of SAH in Greenlandic patients compared to Danish patients, with familial aggregation also higher in Greenland. However, updated data is lacking. To investigate the contemporary incidence, outcome, and familial disposition of SAH/IA in Greenlandic patients in 2018-2021. Greenlandic patients diagnosed with ruptured or unruptured IA (UIA) during 2018-2021 were included. Data was obtained from patient files, x-ray department, and discharge registry. Incidence rates were estimated as cases/100,000/year. Direct age-standardised incidence rates were calculated using WHO 2000-2025 as standards. Of 30 SAH patients, 20 (66.7%) were females, 10 (33.3%) males. Of 36 UIA patients, 27 (75.0%) were females, 9 (25.0%) males. For SAH, crude incidence was 13.4/100,000/year, age-standardised incidence was 10.8/100,000/year. Familial history was observed in 30.0% of SAH patients. 5 patients (16.7%) died before treatment, 28-day case-fatality rate (CFR) for all patients was 23.3%. Overall and age-standardised incidence rates were similar to previous studies but higher among females and compared to neighbouring countries. A high occurrence of familial history was reported. SAH remains a serious condition in Greenland, as evidenced by five fatalities before treatment was administered.

Development and Validation of a Predictive Model for Early Identification of Cognitive Impairment Risk in Community-Based Hypertensive Patients

Objective: To investigate the risk factors for the development of mild cognitive dysfunction in hypertensive patients in the community and to develop a risk prediction model. Method: The data used in this study were obtained from two sources: the China Health and Retirement Longitudinal Study (CHARLS) and the Chinese Longitudinal Healthy Longevity Survey (CLHLS). A total of 1121 participants from CHARLS were randomly allocated into a training set and a validation set, following a 70:30 ratio. Meanwhile, an additional 4016 participants from CLHLS were employed for external validation of the model. The patients in this study were divided into two groups: those with mild cognitive impairment and those without. General information, employment status, pension, health insurance, and presence of depressive symptoms were compared between the two groups. LASSO regression analysis was employed to identify the most predictive variables for the model, utilizing 14-fold cross-validation. The risk prediction model for cognitive impairment in hypertensive populations was developed using generalized linear models. The model's discriminatory power was evaluated through the area under the receiver operating characteristic (ROC) curve and calibration curves. Results: In the modeling group, eight variables such as gender, age, residence, education, alcohol use, depression, employment status, and health insurance were ultimately selected from an initial pool of 21 potential predictors to construct the risk prediction model. The area under the curve (AUC) values for the training, internal, and external validation sets were 0.777, 0.785, and 0.782, respectively. All exceeded the threshold of 0.7, suggesting that the model effectively predicts the incidence of mild cognitive dysfunction in community-based hypertensive patients. A risk prediction model was developed using a generalized linear model in conjunction with Lasso regression. The model's performance was evaluated using the area under the receiver operating characteristic (ROC) curve. Hosmer-Lemeshow test values yielded p = .346 and p = .626, both of which exceeded the 0.05 threshold. Calibration curves demonstrated a significant agreement between the nomogram model and observed outcomes, serving as an effective tool for evaluating the model's predictive performance. Discussion: The predictive model developed in this study serves as a promising and efficient tool for evaluating cognitive impairment in hypertensive patients, aiding community healthcare workers in identifying at-risk populations.

A Multi-Component Intervention to Improve Therapeutic Adherence in Uncontrolled Hypertensive Patients Within the Primary Care Level: A Before-and-After Study

INTRODUCTION

Non-adherence to medication severely affects chronic disease control.

AIM

To assess whether a multi-component intervention implemented at the public primary care level in Argentina improves adherence to antihypertensive medication and helps to reduce blood pressure (BP) levels in uncontrolled hypertensive patients.

METHODS

A before-and-after study was conducted in five public primary care clinics located in the city of Almirante Brown, Argentina. One hundred and twenty-five uncontrolled hypertensive patients received a multi-component intervention based on the Chronic Care model and the 5As strategy (Ask, Advise, Agree, Assist, and Arrange). Medication possession ratio (MPR) and BP values were assessed before and after a 6-month period.

RESULTS

The follow-up rate was 96.8%. Main baseline characteristics were as follows, male: 44.8%, mean age: 57.1 years (± 8.1), exclusive public healthcare coverage: 83.5%, primary school level or less: 68.8%, and mean systolic/diastolic BP: 157.4 (± 13.6)/97.7 (± 8.2) mmHg. After implementing the intervention, a significant increase in the proportion of adequate adherence (MPR ≥ 80%) was observed, from 16.8% at baseline to 47.2% (p < 0.001). A significant reduction of 16.4 mmHg (CI 95%: 19.6, 13.1) was observed for systolic blood pressure (SBP) and 12.0 mmHg (CI 95%: 14.2, 9.9) for diastolic blood pressure (DBP) (p < 0.001). At 6 months, 51.2% of the population achieved blood pressure control (SBP < 140 mmHg and DBP < 90 mmHg).

CONCLUSIONS

The study intervention was associated with an increased adherence rate, achieving a significant reduction in BP values and reaching BP control in more than half of the population.

PAGE-B incorporating moderate HBV DNA levels predicts risk of HCC among patients entering into HBeAg-positive chronic hepatitis B

BACKGROUND & AIMS

Recent studies reported that moderate HBV DNA levels are significantly associated with hepatocellular carcinoma (HCC) risk in hepatitis B e antigen (HBeAg)-positive, non-cirrhotic patients with chronic hepatitis B (CHB). We aimed to develop and validate a new risk score to predict HCC development using baseline moderate HBV DNA levels in patients entering into HBeAg-positive CHB from chronic infection.

METHODS

This multicenter cohort study recruited 3,585 HBeAg-positive, non-cirrhotic patients who started antiviral treatment with entecavir or tenofovir disoproxil fumarate at phase change into CHB from chronic infection in 23 tertiary university-affiliated hospitals of South Korea (2012-2020). A new HCC risk score (PAGED-B) was developed (training cohort, n = 2,367) based on multivariable Cox models. Internal validation using bootstrap sampling and external validation (validation cohort, n = 1,218) were performed.

RESULTS

Sixty (1.7%) patients developed HCC (median follow-up, 5.4 years). In the training cohort, age, gender, platelets, diabetes and moderate HBV DNA levels (5.00-7.99 log10 IU/ml) were independently associated with HCC development; the PAGED-B score (based on these five predictors) showed a time-dependent AUROC of 0.81 for the prediction of HCC development at 5 years. In the validation cohort, the AUROC of PAGED-B was 0.85, significantly higher than for other risk scores (PAGE-B, mPAGE-B, CAMD, and REAL-B). When stratified by the PAGED-B score, the HCC risk was significantly higher in high-risk patients than in low-risk patients (sub-distribution hazard ratio = 8.43 in the training and 11.59 in the validation cohorts, all p <0.001).

CONCLUSIONS

The newly established PAGED-B score may enable risk stratification for HCC at the time of transition into HBeAg-positive CHB.

IMPACT AND IMPLICATIONS

In this study, we developed and validated a new risk score to predict hepatocellular carcinoma (HCC) development in patients entering into hepatitis B e antigen (HBeAg)-positive chronic hepatitis B (CHB) from chronic infection. The newly established PAGED-B score, which included baseline moderate HBV DNA levels (5-8 log10 IU/ml), improved on the predictive performance of prior risk scores. Based on a patient's age, gender, diabetic status, platelet count, and moderate DNA levels (5-8 log10 IU/ml) at the phase change into CHB from chronic infection, the PAGED-B score represents a reliable and easily available risk score to predict HCC development during the first 5 years of antiviral treatment in HBeAg-positive patients entering into CHB. With a scoring range from 0 to 12 points, the PAGED-B score significantly differentiated the 5-year HCC risk: low <7 points and high ≥7 points.

The role of depression and antidepressant treatment in antihypertensive medication adherence and persistence: Utilising electronic health record data

Higher blood pressure levels in patients with depression may be associated with lower adherence to antihypertensive medications (AHMs). Here, we use electronic health record (EHR) data from the Estonian Biobank (EstBB) to investigate the role of lifetime depression in AHM adherence and persistence. We also explore the relationship between antidepressant initiation and intraindividual change in AHM adherence among hypertension (HTN) patients with newly diagnosed depression. Diagnosis and pharmacy refill data were obtained from the National Health Insurance database. Adherence and persistence to AHMs were determined for hypertension (HTN) patients initiating treatment between 2009 and 2017 with a three-year follow-up period. Multivariable regression was used to explore the associations between depression and AHM adherence or persistence, adjusting for sociodemographic, genetic, and health-related factors. A linear mixed-effects model was used to estimate the effect of antidepressant treatment initiation on antihypertensive medication adherence, adjusting for age and sex. We identified 20,724 individuals with newly diagnosed HTN (6294 depression cases and 14,430 controls). Depression was associated with 6% lower probability of AHM adherence (OR = 0.943, 95%CI = 0.909-0.979) and 12% lower odds of AHM persistence (OR = 0.876, 95%CI = 0.821-0.936). Adjusting for sociodemographic, genetic, and health-related factors did not significantly influence these associations. AHM adherence increased 8% six months after initiating antidepressant therapy (N = 132; β = 0.078; 95%CI = 0.025-0.131). Based on the EHR data on EstBB participants, depression is associated with lower AHM adherence and persistence. Additionally, antidepressant therapy may help improve AHM adherence in patients with depression.

Association of uncontrolled blood pressure in apparent treatment-resistant hypertension with increased risk of major adverse cardiovascular events plus

Patients with apparent treatment-resistant hypertension (aTRH) are at increased risk of end-organ damage and cardiovascular events. Little is known about the effects of blood pressure (BP) control in this population. Using a national claims database integrated with electronic medical records, the authors evaluated the relationships between uncontrolled BP (UBP; ≥130/80 mmHg) or controlled BP (CBP; <130/80 mmHg) and risk of major adverse cardiovascular events plus (MACE+; stroke, myocardial infarction, heart failure requiring hospitalization) and end-stage renal disease (ESRD) in adult patients with aTRH (taking ≥3 antihypertensive medication classes concurrently within 30 days between January 1, 2015 and June 30, 2021). MACE+ components were also evaluated separately. Multivariable regression models were used to adjust for baseline differences in demographic and clinical characteristics, and sensitivity analyses using CBP <140/90 mmHg were conducted. Patients with UBP (n = 22 333) were younger and had fewer comorbidities at baseline than those with CBP (n = 11 427). In the primary analysis, which adjusted for these baseline differences, UBP versus CBP patients were at an 8% increased risk of MACE+ (driven by a 31% increased risk of stroke) and a 53% increased risk of ESRD after 2.7 years of follow-up. Greater MACE+ (22%) and ESRD (98%) risk increases with UBP versus CBP were seen in the sensitivity analysis. These real-world data showed an association between suboptimal BP control in patients with aTRH and higher incidence of MACE+ and ESRD linked with UBP despite the use of multidrug regimens. Thus, there remains a need for improved aTRH management.

Medication holidays in osteoporosis: evidence-based recommendations from the Italian guidelines on 'Diagnosis, risk stratification, and continuity of care of fragility fractures' based on a systematic literature review

Background

Noncommunicable, chronic diseases need pharmacological interventions for long periods or even throughout life. The temporary or permanent cessation of medication for a specific period, known as a 'medication holiday,' should be planned by healthcare professionals.

Objectives

We evaluated the association between continuity (adherence or persistence) of treatment and several outcomes in patients with fragility fractures in the context of the development of the Italian Guidelines.

Design

Systematic review.

Data Sources and Methods

We systematically searched PubMed, Embase, and the Cochrane Library up to November 2020 for randomized clinical trials (RCTs) and observational studies that analyzed medication holidays in patients with fragility fracture. Three authors independently extracted data and appraised the risk of bias of the included studies. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Effect sizes were pooled in a meta-analysis using random effects models. Primary outcomes were refracture and quality of life; secondary outcomes were mortality and treatment-related adverse events.

Results

Six RCTs and nine observational studies met our inclusion criteria, ranging from very low to moderate quality. The adherence to antiosteoporotic drugs was associated with a lower risk of nonvertebral fracture [relative risk (RR) 0.42, 95% confidence interval (CI) 0.20-0.87; three studies] than nonadherence, whereas no difference was detected in the health-related quality of life. A reduction in refracture risk was observed when continuous treatment was compared to discontinuous therapy (RR 0.49, 95% CI 0.25-0.98; three studies). A lower mortality rate was detected for the adherence and persistence measures, while no significant differences were noted in gastrointestinal side effects in individuals undergoing continuous versus discontinuous treatment.

Conclusion

Our findings suggest that clinicians should promote adherence and persistence to antiosteoporotic treatment in patients with fragility fractures unless serious adverse effects occur.

Cardiovascular Outcomes and Mortality Associated With Discontinuing Statins in Older Patients Receiving Polypharmacy

IMPORTANCE

Polypharmacy is a major health concern among older adults. While deprescribing may reduce inappropriate medicine use, its effect on clinical end points remains uncertain.

OBJECTIVE

To assess the clinical implications of discontinuing the use of statins while maintaining other drugs in a cohort of older patients receiving polypharmacy.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, population-based cohort study included the 29 047 residents in the Italian Lombardy region aged 65 years or older who were receiving uninterrupted treatment with statins, blood pressure-lowering, antidiabetic, and antiplatelet agents from October 1, 2013, until January 31, 2015, with follow-up through June 30, 2018. Data were collected using the health care utilization database of Lombardy region in Italy. Data analysis was conducted from March to November 2020.

EXPOSURES

Cohort members were followed up to identify those who discontinued statins. Among this group, those who maintained other therapies during the first 6 months after statin discontinuation were 1:1 propensity score matched with patients who discontinued neither statins nor other drugs.

MAIN OUTCOME AND MEASURES

The pairs of patients discontinuing and maintaining statins were followed up from the initial discontinuation until June 30, 2018, to estimate the hazard ratios (HRs) and 95% CIs for fatal and nonfatal outcomes associated with statin discontinuation.

RESULTS

The full cohort inclued 29 047 patients exposed to polypharmacy (mean [SD] age, 76.5 [6.5] years; 18 257 [62.9%] men). Of them, 5819 (20.0%) discontinued statins while maintaining other medications, and 4010 (68.9%) of them were matched with a comparator. In the discontinuing group, the mean (SD) age was 76.5 (6.4) years, 2405 (60.0%) were men, and 506 (12.6%) had Multisource Comorbidity Scores of 4 or 5. In the maintaining group, the mean (SD) age was 76.1 (6.3) years, 2474 (61.7%) were men, and 482 (12.0%) had multisource comorbidity scores of 4 or 5. Compared with the maintaining group, patients in the discontinuing group had increased risk of hospital admissions for heart failure (HR, 1.24; 95% CI, 1.07-1.43) and any cardiovascular outcome (HR, 1.14; 95% CI, 1.03-1.26), deaths from any cause (HR, 1.15; 95% CI, 1.02-1.30), and emergency admissions for any cause (HR, 1.12; 95% CI, 1.05-1.19).

CONCLUSIONS AND RELEVANCE

In this study of patients receiving polypharmacy, discontinuing statins while maintaining other drug therapies was associated with an increase in the long-term risk of fatal and nonfatal cardiovascular outcomes.

Gender Differences in the Risk of Ischemic Heart Disease According to Healthcare Utilization and Medication Adherence among Newly Treated Korean Hypertensive Patients

We aimed to investigate gender differences in ischemic heart disease (IHD) according to healthcare utilization and medication adherence among newly treated Korean hypertensive adults. The National Sample Cohort version 2.0 of the National Health Insurance Service was used for analysis. Newly treated hypertensive patients ≥ 20 years and without IHD in 2002 were selected from a population that underwent health examination during 2003-2006. Of those patients, 11,942 men and 11,193 women were analyzed and followed up for 10 years. We determined the association between IHD and healthcare utilization and medication adherence using the Cox proportional hazards model. Hypertensive women patients had a lower risk of IHD than men patients (hazard ratio [HR] = 0.93, 95% confidence interval [CI] 0.88-1.00). The IHD risk was increased in patients who visited healthcare providers > 12 times/person-year (HR = 2.97, 95% CI 2.79-3.17), paid high out-of-pocket expense/person-year (HR = 1.55, 95% CI 1.41-1.69), and had medication nonadherence (HR = 1.67, 95% CI 1.58-1.77). However, the risk was decreased in patients who used both urban and rural areas (HR 0.75, 95% CI 0.67-0.84) and mixed types of providers (HR = 0.93, CI 0.88-0.99). The risk of IHD was significantly different between men and women only in the visiting frequency to healthcare providers (men, HR = 3.21, 95% CI 2.93-3.52; women, HR = 2.78, 95% CI 2.53-3.04, p for interaction = 0.0188). In summary, the risk of IHD was similar according to healthcare utilization and medication adherence between men and women, except visiting frequency to healthcare providers.

Association of health-related private transfers with treatment compliance of musculoskeletal disorders in the rural elderly: evidence from an underdeveloped region of China

BACKGROUND

The prevalence and economic burdens of musculoskeletal disorders (MSD) are serious in rural China. In addition to formal support, health-related private transfers (HRPTs), including adult children transfers (ACTs), as well as relatives and friends transfers (RFTs), are very common in rural China. We explored the relationship between HRPTs and MSD treatment compliance and the heterogeneity of this relationship in terms of family socioeconomic status.

METHODS

A questionnaire survey was carried out in Enshi, Hubei, China by stratified random sampling in July 15-25,2018. A total of 2679 questionnaires on the economic burden of chronic diseases were collected. We deleted two questionnaires with missing data. The data was described using the mean and proportion. The Chi-square test and one-way ANOVA was used to compare each independent variable in the three groups, and ordered probit regression was used to analyse the relationship between each factor and treatment compliance. The heterogeneity of the effect was examined by group regression analysis of the samples with or without poverty.

RESULTS

In total, 853 samples with MSD were included in the analysis. The age was 70.27 ± 6.97 (mean +/- sd) years old, and the ADL was 11.64 ± 0.12, with more respondents being female (56.15%), partnered (73.51%), primary school educated (45.96%), working (57.91%), feeling poor in health (55.69%), lived alone or with a spouse (54.75%). Respondents with both ACTs and RFTs had better treatment compliance, and this was significant only in poor populations (p < 0.05). Under the same HRPTs' condition, respondents who more compliant with MSD treatment were female (p < 0.01), had primary school education (p < 0.05), has self-reported poor (p < 0.01) and very poor (p < 0.05) health, had a high level of physical disability (p < 0.01), and were living with their children and grandchildren (p < 0.05). Respondents with more chronic diseases had poorer treatment compliance (p < 0.05).

CONCLUSIONS

Only those in poverty who both have ACTs and RFTs are likely to have better treatment compliance for MSD. Promoting a culture of filial piety and fostering harmonious interpersonal relationships, policies that focus on groups that lack social support, and general formal support are essential for sustained access to treatment for MSD.

Associations of Renin-Angiotensin System Antagonist Medication Adherence and Economic Outcomes Among Commercially Insured US Adults: A Retrospective Cohort Study

Background

Medication non‐adherence can result in considerable morbidity, mortality, and costs. The Pharmacy Quality Alliance hypertension medication adherence measure is used by US healthcare payers and providers to assess renin‐angiotensin system antagonist medication adherence. However, associations between renin‐angiotensin system antagonist adherence as calculated in quality measures, and healthcare service use and expenditure in commercial populations over a 1‐year timeframe has not been assessed.

Methods and Results

This retrospective cohort study used eligible commercially insured individuals from the Truven Health MarketScan Commercial Claims and Encounters Research Databases (2009–2015). Generalized linear models with log link and gamma distribution (expenditure) or negative binomial distribution (usage) assessed relationships between hypertension adherence (≥80% proportion of days covered) and healthcare use and expenditures (in 2015 US dollars) while adjusting for covariates (age, sex, geographic region; health plan; Deyo‐Charlson Comorbidity Index, number of chronic medications, and treatment naivety). Beta coefficients were used to compute cost ratios and rate ratios. A total of 4 842 058 subjects were eligible; of those, 3 310 360 (68%) were adherent (adherent mean age 53.3±8.0 years, 55.9% men; non‐adherent mean age 50.3±9.1 years, 53.1% men). Adherence was associated with fewer inpatient (rate ratios, 0.612; 95% CI, 0.607–0.617) and outpatient visits (rate ratios, 0.995; 95% CI, 0.994–0.997); and lower total costs (cost ratios, 0.876; 95% CI, 0.874–0.878) compared with non‐adherence. Adherence was associated with lower average per member per month total costs ($97.98) compared with non‐adherence.

Conclusions

Adherence to renin‐angiotensin system antagonists was associated with fewer outpatient and inpatient visits, and lower total costs compared with non‐adherence in a 1‐year time frame.

Balancing cardiovascular benefit and diabetogenic harm of therapy with statins: Real-world evidence from Italy

AIM

To provide information on the balance between the cardiovascular (CV) benefit and the diabetogenic harm of statin therapy in the current clinical practice.

METHODS

All the 115,939 residents (older than 50 years) in the Italian Lombardy Region newly treated with statins between 2003 and 2005, were followed from the first statin prescription until 2012 to identify those experiencing a macrovascular complication and those with at least one sign suggestive of new onset diabetes. The proportion of days of follow-up covered by statin prescriptions measured adherence with statins. Hazard ratio, and relative 95% confidence interval (CI), for the two considered outcomes associated with statin adherence, were separately estimated (proportional hazard models). Number needed to treat (NNT) and number needed to harm (NNH), i.e., number of individuals who must be treated with statins in order to prevent a macrovascular complication, or to generate a new onset diabetes, respectively, were calculated to evaluate the balance between CV benefit and diabetogenic harm of statin therapy.

RESULTS

Compared to those at very low adherence with statins, patients at high adherence showed a significant reduction of macrovascular risk (28%, 95% CI: 23%-33%) and a greater risk of developing diabetic condition (67%, 50%-86%). In the whole cohort, the NNT was 26, whereas the NNH 65. NNT was lower than NNH also in all considered strata of age, gender, clinical profile.

CONCLUSIONS

This large cohort investigation provides real-world evidence that the balance between CV benefit and diabetogenic harm of statin therapy is largely favourable to treatment benefits.

Development and evaluation of the psychometric properties of a hypertension self-care questionnaire

BACKGROUND

There are a number of tools to assess self-care in hypertension (HTN), but they do not cover all the dimensions of self-care and do not have a good reliability and validity. This study was conducted to develop and evaluate the psychometric properties of a tool for self-care assessment in HTN.

METHODS

This cross-sectional, methodological study was conducted in Isfahan, Iran. An expert panel was held to assess the qualitative face validity of the tool. The content validity ratio (CVR) and content validity index (CVI) were measured. The questionnaire was distributed among 20 patients to measure its internal reliability. After 14 days, it was re-distributed among the same patients, as a measure of external reliability. The questionnaire was completed by 203 patients with HTN and an exploratory factor analysis was performed in order to assess the construct validity of the tool.

RESULTS

The items of the self-care tool were confirmed with a CVR ≥ 0.5, Kappa ≥ 0.71, I-CVI = 0.69, and intraclass correlation coefficient (ICC) = 0.952. The factor analysis showed that the 16-item questionnaire has 5 dimensions, including follow-up [3 items; factor loadings (FL) = 0.619 to 0.869, and Cronbach's alpha (α) = 0.737], healthy lifestyle (5 items; FL = 0.709 to 0.846, α = 0.703), promoting qualifications (4 items; FL = 0.610 to 0.791, α = 0.594), medication therapy (2 items; FL = 0.699 and 0.740, α = 0.717), and following recommendations (2 items, FL = 0.577 and 0.744, α = 0.701). These 5 dimensions explained 62.686% of the variance. The Cronbach's alpha coefficient of the final self-care assessment questionnaire was 0.833.

CONCLUSION

The developed questionnaire proved to have appropriate psychometric properties for measuring self-care in patients with HTN.

Adherence in Hypertension

The global epidemic of hypertension is largely uncontrolled and hypertension remains the leading cause of noncommunicable disease deaths worldwide. Suboptimal adherence, which includes failure to initiate pharmacotherapy, to take medications as often as prescribed, and to persist on therapy long-term, is a well-recognized factor contributing to the poor control of blood pressure in hypertension. Several categories of factors including demographic, socioeconomic, concomitant medical-behavioral conditions, therapy-related, healthcare team and system-related factors, and patient factors are associated with nonadherence. Understanding the categories of factors contributing to nonadherence is useful in managing nonadherence. In patients at high risk for major adverse cardiovascular outcomes, electronic and biochemical monitoring are useful for detecting nonadherence and for improving adherence. Increasing the availability and affordability of these more precise measures of adherence represent a future opportunity to realize more of the proven benefits of evidence-based medications. In the absence of new antihypertensive drugs, it is important that healthcare providers focus their attention on how to do better with the drugs they have. This is the reason why recent guidelines have emphasize the important need to address drug adherence as a major issue in hypertension management.

Impact of number of medications and age on adherence to antihypertensive medications: A nationwide population-based study

This study tried to investigate the effects of number of medications and age on antihypertensive medication adherence in a real-world setting using a nationwide representative cohort.We obtained data from the National Health Insurance Service-National Sample Cohort (NHIS-NSC) of Korea, which is a sample of 2.2% (N = 1,048,061) of total population (N = 46,605,433). Patients aged 20 years or older (N = 150,550) who took antihypertensive medications for at least 1 year were selected. Medication possession ratio (MPR) was used for measuring adherence. The subjects were divided into 5 subgroups according to total number of medications: 1-2, 3-4, 5-6, 7-8, and 9 or more. The mean age and the mean number of medications were 60.3 ± 12.6 years and 4.1 ± 2.2, respectively. The mean MPR was 80.4 ± 23.9%, and 66.9% (N = 100,645) of total subjects were adherent (MPR ≥ 80%). The overall tendency of antihypertensive medication adherence according to the total number of medications displayed an inverted U-shape with a peak at 3-4 drugs. Adherence consistently increased as the age increased until age 69 and started to decrease from age 70. The proportion of adherent patients (MPR ≥ 80%) according to the total number of medications also showed an inverted U-shape with a peak at 3-4 drugs. When the same number of drugs was taken, the proportion of adherent patients according to age featured an inverted U- shape with a peak at 60 to 69 years. Patients taking 9 or more total drugs had the overall odds ratio (95% CI) of non-adherence (MPR < 80%) with 1.17 (1.11-1.24) compared with those taking 1 to 8 total drugs and the odds ratios in the age subgroups of 40 to 49, 50 to 59, 60 to 69 years were 1.57 (1.31-1.87), 1.21 (1.08-1.36), and 1.14 (1.04-1.25), respectively (P < .05).Association between age, total number of medications, and antihypertensive adherence displayed an inverted U-shape with a peak at 3 to 4 total medications and at age 60 to 69 years. When the total number of drugs was 9 or more, adherence decreased prominently, regardless of age.

Differential Patterns of Adherence to Opioid Therapy in Opioid Naïve and Opioid Existing Patients With Different Age Groups

Limited data are available on the adherence to opioid therapy and the influence of different patient groups on adherence. This study examined the patterns of adherence in opioid naïve and opioid existing patients with varying age and gender. This retrospective cohort study was conducted using the prescription databases in tertiary hospital settings in Malaysia from 2010 to 2016. Adult patients aged ≥18 years, receiving at least two opioid prescriptions, were included and stratified into the opioid naïve and existing patient groups. Adherence to opioid therapy was measured using the proportion of days covered (PDC), which was derived by dividing the total number of days covered with any opioids by the number of days in the follow-up period. Generalized linear modeling was used to assess factors associated with PDC. A total of 10,569 patients with 36,650 prescription episodes were included in the study. Of these, 91.7% (n = 9,696) were opioid naïve patients and 8.3% (n = 873) were opioid existing patients. The median PDC was 35.5% (interquartile range (IQR) 10.3–78.7%) and 26.8% (IQR 8.8–69.5%) for opioid naïve and opioid existing patients, respectively. A higher opioid daily dose (coefficient 0.010, confidence interval (CI) 0.009, 0.012 p < 0.0001) and increasing age (coefficient 0.002, CI 0.001, 0.003 p < 0.0001) were associated with higher levels of PDC, while lower PDC values were associated with male subjects (coefficient −0.0041, CI −0.072, −0.010 p = 0.009) and existing opioid patients (coefficient −0.134, CI −0.191, −0.077 p < 0.0001). The suboptimal adherence to opioid medications was commonly observed among patients with non-cancer pain, and the opioid existing patients were less adherent compared to opioid naïve patients. Increasing age and a higher daily opioid dose were factors associated with higher levels of adherence, while male and opioid existing patients were potential determinants for lower levels of adherence to opioid medications.

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.

Effectiveness of two-drug therapy versus monotherapy as initial regimen in hypertension: A propensity score-matched cohort study in the UK Clinical Practice Research Datalink

Purpose

To compare the effectiveness on blood pressure (BP) of initial two‐drug therapy versus monotherapy in hypertensive patients.

Methods

Using the Clinical Practice Research Datalink, linked with Hospital Episode Statistics and Office for National Statistics, we identified a cohort of adults with uncontrolled hypertension, initiating one or two antihypertensive drug classes between 2006 and 2014. New users of two drugs and monotherapy were matched 1:2 by propensity score. Main exposure was “as‐treated,” ie, until first regimen change. Primary and secondary endpoints were systolic and diastolic BP control and major adverse cardiovascular event (MACE), respectively. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated using Cox proportional hazard models.

Results

Of 54 523 eligible patients, 3256 (6.0%) were initiated to a two‐drug combination. Of these, 2807 were matched to 5614 monotherapy users. Mean exposure duration was 12.7 months, with 76.5% patients changing their initial regimen. Two‐drug therapy was associated with a clinically significant BP control increase in all hypertensive patients (HR = 1.17 [95%CI: 1.09‐1.26]), more so in patients with grade 2‐3 hypertension (HR = 1.28 [1.17‐1.41]). An increase of 27% in BP control (HR = 1.27 [1.08‐1.49]) was observed in patients initiating an ACEi+CCB combination compared with initiators of either single class. No significant association was found between two‐drug therapy and MACE. Several sensitivity analyses confirmed the main findings.

Conclusions

Few patients initiated therapy with two drugs, reflecting UK guidelines' recommendation to start with monotherapy. This study supports the greater effectiveness of two‐drug therapy as the initial regimen for BP control.

Combined Effect of Income and Medication Adherence on Mortality in Newly Treated Hypertension: Nationwide Study of 16 Million Person-Years

Background Low socioeconomic status and poor medication adherence are known to be associated with increased morbidity and mortality among patients with hypertension, but their combined effects have not been studied. We therefore evaluated the joint association of household income and medication adherence with death and cardiovascular disease in patients newly treated for hypertension. Methods and Results This was a nationwide cohort study using the Korean National Health Insurance database. We included 1 651 564 individuals, aged 30 to 80 years, with newly treated hypertension and no prior cardiovascular disease and followed them for 10 years. Main exposures were household income in quintiles and adherence to antihypertensive medication, estimated by medication possession ratio: good (≥0.8), moderate (0.5 to <0.8), or poor (<0.5). The primary outcomes were all-cause and cardiovascular deaths. Higher mortality risk was observed in patients with low income (adjusted hazard ratio=1.50, 99% CI=1.46-1.53; lowest versus highest quintile) and poor medication adherence (adjusted hazard ratio=1.66, 99% CI=1.63-1.68; poor versus good adherence). When compared with the highest-income and good-adherence group, adjusted hazard ratio (99% CI) of death was 1.56 (1.52-1.61) for highest-income poor-adherers, 1.46 (1.41-1.51) for lowest-income good-adherers, and 2.46 (2.38-2.54) for lowest-income poor-adherers (P for interaction <0.001). Conclusions Low socioeconomic status and poor adherence to antihypertensive medication are associated with increased mortality and cardiovascular disease risks, but patients with low income are subject to larger excess risks by nonadherence. This highlights the potential importance of promoting medication adherence for risk reduction, especially in low-income patients with hypertension.

Effects of combination drugs on antihypertensive medication adherence in a real-world setting: a Korean Nationwide Study

OBJECTIVES

We tried to clarify, by using representative national data in a real-world setting, whether single-pill combinations (SPCs) of antihypertensives actually improve medication adherence.

DESIGN

A nationwide population-based study.

SETTING

We used a 2.2% cohort (n=1 048 061) of the total population (n=46 605 433) that was randomly extracted by National Health Insurance of Korea from 2008 to 2013.

PARTICIPANTS

We included patients (n=116 677) who were prescribed with the same antihypertensive drugs for at least 1 year and divided them into groups of angiotensin II receptor blocker (ARB)-only, calcium channel blocker (CCB)-only, multiple-pill combinations (MPCs) and SPCs of ARB/CCB.

PRIMARY OUTCOME MEASURES

Medication possession ratio (MPR), a frequently used indirect measurement method of medication adherence.

RESULTS

Adjusted MPR was higher in combination therapy (89.7% in SPC, 87.2% in MPC) than monotherapy (81.6% in ARB, 79.7% in CCB), and MPR of SPC (89.7%, 95% CI 89.3 to 90.0) was higher than MPR of MPC (87.2%, 95% CI 86.7 to 87.7) (p<0.05). In subgroup analysis, adherence of SPC and MPC was 92.3% (95% CI 91.5 to 93.0) vs 88.1% (95% CI 87.1 to 89.0) in those aged 65-74 years and 89.3% (95% CI 88.0 to 90.7) vs 84.8% (95% CI 83.3 to 92.0) in those ≥75 years (p<0.05). According to total pill numbers, adherence of SPC and MPC was 90.9% (CI 89.8 to 92.0) vs 85.3% (95% CI 84.1 to 86.5) in seven to eight pills and 91.2% (95% CI 89.3 to 93.1) vs 82.5% (95% CI 80.6 to 84.4) in nine or more (p<0.05). The adherence difference between SPC and MPC started to increase at five to six pills and at age 50-64 years (p<0.05). When analysed according to elderly status, the adherence difference started to increase at three to four pills in the elderly (≥65 years) and at five to six in the non-elderly group (20-64 years) (p<0.05). These differences all widened further with increasing age and the total medications.

CONCLUSION

SPC regimens demonstrated higher adherence than MPC, and this tendency is more pronounced with increasing age and the total number of medications.

Post-diagnosis use of antihypertensive medications and the risk of death from ovarian cancer

OBJECTIVE

To examine associations between post-diagnosis use of antihypertensive (AH) medications including thiazide diuretics (TDs), angiotensin converting enzyme inhibitors (ACEIs), beta blockers (BBs) [both non-selective (NSBBs) and selective (SBBs)] and calcium channel blockers (CCBs) and ovarian cancer-specific survival.

METHODS

This cohort study used SEER-Medicare data on 2195 women 66+ years of age who were diagnosed with ovarian cancer during 2007-2012 and who survived for at least 12 months. Use of an AH class was defined as two or more fills during the year after diagnosis. Ovarian cancer-specific death was assessed starting one year after diagnosis and continued through the end of 2013. Associations between AH use and ovarian cancer-specific mortality were assessed using Cox proportional hazard models, comparing users of a given class of AH to non-AH users.

RESULTS

Overall, 718 (33%), 690 (31%), 521 (24%), 154 (7%) of women used a TD, ACEI, BB, or CCB, respectively, with some women (48%) using more than one class of drug. Ovarian cancer-specific mortality was found to be lower among women who used an ACEI (adjusted hazard ratio [aHR] 0.76, 95% confidence interval [CI] 0.63-0.92), a TD (aHR 0.82, 95%CI 0.68-0.99), or a NSBB (aHR 0.60, 95%CI 0.43-0.83), but no such association was seen in women who took a SBB or CCB.

CONCLUSION

We observed that women who took certain forms of an AH medication during the year following a diagnosis of ovarian cancer were thereafter at a relatively reduced risk of dying from their disease. However, the potential for residual confounding by disease severity argues for a cautious interpretation.

The association between pharmacy refill-adherence metrics and healthcare utilisation: a prospective cohort study of older hypertensive adults

AIMS

Methods that enable targeting and tailoring of adherence interventions may facilitate implementation in clinical settings. We aimed to determine whether community pharmacy refill-adherence metrics are useful to identify patients at higher risk of healthcare utilisation due to low antihypertensive adherence, who may benefit from an adherence intervention.

METHODS

We conducted a prospective cohort study, recruiting participants (n = 905) from 106 community pharmacies across the Republic of Ireland. Participants completed a structured interview at baseline and 12 months. Antihypertensive medication adherence was evaluated from linked pharmacy records using group-based trajectory modelling (GBTM) and proportion of days covered (PDC). Healthcare utilisation included self-reported number of hospital visits (emergency department visits and inpatient admissions) and general practitioner (GP) visits, over a 6-month period. Separate regression models were used to estimate the association between adherence and number of hospital/GP visits. The relative statistical fit of each model using different adherence metrics was determined using the Bayesian information criterion (BIC).

RESULTS

For the number of hospital visits, significant associations were observed only for PDC but not for GBTM. Each 10% increase in refill-adherence by PDC was significantly associated with a 16% lower rate of hospital visits (adjusted incidence rate ratio 0.84, 95% CI 0.72-0.98, P = 0.036). Poorer adherence using both measures was associated with higher GP visits. Improvements in BIC favoured models using PDC.

CONCLUSIONS

Medication refill-adherence, measured using PDC in community pharmacy settings, could be used to recognise poor antihypertensive adherence to enable effective targeting of clinical interventions to improve hypertension management and outcomes.

Improved adherence and growth outcomes with jet-delivered growth hormone

Background We previously reported improved persistence and adherence to daily recombinant growth hormone (rGH) in children using jet transjection delivery compared to using needle-based devices. This study examines the relationship between improved adherence and medium-term growth outcomes in children receiving jet-delivered rGH (JrGH) at a single centre. Methods This was a retrospective longitudinal follow-up study of children (<16 years) treated with daily JrGH (somatropin; Ferring Pharmaceuticals) in the form of Zomacton® with the Zomajet® device. Delivery schedules of home distribution services were utilised to calculate adherence, quantified as the proportion of days covered (PDC) index (PDC > 0.8 adherent, PDC ≤ 0.8 less adherent). Demography, patient history, height standard deviation scores (HTSDS) and difference from mid-parental height SDS (MPHSDS - HTSDS) were extracted from hospital records for up to 3 years of treatment. Results Of 75 patients eligible for JrGH, 52 had PDC treatment and height data for at least 1 year and 22 for 3 years. A greater proportion of patients were classified as adherent in both 1- and 3-year treated cohorts (adherent 30 [57.7%] and 14 [63.6%], less adherent 22 [42.3%] and 8 [36.4%]). After 1 year of JrGH treatment, HTSDS was not significantly different in either adherence group. After 3 years, only adherent patients demonstrated sustained year-on-year increments in HTSDS and significant improvement in target HTSDS positions (by 1.32 SDS) compared to baseline (p = 0.0008). MPHSDS - HTSDS showed a similar significant improvement at 3 years in adherent patients only (p = 0.0043). Conclusions Patients adherent to JrGH demonstrate significant growth improvement compared to baseline over 3 years.

The Association Between Medication Adherence for Chronic Conditions and Digital Health Activity Tracking: Retrospective Analysis

Background

Chronic diseases have a widespread impact on health outcomes and costs in the United States. Heart disease and diabetes are among the biggest cost burdens on the health care system. Adherence to medication is associated with better health outcomes and lower total health care costs for individuals with these conditions, but the relationship between medication adherence and health activity behavior has not been explored extensively.

Objective

The aim of this study was to examine the relationship between medication adherence and health behaviors among a large population of insured individuals with hypertension, diabetes, and dyslipidemia.

Methods

We conducted a retrospective analysis of health status, behaviors, and medication adherence from medical and pharmacy claims and health behavior data. Adherence was measured in terms of proportion of days covered (PDC), calculated from pharmacy claims using both a fixed and variable denominator methodology. Individuals were considered adherent if their PDC was at least 0.80. We used step counts, sleep, weight, and food log data that were transmitted through devices that individuals linked. We computed metrics on the frequency of tracking and the extent to which individuals engaged in each tracking activity. Finally, we used logistic regression to model the relationship between adherent status and the activity-tracking metrics, including age and sex as fixed effects.

Results

We identified 117,765 cases with diabetes, 317,340 with dyslipidemia, and 673,428 with hypertension between January 1, 2015 and June 1, 2016 in available data sources. Average fixed and variable PDC for all individuals ranged from 0.673 to 0.917 for diabetes, 0.756 to 0.921 for dyslipidemia, and 0.756 to 0.929 for hypertension. A subgroup of 8553 cases also had health behavior data (eg, activity-tracker data). On the basis of these data, individuals who tracked steps, sleep, weight, or diet were significantly more likely to be adherent to medication than those who did not track any activities in both the fixed methodology (odds ratio, OR 1.33, 95% CI 1.29-1.36) and variable methodology (OR 1.37, 95% CI 1.32-1.43), with age and sex as fixed effects. Furthermore, there was a positive association between frequency of activity tracking and medication adherence. In the logistic regression model, increasing the adjusted tracking ratio by 0.5 increased the fixed adherent status OR by a factor of 1.11 (95% CI 1.06-1.16). Finally, we found a positive association between number of steps and adherent status when controlling for age and sex.

Conclusions

Adopters of digital health activity trackers tend to be more adherent to hypertension, diabetes, and dyslipidemia medications, and adherence increases with tracking frequency. This suggests that there may be value in examining new ways to further promote medication adherence through programs that incentivize health tracking and leveraging insights derived from connected devices to improve health outcomes.

Temporal and Geospatial Trends of Hypertension Management in Korea: a Nationwide Study 2002-2016

Background and Objectives

Geographic distribution of hypertension management in Korea has never been reported. We investigated temporal and regional trends of hypertension management in Korea.

Methods

For each calendar year from 2002 to 2016, we identified 2,423,245 to 7,549,989 persons aged ≥30 years treated for hypertension (total 80,564,109 cases). We calculated yearly age-sex standardized rates for medication adherence, combination therapy, blood test, and urine test according to geographic regions. We then used multivariate logistic regression to calculate odds ratios for hypertension management adjusted for individual-level sociodemographic factors.

Results

Adherence rates have markedly increased from 24.4% (2002) to 71.6% (2016) nationwide. Regional difference was prominent in 2002 (highest, 31.7% in Seoul; lowest, 14.4% in Jeonbuk), but has become less noticeable over 15 years (highest, 73.1% in Daejeon; lowest, 69.0% in Jeonnam, 2016). Combination therapy rates increased from 42.8% (2002) to 61.0% (2011), but are in decreasing trend after 2011. Blood test rates were 58.8% in 2016, whereas urine test rates have been stagnant below 50% across all regions. Geographic variations of combination therapy and complication screening rates were not profound. Results from multivariable logistic regression, adjusted for age and sex, were in agreement with trends observed by standardized rates. The odds ratios remained unchanged when the models were further adjusted for employment status and household income.

Conclusions

Regional difference in hypertension management was evident in the past, but has become less apparent over the last 15 years in Korea.

Efficacy of a fixed dose combination of irbesartan and atorvastatin (Rovelito®) in Korean adults with hypertension and hypercholesterolemia

Purpose

Coexistence of hypertension (HTN) and hypercholesterolemia is a major synergistic and modifiable risk factor for cardiovascular disease (CVD). Thus, a fixed-dose combination (FDC) of anti-HTN drugs and statins may be useful for treating CVD. This study evaluated the efficacy of an FDC of irbesartan and atorvastatin (Rovelito^®) in Korean patients.

Patients and methods

Patients with HTN and hypercholesterolemia were screened for this prospective, observational, descriptive, multi-center, phase IV study. Eligible patients were administered with Rovelito for 3 months. Dose adjustment was allowed based on the physician’s discretion. Blood pressure (BP) goal was <140/90 mmHg, and blood lipid goal was based on Adult Treatment Panel III. Compliance with therapeutic lifestyle modification and safety of the study drugs were evaluated.

Results

Of the 2,777 patients enrolled in this study, 931 were analyzed for clinical efficacy. BP and low-density lipoprotein cholesterol (LDL-C) goals were achieved in 801 (86.04%) and 797 (85.61%) patients, respectively. For the BP goal, higher baseline BP and higher body mass index were risk factors for treatment failure. For LDL-C goal, baseline LDL-C level, number of concomitant drugs, smoking status, and alcohol consumption were risk factors for treatment failure. Of the 931 participants, 694 (74.54%) achieved the treatment goals for both BP and LDL-C. Smoking status, alcohol consumption, number of concomitant drugs, and higher baseline LDL-C and BP levels were risk factors for treatment failure in both BP and LDL-C goals. Adherence with Rovelito was 97.90%±5.79%, and incidence of adverse events was 4.19% (116).

Conclusion

FDC of irbesartan and atorvastatin (Rovelito) could be extremely helpful in treating patients with both HTN and hypercholesterolemia. Poor metabolic profiles were risk factors for poor treatment response and the reason for choosing Rovelito. Therapeutic lifestyle modification should still be underscored despite the 75% treatment success rate with Rovelito for both conditions.

Adherence to osteoporosis therapy after an upper extremity fracture: a pre-specified substudy of the C-STOP randomized controlled trial

Despite their proven efficacy for secondary fracture prevention, long-term adherence with oral bisphosphonates is poor.

INTRODUCTION

To compare the effectiveness of two interventions on long-term oral bisphosphonate adherence after an upper extremity fragility fracture.

METHODS

Community-dwelling participants 50 years or older with upper extremity fragility fractures not previously treated with bisphosphonates were randomized to either a multi-faceted patient and physician educational intervention (the active control arm) vs. a nurse-led case manager (the study arm). Primary outcome was adherence (taking > 80% of prescribed doses) with prescribed oral bisphosphonates at 12 months postfracture between groups; secondary outcomes included rates of primary non-adherence and 24-month adherence. We also compared quality of life between adherent and non-adherent patients.

RESULTS

By 12 months, adherence with the initially prescribed bisphosphonate was similar (p = 0.96) in both groups: 38/48 (79.2%) in the educational intervention group vs. 66/83 (79.5%) in the case manager arm. By 24 months, adherence rates were 67% (32/48) in the educational intervention group vs. 53% (43/81) in case managed patients (p = 0.13). Primary non-adherence was 6% (11 patients) in the educational intervention group and 12% (21 patients) in the case managed group (p = 0.07). Prior family history of osteoporosis (aOR 2.1, 95% CI 1.0 to 4.4) and being satisfied with current medical care (aOR 2.3, 95% CI 1.1 to 4.8) were associated with better adherence while lower income (aOR 0.2, 95% CI 0.1 to 0.6, for patients with income < $30,000 per annum) was associated with poorer rates of adherence. There were no differences in health-related quality of life scores at baseline or during follow-up between patients who were adherent and those who were not.

CONCLUSION

While both interventions achieved higher oral bisphosphonate adherence compared to previously reported adherence rates in the general population, primary non-adherence and long-term adherence to bisphosphonates were similar in both arms. Adherence was influenced by family history of osteoporosis, satisfaction with current medical care, and income.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT01401556.

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.

Adherence to treatment of hypertension, hypercholesterolaemia and diabetes in an elderly population of a Spanish cohort

BACKGROUND AND OBJECTIVE

Sub-optimal adherence to treatment in the general population has been highlighted in several studies, especially in the elderly and/or chronic patients. This study aims to describe the adherence to treatment of diabetes mellitus, dyslipidaemia and hypertension, and to identify the factors that influence adherence.

MATERIAL AND METHOD

Retrospective, cross-sectional observational study on 16,208 patients aged ≥65 years from the EpiChron Cohort who initiated monotherapy treatment of an antidiabetic, a lipid-lowering or an antihypertensive medication in 2010. Adherence was measured by calculating the medication possession ratio during one year, considering those cases with medication possession ratio ≥80% to be adherent. We performed a descriptive study, and a logistic regression model was used to identify the predictors of low adherence.

RESULTS

Adherence to antidiabetics, antihypertensive and lipid-lowering drugs was 72.4%, 50.7% and 44.3%, respectively. An increase in adherence of 3-8% was observed for each additional chronic disease suffered by the patient. The presence of mental illness did not affect adherence, and sex, age and number of prescribed drugs did not present consistent effects.

CONCLUSION

The results obtained show a sub-optimal adherence to treatment for the 3chronic diseases studied. Adherence increased with the number of chronic diseases, while sex, age and number of drugs did not show a consistent effect. It is necessary to investigate if there are other factors that may influence therapeutic adherence, since improving adherence may have a greater impact on health than any progress in therapies.

Impact of financial burden, resulting from prescription co-payments, on antihypertensive medication adherence in an older publically insured population

Introduction

Medication co-payments represent a financial barrier to antihypertensive medication adherence. The introduction of co-payments for Irish publically insured patients was associated with a 5% reduction in adherence. However there is socioeconomic variability within this population, and the impact may be greater for those on lower income. We evaluated medication-related financial burden of the co-payment in a cohort of Irish publically insured antihypertensive users and tested its association with adherence at 12 months.

Methods

This was a prospective cohort study of community dwelling older (> 65 yrs) adults (n = 1152) from 106 Irish community pharmacies. Participants completed a structured telephone interview at baseline, and a follow-up interview at 12-months, which we linked to pharmacy records. We assessed medication-related financial burden at baseline using a single questionnaire item, and adherence at 12 months via questionnaire and refill-adherence as Proportion of Days Covered (PDC).

Results

A third of participants (30.1%) reported financial burden due to medication costs. In adjusted linear regression models financially burdened participants had significantly lower self-reported adherence (β = − 0.29, 95% CI -0.48 to − 0.11), although this was not evident with PDC (β = − 2.76, 95% CI -5.65 to 0.14).

Conclusion

This co-payment represents a financial barrier to antihypertensive adherence for many older Irish publically insured patients. The negative impact to adherence will potentially increase the risk of adverse outcomes, such as stroke, and increase long-term healthcare costs.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6209-8) contains supplementary material, which is available to authorized users.

Long-term cost comparison between surgical and medical therapy for benign prostatic hyperplasia: a study using hospital billing data

OBJECTIVES

To analyse actual long-term medical treatment of benign prostatic hyperplasia (BPH) and compare the incurred cost with that of patients with BPH who underwent early surgery.

PATIENTS AND METHODS

Patients who were first diagnosed with BPH from 1 January 2008 to 31 December 2010 were identified using the Clinical Data Warehouse. Hospital billing data generated by the electronic hospital management system were collected until December 2015. For outpatient care, only procedures, materials and drugs directly related to the management of BPH were selected for the analysis. For inpatient care, all procedures, materials and drugs ordered on dates with continuity with BPH surgery date were included. The primary endpoint of the study was the total treatment-related direct costs of patients undergoing a long-term curative medical therapy for BPH (Group 1), which was arbitrarily defined as any medical therapy including a 5α-reductase inhibitor with a minimum medication possession ratio of 0.5 during ≥5 consecutive years, or ≥1 year until BPH surgery due to medical therapy failure. In all, 70 patients who underwent BPH surgery at <1 year of initial visit served as controls (Group 2).

RESULTS

Amongst 137 patients in the Group 1, four patients underwent BPH surgery at a median of 57.8 months after the initial visit (2.9%). At a median follow-up of 76 months, the mean total treatment cost was significantly higher in Group 1 than in Group 2 ($3987 vs $3036 [USA dollars], P < 0.001). Similarly, the mean 'out-of-pocket' cost was significantly higher in Group 1 than in Group 2 ($1742 vs $1436, P = 0.005). When a linear increment of annual BPH treatment cost is assumed for Group 1 and all costs are assumed to be produced within the first year for Group 2, the total and out-of-pocket costs became equal at the end of the fifth year of medical treatment. For both total and out-of-pocket costs, medication-related costs occupied the largest proportion, exceeding half of the costs.

CONCLUSIONS

We suggest patient counselling at the beginning of BPH treatment should include the likelihood that the cumulative out-of-pocket cost at 5 years of continuous medication will exceed that of early surgery. Our cost study using hospital billing data extractable from the electronic hospital management system may be a good model for cost studies that could provide valuable information to health providers and payers.

Pharmacological therapy and blood pressure control in primary health care sites in China: data from 254,848 hypertensive patients

Background

Studies on pharmacological therapy and blood pressure (BP) control in primary health care sites of China are limited. We aimed to investigate drug use and compliance as well as compare BP control between pharmacological therapies for lowering BP in hypertensive population serviced by these sites.

Methods

This is a 1-year cohort study using electronic health care records from the National Primary Public Health Services of China. For patients with antihypertensive drugs at the first follow-up, we defined compliance with treatment as a continued treatment with the same specified class of agents at next three follow-ups. In those with compliance, BP control was defined as systolic BP <140 mmHg and diastolic BP <90 mmHg in four follow-ups within 1 year.

Results

Primary health care sites of four areas managed 254,848 hypertensive patients aged ≥35 years. At the first follow-up, 50.2% of the patients took medicines for lowering BP. In those, calcium channel antagonist monotherapy was the most common medicine in urban areas (57.1% vs 15.6% in rural areas, P<0.001); however, the most common one was single-pill combinations including diuretics and non-first-line drugs in rural areas (34.4% vs 10.7% in urban areas, P<0.001). Compliance was 79.9% and 53.2% for single- and multiple-pill combinations in first-line drugs; this rate was 69.5% and 45.0% in regimens combined with non-first-line drugs, respectively. Compared with calcium channel antagonists, diuretics monotherapy increased the overall BP control by 11% (risk ratio, 1.11; 95% confidence interval, 1.08 to 1.13), but it was used in few patients (3.3%); first-line multiple-pill combinations significantly decreased BP control by 20% to 28% in three less urbanized areas, but a similar BP control was achieved in the highly urbanized area.

Conclusion

Our study indicated that drug use such as diuretics could be strengthened in primary health care sites and combined therapy may be improved particularly in less urbanized areas.

Adherence to Antidepressants and Mortality in Elderly Patients with Cardiovascular Disease

BACKGROUND AND OBJECTIVE: Conflicting findings from studies evaluating the association between use of antidepressant drugs and mortality have been reported. We tested the hypothesis that better adherence to antidepressant therapy may reduce mortality.

METHODS

The cohort included 29,845 individuals aged ≥ 65 years from several Italian health units who were newly treated with antidepressant drugs after hospital discharge with a diagnosis for cardiovascular disease during 2008-2010. These individuals were observed from the first prescription until the end of data availability (i.e. 2012-2014, depending on the local database). During this period, information on (1) prescription of antidepressants and other medications and (2) death from any cause (outcome) was recorded. Proportional hazards models were fitted to estimate the association between better adherence to antidepressants (defined as proportion of days covered ≥ 75%) and outcome, by adjusting and stratifying for several covariates.

RESULTS

Patients with better adherence to antidepressants had a reduced mortality of 9% (95% CI 3-14). Patients who did not use other medicaments during follow-up had reduced mortality associated with better adherence to antidepressants of 21% (- 1-38), 14% (7-20), 20% (13-26) and 13% (7-19) for no users of antihypertensive agents, lipid-lowering agents, other cardiovascular drugs and antidiabetics, respectively.

CONCLUSIONS

Better adherence to antidepressants is associated with reduced all-cause mortality, mainly in patients who did not use other pharmacological treatments. Behavioural changes to enhance adherence among the elderly with cardiovascular disease might offer important benefits in reducing their mortality.

Clinical characteristics and satisfaction with the fimasartan in Korean hypertensive patients: a prospective, cross-sectional and open-label, 8-week switching study (Kanarb-hypertension epidemiology medication satisfaction study; K-HEMS study)

BACKGROUND

Fimasartan (Kanarb; Boryung Pharmaceutical Co., Ltd., Seoul, Republic of Korea) is a non-protein angiotensin II receptor blocker that selectively blocks the AT1 receptor. No prior large-scale study has investigated the impact of demographics, disease, treatment, and clinical characteristics on medication satisfaction and quality of life in Korean hypertensive patients. Additionally, it is unclear whether increased medication compliance affects the achievement of hypertension treatment objectives.

METHODS

This was a multicenter, non-interventional, open-label and 8-week switching study. This study was divided into 2 steps. STEP I was a cross-sectional study composed entirely of hypertensive patients undergoing treatment and STEP II was a prospective observational study of hypertensive patients switching to fimasartan. A total of 12,244 and 2023 patients were analyzed in the STEP I and STEP II groups, respectively. In STEP I, we investigated demographics, clinical, disease, and treatment characteristics at the registration point and then analyzed medication satisfaction, patient compliance, and quality of life. In STEP II, the patients who switched to fimasartan were followed up for 8 weeks, and the data analyzed included changes in medication effects, satisfaction, compliance, and adverse events.

RESULTS

Some baseline characteristics, such as sex, body mass index, region of residence, educational level, and income level, affected the quality of life and medication duration in hypertensive patients. At 4 and 8 weeks, 62.5 and 69.9% of patients, respectively, reached their target blood pressure. The medication satisfaction scores were increased 4.0 ± 1.2, 5.1 ± 1.1, and 5.4 ± 1.0 at baseline, 4 weeks, and 8 weeks, respectively, and the difference was statistically significant (p < 0.0001). Most patients (76.4%) who changed from prior antihypertensive drug to fimasartan were not satisfied with conventional antihypertensive drugs (e.g., lack of efficacy). Among 2183 patients, 234 adverse events occurred in 151 (6.9%) and 50 adverse drug reactions occurred in 39 (1.8%).

CONCLUSION

The demographic, clinical, disease, and treatment characteristics of hypertensive patients were investigated in this study. After switching to fimasartan, blood pressure was significantly decreased and patient satisfaction was improved. Fimasartan treatment was well tolerated and safe in hypertensive patients in Korea.Trial registration.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: (NCT02394392).

Medication monitoring attitudes and perceived determinants to offering medication adherence advice to older hypertensive adults: a factorial survey of community pharmacy interns

INTRODUCTION

Community pharmacy is an ideal setting to monitor medication adherence, however, barriers to pharmacist-led interventions exist. Preparing future pharmacists for enhanced roles may overcome such barriers. Our objective was to identify medication monitoring attitudes and contextual factors that influence adherence monitoring by pharmacy interns to inform educational activities on medication adherence.

METHODS

An online factorial survey of all pharmacy interns (N = 123) in the Republic of Ireland, completing advanced community pharmacy experiential learning in May 2016 was undertaken to evaluate attitudes to medication monitoring and to identify respondent characteristics and contextual factors which influence adherence monitoring of older hypertensive adults during repeat dispensing. The medication monitoring attitude measure (MMAM) was used to evaluate interns' attitudes, and factorial vignette analysis was performed to identify factors influencing behavioural intention to offer adherence advice.

RESULTS

There were 121 completed online surveys. Half of interns reported they felt uncomfortable and confrontational discussing adherence with patients. In factorial vignette analysis, higher medication monitoring attitudes resulted in higher likelihood to offer adherence advice; experiential-learning characteristics such as pharmacy ownership-type (nonchain store) and contextual factors including patients being treated for longer and time-pressures had a significant negative influence on pharmacy interns' likelihood to offer adherence advice.

DISCUSSION

Medication monitoring attitudes and contextual factors influenced responses to offer adherence advice in hypothetical scenarios. Ensuring pharmacy students are educated on patterns of adherence and appropriate skills to address nonadherence, and engage in structured programmes to facilitate patient interactions during experiential learning, may improve medication monitoring attitudes and adherence monitoring.

Protocol of an ongoing randomized controlled trial of care management for comorbid depression and hypertension: the Chinese Older Adult Collaborations in Health (COACH) study

Background

Depression and hypertension are common, costly, and destructive conditions among the rapidly aging population of China. The two disorders commonly coexist and are poorly recognized and inadequately treated, especially in rural areas.

Methods

The Chinese Older Adult Collaborations in Health (COACH) Study is a cluster randomized controlled trial (RCT) designed to test the hypotheses that the COACH intervention, designed to manage comorbid depression and hypertension in older adult, rural Chinese primary care patients, will result in better treatment adherence and greater improvement in depressive symptoms and blood pressure control, and better quality of life, than enhanced Care-as-Usual (eCAU). Based on chronic disease management and collaborative care principles, the COACH model integrates the care provided by the older person’s primary care provider (PCP) with that delivered by an Aging Worker (AW) from the village’s Aging Association, supervised by a psychiatrist consultant. One hundred sixty villages, each of which is served by one PCP, will be randomly selected from two counties in Zhejiang Province and assigned to deliver eCAU or the COACH intervention. Approximately 2400 older adult residents from the selected villages who have both clinically significant depressive symptoms and a diagnosis of hypertension will be recruited into the study, randomized by the villages in which they live and receive primary care. After giving informed consent, they will undergo a baseline research evaluation; receive treatment for 12 months with the approach to which their village was assigned; and be re-evaluated at 3, 6, 9, and 12 months after entry. Depression and HTN control are the primary outcomes. Treatment received, health care utilization, and cost data will be obtained from the subjects’ electronic medical records (EMR) and used to assess adherence to care recommendations and, in a preliminary manner, to establish cost and cost effectiveness of the intervention.

Discussion

The COACH intervention is designed to serve as a model for primary care-based management of common mental disorders that occur in tandem with common chronic conditions of later life. It leverages existing resources in rural settings, integrates social interventions with the medical model, and is consistent with the cultural context of rural life.

Trial registration

ClinicalTrials.gov ID: NCT01938963; First posted: September 10, 2013.

Exploring factors associated with patients' adherence to antihypertensive drugs among people with primary hypertension in the United Kingdom

OBJECTIVE

To explore factors associated with adherence to antihypertensive drugs overall (therapy adherence) and to particular classes (class adherence) in hypertensive patients.

METHODS

The current retrospective cohort study included adults with primary hypertension identified in the UK Clinical Practice Research Datalink from April 2006 to March 2013. Individuals were followed from the date of first-ever antihypertensive drug class (class adherence) prescribed and from the date of the first-ever antihypertensive drug (therapy adherence) issued to the earliest of study end, patient leaving the database, or death. Prescribing episodes (time from a drug class being first prescribed to the end of follow-up time) of six antihypertensive drug classes were recorded. Proportion of days covered (PDC) was used to estimate therapeutic adherence for a patient's antihypertensive drugs therapy during follow-up period and class adherence of a specific antihypertensive class in each episode, respectively. Generalized linear modelling was used to examine factors associated with PDC.

RESULTS

Median therapy and class PDC were 93.9 and 98.3% in the 176 835 patients and 371 605 prescribing episodes; 20 and 38.4% of the patients and episodes had PDC less than 80%, respectively. Higher therapy and class PDC was associated with increasing age, using renin angiotensin drugs, and being preexisting patient and user of antihypertensive drugs. Higher deprivation, multiple comorbidities, and switching of antihypertensive drugs were associated with lower PDC.

CONCLUSION

Several patient factors were confirmed as determinant of adherence to antihypertensive drug classes and therapy; hence, they can assist in identifying patients at risks of nonadherence, thus targeting them for adherence improving interventions.

Good adherence to therapy with statins reduces the risk of adverse clinical outcomes even among very elderly. Evidence from an Italian real-life investigation

AIM

To assess whether in individuals aged 80years or older adherence to statins is accompanied by a reduced risk of all-cause mortality and major cardiovascular events.

METHODS

A nested case-control study was carried out on a cohort of patients aged 80years or older (very elderly individuals), who were under treatment with statins between 2008 and 2009, using the database available for all citizenship (about 10 million) of Lombardy (Italy). Cases were the cohort members who experienced death or hospitalization for stroke, myocardial infarction or heart failure from the initial prescription until 2012. Up to five controls were randomly selected for each case. Logistic regression was used to model the outcome risk associated with the adherence to therapy with statins. Two younger patient cohorts aged 60 to 69years and 70 to 79years were taken for comparison. A set of sensitivity analyses was performed in order to account for sources of systematic uncertainty.

RESULTS

Among very elderly individuals, those who had high adherence to statins showed significant risk reductions of death (56%; 95% Confidence Interval, 54% to 59%), myocardial infarction (15%; 5% to 24%), stroke (13%; 0% to 24%) and heart failure (30%; 23% to 36%) with respect to those at very low adherence. Adherence-related risk reductions were only slightly better for younger cohort members.

CONCLUSIONS

Adherence to therapy with statins reduced the risk of both death and cardiovascular morbidity in patients aged 80years or older.

Group-Based Trajectory Models: Assessing Adherence to Antihypertensive Medication in Older Adults in a Community Pharmacy Setting

Antihypertensive medication nonadherence is highly prevalent, leading to uncontrolled blood pressure. Methods that facilitate the targeting and tailoring of adherence interventions in clinical settings are required. Group‐Based Trajectory Modeling (GBTM) is a newer method to evaluate adherence using pharmacy dispensing (refill) data that has advantages over traditional refill adherence metrics (e.g. Proportion of Days Covered) by identifying groups of patients who may benefit from adherence interventions, and identifying patterns of adherence behavior over time that may facilitate tailoring of an adherence intervention. We evaluated adherence to antihypertensive medication in 905 patients over a 12‐month period in a community pharmacy setting using GBTM, identifying three subgroups of adherence patterns: 52.8%, 40.7%, and 6.5% had very high, high, and low adherence, respectively. However, GBTM failed to demonstrate predictive validity with blood pressure at 12 months. Further research on the validity of adherence measures that facilitate interventions in clinical settings is required.

Effect of adherence to antihypertensive medication on stroke incidence in patients with hypertension: a population-based retrospective cohort study

OBJECTIVE

High blood pressure is a modifiable risk factor for stroke, but non-adherence to antihypertensive medication is a growing concern for healthcare providers in controlling blood pressure. This study aimed to investigate the effect of adherence to antihypertensive medication on stroke incidence.

DESIGN

Retrospective cohort study.

SETTING

We analysed National Health Insurance claim data and check-up data from 2009 to 2013.

PARTICIPANTS

38520patients with hypertension were defined as those diagnosed with hypertension and prescribed antihypertensive medication.

INTERVENTIONS

No interventions were made.

OUTCOME MEASURE

Poisson regression analysis using generalised estimating equations models was performed to examine the association between adherence to antihypertensive medication and stroke incidence.

RESULTS

Among 38 520 patients with hypertension, 957 (2.5%) strokes occurred during the study period. Non-adherence to medication was significantly associated with a higher risk of stroke (intermediate adherence: adjusted relative risk (aRR)=1.13, 95% CI=1.06 to 1.21; poor adherence: aRR=1.27, 95% CI=1.17 to 1.38).

CONCLUSIONS

Non-adherence to antihypertensive medication in patients with hypertension was associated with an increased risk of stroke. Therefore, healthcare providers need to focus on interventional strategies to ensure that these patients adhere to medication therapy and to provide continuing support to achieve long-term adherence, ultimately minimising negative health outcomes.

Different approaches to the assessment of adherence and persistence with cardiovascular-disease preventive medications

OBJECTIVE

To assess suitability and comparability of the most common methods of treatment adherence and persistence assessment, as applied to the same pharmacy dataset.

METHODS

Data on drugs prescribed for cardiovascular primary prevention to participants in the Aragon Workers' Health Study (AWHS) were collected from a regional electronic drug prescription database. Several different approaches were used to measure treatment adherence (with the medication possession ratio [MPR]) and proportion of days covered [PDC]) and persistence in new users by therapeutic subgroup. Defined daily dose (DDD) was used as a proxy of the number of days' supply, or substituted with surrogate daily dose values.

RESULTS

Higher mean adherence values and proportions of adherent patients were obtained using MPR versus PDC, with additional differences depending on the approach used. The proportion of adherent patients was lowest for oral antidiabetics (14.4%-30.6%) and highest for antihypertensives (70.2%-82.1%). The use of surrogate daily dose values increased adherence for antidiabetics and statins and decreased adherence for antihypertensives. After a 1 year follow-up, treatment persistence was observed for 21.1%, 58.7%, and 29.5% of antidiabetic, antihypertensive and statin users, respectively.

CONCLUSIONS

Our findings indicate that use of multiple measures of treatment adherence and persistence provides a more complete overview of medication use patterns, and certain limitations associated with DDD for some drug groups can be overcome with replacement by surrogate doses. The PDC indicator seems to provide a more accurate reflection of patient behavior and treatment continuity than the MPR. Any comparison of adherence/persistence should always consider the method used, variables analyzed, and corresponding data collection process.

Exposure to statins is associated to fracture risk reduction in elderly people with cardiovascular disease: evidence from the AIFA-I-GrADE observational project

PURPOSE

Conflicting findings were observed from clinical trials and observational studies evaluating the association between the use of statins and the risk of fracture. A case-control study nested into a cohort of elderly patients on treatment with statins for cardiovascular secondary prevention was performed on this issue.

METHODS

The cohort was formed by 13 875 individuals aged ≥65 years from several Italian health units receiving statins after hospital discharge for cardiovascular outcomes. From this cohort, 964 patients who experienced fracture were identified (i.e., cases). Up to five controls were randomly selected for each case from the underlying cohort. Conditional logistic regression was used to model the risk of fracture associated with adherence to statins, which was measured from the proportion of days covered (PDC) by treatment. A set of sensitivity analyses was performed in order to account for sources of systematic uncertainty.

RESULTS

Compared with patients with low adherence (PDC ≤ 40%), those on intermediate (PDC 41-80%) and high (PDC > 80%) adherence exhibited a risk reduction of 21% (95% confidence interval 6% to 23%) and 25% (7% to 40%). Similar effects were observed among patients younger and older than 80 years, as well as among men, while there was no evidence that adherence to statins affected the risk of fracture among women. Sensitivity analyses revealed that the associations were consistent and robust.

CONCLUSIONS

Use of statins for secondary cardiovascular prevention is associated with fracture risk reduction in elderly people. Further studies are required to better clarify the statin-fracture association in postmenopausal women. Copyright © 2017 John Wiley & Sons, Ltd.

An upper and lower bound of the Medication Possession Ratio

BACKGROUND

The Medication Possession Ratio (MPR) is a ubiquitous and central measurement for adherence in the health care industry. However, attempts to standardize its calculation have failed, possibly due to the opacity of a single, static MPR, incapability of directly lending itself to a variety of studies, and challenges of comparing the value across studies. This work shows that the MPR strictly depends on the length of the time interval over which it is measured as well as on the dominant dispense quantity for short time intervals. Furthermore, removing a proportion of the patient cohort based on the number of acquisitions may also have a severe impact on the MPR. Therefore, it is suggested that the MPR is represented as a trend over a range of time intervals. To this end, an upper and lower bound of the MPR trend is developed with an upper bound acknowledging patients who change their treatment and the lower bound acknowledging patients who discontinue their treatment.

PURPOSE

Introducing a representation of the MPR value as a trend rather than a static number by developing a quantitative description of an upper and lower bound of the MPR trend, while shedding light on the impacts on prefiltering the patient cohort.

PATIENTS AND METHODS

Anonymized patient-level data was utilized as an example for a suggested calculation of an upper and lower bound of the MPR.

RESULTS

Representation of the MPR for a predefined time interval precludes a reliable MPR assessment. A quantitative approach is suggested to generate an upper and lower trend of the MPR while emphasizing the impact on removing patients with a limited number of acquisitions.

CONCLUSION

An upper and lower trend makes the MPR more transparent and allows a better comparison across different studies. Removing patients with a limited number of acquisitions should be avoided.

Comparison of therapy persistence for fixed versus free combination antihypertensives: a retrospective cohort study

OBJECTIVES

The aim of the study was to compare therapy persistence among patients who started with one of three drug regimens: a monotherapy, or combination therapy either as a fixed combination (ie, 'single pill') or as a free combination (ie, two separate antihypertensive agents).

DESIGN

In a secondary data analysis, we used descriptive statistics and multivariate logistic regression to measure the effect of the three therapy regimens on therapy persistence over 4 years.

SETTING

Prescription data from a large German statutory health insurance provider.

PARTICIPANTS

All patients who started with a new antihypertensive therapy in 2007 or 2008 (n=8032) were included and followed for 4 years.

PRIMARY OUTCOME MEASURE

Therapy persistence, defined as receiving a refill prescription no later than within 180 days.

RESULTS

The persistence rates after 4 years were nearly identical among patients who started with a monotherapy (40.3%) or a fixed combination of two drugs (39.8%). However, significantly more patients who started with free-drug combinations remained therapy persistent (56.4%), resulting in an OR of 2.00 (95% CI 1.6 to 2.5; p<0.0001) for free combinations versus fixed combinations. This trend was observed in all age groups and for men and women. At the end of the study period, the number of different antihypertensive agents was still similar between patients who started with a fixed combination (2.41) and patients who started with a free combination (2.28).

CONCLUSIONS

While single-pill combinations make it easier to take different drugs at once, the risk is high that these several substances are stopped at once. Therapy persistence was significantly better for patients who started with a free-drug combination without taking much fewer different antihypertensive drugs as those with a fixed combination.