Physician adherence to hypertension treatment guidelines and drug acquisition costs of antihypertensive drugs at the cardiac clinic: a pilot study

Assessment of knowledge, attitude, and practice of primary healthcare physicians in Qatar towards hypertension management: An online cross-sectional study

Primary health care is integral to diagnosing and managing hypertension. This study aimed to assess the knowledge, attitude, practice, priority, and confidence of primary care physicians in Qatar toward hypertension diagnosis and management, and to measure the determinants of good knowledge, desirable attitudes, and desirable practices. We conducted a cross-sectional web-based survey using a modified version of the World Hypertension League Questionnaire during the period from August 30th to October 23rd, 2020. All primary care physicians working in any of Qatar's 27 publicly run primary healthcare centers were invited to participate in the survey. Out of the 450 primary care physicians working at that time, 197 completed the study questionnaire with a response rate of 43.8%. Most respondents stated that they followed local or international treatment guidelines for hypertension management (96.4%). Primary care physicians were highly confident and prioritized hypertension management. The overall desirable practice score was 73.8%, with the highest score (95.4%) for assessing adherence to antihypertensive medications, whereas the lowest desirable practice score was 33.5% for counseling on home blood pressure monitoring. Fifty-one-point eight percentage and 62.4% correctly identified 140 mm Hg and 90 mm Hg as the systolic and diastolic blood pressure threshold for diagnosing hypertension in most patients. The lowest knowledge scores were for hypertension epidemiology in Qatar and recommended dietary modification for hypertensive patients. Respondents had positive attitudes toward task sharing with nonphysician healthcare workers for most items (58.9%-78.2%), except for drug prescriptions (30.5%). Primary care physicians in Qatar had positive attitudes, with high overall confidence and conviction (priority) scores toward hypertension. However, their knowledge scores and certain practices were suboptimal. Healthcare policymakers in Qatar should raise primary care physicians awareness of the current burden of untreated hypertension in the country by organizing targeted educational programs and emphasizing the importance of following national clinical practice guidelines in the diagnosis and management of hypertension.

Prescribing patterns of antihypertensive medications: A systematic review of literature between 2010 and 2020

Background

Hypertension has affected over 1.13 billion people worldwide in 2015 and it's one of the most preventable risk-factors for morbidity and mortality. Antihypertensives significantly reduce cardiovascular risks. Several studies on antihypertensives' prescribing patterns were conducted worldwide, and guidelines were developed on hypertension management. However, no systematic reviews were conducted globally to synthesize the evidence from these studies. This review aims to evaluate antihypertensives' prescription patterns, and adherence to international guidelines for hypertension management worldwide.

Methods

Full-text antihypertensives' prescribing patterns evaluation studies were included. Reviews, commentaries, guidelines, and editorials were excluded. Various databases were searched including PubMed, Embase, and others. Studies were limited to English only and to articles published from (01/01/2010) to (20/03/2020). Crowe Critical Appraisal Tool (CCAT) was used for quality assessment.

Results

The most commonly prescribed antihypertensives as monotherapy in adult patients with no comorbidities were ACEIs/ARBs (Angiotensin converting enzyme inhibitors/Angiotensin receptor blockers), followed by CCBs (Calcium channel blockers), and BBs (Beta Blockers). Most commonly prescribed dual combinations were thiazide diuretics+ACEIs/ARBs, BBs + CCBs and CCBs+ACEIs/ARBs. Among diabetic patients, the most common agents were ACEIs/ARBs. Among patients with heart diseases, CCBs were prescribed frequently. While patients with kidney diseases, CCBs and ARBs were most prescribed. Of the 40 studies included in the review, only four studies directly assessed the prescribing patterns of antihypertensives in adherence to clinical practice guidelines. And only two studies confirmed adherence to guidelines. Furthermore, the quality of the majority of studies was moderate (50%), while 25% of articles were reported as either high or low quality.

Conclusion

This review revealed that there are areas for improvement for prescribing practices of antihypertensives in concordance with the latest evidence and with clinical practice guidelines.

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

Background

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

Methods

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

Results

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

Conclusion

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

Assessment of Satisfaction with Drug Provision of Antihypertensive Drugs at the Outpatient Level of Privileged Categories of Residens

Background

The existing system of outpatient drug provision of citizens allows providing certain categories of citizens and patients with certain types of diseases on a free basis. The purpose of the study is to analysis and evaluate the system of providing preferential categories of citizens with antihypertensive drugs at the level of primary health care.

Materials and Methods

To determine the level of satisfaction of citizens with drug provision at the outpatient level, 3118 respondents were interviewed using a questionnaire for persons who received free medicines for the treatment of hypertension. The questionnaire consisted of 20 questions. They were distributed by sex and age criterion. The ratio of male and female respondents was 51.7% and 48.7%, respectively.

Results

Thus, the results of a sociological study to study the opinions of the population about the existing system of free outpatient care revealed some organizational and managerial problems. Although that patients with hypertension since 2012 receive drugs for free, 37% noted that they bought at full cost in pharmacies, which should be released free of charge for privileged categories of citizens. Also, 77% of respondents claimed that they were not invited to outpatient organizations to receive drugs.

Conclusions

In solving the problems of improving the organization and management, it is necessary to take into account regional peculiarities, which allow, based on the use of a set of methods of analysis and forecasting, to assess the state and trends of development, to identify its strengths and weaknesses, to assess the factors of the external and internal environment.

Clinicians' prescribing pattern, rate of patients' medication adherence and its determinants among adult hypertensive patients at Jimma University Medical Center: Prospective cohort study

BACKGROUND

Many studies conducted in the past focused on patients' sociodemographic factors and medical profiles to identify the determinants of suboptimal blood pressure control. However, prescribing patterns and clinicians' adherence to guidelines are also important factors affecting the rate of blood pressure control. Therefore, this study aimed to determine clinicians' prescribing patterns, patients' medication adherence, and its determinants among hypertensive patients at Jimma University Medical Center.

METHODS

A general prospective cohort study was conducted among hypertensive patients who had regular follow-up at Jimma university ambulatory cardiac clinic from March 20, 2018, to June 20, 2018. Patients' specific data was collected with a face-to-face interview and from their medical charts. Clinicians' related data were collected through a self-administered questionnaire. Data were analyzed using SPSS version 21.0. Bivariate and multivariable logistic regression analyses were done to identify key independent variables influencing patients' adherence. P-Values of less than 0.05 were considered statically significant.

RESULTS

From the total of 416 patients, 237(57.0%) of them were males with a mean age of 56.50 ± 11.96 years. Angiotensin-converting enzyme inhibitors were the most frequently prescribed class of antihypertensives, accounting for 261(63.7%) prescriptions. Combination therapy was used by the majority of patients, with 275 (66.1%) patients receiving two or more antihypertensive drugs. Patients' medication adherence was 46.6%, while clinicians' guideline adherence was 44.2%. Patients with merchant occupation (P = 0.020), physical inactivity (P = 0.033), and diabetes mellitus co-morbidity (P = 0.008) were significantly associated with a higher rate of medication non-adherence.

CONCLUSION

The rate of medication adherence was poor among hypertensive patients. Physicians were not-adherent to standard treatment guideline. The most commonly prescribed class of drugs were angiotensin-converting enzyme inhibitors. Effective education should be given to patients to improve medication adherence. Prescribers should be trained on treatment guidelines regularly to keep them up-to-date with current trends of hypertension treatment and for better treatment outcomes.

Regional variability in Canadian routine care of type 2 diabetes, hypercholesterolemia, and hypertension: Results from the The Cardio-Vascular and metabolic treatments in Canada: Assessment of REal-life therapeutic value (CV-CARE) registry

BACKGROUND

Regional differences in the profile and treatment strategies of patients with cardiometabolic diseases have been studied in several different countries. The Cardio-Vascular and metabolic treatments in Canada: Assessment of REal-life therapeutic value (CV-CARE) registry was designed to evaluate patient profiles and medical management of cardiometabolic diseases in routine clinical care settings across Canada. Primary objectives were to (1) evaluate regional variability of patient profiles with cardiometabolic disease(s) and (2) assess treatment differences of patients treated for type 2 diabetes (T2D), hypercholesterolemia (HCh), and hypertension (HTN) across Canada.

METHODS

CV-CARE is a multi-center, observational, prospective registry that enrolled Canadian patients treated with metformin-extended release (MetER) for T2D, colesevelam (C) for HCh, azilsartan (AZI) for mild-to-moderate essential HTN and azilsartan/chlorthalidone (AZI/CHL) for severe, essential HTN. Patient characteristics and treatments were assessed at baseline.

RESULTS

The registry enrolled 6960 patients, with a total of 4194 patients making up the primary analysis population [MetER (n=995); C (n=1639); AZI (n=1364); AZI/CHL (n=498)]. First-line use of MetER was more common in British Columbia (BC; 45.5%) compared to Ontario (ON; 29.8%), and Quebec (QC; 12.9%). C treatment for HCh was used as monotherapy most readily in BC (68.7%) compared with QC (59.7%) and ON (35.8%). Dual action of low-density lipoprotein cholesterol and hemoglobin A1c reduction was the predominant reason for C add-on therapy (46.8%), with highest usage seen in ON (62.9%). AZI treatment for HTN was most frequently used in BC (43.8%), and AZI/CHL was most commonly used in ON (12.0%). First-line use of AZI was more common in QC (50%) vs. ON (34.9%) and BC (24.1%). The primary reason for switching to AZI and AZI/CHL from prior treatment was lack of efficacy across provinces.

CONCLUSION

This is the first regional description of the CV-CARE cohort. Significant variations in both baseline profile and treatments were observed which could have an impact on long-term outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

To what extent do prescribing practices for hypertension in the private sector in Zimbabwe follow the national treatment guidelines? An analysis of insurance medical claims

Background

Hypertension is the most prevalent cardiovascular disease in Zimbabwe. The prevalence of Hypertension in the country is above 30% regardless of the cut off used. Currently, majority of patients in Zimbabwe seek health care from the private sector due to limited government funding for the public health sector. However, Standard treatment guidelines for hypertension are only available in the public sector and are optional in the private sector. This study assesses compliance of private sector prescribing to Standard Treatment guidelines for hypertension.

Methods

We reviewed hypertension prescription claims to a private health insurance company in Zimbabwe for the period Jan 1-Dec 31 2015. We used the last prescription claimed in the year on the assumption that it represented the patient’s current treatment. Prescription data was analyzed by comparing medicines prescribed to those recommended in the Zimbabwe 7th Essential Medicines List and Standard Treatment Guidelines 2015. We used Microsoft Excel© 2010 to conduct the analysis.

Results

A total of 1019 prescriptions were reviewed. Most patients were either on mono or dual therapy (76%). The mostly prescribed class of antihypertensive as first line were Angiotensin Converting Enzyme Inhibitors /Angiotensin Receptor Blockers. Regardless of whether they were being used as first, second or third line this class of antihypertensives emerged as the most prescribed (639 times). Only 358 (35%) prescriptions were compliant with standard treatment guidelines; the rest (661) did not meet several criteria. Areas of non-compliance included use of second line medicines as first line, failure to consider patient characteristics when prescribing, use of contraindicated medicines for certain patients, clinically significant interactions among prescribed medicines and illogical combinations that predispose patients to toxicity.

Conclusion

The poor compliance to standard treatment guidelines observed in our study indicates need to improve prescription practices for Hypertension in the private sector in Zimbabwe for its cost-effective management among the covered patients. However, further investigation is needed to understand the drivers of the prescribing habits and the non-compliance to the Essential Medicines List and Standard Treatment guidelines observed. This will enable design of appropriate educational, managerial and economic interventions to improve compliance.

Antihypertensive drug prescription patterns and their impact on outcome of blood pressure in Ethiopia: a hospital-based cross-sectional study

Background

Irrational prescription is strongly associated with poor control of hypertension. The present study aimed to evaluate antihypertensive drug prescription trends and to measure their impact on the level of blood pressure (BP) control in Gondar University Hospital, Gondar, Ethiopia.

Methods

A hospital-based retrospective cross-sectional study was conducted from May 30 to June 30, 2016. All hypertensive patients on medication were included. A structured data abstraction form was prepared to gather the necessary information. The prescription patterns and BP level were measured retrospectively. A binary logistic regression was computed to determine the effect of different prescription patterns on BP control.

Results

A total of 596 hypertension patients were recruited for the study; of them, 561(94%) met the study criteria. The mean age of the respondents was 55.96±14.6 years. Females constituted 58.2% of the study population. Approximately fifty percent of the prescriptions were monotherapies. Twice-daily dosing was associated with lower risk of uncontrolled hypertension (crude odds ratio [COR] =0.51[0.15–0.73], adjusted odds ratio [AOR] =0.69[0.163–0.91]). Monthly appointment was linked with a nearly 90% reduced incidence of uncontrolled BP (COR =0.15[0.04–0.73], AOR =0.093[0.024–0.359]).

Conclusion

Monotherapies were the most frequently prescribed regimens. Twice-daily dosing and monthly appointments were associated with low incidence of uncontrolled BP. Clinicians should be vigilant in adjusting the frequency of dosing and should fix appointment date in consultation with their patients.

A review on prescribing patterns of antihypertensive drugs

Hypertension continues to be an important public health concern because of its associated morbidity, mortality and economic impact on the society. It is a significant risk factor for cardiovascular, cerebrovascular and renal complications. It has been estimated that by 2025, 1.56 billion individuals will have hypertension. The increasing prevalence of hypertension and the continually increasing expense of its treatment influence the prescribing patterns among physicians and compliance to the treatment by the patients. A number of national and international guidelines for the management of hypertension have been published. Since many years ago, diuretics were considered as the first-line drugs for treatment of hypertension therapy; however, the recent guidelines by the Joint National Commission (JNC8 guidelines) recommend both calcium channel blockers as well as angiotensin-converting enzyme inhibitors as first-line drugs, in addition to diuretics. Antihypertensive drug combinations are generally used for effective long-term management and to treat comorbid conditions. This review focuses on the antihypertensive medication utilization, their cost factors, adherence to treatment by patients, and physicians’ adherence to guidelines in prescribing medications in different settings including Indian scenario. The antihypertensive medication prescribing pattern studies help in monitoring, evaluation and necessary modifications to the prescribing habits to achieve rational and cost-effective treatment. Additionally, periodic updating of recommended guidelines and innovative drug formulations, and prescription monitoring studies help in rational use of antihypertensive drugs, which can be tailored to suit the patients' requirements, including those in the developing countries.

ADHERENCE IN PREGNANCY: A SYSTEMATIC REVIEW OF THE LITERATURE

“Clinical decisions and research programs ultimately depend on the reliable and valid measurement of adherence. Yet, 50 years of research in this field have not provided the data necessary to answer critical measurement questions.”.

Determinants of uncontrolled hypertension in adult type 2 diabetes mellitus: an analysis of the Malaysian diabetes registry 2009

BACKGROUND

Uncontrolled blood pressure (BP) is a significant contributor of morbidity and even mortality in type 2 diabetes (T2D) patients. This study was done to determine the significant determinants of uncontrolled blood pressure in T2D patients in Malaysia.

METHODS

Between 1st January 2009 to 31st December 2009, data from 70 889 patients with Type 2 diabetes was obtained from the Adult Diabetes Control and Management Registry for analysis; 303 centers participated in the study. Their demographic characteristics, the nature of their diabetes, their state of hypertension, treatment modalities, risk factors, and complications are described. Based on their most recent BP values, subjects were divided into controlled BP and uncontrolled BP and their clinical determinants compared. Independent determinants were identified using multivariate logistic regression.

RESULTS

The mean age of patients at diagnosis of diabetes was 52.3 ± 11.1 years old. Most were women (59.0 %) and of Malay ethnicity (61.9 %). The mean duration of diabetes was 5.9 ± 5.6 years. A total of 57.4 % were hypertensive. Of the 56 503 blood pressure (BP) measured, 13 280 (23.5 %) patients had BP <130/80 mmHg. Eighteen percent was on > two anti-hypertensive agents. Health clinics without doctor, older age (≥ 50 years old), shorter duration of diabetes (< 5 years), Malay, overweight were determinants for uncontrolled blood pressure (BP ≥130/80 mmHg). Patients who were on anti-hypertensive agent/s were 2.7 times more likely to have BP ≥130/80 mmHg. Type 2 diabetes patients who had ischaemic heart disease or nephropathy were about 20 % and 15 % more likely to have their blood pressure treated to target respectively.

CONCLUSIONS

Major independent determinants of uncontrolled BP in our group of T2D patients were Malay ethnicity, older age, recent diagnosis of diabetes, overweight and follow-up at health clinics without a doctor and possibly the improper use of anti hypertensive agent. More effort, education and resources, especially in the primary health care centres are needed to improve hypertensive care among our patients with diabetes.