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

Personalized Antihypertensive Treatment Optimization With Smartphone-Enabled Remote Precision Dosing of Amlodipine During the COVID-19 Pandemic (PERSONAL-CovidBP Trial)

BACKGROUND

The objective of the PERSONAL-CovidBP (Personalised Electronic Record Supported Optimisation When Alone for Patients With Hypertension: Pilot Study for Remote Medical Management of Hypertension During the COVID-19 Pandemic) trial was to assess the efficacy and safety of smartphone-enabled remote precision dosing of amlodipine to control blood pressure (BP) in participants with primary hypertension during the COVID-19 pandemic.

METHODS AND RESULTS

This was an open-label, remote, dose titration trial using daily home self-monitoring of BP, drug dose, and side effects with linked smartphone app and telemonitoring. Participants aged ≥18 years with uncontrolled hypertension (5-7 day baseline mean ≥135 mm Hg systolic BP or ≥85 mm Hg diastolic BP) received personalized amlodipine dose titration using novel (1, 2, 3, 4, 6, 7, 8, 9 mg) and standard (5 and 10 mg) doses daily over 14 weeks. The primary outcome of the trial was mean change in systolic BP from baseline to end of treatment. A total of 205 participants were enrolled and mean BP fell from 142/87 (systolic BP/diastolic BP) to 131/81 mm Hg (a reduction of 11 (95% CI, 10-12)/7 (95% CI, 6-7) mm Hg, P<0.001). The majority of participants achieved BP control on novel doses (84%); of those participants, 35% were controlled by 1 mg daily. The majority (88%) controlled on novel doses had no peripheral edema. Adherence to BP recording and reported adherence to medication was 84% and 94%, respectively. Patient retention was 96% (196/205). Treatment was well tolerated with no withdrawals from adverse events.

CONCLUSIONS

Personalized dose titration with amlodipine was safe, well tolerated, and efficacious in treating primary hypertension. The majority of participants achieved BP control on novel doses, and with personalization of dose there were no trial discontinuations due to drug intolerance. App-assisted remote clinician dose titration may better balance BP control and adverse effects and help optimize long-term care.

REGISTRATION

URL: clinicaltrials.gov. Identifier: NCT04559074.

Adherence to pharmacological treatment in non-communicable chronic diseases in the Colombian population: Systematic review and meta-analysis

Introduction. Non-communicable chronic diseases represent the leading cause of death worldwide, and their prevalence is increasing due to the epidemiological transition. Despite the advances in their management, control rates are deficient, attributed to multiple factors like adherence to pharmacological treatment, one of the most significant and least studied in the Colombian population. Objective. To calculate adherence to treatment in Colombian patients with arterial hypertension, cerebrovascular disease, diabetes mellitus, asthma, chronic obstructive pulmonary disease, and dyslipidemia between 2005 and 2022. Materials and methods. We performed a systematic literature review and a meta-analysis of studies identified through the Medline and LILACS databases to quantitatively synthesize treatment adherence percentage. Results. Fourteen studies met the inclusion criteria, and 5,658 patients were analyzed. The treatment adherence was 59%, with significant heterogeneity among the included studies (95% CI= 46- 71%; I2 = 98.8%, p< 0.001). Higher adherence rates were observed for diabetes mellitus (79%; 95% CI = 65- 90%) and dyslipidemia (70%; 95% CI = 66- 74%). Adherence to arterial hypertension treatment was 51% (95 %; CI = 31- 72%). Conclusions. This systematic review showed low adherence to recommendations regarding pharmacological management in non-communicable chronic diseases, which can have implications for long-term clinical outcomes and disease burden.

Hypertension therapy using fixed-dose polypills that contain at least three medications

Fixed-dose combination (FDC) therapy may provide a solution to treatment gaps by overcoming reasons for therapeutic inertia. To synthesise and report on available evidence on standard or low-dose combination medicines that combine at least three antihypertensive medicines. A literature search was conducted via Scopus, Embase, PubMed and the Cochrane clinical trials database. Studies were eligible for inclusion if they were randomised clinical trials that included adults (>18 years) and examined the impact of at least three antihypertensive medications on blood pressure (BP). A total of 18 trials (n=14 307) were identified that examined combinations of three or four antihypertensive medicines. Ten trials investigated the effect of a standard dose triple combination polypill, four the effect of a low-dose triple and four the effect of a low-dose quadruple combination polypill. The mean difference (MD) in systolic BP ranged from -10.6 to -41.4 for the standard dose triple combination polypill in comparison with 2.1 to -34.5 for dual combination; -9.8 to -20.6 for a low-dose combination polypill in comparison with a MD of -0.9 to -5.2 for placebo; -9.0 to -29.3 for a low-dose combination polypill compared with -2.0 to -20.6 for monotherapy or usual care. All trials reported similar rates of adverse events. Ten studies reported medication adherence, six reported >95% adherence. Triple and quadruple combination antihypertensive medications are effective. Studies of low-dose triple and quadruple combinations involving treatment naïve populations suggest initiating such combinations are safe and effective as first-line therapy for stage 2 hypertension (BP >140/90 mm Hg).

Adherence to antihypertensive treatment during the COVID-19 pandemic: findings from a cross-sectional study

BACKGROUND

Nonadherence to antihypertensive treatment is one of the main causes of the lack of blood pressure (BP) control. The coronavirus disease (COVID-19) pandemic imposes substantial social restriction impairing the medical care routine, which may influence adherence to the antihypertensive treatment. To assess the rate of nonadherence to antihypertensive drug treatment during the COVID-19 pandemic.

METHODS

This is a cross-sectional study evaluating hypertensive adult patients from a tertiary outpatient clinic. From March to August 2020, patients were interviewed by telephone during the social distancing period of the COVID-19 pandemic. We evaluated biosocial data, habits, attitudes, and treatment adherence using the 4-item Morisky Green Levine Scale during the social distancing. Uncontrolled BP was defined by BP ≥ 140/90 mmHg. Clinical and prescription variables for drug treatment were obtained from the electronic medical record. We performed a multivariate analysis to determine the predictors of nonadherence to BP treatment.

RESULTS

We studied 281 patients (age 66 ± 14 years, 60.5% white, 62.3% women, mean education of 9.0 ± 4 years of study). We found that 41.3% of the individuals reported poor adherence to antihypertensive drug treatment and 48.4% had uncontrolled BP. Subsample data identified that adherence was worse during the pandemic than in the previous period. The variables that were independently associated with the nonadherence during the pandemic period were black skin color (odds ratio [OR], 2.62; 95% confidence interval [CI], 1.46-4.68), and intermittent lack of access to antihypertensive medication during the pandemic (OR, 2.56; 95% CI, 1.11-5.89).

CONCLUSIONS

Beyond traditional variables associated with poor adherence, the lack of availability of antihypertensive medications during the study underscore the potential role of pandemic on hypertension burden.

Non-persistence to antihypertensive drug therapy in Lithuania

Purpose

Poor persistence to antihypertensive therapy is an important cause of treatment failure. Investigating persistence is especially important in countries with a high cardiovascular mortality, like Lithuania. The aim of this study was to describe the antihypertensive treatment at initiation, to determine the percentage of patients not being persistent with antihypertensive treatment after 1 year and to explore factors associated with non-persistence.

Methods

In this cohort study, data on dispensed prescription medicines from the Lithuanian National Health Insurance Fund (NHIF) were used. All adult patients with a diagnosis of hypertension having first antihypertensive dispensed in 2018 were included. Descriptive statistics was used to determine the number of patients started with monotherapy and combination therapy. Treatment choice by Anatomical Therapeutic Chemical (ATC) and number of active pharmaceutical ingredient (API) was described. Non-persistence was assessed using the anniversary method. Multivariate logistic regression was used to explore factors associated with non-persistence.

Results

A total of 72,088 patients were included into the study, 56% started on monotherapy treatment, with 49% being dispensed an angiotensin converting enzyme inhibitor, and 44% started on combination therapy. Overall, 57% of patients were non-persistent after 1 year. Patients’ gender and prescriber qualification showed no association with non-persistence. Younger patients, patients from rural area, patients started with monotherapy, and patients with no medication change had higher odds to become non-persistent.

Conclusions

The majority of patients were initiated with treatment following hypertension management guidelines, but it is of concern that over half of the patients were non-persistent to antihypertensive therapy in the first year.

Impact of physician’ and pharmacy staff supporting activities in usual care on patients’ statin adherence

Aims

Little is known about usual care by physicians and pharmacy teams to support adherence to statins and whether the extent of this care is associated with adherence to statins. Objective of the study was to examine the relationship between the extent of adherence supporting activities of healthcare practitioners (HCPs) and patients’ adherence to statins.

Methods

Cross-sectional study in 48 pharmacies and affiliated physicians’ practices, between September 3, 2014 and March 20, 2015. Patients visiting the pharmacy with a statin prescription from participating prescribers were invited to participate. Usual care to support adherence was assessed among HCPs with the Quality of Standard Care questionnaire about usual care activities to support adherence. Adherence to statins was assessed among patients with the MARS-5 questionnaire. The association between the extent of HCPs’ adherence supporting activities and patients’ adherence was examined by means of multilevel regression analysis.

Results

1,504 patients and 692 HCPs (209 physicians, 118 pharmacists and 365 pharmacy technicians) participated. No association was found between the extent of physicians’ adherence supporting activities and patients’ adherence to statins. The extent of adherence supporting activities by pharmacy teams in usual care was negatively associated with patients’ adherence to statins (B coefficient -0.057 (95%CI: -0.112- -0.002).

Conclusions

This study suggests that there is no positive relationship between the extent of HCPs’ adherence supporting activities in usual care and patients’ adherence to statins. Other methods than questionnaires (e.g. electronic monitors (to assess adherence) and observations (to assess usual care) should be applied to confirm the results of this study.

Treatment Adherence in Integrative Medicine-Part One: Review of Literature

Treatment adherence is a topic that is well studied but not well understood. Low treatment adherence is a significant issue that limits the effective management and treatment of chronic conditions, creating significant health care burden, costs, and poor patient outcomes. This report provides a review of the factors that facilitate or create barriers to treatment adherence, as well as strategies recommended to overcome adherence barriers. A total of 25 interviews were conducted with practitioners demonstrating both high (n = 16) and low (n = 9) treatment adherence rates. A total of 185 survey responses were received from high-treatment adherence rate practitioners (n = 21), low-treatment adherence rate practitioners (n = 83), and practitioners that were neither in the high- or low-treatment adherence rate range (n = 81). Practitioner prescribing behaviors and adherence statistics were determined and stratified by high-treatment adherence rate and low-treatment adherence rate practitioners. From the interviews, 78% of low-rate practitioners mentioned that establishing trust is a primary best practice for optimizing adherence, and for high-rate practitioners, 69% thought that facilitating trust was important to optimizing adherence. Both low- and high-adherence rate practitioners prioritized using a staged approach as a strategy to overcome barriers to adherence. From the total survey sample it was found that key strategies to improving adherence included the practice of booking follow-up appointments, using lab results to explain treatment plans, and using a staged approach for treatment plans. Our research sought to elicit strategies and skills that can help improve treatment adherence in integrative medicine and our findings have identified several common practices that can help to improve adherence. Research taking advantage of mobile devices and the internet for adherence has started to expand within the last 10 to 15 years. Technology has the potential to lead the development and establishment of a centralized database that acquires adherence information and provides solutions to its practitioners and patients. Further work to advance the field of integrative medicine through additional research and interventions that support treatment adherence would be valuable to the effective treatment and management of integrative medicine patients.

Mental health and socioeconomic status impact adherence to youth activity and dietary programs: a meta-analysis

PURPOSE

Substantial efforts have gone into reducing the physiological and psychological harm of obesity in youth, but few studies have reviewed the factors contributing to adherence to pediatric weight management programs. The attrition rates to programs offering multiple components to address BMI improvement and healthy lifestyle change among youth are quite high. The purpose of this study is to review the literature for factors contributing to adherence to these programs among children and youth with obesity and determine pooled effect of these factors.

METHODS

A systematic literature search and meta-analysis was conducted through the PubMed database on pediatric weight management interventions offering at least physical activity and dietary support for obese youth aged 10-17 years, where variables contributing to adherence were reported. Only those studies achieving a threshold of methodological rigour were included.

RESULTS

Altogether, seven studies were included in the analysis. There was a pooled RR of lower socioeconomic status on non-adherence of 1.34 [95% confidence intervals 1.19-1.52] and poorer mental health on non-adherence of 1.12 [95% confidence intervals 1.08-1.17].

CONCLUSION

It is important to address barriers related to lower socioeconomic status in pediatric weight management programs to increase adherence. Further, addressing supports for those with poorer mental health can reduce the risk of non-adherence in multi-disciplinary programs targeting youth with obesity.

Reasons for poor blood pressure control in Eastern Sub-Saharan Africa: looking into 4P's (primary care, professional, patient, and public health policy) for improving blood pressure control: a scoping review

AIM

Hypertension control in Sub-Saharan Africa (SSA) is the worst (less than one out of ten) when compared to the rest of the world. Therefore, this scoping review was conducted to identify and describe the possible reasons for poor blood pressure (BP) control based on 4Ps' (patient, professional, primary healthcare system, and public health policy) factors.

METHODS

PRISMA extension for scoping review protocol was used. We systematically searched articles written in the English language from January 2000 to May 2020 from the following databases: PubMed/Medline, Embase, Scopus, Web of Science, and Google scholar.

RESULTS

Sixty-eight articles were included in this scoping review. The mean prevalence of hypertension, BP control, and patient adherence to prescribed medicines were 20.95%, 11.5%, and 60%, respectively. Only Kenya, Malawi, and Zambia out of ten countries started annual screening of the high-risk population for hypertension. Reasons for nonadherence to prescribed medicines were lack of awareness, lack of access to medicines and health services, professional inertia to intensify drugs, lack of knowledge on evidence-based guidelines, insufficient government commitment, and specific health behaviors related laws. Lack of screening for high-risk patients, non-treatment adherence, weak political commitment, poverty, maternal and child malnutrition were reasons for the worst BP control.

CONCLUSION

In conclusion, the rate of BP treatment, control, and medication adherence was low in Eastern SSA. Screening for high-risk populations was inadequate. Therefore, it is crucial to improve government commitment, patient awareness, and access to medicines, design country-specific annual screening programs, and empower clinicians to follow individualized treatment and conduct medication adherence research using more robust tools.

Influential factors in adherence to the therapeutic regime in patients with type 2 diabetes and hypertension

BACKGROUND

Medication non-adherence is a global problem and the most common cause of treatment failure. Researchers warn that only one in two patients with chronic conditions adhere to their medication. Therefore, the primary objective of the study was to assess influential factors in adherence to the therapeutic regime in patients with type 2 diabetes and hypertension. The secondary objective was to evaluate medication adherence in patients with hypertension (HT) and/or diabetes (DM) and compare the level of adherence among patients with either diabetes or hypertension.

METHODS

The study included 1303 patients divided into three groups according to the type of chronic condition. The Adherence to Refills and Medications Scale (ARMS) was used to assess the level of adherence with pharmacological recommendations.

RESULTS

A comparison of adherence between the groups demonstrated that the level of adherence was highest in patients with diabetes alone (17 ± 5.15) and was lowest in patients with co-existing HT and diabetes (19.9 ± 7.51). A single-factor linear regression model analysis showed that the presence of hypertension alone has a positive effect on adherence to medications, while the co-existence of diabetes and hypertension has a statistically significantly negative impact on medication adherence. The sociodemographic predictors of higher adherence included female gender (β = -0.06; p = 0.024), high school education (β = -0.16 and p = 0.001) and being unemployed (β = -0.08; p = 0.0100).

CONCLUSION

Patients with co-existing diabetes and HT taking antihypertensive and antidiabetic drugs have the lowest adherence rates, and the co-existence of two chronic conditions is a statistically significant independent determinant of decreased adherence. Variables confirmed in the multiple-factor model as having an independent impact on the level of adherence include the type of condition suffered, female gender, education and professional status. Practical implication. The primary objective is to undertake actions whose aim is to improve adherence in order to enhance patients' functioning, reduce the number of follow-up visits and the hospitalisation rate, and thus limit the economic consequences of treating disease complications.

Prevalence and factors associated with adherence to anti-hypertensives among adults with hypertension in a developed Asian community: A cross-sectional study

Introduction:

Poor adherence to anti-hypertensive medications (AHM) results in hypertension treatment failure. Understanding and addressing the factors associated with adherence to AHM may potentially improve health outcomes. This study aimed to assess the prevalence and factors associated with patients’ adherence to AHM in a developed Asian community.

Methods:

An assistant-administered questionnaire survey was conducted on multi-ethnic Asian adults aged 31–80 years with essential hypertension based on their electronic health records (EHR) at a public primary-care clinic. Data on their demographic characteristics, clinical measurements of blood pressure and body mass index, co-morbidities and prescriptions from the EHR, along with the Medication Adherence Report Scale-5 scores were collated, audited and analysed. A MARS-5 score of <25 indicated poor adherence. Logistic regression was used to identify factors associated with adherence to AHM.

Results:

Data of 395 patients were analysed. Of these, 179 (45.3%) had poor adherence to at least one AHM. Bivariate analysis showed that poor adherence was significantly associated with lower mean age (59 years old vs. 63 years old), higher mean clinic diastolic blood pressure (76 mmHg vs. 73 mmHg) and higher mean weight (70.4 kg vs. 67.4 kg). Logistic regression showed that patients with no co-morbidities (such as diabetes mellitus, dyslipidaemia, stroke and ischaemic heart disease) had better medication adherence (MA; odds ratio=1.98; 95% confidence interval 1.14–3.45; p=0.02). There was no significant MA difference between the classes, dose frequency and number of AHM.

Conclusion:

Almost half of the patients had poor adherence to at least one AHM. Co-morbidity significantly influenced their MA. Attention should be directed to patients with co-morbidities to assess their AHM adherence.

Necessity and concerns about lipid-lowering medical treatments and risk factors for non-adherence: A cross-sectional study in Palestine

AIMS

Strong evidence indicates that drugs reduce blood lipids and improve cardiovascular end-points, leading to their wide usage. However, the success of these drugs can be affected by poor patient's adherence to prescribed medication. This study aimed to evaluate medication adherence in patients with dyslipidaemia in association with patient beliefs about medicines.

METHODS

The study was conducted from January 2019 to July 2019 at the middle governmental primary healthcare clinics in Ramallah and Bethlehem cities, and used a cross-sectional design. Adherence was determined using the 4-item Morisky medication adherence scale, while beliefs were determined using the Beliefs about Medicines Questionnaire.

RESULTS

Of 220 patients, 185 agreed to participate in the study, resulting in a response rate of 84.1%. Of the participants, 106 (57.3%) were men, and almost half (88, 46.5%) were ≥56 years. Medication non-adherence was high (47.6%), but a majority (65.5%) reported believing their treatment to be necessary for their continued good health. Accordingly, the mean necessity score (17.3, SD 3.7) significantly outweighed (P < .001) the mean concerns score (14.0, SD 3.5). Multivariate regression demonstrated four variables to be significantly correlated with non-adherence: illiterate (OR = 2.52; CI: 0.9-4.3; P = .03), polypharmacy (OR = 3.18; CI: 1.9-5.7; P = .007), having comorbidity (OR = 3.10; CI: 2.2-4.6; P = .005) and having concerns about side effects (OR = 2.89; CI: 1.1-4.6, P = .04).

CONCLUSION

Non-adherence among patients taking lipid-lowering agents was high despite most holding positive beliefs regarding medication necessity. This may be due to concern also being high. Physicians should identify and target high-risk patients and individualise their treatment plans in order to achieve adequate control of dyslipidaemia.

Relationship of non-melancholic and melancholic depressive symptoms with all-cause mortality: A prospective study in a primary care population

OBJECTIVE

To assess relationship of non-melancholic and melancholic subtypes of depressive symptoms with all-cause mortality among cardiovascular risk persons.

METHODS

A population-based prospective study of 2522 Finnish middle-aged persons with elevated cardiovascular risk was conducted. Depressive symptoms were assessed by the Beck's Depression Inventory. Data on mortality were obtained from The Official Statistics of Finland after 11-year follow-up.

RESULTS

At baseline, the prevalence of non-melancholic and melancholic depressive symptoms was 14.9% and 5.2%, respectively. During the mean follow-up time of 11 years, 8.1% (n = 164) of those without, 13.9% (n = 52) of those with non-melancholic, and 10.7% (n = 14) of those with melancholic depressive symptoms died. Compared to non-depressive subjects, the hazard ratio for time to all-cause mortality was 1.67 (95% CI: 1.21-2.32, p = .002) in non-melancholically depressive and 1.01 (95% CI: 0.56-1.83, p = .97) in melancholically depressive subjects, when adjusted for age, gender, education, smoking, alcohol use, BMI, hypertension, dyslipidaemia, and glucose disorders. In comparison to the mortality rate in the general population throughout Finland over the same period, non-depressiveness was associated with a decreased standardized mortality rate.

CONCLUSION

Non-melancholic depressive symptoms seem to be associated with excess all-cause mortality. In clinical settings, recognition of non-melancholic depressive symptoms should be emphasised.

Adherence to Triple-Free-Drug Combination Therapies Among Patients With Cardiovascular Disease

Combination therapies are often needed to modify the concomitant risk factors for cardiovascular disease. Nonadherence to cardiovascular medications is a relevant concern, especially in polytherapy. We conducted a population-based, cohort study with the aim of quantifying the level of adherence and its related determinants in patients exposed to free 3-drug combination therapies, namely concurrent use of angiotensin-converting-enzyme inhibitor (ACEi), calcium channel blocker (CCB), and statin or of ACEi, statin, and low-dose aspirin. Within Health Search Database, we selected a cohort of adult patients concurrently prescribed with ACEi, CCB, and statin, as well as those prescribed with ACEi, statin and low-dose aspirin, from the January 1, 2002 to the December 31, 2014. Adherent patients were concurrent users of triple free pill regimen with a proportion of days covered ≥80% during 1-year follow-up; demographics and clinical determinants of 1-year adherence were identified by multivariate logistic regression. We found that more than half of patients prescribed with triple free drug combination therapy with ACEi plus CCB plus statin or ACEi plus statin plus low-dose aspirin, were found to be nonadherent to these treatments. Males and patients at high/very-high cardiovascular risk were more likely to be adherent, whereas depression and atrial fibrillation were associated with nonadherence. Our findings indicate that sex, cardiovascular risk, presence of atrial fibrillation, and depression can influence adherence to polytherapy. In conclusion, given that patients suffering from multiple cardiovascular risk factors are at higher risk of fatal events, strategies are needed to improve medication adherence to combination therapies.

Hypertension prevalence alteration in 92 815 nurses based on the new standard by 2017 ACC/AHA hypertension guideline: observational cross-sectional study from China

OBJECTIVES

This study aimed to elucidate the status of hypertension and to analyse the hypertension changes in prevalence, awareness, treatment and control rate among the portion of Chinese nursing staff based on the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) High Blood Pressure Guideline and the 2010 Chinese Guideline for the Management of Hypertension.

DESIGN

Cross-sectional study.

SETTING

512 medical institutions in 13 cities in Hebei Province.

PARTICIPANTS

The candidates of registered nurses from 512 medical institutions in 13 cities in Hebei Province (N=143 772) were invited to participate in the survey, and few of them who refused to participate were excluded from the research group based on the reasons that 93 603 incumbent nurses at the age of 18-65 accepted to the survey and submitted questionnaires online. Undoubtedly, a response rate of 65.11% was achieved. After excluding 788 individuals with incomplete information in the questionnaires, 92 815 participants were included in the final analysis.

MAIN OUTCOME MEASURES

The prevalence, awareness, treatment and control rates of hypertension.

RESULTS

92 815 participants were included in the final analysis, among which consisted of 3677 men (3.96%) and 89 138 women (96.04%). The mean age of the participants was 31.65 (SD=7.47) years.We demonstrated that 26 875 nursing staff were diagnosed as having hypertension according to the new standard by the 2017 ACC/AHA guideline, more than 20 551 cases compared with the previous threshold on the 2010 Chinese guideline. The prevalence of hypertension among nursing staff was 28.96% in the context of the 2017 ACC/AHA guideline, 3.25 times higher than that (6.81%) evaluated by the criteria of the 2010 Chinese guideline. However, the awareness, treatment and control rate (13.50%, 10.73% and 0.81%) were 3.25, 3.22 and 17.48 times lower than those (57.37%, 45.30% and 14.97%) based on the 2010 Chinese guideline, respectively.

CONCLUSIONS

This research illustrated that it was crucial to improve the awareness rate, drug treatment rate and control rate of hypertension for nurses. Meanwhile, according to the 2017 ACC/AHA guideline, the prevalence of hypertension in China will increase significantly, which poses a more severe challenge to the management of hypertension in China.

Association Between Medication Literacy and Medication Adherence Among Patients With Hypertension

Background: Few studies have investigated the association between medication literacy and medication adherence as well as the influence of medication literacy on medication adherence in hypertensive patients. Thus, the goal of the present study was to determine the association between medication literacy and medication adherence in hypertensive patients. Methods: A cross-sectional survey was conducted between August 2016 and December 2016. Self-administered questionnaires were completed, including a self-developed and structured socio-demographic questionnaire; a self-developed, validated, and self-reported Medication Literacy Scale for Hypertensive Patients (C-MLSHP) used for medication literacy measurement; and the Chinese Version of the Morisky Medication Adherence Scale-8 (C-MMAS-8), an eight-item validated, self-report scale for adherence measurement with a total score range of 0-8. A cut-off of 6 was applied to differentiate adherence levels, including patients with an MMAS score <6 (low adherence), MMAS score = 8 (high adherence), and MMAS score ≥6 and <8 (moderate adherence). In this study, hypertensive patients' medication literacy levels and adherence to antihypertensive agents were identified. Pearson correlation analysis was carried out to identify the correlation between medication literacy and adherence. Binary logistic regression analysis was performed with medication adherence as the outcome variable in order to confirm factors associated with medication adherence. Results: A total of 420 hypertensive patients, including 198 women and 222 men with a mean age of 60.6 years (SD = 12.4), were recruited. The mean score of hypertensive patients on the medication literacy scale was 24.03 (SD = 5.13). The mean scores of the four dimensions of knowledge, attitude, skill, and behavior on the medication literacy scale of this study were 6.22 ± 2.22, 5.04 ± 1.16, 4.50 ± 2.21, and 8.27 ± 1.90, respectively. Regarding medication adherence, the mean score of the C-MMAS-8 in this study was 4.82 (SD = 2.11). A total of 63.6% of patients presented with low adherence, 29.5% presented with moderate adherence, and 7.6% presented with high adherence. The Pearson correlation results showed that medication literacy (r = 0.342, P < 0.01) as a whole variable and the three dimensions of knowledge (r = 0.284, P < 0.01), attitude (r = 0.405, P < 0.01), and behavior (r = 0.237, P < 0.01) were significantly associated with medication adherence. Binary logistic regression analysis indicated that annual income [OR 1.199 (95% CI: 1.011-1.421); P = 0.037] and two dimensions of attitude [OR 2.174 (95% CI: 1.748-2.706); P = 0.000] and behavior [OR 1.139 (95% CI: 1.002-1.294); P = 0.046] in medication literacy were found to be independent predictors of medication adherence. Individuals with better attitudes and behavior literacy in medication literacy were more likely to adhere to the use of antihypertensive agents. Those who had higher annual incomes were more likely to adhere to the use of antihypertensive agents. Conclusion: The levels of medication literacy and medication adherence of hypertensive patients are suboptimal and need to be improved in China. The level of medication literacy in patients with hypertension could affect their adherence to antihypertensive drugs. It was suggested that hypertensive patients' medication adherence could be improved and driven by increasing the medication literacy level, especially in the attitude and behavior domains. Pertinent strategies that are specific to several dimensions of medication literacy should be developed and implemented in order to promote full medication literacy among hypertensive patients, thus facilitating optimal adherence and blood pressure control.

Adherence to cardiovascular medication: a review of systematic reviews

BACKGROUND

Use of cardiovascular medication has increased over time, especially for primary and secondary prevention, with polypharmacy common.

METHODS

Review of published systematic reviews of the factors and outcomes associated with adherence to cardiovascular medication using MEDLINE, Embase, CINAHL and PsycINFO databases. Quality was assessed using the AMSTAR tool.

RESULTS

Of 789 systematic reviews identified, 45 met the inclusion criteria and passed the quality assessment; 34 focused on factors associated with adherence, and 11 on outcomes. High heterogeneity, both between and within reviews, precluded meta-analysis and so a pooled estimate of adherence levels could not be derived. Adherence was associated with disease factors, therapy factors, healthcare factors, patient factors and social factors, though with some inconsistencies. In total, 91% of reviews addressing outcomes reported that low adherence was associated with poorer clinical and economic endpoints.

CONCLUSIONS

Factors from across five key domains relate to non-adherence to cardiovascular medications, and may contribute to poorer clinical outcomes. Interventions to improve adherence should be developed to address modifiable factors and targeted at those at highest risk of non-adherence. Adherence research is highly heterogeneous to-date and efforts to standardize this should be implemented to improve comparability.

Modelling the impact of new patient visits on risk adjusted access at 2 clinics

OBJECTIVE

To evaluate the effect new outpatient clinic visits has on the availability of follow-up visits for established patients when patient visit frequency is risk adjusted.

DATA SOURCES

Diagnosis codes for patients from 2 Internal Medicine Clinics were extracted through billing data.

STUDY DESIGN

The HHS-HCC risk adjusted scores for each clinic were determined based upon the average of all clinic practitioners' profiles. These scores were then used to project encounter frequencies for established patients, and for new patients entering the clinic based on risk and time of entry into the clinics.

PRINCIPAL FINDINGS

A distinct mean risk frequency distribution for physicians in each clinic could be defined providing model parameters. Within the model, follow-up visit utilization at the highest risk adjusted visit frequencies would require more follow-up slots than currently available when new patient no-show rates and annual patient loss are included. Patients seen at an intermediate or lower visit risk adjusted frequency could be accommodated when new patient no-show rates and annual patient clinic loss are considered.

CONCLUSIONS

Value-based care is driven by control of cost while maintaining quality of care. In order to control cost, there has been a drive to increase visit frequency in primary care for those patients at increased risk. Adding new patients to primary care clinics limits the availability of follow-up slots that accrue over time for those at highest risk, thereby limiting disease and, potentially, cost control. If frequency of established care visits can be reduced by improved disease control, closing the practice to new patients, hiring health care extenders, or providing non-face to face care models then quality and cost of care may be improved.

The current and potential health benefits of the National Health Service Health Check cardiovascular disease prevention programme in England: A microsimulation study

BACKGROUND

The National Health Service (NHS) Health Check programme was introduced in 2009 in England to systematically assess all adults in midlife for cardiovascular disease risk factors. However, its current benefit and impact on health inequalities are unknown. It is also unclear whether feasible changes in how it is delivered could result in increased benefits. It is one of the first such programmes in the world. We sought to estimate the health benefits and effect on inequalities of the current NHS Health Check programme and the impact of making feasible changes to its implementation.

METHODS AND FINDINGS

We developed a microsimulation model to estimate the health benefits (incident ischaemic heart disease, stroke, dementia, and lung cancer) of the NHS Health Check programme in England. We simulated a population of adults in England aged 40-45 years and followed until age 100 years, using data from the Health Survey of England (2009-2012) and the English Longitudinal Study of Aging (1998-2012), to simulate changes in risk factors for simulated individuals over time. We used recent programme data to describe uptake of NHS Health Checks and of 4 associated interventions (statin medication, antihypertensive medication, smoking cessation, and weight management). Estimates of treatment efficacy and adherence were based on trial data. We estimated the benefits of the current NHS Health Check programme compared to a healthcare system without systematic health checks. This counterfactual scenario models the detection and treatment of risk factors that occur within 'routine' primary care. We also explored the impact of making feasible changes to implementation of the programme concerning eligibility, uptake of NHS Health Checks, and uptake of treatments offered through the programme. We estimate that the NHS Health Check programme prevents 390 (95% credible interval 290 to 500) premature deaths before 80 years of age and results in an additional 1,370 (95% credible interval 1,100 to 1,690) people being free of disease (ischaemic heart disease, stroke, dementia, and lung cancer) at age 80 years per million people aged 40-45 years at baseline. Over the life of the cohort (i.e., followed from 40-45 years to 100 years), the changes result in an additional 10,000 (95% credible interval 8,200 to 13,000) quality-adjusted life years (QALYs) and an additional 9,000 (6,900 to 11,300) years of life. This equates to approximately 300 fewer premature deaths and 1,000 more people living free of these diseases each year in England. We estimate that the current programme is increasing QALYs by 3.8 days (95% credible interval 3.0-4.7) per head of population and increasing survival by 3.3 days (2.5-4.1) per head of population over the 60 years of follow-up. The current programme has a greater absolute impact on health for those living in the most deprived areas compared to those living in the least deprived areas (4.4 [2.7-6.5] days of additional quality-adjusted life per head of population versus 2.8 [1.7-4.0] days; 5.1 [3.4-7.1] additional days lived per head of population versus 3.3 [2.1-4.5] days). Making feasible changes to the delivery of the existing programme could result in a sizable increase in the benefit. For example, a strategy that combines extending eligibility to those with preexisting hypertension, extending the upper age of eligibility to 79 years, increasing uptake of health checks by 30%, and increasing treatment rates 2.5-fold amongst eligible patients (i.e., 'maximum potential' scenario) results in at least a 3-fold increase in benefits compared to the current programme (1,360 premature deaths versus 390; 5,100 people free of 1 of the 4 diseases versus 1,370; 37,000 additional QALYs versus 10,000; 33,000 additional years of life versus 9,000). Ensuring those who are assessed and eligible for statins receive statins is a particularly important strategy to increase benefits. Estimates of overall benefit are based on current incidence and management, and future declines in disease incidence or improvements in treatment could alter the actual benefits observed in the long run. We have focused on the cardiovascular element of the NHS Health Check programme. Some important noncardiovascular health outcomes (e.g., chronic obstructive pulmonary disease [COPD] prevention from smoking cessation and cancer prevention from weight loss) and other parts of the programme (e.g., brief interventions to reduce harmful alcohol consumption) have not been modelled.

CONCLUSIONS

Our model indicates that the current NHS Health Check programme is contributing to improvements in health and reducing health inequalities. Feasible changes in the organisation of the programme could result in more than a 3-fold increase in health benefits.

Primary nonadherence to chronic disease medications: a meta-analysis

BACKGROUND

Medication nonadherence is a global problem that requires urgent attention. Primary nonadherence occurs when a patient consults with a medical doctor, receives a referral for medical therapy but never fills the first dispensation for the prescription medication. Nonadherence to chronic disease medications costs the USA ~$290 billion (USD) every year in avoidable health care costs. In Canada, it is estimated that 5.4% of all hospitalizations are due to medication nonadherence.

OBJECTIVES

The objective of this study was to quantify the extent of primary nonadherence for four of the most common chronic disease medications. The second objective was to identify factors associated with primary nonadherence to chronic disease medications.

MATERIALS AND METHODS

We conducted an extensive systematic literature review of eight databases with a wide range of keywords. We identified relevant articles for primary nonadherence to antihypertensives, lipid-lowering agents, hypoglycemics, and antidepressants. After further screening and assessment of methodologic quality, relevant data were extracted and analyzed using a random-effects model.

RESULTS

Twenty-four articles were included for our meta-analysis after full review and assessment for risk of bias. The pooled primary nonadherence rate for the four chronic disease medications was 14.6% (95% CI: 13.1%-16.2%). Primary medication nonadherence was higher for lipid-lowering medications among the four chronic disease medications assessed (20.8%; 95% CI: 16.0%-25.6%). The rates in North America (17.0%; 95% CI: 14.4%-19.5%) were twice those from Europe (8.5%; 95% CI: 7.1%-9.9%). The absence of social support (20%; 95% CI: 14.4%-26.6%) was the most common sociodemographic variable associated with chronic disease medication primary nonadherence.

CONCLUSION

Evidence suggests that a considerable percentage of patients do not initially fill their medications for treatable chronic diseases or conditions. This represents a major health care problem that can be successfully addressed. Efforts should be directed toward proper medication counseling, patient social support, and clinical follow-up, especially when the indications for the prescribed medication aim to provide primary prevention.

Factors associated with antihypertensive medication non-adherence: a systematic review

Non-adherence to antihypertensive medication is the most important cause of uncontrolled blood pressure and is influenced by multiple interrelating factors. Understanding the complexity of medication non-adherence and its associated factors is important to determine intervention strategies. Therefore, a systematic review was performed aimed to identify factors associated with antihypertensive medication non-adherence. Different databases were searched for observational studies reporting on factors associated with non-adherence to antihypertensive medication. Titles, abstracts and full texts were reviewed by three researchers. Subsequently, the methodological quality of each study was assessed. Factors that were extracted from the included studies were categorised as factors with consistent or inconsistent evidence to put their potential importance into perspective. Forty-four studies were included. Higher co-payment, side effects and a poor patient-provider relationship were identified as factors with consistent evidence since consistent significant relationships were found for these factors whenever studied. The relationships between non-adherence and multiple other factors were inconsistent among the reviewed studies. However, some of these factors deserve some consideration. Since multiple potentially relevant factors were identified, patient-tailored interventions focussing on identifying and addressing patients' specific barriers to adherence are needed. Further research should clarify the influence of inconsistent factors on adherence and their potential to be addressed in interventions.

Optimal blood pressure control after coronary events: the challenge remains

We identified sociodemographic, medical, and psychosocial factors associated with unfavorable blood pressure (BP) control in 1012 patients, hospitalized with myocardial infarction and/or a coronary revascularization procedure. This cross-sectional study collected data from hospital records, a comprehensive self-report questionnaire, clinical examination, and blood samples after 2-36 (mean 17) months follow-up. Forty-six percent had unfavorable BP control (≥140/90 [80 in diabetics] mm Hg) at follow-up. Low socioeconomic status and psychosocial factors did not predict unfavorable BP control. Patients with unfavorable BP used on average 1.9 (standard deviation 1.1) BP-lowering drugs at hospital discharge, and the proportion of patients treated with angiotensin inhibitors and beta-blockers decreased significantly (P < .001) from discharge to follow-up. Diabetes (odds ratio [OR] 2.4), higher body mass index (OR 1.05 per 1.0 kg/m²), and older age (OR 1.04 per year) were significantly associated with unfavorable BP control in adjusted analyses. Only age (standardized beta [β] 0.24) and body mass index (β 0.07) were associated with systolic BP in linear analyses. We conclude that BP control was insufficient after coronary events and associated with obesity and diabetes. Prescription of BP-lowering drugs in hypertensive patients seems suboptimal. Overweight and intensified drug treatment thus emerge as the major factors to target to improve BP control.

Antihypertensive Adherence Trajectories Among Older Adults in the First Year After Initiation of Therapy

BACKGROUND

Adherence to antihypertensives is suboptimal, but previous methods of quantifying adherence fail to account for varying patterns of use over time. We sought to improve classification of antihypertensive adherence using group-based trajectory models, and to determine whether individual factors predict adherence trajectories.

METHODS

We identified older adults initiating antihypertensive therapy during 2008-2011 using a 20% sample of Medicare (federal health insurance available to US residents over the age of 65) beneficiaries enrolled in parts A (inpatient services), B (outpatient services), and D (prescription medication). We developed monthly adherence indicators using prescription fill dates and days supply data in the 12 months following initiation. Adherence was defined as having at least 80% of days covered. Logistic models were used to identify trajectory groups. Bayesian information criterion and trajectory group size were used to select the optimal trajectory model. We compared the distribution of covariates across trajectory groups using multivariable logistic regression.

RESULTS

During 2008-2011, 282,520 Medicare beneficiaries initiated antihypertensive therapy (mean age 75 years, 60% women, 84% White). Six trajectories were identified ranging from perfect adherence (12-month adherence of 0.97, 40% of beneficiaries) to immediate stopping (12-month adherence of 0.10, 18% of beneficiaries). The strongest predictors of nonadherence were initiation with a single antihypertensive class (adjusted odds ratio = 2.08 (95% confidence interval: 2.00-2.13)), Hispanic (2.93 (2.75-3.11)) or Black race/ethnicity (2.04 (1.95-2.13)), and no prior history of hypertension (2.04 (2.00-2.08)) (Area under the receiving operating characteristic curve: 0.53).

CONCLUSIONS

There is substantial variation in antihypertensive adherence among older adults. Certain patient characteristics are likely determinants of antihypertensive adherence trajectories.

Pharmacological control of diabetes and hypertension comorbidity in the elderly: A study of "real world" data

AIMS

The study aimed to determine which drug combinations achieve better control in comorbid diabetes and hypertension in a pragmatic sample of primary health care patients.

METHODS

Cross-sectional study.

SETTING

251 primary health care centres in Catalonia, Spain.

PARTICIPANTS

individuals ≥65 years old with a dual diagnosis of hypertension and diabetes.

MAIN OUTCOME MEASURES

good control criteria were established as glycated haemoglobin ≤7% and blood pressure <140/90mmHg. Antihypertensive and hypoglycaemic drugs and treatment adherence were analysed in relation to their association with good control.

RESULTS

27,637 patients (58.0% women) had hypertension and diabetes and met selection criteria. Mean age was 75.9 years (standard deviation [SD]: 6.7). Both diseases were well controlled simultaneously in 34.2% of patients. The combination of biguanides and diuretics achieved the highest association with good control. Adherence to pharmacological treatment was more difficult in diabetes than in hypertension. Lack of control was associated significantly with non-adherence to treatment, 0-12 PHC visits, obesity and increasing number of diabetes prescriptions.

CONCLUSIONS

Good control of diabetes and hypertension comorbidity with pharmacological treatment in elderly patients is challenging. Some drug combinations achieved better control than others. The greatest effort should focus on improving the low adherence to diabetes treatment.

Factors associated with adherence to pharmacological treatment among elderly persons using antihypertensive drugs

Abstract Objective: analyze adherence to pharmacotherapy and associated factors among elderly patients using at least one antihypertensive medication. Methods: A cross-sectional, population-based study was performed of elderly patients resident in Juiz de Fora, Minas Gerais, Brazil. Adherence to medication was assessed with the Morisky-Green Test. Socio-demographic variables and variables related to health status, the health service and drug therapy were collected. The Poisson regression model was used to assess crude and adjusted (95% confidence interval) prevalence ratios (PR). The level of significance was tested using the Wald test. Results: The prevalence of adherence to pharmacological therapy was 47% (95% CI: 41%-53%). The sample consisted of 279 elderly persons, the majority of whom were women (69%), described themselves as white (45.5%), and had up to four years of schooling (76.48%). Regarding pharmacological therapy, the subjects took 5.19 (±2.8) medications and 7.1 (±4.4) tablets per day. Conclusion: a significant association was observed between adherence to pharmacological therapy and the variables positive perception of vision, positive perception of hearing and absence of frailty.

Weight loss intervention adherence and factors promoting adherence: a meta-analysis

BACKGROUND

Adhering to weight loss interventions is difficult for many people. The majority of those who are overweight or obese and attempt to lose weight are simply not successful. The objectives of this study were 1) to quantify overall adherence rates for various weight loss interventions and 2) to provide pooled estimates for factors associated with improved adherence to weight loss interventions.

METHODS

We performed a systematic literature review and meta-analysis of all studies published between January 2004 and August 2015 that reviewed weight loss intervention adherence.

RESULTS

After applying inclusion and exclusion criteria and checking the methodological quality, 27 studies were included in the meta-analysis. The overall adherence rate was 60.5% (95% confidence interval [CI] 53.6-67.2). The following three main variables were found to impact adherence: 1) supervised attendance programs had higher adherence rates than those with no supervision (rate ratio [RR] 1.65; 95% CI 1.54-1.77); 2) interventions that offered social support had higher adherence than those without social support (RR 1.29; 95% CI 1.24-1.34); and 3) dietary intervention alone had higher adherence than exercise programs alone (RR 1.27; 95% CI 1.19-1.35).

CONCLUSION

A substantial proportion of people do not adhere to weight loss interventions. Programs supervising attendance, offering social support, and focusing on dietary modification have better adherence than interventions not supervising attendance, not offering social support, and focusing exclusively on exercise.

Subclinical Mood and Cognition Impairments and Blood Pressure Control in a Large Cohort of Elderly Hypertensives

BACKGROUND

Blood pressure (BP) control in the elderly is often limited by poor compliance with prescribed regimen. Both can be influenced by clinical cognitive or mood impairments; however, the impact of subclinical alterations of cognition or mood remains unknown.

OBJECTIVES

To assess the relation between cognition, mood, and BP control in treated older hypertensive patients.

DESIGN

Cross-sectional association study.

SETTING

Predefined substudy to the POLFOKUS nationwide survey investigating the correlates of poor BP control in patients randomly drawn from primary and specialist practices across Poland.

PARTICIPANTS

1988 outpatients ≥65 years of age treated for hypertension for at least 1 year.

MEASUREMENTS

BP was mean of at least 2 office measurements. We assessed adherence to antihypertensive medications using a questionnaire and performed screening tests for cognitive deficits [Abbreviated Mental Test Score (AMTS)] and mood disorders [Geriatric Depression Scale (GDS)]. In all patients, we used a unified (BP <140/90 mm Hg) and in ≥80 years old a unified or age-specific (<150 mm Hg systolic BP) definition of BP control. We fitted logistic regression models to assess the probability of poor BP control in association with cognitive and mood disturbances.

RESULTS

The mean [standard deviation (SD)] age of 1988 (65.6% women) patients was 73.9 (6.0) years (19.3% ≥80 years old). Cognitive and mood impairments were observed in 8.0% and 37.2%, respectively. Mean systolic and diastolic BP were 141.8 (16.4) and 83.6 (9.5) mm Hg, respectively. According to age-stratified and unified definition of proper BP control, goal BP was achieved in 65.4% and 38.5% patients ≥80 years of age, respectively. In younger patients, the control reached 46%. Globally, 66% patients adhered to antihypertensive medications. Poor compliance was related to cognitive and mood impairments. When unified goal was applied, there was a 15.0% higher risk of finding poor BP control per 1 score lost in AMTS and an 8.0% increase per 1 score gained in GDS (all P < .001).

CONCLUSION

Poorer BP control is related to subclinical worsening of cognition and mood, which supports widespread use of the Comprehensive Geriatric Assessment even in apparently self-dependent older patients with hypertension.

Training primary care physicians in cognitive behavioral therapy: A review of the literature

OBJECTIVE

Patients often seek mental health treatment through primary care. Training primary care physicians (PCPs) in approaches to address common mental health concerns may be a useful method for narrowing gaps in care. Cognitive Behavioral Therapy (CBT) is especially applicable in medical settings given its brief, skill-based approach and strong evidence for a number of presenting problems. This paper reviews the current literature on training PCPs in CBT with a focus on PCP-level outcomes.

METHODS

We reviewed studies that described and evaluated CBT training programs for PCPs. Of 652 records identified and screened, 33 full-text articles were assessed for eligibility, resulting in 9 articles identified for inclusion.

RESULTS

We extracted and report information about study design, participants, intervention and dose, training content, and outcomes (PCP reaction, learning, and performance; patient outcomes).

CONCLUSION

There was substantial variability in sample size, methodology, training content and design, and assessment of outcomes, which translated into mixed findings across studies. In order to best assess effectiveness and allow replicability, future studies should provide adequate information about training curricula and assess multiple levels of learning outcomes.

PRACTICE IMPLICATIONS

Additional studies are needed to determine whether PCPs effectively implement skills within routine practice after CBT training.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Non-adherence to anti-hypertensive medication in low- and middle-income countries: a systematic review and meta-analysis of 92443 subjects

Hypertension is a rising global burden, and low- and middle-income countries account for 80% of deaths due to complications of hypertension. Hypertension can be controlled by adhering to anti-hypertensive medication. However, non-adherence is an increasing challenge. This review aims to systematically evaluate non-adherence to anti-hypertensive medication among adults in low- and middle-income countries and explore factors affecting non-adherence to anti-hypertensive medication. We performed a systematic search for studies published between 1 January 2000 and 31 August 2015. A selection process was performed for data extraction with a combination of Medical Subject Headings terms: 'hypertension' and 'adherence'. Further search criteria were: language ('english'), species ('humans'), and low- and middle-income countries. A total of 22 studies met the inclusion criteria. The pooled percentage of non-adherence when using the eight-item Morisky Medication Adherence Scale (MMAS) was 63.35% (confidence of interval (CI): 38.78-87.91) and 25.45% (CI:17.23-33.76) when using the 80 and 90% cut-off scales. The factors were classified into the five dimensions of adherence defined by the World Health Organization, and the majority of the studies reported factors from the dimension 'social and economic factors'. This systematic review demonstrated considerable variation of non-adherence to anti-hypertensive medication in low- and middle-income countries depending on the methods used to estimate non-adherence. The results showed a high non-adherence when the MMAS eight-item scale was used and low when the 80 and 90% cut-off scales were used. The majority of factors affecting non-adherence to anti-hypertensive medication fell within the World Health Organization defined dimension 'social and economic factors'.

Interventions for improving adherence to treatment for latent tuberculosis infection: a systematic review

BACKGROUND

Latent tuberculosis infection (LTBI) control relies on high initiation and completion rates of preventive treatment to preclude progression to tuberculosis disease. Specific interventions may improve initiation and completion rates. The objective was to systematically review data on determinants of initiation, adherence and completion of LTBI treatment, and on interventions to improve initiation and completion.

METHODS

A systematic review of the literature (PubMed, Embase) published up to February 2014 was performed. Relevant prospective intervention studies were assessed using GRADE.

RESULTS

Sixty-two articles reporting on determinants of treatment initiation and completion were included and 23 articles on interventions. Determinants of LTBI treatment completion include shorter treatment regimen and directly observed treatment (DOT, positive association), adverse events and alcohol use (negative association), and specific populations with LTBI (both positive and negative associations). A positive effect on completion was noted in intervention studies that used short regimens and social interventions; mixed results were found for intervention studies that used DOT or incentives.

CONCLUSION

LTBI treatment completion can be improved by using shorter regimens and social interventions. Specific needs of the different populations with LTBI should be addressed taking into consideration the setting and condition in which the LTBI treatment programme is implemented.

Characteristics Associated With Antihypertensive Treatment and Blood Pressure Control: A Population-Based Follow-Up Study in Peru

BACKGROUND

Over one-quarter of the world's adult population has hypertension, yet achieving adequate treatment or control targets remains a challenge.

OBJECTIVE

This study sought to identify, longitudinally, characteristics associated with antihypertensive treatment and blood pressure (BP) control among individuals with hypertension.

METHODS

Data from individuals enrolled in the population-based CRONICAS Cohort Study (adults ≥35 years, living in 4 different rural/urban and coastal/high-altitude Peruvian settings) with hypertension at baseline were used. Antihypertensive treatment and BP control were assessed at baseline and at 15 months. Multinomial logistic regressions were used to estimate relative risk ratios (RRR) and 95% confidence intervals (95% CI) of factors associated with antihypertensive treatment and BP control at follow-up.

RESULTS

At baseline, among 717 individuals with hypertension (53% women, mean age 61.5 ± 12.4 years), 28% were unaware of their hypertension status, 30% were aware but untreated, 16% were treated but uncontrolled, and 26% were treated and controlled. At follow-up, 89% of unaware and 82% of untreated individuals persisted untreated, and only 58% of controlled individuals remained controlled. Positive predictors of receiving treatment and being controlled at follow-up included age (RRR: 0.81; 95% CI: 0.73 to 0.91 for every 5 years) and family history of a chronic disease (RRR: 0.53; 95% CI: 0.31 to 0.92 vs. no history); whereas Puno rural site (RRR: 16.51; 95% CI: 1.90 to 143.56 vs. Lima) and male sex (RRR: 2.59; 95% CI: 1.54 to 4.36) were risk factors. Systolic BP at baseline (RRR: 1.27; 95% CI: 1.16 to 1.39 for every 5 mm Hg) and male sex (RRR: 1.75, 95% CI: 1.02 to 2.98) were risk factors for being treated but uncontrolled at follow-up.

CONCLUSIONS

Large gaps in treatment of hypertension were observed. Targeting specific populations such as men, younger individuals, or those without family history of disease may increase coverage of antihypertensive treatment. Also, targeting male individuals or those with higher systolic BP could yield better rates of BP control in the short term.

Social support and adherence to treatment in hypertensive patients: a meta-analysis

BACKGROUND

It is important to examine factors associated with patient adherence to hypertension control strategies.

PURPOSE

A meta-analysis was conducted to examine whether social support was related to adherence to healthy lifestyle and treatment medication in hypertensive patients.

METHODS

Journal articles were searched in medical (CINAHL, MEDLINE), psychological (PsycINFO, PsycARTICLES), and educational (ERIC) electronic databases; in reference lists of selected papers; and in the reference list of a previous review.

RESULTS

Findings of a set of meta-analyses indicated that (a) structural social support was not significantly related to overall adherence, (b) functional social support was significantly and positively related to overall adherence, (c) these findings were further confirmed in meta-analyses conducted on specific types of adherence, and (d) most results were characterized by heterogeneity across studies that was partially explained by moderator analyses.

CONCLUSIONS

Functional social support, but not structural social support, was associated with adherence in hypertensive patients.

Persistence with Antihypertensive Medications in Uncomplicated Treatment-Naïve Patients: Effects of Initial Therapeutic Classes

We aimed to assess one-year persistence with antihypertensive therapy (AHT) among newly treated uncomplicated hypertensive patients in Korea and to evaluate the effect of initial therapeutic classes on persistence. We retrospectively analyzed a random sample of 20% of newly treated uncomplicated hypertensive patients (n = 45,787) in 2012 from the National Health Insurance claims database. This group was classified into six cohorts based on initial AHT class. We then measured treatment persistence, allowing a prescription gap of 60 days. Adherence to AHT was assessed with the medication possession ratio. Calcium channel blockers (CCB, 43.7%) and angiotensin receptor blockers (ARB, 40.3%) were most commonly prescribed as initial monotherapy. Overall, 62.1% and 42.0% were persistent with any AHT and initial class at one year, respectively, and 64.2% were adherent to antihypertensive treatment. Compared with ARBs, the risk of AHT discontinuation was significantly increased with initial use of thiazide diuretics (hazard ratio [HR], 3.16; 95% confidence interval [CI] 2.96-3.74) and beta blockers (HR, 1.86; CI, 1.77-1.95) and was minimally increased with CCBs (HR, 1.12; CI, 1.08-1.15). In conclusion, persistence and adherence to AHT are suboptimal, but the differences are meaningful in persistence and adherence between initial AHT classes.

Evaluation of an mHealth Medication Regimen Self-Management Program for African American and Hispanic Uncontrolled Hypertensives

African Americans and Hispanics have disproportionate rates of uncontrolled essential hypertension (EH) compared to Non-Hispanic Whites. Medication non-adherence (MNA) is the leading modifiable behavior to improved blood pressure (BP) control. The Smartphone Medication Adherence Stops Hypertension (SMASH) program was developed using a patient-centered, theory-guided, iterative design process. Electronic medication trays provided reminder signals, and Short Message Service [SMS] messaging reminded subjects to monitor BP with Bluetooth-enabled monitors. Motivational and reinforcement text messages were sent to participants based upon levels of adherence. Thirty-eight African-American (18) and Hispanic (20) uncontrolled hypertensives completed clinic-based anthropometric and resting BP evaluations prior to randomization, and again at months 1, 3 and 6. Generalized linear mixed modeling (GLMM) revealed statistically significant time-by-treatment interactions (p < 0.0001) indicating significant reductions in resting systolic blood pressure (SBP) and diastolic blood pressure (DBP) for the SMASH group vs. the standard care (SC) control group across all time points. 70.6% of SMASH subjects vs. 15.8% of the SC group reached BP control (< 140/90 mmH) at month 1 (p < 0.001). At month 6, 94.4% of the SMASH vs. 41.2% of the SC group exhibited controlled BP (p < 0.003). Our findings provide encouraging evidence that efficacious mHealth, chronic disease, medical regimen, self-management programs can be developed following principles of patient-centered, theory-guided design.

Factors Associated with Medication Nonadherence among Hypertensives in Ghana and Nigeria

Background. Blood pressure (BP) control is poor among hypertensives in many parts of sub-Saharan Africa. A potentially modifiable factor for control of BP is medication nonadherence (MNA); our study therefore aimed to determine factors associated with MNA among hypertensives in Ghana and Nigeria. Methodology. We conducted a multicenter cross-sectional study. Patients were recruited from Korle-Bu Hospital (n = 120), Ghana; and University of Port Harcourt Teaching Hospital, (n = 73) Apapa General Hospital Lagos (n = 79) and University College Hospital Ibadan (n = 85), Nigeria. Results. 357 hypertensive patients (42.6% males) participated. MNA was found in 66.7%. Adherence showed correlation with depression (r = -0.208, P < 0.001), concern about medications (r = -0.0347, P = 0.002), and knowledge of hypertension (r = 0.14, P = 0.006). MNA was associated with formal education (P = 0.001) and use of herbal preparation (P = 0.014). MNA was found in 61.7% of uninsured participants versus 73.1% of insured participants (P = 0.032). Poor BP control was observed in 69.7% and there was significant association between MNA and poor BP control (P = 0.006). Conclusion. MNA is high among hypertensives in Ghana and Nigeria and is associated with depression, concern about hypertensive medications, formal education, and use of herbal preparations. The negative association between health insurance and MNA suggests interplay of other factors and needs further investigation.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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