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

Green Urbanism and its Application to Singapore

Green urbanism has been applied to cities but not in Asia. Seven characteristics of green urbanism are outlined and then applied to Singapore. The Renewable City is not yet a concept for Singapore. The Carbon Neutral City is being developed for an island Palau Ubin and by some firms but not to significant sectors or parts of urban Singapore. The Distributed City is being developed around Singapore’s polycentric model but needs specific infrastructure plans similar to ones developed by Singapore for Tianjin Eco-City. The Biophillic City is being developed as a world first through its Skyrise Greenery initiative and urban landscaping. The Eco-Efficient City is also being demonstrated through Singapore closing the loop on their water and solid waste systems. The Place Based City is very evident in all its 22 sub centres. And the Sustainable Transport City is an Asian leader in integrated transport planning though there are signs of this becoming harder to achieve