Trends in Antihypertensive Medication Discontinuation and Low Adherence Among Medicare Beneficiaries Initiating Treatment From 2007 to 2012

Low antihypertensive medication adherence is common. During recent years, the impact of low medication adherence on increased morbidity and healthcare costs has become more recognized, leading to interventions aimed at improving adherence. We analyzed a 5% sample of Medicare beneficiaries initiating antihypertensive medication between 2007 and 2012 to assess whether reductions occurred in discontinuation and low adherence. Discontinuation was defined as having no days of antihypertensive medication supply for the final 90 days of the 365 days after initiation. Low adherence was defined as having a proportion of days covered <80% during the 365 days after initiation among beneficiaries who did not discontinue treatment. Between 2007 and 2012, 41 135 Medicare beneficiaries in the 5% sample initiated antihypertensive medication. Discontinuation was stable during the study period (21.0% in 2007 and 21.3% in 2012; P-trend=0.451). Low adherence decreased from 37.4% in 2007 to 31.7% in 2012 (P-trend<0.001). After multivariable adjustment, the relative risk of low adherence for beneficiaries initiating treatment in 2012 versus in 2007 was 0.88 (95% confidence interval, 0.83-0.92). Low adherence was more common among racial/ethnic minorities, beneficiaries with Medicaid buy-in (an indicator of low income), and those with polypharmacy, and was less common among females, beneficiaries initiating antihypertensive medication with multiple classes or a 90-day prescription fill, with dementia, a history of stroke, and those who reached the Medicare Part D coverage gap in the previous year. In conclusion, low adherence to antihypertensive medication has decreased among Medicare beneficiaries; however, rates of discontinuation and low adherence remain high

Reproducibility of visit-to-visit variability of blood pressure measured as part of routine clinical care

Objectives: Secondary analysis of clinical trial data suggests visit-to-visit variability (VVV) of blood pressure is strongly associated with the incidence of cardiovascular disease. Measurement of blood pressure in usual practice settings may be subject to substantial error, calling into question the value of VVV in real-world settings. Methods: We analyzed data on adults of at least 65 years of age with diagnosed hypertension who were taking antihypertensive medication from the Cohort Study of Medication Adherence among Older Adults (n = 772 with 14 or more blood pressure measurements). All blood pressure measurements, taken as part of routine outpatient care over a median of 2.8 years, were abstracted from patients’ medical charts. Results: Using each participant's first seven SBP measurements, the mean intraindividual standard deviation was 13.5 mmHg. The intraclass correlation coefficient for the standard deviation based on the first seven and second seven SBP measurements was 0.28 [95% confidence interval (CI) 0.20–0.34]. Individuals in the highest quintile of standard deviation of SBP based on their first seven measurements were more likely to be in the highest quintile of VVV using their second seven measurements (observed/expected ratio = 1.71, 95% CI 1.29–2.22). Results were similar for other metrics of VVV. The intraclass correlation coefficient was lower for DBP than SBP. Conclusion: These data suggest VVV of SBP measured in a real-world setting is not random. Future studies are needed to assess the prognostic value of VVV of SBP assessed in routine clinical practice.visit-to-visit variabilit

Prevalence and Correlates of Low Medication Adherence in Apparent Treatment-Resistant Hypertension

Low medication adherence may explain part of the high prevalence of apparent treatment-resistant hypertension (aTRH). The authors assessed medication adherence and aTRH among 4026 participants taking ≥3 classes of antihypertensive medication in the population-based Reasons for Geographic and Racial Differences in Stroke (REGARDS) trial using the 4-item Morisky Medication Adherence Scale (MMAS). Low adherence was defined as an MMAS score ≥2. Overall, 66% of participants taking ≥3 classes of antihypertensive medication had aTRH. Perfect adherence on the MMAS was reported by 67.8% and 70.9% of participants with and without aTRH, respectively. Low adherence was present among 8.1% of participants with aTRH and 5.0% of those without aTRH (P<.001). Among those with aTRH, female sex, residence outside the US stroke belt or stroke buckle, physical inactivity, elevated depressive symptoms, and a history of coronary heart disease were associated with low adherence. In the current study, a small percentage of participants with aTRH had low adherence

Predictors of uncontrolled hypertension and antihypertensive medication nonadherence

http://www.jcdronline.com/text.asp?2010/1/4/196/74263Background: Although hypertension is, in most cases, a controllable major risk factor in the development of cardiovascular disease, studies have demonstrated that hypertension remains poorly controlled in Portugal. Our aim was to evaluate the covariates associated with poor blood pressure (BP) control in a Portuguese hypertensive population. Patients and Results: We conducted a cross-sectional survey in a hospital hypertension outpatient clinic, located in the Eastern Central Region of Portugal. Patients attending the clinic from July to September 2009 were asked to participate in a structured interview including medication adherence and knowledge about hypertension. Eligible participants were all adults aged 18 or over with an established diagnosis of arterial hypertension and had been on antihypertensive drug treatment for at least 6 months. Exclusion criteria were dementia, pregnancy, and breastfeeding. Detailed clinical information was prospectively obtained from medical records. A total of 197 patients meeting the inclusion criteria and consenting to participate completed the interview. Of these, only 33.0% had their BP controlled according to the JNC 7 guidelines. Logistic regression analysis revealed three independent predictors of poor BP control: living alone (OR = 5.3, P = 0.004), medication nonadherence (OR = 4.8, P < 0.001), and diabetes (OR = 4.4, P = 0.011). Predictors of medication nonadherence were: unawareness of target BP values (OR = 3.7, P < 0.001), a report of drug side effects (OR = 3.7, P = 0.002), lack of BP monitoring (OR = 2.5, P = 0.015) and unawareness of medication indications (OR = 2.4, P = 0.021), and of hypertension risks (OR = 2.1, P = 0.026). Conclusions: Poor medication adherence, lack of information about hypertension, and side effects should be considered as possible underlying causes of uncontrolled BP and must be addressed in any intervention aimed to improve BP control

Determinants of medication adherence to antihypertensive medications among a Chinese population using Morisky medication adherence scale

&lt;b&gt;Background and objectives&lt;/b&gt; Poor adherence to medications is one of the major public health challenges. Only one-third of the population reported successful control of blood pressure, mostly caused by poor drug adherence. However, there are relatively few reports studying the adherence levels and their associated factors among Chinese patients. This study aimed to study the adherence profiles and the factors associated with antihypertensive drug adherence among Chinese patients.&lt;p&gt;&lt;/p&gt; &lt;b&gt;Methods&lt;/b&gt; A cross-sectional study was conducted in an outpatient clinic located in the New Territories Region of Hong Kong. Adult patients who were currently taking at least one antihypertensive drug were invited to complete a self-administered questionnaire, consisting of basic socio-demographic profile, self-perceived health status, and self-reported medication adherence. The outcome measure was the Morisky Medication Adherence Scale (MMAS-8). Good adherence was defined as MMAS scores greater than 6 points (out of a total score of 8 points).&lt;p&gt;&lt;/p&gt; &lt;b&gt;Results&lt;/b&gt; From 1114 patients, 725 (65.1%) had good adherence to antihypertensive agents. Binary logistic regression analysis was conducted. Younger age, shorter duration of antihypertensive agents used, job status being employed, and poor or very poor self-perceived health status were negatively associated with drug adherence.&lt;p&gt;&lt;/p&gt; &lt;b&gt;Conclusion&lt;/b&gt; This study reported a high proportion of poor medication adherence among hypertensive subjects. Patients with factors associated with poor adherence should be more closely monitored to optimize their drug taking behavior

A Study on Impact of Clinical Pharmacist Interventions on Medication Adherence and Quality of Life in Rural Hypertensive Patients

Hypertension is the very common chronic disease in rural, urban and semi-urban areas of today's world, which needs continuous monitoring and treatment through out the life. Lack of education, lifestyle modification, and low level of understanding on disease management in rural people will influence directly on their quality of life (QOL). The objective of this study was to know the impact of clinical pharmacist interventions on medication adherence and QOL. It was a prospective, randomized and interventional study. Fifty-six patients were enrolled; only 52 patients completed the study. Interventional group patients received patient counselling, patient information leaflets (PILS), and frequent telephonic reminding. In the baseline, first and second follow-ups, medication adherence and QOL were assessed by using Morisky Medication Adherence Scale (MMAS) and Medication Adherence Report Scale (MARS) Questionnaires and SF-12v2 Quality of life Questionnaire in both the groups. The results showed that systolic blood pressure P value in the second follow-up was 0.086+ when compared to baseline follow-up P value 0.094. The diastolic blood pressure reading of the intervention group at the second follow-up was 77.73 ± 3.63 in mmHg when compared to the baseline, i.e. 86.62 ± 11.35 in mmHg. The MMAS and MARS scores P values were 0.007**, 1.000, <0.001**; 0.007, 0.014 and 0.000 at the baseline, first and second follow-ups, respectively. The QOL score P values of physical component scale and mental component scale showed highly significant. This study concluded/showed that the impact of clinical pharmacist provided patient counselling had a positive impact on medication adherence and QOL

Assessing the multidimensional relationship between medication beliefs and adherence in older adults with hypertension using polynomial regression.

The Necessity-Concerns Framework (NCF) is a multidimensional theory describing the relationship between patients' positive and negative evaluations of their medication, which interplay to influence adherence. Most studies evaluating the NCF have failed to account for the multidimensional nature of the theory, placing the separate dimensions of medication 'necessity beliefs' and 'concerns' onto a single dimension (e.g. the Beliefs about Medicines Questionnaire-difference score model). The purpose of this study was to assess the multidimensional effect of patient medication beliefs (concerns and necessity beliefs) on medication adherence using polynomial regression with response surface analysis. Community-dwelling older adults over 65 years old (n = 1,211), presenting their own prescription for antihypertensive medication to 106 community pharmacies in the Republic of Ireland, rated their concerns and necessity beliefs to antihypertensive medications at baseline and their adherence to antihypertensive medication at 12 months via structured telephone interview. Confirmatory polynomial regression found the difference-score model to be inaccurate; subsequent exploratory analysis identified a quadratic model to be the best-fitting polynomial model. Adherence was lowest among those with strong medication concerns and weak necessity beliefs, and adherence was greatest for those with weak concerns and strong necessity beliefs (slope β = -0.77, p < 0.001; curvature β = -0.26, p = 0.004). However, novel nonreciprocal effects were also observed; patients with simultaneously high concerns and necessity beliefs had lower adherence than those with simultaneously low concerns and necessity beliefs (slope β = -0.36, p = 0.004; curvature β = -0.25, p = 0.003). The difference-score model fails to account for the potential nonreciprocal effects. The results therefore extend evidence supporting the use of polynomial regression to assess the multidimensional effect of medication beliefs on adherence

Longitudinal association between medication adherence and glycaemic control in Type 2 diabetes

Aim Despite the widespread assumption that adherence drives glycaemic control, there is little published support for this in Type 2 diabetes. The study objective was to determine whether self‐reported medication adherence predicts future glycaemic control in Type 2 diabetes, after accounting for baseline control. Methods Medication adherence (4‐item Morisky scale), glycaemic control (HbA 1c %), and other variables were assessed in 287 adult primary care patients prescribed oral medication (40% also on insulin) for Type 2 diabetes. Glycaemic control was reassessed 6 months later. Regression analyses examined concurrent and future glycaemic control as a function of baseline medication adherence after adjustment for baseline glycaemia and other potential confounders. Results Only half of patients reported high adherence. Cross‐sectional adjusted analysis replicated prior reports of an adherence‐HbA 1c association ( P  = 0.011). Even after adjusting for baseline HbA 1c , each one‐point increase in baseline Morisky total score was associated with a 1.8 mmol/mol (or 0.16%) increase in HbA 1c measured 6 months later. Additionally, baseline endorsement of forgetting to take medication was associated with a 4.7 mmol/mol (or 0.43%) increase in 6‐month HbA 1c ( P  = 0.005). This effect persisted after adjusting for psychological distress and did not vary by key demographic and medical features. Conclusions Even after stringent adjustment for baseline glycaemic control, self‐reported adherence to diabetes medication predicts long‐term glycaemic control. The Morisky scale is an easy‐to‐use clinical tool to identify patients whose glycaemic control will subsequently worsen, regardless of age, gender and psychological distress.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/96675/1/dme12046.pd

Opt-out as an acceptable method of obtaining consent in medical research: a short report

<p>Abstract</p> <p>Background</p> <p>A prospective cohort study was set up to investigate a possible association between antibiotic prescribing and antibiotic resistance of <it>E. coli </it>urinary tract infection in the community. Participation of patients with urinary tract infection was obtained through an opt-out methodology. This short paper reports on the acceptability of the opt-out recruitment approach.</p> <p>Methods</p> <p>Participating practices (22) were requested to send a urine sample from all patients presenting with symptoms of urinary tract infection. Upon receipt of the sample in the laboratory, a letter explaining the study, an opt-out form and a freepost envelope were sent to all adult patients. A website with additional information and including an 'opt-out' button was set up for the study.</p> <p>Results</p> <p>A total of 1362 urine samples were submitted by the 22 participating practices representing 1178 adult patients of whom 193 actively responded to the letter: 142 opted out by letter, 15 through the website, 2 by phone and 12 sent the letter back without indication, making a total of 171 patients or 14.5% opt-out; the remaining 22 patients (1.9%) explicitly opted in. The total group consisted of 80% women and the mean age was 50.9 years (sd 20.8). No significant differences were found between patients who participated and those who opted out in terms of age, gender or whether the urine sample was positive or not.</p> <p>Conclusions</p> <p>Overall the opt-out method was well received and participation in the study reached 85.5%. The low number of complaints (2) indicates that this is a generally acceptable method of patient recruitment. The 14.5% opt-out shows that it effectively empowers patients to decline participation. The similarity between patients opting out and the rest of the patients is reassuring for extrapolation of the results of the study.</p