Simplification of the dosing regimen (eg, once-daily instead of multiple dosing) improves patients' adherence to anti- hypertensive medications (strength of recommendation [SOR]: B, based on a high- quality systematic review of lower-quality randomized controlled trials). Dietary advice promotes modest short-term improvements in self-reported fat intake and fruit and vegetable consumption (SOR: B, based on a high-quality systematic review of lower-quality, randomized controlled trials)

Jamieson, Barbara

Viera, Anthony J.

University of Missouri: MOspace

	 vol	56,	No	3	/	march	2007	 229www.jfponline.comCliniCal INquIrIes From the Family Physicians Inquiries Networkanthony J. Viera, MD, MPHDepartment of Family Medicine, University of North Carolina at Chapel HillBarbara Jamieson, MlSMedical College of Wisconsin Libraries, MadisoncoNT INueDDietary advice promotes modest short-term  improvementsfast trackHow effective are  hypertension self-care  interventions?  simplification	of	the	dosing	regimen	(eg,	once-daily	instead	of	multiple	dosing)	improves	patients’	adherence	to	antihyper-tensive	medications	(strength	of	recom-mendation	[sor]:	B,	based	on	a	high-quality	systematic	review	of	lower-quality	randomized	controlled	trials).	Dietary	advice	promotes	modest	short-term	improvements	in	self-reported	fat	intake	and	fruit	and	vegetable	consumption	(sor:	B,	based	on	a	high-quality	systematic	review	of	lower-quality,	randomized	controlled	trials).	educational	interventions	alone,	in	general,	do	not	improve	patient	adher-ence	to	antihypertensive	medication	regimens	(sor:	B,	based	on	a	high-	quality	systematic	review	of	lower-quality,	randomized	controlled	trials).	Physicians’	advice	to	increase	physical	activity	is	not	effective,	even	as	part	of	a	self-care	plan	for	hypertension	(sor:	B,	based	on	1	randomized	trial).	Work with patients to set goals  for lifestyle changes, and follow-up  to see if these goals are metPromoting	behavior	change	and	self-care	for	chronic	illness	challenges	every	family	physician.	start	with	the	evidence	and	promote	adherence	by	simplifying	your	patient	dosing	regimens.	Watch	costs	and	co-pays.	advise	patients	at	the	start	of	treatment	that	they	are	likely	to	need	more	than	one	medication	to	control	their	blood	pressure.	use	combination	medications	when	possible.	emphasize	the	importance	of	controlling	blood	pressure	through	weekly	follow-up	appointments	until	the	patient	meets	his	blood	pressure	target.	remind	patients	that	hypertension	is	a	“silent	disease”—the	first	symptom		of	high	blood	pressure	is	often	a	heart		attack	or	stroke.	show	patients	their		Framingham	risk	score.	Work	with	your	patient	to	set specific goals	for	lifestyle	changes.	Follow-up	to	see	if	these	goals	are	met.	assess	barriers	to	change	if	goals	are	not	met.	use	your	health	care	team	and		outside	resources.	screen	for	and	treat	depression.	To	promote	adherence	and	mo-tivate	lifestyle	changes,	encourage	patients	to	use	home	blood	pressure	monitors.	Lauren DeAlleaume, MDuniversity	of	colorado	Denver	and	health	sciences	centerEvidence-based answerClinical commentaryz Evidence summarySelf-care can be defined as activities that a patient undertakes with the intention of improving health or preventing dis-ease. Self-care for hypertension includes taking medicine as prescribed, monitor-ing blood pressure response to therapy, and adopting lifestyle recommenda-Copyright® Dowden Halth Media  For personal use onlyFor mass reproduction, content licensing and permissions contact Dowden Health Media.230 vol	56,	No	3	/	march	2007		ThE JournAL of fAMiLy PrACTiCECliniCal INquIrIesdosage regimens. Relative improvement in adherence ranged from 8% to 20%. Educational strategies alone were largely ineffective in improving adher-ence. Only 1 of 6 studies of patient edu-cation intervention demonstrated im-proved adherence, but the trial was small (n=110), and the effect was not seen in the other studies (total of 1103 patients). Research on motivating patients  is inconsistentMotivation and support strategies con-sisted of interventions such as drug reminder charts, self-recording of blood pressure, mail reminders, and home visits. Overall, out of 24 RCTs studying motivational, support, and reminder interventions, 10 demonstrated statisti-cally significant but small improvements in adherence. These studies relied on measures such as pill counts and self-report to assess adherence rather than electronic monitoring. The marked in-consistency among the body of evidence makes it difficult to determine whether motivational, support, and reminder interventions alone are effective in im-proving adherence. Out of 18 studies of interventions classified as complex health and organi-zational interventions, including many with an educational or motivational component, interventions in 8 studies led to a statistically significant improve-ment in adherence. Complex interven-tions included structured hypertension management programs such as work-site care provided by trained nurses. An example of an intervention given in combination is a program of home vis-its, education, and specialized dosing devices. Because these interventions var-ied considerably, an overall statement of effectiveness is not appropriate. Modest success seen  in improving dietA Cochrane review of dietary advice for reducing cardiovascular disease risk 7 studies found  a statistically  significant  improvement  in adherence  with once-daily  vs twice-daily regimensfast tracktions—increasing exercise, decreasing salt intake, and increasing fruits and vegetable consumption.Keeping meds simple  improves adherenceVarious interventions have been devel-oped with the goal of improving medica-tion adherence among patients with hy-pertension. A Cochrane review included 38 randomized controlled trials (RCTs) of 58 various types of interventions (some tested in factorial trials) designed to improve patient adherence to antihy-pertensive medications in ambulatory settings.1 The quality of the studies was generally low due to inadequate alloca-tion concealment, lack of blinding of out-come assessors, loss to follow-up, and the small number of participants in trials. The authors grouped interventions into 4 broad categories: simplification of dosing regimens; patient education; patient motivation, support, and re-minders; and complex interventions. Comparison groups received either no intervention, usual care, or—in the case of simplification of dosing regimens—a daily regimen consisting of more than 1 pill per day vs a once-daily regimen. Be-cause of various types of interventions and different methods of assessing out-comes, pooling of results was, appropri-ately, not done.Of all the interventions, simplifica-tion of dosing regimens had the most evidence of effectiveness, with 7 out of 9 studies demonstrating a statistically significant improvement in adherence in the intervention group. In the other 2 studies, improved adherence was observed in the intervention group; however, the effect was either not statis-tically significant or not reported. Five of the studies used a system that electronically recorded the time and date when a medicine container was opened. All studies using this rigorous system for outcome measurement demonstrated statistically significant improvement in adherence with once-daily vs twice-daily 	 vol	56,	No	3	/	march	2007	 231www.jfponline.comamong healthy adults included 29 tri-als.2 Individuals or groups of patients received verbal or printed dietary advice over 1 or more personal contacts. They also received advice by telephone. Ten RCTs of dietary advice in 4328 partici-pants or groups of participants assessed self-reported dietary fat intake. Overall, intake of dietary fat (expressed as a percentage of total ca-loric intake) fell by 6.2% (95% confi-dence interval [CI], reduced 8.4% to in-creased 4.0%) with dietary intervention over 6 to 48 months. Due to significant heterogeneity between the studies, this overall estimate must be viewed with caution. Eight RCT studies in 3952 partici-pants or groups of participants assessed self-reported fruit and vegetable in-take as an outcome. Overall, intake of fruits and vegetables increased by 1.2 servings per day (95% CI, 0.43–2.1) with interventions over 6 to 48 months. Again, there was significant heterogene-ity between the studies. Therefore, this overall estimate must be viewed with caution. In general, the quality of the studies included in this systematic review was low due to poor descriptions of ran-domization, lack of allocation conceal-ment, and lack of blinding of outcome assessment. The use of food frequency questionnaires to measure fat and fruit/vegetable intake likely led to report-ing bias in these dietary intervention studies. Also, the trials were in healthy adults and not specific to hypertensive patients. Motiviating patents to exercise remains a challengeWe found 1 randomized trial that evalu-ated the effectiveness of a physician’s ad-vice to increase physical activity among patients with hypertension in a general practice setting.3 Physical activity was measured using a validated question-naire. Patients given the advice as part of self-care for hypertension (n=192) were no more likely to have increased their physical activity than those not given the advice (n=108) at 2- and 6-month follow-ups.Recommendations from othersThe Seventh Report of the Joint Na-tional Committee on Prevention, Detec-tion, Evaluation, and Treatment of High Blood Pressure (JNC 7) states that self-measurement of blood pressure may benefit patients by providing informa-tion on response to antihypertensive medication and improving adherence with therapy.4 The report also notes that the pa-tient and clinician must agree on blood pressure goals, and that patient motiva-tion to adopt lifestyle changes and take prescribed medication improves when patients have positive experiences and trust their clinicians. nreferences	 1.	 	schroeder	 K,	 Fahey	 T,	 ebrahim	 s.	 Interventions	for	 improving	 adherence	 to	 treatment	 in	 patients	with	 high	 blood	 pressure	 in	 ambulatory	 settings.	Cochrane Database Syst Rev	2004;	(2):cD004804.	 2.	 	Brunner	eJ,	Thorogood	m,	rees	K,	hewitt	G.	Di-etary	 advice	 for	 reducing	 cardiovascular	 risk.	Cochrane Database Syst Rev	2005;	(4):cD002128.	 3.	 	marshall	 al,	 Booth	 ml,	 Bauman	 ae.	 Promoting	physical	activity	 in	australian	general	practices:	a	randomized	trial	of	health	promotion	advice	versus	hypertension	 management.	 Patient Educ Couns 2005;	56:283–290.	 4.	 	chobanian	av,	Bakris	Gl,	Black	hr,	et	al.	The	sev-enth	 report	 of	 the	 Joint	 National	 committee	 on	Prevention,	 Detection,	 evaluation,	 and	 Treatment	of	high	Blood	Pressure:	 the	JNc	7	 report.	JAMA	2003;	289:2560–2572.Patients’  physical activity did not change when physicians suggested they exercise moreHow effective are hypertension self-care interventions?fast track

How effective are hypertension self-care interventions?

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