The effectiveness of health coaching, home blood pressure monitoring, and home-titration in controlling hypertension among low-income patients: protocol for a randomized controlled trial

Background  

Despite the many antihypertensive medications available, two-thirds of patients with hypertension do not achieve blood pressure control. This is thought to be due to a combination of poor patient education, poor medication adherence, and "clinical inertia." The present trial evaluates an intervention consisting of health coaching, home blood pressure monitoring, and home medication titration as a method to address these three causes of poor hypertension control.     

Health beliefs of hypertensive patients in a family medicine residency program.

This paper presents the results of a survey of the hypertensive patient population in a university family medicine practice to determine health beliefs, patient perceptions of the severity of their condition, stated levels of compliance to drug regimens, frequency of drug side effects, and frequency of physician discussions of drug side effects and diet. Health beliefs were then associated with diastolic hypertension and increase in medication dosage over a four-month period. Results of the survey sharpen the focus of patient education efforts by the family physician on specific attitudes, beliefs, and treatment issues which are most appropriate for the hypertensive patient. The physician may improve his/her management of hypertensive patients by: (1) anticipating prevalent myths and misconceptions which patients have concerning hypertension; (2) alleviating patient anxiety by stressing that control of blood pressure decreases the likelihood of complications; (3) effectively communicating to each patient the current status of his/her condition at each visit; and (4) initiating discussion of side effects through direct questioning for those effects most frequently seen.     

辽宁省农村高血压患者服药依从性与血压控制水平研究

目的评价辽宁省农村高血压患者服药依从性及其与血压控制水平之间的关系。方法按照多级整群随机抽样原则,采用统一问卷调查辽宁省五县386名≥35岁高血压服药患者的服药顺应性、服药持续性、服药依从性及血压持续控制水平。结果随年龄增加血压控制率降低,70岁以上患者血压控制率低于低年龄组(OR=0.31,95%CI:0.12～0.80)。服药持续性、顺应性和依从性良好比例分别为51.30%,31.09%和22.28%。服药控制率随服药顺应性(OR=0.35,95%CI:0.18～0.69)和依从性水平(OR=0.45,95%CI:0.21～0.94)降低而下降,仅8.03%的服药患者血压持续控制优良。结论辽宁省农村高血压患者服药依从性差,致使血压控制不理想。需采取综合干预措施提高血压控制率,降低并发症发生。     

The Knowledge, Attitude and Practice of Blood Pressure Management from the Patient's Viewpoint: A Qualitative Study

OBJECTIVES: This study adopted a qualitative method to explore the layman's beliefs and experience concerning high blood pressure and its management in order to develop a strategy to increase adherence to proper medical treatment. METHODS: Semi-structured interviews that focused on personal experiences with hypertension and its management were conducted with 26 hypertensive patients. The participants were selected according to a BP above 140/90 mmHg (hypertension stage 1), based on the seventh report of the Joint National Committee on prevention, detection, evaluation and treatment of high blood pressure (JNC-VII). The interviews lasted for approximately 30 minutes (range: 20-60 minutes). The resulting questions were formulated into open-ended questions. The interview questionnaire was composed 17 items to examine non-adherence to treatment and 19 items to examine adherence to treatment. RESULTS: Most participants recognized that the direct cause of high blood pressure was unhealthy behavior rather than inheritance. Thus, the hypertensive patient believed they could recover their blood pressure to a normal level through removing the direct cause of hypertension (weight reduction, diet, exercise) instead of taking drugs. The reasons for these statements were that the drugs for controlling hypertension are not natural or they are artificial, and they may have side effects, and drugs are not treatment for the root cause of hypertension. Most of the hypertensive patients chose to manage their behaviors as soon as they knew their blood pressure was high. Therefore, we should not divide the subjects into two groups according to their taking drugs or not, but they should be divided into two groups according to their willingness or not to manage their condition. CONCLUSIONS: For developing a strategy for an individual approach to hypertension management, we need to develop a client-centered attitude and strategy. That is, we need to tailor our approach to individual cases to avoid generalizations and stereotyping when developing an adherence increasing strategy.     

天津市社区中老年高血压患者服药依从性及卫生服务利用情况

目的评价天津市社区中老年高血压患者服药依从性和卫生服务利用情况。方法于2010年对2个社区中老年高血压患者727人进行问卷调查和血压测量。调查内容包括抗高血压药物服药情况、就医方式及医疗费用支付形式等。结果服药者388人,其中治疗依从性佳者占22.35%;不依从的322名患者中,主要原因是"遗忘",占33.54%。在727名调查对象中,身体不适时首选到正规大医院就诊的占44.57%,到社区卫生服务中心就诊的占24.21%。社会医疗保险为主要医疗费用支付形式(60.11%),医疗费用全自费的占33.43%。结论社区中老年高血压患者的服药依从性有待加强,应提高其自我保健意识,并进一步发挥社区卫生服务中心的作用。     

A cluster-randomized controlled trial evaluating the effect of culturally-appropriate hypertension education among Afro-Surinamese and Ghanaian patients in Dutch general practice: study protocol

Background  

Individuals of African descent living in western countries have increased rates of hypertension and hypertension-related complications. Poor adherence to hypertension treatment (medication and lifestyle changes) has been identified as one of the most important modifiable causes for the observed disparities in hypertension related complications, with patient education being recommended to improve adherence. Despite evidence that culturally-appropriate patient education may improve the overall quality of care for ethnic minority patients, few studies have focused on how hypertensive individuals of African descent respond to this approach. This paper describes the design of a study that compares the effectiveness of culturally-appropriate hypertension education with that of the standard approach among Surinamese and Ghanaian hypertensive patients with an elevated blood pressure in Dutch primary care practices.     

The impact of reference pricing on healthcare outcomes in patients with arterial hypertension

ObjectivesReference pricing is a proven cost-containment measure; however, there are concerns about its potential negative effects on patients. Slovenia introduced generic reference pricing (GRP) in 2003 and therapeutic reference pricing (TRP) in 2013, including TRP for ACE inhibitors and a new group of angiotensin II receptor blockers in September 2018. We aimed to evaluate the impact of GRP and TRP on medication adherence and blood pressure control in patients with hypertension.MethodsWe performed a prospective cohort study in community pharmacies in Slovenia. At visit 1, we recorded patient characteristics, including history of antihypertensive treatment, medicine substitutions, and co-payments, as well as blood pressure measurements and medication adherence. Eight weeks later on visit 2, we re-assessed medication adherence and blood pressure.ResultsOf the 114 patients, only three (2.6%) patients’ therapies changed because of GRP and none changed due to TRP. Thirty-six (31.6%) patients co-paid for prescribed antihypertensive medicine. Medication adherence was significantly better among patients who co-paid for their blood-pressure-lowering therapy than it was among those prescribed a reference medicine. Patients with reference medicines had lower blood pressure compared to patients with co-payments; however, the multiple linear regression models showed no effect of co-payment on blood pressure.ConclusionWe conclude that reference pricing did not negatively affect blood pressure control in patients with hypertension; in fact, it may promote medication adherence in these patients.     

提高高血压患者服药依从性的探讨

目的：探讨高血压患者坚持服药治疗的的护理方法。方法：对在某院就诊的368例高血压患者进行服药情况及相关因素进行调查。结果：服药依从性佳者152例,服药依从性不佳者216例,依从率为41.3%。影响服药依从性的因素有性别、年龄、文化程度、家庭经济、亲友病史、高血压常识、血压升高程度、药物不良反应、药费贵等因素。结论：提高服药依从率的关键是采用有针对性的个性化措施和积极的护理策略。     

Nurse-led adherence support in hypertension: a randomized controlled trial

BACKGROUND: Lack of medication adherence is a common reason for poor control of blood pressure in the community, increasing the risk of heart attacks and strokes. OBJECTIVE: To evaluate the effect of nurse-led adherence support for people with uncontrolled high blood pressure compared with usual care. METHODS: We recruited 245 women and men with uncontrolled hypertension (> or = 150/90 mmHg) from 21 general practices in Bristol, UK. Participants were randomized to receive nurse-led adherence support or usual care alone. Main outcome measures were adherence to medication ('timing compliance') and blood pressure. RESULTS: Mean baseline timing compliance (+/- SD) was high in both the intervention (90.8 +/- 15.6%) and the control group (94.5 +/- 7.6%). There was no evidence of an effect of the intervention on timing compliance at follow-up (adjusted difference in means -1.0%; 95% confidence interval (CI) -5.1 to 3.1). There was also no difference at follow-up between the groups with regard to systolic blood pressure (-2.7 mmHg; 95% CI -7.2 to 1.8) or diastolic blood pressure (0.2 mmHg; 95% CI -1.9 to 2.3). Projected costs for the primary care sector per consultation were 6.60 pound sterling for the intervention compared with 5.08 pound sterling for usual care. CONCLUSION: In this study, adherence to blood pressure medication was much higher than previously reported. There was no evidence of an effect of nurse-led adherence support on medication adherence or blood pressure compared with usual care. Nurse-led adherence support was also more expensive from a primary care perspective.     

儿童注意缺陷多动障碍药物依从性及影响因素

注意缺陷多动障碍(ADHD)是儿童和青少年期最常见的神经发育障碍,约影响全世界5%～11%的儿童。药物治疗是6岁以上ADHD儿童首选方案,约70%患者药物治疗有效。多种药物已被应用于ADHD临床治疗,如盐酸哌甲酯和苯丙胺、盐酸托莫西汀及可乐定和胍法辛等。药物副作用、药物剂型、患儿生长速度、家庭因素、患儿用药体验、睡眠问题或障碍等多种因素均会影响药物依从性。医生、父母和患儿共享信息、商讨治疗方案、监测疗效和副作用,并积极开展医教结合、家校结合,实施行为管理和干预,有助于提高依从性、改善治疗效果,促进患儿学业成绩及社会功能、生活质量全面提升。     

Adherence and effectiveness of drug combination in curative treatment among children suffering uncomplicated malaria in rural Senegal

Increased Plasmodium falciparum resistance to chloroquine has prompted national malaria programs to develop new policies in several African countries. Less than a year after the introduction of amodiaquine/sulfadoxine-pyrimethamine (AQ/SP) as first-line treatment in Senegal, we examined adherence rates to therapy and its efficacy among children. The study was conducted in five dispensaries in rural Senegal. Children aged 2-10 years with a presumptive diagnosis of malaria were prescribed AQ/SP. Thick blood film analyses were carried out on days 0, 3, 7, 14 and 28. Blood and urine samples were collected on day 3 for drug level measurements. The principal caregivers were questioned on treatment adherence. Among the 289 recruited children, 144 had a parasitemia >2500/microl. The results demonstrated markedly good efficacy for the treatment, as no detectable parasitemia was observed on day 28 for 97.9% of the children. However, we noticed that 35.3% of children did not comply with the recommended doses and 62.3% did not exactly adhere to the drug schedule. Despite the good efficacy of the drugs, adherence to the therapeutic scheme was poor. Strategies to promote patient adherence would improve drug performance and thus might help to prevent the rapid emergence of drug resistance.     

Relationship of blood pressure self-monitoring, medication adherence, self-efficacy, stage of change, and blood pressure control among municipal workers with hypertension

Uncontrolled blood pressure remains a major public health issue. Medication adherence is a key factor in blood pressure management; however, adherence behavior is not clearly understood and the most significant factors contributing to poor medication adherence and blood pressure control are unknown. The purpose of this study was to determine the relationship of self-monitoring of blood pressure, medication adherence, self-efficacy, stage of change, and blood pressure control among municipal workers with access to health insurance. Stage of change was a significant independent predictor of self-monitoring of blood pressure, but not blood pressure control. A strong relationship was found between medication adherence and medication adherence self-efficacy (r = .549, p < .05).     

杭州市余杭区社区管理高血压病患者不同服药情况对血压控制的影响

目的探索高血压病患者不同服药情况对血压控制的影响,为防治对策提供依据。方法利用2009年杭州市余杭区4个示范社区高血压病患者随访记录。按照年度内服药时间和血压测定结果,服药分规则、间断、偶治;血压控制分优良、尚可、不良。分析不同服药时间的长、短,对血压控制的效果影响。对有关数据进行χ2检验,P〈0.05为差异有统计学意义。结果共调查社区管理的高血压病病患者800例,规则服药率66.2%,影响规则服药依从性的主要与个体的患病年限有关,而性别、年龄差异无统计学意义。高血压病患者血压控制率为64.4%,规则和不规则服药患者的血压控制率分别为79.8%和34.1%,差异有统计学意义（P〈0.01,RR=2.34）。结论坚持规则服药对高血压病患者的血压控制是必要的,社区随访中提高患者规则服药依从性对血压控制具有重要意义。     

Positive benefits of a pharmacist-managed hypertension clinic in Nigeria

OBJECTIVE: The aim of this study was to determine whether the provision of further practice-based support by pharmacists will bring about improved outcomes for blood pressure (BP) control in middle-aged and elderly Nigerian hypertensive patients managed with combination diuretics (amiloride hydrochloride 5 mg+hydrochlorothiazide 50 mg) and/or methyl dopa at the primary care level. DESIGN AND SETTING: This was a 1-year prospective, randomized cohort study of the outpatients of a state comprehensive health centre in South-western Nigeria. Free primary health services including free drugs were provided for all patients. PATIENTS AND METHOD: The study population comprised 51 Nigerian patients with uncomplicated hypertension aged 45 years or more, with a 0.2-3.0-year history of hypertension, registered at the Comprehensive Health Centre, Ife between October 2002 and March 2003. They were invited into the pharmacist-managed hypertension clinic and followed for the study period. Participating pharmacists counselled for current medication, personalized goals of lifestyle modification stressing weight loss and/or increased activity, increased patient awareness by providing relevant education about hypertension and associated/related diseases, adjusted drug therapy to optimize effectiveness and minimize adverse events, utilized treatment schedules that enhanced patients' adherence to therapy, and monitored treatment outcomes between enrollment and return visits. Patient satisfaction and the number of treatment failures within 6 months post enrollment were compared with retrospective data from our earlier study involving physician-managed patients under a similar setting. RESULTS: Uncontrolled BP reduced from 92 to 36.2% by 10.15+/-5.02 days after enrollment. Treatment failures were observed at 5.9% of the total return visits (n=184) within 6 months. CONCLUSION: Pharmacist-managed hypertension clinics can improve BP control, reduce treatment failure and increase patient satisfaction.     

Integration of depression and hypertension treatment: a pilot, randomized controlled trial

PURPOSE We wanted to examine whether integrating depression treatment into care for hypertension improved adherence to antidepressant and antihypertensive medications, depression outcomes, and blood pressure control among older primary care patients.METHODS Older adults prescribed pharmacotherapy for depression and hypertension from physicians at a large primary care practice in West Philadelphia were randomly assigned to an integrated care intervention or usual care. Outcomes were assessed at baseline, 2, 4, and 6 weeks using the Center for Epidemiologic Studies Depression Scale (CES-D) to assess depression, an electronic monitor to measure blood pressure, and the Medication Event Monitoring System to assess adherence.RESULTS In all, 64 participants aged 50 to 80 years participated. Participants in the integrated care intervention had fewer depressive symptoms (CES-D mean scores, intervention 9.9 vs usual care 19.3; P <.01), lower systolic blood pressure (intervention 127.3 mm Hg vs usual care 141.3 mm Hg; P <.01), and lower diastolic blood pressure (intervention 75.8 mm Hg vs usual care 85.0 mm Hg; P <.01) compared with participants in the usual care group at 6 weeks. Compared with the usual care group, the proportion of participants in the intervention group who had 80% or greater adherence to an antidepressant medication (intervention 71.9% vs usual care 31.3%; P <.01) and to an antihypertensive medication (intervention 78.1% vs usual care 31.3%; P <.001) was greater at 6 weeks.CONCLUSION A pilot, randomized controlled trial integrating depression and hypertension treatment was successful in improving patient outcomes. Integrated interventions may be more feasible and effective in real-world practices, where there are competing demands for limited resources.     

Longitudinally measured blood pressure, antihypertensive medication use, and cognitive performance: the Framingham Study

The relation of longitudinally measured blood pressure to cognitive performance in the absence of clinically diagnosed cerebrovascular disease was investigated in the Framingham Study. In 1976-1978, neuropsychologic testing was administered to 1993 participants aged 55-89 years. Performance on an education-adjusted composite of these tests was examined in relation to measures of chronicity of hypertension as well as the average systolic and average diastolic blood pressure. All analyses were stratified by antihypertensive medication use during the 2 years prior to cognitive testing and adjusted for age, sex, occupation, alcohol consumption, and participation rate in prior examination cycles. Among subjects on drug therapy for hypertension, there was no association between cognitive performance and longitudinally measured blood pressure. The proportion of cycles in which hypertension was present and average systolic and diastolic blood pressure had a significant inverse relation with cognitive performance only in the group not on antihypertensive drug therapy. However, among subjects on antihypertensive medication at earlier cycles, there was a highly significant graded relation between cognitive impairment and the probability of being off medication at the time of testing. These results suggest that hypertension-related subclinical vascular disease is not an important cause of cognitive impairment in the elderly. Cognitive impairment may, however, be associated with a reduced adherence to drug treatment regimens.