Hannah Durand

Medication adherence among patients with apparent treatment-resistant hypertension: systematic review and meta-analysis.

Objectives: Medication nonadherence is a known behavioural contributor to poor blood pressure (BP) control that puts patients with hypertension at elevated cardiovascular risk. Studies of medication adherence for apparent treatment-resistant hypertension (aTRH) vary significantly with respect to design, methods, and setting, and, as a result, have produced highly variable figures describing the prevalence of nonadherence. This review aimed to describe the prevalence and potential moderators of medication nonadherence estimates for aTRH. Methods: Systematic review and random effects meta-analysis. Results: From an initial discovery of 921 studies, we identified 24 studies that measured medication adherence for patients with uncontrolled BP despite being prescribed three or more antihypertensive medications of different classes. By using a random effects model, the pooled prevalence of nonadherence was 31.2% (95% confidence interval = 20.2–44.7, I2 = 99.50) with nonadherence rates ranging from 3.3 to 86.1%. The strongest contributor to variance in nonadherence rates was the method of adherence assessment used. Studies that relied on self-report measures of adherence and/or pharmacy data reported lower levels of nonadherence than studies using more objective methods, such as liquid chromatography–mass spectrometry in single time-point bioassays or directly observed therapy. Conclusion: Findings indicate that medication nonadherence is a significant problem among aTRH patients. Identifying the most accurate and clinically feasible adherence assessment methods is necessary to reduce BP and cardiovascular morbidity, facilitate early behavioural intervention, prevent unnecessary diagnostic testing, and limit sometimes unnecessary and expensive BP lowering procedures. Registration number: CRD42016028121.

Effectiveness and content analysis of interventions to enhance medication adherence and blood pressure control in hypertension: A systematic review and meta-analysis

Objective: The objective of this systematic review is to evaluate the effectiveness of medication adherence interventions on blood pressure control in hypertensive patients. In addition, we aim to explore what barriers and facilitators in the interventions may have been targeted and how these might be related to the effect size on blood pressure (BP). Design: This review is a hypertension-specific update to the previous Cochrane Review by Nieuwlaat et al. (2014) on interventions to enhance medication adherence. A systematic literature search was carried out and two authors independently screened titles and abstracts for their eligibility for inclusion and independently extracted data from the selected studies and assessed the methodological quality using the Cochrane Collaboration Risk of Bias Tool. A meta-analysis was conducted and additionally, theoretical factors in interventions were identified using the Theoretical Domains Framework. Results: The meta-analysis found a modest main effect of adherence interventions on SBP (MD −2.71 mm Hg, 95% CI −4.17 to −1.26) and DBP (MD −1.25 mm Hg, 95% CI −1.72 to −.79). However, there was substantial significant heterogeneity across both outcomes. A narrative review on adherence outcomes was conducted. In terms of the theoretical analysis, the relationship between the total number of times the domains were coded within an intervention and change of SBP (r  =  −.234, p = .335) and DBP was not significant (r  =  −.080, p = .732). Similarly, the relationship between the total number of times different domains were coded within an intervention and change of SBP (r  =  .080, p = .746) and DBP was not significant (r  =  −.188, p = .415). Discussion: This review and meta-analysis of interventions documented significant but modest post-intervention improvements in BP outcomes among hypertensive patients. However, this is a tentative finding as substantial heterogeneity and potential biases were present. One of the greatest challenges of this review was assessing risk of bias, extracting sufficient data to calculate effect size and coding interventions with the amount of information provided in papers. It is imperative that future adherence research comprehensively reports methodology.

Judgement analysis of case severity and future risk of disability regarding chronic low back pain by general practitioners in Ireland

Chronic low back pain is a major healthcare burden that has wide ranging effects on the individual, their family, society and the workplace. However, appropriate management and treatment is often difficult, as a majority of cases are non-specific in terms of underlying pathology. As a result, there are extensive differences in both individual patient preferences for treatment and treatment decisions amongst general practitioners. The current study examined the clinical judgements of GPs in Ireland, regarding fictional patients’ case severity and future risk of disability, through judgement analysis. Judgement analysis (JA) is an idiographic regression modelling technique that has been utilised in extant healthcare research for the purpose of allocating weighting to judgement criteria, or cues, observed by professionals in their clinical decision-making. The primary aim of the study was to model two critical information utilisation tasks performed by GPs with regard to CLBP–in combining information cues to form a judgement about current case severity and a judgement about the same patient’s risk of future disability. It was hypothesised that the judgement weighting would differ across the two judgements and that judgements regarding future risk of disability would be less consistent among GPs than judgements about case severity. Results from the regression-based judgement analysis and subsequent follow-up statistical analysis provided support for both study hypotheses. Study findings are discussed in light of theory and research on judgement, clinical decision-making and chronic low back pain.

[LB.02.06] APPARENT AND TRUE TREATMENT RESISTANT HYPERTENSION IN GP: A CROSS SECTIONAL STUDY OF PREVALENCE WITH CONSIDERATION OF MORBIDITY, WHITE COAT HYPERTENSION, DOSING AND ADHERENCE

Objective: Treatment Resistant Hypertension (TRH) is defined as high blood pressure in patients taking three or more groups of anti-hypertensive medications (one must be a diuretic) or those taking four or more medications regardless of type and BP level. Target BP levels need to be adapted to specific morbidity (e.g. diabetes), ambulatory blood pressure measurement (ABPM) should be used to exclude white coat hypertension, doses should be the optimal tolerated, and both non-adherence and lifestyle should be examined. Most previous studies have not accounted for these considerations. We conducted a cross sectional study of the prevalence of apparent TRH in general practice, utilizing the appropriate definition, and then considered these issues. Design and method: Forty university-research affiliated practices were invited to participate. We ran a standard ATC drug search identifying patients on any possible hypertensive medications. Two researchers reviewed individual patients records. The World Health Organisation-Defined Daily Dosing guidelines determined adequate dosing. A measure of adherence was whether patients were printed greater than nine repeat prescriptions within the last year. Results: Sixteen practices participated (N = 50, 878). 2, 807 patients had been prescribed three or more medications previously and of these 646 were deemed to have aTRH. They were largely elderly, male and had co-morbidities (Diabetes 36.7% and Chronic Kidney Disease 40%). 19.0% had adequate medication dosing for each medication and 79.9% were deemed adherent by printed prescription record. Using a BP cut-off of 140/90 mm Hg, the prevalence of aTRH was 6.4% (95%CI 5.8–7.0),130/80 mm Hg for patients with diabetes or CKD, the prevalence was 10.0% (95%CI 9.3–10.8), reducing to 9.0% (95%CI 8.3–9.7) when a threshold BP of 150/80 mm Hg was applied for over eighties. Considering adequate dosing and adherence reduces prevalence rates even further. Conclusions: Reviewing individual patient records results in a lower estimate of the prevalence of aTRH than has been generally previously reported. Consideration for individual patients of criteria such as morbidity, dosing, white coat hypertension and adherence additionally lowers these estimates, and may be all that is required for the management of the vast majority of cases.