Antihypertensive Medication Nonadherence Research Articles

Decomposing the effect of drug benefit program on antihypertensive medication adherence among the elderly in urban China.

PurposeHypertension is a rapidly growing epidemic in People’s Republic of China, yet it remains inadequately controlled. This study aimed to identify the relative contributions of program effects and patients’ characteristics to the differences in antihypertensive medication nonadherence between drug benefit program enrollees and non-enrollees.Patients and methodsData were from a cross-sectional survey of 1,969 community-dwelling elderly adults with hypertension. Self-reported adherence was measured following previous studies in People’s Republic of China. The Blinder-Oaxaca nonlinear decomposition method was used to identify the relative contributions of program effects and patients’ individual characteristics.ResultsEleven percent of the drug benefit program enrollees were nonadherent to their medication, while 17% of non-enrollees were. Blinder-Oaxaca decomposition identified that over 60% of the gap between the two groups was due to the program effects (P=0.024). The rest could be explained by differences in observable characteristics (P<0.001), such as diabetic status, duration of hypertension, and blood pressure control.ConclusionThe study confirmed that drug benefit program enrollees were more likely to be adherent to their antihypertensive medication than non-enrollees in the context of People’s Republic of China.

Treatment of Resistant and Refractory Hypertension.

Resistant hypertension (RHTN) is defined as uncontrolled blood pressure despite the use of ≥3 antihypertensive agents of different classes, including a diuretic, usually thiazide-like, a long-acting calcium channel blocker, and a blocker of the renin- angiotensin system, either an ACE (angiotensin-converting enzyme) inhibitor or an ARB (angiotensin receptor blocker), at maximal or maximally tolerated doses. Antihypertensive medication nonadherence and the white coat effect, defined as elevated blood pressure when measured in clinic but controlled when measured outside of clinic, must be excluded to make the diagnosis. RHTN is a high-risk phenotype, leading to increased all-cause mortality and cardiovascular disease outcomes. Healthy lifestyle habits are associated with reduced cardiovascular risk in patients with RHTN. Aldosterone excess is common in patients with RHTN, and addition of spironolactone or amiloride to the standard 3-drug antihypertensive regimen is effective at getting the blood pressure to goal in most of these patients. Refractory hypertension is defined as uncontrolled blood pressure despite use of ≥5 antihypertensive agents of different classes, including a long-acting thiazide-like diuretic and an MR (mineralocorticoid receptor) antagonist, at maximal or maximally tolerated doses. Fluid retention, mediated largely by aldosterone excess, is the predominant mechanism underlying RHTN, while patients with refractory hypertension typically exhibit increased sympathetic nervous system activity.

Abstract P209: Antihypertensive Medication Non-Adherence is Common in Patients With Suspected Refractory Hypertension

Introduction: Refractory hypertension is a phenotype of antihypertensive treatment failure defined as uncontrolled BP (&gt; 135/85 mmHg) despite the use of five or more different antihypertensive agents, including long-acting thiazide like diuretic (chlorthalidone) and mineralocorticoid receptor antagonist (Spironolactone or Eplerenone). Recently white coat effect has been shown to be uncommon in patients with refractory hypertension. However, the degree of medication non-adherence, an important cause of apparent refractory hypertension, is unknown. Methods: In this prospective evaluation, 37 refractory hypertensive patients were recruited from the University of Alabama at Birmingham Hypertension Clinic after having uncontrolled BP at three or more clinic visits. All patients were evaluated by automated office BP (AOBP) with the BpTRU device, ambulatory BP monitoring (ABPM), and 24-hr urine collection to detect antihypertensive medication adherence by high-performance liquid chromatography-tandem mass spectrometry. Out of 34 patients who underwent ABPM monitoring, 30 (88%) patients were refractory hypertensive by AOBP and by ABPM. Of these, 27 patients had 24-hr urine collection for detection of prescribed antihypertensive medications or their metabolites. Results: Out of 27 patients, 11 (40.7%) patients had complete adherence with five or more antihypertensive medications, indicating true refractory hypertension. Ten (37.0%) patients were partially adherent, and 6 (22.2%) patients had total non-adherence to their antihypertensive medications. Conclusion: Of patients identified as having apparent refractory hypertension, 40% were adherent with at least 5 of their prescribed antihypertensive agents, confirming true refractory hypertension. The remaining 60% were partially or fully non-adherent. These results indicate that non-adherence is common in patients suspected of having refractory hypertension.

Abstract P178: Trends in Antihypertensive Medication Nonadherence Among US Adults With Commercial Health Insurance Initiating Treatment Between 2007 and 2014

Introduction: Nonadherence to antihypertensive medication is common and associated with cardiovascular disease events. A previous study reported improvements in antihypertensive medication adherence among adults ≥65 years of age. It is unclear if this trend has also occurred among younger adults. Methods: Changes in antihypertensive medication nonadherence were calculated among commercially-insured US adults &lt;65 years of age initiating treatment from 2007 to 2014 using MarketScan claims data. We required beneficiaries have ≥2 diagnoses for hypertension (ICD-9, 401.xx) and insurance coverage for 365 days prior to and following antihypertensive medication initiation. Initiation was defined by a pharmacy claim for antihypertensive medication with no claims for medication within the previous 365 days. During the 365 days after initiation, nonadherence was defined as having a proportion of days covered &lt;80%. Results: The percentage of patients who were nonadherent to their antihypertensive medication was 55.6% in 2007 and 54.1% in 2014 (p-trend&lt;0.001) ( Table ). After multivariable adjustment, the relative risk (RR) of nonadherence in 2014 compared with 2007 was 0.98 (95% CI 0.96-0.99). Risk for nonadherence was lower at older age (RR 0.73, 95% CI 0.71-0.74 comparing adults 55-64 to &lt;25 years of age). Nonadherence was more common among adults that were female versus male (RR 1.05; 95% CI 1.05-1.06), initiated treatment with a loop diuretic (RR 1.26; 95% CI 1.24-1.28), had diabetes (RR 1.11; 95% CI 1.10-1.12), or experienced a serious fall injury after medication initiation (RR 1.10; 95% CI 1.06-1.15), and less common among adults initiating treatment with an angiotensin receptor blocker (RR 0.96; 95% CI 0.95-0.96), multiclass regimen (RR 0.89; 95% CI 0.88-0.90), receiving 90-day fills (RR 0.73; 95% CI 0.73-0.74), or medications by mail (RR 0.92; 95% CI 0.91-0.93). Conclusion: Among adults &lt;65 years of age, nonadherence to antihypertensive medication did not meaningfully decrease between 2007 and 2014.

Group-Based Trajectory Models: Assessing Adherence to Antihypertensive Medication in Older Adults in a Community Pharmacy Setting.

Antihypertensive medication nonadherence is highly prevalent, leading to uncontrolled blood pressure. Methods that facilitate the targeting and tailoring of adherence interventions in clinical settings are required. Group‐Based Trajectory Modeling (GBTM) is a newer method to evaluate adherence using pharmacy dispensing (refill) data that has advantages over traditional refill adherence metrics (e.g. Proportion of Days Covered) by identifying groups of patients who may benefit from adherence interventions, and identifying patterns of adherence behavior over time that may facilitate tailoring of an adherence intervention. We evaluated adherence to antihypertensive medication in 905 patients over a 12‐month period in a community pharmacy setting using GBTM, identifying three subgroups of adherence patterns: 52.8%, 40.7%, and 6.5% had very high, high, and low adherence, respectively. However, GBTM failed to demonstrate predictive validity with blood pressure at 12 months. Further research on the validity of adherence measures that facilitate interventions in clinical settings is required.

Factors associated with antihypertensive medication non-adherence: a systematic review.

Non-adherence to antihypertensive medication is the most important cause of uncontrolled blood pressure and is influenced by multiple interrelating factors. Understanding the complexity of medication non-adherence and its associated factors is important to determine intervention strategies. Therefore, a systematic review was performed aimed to identify factors associated with antihypertensive medication non-adherence. Different databases were searched for observational studies reporting on factors associated with non-adherence to antihypertensive medication. Titles, abstracts and full texts were reviewed by three researchers. Subsequently, the methodological quality of each study was assessed. Factors that were extracted from the included studies were categorised as factors with consistent or inconsistent evidence to put their potential importance into perspective. Forty-four studies were included. Higher co-payment, side effects and a poor patient-provider relationship were identified as factors with consistent evidence since consistent significant relationships were found for these factors whenever studied. The relationships between non-adherence and multiple other factors were inconsistent among the reviewed studies. However, some of these factors deserve some consideration. Since multiple potentially relevant factors were identified, patient-tailored interventions focussing on identifying and addressing patients' specific barriers to adherence are needed. Further research should clarify the influence of inconsistent factors on adherence and their potential to be addressed in interventions.

Vital Signs: Disparities in Antihypertensive Medication Nonadherence Among Medicare Part D Beneficiaries - United States, 2014.

Nonadherence to taking prescribed antihypertensive medication (antihypertensive) regimens has been identified as a leading cause of poor blood pressure control among persons with hypertension and an important risk factor for adverse cardiovascular disease outcomes. CDC and the Centers for Medicare and Medicaid Services analyzed geographic, racial-ethnic, and other disparities in nonadherence to antihypertensives among Medicare Part D beneficiaries in 2014. Antihypertensive nonadherence, defined as a proportion of days a beneficiary was covered with antihypertensives of <80%, was assessed using prescription drug claims data among Medicare Advantage or Medicare fee-for-service beneficiaries aged ≥65 years with Medicare Part D coverage during 2014 (N = 18.5 million). Analyses were stratified by antihypertensive class, beneficiaries' state and county of residence, type of prescription drug plan, and treatment and demographic characteristics. Overall, 26.3% (4.9 million) of Medicare Part D beneficiaries using antihypertensives were nonadherent to their regimen. Nonadherence differed by multiple factors, including medication class (range: 16.9% for angiotensin II receptor blockers to 28.9% for diuretics); race-ethnicity (24.3% for non-Hispanic whites, 26.3% for Asian/Pacific Islanders, 33.8% for Hispanics, 35.7% for blacks, and 38.8% for American Indians/Alaska Natives); and state of residence (range 18.7% for North Dakota to 33.7% for the District of Columbia). Considerable county-level variation in nonadherence was found; the highest nonadherence tended to occur in the southern United States (U.S. Census region nonadherence=28.9% [South], 26.7% [West], 24.1% [Northeast], and 22.8% [Midwest]) More than one in four Medicare Part D beneficiaries using antihypertensives were nonadherent to their regimen, and certain racial/ethnic groups, states, and geographic areas were at increased risk for nonadherence. These findings can help inform focused interventions among these groups, which might improve blood pressure control and cardiovascular disease outcomes.

Abstract P258: Antihypertensive Medication Nonadherence Among Hispanic Adults by Healthcare Access and Acculturation Characteristics - Estilos Survey, 2015

Medication adherence for hypertensive adults (HTNs) is an important factor in achieving and maintaining blood pressure control, as it has been associated with better health outcomes and lower costs of medical care. We assessed the differences in the prevalence of self-reported antihypertensive medication use and adherence among Hispanic HTNs by selected characteristics. Methods: ESTILOS is an online panel for health survey data of Hispanic adults in the USA. In 2015, 1,000 adults completed the survey with a response rate of 29%. The resulting data were weighted using 8 factors: gender, age, household income, household size, education, census region, country of origin, and acculturation (based on years living in the USA, language spoken at home, cultural self-identification, and use of Spanish language). The differences among characteristics for prevalence ± standard error of medication use and adherence were compared by using χ 2 statistics. Results: The prevalence of hypertension was 27.5±2.7%. The prevalence of antihypertensive medication use in HTNs was 67.9±4.6%) overall and was higher among those ≥55 years of age (95.2±2.1%; P =&lt;0.0001), retirees (92.3±4.0%; P =0.0002), who had healthcare coverage (72.5±4.8%; P =0.02) and had a primary care physician (PCP) (71.9±4.9%; P =0.03), did not have any reported cost barriers to seeing their PCP within past 12 months (71.9±5.3%; P =0.001), and took 3-4 lifestyle actions (79.7±5.4%; P =0.015) than &lt;3 lifestyle actions). Among HTNs taking antihypertensives, 24.0±7.0% reported missing or skipping medication doses. HTNs aged &lt;55 years or who could not see a PCP within the past year due to cost barriers, were more likely to miss or skip doses of antihypertensive medication (&lt;55=54.1±13.4%) vs &gt;55=11.5±5.3%; P =0.03 and could not see PCP=45.2±12.1% vs 12.0±5.2%; 0.01, respectively). Conclusion: Poor antihypertensive medication adherence among Hispanics with hypertension was associated with younger age groups and those who reported barriers to engaging with a PCP. Public health practitioners and clinicians can utilize this information to support their programs and can tailor strategies for improved outcomes.

Risk Factors Associated With Antihypertensive Medication Nonadherence in a Statewide Medicaid Population

BackgroundThis study seeks to determine the most important patient factors and health care exposures available through administrative databases associated with antihypertensive nonadherence. MethodsThis is a cross-sectional analysis of Medicaid hypertensive patients of Tennessee enrolled for 3 to 7 years from 1994 to 2000. Demographic characteristics, comorbidity and health care utilization were assessed during a 2-year period. The primary outcome was antihypertensive medication refill nonadherence. Subjects were categorized as adherent or nonadherent using an 80% cutoff criteria. Associations with nonadherence were assessed using logistic regression modeling. ResultsOf 49,479 subjects, 60.6% (n = 29,970) were classified as nonadherent and 39.4% (n = 19,509) as adherent. Significant predictors of nonadherence in multivariate analysis (P < 0.05) included male sex (odds ratio [OR] 1.12), black race (OR 1.67), urban residence (OR 1.12), obesity (OR 1.10), mental illness (OR 1.08) and substance abuse (OR 1.43). Significant protective factors included age (OR 0.97), disability (OR 0.62), diabetes (OR 0.76), hypercholesterolemia (OR 0.72) and Charlson index (OR 0.97). When health care utilization was considered, increased outpatient visits were associated with decreased nonadherence. Emergency department visits (OR 1.07) and hospital visits (OR 1.12) were associated with increased nonadherence. ConclusionsThis cross-sectional study suggests that substance abuse, black race, emergency department visits and hospitalizations are risk factors associated with nonadherence. Outpatient visits are associated with a small decrease in nonadherence. Further studies are needed to determine the characteristics of outpatient visits that most improve adherence.

Characterizing weekly self-reported antihypertensive medication nonadherence across repeated occasions.

BackgroundLittle is known about weekly variability in medication nonadherence both between and within persons.PurposeTo characterize medication nonadherence across repeated, closely spaced occasions.MethodsThis prospective cohort study comprised four unannounced telephone assessment occasions, each separated by approximately 2 weeks. On each occasion, adult outpatients taking at least a single antihypertensive medication completed a measure of extent of, and reasons for, nonadherence.ResultsTwo hundred and sixty-one participants completed 871 (83%) of 1,044 occasions. Nonadherence was reported on 152 (17.5%) of 871 occasions by 93 (36%) of 261 participants. The most commonly endorsed reasons for nonadherence were forgetting (39.5%), being busy (23.7%), and traveling (19.7%). Among 219 participants completing at least three occasions, 50% of the variability in extent of nonadherence was a result of within-person fluctuations, and 50% was a result of between-person differences.ConclusionInterventions to reduce nonadherence should be informed by variability in the extent of nonadherence and specific reasons for nonadherence.

Characterizing weekly self-reported antihypertensive medication nonadherence across repeated occasions

Characterizing weekly self-reported antihypertensive medication nonadherence across repeated occasions

Antihypertensive Medication Non-Adherence in Black Men: Direct and Mediating Effects of Depressive Symptoms, Psychosocial Stressors and Substance Use

Antihypertensive Medication Non-Adherence in Black Men: Direct and Mediating Effects of Depressive Symptoms, Psychosocial Stressors and Substance Use

Antihypertensive Medication Nonadherence in Black Men: Direct and Mediating Effects of Depressive Symptoms, Psychosocial Stressors, and Substance Use

Black men suffer disproportionately from hypertension. Antihypertensive medication nonadherence is a major contributor to poor blood pressure control, yet few studies consider how psychosocial functioning may impact black men's medication adherence. The authors examined the direct and mediating pathways between depressive symptoms, psychosocial stressors, and substance use on antihypertensive medication nonadherence in 196 black men enrolled in a clinical trial to improve hypertension care and control. The authors found that greater depressive symptoms were associated with more medication nonadherence (β=0.05; standard error [SE], 0.01; P<.001). None of the psychosocial stressor variables were associated with antihypertensive medication nonadherence. Alcohol misuse was associated with increased medication nonadherence (β=0.81; SE, 0.26; P<.01), but it did not mediate the association between depressive symptoms and medication nonadherence. Clinicians should consider screening for depressive symptoms and alcohol misuse if patients are found to be nonadherent and should treat or refer patients to appropriate resources to address those issues.

Factors related to medication non‐adherence for patients with hypertension in Taiwan

To characterise a Taiwanese population and to examine the prevalence of antihypertensive medication non-adherence and how the cultural/clinical factors were associated with non-adherence in Taiwan. Antihypertensive medication non-adherence is a significant clinical issue in the United States. However, little is known about hypertension (HTN) control and cultural/clinical factors related to non-adherence in Taiwan. A convenience sample survey design was used. Data were gathered from a convenience sample of 200 subjects recruited from a large teaching hospital. Medication non-adherence and cultural/clinical factors were recorded using various self-administered questionnaires, and blood pressure was taken twice for each participant. The mean age of the participants was 60.4 (SD 11.5 years) including 62% men. Two-thirds had less than a high school education (64.5%), and the majority of them were married (86·0%) and lived with family or close friends (93.5%). The average length of HTN diagnosis was 8.6 years (SD 9.0 years). Medication non-adherence rate was 47·5%, and uncontrolled HTN rate was 49.0%. Some participants (17.0%) used Chinese herbs for treating their disease (e.g. cough) and promoting health in addition to their regular antihypertensive medications. Two factors were found to be statistically significant for predicting medication non-adherence: Lower Perceived Susceptibility to Specific Diseases [OR = 1.15 (95%CI, 1.01-1.31)] and Longer Length of HTN Diagnosis [OR = 1.06 (95%CI, 1.01-1.12)]. Taiwanese at risk of non-adherence included those who perceived lower susceptibility to specific diseases and had been diagnosed with HTN for a longer time. Those using herbs need to be studied for an impact of herbs on their adherence behaviour. These findings can help guide the development of culturally sensitive and clinically appropriate nursing interventions for HTN management in Taiwan.

Predictors of uncontrolled hypertension and antihypertensive medication nonadherence

Background: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.

Antihypertensive Medication Adherence Among Elderly Chinese Americans

This study explored the level of antihypertensive medication adherence and examined certain demographic attributes and influential factors in relation to antihypertensive medication nonadherence among Chinese American elders using a descriptive cross-sectional survey design. Findings revealed that 52% of the elderly Chinese Americans adhered to their antihypertensive medications. Gender, education, years of residency in the United States, years of diagnosed hypertension, and perceived safety of taking antihypertensive medications did not contribute to the differences in medication adherence. Forgetfulness, medication adverse effects, language difficulties, and cultural barriers were the influential factors that hinder antihypertensive medication adherence. Developing effective and culturally appropriate strategies for Chinese American elders is recommended.