Advantages to Using Social-Behavioral Models of Medication Adherence in Research and Practice.

Achieving and sustaining high levels of adherence to medication regimens is essential to improving health outcomes, but continues to be a challenge for a sizable proportion of patients. Decades of research suggests that medication adherence is determined by a complex constellation of factors. Social-behavioral science research has focused on creating frameworks that identify which contextual, personal, social, or drug-related factors appear to most influence adherence. Comprehensive models of adherence propose specific structural relationships between these factors that can be used to plan for, implement, and monitor programs that seek to optimize adherence. The use of social-behavioral models offers multiple advantages in both practice and research environments; however, the breadth and depth of these models can deter many from engaging in this important exercise. To promote the use of social-behavioral frameworks and models of adherence, we provide a brief overview of the advantages in using a social-behavioral lens in adherence work, a sampling of models used in HIV medication adherence research that have high generalizability to other conditions, and practical guidance for grounding adherence promotion strategies in evidence informed by social-behavioral science research.

Intensive vs Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years: A Randomized Clinical Trial.

IMPORTANCE: The appropriate treatment target for systolic blood pressure (SBP) in older patients with hypertension remains uncertain. OBJECTIVE: To evaluate the effects of intensive (<120 mm Hg) compared with standard (<140 mm Hg) SBP targets in persons aged 75 years or older with hypertension but without diabetes. DESIGN, SETTING, AND PARTICIPANTS: A multicenter, randomized clinical trial of patients aged 75 years or older who participated in the Systolic Blood Pressure Intervention Trial (SPRINT). Recruitment began on October 20, 2010, and follow-up ended on August 20, 2015. INTERVENTIONS: Participants were randomized to an SBP target of less than 120 mm Hg (intensive treatment group, n = 1317) or an SBP target of less than 140 mm Hg (standard treatment group, n = 1319). MAIN OUTCOMES AND MEASURES: The primary cardiovascular disease outcome was a composite of nonfatal myocardial infarction, acute coronary syndrome not resulting in a myocardial infarction, nonfatal stroke, nonfatal acute decompensated heart failure, and death from cardiovascular causes. All-cause mortality was a secondary outcome. RESULTS: Among 2636 participants (mean age, 79.9 years; 37.9% women), 2510 (95.2%) provided complete follow-up data. At a median follow-up of 3.14 years, there was a significantly lower rate of the primary composite outcome (102 events in the intensive treatment group vs 148 events in the standard treatment group; hazard ratio [HR], 0.66 [95% CI, 0.51-0.85]) and all-cause mortality (73 deaths vs 107 deaths, respectively; HR, 0.67 [95% CI, 0.49-0.91]). The overall rate of serious adverse events was not different between treatment groups (48.4% in the intensive treatment group vs 48.3% in the standard treatment group; HR, 0.99 [95% CI, 0.89-1.11]). Absolute rates of hypotension were 2.4% in the intensive treatment group vs 1.4% in the standard treatment group (HR, 1.71 [95% CI, 0.97-3.09]), 3.0% vs 2.4%, respectively, for syncope (HR, 1.23 [95% CI, 0.76-2.00]), 4.0% vs 2.7% for electrolyte abnormalities (HR, 1.51 [95% CI, 0.99-2.33]), 5.5% vs 4.0% for acute kidney injury (HR, 1.41 [95% CI, 0.98-2.04]), and 4.9% vs 5.5% for injurious falls (HR, 0.91 [95% CI, 0.65-1.29]). CONCLUSIONS AND RELEVANCE: Among ambulatory adults aged 75 years or older, treating to an SBP target of less than 120 mm Hg compared with an SBP target of less than 140 mm Hg resulted in significantly lower rates of fatal and nonfatal major cardiovascular events and death from any cause. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01206062.

Characterizing Frailty Status in the Systolic Blood Pressure Intervention Trial.

BACKGROUND: The Systolic Blood Pressure Intervention Trial (SPRINT) is testing whether a lower systolic blood pressure (BP) target of 120 mm Hg leads to a reduction in cardiovascular morbidity and mortality among hypertensive, nondiabetic adults. Because there may be detrimental effects of intensive BP control, particularly in older, frail adults, we sought to characterize frailty within SPRINT to address ongoing questions about the ability of large-scale trials to enroll representative samples of noninstitutionalized, community-dwelling, older adults. METHODS: We constructed a 36-item frailty index (FI) in 9,306 SPRINT participants, classifying participants as fit (FI ≤ 0.10), less fit (0.10 < FI ≤ 0.21), or frail (FI > 0.21). Recurrent event models were used to evaluate the association of the FI with the incidence of self-reported falls, injurious falls, and all-cause hospitalizations. RESULTS: The distribution of the FI was comparable with what has been observed in population studies, with 2,570 (27.6%) participants classified as frail. The median FI was 0.18 (interquartile range = 0.14 to 0.24) in participants aged 80 years and older (N = 1,159), similar to the median FI of 0.17 reported for participants in the Hypertension in the Very Elderly Trial. In multivariable analyses, a 1% increase in the FI was associated with increased risk for self-reported falls (hazard ratio [HR] = 1.030), injurious falls (HR = 1.035), and all-cause hospitalizations (HR = 1.038) (all p values < .0001). CONCLUSIONS: Large clinical trials assessing treatments to reduce cardiovascular disease risk, such as SPRINT, can enroll heterogeneous populations of older adults, including the frail elderly, comparable with general population cohorts.

Medication Adherence in Older Adults: A Qualitative Study.

To effectively address medication adherence and improve cardiovascular health among older adults, a deeper understanding is needed of the barriers that this age group faces and approaches that would be most effective and feasible for improving adherence. We conducted a focus group study (n=25) in a diverse population of older adults with hypertension recruited from the Cohort Study of Medication Adherence in Older Adults (CoSMO). A structured guide was used to collect feedback on barriers to adherence and acceptability and feasibility of intervention strategies. The final coding framework outlines factors at the individual, relationship, health care system, and environmental or policy level which affect adherence in older adults, including memory, knowledge, attitudes and beliefs, side effects, social support, interaction with health care providers, and cost and convenience of medication filling. Patient responses highlighted the varied nature of barriers and the need for interventions which are both multi-faceted and tailored.

Quality of life in hypertensive clinic patients following hurricane katrina.

BACKGROUND: The purpose of this study was to assess quality of life among hypertensive patients in the year following Hurricane Katrina. METHODS: Hypertensive patients (n â€Š=  211) in a multispecialty group practice in New Orleans completed validated surveys during the year after Hurricane Katrina. We assessed patients' demographics, quality of life (Medical Outcomes Study 36), hurricane coping self-efficacy, property damage, stress, and changes in distance from and visits with family and friends. RESULTS: The mean age of participants was 63.5 years, 45.0% were men, 70.6% were white, 89.5% had graduated from high school, and 68.3% were married. Mean quality of life scores (standard deviation) were physical functioning 64.6 (30.0), role physical 60.0 (42.8), bodily pain 59.9 (24.3), general health 60.4 (20.5), vitality 53.6 (26.5), social functioning 74.5 (28.1), role emotional 67.8 (41.1), and mental 72.3 (22.0). After adjustment for age, gender, and race, lower coping self-efficacy, more damage to their residence, higher levels of stress after the storm, increased distance from family and friends, and decreased visits with family and friends were associated with lower quality of life. Personal and financial losses were identified as the most common cause of postdisaster stress, reported by 29.6% of participants. CONCLUSIONS: Storm-related factors were associated with lower quality of life in adult patients with hypertension after Hurricane Katrina. Providers managing hypertensive patients in disaster-prone areas may want to consider these factors in identifying patients at risk for lower quality of life following catastrophes.

Health-related quality of life and antihypertensive medication adherence among older adults.

PURPOSE: health-related quality of life (HRQOL) is an important psycho-social characteristic which may impact an individual's ability to manage their chronic disease. We examined the association between HRQOL and antihypertensive medication adherence in older adults. METHODS: participants were part of a cohort study of older adults enrolled in a managed care organisation and treated for hypertension (n = 2,180). Physical and Mental Component Summary Scores (PCS and MCS) of HRQOL were assessed using the RAND Medical Outcomes Study 36-item tool. Adherence to antihypertensive medication was assessed with the eight-item Morisky Medication Adherence Scale. RESULTS: the mean age of participants was 75.0 +/- 5.6 years, 69.3% were white, 58.5% were women and 14.1% had low antihypertensive medication adherence. Low HRQOL scores were associated with lower levels of antihypertensive medication adherence in older adults. After adjustment for covariates, those with low PCS and MCS scores were 1.33 (95% CI 1.01, 1.74) and 2.26 (95% CI 1.74, 2.97) times more likely, respectively, to have low antihypertensive medication adherence than those with PCS and MCS scores in the top 2 tertiles. CONCLUSIONS: low HRQOL may be an important barrier to achieving high medication adherence.

Adverse effects of complementary and alternative medicine on antihypertensive medication adherence: findings from the cohort study of medication adherence among older adults.

OBJECTIVES: To determine the association between complementary and alternative medicine (CAM) use and antihypertensive medication adherence in older black and white adults. DESIGN: Cross-sectional. SETTING: Patients enrolled in a managed care organization. PARTICIPANTS: Two thousand were hundred eighty black and white adults aged 65 and older and prescribed antihypertensive medication. MEASUREMENTS: Information on CAM use (health food and herbal supplements, relaxation techniques) for blood pressure control and antihypertensive medication adherence were collected in a telephone survey between August 2006 and September 2007. Low medication adherence was defined as a score less than 6 using the eight-item Morisky Medication Adherence Scale. RESULTS: The mean age of participants was 75.0+/-5.6, 30.7% were black, 26.5% used CAM, and 14.1% had low antihypertensive medication adherence. In managing blood pressure, 30.5% of black and 24.7% of white participants had used CAM in the last year (P=.005), and 18.4% of black and 12.3% of white participants reported low adherence to antihypertensive medication (<.001). After multivariable adjustment for sociodemographic information, depressive symptoms, and reduction in antihypertensive medications because of cost, the prevalence ratios of low antihypertensive medication adherence associated with CAM use were 1.56 (95% confidence interval (CI)=1.14-2.15; P=.006) in blacks and 0.95 (95% CI=0.70-1.29; P=.73) in whites (P value for interaction=.07). CONCLUSION: In this cohort of older managed care patients, CAM use was associated with low adherence to antihypertensive medication in blacks but not whites.

Barriers to and determinants of medication adherence in hypertension management: perspective of the cohort study of medication adherence among older adults.

Low adherence to antihypertensive medication remains a public health challenge. Understanding barriers to, and determinants of, adherence to antihypertensive medication may help identify interventions to increase adherence and improve outcomes. The Cohort Study of Medication Adherence in Older Adults is designed to assess risk factors for low antihypertensive medication adherence, explore differences across age, gender, and race subgroups, and determine the relationship of adherence with blood pressure control and cardiovascular outcomes over time. This article discusses the relevance of this study in addressing the issue of barriers to anithypertensive medication adherence.

Cohort study of medication adherence in older adults (CoSMO): extended effects of Hurricane Katrina on medication adherence among older adults.

BACKGROUND: Previous research indicates that many patients with hypertension ran out of medications and had difficulties getting refills immediately after Hurricane Katrina. The extended effect of Hurricane Katrina on antihypertensive medication adherence is not well characterized. METHODS: Data were analyzed for 2194 participants who completed the baseline survey for the Cohort Study of Medication Adherence among Older Adults between August 2006 and September 2007. Based on pre-Katrina zip codes, the study population was categorized into high- and low-affected areas. Low medication adherence was defined as a score less than 6 on the 8-item Morisky Medication Adherence Scale. RESULTS: Prevalence of low adherence was similar among participants living in high and low affected areas. Low medication adherence was similar for participants with greater than or less than 25% of the residence damaged by Hurricane Katrina and for participants with and without symptoms of post-traumatic stress disorder. In high affected areas, nonsignificant associations were present for those who had moved since the storm and those with a friend or immediate family member who had died in the month after the storm. These factors were not associated with low medication adherence in low affected areas. In both high- and low-affected areas, lower scores on the hurricane coping self-efficacy scale were associated with low medication adherence (P < 0.05). CONCLUSIONS: The effect of Hurricane Katrina on patient adherence to antihypertensive medication was limited in the second year after the storm. Intrinsic patient factors, such as low coping self-efficacy, remain important factors associated with low adherence.

Medication adherence in older clinic patients with hypertension after Hurricane Katrina: implications for clinical practice and disaster management.

BACKGROUND: In post-disaster situations, additional barriers may reduce antihypertensive medication adherence. METHODS: Between November 2005 and August 2006, 210 hypertensive patients receiving care at a multispecialty group practice in New Orleans completed a structured questionnaire. Antihypertensive medication adherence was measured with the Hill-Bone medication compliance subscale. In a subset of patients, data on difficulties patients encountered with blood pressure medications in the aftermath of Hurricane Katrina were collected. RESULTS: : Seventy-six percent of patients reported damage to their residence and 46% of patients had less-than-perfect medication adherence. After multivariate adjustment, less than perfect medication adherence postdisaster was more common among people aged <65 years (prevalence ratio = 1.37; 95% confidence interval: 1.03-1.82) and non-whites (1.32; 95% confidence interval: 1.02-1.71). Uncontrolled blood pressure (systolic/diastolic > or =140/> or =90 mm Hg) was more common in those with less-than-perfect adherence than their counterparts with perfect adherence (51% versus 42%, respectively). In addition, 7% of patients reported not bringing their blood pressure medications when they evacuated, 28% ran out of blood pressure medications, 16% reported difficulties getting medications filled, and 28% reported a blood pressure medication change postdisaster. CONCLUSIONS: Opportunities exist to improve disaster planning and prescription refill processes and increase medication adherence and hypertension control postdisasters.

Prevalence and predictors of poor antihypertensive medication adherence in an urban health clinic setting.

Poor medication adherence may contribute to low hypertension control rates. In 2005, 295 hypertensive patients who reported taking antihypertensive medication were administered a telephone questionnaire including an 8-item scale assessing medication adherence. Overall, 35.6%, 36.0%, and 28.4% of patients were determined to have good, medium, and poor medication adherence, respectively. After multivariable adjustment, adults younger than 50 years and 51 to 60 years were 1.39 (95% confidence interval [CI], 0.56-3.42) and 1.53 (95% CI, 0.64-3.66), respectively, times more likely to be less adherent when compared with their counterparts who were older than 60 years. Black adults and men were 4.30 (95% CI, 1.06-17.5) and 2.45 (95% CI, 1.04-5.78) times more likely to be less adherent, respectively. Additionally, caring for dependents, an initial diagnosis of hypertension within 10 years, being uncomfortable about asking the doctor questions, and wanting to spend more time with the doctor if possible were associated with poor medication adherence. The current study identified a set of risk factors for poor antihypertensive medication adherence in the urban setting.

Effect of dietary fiber intake on blood pressure: a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: To examine the effect of dietary fiber intake on blood pressure (BP). DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING AND PARTICIPANTS: A total of 110 trial participants aged 30 to 65 years who had untreated, but higher than optimal BP or stage-1 hypertension were recruited from the community in New Orleans, Louisiana, USA. INTERVENTIONS: Study participants were randomly assigned to receive 8 g/day of water-soluble fiber from oat bran or a control intervention. MAIN OUTCOME MEASURES: Nine BP measurements were obtained by trained observers using random-zero sphygmomanometers, over three clinical visits, at the baseline and termination visits of the trial. An average of the nine measurements was used to determine mean BP at the baseline and termination visits. RESULTS: The net changes [95% confidence interval, (CI)] in systolic blood pressure were -1.8 mmHg (-4.3 to 0.8, P = 0.17) following 12 weeks, -2.2 mmHg (-5.3 to 1.0, P = 0.18) following 6 weeks, and -2.0 mmHg (-4.4 to 0.3, P = 0.09) for an average of the 6- and 12-week visits. The corresponding net changes (95% CI) in diastolic blood pressure were -1.2 mmHg (-3.0 to 0.5, P = 0.17) following 12 weeks, -0.8 mmHg (-3.1 to 1.4, P = 0.47) following 6 weeks, and -1.0 mmHg (-2.6 to 0.5, P = 0.19) for an average of the 6- and 12-week visits. CONCLUSIONS: Our findings suggest that a diet rich in fiber may have a moderate BP-lowering effect and indicate the need for further investigation of this important question.