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Patient Prefer Adherence. 2010; 4: 335343.Published online 2010 September 7.

PMCID: PMC2943225

Copyright 2010 Tsiantou et al, publisher and licensee Dove Medical Press Ltd.Factors affecting adherence to antihypertensive medication in Greece: results from a qualitativestudy

Vassiliki Tsiantou,1

Polina Pantzou,2

Elpida Pavi,1

George Koulierakis,2

and John Kyriopoulos1

1Department of Health Economics, National School of Public Health, Athens, Greece;2Department of Sociology, National School of Public Health, Athens, GreeceCorrespondence: Vassiliki Tsiantou, National School of Public Health, Department of HealthEconomics, Alexandras Ave 196, 11521 Athens, Greece, Tel +30 210 64 35 328, Fax +30 21064 49 571, Email [email protected] Received August 26, 2010This is an Open Access article which permits unrestricted noncommercial use, provided theoriginal work is properly cited.

y Other Sections o

Abstract o Introduction o Methods o Results o Patientphysician relationship o Patientpharmacist relationship o Discussion o Conclusion o References

Abstract

Introduction:Although hypertension constitutes a major risk factor for cardiovascular morbidity and mortality,research on adherence to antihypertensive treatment has shown that at least 75% of patients arenot adherent because of the combined demographic, organizational, psychological, and disease-and medication-related factors. This study aimed to elicit hypertensive patients beliefs onhypertension and antihypertensive treatment, and their role to adherence.Methods:Transcripts from semistructured interviews and focus groups were content analyzed to extract

participants beliefs about hypertension and antihypertensive treatment, and attitudes toward patientphysician and patientpharmacist relationships.Results:Hypertension was considered a very serious disease, responsible for stroke and myocardialinfarction. Participants expressed concerns regarding the use of medicines and the adverse drugreactions. Previous experience with hypertension, fear of complications, systematic diseasemanagement, acceptance of hypertension as a chronic disease, incorporation of the role of the

patient and a more personal relationship with the doctor facilitated adherence to the treatment.On the other hand, some patients discontinued treatment when they believed that they hadcontrolled their blood pressure.Conclusion:


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Cognitive and communication factors affect medication adherence. Results could be used todevelop intervention techniques to improve medication adherence.Keywords: hypertension, medication adherence, patient compliance, doctorpatientcommunication, antihypertensive medicine

y Other Sections

o Abstract o Introduction o Methods o Results o Patientphysician relationship o Patientpharmacist relationship o Discussion o Conclusion o References

Introduction Nonadherence to treatment medication, especially in chronic diseases, is a complicated issueaffecting patients health, health expenditure, and recourses utilization. 1,2 A number of studies,

both qualitative and quantitative, examine the factors that are believed to explain variations inadherence in other chronic diseases. 3 5 Based on such findings, interventions have beendesigned to improve patient compliance. 6 Research on health behaviors, such as medication adherence, has resulted in the formulation of specific psychological theories addressing patients beliefs and roles. Leventhal and co lleaguesSelf-Regulatory Model (SRM) 7 suggests that when individuals face a health threat, they form

both cognitive and emotional representations of the disease, which act in parallel to influenceassociated health behaviors. Cognitive representations comprise of beliefs on illness identity,

antecedent causes, consequences, timeline, and cure-control, 8 whereas the emotionalrepresentations comprise individuals emotional reaction to the disease. Furthermore,individuals beliefs about treatment have been proposed as another determinant to understand theway in which patients make decisions about their treatment. 9 Finally, different aspects of doctorpatient communication have been examined as potential predictors of medicationadherence. 10 Hypertension is the medical condition where the systolic blood pressure is more than 140 mmHg and the diastolic blood pressure is more than 90 mm Hg. 11 It is a chronic disease which isconsidered to be one of the major public health problems and a significant cardiovascular risk factor. According to the World Health Organization (WHO), each year, at least 7.1 million

people die as a result of increased blood pressure. 12 For the treatment of hypertension, a broadrange of antihypertensive medications are currently available, as well as Therapeutic LifestyleChanges such as weight reduction, increased physical activity, and reduction of dietary saltintake, which have proven to be important in disease management. 13 Although there is evidencethat increased blood pressure can actually be controlled with the cardiovascular risk factor beingthus reduced, 14 75% of patients diagnosed with hypertension cannot achieve full control of their

blood pressure. 13 Poor blood pressure control is associated with higher healthcare resourceutilization and costs 15 and increased risk of cardiovascular diseases. Nonadherence to


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antihypertensive medication is the main reason for failure to control blood pressure among thoseunder treatment. 16 In Greece, although there is no nationwide data available for the prevalence of hypertension, it isestimated that 25% of the adult population are suffering from it. 11 Moreover, it is estimated that40% of hypertensive adults are unaware of their condition, and 25% of those receiving treatment

do not succeed in controling their blood pressure. 11 Other studies have shown that awarenessand control of hypertension and blood pressure is lower in Greece compared with other countries. 17,18 In addition, few studies have been conducted in Greece investigating the issue of adherence totreatment. The aim of the present study was to investigate the factors affecting antihypertensivemedication adherence in Greece.

y Other Sections o Abstract o Introduction o Methods o

Results o Patientphysician relationship o Patientpharmacist relationship o Discussion o Conclusion o References

MethodsStudy designSemistructured interviews and focus groups were conducted in order to elicit data from peoplewith hypertension. Semistructured interviews were preferred for those attending the

Hypertension Centers (HCs) (Group A), allowing the investigators to approach themindividually, as HC attendees were of older age. Older age is related to sensory loss thatinterferes with reception of the spoken message. People with sensory loss thus frequentlyexperience communication problems. 19 One-to-one semistructured interviews could overcomethis problem, which might otherwise influence older age participants ability to participateeffectively in focus groups. Focus groups were preferred for the group of younger participants(Group B), aged between 40 and 50 years, who were not or usually were not attending the HC,suffer from sensory loss. The age criterion was based on the available data regardinghypertension prevalence in Greece. 20 According to these data, diagnosed hypertensive patientsyounger than the age of 40 years represent less than 1.6% of the total number of hypertensive

patients. Although it would be really hard for these patients to be identified, we decided to havethis age criterion of hypertensive patients older than 30 years in case we could not find anyone

between the ages of 3040 years. In the case of focus groups, the lower limit was increased, from30 to 40 years of age, because it was impossible for us to identify hypertensive patients betweenthe ages of 3040 years among the registered hypertensive patients. Fieldwork was conductedduring the period MayJuly 2008.Participants and settingsGroup A participants were recruited from HC established in hospitals of the greater Athens area.Three HCs were purposively selected in order to reflect different geographic and socioeconomic


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regions. Two were established in public hospitals, and the third was established in an insurancefund hospital. In each center, the physician in charge assisted researchers to recruit patients.Participants had to meet the following inclusion criteria in order to participate in the study: (a)

being aged above 30 years, (b) receiving antihypertensive treatment for at least 1 year, and (c)speaking the Greek language fluently.

When patients who met the inclusion criteria attended the HC, on a specific day, an invitationletter was given to them by their physician explaining the purpose and the methodology of thestudy. In total, 25 patients accepted to be interviewed. Interviews were conducted, immediatelyafter patients medical examination in a private room in the HC, provided for the purposes of thisstudy.All interviews were facilitated by two researchers (psychologist [PP] and co-moderator [VT]).All interviews were anonymous and were audio taped, after participants consent.For Group B participants, the inclusion criteria were as follows: (a) being aged between 40 and50 years, (b) receiving antihypertensive treatment for at least 1 year, (c) not consulting an HC,and (d) speaking the Greek language fluently.Recruitment for Group B participants was made with convenience and purposive sampling. A

telephone invitation survey among 200 registered hypertensive patients was conducted in order to identify those who met the inclusion criteria and were willing to attend the focus groupsessions. In total, 18 patients (50% female) accepted to participate. Similar to semistructuredinterviews, participants were informed about the aims of the study, the methodology, and wereassured of anonymity and confidentiality.Two focus groups were organized, one comprising of 9 males and the other comprising of 9females, in order to facilitate group dynamics and achieve higher homogeneity. 21 Each groupwas moderated by an experienced psychologist and a co-moderator whose primary responsibilitywas to take notes during sessions. Both researchers met after each session in order to assess the

procedure and identify crucial elements for the interpretation of the data.Focus groups took place at the Department of Health Economics, National School of PublicHealth in Athens. The first session had a duration of 2 hours 8 minutes and the second 2 hours 22minutes. Comfortable chairs, beverages, and snacks were offered in order to create a pleasantatmosphere and lighten the burden of the long duration of the focus group. Focus group sessionswere tape-recorded, after participants written consent.Content and questionsAccording to standard methodology, open-ended questions and probes were predetermined for use during the semistructured interviews and the focus groups. These were based on the reviewof the relevant literature, taking into consideration the recommendations of the research team.Questions and probes fell within four research topics (see Table 1 ): perceptions and beliefs abouthypertension, perceptions and beliefs toward antihypertensive treatment, patientphysicianrelationship, and patientpharmacist relationship. Commencing questions in each research topicwere general, capturing participants beliefs in hypertension and treatment. Probes were morespecific in order to elicit the opinion, experience, and behavior of the participant. Onlydemographic information was collected by a purpose-made short questionnaire.

Table 1 Topics and subtopics of the qualitative study

Analysis


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All interviews and focus group recordings, as well as notes kept by the focus group co-moderator, during the sessions were fully transcribed. Transcriptions were analyzed usingcontent analysis, 22 without using any qualitative data software. Each researcher (PP and VT)separately studied the transcriptions and the notes kept by the co-moderator, identified theemergent themes and keywords, and categorized the findings according to the four research

topics. Then, the research team met in order to compare the findings, interpret results, andformulate conclusions. Demographic data were analyzed using MS Excel 2007.

y Other Sections o Abstract o Introduction o Methods o Results o Patientphysician relationship o Patientpharmacist relationship o Discussion o

Conclusion o References

ResultsGroup A comprised of 25 participants aged between 47 and 79 years (mean age, 63.7 years),whereas the 18 participants in Group B were aged between 40 and 50 years (mean age, 44.6years; Table 2 ). Participants did not differ significantly in relation to gender. Group A

participants were more likely (84%) to be under medication treatment for co-morbidities thantheir Group B counterparts (66.7%); however, this difference did not reach statisticalsignificance.

Table 2

Demographic characteristics of the participants

Perceptions and beliefs about hypertensionHypertension was considered a very serious disease responsible for even more dangerousmedical conditions such as stroke and myocardial infarction. Stress, anxiety, limited physicalactivity, and unhealthy diet emerged as the perceived most important risk factors of hypertension.

y Hypertension has very serious consequences, you can have a stroke it is very bad.(Group A, female)

y Cardiovascular diseases and death. This is what I am thinking when I hear hypertension. If you dont control it you will die. (Group B, female)

y I believe that stress is the major factor that makes all of us or at least most of ussuffering from hypertension (Group B, male)

y It is not only stress, but the way of life in general. (Group B, male)

Sources of information


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The main sources of information were the physician or the pharmacist, the media, the Internet,and people who suffered from hypertension. However, participants admitted that their physicianwas the most trusted source. Participants were interested in further information for two reasons:to achieve a better understanding of their doctors advice and to check the validity of this advice.

y My doctor gave me some information, but I search information through Internet too, so Ican cross-check what he says. (Group A, male)

y mainly my doctor and some books. But usually I talk with people who also suffer from hypertension, I feel more comfortable discussing with them (Group A, female)

y There are TV programs about health, but I always discuss everything I hear with mydoctor (Group B, male)

Symptoms and disease diagnosisAlthough hypertension was associated with well-recognized symptoms, such as headaches anddizziness, participants often did not seek health care, at least until those symptoms becameunbearable.

y I knew that I had high blood pressure but I had never gone to a doctor, until I couldnt bear the pain of the headaches (Group A, male)

y I was feeling a constant pressure in my head, so I decided to consult a doctor (GroupB, female)

When symptoms were mild, participants were usually referring to a pharmacist. If symptomswere more intense, they were looking for a specialist mainly an internist or a cardiologist.

y I was not feeling well, so I went to a pharmacist to measure my blood pressure (Group B, female)

y One day, I felt very strange, like having a heart attack or stroke; I was so scared that Iwent to the hospital (Group B, male)

y I had strong headaches and because my father had also hypertension, I went to acardiologist (Group A, female)

Participants perceptions and beliefs toward antihypertensive treatmentAttitudes and beliefs towards drugsConcerns and fear were expressed by the majority of participants regarding the use of medicines.Some of them expressed the opinion that the long-term use of medicines will have an impact ontheir immune system.

y In general, I avoid taking medicines. If the decision is on me I will not take any drugs (Group A, male)

y Some years ago I was suffering from spondylolisthesis and my doctor prescribedanti-inflammatory, and then my blood pressure was 18 to 19. (Group A, female)

y I have taken so many drugs that I have destroyed my immune system (Group A,female)

y I dont like it (taking drugs) at all, because you try to fix one thing and somethingelse goes wrong (Group A, female)


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y Y es, but so many drugs? Dont all of these end up in the liver? For how long can it (theliver) bear all these? and it is only one. I dont know, I am a little afraid. (Group B,female)

Adverse drug reactions

Adverse drug reactions were an issue of great concern for the majority of study participants.Some of them had stopped their treatment because they were afraid of the possible side effects.Avoidance of getting to know the possible side effects was also one of the reasons given for notreading the information leaflet of the drug.

y If I read (in the leaflet) that the drug has adverse drug reactions and this or that canhappen to me, I stop the treatment (Group A, male)

y If you read about side effects you should not take any medicine. However, I have prevented some reactions because I had read the information leaflet (Group A, male)

y I dont read the side effects, because then I think that I suffer from all these reactions(Group B, female)

y I usually read the side effects, but I cant understand everything I trust my doctor who prescribes it. If something goes wrong I believe that I will understand it (Group B,

male)

Factors influencing adherence to antihypertensive treatmentThe level of adherence among participants ranged. Previous experiences regarding hypertensionand the fear or knowledge that they could suffer from a complication if they did not control their

blood pressure were important reasons for medication adherence.

y I didnt know what it means to have high blood pressure for years and what this cancause to you (Group A, male)

y because I have read and I know what can happen to me if I do not follow thetreatment (Group A, female)

y I take the pill every day, because I am afraid (Group B, female)y my neighbor had a stroke 5 years ago and he hasnt recovered yet. I see all these and

I follow my treatment because I am afraid that this will happen to me too. (Group B,male)

y I am afraid of what will happen to me because of the hypertension, there is also theheredity. (Group B, male)

In addition, systematic disease management, especially in HC, was a significant factor influencing treatment adherence.

y Here (in the HC) I have a program and I come regularly for my blood pressure (Group A, male)

y First of all, it is very important that I come here regularly and I have a program, anantihypertensive program, and since Ive started taken my pills nothing has gone wrong (Group A, male)


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Another important factor affecting adherence was the acceptance of the disease and the adoptionof the patients role. Most of the participants, especially the younger ones who participated infocus groups, were hesitant and negative to the idea of taking a medicine for their whole life. Thesooner they perceived hypertension as a chronic disease, the more adherent they became.

y at first I was really stressed. I didnt want to believe that I will receive anantihypertensive treatment, why me? I was feeling really sad, it was like killing me

(Group B, male)y I believe that it is tragic to take a medication for the whole of your life, I cant stand it. I

believe that it is the beginning of the end, the beginning of taking more drugs (GroupB, male)

Sometimes, acceptance of the disease led to the change of patients lifestyle.

y after this (the diagnosis of hypertension) the whole perspective about my dietchanged (Group B, male)

Adherence characteristicsAdherence to treatment was easier if the medication were received in the morning. In this case,the majority of participants had associated their medication with their breakfast or had inventeddifferent tricks in order to remember it.

y I take it during breakfast, I am used to it now (Group A, female)y I take it every morning, I set the alarm clock in order to remember it, you have to

associate it with something, otherwise you forget it (Group B, male)

Most of the participants admitted during weekends they received their medication some hours

later than the appropriate, believing that this was aninnocent tactic, although their doctor hadwarned them for the opposite.

y At the weekends I take my pill 3 hours later I dont believe it does any harm. On thecontrary, three hours more sleep is good because our organism is calm when we aresleeping. When we wake up we need the pill (Group B, female)

The drug substance also seemed to be an important factor affecting adherence when its effectsinterferes with patients activities.

y I take one pill every morning. But, because it is diuretic, when I go out I do not take it

(Group A, male)Finally, some of the participants mentioned that they stopped the treatment from time-to-timewhen they no longer suffered from symptoms or when they believed that they had controlledtheir blood pressure.

y If my blood pressure is at good levels, I cant see the reason to take it (the pill). I amafraid to take it because it might cause hypotension to me. (Group A, female)


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y When I have symptoms I follow my treatment, when I feel good I dont . (GroupB, female)

y I stopped the treatment for a period, just to see what will happen, if I will get better but it didnt work (Group B, male)

y Other Sections


Patientphysician relationshipThe majority of participants considered the relationship with their physician of great importance.Good atmosphere during consultation and physicians time spent on giving advice and answeringquestions were mentioned as the most important characteristics of a good doctor. Distant andformal behavior of physician could be a reason for changing the doctor for some participants.

y I appreciate my doctor very much, he explains everything to me. He doesnt care onlyabout prescribing. He practices real medicine. (Group A, male)

y First of all they really seem to care about me. They listen to my questions and wishesand I understand it (Group A, male)

y I stopped consulting my first doctor because of his behavior. I dont know, this was

probably because of his age, he was old, but the distance between me and the physicianwas big. I wanted to ask something and I hesitated, and when I did so his answers wereyes or no, nothing more . (Group B, female)

Good communication and a rewarding behavior of the physician as well as a high level of confidence also seemed to facilitate adherence.

y If I have good results, then my doctor congratulates me (Group A, female)y I believe that the doctor should inspire you confidence, then you will follow the

treatment and if the doctor is strict you will comply . (Group A, female)y I feel gratitude; the whole team here works for me. (Group A, male)

y Other Sections o Abstract o Introduction o Methods o Results o Patientphysician relationship o Patientpharmacist relationship


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o Discussion o Conclusion o References

Patientpharmacist relationship

Regarding patientpharmacist relationship, participants trusted their pharmacists advice ontaking the appropriate medication when they concerned a minor health condition such as a sorethroat or a cold. For more serious conditions such as hypertension, they trusted only their

physician for prescribing a drug. Still, participants consult their pharmacist for additionalinformation on treatment, such as whether they should take the drug before or after dinner.

y I dont want to take medicines if my doctor hasnt prescribed them (Group A,female)

y (I trust the pharmacist) for simple things like throat, nose and things like these. For more serious conditions I consult the doctor (Group A, male)

y I could trust my pharmacist for something simple like a sore throat. In that case I could

consult the pharmacist instead of the physician (Group B, male)y I will ask the pharmacist for additional information, for example if I should take mymedication before or after dinner, things like that (Group A, male)

y the pharmacist is not a doctor. The pharmacist sells drugs (Group B, female)

Participants from the insurance fund HC referred to drug cost as another reason for not seeking pharmacists advice on taking the appropriate medication.

y These are expensive (the antihypertensive drugs). How can I pay for these without a prescription? I am a pensioner and my pension is low (Group A, female)

y my doctor has prescribed all the drugs I take I cant take it without a prescription,

I am a pensioner and you understand (Group A, female)y Other Sections


DiscussionResearch on the adherence of antihypertensive treatment has shown that patients nonadherenceto medication is related with a mix of demographic, organizational, psychological, and disease-and medication-related variables. 23,24 Thus, investigating patients beliefs regardinghypertension itself and antihypertensive treatment, as well as communication factors that affect


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adherence, can have a great impact on designing effective interventions in order to improvetreatment adherence.The present study is the first in Greece, which examined hypertensive patients beliefs abouthypertension and antihypertensive medicines, as well as patients behaviors concerning treatmentadherence. It also examined patientdoctor relationship and its impact on adherence. Finally, the

study examined patients beliefs about the role of pharmacists. In general, results are consistentwith findings from other qualitative studies on antihypertensive medication adherence. 25,26 The majority of participants considered hypertension as a very serious disease and were afraidand anxious about potential serious consequences on their health in case of failure to manage thedisease. These negative feelings toward hypertension represent a finding that differs from thoseof other studies, where hypertension was found to be considered a less important disease withwell-recognized symptoms. 23 Further research based on theoretical models like SRM is requiredso that Greek patients beliefs about hypertension is further explored.Stress emerged as one of the main risk factors of hypertension. Even though participantsacknowledged the importance of this factor, stress was believed to be inevitable, and thissituation was attributed to the modern way of living.

Participants were being informed about hypertension from a plethora of sources, but they trustedmainly their physician. Furthermore, they were feeling comfortable to discuss abouthypertension with other hypertensive patients. This finding was also confirmed during the focusgroup sessions where participants were interested in sharing their experiences and discussingtheir health problem with each other.Participants reported that they attend different health care facilities depending on the severity of symptoms. This behavior reflects the characteristics of the health care system in Greece and theway it is organized. In the absence of integrated primary care with a gate-keeping system,

patients seek care and advice of the pharmacists when it concerns minor health conditions whilethey face limited or no barriers at all in accessing and choosing health care providers. Thisenables them to visit a specialist as often as they wish without referral from a general

practitioner.Based on the results of our study, the factors that influence medication adherence concern themanagement of the disease, the treatment characteristics, and the patientphysician relationship.The systematic disease management includes regular appointments with the physician andintense counseling in order for the patient to be aware of the complications of uncontrolled blood

pressure. Treatment characteristics, such as the time of receiving the medicine, the number of doses, and the drug substance, were reported as influential factors. These characteristics, whichmay be considered minor, are really important for patient compliance and have been identified inother studies as well. 23,25 27 Although an association between adherence and demographic characteristics such as age andgender could not be established due to the nature of the study, it seems that younger adults inGreece face greater difficulty in the acceptance of the disease and consequently in adhering totreatment. Age-related illness perception, with the elderly being more adherent, has also beenreported in other studies. 27 Building on the results of the present study, a longitudinalquantitative survey would be useful in order to further explore confirm or reject theaforementioned finding.Results suggest that the major factor affecting positive medication adherence is a good doctor

patient relationship. A physician who encourages and rewards patients, and most importantly,spends quality time with them in giving information and providing explanations about the


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disease and treatment contributes significantly in patients compliance. This finding is consistentwith a number of previous studies that have established the importance of thisrelationship. 23,25,26 In contrast, pharmacistpatient relationship seems that it did not affect medication adherenceamong study participants. However, a finding worthwhile to be further researched is the role of

cost of drugs in adherence because this was a matter of great concern for a number of participants, especially those attending insurance funds HC. Cost and particularly level of copayment has been identified as an important factor associated with adherence to pharmaceuticaltreatment. 28 Perceptions of personal risk and outcome expectancies, as well as redefinition of self concept or social role, have been proven to create a teachable moment for risk-reducing health

behaviors. 29,30 In our study, participants do create a teachable moment about hypertension, by cognitively escalating the severity of their symptoms. Previous experiences regardinghypertension, either personal or those of friends and family, and knowledge about thecomplications of the disease were major determinants of a teachable moment. Nevertheless, dueto organizational factors, participants seem to adopt a risk-reducing health behavior (ie, visit an

HC) only at a very late stage. A primary intervention stage should be identified, and early prevention strategies should be adopted so that hypertensive patients benefit at an earlier prohypertension stage rather than waiting until they are diagnosed with hypertension.LimitationsAll participants of the present study reported adherence to treatment at the time of the study, afinding initially indicating high levels of adherence in Greek hypertensive patients comparedwith previous studies conducted in Greece. 20 Nevertheless, participants mentioned that they didnot take medication at the right time, or skipped if they felt well, indicating a rather nonadherentthan adherent pattern of behavior. This inconsistency perhaps shows a cognitive bias, whichunderline causes worth further investigation. Psychological factors like patients frustration dueto inefficient antihypertensive treatment or the meaning of monitoring blood pressure at home or telemonitoring might have some effects on adherence. Furthermore, the detected inconsistencycould represent a time-related reference: participants referred to all these behaviors regardingtheir pharmaceutical treatment, considering them as past behaviors and not things that theyusually do in the present. In addition, this result may only be due to a volunteer effect and can beconsidered a methodological limitation given that, according to literature, adherence toantihypertensive treatment ranges between 50% and 70%. 13 Unanimous adherence allowed theidentification of the factors contributing to adherence but prevented us from exploring the factorsthat inhibit it (although it could well be assumed that the opposite factors can be responsible for nonadherence).From a methodological point of view, the smaller number of participants interviewed in HC,three compared to the number of participants in the other two HCs, could be considered another limitation of the study. However, due to the qualitative methodology adopted and the fact thatdirect comparisons among HCs were not an objective of the study, this sample difference has alimited effect on results.Finally, the long duration of the focus groups may be considered another limitation of the study.Although we took care to achieve a comfortable environment for participants, it is not quite surewhether they were fully engaging in the end of the discussion.Conclusion


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In conclusion, the present study confirmed that cognitive and communication factorspatientswho were better informed, had previous experiences of the disease, and a good relationship andcommunication with their physicianwere important determinants for adherence. These resultscould form the basis for designing effective interventions adjusted to the Greek reality aiming at

both enhancing doctorpatient communication and empowering the patient himself. Such

interventions have the potential to improve the adherence of hypertensive patients medicationand can consequently reduce hypertension-related costs.AcknowledgmentsThis study was supported by NOVARTIS Hellas S.A.C.I. We are also grateful to the physiciansand all the patients who participated in the study.FootnotesDisc losur e The authors report no conflicts of interest in this work.

y Other Sections o Abstract o

Introduction o Methods o Results o Patientphysician relationship o Patientpharmacist relationship o Discussion o Conclusion o References

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15. Paramore LC, Halpern MT, Lapuerta P, et al. Impact of poorly controlled hypertension onhealthcare resource utilization and cost. Am J Manag Care. 2001;7(4):389398. [ PubMed ]16. Neutel JM, Smith D. Improving patient compliance: a major goal in the management of Hypertension. J Clin Hypertens. 2003;5(2):127132.17. Efstratopoulos A, Voyaki S, Baltas A, et al. Prevalence, awareness, treatment and control of hypertension in Hellas, Greece. The Hypertension Study in General Practice in Hellas. Am JHypertens. 2006;19(1):5360. [ PubMed ]18. Psaltopoulou T, Orfanos P, Naska A, Lenas D, Trichopoulos D, Trichopoulou A. Prevalence,awareness, treatment and control of hypertension in a general population sample 26913 adults inthe Greek EPIC study. Int J Epidemiol. 2004;33(6):13451352. [ PubMed ]19. Heine C, Browning CJ. Communication and psychosocial consequences of sensory loss inolder adults: overview and rehabilitation directions. Disabil Rehabil. 2002;4(15):763773.[PubMed ]20. Y iannakopoulou ECh, Papadopoulos JS, Cokkinos DV, Mountokalakis TD. Adherence toantihypertensive treatment: a critical factor for blood pressure control. Eur J Cardiovasc prevRehabil. 2005;12(3):243249. [ PubMed ]21. Gibbs A Focus Groups Guildford, United Kingdom: University of Survey; 1997. Availablefrom: http://sru.soc.surrey.ac.uk/SRU19.html . Accessed Jun 5, 2010.22. Bowling A. Research methods in Health: Investigating Health and Health Services. 2nd ed.Berkshire, UK: Open University Press; 2002.23. Gascon J, Sanchez-Ortuno M, Llor B, et al. Why hypertensive patients do not comply withthe treatment. Results from a qualitative study. Fam Pract. 2003;21(2):125130. [ PubMed ]24. Chapman RH, Benner JS, Petrilla AA, et al. Predictors of adherence with antihypertensiveand lipid-lowering therapy. Arch Intern Med. 2005;165(10):11471152. [ PubMed ]25. Benson J, Britten N. Patients decision about whether or not to take antihypertensive drugs:qualitative study. BMJ. 2002;325:873. [ PMC free article ] [PubMed ]26. Bane C, Hughes C, Cupples M, McElnay J. The journey to concordance for patients withhypertension: a qualitative study in primary care. Pharm World Sci. 2007;29(5):534540.[PubMed ]


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27. Jin J, Sklar G, Oh V, Li S. Factors affecting therapeutic compliance: a review from the patients perspective. Ther Clin Risk Manag. 2008;4(1):269286. [ PMC free article ] [PubMed ]28. Taira DA, Wong KS, Frech-Tamas F, Chung RS. Copayment level and compliance withantihypertensive medication: analysis and policy implications for managed care. Am J ManagCare. 2006;12(11):678683. [ PubMed ]

29. McBride C, Emmons K, Lipkus I. Understanding the potential of teachable moments: thecase of smoking cessation. Health Educ Res. 2003;18(2):156170. [ PubMed ]30. Rohrer J, Anderson G, Furst J. Obesity and pre-hypertesion in family medicine: implicationsfor quality improvement. BMC Health Serv Res. 2007;7:212. [ PMC free article ] [PubMed ]

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2943225/


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P r ed isp osing Fa ct ors fo r Seve r e,Unc ontr olled Hy pert ensi on in an Inn er-Cit y

M in orit yP

opu la tion Steven Shea, M.D., Dawn Misra, Martin H. Ehrlich, M.D., M.P.H., Leslie Field, R.N., andCharles K. Francis, M.D.

N Engl J Med 1992; 327:776-781 September 10, 1992

AbstractArticleReferencesCiting Articles (40)

HY PERTENSION is one of the most common medical conditions in the United States,with a prevalence of about 22 percent among adults 18 to 74 years of age, according tothe second National Health and Nutrition Examination Survey. 1 The results of at least 15randomized controlled clinical trials of drug treatment for hypertension 2 , 3 support thecurrent consensus recommendations for treatment. 4 The development of a broad

pharmacologic armamentarium and the dissemination of information to both physiciansand the general public through the National High Blood Pressure Education Program 5 have led to improvements in blood-pressure control 6 7 8 and have contributed toreductions in the incidence of stroke and ischemic heart disease. 9 10 11 Despite thesegains, poorly controlled hypertension remains a major health problem, particularly among

minority populations, the poor, those with lower educational levels, and those withlimited access to medical care. 12 13 14 Increasing the rate of blood-pressure controlamong patients with hypertension to at least 50 percent is one of the national health

promotion and disease prevention objectives for the year 2000. 15

Hypertensive emergencies and urgent hypertension are the most extreme forms of poorlycontrolled hypertension 4 , 16 and thus can be used as indicator conditions for poorlycontrolled hypertension. Hypertensive emergencies, which include malignanthypertension, are evidenced by acute end-organ damage and require blood-pressurereduction within one hour. 4 , 16 Urgent hypertension, characterized by a severe or accelerated elevation in blood pressure that should be treated within several hours, 4 mayoften be treated in the emergency room with fast-acting drugs, without hospitaladmission. 17 18 19 20 An earlier retrospective study of pat ients with hypertensiveemergencies found that hypertension had previously been diagnosed in more than 90

percent, 21 suggesting that hypertensive emergency is almost entirely preventable and thatcorrectable barriers to its prevention may exist. Specific hypotheses suggested in thatstudy were that the lack of medical insurance, the lack of a primary care physician,noncompliance with an antihypertensive drug regimen, and alcohol abuse or the use of illicit drugs may be predisposing factors for hypertensive emergencies and urgent


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hypertension. We report here the results of a casecontrol study conducted to test thesehypotheses.

Me th od s

Se tting and S ubje cts

The study was conducted between October 1989 and June 1991 at the PresbyterianHospital and Harlem Hospital Center in New Y ork. The case patients presented to or were admitted from the emergency room at one of these two hospitals with malignanthypertension (codes 401.0, 402.00, 402.01, 403.0, 404.0, 405.0, and 405.01 of the

International Classification of Diseases, 9th revision [ICD-9] 22), hypertensiveencephalopathy (ICD-9 code 437.2), hypertensive emergency, or severe, uncontrolledhypertension. The control patients had hypertension as indicated by current drugtreatment for hypertension or a history of hypertension; these patients presented to or were admitted from the emergency room at Presbyterian Hospital or Harlem Hospital

with acute conditions not known to be related to the hypothesized risk factors for severe,uncontrolled hypertension. Examples of such conditions were gastroenteritis, musclespasm, allergy, backache, hernia, and otitis media. Patients were excluded from thecontrol group if they had previously been admitted for hypertensive emergency,malignant hypertension, or severe, uncontrolled hypertension. Patients were excludedfrom both the case and control groups if they were admitted for acute myocardialinfarction, acute pulmonary edema, aortic dissection, stroke, or renal failure, if they wereunder 21 years of age, or if they were pregnant.

Eligible subjects were identified each day from admission logs in the emergency roomsand the medical and surgical services at the two hospitals. Five eligible case patients and

six eligible control patients declined to participate in the study. There were no patientswhose physicians refused permission for the research assistants to screen and attempt toenroll the patient. Altogether, 94 potential case patients and 116 potential controls wereinterviewed. We excluded three subjects who were not black or Hispanic from theanalysis (one white case patient, one white control patient, and one Native Americancontrol patient). One French-speaking Haitian black case patient was not excluded, sincethe research assistant spoke fluent French. Thus, data on 93 case patients and 114controls were analyzed. A computerized search of all discharges from the PresbyterianHospital during the study period, using the ICD-9 codes used to define cases, showed thatall eligible case patients had been identified and enrolled.

Data Colle cti on

Data were collected by trained research assistants in structured interviews with patientsand with use of chart-abstraction forms. Interview forms were available in Spanish andEnglish; the research assistant at the Presbyterian Hospital, where all the Hispanic

patients were seen, was bilingual. All interview data were obtained in the patient's preferred language at the time of the visit to the emergency room or during the hospitaladmission. This study was approved by the institutional review boards of Columbia


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Presbyterian Medical Center and the Harlem Hospital Center, and informed consent wasobtained from all patients.

Mea sur eme nts

The blood pressure on admission was defined as the first blood pressure recorded on theemergency room chart. The KeithWagenerBarker grade of hypertensiveretinopathy, 23 the presence of new microscopic hematuria (three or more red cells per high-power field), the presence of encephalopathy attributed to hypertension (indicated

by an altered level of consciousness or clouding of the sensorium), and the presence or absence of exclusionary criteria were ascertained by review of the patients' charts. For control patients, the diagnoses recorded in the emergency room or on admission and the

presence or absence of hypertension were ascertained by review of the charts.Information on demographic variables, educational level, employment, marital status, useof health services, cigarette-smoking habits, previous diagnosis and treatment of hypertension, and use or abuse of alcohol and illicit drugs was obtained in the interview.

For the 81 patients who reported consuming any alcohol in the previous year, the number of alcohol-related problems during that period was ascertained with use of 41 questionsfrom the 1988 Health Interview Survey. Complete data were obtained from 78 patients.Acceptable detection rates for these questions have been reported. 24 We assumed that

patients who reported no alcohol consumption during the previous year had no problemsrelated to alcohol. The interview also included questions on the use of several categoriesof illicit drugs (marijuana, cocaine, "crack" cocaine, heroin, methadone, and "other drugs") during the previous year.

Adherence to the prescribed regimen of blood-pressure medication was assessed with a

five-item compliance scale derived from the four-item scale developed by Morisky etal.25 On the basis of preliminary studies in the population we were studying, we mademinor changes in the wording of the four yesno questions in the scale of Morisky et al.The revised versions read as follows: Do you ever forget to take your high-blood-

pressure pills? Are you ever careless in taking your pills? Do you ever miss taking your pills when you are feeling better? Do you ever miss taking any of your pills because youare feeling sick? We also added a fifth question: Do you ever miss taking your high-

blood-pressure medication for any reason? This scale was scored by assigning one pointto each positive response, so that a higher score indicated a lower level of compliance.Cronbach's coefficient alpha, 26 a measure of the internal consistency of the scale, was0.71 for the 202 patients who provided complete data for all five items. Morisky et al.

reported that Cronbach's alpha was 0.61 for their four-item scale. 25

Sta tistic al A naly sis

Bivariate associations were tested with use of the chi-square statistic for categorical dataand the t-test for continuous data. The use of a continuity correction for tables with fewer than five subjects in the smallest cell did not materially affect the odds ratio or the teststatistic, and the results are reported without this correction. Multiple logistic-regression


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models were used to calculate adjusted regression coefficients. In these models, age wascoded as a continuous variable, and sex, race or ethnic group (black or Hispanic),educational level (less than high-school graduation vs. high-school graduation or equivalency or more), current smoking, one or more alcohol-related problems, and use of illicit drugs in the past year were coded as dichotomous variables. Odds ratios and

confidence intervals were calculated from these adjusted regression coefficients. 27 Inorder to simplify the interpretation of the results, all these control variables were retainedin all the multiple logistic-regression models, even though in some models thecoefficients were not materially affected by the removal of one or more of the controlvariables. Adjustment for additional variables, including employment, marital status, andsite of data collection (Presbyterian Hospital vs. Harlem Hospital) did not materiallyaffect the odds ratios in any model we examined, and these variables were not included inthe final models. Additional multiple logistic-regression analyses were performed to testthe independence of the three main independent variables examined namely, whether the patient had any medical insurance, whether the patient had a primary care physician,and the score for compliance with the antihypertensive drug regimen on the five-point

scale by adjusting each for the other two. Logistic-regression analyses were performedwith SAS/PC software. 28 Other analyses were performed with SPSS/PC +. 29 Allreported P values are two-tailed.

R esu lts

At the time of the visit to the emergency room, the 93 case patients had severely elevated

blood pressure (mean, 222/141 mm Hg) ( Table 1 Table 1 ClinicalCharacteristics of 93 Case Patients with Severe, Uncontrolled Hypertension.), and 30case patients (32 percent) had clinical evidence of acute end-organ damage manifested byhypertensive encephalopathy, grade III or grade IV retinopathy, or new microscopichematuria. Ninety-one of the case patients (98 percent) reported that they had previously

been given a diagnosis of hypertension and had previously been treated for this condition.Case patients who were admitted to the hospital did not differ from those who weretreated in the emergency room and released in terms of mean systolic blood pressure,mean age, or the proportion who were male. The mean diastolic blood pressure wassomewhat higher among the case patients who were admitted than among those whowere treated and released (144 mm Hg vs. 137 mm Hg), and the case patients who were

admitted were more likely to be black, reflecting the higher proportion of patientsadmitted at Harlem Hospital Center, where the patient population was predominantly black, than at Presbyterian Hospital, where the patient population included moreHispanics.

The case and control patients were similar with regard to education and place of interview; case patients were younger and were more likely to be male, black, employed,


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and married ( Table 2 Table 2 Selected Characteristics of Case Patients andControls.). In bivariate analyses, the lack of a primary care physician, the lack of medicalinsurance, the presence of one or more alcohol-related problems, and illicit drug use were

associated with severe, uncontrolled hypertension ( Table 3 Table 3 BivariateOdds Ratios for Severe, Uncontrolled Hypertension among Case Patients and Controls,According to Various Characteristics.*). The mean score on the compliance scale was

2.3 1.3 for case patients, as compared with 1.1 1.2 for controls (t = 6.78, 200 df;P


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medical insurance was marginally associated with severe hypertension. The magnitude of the odds ratios was minimally changed by this additional adjustment.

Analyses were also conducted in which patients with Medicaid insurance only (n = 56)were classified as uninsured, to test whether such patients were effectively uninsured

because of physicians' reluctance to treat patients covered by Medicaid, but the oddsratios for lack of medical insurance combined with Medicaid coverage, as compared withall other insurance, were smaller than when the original classification scheme was used,indicating that Medicaid patients were best classified as insured. The results of subgroupanalyses in which the case patients who were admitted and those who were treated in theemergency room and released were compared separately with the whole control groupwere consistent with the findings of the main analyses.

The lack of a primary care physician was associated with a greater likelihood that a patient would usually have blood-pressure checks performed in an emergency room(odds ratio, 10.5; 95 percent confidence interval, 3.7 to 29.4), that he or she would not

have regular blood-pressure checks (odds ratio, 12.1; 95 percent confidence interval, 6.1to 24.1), and that he or she would not have had a blood-pressure check within six monthsof admission or the index visit to the emergency room (odds ratio, 9.1; 95 percentconfidence interval, 3.5 to 24.0). No patient who had a primary care physician reportedreceiving prescriptions for antihypertensive medications in the emergency room, whereas20 of the 70 patients without a primary care physician (29 percent) did receive suchmedication there. The lack of medical insurance was associated with not having a

primary care physician (odds ratio, 2.7; 95 percent confidence interval, 1.4 to 5.1), nothaving regular blood-pressure checks (odds ratio, 2.9; 95 percent confidence interval, 1.5to 5.6), and not having had a blood-pressure check within six months of admission or theindex visit to the emergency room (odds ratio, 2.7; 95 percent confidence interval, 1.2 to

6.1).

Discussi on

During the 21 months of data collection at two hospitals, all but 1 of the 93 case patientswith severe, uncontrolled hypertension, as defined in this study, were either black or Hispanic. At Harlem Hospital Center, this racial and ethnic distribution is explained bythe fact that the population served by the hospital is almost entirely black. A differentexplanation is required for the case patients enrolled at the Presbyterian Hospital, wherethe population served includes a large number of white and privately insured referral

patients. No cases of severe, uncontrolled hypertension were identified among these

patients. A similar observation was made in an earlier study of hypertensive emergenciesat the Presbyterian Hospital during the 1980s. 21 The overcrowding of inner-cityemergency rooms 30 31 32 has led many physicians to avoid or bypass the emergencyroom in caring for their privately insured patients. Thus, we could not estimate themagnitude of the effects of race and socioeconomic status as risk factors from our data,which were obtained by enrolling patients either seen in the emergency room andreleased or admitted from the emergency room. Nonetheless, the racial and ethniccomposition of the group of case patients in this study and in our earlier study 21 indicates


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that severe, uncontrolled hypertension occurs more frequently among blacks andHispanics than among non-Hispanic whites and that severe, uncontrolled hypertension isstrongly linked to socioeconomic status.

This study confirms our earlier finding 21 that almost all cases of hypertension had

previously been diagnosed and treated. Thus, the failure to detect hypertension, to make patients aware that they have hypertension, or to initiate treatment does not seem to have been a major contributor to the occurrence of severe, uncontrolled hypertension in this population.

The lack of a primary care physician was the strongest predictor of severe hypertension.The lack of health care insurance was also a risk factor, suggesting that financial barriersto care contribute to the poor control of hypertension. This finding is consistent with datafrom the Rand Health Insurance Experiment, which showed that hypertensive patientsrandomly assigned to free care had lower mean blood pressures than those randomlyassigned to health care plans that entailed cost sharing, a difference that was greatest

among low-income persons with hypertension. 14

Compliance with treatment has been widely recognized as a key issue in achieving blood- pressure control. 33 We found that noncompliance with an antihypertensive regimen wasstrongly associated with severe, uncontrolled hypertension. Several factors have beenidentified as obstacles to compliance with antihypertensive treatment, including the costof medications 34 , 35 and dosing frequency. 36 Another factor contributing tononcompliance and the resulting poorly controlled hypertension may be a lack of knowledge about blood pressure. Data from a 1989 survey indicate that higher educational attainment is associated with knowing one's own blood pressure and withknowing that a "good" blood pressure is 140/90 mm Hg or less. 37 That study also found

that blacks and Hispanics were less likely than whites to know their own blood pressuresor to know what constitutes a "good" blood pressure, even after adjustment for educational attainment.

It is possible that our findings may not pertain to persons with hypertension who liveunder different circumstances. In particular, rural populations may face different barriersto blood-pressure control than the urban population we studied. However, large numbersof blacks and Hispanics with hypertension live in inner cities in the United States, andour findings are likely to apply to them.

The hypertension-control strategy followed by the U.S. Public Health Service in concertwith state and local health agencies focuses on increasing knowledge of high blood

pressure and its consequences, encouraging the adoption of behavior conducive to blood- pressure control, and implementing systems to improve surveillance and control. 38 Our data support the recognition that a key variable is compliance with antihypertensivetreatment. Our findings also emphasize the potential importance of changes in the healthcare system to address the inadequacy of emergency rooms for the treatment of chronicconditions and to increase access to physicians who provide primary or long-term carefor hypertension. 39 Our findings also point to the importance of health insurance as a


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means of providing such access to health care, especially for poor and minority population groups.

Supported by a grant (RO1-HL38260) from the National Heart. Lung, and Blood Institute(to Dr. Shea).

Steven Shea, M.D.Dawn MisraMartin H. Ehrlich, M.D., M.P.H.Leslie Field, R.N.Charles K. Francis, M.D.From the Department of Medicine, Division of General Medicine. Columbia UniversityCollege of Physicians and Surgeons (S.S.), the Division of Epidemiology. ColumbiaUniversity School of Public Health (S.S., D.M.), and the Department of Medicine,Harlem Hospital Center (M.H.E., L.F., C.K.F.), all in New Y ork. Address reprint requeststo Dr. Shea at Atchley Pavilion 1310, 161 Fort Washington Ave., New Y ork, N Y 10032.

We are indebted to Dr. Deborah Hasin for her assistance in designing the sections of theinterview dealing with alcohol and illicit drug abuse, to Dr. Bruce Levin for statisticaladvice, to Drs. Benjamin Okonta and Haydee Rondon for their assistance in datacollection, and to Drs. Nancy M. Bennett, Lee Goldman, Jennifer L. Kelsey, andKatherine G. Nickerson for their comments on the manuscript.

http://www.nejm.org/doi/full/10.1056/NEJM199209103271107#t=article+Methods


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J ournal of Human Hypertension (2004) 18, 207213. doi:10.1038/sj.jhh.1001656

Risk factors for uncontrolled hypertension in Italy

This work was carried out by CliCon Srl.

E Degli Esposti 1, M Di Martino 2, A Sturani 3, P Russo 4, C Dradi 5, S Falcinelli 5 and S Buda 2

1. 1Clinical Effectiveness Unit, AUSL Ravenna, Italy2. 2CliCon Srl, Health Economics and Outcomes Research, Ravenna, Italy3. 3Hypertension Unit, AUSL, Ravenna, Italy4. 4Department of Human Physiology and Pharmacology, University of Rome "La Sapienza", Italy5. 5General Practitioner, Ravenna, Italy

Correspondence: M Di Martino, CliCon Srl, Via San Vitale, 5, 48100 Ravenna, Italy. E-mail:[email protected]

Received 26 June 2003; Revised 18 September 2003; Accepted 29 September 2003.

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Ab str act

To identify factors related to poor control of blood pressure in primary care, we designed aretrospective casecontrol analysis of clinical and demographic data recorded in the GeneralPractitioners (GP) database. Study data were provided on a voluntary basis by 21 GPs from a

practice-based network in primary care. The study included 2519 hypertensive patients enrolled

between January 1 and December 31, 2000. The interventions were antihypertensive medication,and the main outcome measures were control of systolic and diastolic blood pressure (BP). Theindependent variables considered were: age of patient and GP; patient gender, body mass index,history of smoking, diabetes mellitus, or cholesterol tests; family history of hypertension;

previous visits for cardiologic, nephrologic, or vascular surgery evaluation; prior hospitalizationsfor myocardial infarction or heart failure, and number of admissions for surgery; length of

patient follow-up, type of antihypertensive medication, mean daily dosage, adherence to the drugregimen, and number of other medications currently being taken by the patient. Blood pressurewas uncontrolled (>140/90 mmHg) in 1525 (60%) of the 2519 hypertensive patients enrolled.The presence of diabetes mellitus, increasing patient age, and increasing GP age significantlyincreased the risk of uncontrolled BP. Factors significantly associated with a reduced risk of

uncontrolled BP were the number of other medications currently being taken by the patient and a prior history of MI. We conclude that the failure of antihypertensive medication to adequatelycontrol BP is determined by both the patient's characteristics and factors related to the patient doctor relationship. Successful treatment of hypertension requires patient adherence to theregimen that has been agreed on by the patient and the physician.


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Keywords:

uncontrolled blood pressure, antihypertensive drugs, General Practitioner

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Intr od ucti on

In Italy, hypertension is a common medical disorder affecting more than 8 million people. 1 In theRavenna (Italy) area, antihypertensive drugs are prescribed for an estimated 19% of the

population of 355 000. 2 Despite significant efforts to diagnose and treat hypertension,approximately two out of three people with hypertension have not achieved the generallyrecommended target blood pressure (BP) of less than 140/90 mmHg, 3,4 thus remaining at ahigher risk for heart attack, stroke, heart failure, and kidney disease. Failure to achieve thetargeted BP control is a global problem. In the United States, fewer than 30% of hypertensive

patients have BP values lower than 140/90 mmHg, 5 while, in the United Kingdom, only 6% of

hypertensive patients have attained these target BP levels.6

Even with less stringent levels of BPcontrol of 160/95 mmHg, data from Australia, Canada, Finland, India, Scotland, and Spainsuggest that no more than 20% of the population would achieve this goal. 7

The identification of factors related to poor control of BP can help to target populations in needof medical attention, and to aid in the development of effective treatment strategies for specificsubpopulations. 7 The objective of the present casecontrol study was to identify risk factors for uncontrolled BP among those patients enrolled in the Pandora project, a prospective ongoingglobal outcomes study begun in 1996 to organize a database for epidemiological assessments andto improve the management of hypertension in primary care.

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Me th od s

Data collec ti on a nd p ati en t s

Of 330 general practitioners (GPs) in the Ravenna, Italy area, 21 voluntarily participated in thePANDORA project. In Italy, the GP is the doctor working outside the hospital, who is delegated

by the National Health System to provide care for a known number of subjects. Each GP wasasked to enrol two hypertensive patients per week in the study, starting on 01/01/1996. Whenthis study was carried out, the GPs participating in the Pandora project had a cohort of about33 000 beneficiary subjects representing 9.3% of persons living in the Ravenna area. ThePandora project was approved by the Local Ethics Committee, and informed consent wasobtained from each patient enrolled.

All GPs were supplied with a personal computer that was connected to a remote server via amodem, a printer, an automatic BP device (Dinamap 1846SX, Critikon, Tampa, FL, USA), and adedicated software package dubbed So.Ge.Pa. The remote server is also linked to the LocalHealth Unit database (patient, GP, prescription, hospital, and death records) and to the


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hypertension unit. At the remote station, a team of different specialists (computer scientist,economist, statist, epidemiologist, pharmacologist) produces a variety of reports which areregularly returned to the various operators. The So.Ge.Pa. software controlled the operation of the BP device, which was connected to the computer. The BP value recorded and entered into thedatabase at each visit represented the average of three consecutive readings obtained at 1-min

intervals after the patient had remained seated for 5 min. BP was measured in the dominantupper arm during the daytime, morning or afternoon, in accordance with conventional clinical practice. A tube 3.6 m in length and a cuff of 2333 cm for normal subjects or 3140 cm for obese subjects were used. Clinical and laboratory data were gathered and stored either by theGPs themselves or through links with Health Service databases, as already documented. 8

At the enrolment visit, the GP recorded the patient's currently prescribed antihypertensiveregimen, defining the drug(s), active ingredient(s), and the number of tablets the patient wasinstructed to take daily. At the end of each visit, the antihypertensive treatment was again

prescribed by the GP, who had complete discretion to decide the type of drug and the dosage for an individual patient, and the frequency with which BP would be measured. The

antihypertensive drugs purchased by each patient were identified from the pharmaceuticaldatabase kept by the Local Health Unit of Ravenna, which logs each prescription, records thecode number of the prescribing physician, the national health number of the patient, the datedispensed, the AnatomicalTherapeuticChemical classification (ATC), the number of packs,and the number of tablets per pack.

All drug prescriptions considered in this study are fully reimbursed by the National HealthSystem.

The completeness and coherence of the information recorded for each patient were periodicallychecked at the remote station and only those patients whose recorded data which satisfied the

inclusion criteria of the study were considered in the analysis.P ati en t ch a r a c t er i s ti cs a nd ou t come me a sures

The main outcome measure for this casecontrol study was BP control (yes/no). Adequatecontrol was defined as a representative SBP of less than 140 mmHg and a DBP of less than90 mmHg; for patients with diabetes, BP control was defined as a representative SBP of


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patient follow-up period was defined retrospectively as the interval, in days, between therepresentative BP and the earliest BP value present in the patient's record.

The independent variables considered in this study included the age of the patient and GP; patient gender, body mass index (BMI); history of smoking, diabetes mellitus, or cholesterol

tests; family history of hypertension; previous visits for cardiologic, nephrologic, or vascular surgery evaluation; prior hospitalizations for myocardial infarction (MI) or heart failure; number of admissions for surgery; and length of patient follow-up, type of antihypertensive medication,mean daily dosage (MDD), utilization of antihypertensive drugs and number of other medications currently being taken by the patient (antiaggregants, anti-inflammatories,anithypolipaemia drugs, antiasthmatics, and drugs for the treatment of heart diseases).

U ti l izati on of a n ti hyper t ens iv e drugs

Utilization of antihypertensive agents was defined for the purpose of this study as the MDD of the drugs purchased during the follow-up period, expressed as the number of tablets per day. The

formula utilized was: number of tablets prescribed from the first to the penultimate prescription,divided by the number of days from the first to the last prescription. The duration (expressed indays) of the antihypertensive treatment (DT) was then calculated as the number of days from thefirst to the last prescription plus the number obtained by dividing the number of tablets indicatedin the final prescription by the MDD.

The calculations were based on the total number of tablets purchased by each patient, regardlessof the active principle that each contained. Three categories for use of antihypertensivemedication were defined, regardless of the type and number of active ingredients taken: patientswere defined as (1) occasional users if they received only one prescription of antihypertensivemedication during the study period; (2) interrupted users if, during the study period, they

interrupted the use of any antihypertensive drug; (3) continuous users if, during the study period,they continuously took antihypertensive drugs (by maintaining, combining or switching theactive ingredient) without interrupting the pharmacological therapy. In the case of nonoccasionalusers, four types of antihypertensive treatment were identified on the basis of MDD: patientswith MDD


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setting entry/removal criteria for each independent variable at ( P -value (in)=0.05, P -value (out) =0.10) using the Wald test statistic. The fit of the model was assessed with the Hosmer Lemeshow goodness-of-fit test statistic, 10 with P


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Table 2 - Utilization of antihypertensive drugs in the two groups of patients.

F ull table

The MDD value increased significantly ( P


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R i sk f a c t ors

On enrolment in the study, there were significant differences in the risk factors present in cases

and controls ( Table 3 ). Several factors were significantly associated with the persistence of elevated BP, especially patient age of 50 years or more, the presence of diabetes mellitus, and theabsence of a prior admission for MI. The risk of persistence of elevated BP, moreover, decreasedwith the increase in the number of other medications currently being taken by the patient. Withregard to the characteristics of antihypertensive therapy, the risk of persistent elevated BP washigher in patients who used medication continuously, and in those receiving the highest MDD(Table 4 ).

Table 3 - Bivariate odds ratios about patients' characteristics.

F ull table

Table 4 - Bivariate odds ratios about utilization of antihypertensive drugs.

F ull table

The results of the multivariate logistic regression model ( Table 5 ) indicate that the presence of diabetes mellitus, increasing patient age, and increasing age of the GP significantly increased therisk of uncontrolled BP. Hypertensive patients with diabetes were almost six times more likely tohave uncontrolled BP compared to those without diabetes. Significant factors that reduced therisk of uncontrolled BP were an increasing number of other medications currently being taken by

the patient and a prior MI. The HosmerLemeshow goodness-of-fit test ( P =0.900) indicated agood fit of the model.


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Table 5 - Logistic regression model: predictors of not achieving adequate blood pressure control.

F ull table

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Discussi on

Poor control of BP appears to be determined by both the patient's characteristics and factorsrelated to the patientdoctor relationship. Randomized controlled trials (RCT) generally

conducted at tertiary-care centres in highly selected patient populations have demonstrated thatany reduction of elevated BP either to levels within the normal range 12 ,13 or to those above140/90 mmHg lowers the likelihood of morbidity and mortality due to cardiovascular or renalevents, as well as premature death. 14,15,16 ,17 However, the lack of applicability of these findings tothe community-based practice setting is demonstrated by the finding that normal BP levels areachieved in more than 50% of patients treated in RCTs 13,14 ,15 ,16 and only in less than 30% of those treated in actual clinical practice. 4,5,6,7

In this observational, practice-based study, the majority (60%) of hypertensive patients failed toreach the targeted goal BP. A possible bias could have been introduced by the patient selection

process, because the GPs might have selected those patients who were generally more compliant

than the general patient population. If true, such a bias could contribute to further support presentfindings since the general population of hypertensive patients in Ravenna could be expected tohave even poorer BP control. The use of clinic BP measurements might have substantiallyoverestimated the proportion of patients with uncontrolled hypertension as a result of the 'whitecoat' component. 18 ,19 However, most of the patients had been treated with antihypertensive drugsfor an average of 2.5 years prior to study enrolment, suggesting that the BP values recorded wererepresentative. Lastly, pretreatment BPs could not be reliably ascertained for most of the

patients, and they were included because they had established hypertension and were takingantihypertensive drugs.

The purpose of this study was to identify factors contributing to poor control of BP in patients

receiving long-term antihypertensive therapy. Other studies have evaluated barriers andfacilitators to the management of hypertension in primary care, including physician-relatedfactors, ethnicity of the patients, co-morbidity, and continuity of care. 20,21 ,22 ,23 ,24 In this study,several factors appear to affect the risk of uncontrolled BP in the primary care setting: the

patient's age, the presence of comorbidities such as diabetes mellitus and/or target organ damage(ie previous MI), the number of other medications currently being taken by the patient, and theGP's age. How these factors affect BP control is not known. However, the medical status of the

patient is known to be an important determinant. In the present study, confirming the results of


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other papers, 22,23 a prior MI enhanced the probability of achieving goal BP, possibly because GPsand patients may be more motivated to treat a symptomatic disease than asymptomaticconditions, or because patients with a prior MI were seen by hospital physicians and had their treatment regimen prescribed by specialists rather than by their primary-care physician.Moreover, our physicians have little training and experience in treating to target, as we have

observed in patients with diabetes.

According to the results of this study, an increase in the number of other medications currently being taken by the patient decreases the probability of poor control of BP. A possible explanationfor this phenomenon is that, although the patients taking other medications present a morecomplex clinical situation, they are more accustomed to and careful about their treatment, theytake higher doses of the drugs and thus control their BP in a better way.

An unexpected finding was that the dosing regimen of antihypertensive drugs and utilization of antihypertensive drugs did not influence BP. A study at a hypertension hospital clinic found thatthe intensity of antihypertensive therapy was not associated with the degree of BP control, and

that older patients needed more than one drug to reduce their BP.25

Others have found that theBP in adult hypertensive patients gradually increases over time, 26 which may have contributed tothe findings in the present study. An additional factor may have been the fact that fewer than10% of cases received diuretics, the use of which often results in BP control in patients withresistant hypertension. 27

The recent findings of Berlowitz et al 28 strongly support a substantial physician component to poor BP control, for reasons that are not entirely clear. Other studies have indicated the doctor patient relationship as an important factor affecting the control of hypertension. 20 ,21 In the presentstudy, the likelihood of poor BP control was increased when the GP was aged 50 years and older.Moreover, in a previous study, we found that adherence to antihypertensive treatment was lower

in newly treated patients who were followed by older physicians.29

This study provides aframework for identifying hypertensive patients who are at a high risk of poor control, and manyof the factors identified may be amenable to improvement. Older patients and diabetics can betargeted for greater attention to BP control, particularly in view of the evidence for improvementin clinical outcomes with hypertension therapy in these populations. 17,16 In conclusion, the failureof antihypertensive medication to adequately control BP is determined by both the patient'scharacteristics and factors related to the patientdoctor relationship. Successful treatment of hypertension, also in asymptomatic conditions, requires patient adherence to the regimen that has

been agreed on with the physician.

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