[Primary care evaluation of the hypertensive patient management in specialized care after derivation (DERIVA-2 Study)]. / Valoración desde atención primaria del manejo del hipertenso en atención especializada (estudio DERIVA-DOS).

INTRODUCTION: To know the opinion/evaluation of the primary care physicians (PCPH) of the received information about patients that were attended in specialized care (SC). DESIGN: Cross-sectional study. LOCATION: Performed nationwide in primary care centers. PARTICIPANTS: Researchers from the primary care network. METHODS: We used the SEH-LELHA derivation criteria guidelines, plus an ad hoc survey that included demographic and anthropometric data, blood pressure levels, and the main reason for derivation to SC at the baseline and final (post-derivation) visit. In addition, time deployed for the study of every patient, changes in diagnosis and treatment, type of follow-up, issues throughout the derivation process and assessment of the medical referred to the PCPH were evaluated. RESULTS: With participation of 578 researchers from primary, the study included 1715 patients aged 60.7±13.3years, 62.7% male. Patients were taking 2.3±1.2 (range 0-10) antihypertensive drugs pre-referral and 2.5±1.2 (0-9) after derivation. Blood pressure levels changed from 166±21.6 /97.7±12.6mmHg to 143±14.4 /85.5±10.5mmHg. The number of controlled patients (BP<140 and <90mmHg) increased from 5.8% to 32.2%. Time between pre- and post-derivation visit was 72±64days (median 57days, IQ26-99). The PCPH received a medical report in 80.3% of cases, 76.9% with an explanation of the results of the complementary tests, 75.8% with additional information or a reasoning of treatment and in 71% of cases information about the patient future management. 63% of PCPH were fully agreed with the management of the specialist, 29% agree and 2% strongly disagree. The derivation was evaluated as effective or very effective in 86% of patients and no effective in 9%. CONCLUSIONS: Communication between AE and SC in HTA is valued satisfactorily by MAP. However there is still room for improvement in the process.

Quality of life with rivaroxaban in patients with non-valvular atrial fibrilation by therapeutic compliance.

OBJECTIVE: To assess the quality of life (QOL) with rivaroxaban in patients with non-valvular atrial fibrilation (NVAF) related to therapeutic compliance. METHODS: Prospective, longitudinal, multicenter study was developed in 160 Spanish primary or specialized care centers. We included 412 patients treated with rivaroxaban, prescribed for stroke prevention. Three visits were conducted: baseline, 6 and 12 months. Compliance was measured by electronic monitoring systems. QOL was measured by a specific questionnaire. We calculated the percentage of compliance means, the percentage of daily compliers and the score of QOL. RESULTS: Three hundred and seventy patients finished the study (mean age 75.19 SD: 7.5 years). Daily compliance was 83.5% (CI 78.53-88.57%) (n = 309) and 80% (CI 74.65-85.35%) at 6 and 12 months, respectively. Average QOL rating was 112.85 (SD 29.31) in non-compliant and 111.80 (SD 29.31) in the compliant group (p = Not significant), and after 12 months of 124.67 (SD 30.78) and 83.47 (SD 26.44), respectively (p < 0.0001), with a decrease in the score compliers (p < 0.01) and an increase in non-compliant group (p < 0.05). A higher number of drugs consumed, as well as the number of diseases/conditions suffered, the older age of the patients and having been previously treated with VKA were associated with a higher overall score (worse QOL). CONCLUSIONS: QOL in NVAF patients treated with rivaroxaban improved significantly over the study group at the expense of compliers. A worse QOL was associated with pluripathology, polymedication, older patients and previous treatment with VKA.

[Prevention of therapeutic inertia in the treatment of arterial hypertension by using a program of home blood pressure monitoring]. / Eficacia de un programa de automedida domiciliaria de la presión arterial como estrategia para disminuir la inercia terapéutica.

OBJECTIVE: To evaluate the efficacy of a program of home blood pressure monitoring (HBPM) on therapeutic Inertia (TI) in mild-to-moderate hypertension (AHT). DESIGN: Controlled, randomised clinical trial. SETTING: Forty six clinics in 35 primary care centres. Spain. PARTICIPANTS: A total of 232 patients with uncontrolled hypertension were included. INTERVENTION: Two groups with 116 patients were formed: 1) Control group (CG): standard health intervention; 2) Intervention group (IG): patients who were included in the HBPM program. MAIN MEASUREMENTS: TI was calculated by the ratio: Number of patients whose pharmacological treatment was not changed in each visit/Number of patients with an average BP 140mmHg and/or 90mmHg in the general population or 130 and/or 90 mmHg in diabetics. The mean BPs and the percentage of controlled patients were calculated. The mean number of people that required an intervention in order to avoid TI was calculated (NI). RESULTS: A total of 209 patients completed the study, with TI in 35.64% (95% CI=29.85%-41.43%) of the sample, and in 71.63% (95% CI=63.9-79.36%) of the uncontrolled hypertensive patients. The TI was 22.42% (95% CI=24.2-37%) in the IG and 50% (95% CI=37.75-62.25) in the CG (p<.05) in visit 2, and 25.23% (95% CI=14.84-35.62) and 46.07% (95% CI=33.85-58.29) in the final visit for IG and CG, respectively (P<.05). The NI was 4.3. CONCLUSIONS: TI was very significant among the uncontrolled hypertensive patients. The studied interventions are effective for improving TI.

[Therapeutic non-compliance with insulin in the treatment of diabetes mellitus 2]. / El cumplimiento terapéutico con insulina en el tratamiento de la diabetes mellitus tipo 2: estudio CUMINDIAB.

OBJECTIVE: To determine the percentage of therapeutic noncompliance among type 2 diabetes patients on treatment with insulin. DESIGN: Prospective multicentre study. SETTING: Nine Primary Care Health Centre in Huelva (Spain). PARTICIPANTS: A total of 121 type 2 diabetics, who, in the opinion of their doctor, need to start treatment with insulin or have their insulin treatment modified. MAIN MEASUREMENTS: Five visits were made (enrolment, 6, 12, 18 and 24 months). The variables analysed were, fasting blood glucose, glycosylated haemoglobin, compliance with insulin treatment, measured by counting insulin units. The percentage compliance (PC) was calculated by (PC = Total No. of insulin units expected to be consumed / Total No. of insulin units that should have been taken x 100). A complier was considered as one who achieved a PC between 80 and 100%. RESULTS: There were 103 evaluable subjects (85.8%) with a mean age of 66.4 (SD 11.6) years, and 45 were male (42.8%). The mean percentage compliance with insulin was 90.9% (95% CI, 84.2-97.6%). At the 6, 12, 18 and 24 months visits it was 92.1% (95% CI, 85.6-98.6%), 92.3, 90.1 and 89.2% (95% CI, 81.7-96.7%), respectively. Overall patient compliance was 74.75% (95% CI, 64.3-85.2%). For the visits, compliance was 82.5% (95% CI, 73.3-91.7%), 77.7%, 73.8% and 71.8% (95% CI, 60.9-82.7%), respectively (P<.05 initial-final). CONCLUSIONS: A quarter of the diabetic patients did not comply with their insulin treatment.

Barriers and Solutions to Improve Therapeutic Adherence from the Perspective of Primary Care and Hospital-Based Physicians.

Purpose: To identify the barriers affecting treatment adherence in patients with chronic disease and to determine solutions through the physician's opinion of primary care and hospital settings. Methods: An observational study using the nominal group technique was performed to reach a consensus from experts. A structured face-to-face group discussion was carried out with physicians with more than 10 years of experience in the subject of treatment adherence/compliance in either the primary care setting or the hospital setting. The experts individually rated a list of questions using the Likert scale and prioritized the top 10 questions to identify barriers and seek solutions afterward. The top 10 questions that obtained the maximum score for both groups of experts were prioritized. During the final discussion group, participating experts analyzed the prioritized items and debated on each problem to reach consensual solutions for improvement. Results: A total of 17 professionals experts participated in the study, nine of them were from a primary care setting. In the expert group from the primary care setting, the proposed solution for the barrier identified as the highest priority was to simplify treatments, measure adherence and review medication. In the expert group from the hospital setting, the proposed solution for the barrier identified as the highest priority was training on motivational clinical interviews for healthcare workers undergraduate and postgraduate education. Finally, the expert participants proposed implementing an improvement plan with eight key ideas. Conclusion: A consensual improvement plan to facilitate the control of therapeutic adherence in patients with chronic disease was developed, taking into account expert physicians' opinions from primary care and hospital settings about barriers and solutions to address therapeutic adherence in patients with chronic disease.

Medication Non-Adherence in Rheumatology, Oncology and Cardiology: A Review of the Literature of Risk Factors and Potential Interventions.

Medication adherence is directly associated with health outcomes. Adherence has been reviewed extensively; however, most studies provide a narrow scope of the problem, covering a specific disease or treatment. This project's objective was to identify risk factors for non-adherence in the fields of rheumatology, oncology, and cardiology as well as potential interventions to improve adherence and their association with the risk factors. The project was developed in three phases and carried out by a Steering Committee made up of experts from the fields of rheumatology, oncology, cardiology, general medicine, and hospital and community pharmacy. In phase 1, a bibliographic review was performed, and the articles/reviews were classified according to the authors' level of confidence in the results and their clinical relevance. In phase 2, 20 risk factors for non-adherence were identified from these articles/reviews and agreed upon in Steering Committee meetings. In phase 3, potential interventions for improving adherence were also identified and agreed upon. The results obtained show that adherence is a dynamic concept that can change throughout the course of the disease, the treatments, and other factors. Educational interventions are the most studied ones and have the highest level of confidence in the authors' opinion. Information and education are essential to improve adherence in all patients.

Specific hypertension smartphone application to improve medication adherence in hypertension: a cluster-randomized trial.

Introduction: Digital interventions, such as smartphone applications (apps), are becoming an increasingly common way to support medication adherence and self-management in chronic illness.Aim: To evaluate the effectiveness of the intervention in pharmacological therapeutic adherence in mild to moderate arterial hypertension (AHT), through an app installed on a mobile phone, as well as the degree of control reached by the patient with this tool.Methods: Prospective, randomized controlled trial, full study and multicenter study. Four primary care centers participated. One hundred and fifty-four hypertensive patients under antihypertensive treatment were included. Two groups were established: a control group (CG) with usual intervention (n = 77) and an intervention group (n = 77) (IG), targeting hypertensive people who owned and regularly used a mobile smartphone, specifically using the app called AlerHTA to promote health education and reminder of appointments. There were three visits: initial, 6 and 12 months. Drug adherence was measured by electronic monitors (MEMSs). The primary outcomes were average daily percentage adherence between 80 and 100%, and AHT control.Results: A total of 148 patients finished the study. Mean age was 57.5 ± 9.9. Global adherence was 77.02% (CI = 70.25-83.79) and daily adherence was 74.32% (CI = 67.29-81.35%). Daily adherence was 93.15% and 86.3% in IG, and 70.66% and 62.66% in CG after 6 and 12 months respectively (p < .05). The percentage of uncontrolled patients was 28.3% (CI = 21.05-35.55%). The control of high blood pressure at 12 months was 17.8% and 38.6% for IG and CG respectively (p < .05). The number of patients needed to treat to avoid non-adherence (NNT) was 4.23 patients.Conclusions: The intervention with an app installed on the mobile phones of hypertensive patients favors pharmacological therapeutic adherence and improves the percentage of hypertensive patient control.Trial registration: Spanish Agency of Medicine: EPA-SP UN-HTA-2015-01.

[The influence of correct blood pressure measurement on the diagnostic decisions in hypertensive patients. MEDIDA study]. / Influencia de la medida correcta de la presión arterial en la toma de decisiones diagnósticas en la hipertensión arterial. Estudio MEDIDA.

BACKGROUND AND OBJECTIVE: We aimed to assess the influence of correct blood pressure (BP) measurement, following the recommendations of the Spanish Guideline of Hypertension 2005 (SGH), on the diagnostic decisions in hypertensive patients. PATIENTS AND METHOD: Prospective, longitudinal, observational, multicenter study conducted in hypertensive patients with stable pharmacologic therapy in primary care units. 4040 patients were included, in whom BP was measured following current clinical practice at the first visit (visit 1). After 7 days no therapeutic changes could be made and BP was measured following the criteria of good BP measurement from the SGH (visit 2). Control rate was assessed both, following the investigators opinion and the SGH algorithm, at visits 1 and 2. Differences in therapeutic recommendations between visits were assessed. RESULTS: 3436 patients were evaluable (48.9% women), with mean age (standard deviation) of 63.4 (11.4) years. Decreases in systolic/diastolic BP of 4.8 mmHg (95% confidence interval [CI], 4.5-5.1) and 2.8 mmHg (95% CI, 2.6-3.0) between visits were observed. The control rate following the investigators opinion was of 59.1% (95% CI, 57.4-60.8%) at visit 1 and 76.4% (95% CI, 75.0-77.9%) at visit 2, and the one following the criteria of the SGH was 32.2% (95% CI, 30.6-33.7%) at visit 1 and 46.6% (95% CI, 44.9-48.3%) at visit 2. The rate of patients in which therapeutic recommendations were changed was of 54.1% (95% CI, 52.4-55.7%). CONCLUSIONS: Applying the recommendations of the SHG for correct BP measurement led to increased control rate in relation to a previous measurement, prompting changes in the therapeutic attitude.

Strategies for improving dabigatran adherence for stroke prevention in patients with non-valvular atrial fibrillation: education and drug intake reminders (FACILITA study).

Objective To assess the efficacy of a mixed intervention, educational, and reminder calendar of the intake, as a strategy to improve therapeutic adherence with dabigatran in patients with non-valvular atrial fibrillation (NVAF). Methods This was a prospective, longitudinal, multi-center study, carried out in 110 specialized healthcare centers in Spain. Seven hundred and twenty-six patients treated with dabigatran prescribed for stroke prevention were included. A cluster randomization was performed based on two groups: (1) Control Group (CG) as usual clinical practice, and (2) Intervention Group (IG) with a mixed strategy: (a) Healthcare education, and (b) Use of a reminder calendar for taking the anticoagulant medication. Three visits took place: baseline and follow-up at 6 and 12 months. Compliance was measured by using electronic monitors (MEMS). Average adherence percentage (%; Average AP) and daily compliance (%; Daily AP) was calculated. A patient was considered adherent when AP was 80-100%. Results Six hundred and twenty-five patients completed the study (315 in the IG and 310 in the CG). Daily AP was 91.97% at 6 months and 91.05% after 12 months in the IG and 82.26% and 82.63% in the CG. Average adherence was 90.79% and 89.20% in the IG and 64.51% and 63.22% in the CG at 6 and 12 months, respectively. Significant differences were observed in the Daily AP and Average AP, with higher percentages in the IG. In the non-adherents group, the number of concomitant drugs, baseline, and 6 months SBP values, 6 and 12 months DBP values, and weight, total cholesterol, and LDL cholesterol were significantly higher. The number needed to treat (NNT) was 3.84 patients to prevent one non-adherence. Conclusions A mixed intervention, consisting of patient education and a simple calendar reminder of drug intake, is an effective strategy to improve dabigatran therapeutic adherence in patients with NVAF. The percentage of adherence with dabigatran was high.

Validation of the electronic prescription as a method for measuring treatment adherence in hypertension.

OBJECTIVE: To validate electronic prescriptions (e-prescriptions) as a method for measuring treatment adherence in patients with hypertension. METHODS: This prospective study initially included 120 patients treated for hypertension in primary care centers. Adherence was measured using the gold standard, the medication event monitoring system (MEMS), versus the index test, the e-prescription program, at baseline and at 6, 12, 18 and 24 months. We calculated the adherence rate using the MEMS and the medication possession ratio (MPR) for the e-prescriptions. We considered patients adherent if they had an adherence rate of 80% to 100%. To validate the e-prescription, we obtained measures of diagnostic accuracy, the Kappa concordance index, and the area under the ROC curve (AUC). RESULTS: We included 102 patients. Overall adherence was 77.4% by MEMS (95%CI: 66.8-88) and 80.4% (95%CI: 70.3-90.5) by MPR. At 24 months, sensitivity was 87% and specificity, 93.7%. The AUC was 0.903 (95%CI: 0.817-0.989). CONCLUSION: Measures of treatment adherence were not significantly different between e-prescription and gold standard at most visits, and the e-prescription showed good discriminatory diagnostic capacity. PRACTICE IMPLICATIONS: If patients are included in an e-prescription program for at least 2 years, e-prescription is an inexpensive method to measure adherence in hypertension.

Effect of moderate and regular consumption of Cinco Jotas acorn-fed 100% Iberian ham on overall cardiovascular risk: A cohort study.

OBJECTIVE: To evaluate the impact that the moderate and regular consumption of Cinco Jotas acorn-fed 100% Iberian ham has on overall cardiovascular risk, lipid parameters, blood pressure, and weight. METHODS: A longitudinal, analytical, and quasi-experimental clinical study with repeated measures was carried out with 100 randomly selected individuals in primary care. The sample population included men and women (64%) between the ages of 25 and 55 (42.08, SD 9.6) who were not diagnosed with any cardiovascular illness or diabetes, were not undergoing antihypertensive treatment, nor taking lipid-lowering drugs. There were four visits during a 2-week washout period for the first of three phases. Phases 2 and 3 included an 8-week habitual diet phase followed by an 8-week intervention phase when participants consumed 40 g daily of acorn-fed 100% Cinco Jotas Iberian ham. Measurements of cardiovascular risk factors were taken following the SCORE table. These included total cholesterol, high-density lipoproteins cholesterol (HDL-c), low-density lipoproteins cholesterol (LDL-c), triglycerides (TG), and weight. RESULTS: The average vascular risk (SCORE) was 0.20 (SD 0.49) before the consumption phase and 0.18 (SD 0.48) at the end of the study (p > 0.05). An increase in HDL-c of 5 mg/dl was observed while there was a decrease in LDL-c and TG of 10 mg/dl (p < 0.05). There were no differences in total cholesterol levels, blood pressure, or weight; nor were differences observed in average consumption of calories, protein, lipids, carbohydrates, or alcohol (p > 0.05). CONCLUSIONS: The daily consumption of 40 g of Cinco Jotas acorn-fed 100% Iberian ham does not increase the risk of cardiovascular disease and has a favorable impact on lipid levels without affecting blood pressure or weight.

[Cardiovascular risk profile of uncontrolled hypertensive patients. The Control-Project study]. / Perfil de riesgo cardiovascular de los pacientes con hipertensión arterial no controlada. Estudio Control-Project.

BACKGROUND AND OBJECTIVE: To assess absolute cardiovascular risk and co-morbidities in uncontrolled hypertensive patients (blood pressure [BP]>or=140/90 mmHg or>or=130/80 mmHg in diabetics) attending Primary Care Physicians in Spain, and to determine the attitudes of these physicians towards this problem. PATIENTS AND METHOD: Cross-sectional, multicenter study involving 356 general practitioners around Spain. Absolute cardiovascular risk was assessed according to ESH-ESC 2003 Guidelines in a sample of 1,710 patients. RESULTS: Two hundred ninety seven patients were excluded by several reasons and a total of 1,413 hypertensive patients were valuable (mean age: 65.3+/-11.4 years; 56.7% women). Normal BP values (<140/90 mmHg) were exhibited by 0.2%, high-normal BP (120-139/80-89 mmHg) were exhibited by 2.8%, grade 1 hypertension (140-159/90-99 mmHg) by 49.9%, grade 2 hypertension (160-179/100-109 mmHg) by 39.3%, and grade 3 hypertension (>or=180/110 mmHg) by 7.9%. Associated cardiovascular risk factors were observed in 96.0% of patients (95% CI=94.7-97.2%), target organ damage in 34.5% (95% CI=31.6-36.5%), and cardiovascular clinical disease in 36.0% (95% CI=33.5-38.5%). According to ESH-ESC 2003 Guidelines 34.0% (CI=31.5-38.2%) were at very-high risk; 29.4% (95% CI=26.4-32.8%) at high risk; 30.4% (95% CI=27.2-33.7%) at moderate risk and 5.4% (95% CI=3.9-7.2%) at low risk of cardiovascular disease. Despite the high absolute risk, physicians did not do any therapeutic change in 30.4% (95% CI=28.2-33.5%) of uncontrolled hypertensive patients. Most of them (64.26%) considered that bad compliance to life style changes was the reason for inadequate BP control. The most frequent measure introduced was the association of additional drugs. CONCLUSIONS: Absolute cardiovascular risk in uncontrolled hypertensive patients attending Primary Care Physicians in Spain is very relevant. Sixty-five percent of these patients are at high or very high risk with a high prevalence of target organ damage or associated cardiovascular clinical disease. Therapeutic attitudes towards these patients are still very conservative although they are improving compared with previous studies.

Efficacy of a home blood pressure monitoring programme on therapeutic compliance in hypertension: the EAPACUM-HTA study.

OBJECTIVE: To evaluate the efficacy of a programme of home blood pressure measurement (HBPM) on therapeutic compliance in mild-to-moderate hypertension. DESIGN: A prospective controlled multicentre clinical trial. SETTING: Forty primary care centres in Spain, with a duration of 6 months. PATIENTS: A total of 250 patients with newly diagnosed or uncontrolled hypertension were included. INTERVENTIONS: The patients were randomly selected and distributed in two groups: (1) the control group (CG) who received standard health intervention; (2) the intervention group (IG): the patients in this group received an OMRON in their homes for a programme of HBPM. MAIN OUTCOME MEASURE: Four visits were scheduled, for the measurement of blood pressure (BP). They were provided with an electronic monitor for measuring compliance (monitoring events medication system; MEMS). Therapeutic compliance was defined as a drug consumption of 80-110%. A number of variables were calculated using the MEMS. The mean BP were calculated and the percentage of controlled patients. RESULTS: A total of 200 patients completed the study (100 in each group). Compliance was observed in 74 and 92%, respectively, in the CG and IG [95% confidence interval (CI) 63.9-84.1 and 86.7-97.3; P = 0.0001], the mean percentage compliances were 87.6 and 93.5% (95% CI 81.2-94 and 80.7-98.3; P = 0.0001), the percentages of correct days were 83.6 and 89.4%, the percentages of subjects who took the medication at the prescribed time were 79.89 and 88.06%, and the levels of therapeutic cover were 86.7 and 93.1%. The number needed to treat to avoid one case of non-compliance was 5.6 patients. The differences in the mean decreases in BP were significant for diastolic BP, with a greater decrease observed in the IG. CONCLUSIONS: An HBPM programme using electronic monitors is effective in improving compliance in arterial hypertension, measured using the MEMS.

Therapeutic compliance with rivaroxaban in preventing stroke in patients with non-valvular atrial fibrillation: CUMRIVAFA study.

OBJECTIVE: To assess compliance with treatment with rivaroxaban in patients with non-valvular atrial fibrillation. METHODS: Prospective, longitudinal, multicenter study, developed in 160 Spanish primary or specialized care centers. We included 412 patients treated with rivaroxaban, prescribed for stroke prevention. Three visits were conducted: baseline, 6 and 12 months. Compliance was measured by using electronic monitors (MEMSs) that use a digital record in the form of a microchip in the lid of the drug container that automatically controls its opening and registers the time and date of the opening. We calculated the average compliance percentage (CP), global and daily compliance. We considered compliance to be when CP was 80-100%. RESULTS: Three hundred and seventy patients ended the study (mean age 75.19, SD: 7.5 years). Global compliance was 84.1% (CI = 79.21-88.99%) and 80.3% (CI = 74.98-85.62%) after 6 and 12 months respectively. Daily compliance was 83.5% (CI = 78.53-88.57%) and 80% (CI = 74.65-85.35%) at 6 and 12 months. Significant differences in the CP between 6 and 12 months were observed. Global CP was 90.77% after 6 months and 89.65% at the end of the study. Daily CP was 90.14% and 87.66% at 6 and 12 months. There were significant CP differences between 6 and 12 months. Non-compliance was associated with a higher number of concomitant diseases, number of drugs taken and weight. CONCLUSIONS: The percentage of compliance with rivaroxaban was high. A profile of variables that need to be modified in current medical practice, associated with non-compliance, was detected.

Non-compliance and inertia in hypertensive Spaniards at high cardiovascular risk: CUMPLE study.

OBJECTIVE: To assess non-compliance (NC) and therapeutic inertia (TI) after 6 months of follow-up in hypertensive patients with poorly controlled blood pressure and high cardiovascular risk. RESEARCH DESIGN AND METHODS: Longitudinal, multicentre study; 3900 uncontrolled hypertensive patients were recruited from 585 primary healthcare centres. Tablets were counted during visits at baseline, 1, 3 and 6 months. A tablet count between 80-100% was considered as compliant. Multivariate logistic regression was performed to determine variables associated with NC and TI. RESULTS: A total of 3636 patients completed, mean age was 64.8 (SD 10.8) years, 53.7% being male. After one month, 61.8% (60.2-63.4) had uncontrolled blood pressure, 39.5% (37.9-41.1) were NC and 52.3% (50.2-54.4) had TI. At the end of follow-up, uncontrolled blood pressure was 34.6% (33.1-36.1) (p < 0.05), NC was 46.8% (45.2-48.4) (p < 0.05) and TI was 34.2% (31.6-36.8) (p < 0.05). The variable associated with NC was greatest number of antihypertensive treatments (OR 1.09, 95% CI 1.05-1.13, p < 0.001), and variables associated with TI were least number of antihypertensive drugs (OR 0.88, 95% CI 0.84-0.98, p < 0.001) and least number of diseases suffered (OR 0.95, 95% CI 0.92-0.98, p = 0.002). LIMITATIONS: Due to the complexity of measuring compliance, we have to assume measurement bias. CONCLUSIONS: Among uncontrolled hypertensive patients, after completing 6 months follow-up, approximately one out of two patients were NC and one out of three physicians committed TI.

Clinical inertia in poorly controlled elderly hypertensive patients: a cross-sectional study in Spanish physicians to ascertain reasons for not intensifying treatment.

BACKGROUND: Clinical inertia, the failure of physicians to initiate or intensify therapy when indicated, is a major problem in the management of hypertension and may be more prevalent in elderly patients. Overcoming clinical inertia requires understanding its causes and evaluating certain factors, particularly those related to physicians. OBJECTIVE: The objective of our study was to determine the rate of clinical inertia and the physician-reported reasons for it. METHODS: An observational, cross-sectional, multi-center study was carried out in a primary care setting. We included 512 physicians, with a consecutive sampling of 1,499 hypertensive patients with clinical inertia. MAIN OUTCOME MEASURE: Clinical inertia was defined when physicians did not modify treatment despite knowing that the therapeutic target had not been reached. Clinical inertia was considered to be justified (JCI) when physicians provided an explanation for not intensifying treatment and as not justified (nJCI) when no reasons were given. RESULTS: JCI was observed in 30.1 % (95 % CI 27.8-32.4) of patients (n = 451) and nJCI in 69.9 % (95 % CI 67.6-72.2) (n = 1,058). JCI was associated with higher blood pressure (BP) values (both systolic and diastolic) and diabetes (p = 0.012) than nJCI. nJCI was associated with patients having an isolated increase of systolic or diastolic or high borderline BP values or cardiovascular disease. CONCLUSION: Physicians provided reasons for not intensifying treatment in poorly controlled patients in only 30 % of instances. Main reasons for not intensifying treatment were borderline BP values, co-morbidity, suspected white coat effect, or perceived difficulty achieving target. nJCI was associated with high borderline BP values and cardiovascular disease.

Do Patients With High Vascular Risk Take Antihypertensive Medication Correctly? Cumple-MEMS Study.

INTRODUCTION AND OBJECTIVES: To assess compliance with treatment inhibit the renin-angiotensin system (angiotensin-converting enzyme inhibitors or angiotensin receptor blockers) in uncontrolled hypertension in patients at high cardiovascular risk. METHODS: Prospective, longitudinal, multicenter study, carried out in 102 Spanish primary care centers. We included 808 uncontrolled hypertensive patients treated with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers who were at high vascular risk; 4 visits were conducted: baseline and 1, 3, and 6 months later. Compliance was measured by electronic monitors. We calculated the mean percentage compliance, the overall percentage of compliers, once-daily compliers, compliers with the prescribed time frame, and antihypertensive coverage. We considered a patient to be a complier when the percentage compliance was 80%-100%. RESULTS: In all, 701 patients completed the study (mean age, 63.7 [11.1] years). The systolic and diastolic blood pressures decreased significantly (P<.0001) to 18.8 mmHg and 9.8 mmHg, respectively. The control rate was 70% (95% confidence interval, 65.6%-74.4%) (P=.0001). The rate of control was significantly higher among compliers than noncompliers (P<.05). The mean percentage of doses taken was 87.9% (95% confidence interval, 84.8%-91%) and the mean therapeutic coverage was 82.4% (95% confidence interval, 78.7%-86.1%). Overall, 73.3% of the patients were compliers (95% confidence interval, 69%-77.6%), 52.8% (95% confidence interval, 48%-57.6%) were once-daily compliers, and 46.5% (95% confidence interval, 41.9%-51.1%) complied with the prescribed time frame. Noncompliance was associated with a higher number of drugs prescribed (P<.001). CONCLUSIONS: In hypertensive patients at high vascular risk, the rate of therapeutic noncompliance was very high, mainly when they took 5 or more pills daily.

Is there a predictive profile for clinical inertia in hypertensive patients? An observational, cross-sectional, multicentre study.

BACKGROUND: Some studies have described a large number of hypertensive patients who are followed by a primary care physician without achieving adequate blood pressure (BP) control but whose treatment nevertheless is not intensified. It is not known whether physicians are aware of this clinical inertia and what factors are associated with this problem. OBJECTIVE: The aim of this study was to describe the factors associated with clinical inertia in hypertensive patients. METHODS: This was an observational, cross-sectional, multicentre study conducted in a network of primary care centres and hospital hypertension units in Spain. Using a consecutive sampling approach, 512 physicians selected 5077 hypertensive patients in whom they suspected poor BP control after chart review. The main variables documented were BP control and cardiovascular risk according to European Society of Hypertension guidelines, changes in treatment after visit, type of treatment, and healthcare setting. A binomial logistic regression multivariate analysis, adjusted for physician, was performed. RESULTS: Of the selected patients, 70.9% had poor BP control according to measurements taken in the physician's office, and in 1499 (42.1%) of those poorly controlled patients, treatment was not intensified (clinical inertia). Factors associated with clinical inertia were as follows: being seen at a primary care centre (p < 0.001), not having left ventricular hypertrophy (p < 0.001) or microalbuminuria (p < 0.001), taking fixed-dose (p = 0.049) or free-dose (p = 0.001) combination therapy, BP measured in other settings (nurse's office, patient's home) than the physician's office (p = 0.034) or the pharmacy (p = 0.019), older age (p = 0.032), and lower systolic (p < 0.001) and diastolic (p < 0.001) BP. Of the hypertensive patients with clinical inertia, 90.2% (95% CI 88.7, 91.7) had high cardiovascular risk. CONCLUSIONS: Clinical inertia was associated with a profile that included older age, lack of co-morbid conditions and being seen at a primary care centre.

[A study on the subjective compliance and acceptance of oral lanzoprazole in traumatology. The ECOFT-TR Study]. / Estudio sobre el cumplimiento subjetivo y la aceptabilidad de lansoprazol comprimidos bucodispersables en traumatología. Estudio ECOF-TR.

OBJECTIVE: To assess compliance with oral lansoprazole disintegrating tablets (LODT) in patients treated by traumatology specialists. MATERIAL AND METHOD: A multicenter, observational, cross-sectional study involving 370 traumatology specialists and patients aged 18 or more. Study logistics were sponsored by Almirall Laboratories, S.A.; neither investigators nor patients received any economic compensation for their participation. Patient subjective compliance with LODT was assessed with the Haynes Sackett test. Acceptability was based on patients' global assessments of the drug's organoleptic characteristics and properties of use, and preferences regarding previous treatments, recorded by means of a self-administered 15-item ad hoc questionnaire with a 2-5-point Likert-type scale, that patients fulfilled once. RESULTS: One thousand and eighty five patients were evaluable for the main endpoint. Mean age was 56.09±13.8 years; 56.77% were women. Mean treatment duration was 51.24±38.8 days. 94.74% of the patients complied with the treatment. Mean percentage of compliance was 94.5±12.12; 91.09% of patients rated the treatment as «acceptable or highly acceptable¼. No significant differences were observed between compliant and non-compliant patients in terms of demographic or clinical variables. Mean percentage of compliance was significantly higher among patients without concomitant illness or treatment and without difficulties in taking tablets. One non-serious adverse reaction was reported in one (0.09%) patient. CONCLUSIONS: Compliance with lansoprazole orally disintegrating tablets was high. Patients reported that this formulation improved their compliance and that they preferred LODT to previous medication. Tolerability was excellent.

[Control of therapeutic inertia in the treatment of arterial hypertension by using different strategies]. / El control de la inercia terapéutica en el tratamiento de la hipertensión arterial mediante diferentes estrategias.

OBJECTIVE: To evaluate the efficacy of different interventions on therapeutic Inertia (TI) in mild-to-moderate hypertension (AHT). DESIGN: Controlled, randomised clinical trial. SETTING: Two hundred clinics in 5 primary care centres. Spain. PARTICIPANTS: A total of 1104 patients with uncontrolled hypertension were included. INTERVENTION: Four groups with 276 patients were formed: 1) Control group (CG): standard health intervention; 2) Education intervention and a program of home blood pressure monitoring (HBPM) (EG); 3) Card control intervention and HBPM programme (CHG); 4) Education intervention, card control and HBPM programme (ECHG). MAIN MEASUREMENTS: TI was calculated by the rate: (Number of patients whose pharmacological treatment was not changed in each visit/Number of patients with an average BP 140mmHg and/or 90mmHg in the general population or 130 and/or 90 mmHg in diabetics). The mean BPs and the percentage of controlled patients were calculated. The mean number of people that required an intervention in order to avoid TI was calculated (NI). RESULTS: A total of 921 patients completed the study, and 1842 visits were made, with TI in 36.8% (IC=5.8%) of the sample and in 82.58% (IC=8.2%) of the uncontrolled hypertensive patients. The TI was 60% (CI=4.2%), 38.4% (CI=4.4%) 30.2 (CI=4.3%) and 14.7 (CI=3.3%) (p=0.001) for CG, EG, CHG and ECHG, respectively. The percentage controlled at the end of study was 35.3% (CI=1.1%), 54.7% (CI=1.8%), 60.2% (CI=2.1%) and 65.1% (CI=2.2%) (p<0.01) for CG, EG, CHG and ECHG, respectively. The NI were 4.6, 3.3 and 2.2 for CG, EG, CHG and ECHG, respectively. CONCLUSIONS: TI was very significant among the uncontrolled hypertensive patients. The studied interventions are effective for improving TI.