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.

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.

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.

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.

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

INTRODUCCIÓN: Estudiar la opinión del médico de atención primaria (MAP) de la información de los pacientes remitida desde el médico especialista en hipertensión arterial (MEHTA). DISEÑO: Estudio observacional descriptivo. Emplazamiento: Realizado a nivel nacional. PARTICIPANTES: Médicos de atención primaria que reciben hipertensos estudiados por MEHTA. MÉTODOS: Se utilizó el consenso de derivación de la SEH-LELHA, y una encuesta en la que se recogían en la visita basal las características demográficas, antropométricas, presión y causa de derivación; en la posderivación se añaden preguntas sobre: tiempo utilizado en estudiar al paciente, modificaciones del diagnóstico y fármacos. Además se preguntó sobre el tiempo en recibir respuesta y se pidió la valoración del informe que le remite el MEHTA. RESULTADOS: Participaron 578 investigadores de AP que incluyeron 1.715 pacientes válidos. Edad 60,7 ± 13,3 años, varones 62,7%. En prederivación los pacientes tomaban 2,3 ± 1,2 fármacos antihipertensivos, y 2,5 ± 1,2 en posderivación; la presión arterial pasó de 166 ± 21.6 /97,7±12,6 mmHg a 143 ± 14,4 /85,5 ± 10,5mmHg. Los pacientes controlados (PA < 140 y < 90 mmHg) pasaron del 5,8 al 32,2%. El tiempo transcurrido entre la visita al hospital y la recepción del informe fue de 72 ± 64días. Se realizó ampliación del estudio por parte del MEHTA en 1.250 casos (72,9%). El MAP médico de familia recibió informe reglado en el 80,3% de los casos. Globalmente, el 63% de los MAP están totalmente de acuerdo con la actuación del especialista, el 29% parcialmente de acuerdo y el 2% nada de acuerdo. La derivación se ha valorado mediante opinión subjetiva del MAP como efectiva o muy efectiva en el 86% de los pacientes y nada efectiva en el 9%. CONCLUSIONES: La comunicación entre niveles es clave en el cuidado de algunos pacientes hipertensos, como corresponde a una entidad crónica

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 ± 13.3 years, 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 ± 10.5 mmHg. The number of controlled patients (BP < 140 and < 90 mmHg) increased from 5.8% to 32.2%. Time between pre- and post-derivation visit was 72 ± 64days (median 57 days, 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

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.

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.

[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.

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.

El incumplimiento en el tratamiento de la diabetes mellitus tipo 2 en España / Therapeutic nonadherence in diabetes mellitus type 2 in Spain

El incumplimiento del tratamiento farmacológico es considerada como una de las causas principales de la falta de control de la diabetes mellitus (DM). En España el incumplimiento del tratamiento antidiabético oral (ADO) ha sido analizado en varios estudios a corto plazo, habiéndose observado un incumplimiento entre el 45 y el 51,5%, mientras que el incumplimiento con insulina se ha analizado en un único estudio, donde se ha observado un incumplimiento del 25,2%. En el ámbito internacional, la magnitud del incumplimiento en la DM con ADO ronda entre el 6,7 y el 55%. El incumplimiento del tratamiento se ha asociado a un mal control de las cifras de glucemia y hemoglobina glucosilada, incremento de los costes sanitarios, mayor hospitalización y a una mayor morbimortalidad (AU)

Therapeutic noncompliance is considered one of the main causes of the lack of control of diabetes mellitus (DM). In Spain, the oral antidiabetic (OAD) treatment noncompliance has been analyzed in several short-term studies, having been between 45% and 51.5%, while noncompliance with insulin was analyzed in a single study, where there has been a noncompliance of 25.2%. Internationally, the magnitude of noncompliance in DM with OAD is from 6.7 to 55%. Noncompliance was associated with poor control of blood glucose and glycosylated hemoglobin, increased health care costs, hospitalization, morbidity and mortality (AU)

¿Los pacientes con alto riesgo vascular toman correctamente la medicación antihipertensiva? Estudio Cumple-MEMS / Do patients with high vascular risk take antihypertensive medication correctly? Cumple-MEMS study

Introducción y objetivos. Valorar el cumplimiento terapéutico del tratamiento con inhibidores del sistema renina-angiotensina (inhibidores de la enzima de conversión de la angiotensina o antagonistas de los receptores de la angiotensina II) en la hipertensión arterial no controlada de pacientes de alto riesgo vascular. Métodos. Estudio prospectivo, longitudinal y multicéntrico desarrollado en 102 centros de atención primaria españoles. Se incluyó a 808 hipertensos tratados con inhibidores del sistema renina-angiotensina (inhibidores de la enzima de conversión de la angiotensina o antagonistas de los receptores de la angiotensina II), no controlados y con alto riesgo vascular. Se realizaron cuatro visitas (inicial y tras 1, 3 y 6 meses). Se midió el cumplimiento mediante monitores electrónicos. Se calculó el porcentaje de cumplimiento medio, el porcentaje de cumplidores en general, cumplidores de una toma diaria, cumplidores en horario correcto y cobertura antihipertensiva. Se consideró cumplidor a aquel cuya tasa de cumplimiento estuviera entre el 80 y el 100%. Resultados. Finalizaron el estudio 701 pacientes (media de edad, 63,7±11,1 años). Las presiones arteriales sistólicas y diastólicas se redujeron significativamente (p<0,0001): 18,8 y 9,8mmHg respectivamente. Los controlados fueron el 70% (intervalo de confianza del 95%, 65,6-74,4%). Se observaron diferencias significativas con mayor control entre los cumplidores que entre los incumplidores (p<0,05). La media del porcentaje de dosis tomadas fue del 87,9% (intervalo de confianza del 95%, 84,8-91%) y la cobertura terapéutica, el 82,4% (intervalo de confianza del 95%, 78,7-86,1%). Fueron cumplidores en general el 73,3% (intervalo de confianza del 95%, 69-77,6%); de una toma diaria, el 52,8% (intervalo de confianza del 95%, 48-57,6%), y en horario correcto, el 46,5% (intervalo de confianza del 95%, 41,9-51,1%). El cumplimiento se asoció a menor número de fármacos prescritos y no estar diagnosticado de diabetes (p<0,001). Conclusiones. Entre los hipertensos de alto riesgo vascular, el incumplimiento fue muy alto, fundamentalmente cuando toman cinco o más comprimidos diarios (AU)

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 18.8mmHg 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 (AU)

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.

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

Objetivo: Determinar la magnitud del incumplimiento del tratamiento farmacológico con insulina, en pacientes con diabetes mellitus tipo 2 (DM2). Diseño: Estudio prospectivo, longitudinal y multicéntrico. Emplazamiento: 9 centros de salud. Distrito Huelva-Costa. España. Participantes: 121 diabéticos tipo 2 que precisaron según criterio de su médico inicio o modificación del tratamiento con insulina, con un seguimiento de 2 años. Mediciones principales: Se efectuaron 5 visitas (inclusión, 6, 12, 18 y 24 meses). Variables analizadas: glucemia basal, hemoglobina glucosilada, cumplimiento del tratamiento con insulina, medido mediante recuento de unidades de insulina. Se calculó el tanto por ciento de cumplimiento (PC) (PC=N.° total de unidades de insulina presumiblemente consumida/N.° total de unidades de insulina que debiera haber sido administrada x 100). Se consideró cumplidor aquel cuyo PC estaba entre 80 y 100%. Resultados: Concluyeron 103 pacientes (85,1%) (edad 66,4, DE 11,6 años). Fueron 45 varones (42,8%). El porcentaje de cumplimiento medio fue de 90,9% (IC 84,2-97,6%). Por visitas (6, 12, 18 y 24 meses, respectivamente) fue de 92,1% (IC 85,6-98,6%), 92,3, 90,1 y 89,2% (IC 81,7-96,7%). El porcentaje de cumplidores fue del 74,75% (IC 64,3-85,2%). Por visitas fue respectivamente 82,5 (IC 73,3-91,7%), 77,7, 73,8 y 71,8 (IC 60,9-82,7%) (p<0,05 entre inicio y final). El porcentaje de control final de glucemias basales y hemoglobina glucosilada fueron del 22,33% (IC 12,17-32,49%) y del 11,65% (IC 3,83-19,47%). Conclusiones: Una cuarta parte de los diabéticos fueron incumplidores del tratamiento con insulina(AU)

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(AU)

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

Objetivo: Evaluar si un programa de automedida domiciliaria de presión arterial (AMPA) es eficaz para obtener una menor inercia terapéutica (IT) en el tratamiento de la HTA. Diseño: Estudio clínico controlado, aleatorizado y multicéntrico. Emplazamiento: 35 centros de salud de España. Participantes: Se incluyeron 232 hipertensos. Intervención: Se formaron 2 grupos con 116 individuos: 1, grupo de control (GC): recibieron la intervención habitual; 2, grupo de intervención: se inscribieron en un programa de AMPA. Mediciones principales: La IT se midió mediante el cociente: (Número de pacientes sin modificación del tratamiento farmacológico en cada visita / Número de pacientes con cifras medias de PA ≥ 140 mmHg y/o ≥ 90 mmHg en población general o ≥ 130 y/o 80 mmHg en diabéticos) y multiplicado por 100. Se calculó la IT por visitas, las PA medias y grado de control de la HTA. Resultados: Concluyeron 209 individuos (edad media 69,28±11,6 años) (p=NS por grupos) (GI 107 individuos y GC 102).La IT fue 35,64% de las visitas de la muestra (IC=29,85-41,43%) y en el 71,63% (IC=63,9-79,36%) en hipertensos no controlados. La IT fue del 22,42% (IC=24,2-37%) en el GI y 50% (IC=37,75-62,25) en el GC (p < 0,05) en visita 2, y del 25,23% (IC=14,84-35,62) y 46,07% (IC=33,85-58,29) en visita final para GI y GC respectivamente (p<0,05). Conclusiones: La IT ha sido muy relevante. El programa de AMPA es eficaz para obtener una menor IT(AU)

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(AU)

[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.

[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.

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.