Hierarchical modeling of blood pressure determinants and outcomes following valsartan treatment in hypertensive patients with known comorbidities: pooled analysis of six prospective real-world studies including 11,999 patients.

AIMS: Six prospective real-world studies of antihypertensive treatment with valsartan-centric regimens were pooled to: (1) examine the effectiveness of ∼90 days of second- or later-line valsartan treatment in hypertensive patients with known comorbidities; and (2) identify physician- and patient-related determinants associated with systolic (SBP) and diastolic blood pressure (DBP) outcomes in these patients. METHODS AND MATERIALS: A pooled analysis was performed of an evaluable sample of 11,999 hypertensive patients with known comorbidities treated ∼90 days with valsartan-centric regimens. We applied hierarchical linear and logistic regression models to identify determinants of blood pressure (BP) outcomes and a potential physician class effect. RESULTS: Valsartan regimens resulted in mean (SD) SBP and DBP reductions of 18.0 (15.8) mmHg and 9.5 (10.1) mmHg, respectively, at ∼90 days, yielding SBP, DBP and combined SBP/DBP control rates of 44.0%, 67.2% and 39.3%, respectively. About a quarter of the variance in 90 day BP values was attributable to a physician class effect. BP outcomes declined with physicians' increasing years in practice and being male. At the patient level, BP outcomes declined with SBP and DBP at diagnosis; diabetes; higher cholesterol and BMI; lower valsartan and hydrochlorothiazide (HCTZ) doses; and concomitant anti-hypertensives. Older age was associated with improved DBP. A proxy of physician vigilance, cardiovascular disease history, was associated with improved BP outcomes, as were patient adherence and higher doses of valsartan in combination with HCTZ. CONCLUSIONS: Valsartan-centric regimens have significant BP lowering benefits in this pooled sample of patients with known comorbidities. Many observed determinants of BP outcomes are modifiable or manageable.

Determinants of methotrexate adherence in rheumatoid arthritis patients.

In rheumatoid arthritis (RA) patients, weekly intake of methotrexate (MTX) is the basic drug treatment. This observational study aims to investigate how many RA patients are adherent in terms of MTX intake and to identify determinants of non-adherence. Intake of MTX (orally or via injection) was recorded in 129 RA patients with an electronic monitoring system (MEMS(®)) during 16 weeks. In addition, two adherence questionnaires, the Medication Adherence Report Scale (MARS-5) and the Compliance-Questionnaire-Rheumatology (CQR) as well as a visual analogue scale (VAS) measuring MTX adherence, were administered to these patients. As possible determinants of adherence, data on demographics, disease and treatment characteristics, depression, illness cognitions, motivation, and social support were collected. Of all participants, 58 % were fully adherent and 75 % skipped at most one dose during 16 weeks. A better mental health status and suffering from comorbidities had a positive effect on adherence, while living alone had a negative effect. These three predictors explained 30 % of the variance in MTX adherence. Of the three self-report medication adherence measures, the VAS correlated the highest with the results of the electronic monitoring system (r = 0.552, p = 0.01). A relatively high adherence rate was observed in RA patients treated with MTX. The determinants identified by this study could be used to screen patients at risk for non-adherence. A simple VAS scale seems to be an acceptable way for a preliminary screening of MTX adherence.

Prevalence and management of antibiotic associated diarrhea in general hospitals.

BACKGROUND: Antibiotic-associated diarrhea (AAD) is a common adverse effect of antibiotic (AB) treatment. This study aimed to measure the overall prevalence of AAD (including mild to moderate diarrhea) in hospitalized AB treated patients, to investigate associated risk factors and to document AAD associated diagnostic investigations, contamination control and treatment. METHODS: During 8 observation days (with time delay of 10-14 days between each observation day), all adult patients hospitalized at an internal medicine ward of 4 Belgian participating hospitals were screened for AB use. Patients receiving AB on the observation day were included in the study and screened for signs and symptoms of AAD using a period prevalence methodology. Clinical data were collected for all AB users and AAD related investigations and treatment were collected for the entire duration of AAD. Additionally, nurses noted daily the frequency of all extra care associated to the treatment of the diarrhea. RESULTS: A total of 2543 hospitalized patients were screened of which 743 were treated with AB (29.2%). Included AB users had a mean age of 68 yr (range 16-99) and 52% were male. Penicillins were mostly used (63%) and 19% received more than one AB. AAD was observed in 9.6% of AB users including 4 with confirmed Clostridium difficile infection. AAD started between 1 and 16 days after AB start (median 5) and had a duration of 2 to 41 days (median 4). AAD was significantly associated with higher age and the use of double AB and proton pump inhibitors. AAD patients had extra laboratory investigations (79%), received extra pharmacological treatment (42%) and 10 of them were isolated (14%). AAD related extra nursing time amounted to 51 minutes per day for the treatment of diarrhea. CONCLUSIONS: In this observational study, with one third of hospitalized patients receiving AB, an AAD period prevalence of 9.6% in AB users was found. AAD caused extra investigations and treatment and an estimated extra nursing care of almost one hour per day. Preventive action are highly recommended to reduce the prevalence of AAD and associated health care costs.

Adherence to phosphate binders in hemodialysis patients: prevalence and determinants.

BACKGROUND: Phosphate control is a crucial treatment goal in end-stage renal disease, but poor patient adherence to phosphate binder therapy remains a challenge. This study aimed to estimate the extent of phosphate binder adherence in hemodialysis patients and to identify potential determinants. METHODS: Phosphate binder adherence was measured blindly in 135 hemodialysis patients for 2 months using the medication event monitoring system. Patient data, gathered at inclusion through medical records, ad hoc questionnaires and the short form (SF)-36 health survey, included: (1) demographics, (2) perceived side-effects, belief in benefit, self-reported adherence to the therapy, (3) knowledge about phosphate binder therapy, (4) social support, and (5) quality of life (SF-36). Phosphatemia data was collected from charts. 'Being adherent' was defined as missing <1 total daily dose/week and 'being totally adherent' as missing <1 total daily dose/week, every week. RESULTS: Mean age of patients was 67 years and 64 % of the sample was male. Over the 2 months, 78 % of the prescribed doses were taken. Every week, about half of patients were adherent. Over the entire 8-week period, 22 % of patients were totally adherent. Mean phosphatemia levels were 0.55 mg/dl lower in adherent than nonadherent patients (4.76 vs. 5.31 mg/dl). Determinants for being totally adherent were living with a partner, higher social support (both were interrelated) and higher physical quality of life. Experiencing intake-related inconvenience negatively affected adherence. The social support and quality of life physical score explained 26 % of the variance in adherence. CONCLUSIONS: Phosphate binder nonadherence remains a major problem. Interventions should aim, at least, to improve social support. With few associated factors found and yet low adherence, an individualized approach seems indicated.

Hierarchical modeling of patient and physician determinants of blood pressure outcomes in adherent vs nonadherent hypertensive patients: pooled analysis of 6 studies with 14,646 evaluable patients.

The authors used pooled data from 6 valsartan-related studies including 3983 adherent and 10,663 nonadherent patients to evaluate blood pressure (BP) outcomes in both groups after 90 days of treatment, applying hierarchical linear and logistic regression to identify determinants of BP outcomes. The principal findings were that: (1) BP outcomes were consistently better in adherent patients; (2) approximately a quarter of the variance in 90-day BP values was attributable to a physician class effect; (3) common and unique patient- and physician-related variables were associated with BP outcomes in both groups; (4) physician vigilance was associated with better outcomes, especially in adherent patients; and (5) adherent patients were more likely to exhibit target organ damage and associated events while being prescribed more complex medication regimens. Adherence to antihypertensive medication may be a function of prior line treatment failure, severity of illness, and sequelae, and the ensuing patient resolution to change medication behavior.

Nurse-led interventions to enhance adherence to chronic medication: systematic review and meta-analysis of randomised controlled trials.

PURPOSE: Non-adherence to chronic medication remains an important problem with vast consequences and without solutions to date. Nurses are well positioned to provide adherence care, yet currently represent an underutilised force in improving adherence and outcomes. This review aims to synthesise the effect of nurse-led interventions on adherence to chronic medication. METHODS: Using Review Manager software, a meta-analysis was conducted. The search term medication adherence was combined with random* and nurse in PubMed and ISI Web of Knowledge. Retrieved articles' reference lists were hand searched. Included were randomised controlled trials on nurse-led interventions, aiming to improve chronic medication adherence. Articles were to be in English and published from 2006 to 2011. Quality was assessed using an adapted version of the CONSORT tool. RESULTS: Ten studies met the selection criteria, seven of which were on HIV-positive patients. Their quality was acceptable to high. Counselling was the intervention most frequently assessed, mostly given face-to-face, but also in groups and via electronic messages. All interventions enhanced adherence. Of the five studies reporting adherence as mean percentage of adherence, pooled mean differences were +5.39 (1.70-9.07) (short term) and +9.49 (4.68-14.30) (long term), favouring the intervention groups. Of the studies reporting adherence dichotomously, odd's ratios were 1.55 (1.04-2.29) (short term) and 1.87 (1.35-2.61) (long term). The longer counselling was effectuated, the better the results. CONCLUSIONS: Counselling appears to be an effective approach that nurses can use to supplement other methods, building a multifaceted strategy to enhance adherence. Tackling non-adherence seems to demand continuous efforts and follow-up.

Nurse-led education and counselling to enhance adherence to phosphate binders.

AIMS AND OBJECTIVES: To investigate whether nurse-led education and counselling enhance phosphate binder adherence in chronic dialysis patients. BACKGROUND: One in two chronic dialysis patients experiences difficulties in adhering to phosphate binders. The reasons for non-adherence are multifactorial and accordingly require a multifaceted strategy. To date, investigations have been confined primarily to single interventions to promote adherence. This study examines the effect of a multifaceted approach. DESIGN: The design was interventional. METHOD: Adherence to phosphate binders was blindly and electronically monitored for 17 consecutive weeks with the Medication Event Monitoring System (MEMS). After four weeks baseline monitoring, the effects of the intervention were studied for an additional 13 weeks. In week 5, the study nurse gave all 41 participating patients education on phosphate binders. Thereafter, the study nurse gave bi-weekly personalised counselling to enhance adherence to phosphate binders. The evolution of adherence over time was assessed and compared with historical control data. Secondary outcome variables included serum values of phosphate, calcium and parathyroid hormone and phosphate binder knowledge. RESULTS: In week 1, mean adherence was 83% in this study (intervention group), compared with 86% in the historical control group. In the intervention group, mean adherence increased from 83-94% after 13 weeks. By contrast, in the historical control group, mean adherence declined from 86-76%. In the intervention group, serum phosphate values decreased from 4·9-4·3 mg/dl and phosphate binder knowledge increased from a mean score of 53-75%. CONCLUSIONS: Combining education and continuous counselling holds promise in enhancing phosphate binder adherence. Large-scaled and long-term field studies are indicated to determine which nurse-led practices lead to an integral and sustained medication adherence management. RELEVANCE TO CLINICAL PRACTICE: Nursing strategies to scale up adherence should at least include educating patients and regularly reinforcing adherence behaviour.