Systematic review of motivational interventions to improve adherence to medication in patients with hypertension and meta-analysis / Revisión sistemática de intervenciones motivacionales para mejorar la adherencia a la medicación en pacientes con hipertensión y metanálisis

Introduction: Antihypertensive medication non-adherence is an important cause of poor control in hypertension. The role of motivational interventions to increase antihypertensive medication adherence remains unclear. Objective: To systematically review RCTs of motivational interventions for improving medication adherence in hypertension. Methods: EMBASE and Pubmed were searched from inception to February 2019 for RCTs of motivational interventions for improving medication adherence in hypertension vs. usual care. Inclusion criteria: RCTs with motivational intervention to improve medication adherence in adults with hypertension. A blinded review was conducted by 2 reviewers. Disagreements were resolved by consensus/a third reviewer. Data extraction and quality appraisal was performed using the risk of bias tool from cochrane collaboration. The meta-analyses of blood pressure control used random-effects models to report mean difference and 95% CIs. Primary outcome was medication adherence and second outcome was blood pressure control. Results: The search methodology yielded 10 studies comprising 1171 participants. Medication adherence improved significantly in 5 studies. We could not perform pool analysis for this outcome due to different measurements of medication adherence. Seven trials reported significant results regarding blood pressure control. On pooled analysis, motivational interventions were not significantly associated with a systolic blood pressure (mean difference, −0.06; 95% CI, −0.05 to 0.18; p=0.63; I2=0.0%) or diastolic blood pressure (mean difference, −0.11; 95% CI, −0.10 to 0.31; p=0.28; I2=23.8%) decrease or blood pressure control. (AU)

Introducción: La falta de adherencia a la terapia farmacológica es una de las principales razones del descontrol de la hipertensión arterial. Se desconoce el papel de las intervenciones motivacionales en el aumento de la adherencia. Objetivo: Realizar una revisión sistemática de ensayos clínicos aleatorizados (ECA) dirigidos a mejorar la adherencia a la medicación en hipertensión arterial. Métodos: Se buscaron ECA de intervenciones motivacionales vs. atención habitual en las bases de datos Embase y PubMed desde su inicio hasta febrero de 2019. Criterios de inclusión: ECA de intervenciones motivacionales para aumentar la adherencia a la terapia con medicamentos en adultos con hipertensión. Dos revisores realizaron una revisión ciega y sus desacuerdos se resolvieron por consenso/por un tercer revisor. La extracción de datos y la evaluación de la calidad se realizaron mediante la herramienta Cochrane de evaluación del riesgo de sesgo. El metaanálisis del control de la presión arterial utilizó modelos de efectos aleatorios para informar la diferencia en las medias y los intervalos de confianza de 95% (IC 95%). El outcome primario fue la adherencia a la medicación y el secundario fue el control de la presión arterial. Resultados: Se obtuvieron 10 estudios con 1.171 participantes. La adherencia mejoró significativamente en cinco estudios. No fue posible realizar un análisis agrupado de la adherencia debido al uso de diferentes medidas de cumplimiento. Siete estudios mostraron una diferencia significativa en el control de la presión arterial. En el análisis conjunto, las intervenciones motivacionales no se asociaron a una disminución significativa de la presión arterial sistólica (diferencia de medias, -0,06; IC 95%, -0,05-0,18; p=0,63; I2=0%) o de la presión arterial diastólica (diferencia de medias, -0,11; IC 95%, -0,10-0,31; p=0,28; I2=23,8%) o a mejora en control de la misma.(AU)

Headache service quality evaluation: implementation of quality indicators in primary care in Europe.

BACKGROUND: Lifting The Burden (LTB) and European Headache Federation (EHF) have developed a set of headache service quality indicators, successfully tested in specialist headache centres. Their intended application includes all levels of care. Here we assess their implementation in primary care. METHODS: We included 28 primary-care clinics in Germany (4), Turkey (4), Latvia (5) and Portugal (15). To implement the indicators, we interviewed 111 doctors, 92 nurses and medical assistants, 70 secretaries, 27 service managers and 493 patients, using the questionnaires developed by LTB and EHF. In addition, we evaluated 675 patients' records. Enquiries were in nine domains: diagnosis, individualized management, referral pathways, patient education and reassurance, convenience and comfort, patient satisfaction, equity and efficiency of headache care, outcome assessment and safety. RESULTS: The principal finding was that Implementation proved feasible and practical in primary care. In the process, we identified significant quality deficits. Almost everywhere, histories of headache, especially temporal profiles, were captured and/or assessed inaccurately. A substantial proportion (20%) of patients received non-specific ICD codes such as R51 ("headache") rather than specific headache diagnoses. Headache-related disability and quality of life were not part of routine clinical enquiry. Headache diaries and calendars were not in use. Waiting times were long (e.g., about 60 min in Germany). Nevertheless, most patients (> 85%) expressed satisfaction with their care. Almost all the participating clinics provided equitable and easy access to treatment, and follow-up for most headache patients, without unnecessary barriers. CONCLUSIONS: The study demonstrated that headache service quality indicators can be used in primary care, proving both practical and fit for purpose. It also uncovered quality deficits leading to suboptimal treatment, often due to a lack of knowledge among the general practitioners. There were failures of process also. These findings signal the need for additional training in headache diagnosis and management in primary care, where most headache patients are necessarily treated. More generally, they underline the importance of headache service quality evaluation in primary care, not only to identify-quality failings but also to guide improvements. This study also demonstrated that patients' satisfaction is not, on its own, a good indicator of service quality.

[Non steroidal anti-inflammatory drugs prescription in General Practice in the centre of Portugal from 2007 to 2009]. / Prescrição de anti-inflamatórios não esteróides em medicina geral e familiar no centro de Portugal entre 2007 e 2009.

BACKGROUND: Non steroidal anti-inflammatory drugs computer-assisted prescription in General Practice/Family Medicine (GP/FM) ambience can give information about the prescription profile during a period of time and understand its trend. Such prescription profile could vary according to the urban (city) vs non urban (village) setting of the GP/FM practice. OBJECTIVES: To characterize the prescription trends of non steroidal inflammatory drugs (NSAIDs) in General Practice, from 2007 to 2009, by public sales price per inscript, daily defined doses (DDD) per inscript and price of DDD. To verify differences of the three fractions according to the urban vs non urban health centre. MATERIAL AND METHODS: Retrospective observational study conducted in February 2010, by the analysis of prescription informatic files automatically generated when the prescription was made. Population calculated at the middle point of each period of study. The differences in volume prescription in Daily Defined Dose (DDD) per registered patient in the middle of 2006 and 2007 two semesters, as well as the value of prescription measured by the price per registered patient were calculated and medicines were studied by the third level of the Portuguese medicines classification very similar to the ATC. The price per DDD was calculated as well. RESULTS: The studied population was of 315.377 subjects in 2007, 321.784 in 2008 and 331.106 in 2009. In price per inscript urban health centres showed a growth from 2007 to 2009 in "Indol and Inden" derivatives (+51.6%), in "Propionic acid derivatives" (+39.4%) and in "Selective cox-2 inhibitors" (+33.6%). For "Sulfanilamidic derivatives, a reduction of 3.8% was verified. For non urban Health Centres prescription a generalised reduction in price per inscript was observed. For DDD/per inscript from 2007 to 2009 we found a generalised increase for urban health centres, except for "Oxicans". For non urban Health Centres there is a generalised decrease of DDD/per inscript from 2007 to 2009, with a special decrease for non-acidic compounds. As for Price of DDD from 2007 to 2009 there is a generalised reduction of such ratio with the only exception of "non acidic compounds" (+9,1%) for urban Health Centres. In view of the calculated ratios, the differences by urban vs non urban Health Centre in each of the studied years there is a significant higher value in non urban health centre, with the exception of Price of DDD for 2008 and 2009 where such ratio is non significantly higher in urban heath centre. CONCLUSIONS: During the study period, demographic growth was higher than the prescription growth in volume and in value. Prescription was more frequent and expensive in non-urban Health Centres. Price of DDD decreases from 2007 to 2009 signifying a much cheaper NSAIDs therapeutics.