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

Abstract

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.J Clin Hypertens (Greenwich). 2013;15:663-673. ª2013 Wiley Periodicals, Inc.The prevalence of nonadherence has been estimated at 25% in general, 1 23% among patients with cardiovascular disease 1 and 50% among patients with hypertension.2,3 Nonadherence to antihypertensive medication is associated with a 30% loss of treatment effectiveness, 4 while adherence is associated with a 38% decreased risk of cardiovascular events.5 While blood pressure (BP) control is a challenge in general, 6-10 achieving BP targets is particularly difficult in nonadherent patients. 11Prior studies have focused mainly on identifying patient variables associated with nonadherence to antihypertensive medication, 12,13 even though the determinants of nonadherence are believed to be multifactorial and to include, among others, health care providers and treatment-related factors.14 Adherence behavior was a consistent determinant of BP outcomes in multivariate analyses in a series of large observational studies on second-line treatment of hypertension with various valsartan regimens conducted in Belgium. 15 We pooled the data of 6 of these studies to examine whether there were differences in BP outcomes between adherent and nonadherent patients after 90 days of treatment, the proportion of variance in BP outcomes attributable to a physician class effect, and the patient-and physician-related determinants of BP outcomes common across and unique in each of these groups. The 14,646 evaluable patients were classified as nonadherent if they recalled not having taken their medication at some time in the 4 weeks prior to the 90-day follow-up visit; if not, they were classified as adherent. While perhaps a crude criterion potentially subject to bias, we have reported elsewhere that such a simple query is highly predictive of BP outcomes. Table I summarizes the key characteristics of the studies from which the data were pooled. The common methodology of these studies has been described in detail elsewhere. 16 METHODS1...

Hierarchical Modeling of Patient and Physician Determinants of Blood Pressure Outcomes in Hypertensive Patients with and without Diabetes: Pooled Analysis of Six Observational Valsartan Studies with 15,282 Evaluable Patients

“…Adherence was associated with lower SBP and DBP values and higher odds of achieving BP control. In an analysis of this same pooled data set comparing adherent and nonadherent patients, BP values and BP control rates were consistently better among adherent patients [10]. Interestingly, this analysis revealed that adherence to antihypertensive regimens may be a function of prior treatment-line failure, severity of illness, and patients experiencing (major) health problems related to their hypertension and/or diabetes.…”

The analisis of factors, associated with office and home blood pressure control in patients who received algorithmic antihypertensive therapy

“…Такий результат дозволяє припустити, що для лікування зазначеної групи пацієнтів раціонально застосовувати структурований підхід до антигіпер-тензивної терапії, що передбачає її вчасну інтенсифі-кацію та використання фіксованих медикаментозних комбінацій від початку лікування. За нашими даними висока прихильність до лікування була чинником, що через 6 місяців засто-сування алгоритмізованої терапії незалежно асоці-ювався як з контролем офісного, так і з контролем домашнього АТ, що узгоджується з результатами інших досліджень [6, 7,19]. Відомо, що завелика кількість медикаментозних засобів негативно впли-ває на комплаенс пацієнтів.…”

The Evolving Clinical Management of Hypertension

“…In view of these reports indicating that both patients and clinicians may share responsibility for poor BP results, it is interesting to consider the article by Dr Ivo Abraham and colleagues that looked at a meta‐analysis of 14,646 patients to evaluate whether physicians or patients might be primarily responsible for inadequate responses to treatment. As already discussed, hypertension is an asymptomatic disease and is particularly susceptible to nonadherence, which has been reported in up to 50% of patients with this condition .…”