BACKGROUND
Medication adherence is essential to optimizing blood pressure (BP) control. Prior research has demonstrated differences in pharmacy refill patterns according to antihypertensive drug ...class. No prior study has assessed the association between drug class and day-to-day adherence.
METHODS
Between 2011 and 2014, we enrolled a convenience sample of 149 patients with persistently uncontrolled hypertension from two inner-city clinics and concurrently measured adherence of up to four antihypertensive medications using electronic pillboxes during the interval between two primary care visits. The main outcome was mean percent of days adherent to each drug. Mixed effects regression analyses were used to assess the association between drug class and adherence adjusting for age, gender, race, ethnicity, education, health insurance, coronary artery disease, heart failure, chronic kidney disease, diabetes, number of medications, days monitored, and dosing frequency.
RESULTS
The mean age was 64 years; 72% women, 75% Hispanic, 88% prescribed ≥1 BP medication. In unadjusted analyses, adherence was lower for beta-blockers (70.9%) compared to angiotensin receptor blocking agents (75.0%, P = 0.11), diuretics (75.9%, P < 0.001), calcium channel blockers (77.6%, P < 0.001) and angiotensin-converting enzyme inhibitors (78.0%, P < 0.0001). In the adjusted analysis, only dosing frequency (P = 0.0001) but not drug class (P = 0.71) was associated with medication adherence.
CONCLUSIONS
Antihypertensive drug class was not associated with electronically measured adherence after accounting for dosing frequency amongst patients with uncontrolled hypertension. Low adherence to beta-blockers may have been due to the common practice of prescribing multiple daily dosing. Providers may consider using once daily formulations to optimize adherence and should assess adherence among all treated patients with uncontrolled hypertension.
The probability that patients met the guidelines each week was estimated using logistic regression with generalized estimating equations accounting for within-subject correlation and adjusting for ...covariates that influence physical activity: age, sex, ethnicity, race, partner status, GRACE (Global Registry of Acute Coronary Events) score, Charlson comorbidity index, depression (Beck Depression Inventory score >=10), decreased left ventricular ejection fraction (left ventricular ejection fraction <40%), body mass index, regular exercise before ACS, ACS type (unstable angina, non-ST-segment elevation myocardial infarction, or ST-segment elevation myocardial infarction), and ACS treatment (medical management, percutaneous coronary intervention, or coronary artery bypass graft). Limitations of our findings include the moderate sample size, enrollment from a single center, accelerometer noncompliance, and inability to assess physical activity during nonwear time.
Background
Professional guidelines in the U.S. do not recommend routine screening mammography for women ≥75 years with limited life expectancy and/or poor health. Yet, routine mammography remains ...widely used in older women. We examined older women's experiences, beliefs, and opinions about screening mammography in relation to aging and health.
Methods
We performed thematic analysis of transcribed semi‐structured interviews with 19 women who had a recent screening visit at a mammography clinic in New York City (average age: 75 years, 63% Hispanic, 53% ≤high school education).
Results
Three main themes emerged: (1) older women typically perceive mammograms as a positive, beneficial, and routine component of care; (2) participation in routine mammography is reinforced by factors at interpersonal, provider, and healthcare system levels; and (3) older women do not endorse discontinuation of screening mammography due to advancing age or poor health, but some may be receptive to reducing screening frequency. Only a few older women reported having discussed mammography cessation or the potential harms of screening with their providers. A few women reported they would insist on receiving mammography even without a provider recommendation.
Conclusions
Older women's positive experiences and views, as well as multilevel and frequently automated cues toward mammography are important drivers of routine screening in older women. These findings suggest a need for synergistic patient, provider, and system level strategies to reduce mammography overuse in older women.
Older women’s positive experiences and views towards mammography, as well as multilevel and frequently automated cues for mammography are important drivers of routine screening. These findings suggest a need for synergistic patient, provider, and system level strategies to reduce mammography overuse in older women.
The US Preventive Services Task Force (USPSTF) recommends out-of-office blood pressure (BP) testing to exclude white coat hypertension prior to hypertension diagnosis. Despite improved availability ...and coverage of home and 24-h ambulatory BP monitoring (HBPM, ABPM), both are infrequently used to confirm diagnoses. We used the Behavior Change Wheel (BCW) framework, a multi-step process for mapping barriers to theory-informed behavior change techniques, to develop a multi-component implementation strategy for increasing out-of-office BP testing for hypertension diagnosis. Informed by geographically diverse provider focus groups (n = 63) exploring barriers to out-of-office testing and key informant interviews (n = 12), a multi-disciplinary team (medicine, psychology, nursing) used rigorous mixed methods to develop, refine, locally adapt, and finalize intervention components. The purpose of this report is to describe the protocol of the Effects of a Multi-faceted intervention on Blood pRessure Actions in the primary Care Environment (EMBRACE) trial, a cluster randomized control trial evaluating whether a theory-informed multi-component strategy increased out-of-office testing for hypertension diagnosis.
The EMBRACE Trial patient sample will include all adults ≥ 18 years of age with a newly elevated office BP (≥ 140/90 mmHg) at a scheduled visit with a primary care provider from a study clinic. All providers with scheduled visits with adult primary care patients at enrolled ACN primary care clinics were included. We determined that the most feasible, effective implementation strategy would include delivering education about out-of-office testing, demonstration/instruction on how to perform out-of-office HBPM and ABPM testing, feedback on completion rates of out-of-office testing, environmental prompts/cues via computerized clinical decision support (CDS) tool, and a culturally tailored, locally accessible ABPM testing service. We are currently comparing the effect of this locally adapted multi-component strategy with usual care on the change in the proportion of eligible patients who complete out-of-office BP testing in a 1:1 cluster randomized trial across 8 socioeconomically diverse clinics.
The EMBRACE trial is the first trial to test an implementation strategy for improving out-of-office testing for hypertension diagnosis. It will elucidate the degree to which targeting provider behavior via education, reminders, and decision support in addition to providing an ABPM testing service will improve referral to and completion of ABPM and HBPMs.
Clinicaltrials.gov , NCT03480217 , Registered on 29 March 2018.
Background
Depression is a relapsing and remitting disease. Prior studies on the association between depressive symptoms and incident cardiovascular disease (CVD) have been limited by single ...measurements, and few if any have examined both incident coronary heart disease and stroke in a large biracial national cohort. We aimed to assess whether time‐dependent depressive symptoms conferred increased risk of incident CVD.
Methods and Results
Between 2003 to 2007, 22 666 black and white participants (aged ≥45 years) without baseline CVD in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study were recruited. Cox proportional hazards regression analyses assessed the association between up to 3 measurements of elevated depressive symptoms (4‐item Center for Epidemiologic Studies Depression Scale score ≥4) and incident coronary heart disease, stroke, and CVD death adjusting for age, sex, region, income, health insurance, education, blood pressure, cholesterol, medication, obesity, diabetes mellitus, kidney disease, C‐reactive protein, corrected QT interval, atrial fibrillation, left ventricular hypertrophy, smoking, alcohol, physical inactivity, medication adherence, and antidepressant use. The participants’ average age was 63.4 years, 58.8% were female, and 41.7% black. Time‐varying depressive symptoms were significantly associated with CVD death (adjusted hazard ratio 1.30, 95% CI 1.04–1.63), with a trend toward significance for fatal and nonfatal stroke (adjusted hazard ratio 1.26, 95% CI 0.99–1.60) but not fatal and nonfatal coronary heart disease (adjusted hazard ratio 1.11, 95% CI 0.89–1.38). Race did not moderate the association between depressive symptoms and CVD.
Conclusions
Proximal depressive symptoms were associated with incident fatal and nonfatal stroke and CVD death even after controlling for multiple explanatory factors, further supporting the urgent need for timely management of depressive symptoms.
Telemedicine visit use vastly expanded during the COVID-19 pandemic, and this has had an uncertain impact on cardiovascular care quality.
We sought to examine the association between telemedicine ...visits and the failure to meet the Controlling High Blood Pressure (BP) quality measure from the Centers for Medicare & Medicaid Services.
This was a retrospective cohort study of 32,727 adult patients with hypertension who were seen in primary care and cardiology clinics at an urban, academic medical center from February to December 2020. The primary outcome was a failure to meet the Controlling High Blood Pressure quality measure, which was defined as having no BP recorded or having a last recorded BP of ≥140/90 mm Hg (ie, poor BP control). Multivariable logistic regression was used to assess the association between telemedicine visit use during the study period (none, 1 telemedicine visit, or ≥2 telemedicine visits) and poor BP control; we adjusted for demographic and clinical characteristics.
During the study period, no BP was recorded for 2.3% (486/20,745) of patients with in-person visits only, 27.1% (1863/6878) of patients with 1 telemedicine visit, and 25% (1277/5104) of patients with ≥2 telemedicine visits. After adjustment, telemedicine use was associated with poor BP control (1 telemedicine visit: odds ratio OR 2.06, 95% CI 1.94-2.18; P<.001; ≥2 telemedicine visits: OR 2.49, 95% CI 2.31-2.68; P<.001; reference: in-person visits only). This effect disappeared when the analysis was restricted to patients with at least 1 recorded BP (1 telemedicine visit: OR 0.89, 95% CI 0.83-0.95; P=.001; ≥2 telemedicine visits: OR 0.91, 95% CI 0.83-0.99; P=.03).
Increased telemedicine visit use is associated with poorer performance on the Controlling High Blood Pressure quality measure. However, telemedicine visit use may not negatively impact BP control when BP is recorded.
Background Depressive symptoms are associated with mortality. Data regarding moderation of this effect by age and sex are inconsistent, however. We aimed to identify whether age and sex modify the ...association between depressive symptoms and all-cause and cardiovascular disease (CVD) mortality. Methods and Results The REGARDS (Reasons for Geographic and Racial Differences in Stroke) study is a prospective cohort of Black and White individuals recruited between 2003 and 2007. Associations between time-varying depressive symptoms (Center for Epidemiologic Studies Depression scale score ≥4 versus <4) and all-cause and CVD mortality were measured using Cox proportional hazard models adjusting for demographic and clinical risk factors. All results were stratified by age or sex and by self-reported health status. Of 29 491 participants, 3253 (11%) had baseline elevated depressive symptoms. Mean age was 65 (9.4) years, with 55.1% of participants female, 41.1% Black, and 46.4% had excellent/very good health. Depressive symptoms were measured at baseline, on average 4.9 (SD, 1.5), then 2.1 (SD, 0.4) years later. Neither age nor sex moderated the association between elevated time-varying depressive symptoms and all-cause or CVD mortality (all-cause: age 45-64 years adjusted hazard ratio aHR, 1.38; 95% CI, 1.18-1.61 versus age ≥65 years aHR,1.36; 95% CI, 1.23-1.50;
=0.05; CVD: age 45-64 years aHR, 1.17; 95% CI, 0.90-1.53 versus age ≥65 years aHR, 1.26; 95% CI, 1.06-1.50;
=0.54; all-cause: males aHR, 1.46; 95% CI, 1.29-1.64 versus female aHR, 1.34; 95% CI, 1.19-1.50;
=0.35; CVD: male aHR, 1.32; 95% CI, 1.08-1.62 versus female aHR, 1.22; 95% CI, 1.00-1.47;
=0.64). Similar results were observed when stratified by self-reported health status. Conclusions Depressive symptoms confer mortality risk regardless of age and sex, including individuals who report excellent/very good health.
Few real-world examples exist of how best to select and adapt implementation strategies that promote sustainability. We used a collaborative care (CC) use case to describe a novel, theory-informed, ...stakeholder engaged process for operationalizing strategies for sustainability using a behavioral lens.
Informed by the Dynamic Sustainability Framework, we applied the Behaviour Change Wheel to our prior mixed methods to identify key sustainability behaviors and determinants of sustainability before specifying corresponding intervention functions, behavior change techniques, and implementation strategies that would be acceptable, equitable and promote key tenets of sustainability (i.e., continued improvement, education). Drawing on user-centered design principles, we enlisted 22 national and local stakeholders to operationalize and adapt (e.g., content, functionality, workflow) a multi-level, multi-component implementation strategy to maximally target behavioral and contextual determinants of sustainability.
After reviewing the long-term impact of early implementation strategies (i.e., external technical support, quality monitoring, and reimbursement), we identified ongoing care manager CC delivery, provider treatment optimization, and patient enrollment as key sustainability behaviors. The most acceptable, equitable, and feasible intervention functions that would facilitate ongoing improvement included environmental restructuring, education, training, modeling, persuasion, and enablement. We determined that a waiting room delivered shared decision-making and psychoeducation patient tool (DepCare), the results of which are delivered to providers, as well as ongoing problem-solving meetings/local technical assistance with care managers would be the most acceptable and equitable multi-level strategy in diverse settings seeking to sustain CC programs. Key adaptations in response to dynamic contextual factors included expanding the DepCare tool to incorporate anxiety/suicide screening, triage support, multi-modal delivery, and patient activation (vs. shared decision making) (patient); pairing summary reports with decisional support and yearly onboarding/motivational educational videos (provider); incorporating behavioral health providers into problem-solving meetings and shifting from billing support to quality improvement and triage (system).
We provide a roadmap for designing behavioral theory-informed, implementation strategies that promote sustainability and employing user-centered design principles to adapt strategies to changing mental health landscapes.
Primary care providers are increasingly involved in the management of patients with mental disorders, particularly as integrated models of care emerge. The recent publication of the fifth edition of ...the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) represents a shift in the classification of several mental disorders commonly encountered by primary care providers. With the advent of ICD-10 and the movement toward diagnostic specificity, it is crucial that primary care providers understand the rationale behind these changes. This paper provides an overview of the changes in the classification of mental disorders in DSM-5, a description of how these changes relate to frequently used screening tools in the primary care setting, and a critique of how these changes will affect mental health practice from a primary care perspective.
PDF
