Predictors of Persistence With Antihypertensive Therapy: Results From the NHANES Leonelo E. Bautista This study was funded...
Background <ul><li>Only 57% of known hypertensive patients receiving pharmacologic treatment in the United States have the...
Background <ul><li>Previous studies of non-adherence are of limited generalizability because: </li></ul><ul><ul><li>they i...
Background <ul><li>The objective of this study was to evaluate how the following factors affect persistence with antihyper...
Methods <ul><li>Analyses in this study were based on data from NHANES III (1988–1994), NHANES 1999–2000, and NHANES 2001–2...
Methods <ul><li>Trained NHANES interviewers verified the medications being used during the 30 days prior to the survey dat...
Methods <ul><li>All analyses were statistically weighted to: </li></ul><ul><ul><li>maintain the representativeness of the ...
Methods <ul><li>Multiple logistic regression with sampling weights was used to estimate the independent effect of each fac...
Results <ul><li>Predisposing characteristics by persistence with antihypertensive medication (NHANES) </li></ul><ul><li>__...
Results <ul><li>Enabling and need characteristics by persistence with use of antihypertensive medication </li></ul><ul><li...
Results <ul><li>Multivariate adjusted odds ratios for non-persistence with  </li></ul><ul><li>antihypertensive therapy. </...
Results <ul><li>Multivariate adjusted odds ratios for non-persistence with  </li></ul><ul><li>antihypertensive therapy. </...
Conclusions <ul><li>Non-persistence with antihypertensive medication increased significantly with young age, in men, and a...
Implications <ul><li>Policies that improve access to health care and patient follow-up may be of great importance in maint...
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Predictors of persistence with antihypertensive therapy: results from the NHANES

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Leonelo E. Bautista

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Predictors of persistence with antihypertensive therapy: results from the NHANES

  1. 1. Predictors of Persistence With Antihypertensive Therapy: Results From the NHANES Leonelo E. Bautista This study was funded by the American Heart Association, Award No. 0675049N. Bautista LE, Am J Hypertens 2008 21;2:183-188
  2. 2. Background <ul><li>Only 57% of known hypertensive patients receiving pharmacologic treatment in the United States have their blood pressure controlled. </li></ul><ul><li>It is estimated that 15% of all cases of acute myocardial infarction and 32% of all strokes among subjects treated for hypertension can be attributed to uncontrolled blood pressure. </li></ul><ul><li>Failure by patients to use medications as prescribed is considered a major contributor to poor control of hypertension </li></ul><ul><li>32–53% of newly treated hypertensives stop using their medication by the end of the first year of treatment. </li></ul>Bautista LE, Am J Hypertens 2008 21;2:183-188
  3. 3. Background <ul><li>Previous studies of non-adherence are of limited generalizability because: </li></ul><ul><ul><li>they included mostly middle-aged and elderly patients enrolled in a single health insurance </li></ul></ul><ul><ul><li>they provided little data on the effects of enabling factors (health insu rance, income, and use of health services) </li></ul></ul><ul><ul><li>the pattern of medication prescription and use has likely changed as a consequence of increasing awareness, new practice guidelines, and availability of newer drugs with fewer side effects </li></ul></ul>Bautista LE, Am J Hypertens 2008 21;2:183-188
  4. 4. Background <ul><li>The objective of this study was to evaluate how the following factors affect persistence with antihypertensive medication: </li></ul><ul><ul><li>a) Predisposing factors (those that describe the propensity of patients to comply): age, gender, ethnicity, education, marital status, language, alcohol intake, and smoking </li></ul></ul><ul><ul><li>b) Enabling factors (those that comprise the resources available to help patients in obtaining health care and medications): average family annual income, having health insurance, and visits to the doctor during the last year </li></ul></ul><ul><ul><li>c) Need characteristics ( factors that reflect the patients’ requirements for care and medication): body mass index, self-reported health status, and coexisting chronic disease </li></ul></ul>Bautista LE, Am J Hypertens 2008 21;2:183-188
  5. 5. Methods <ul><li>Analyses in this study were based on data from NHANES III (1988–1994), NHANES 1999–2000, and NHANES 2001–2002. </li></ul><ul><li>The study sample included NHANES participants who reported they had been diagnosed with hypertension and advised by their physicians to use antihypertensive medication ( n = 6,733). </li></ul><ul><li>Participants who were not taking antihypertensive medication and had normal blood pressure during the physical exam were excluded (n=571) </li></ul>Bautista LE, Am J Hypertens 2008 21;2:183-188
  6. 6. Methods <ul><li>Trained NHANES interviewers verified the medications being used during the 30 days prior to the survey date by direct inspection of medication containers. </li></ul><ul><li>Individuals who did not use antihypertensive medication during the 30 days prior to the interview were classified as non-persistent. </li></ul><ul><li>Individuals with diseases that require regular and persistent use of medications were classified as having a chronic disease: arthritis, stroke, emphysema, cancer, asthma, bronchitis, diabetes, or acute myocardial infarction. </li></ul>Bautista LE, Am J Hypertens 2008 21;2:183-188
  7. 7. Methods <ul><li>All analyses were statistically weighted to: </li></ul><ul><ul><li>maintain the representativeness of the sample for the US population </li></ul></ul><ul><ul><li>avoid selection bias, and </li></ul></ul><ul><ul><li>correctly estimate the precision of regression coefficients. </li></ul></ul><ul><li>Multiple imputation was used to fill out missing values (10 imputed data sets) to: </li></ul><ul><ul><li>avoid selection bias due to the exclusion of subjects with missing data </li></ul></ul><ul><ul><li>retain subjects with missing values in the analysis so that the sum of the sampling weights equals the population size </li></ul></ul>Bautista LE, Am J Hypertens 2008 21;2:183-188
  8. 8. Methods <ul><li>Multiple logistic regression with sampling weights was used to estimate the independent effect of each factor on non-persistence </li></ul><ul><li>The first imputed data set was used for model building and variable selection </li></ul><ul><li>The resulting model was applied to the remaining data sets and then the estimates from all datasets were averaged </li></ul>Bautista LE, Am J Hypertens 2008 21;2:183-188
  9. 9. Results <ul><li>Predisposing characteristics by persistence with antihypertensive medication (NHANES) </li></ul><ul><li>___________________________________________________________________________ </li></ul><ul><li> Persistent Non-persistent p </li></ul><ul><li>(n=5197) (n=903) </li></ul><ul><li>___________________________________________________________________________ </li></ul><ul><li>Age (mean) 62.0 (61.3, 62.6)* 55.3 (53.2, 57.5) <0.001 </li></ul><ul><li>Male gender (%) 40.6 (38.6, 42.6) 51.0 (46.1, 55.9) <0.001 </li></ul><ul><li>Race (%) 0.013 </li></ul><ul><li>White 76.8 (73.8, 79.7) 69.2 (63.4, 74.9) </li></ul><ul><li>Black 14.2 (11.6, 16.8) 17.9 (13.4, 22.3) </li></ul><ul><li>Hispanic 5.3 (3.5, 7.2) 8.4 (4.9, 11.9) </li></ul><ul><li>Other 3.7 (2.6, 4.8) 4.6 (1.3, 7.8) </li></ul><ul><li>Education (%) 0.012 </li></ul><ul><li>Less than HS† 31.9 (29.8, 34.0) 38.0 (32.4, 43.6) </li></ul><ul><li>HS Diploma 29.6 (27.4, 31.8) 31.6 (26.3, 37.0) </li></ul><ul><li>More than HS 38.5 (36.1, 40.9) 30.4 (25.2, 35.5) </li></ul><ul><li>Alcohol drinks/day </li></ul><ul><li>≥ 2 (%) 42.0 (38.7, 45.2) 56.4 (48.7, 64.0) 0.007 </li></ul><ul><li>Current smoker 15.4 (14.1, 16.7) 25.6 (21.5, 29.7) <0.001 </li></ul><ul><li>_____________________________________________________________________________ </li></ul><ul><li>* Figures in parenthesis are 95% confidence intervals; † HS: High school </li></ul>
  10. 10. Results <ul><li>Enabling and need characteristics by persistence with use of antihypertensive medication </li></ul><ul><li>___________________________________________________________________________ </li></ul><ul><li>Non-persistent Persistent p-value </li></ul><ul><li>___________________________________________________________________________ </li></ul><ul><li>Low income* (%) 72.8 (70.4, 75.3) † 84.3 (79.6, 89.0) 0.003 </li></ul><ul><li>No health insurance (%) 5.2 (4.1, 6.4) 14.8 (11.2, 18.5) <0.001 </li></ul><ul><li>No medical visits last year (%) 2.00 (1.6, 2.4) 19.4 (15.0, 23.8) <0.001 </li></ul><ul><li>Body mass index (mean kg/m2) 30.4 (30.0, 30.7) 30.4 (29.0, 31.8) 0.946 </li></ul><ul><li>Health Status (%) 0.122 </li></ul><ul><li>Excellent 7.3 (6.1, 8.5) 6.9 (4.6, 9.2) </li></ul><ul><li>Very good 22.6 (20.9, 24.3) 19.6 (15.1, 24.2) </li></ul><ul><li>Good 37.3 (35.3, 39.3) 44.2 (39.5, 48.9) </li></ul><ul><li>Fair 24.1 (225, 25.8) 21.8 (17.5, 26.0) </li></ul><ul><li>Poor 8.7 (7.4, 10.0) 7.4 (4.9, 10.0) </li></ul><ul><li>With chronic disease (%) ‡ 67.8 (65.6, 70.0) 55.4 (48.4, 62.4) 0.006 </li></ul><ul><li>___________________________________________________________________________ </li></ul><ul><li>* Family income <$55,000/year; †Figures in parenthesis are 95% confidence intervals; ‡Arthritis, stroke, emphysema, cancer, asthma, bronchitis, diabetes, or myocardial infarction </li></ul>Bautista LE, Am J Hypertens 2008 21;2:183-188
  11. 11. Results <ul><li>Multivariate adjusted odds ratios for non-persistence with </li></ul><ul><li>antihypertensive therapy. </li></ul><ul><li>______________________________________________________ </li></ul><ul><li>Risk factor Odds ratio (95% CI) p </li></ul><ul><li>______________________________________________________ </li></ul><ul><li>Age (years) </li></ul><ul><li>≥ 50 1.00 </li></ul><ul><li>40 - 49 2.30 (1.54, 3.44) <0.001 </li></ul><ul><li>30 - 39 2.61 (1.69, 4.02) <0.001 </li></ul><ul><li><30 12.1 (4.25, 34.56) <0.001 </li></ul><ul><li>Male gender 1.31 (1.07, 1.61) 0.011 </li></ul><ul><li>Race </li></ul><ul><li>Other 1.00 </li></ul><ul><li>Hispanics 1.43 (1.05, 1.94) 0.027 </li></ul><ul><li>______________________________________________________ </li></ul>Bautista LE, Am J Hypertens 2008 21;2:183-188
  12. 12. Results <ul><li>Multivariate adjusted odds ratios for non-persistence with </li></ul><ul><li>antihypertensive therapy. </li></ul><ul><li>______________________________________________________ </li></ul><ul><li>Risk factor Odds ratio (95% CI) p </li></ul><ul><li>______________________________________________________ </li></ul><ul><li>Low income* 1.96 (1.35, 2.83) <0.001 </li></ul><ul><li>No health insurance 1.88 (1.24, 2.83) 0.002 </li></ul><ul><li>No medical visits last year 10.36 (6.59, 16.29) <0.001 </li></ul><ul><li>1999-2002 vs. 1988-1994 0.73 (0.55, 0.96) 0.019 </li></ul><ul><li>______________________________________________________ </li></ul><ul><li>*Family income <$55,000/year </li></ul>Bautista LE, Am J Hypertens 2008 21;2:183-188
  13. 13. Conclusions <ul><li>Non-persistence with antihypertensive medication increased significantly with young age, in men, and among Hispanics. </li></ul><ul><li>This study also shows that non-persistence is considerably increased in individuals with financial barriers to access health care. </li></ul><ul><li>Low income, having no health insurance, and not visiting the doctor during the last year accounted for more than 50% of the cases of non-persistence. </li></ul>Bautista LE, Am J Hypertens 2008 21;2:183-188
  14. 14. Implications <ul><li>Policies that improve access to health care and patient follow-up may be of great importance in maintaining long-term persistence with antihypertensive medication. </li></ul><ul><li>Efforts to improve compliance should be focused on young patients, men, and Hispanics. </li></ul>Bautista LE, Am J Hypertens 2008 21;2:183-188

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