Articles

CLINICAL INQUIRIES From the Family Physicians Inquiries Network How effective are hypertension self-care interventions?

Evidence-based answer Simplification of the dosing regimen (eg, once-daiiy instead of muitipie dosing) improves patients' adherence to antihyper- tensive medications (strength of recom- mendation [SOR]: B, based on a high- quality systematic review of lower-quaiity randomized controiied triais). Dietary advice promotes modest short-term improvements in self-reported fat intake and fruit and vegetable consumption (SOR: B, based on a high-quality systematic review of iower- Clinieal commentary quaiity, randomized controiied trials).

Educational interventions alone, in generai, do not improve patient adher- ence to antihypertensive medication regimens (SOR: B, based on a high- quality systematic review of iower-quality, randomized controiied trials). Physicians' advice to increase physical activity is not effective, even as part of a self-care plan for hypertension (SOR: B, based on 1 randomized trial).

Work with patients to set goals for lifestyle changes, and follow-up to see if these goals are met Promoting behavior change and self-care for chronic iilness challenges every famiiy physician.

Start with the evidence and promote adherence by simplifying your patient dosing regimens. Watch costs and co-pays. Advise patients at the start of treatment that they are iikeiy to need more than one medication to control their biood pressure. Use combination medications when possible. Emphasize the importance of controlling blood pressure through weekiy foilow-up appointments until the patient meets his blood pressure target.

I Evidence summary Self-care can be defined as activities that a patient undertakes with the intention of improving health or preventing dis- Remind patients that hypertension is a "siient disease"—the first symptom of high blood pressure is often a heart attack or stroke. Show patients their Framingham risk score. Work with your patient to set specific goals for iifestyie changes. Follow-up to see if these goals are met. Assess barriers to change if goais are not met. Use your health care team and outside resources. Screen for and treat depression. To promote adherence and mo- tivate iifestyie changes, encourage patients to use home biood pressure monitors.

Lauren DeAlleaume, MD University of Coiorado Denver and Heaith Sciences Center ease.

Self-care for hypertension includes taking medicine as prescribed, monitor- ing blood pressure response to therapy, and adopting lifestyle recommenda- Anthony J.

Viera, MD, MPH Department of Famiiy Medicine, University of North Caroiina at Chapel Hill Barbara Jamieson, MLS IVIedicai Coiiege of Vi'isconsin Libraries, Madison FAST TRACK Dietary advice promotes modest short-term improvements CONTINUED www.jfponline.com VOL 56, NO 3 / MAROH 2007 229 UJ cc D o < o FAST TRACK 7 Studies found a statistically significant improvement in adherence with once-daily vs twice-daily regimens tions—increasing exercise, decreasing salt intake, and increasing fruits and vegetable consumption.

Keeping meds simple improves adherence Various interventions have been devel- oped with the goal of improving medica- tion adherence among patients with hy- pertension. A Cochrane review included 38 randomized controlled trials (RCTs) of 58 various types of interventions (some tested in factorial trials) designed to improve patient adherence to antihy- pertensive medications in ambulatory settings.' The quality of the studies was generally low due to inadequate alloca- tion concealment, lack of blinding of out- come assessors, loss to follow-up, and the small number of participants in trials.

The authors grouped interventions into 4 broad categories: simplification of dosing regimens; patient education; patient motivation, support, and re- minders; and complex interventions.

Comparison groups received either no intervention, usual care, or—in the case of simplification of dosing regimens—a daily regimen consisting of more than 1 pill per day vs a once-daily regimen. Be- cause of various types of interventions and different methods of assessing out- comes, pooling of results was, appropri- ately, not done.

Of all the interventions, simplifica- tion of dosing regimens had the most evidence of effectiveness, with 7 out of 9 studies demonstrating a statistically significant improvement in adherence in the intervention group. In the other 2 studies, improved adherence was observed in the intervention group; however, the effect was either riot statis- tically significant or not reported.

Five of the studies used a system that electronically recorded the time and date when a medicine container was opened.

All studies using this rigorous system for outcome measurement demonstrated statistically significant improvement in adherence with once-daily vs twice-daily dosage regimens. Relative improvement in adherence ranged from 8% to 20%.

Educational strategies alone were largely ineffective in improving adher- ence.

Only 1 of 6 studies of patient edu- cation intervention demonstrated im- proved adherence, but the trial was small (n=110), and the effect was not seen in the other studies (total of 1103 patients).

Research on motivating patients is inconsistent Motivation and support strategies con- sisted of interventions such as drug reminder charts, self-recording of blood pressure, mail reminders, and home visits.

Overall, out of 24 RCTs studying motivational, support, and reminder interventions, 10 demonstrated statisti- cally significant but small improvements in adherence. These studies relied on measures such as pill counts and self- report to" assess adherence rather than electronic monitoring. The marked in- consistency among the body of evidence makes it difficult to determine whether motivational, support, and reminder interventions alone are effective in im- proving adherence.

Out of 18 studies of interventions classified as complex health and organi- zational interventions, including many with an educational or motivational component, interventions in 8 studies led to a statistically significant improve- ment in adherence. Complex interven- tions included structured hypertension management programs such as work- site care provided by trained nurses. An example of an intervention given in combination is a program of home vis- its, education, and specialized dosing devices. Because these interventions var- ied considerably, an overall statement of effectiveness is not appropriate.

iVIodest success seen in improving diet A Cochrane review of dietary advice for reducing cardiovascular disease risk 230 VOL 56, NO 3 / MARCH 2007 THE JOURNAL OF FAMILY PRACTICE How effective are hypertension self-care interventions?

among healthy adults included 29 tri- als.^ Individuals or groups of patients received verbal or printed dietary advice over 1 or more personal contacts. They also received advice by telephone. Ten RCTs of dietary advice in 4328 partici- pants or groups of participants assessed self-reported dietary fat intake.

Overall, intake of dietary fat (expressed as a percentage of total ca- loric intake) fell by 6.2% (95% confi- dence interval [CI], reduced 8.4% to in- creased 4.0%) with dietary intervention over 6 to 48 months. Due to significant heterogeneity between the studies, this overall estimate must be viewed with caution.

Eight RCT studies in 3952 partici- pants or groups of participants assessed self-reported fruit and vegetable in- take as an outcome. Overall, intake of fruits and vegetables increased by 1.2 servings per day (95% CI, 0.43-2.1) with interventions over 6 to 48 months.

Again, there was significant heterogene- ity between the studies. Therefore, this overall estimate must be viewed with caution.

In general, the quality of the studies included in this systematic review was low due to poor descriptions of ran- domization, lack of allocation conceal- ment, and lack of blinding of outcome assessment. The use of food frequency questionnaires to measure fat and fruit/ vegetable intake likely led to report- ing bias in these dietary intervention studies. Also, the trials were in healthy adults and not specific to hypertensive patients.

Motiviating patents to exercise remains a chailenge We found 1 randomized trial that evalu- ated the effectiveness of a physician's ad- vice to increase physical activity among patients with hypertension in a general practice setting.^ Physical activity was measured using a validated question- naire. Patients given the advice as part of self-care for hypertension (n=192) were no more likely to have increased their physical activity than those not given the advice (n=108) at 2- and 6- month follow-ups.

Recommendations from others The Seventh Report of the Joint Na- tional Committee on Prevention, Detec- tion, Evaluation, and Treatment of High Blood Pressure (JNC 7) states that self- measurement of blood pressure may benefit patients by providing informa- tion on response to antihypertensive medication and improving adherence with therapy."* The report also notes that the pa- tient and clinician must agree on blood pressure goals, and that patient motiva- tion to adopt lifestyle changes and take prescribed medication improves when patients have positive experiences and trust their clinicians. • References 1.

Schroeder K, Fahey T, Ebrahim S. Interventions for improving adherence to treatment in patients with high biood pressure in ambulatory settings.

Cochrane Database Syst Rev 2004; (2):CD004804.

2.

Brunner EJ, Thorogood M, Rees K, Hewitt G. Di- etary advice for reducing cardiovascular risk.

Cochrane Database Syst Rev 2005; (4):CD002128.

3. Marshall AL, Booth ML, Bauman AE. Promoting physical activity in Austraiian generai practices; a randomized triai of heaith promotion advice versus hypertension management. Patient Educ Couns 2005; 56;283-290.

4.

Chobanian AV, Bakris GL, Black HR, et al.

The Sev- enth Report of the Joint National Committee on Prevention, Detection, Evaiuation, and Treatment of High Biood Pressure; the JNC 7 report. JAMA 2003; 289;2560-2572.

FAST TRACK Patients' physical activity did not change when physicians suggested they exercise more www.jfponline.com VOL 56, NO 3 / MARCH 2007 231