Hypertensive Patients in Evidence-Based Practice

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Hypertensive Patients in Evidence-Based Practice

Research Support

In the PICOT question for this project, the constituent parts are as follows:

P patients aged 50 years and older;
I the adherence to antihypertension drugs;
C inconsistency or nonadherence to antihypertension drugs;
O decrease in hypertension;
T when done over six months.

The specified population is important for this project because older adults are more subject to hypertension and its complications. The adherence to antihypertension drugs has been proved to increase patient outcomes; therefore, it has been chosen as an intervention. A significant part of hypertensive patients do not or poorly adhere to their medications (Abegaz et al., 2017). Therefore, it has been chosen as a comparison since it is important to identify the magnitude of the effect of adherence compared to nonadherence. Hypertensive patients suffer from high blood pressure, so the desired health outcome for them is a decrease in hypertension. Finally, the project should be long enough to identify the difference in health outcomes resulting from the chosen intervention; therefore, a period of six months has been chosen.

The need for research guided by the identified PICOT question is supported by the existing literature. For example, Peacock and Krousel-Wood (2017) admit that the link between high adherence to antihypertensive drugs and decreased blood pressure is strong Yet, they call for further research in this field to find out the relation between adherence to medications and a broad spectrum of patient health outcomes (Peacock & Krousel-Wood, 2017). Various studies show that hypertension is a common disease, especially among older adults, and high adherence is a feasible solution for patients suffering from this illness.

Search Method

To identify studies related to the formulated PICOT question, the search through two databases, Google Scholar and PubMed, was performed. The criterion for exclusion was the date of publication earlier than 2016; therefore, the search was limited to the articles published between 2016 and 2020. The keywords used included antihypertensive drugs, adherence, and older adults. The operator AND was used to find results related to all three keywords. In PubMed, the search filters were also applied, namely, meta-analysis, randomized control trial, and systematic reviews. PubMed found 14 articles matching the specified publication date, filters, and keywords, two of which appeared to be relevant to the topic. In Google Scholar, the search showed 19,400 results, which were sorted by relevance; therefore, only the first several pages were explored, and five more relevant articles were found.

Out of the total of seven articles that appeared in the initial reference list, three were excluded. The criterion for exclusion was an irrelevance to the PICOT question since these articles did not investigate the association between adherence to hypertension and patient health outcomes. Instead, they were focused on reasons why patients did not adhere to medications and possible interventions to improve adherence. The final selection of articles included three studies: one systematic review, one cohort study, and one case-control study.

Summary of Studies Used

The first study was a systematic review of studies exploring hypertensive patients nonadherence to their medications. It was conducted by Abegaz et al. (2017), and the findings indicated that 45.2% of hypertensive patients and 83.7% of patients with uncontrolled blood pressure did not adhere to their antihypertensive drugs. They also found evidence that nonadherence to medications leads to high risks of cardiovascular events and stroke. The strength of their study is that they used 28 high-quality articles from 15 countries, which included a total sample of 13,688 subjects (Abegaz et al., 2017). The study is of value to healthcare professionals since it identified characteristics of patients who were more likely to show poor adherence to medications. Yet, it has limitations, which is the high level of heterogeneity of studies. See Appendix for the review of literature evaluation table, which includes data about this and further articles.

The second study aimed at proving the hypothesis that high adherence to medications in adults aged 85 years and older led to a reduced risk of cardiovascular events. It was performed by Corrao et al. (2017), who used a cohort of older patients with hypertension who were not previously treated with antihypertensive drugs. Their results confirmed their hypothesis since older patients who adhered to their medications showed a decreased risk of cardiovascular events than their low-adherent counterparts. The strength of the study was the exploration of a large unselected sample, and the limitation was the use of information about drug prescriptions to determine levels of adherence.

Kim et al. (2018) aimed at exploring the long-term effects of adherence to medications in patients who survived an acute hemorrhagic stroke. Their retrospective cohort study showed that patients who adhered to antihypertensive drugs after the acute hemorrhagic stroke had a reduced risk of such adverse events as recurrent stroke or myocardial infarction compared to non-adherent patients. The strength of the study is that it explores the effects of adherence in a specific group of patients. Yet, the limitation is that the study was retrospective, which means that the causal relationship between adherence and adverse events after acute hemorrhagic stroke could not be established.

Selection of Research

All the studies selected for the research support were evaluated using Rapid Critical Appraisal Checklists fit for particular types of studies and appeared to have valid results, which corresponded to the expected outcomes. The chosen three articles are relevant to the PICOT question since they prove the benefit of high adherence to antihypertensive drugs for a decrease in hypertension and demonstrate that nonadherence leads to increased health risks. The selected studies have levels of evidence IV and V; therefore, the evidence provided in them is reliable.

References

Abegaz, T. M., Shehab, A., Gebreyohannes, E. A., Bhagavathula, A. S., & Elnour, A. A. (2017). Nonadherence to antihypertensive drugs. Medicine, 96(4), 1-9.

Corrao, G., Rea, F., Monzio Compagnoni, M., Merlino, L., & Mancia, G. (2017). Protective effects of antihypertensive treatment in patients aged 85 years or older. Journal of Hypertension, 35(7), 1432-1441.

Kim, J., Bushnell, C. D., Lee, H. S., & Han, S. W. (2018). Effect of adherence to antihypertensive medication on the long-term outcome after hemorrhagic stroke in Korea. Hypertension, 72(2), 391-398.

Peacock, E., & Krousel-Wood, M. (2017). Adherence to antihypertensive therapy. Medical Clinics of North America, 101(1), 229-245.

Appendix

Review of Literature Evaluation Table

Citation: Author Date of Publication & Title	Purpose of study	Conceptual Framework	Design Method	Sample/ Setting	Major Variable Studied and Their Definition	Measurement of Major Variables	Data Analysis	Study Findings	Worth to Practice: LOE Strengths/ Weaknesses Feasibility Conclusion Recommendation
Abegaz, T. M., Shehab, A., Gebreyohannes, E. A., Bhagavathula, A. S., & Elnour, A. A. (2017). Nonadherence to antihypertensive drugs. Medicine, 96(4), 1-9. Web.	To explore nonadherence to medications in adults hypertensive patients	Identifying research studies investigating hypertensive patients adherence to drugs	Systematic review using narrative synthesis Inclusion and exclusion criteria specified	Out of 912 identified articles retrieved from PubMed, Google Scholar, and Scopus, 28 were included in the review, 25 of which were included in the meta-analysis.	Nonadherence	Included various study designs from the 28 studies	Meta-analysis using StatsDirect statistical software version 3.0.	Nonadherence to antihypertensive drugs leads to increased risks of cardiovascular events and strokes. 42,5% of hypertensive patients were nonadherent to drugs. 83,7% of patients with uncontrolled BP did not adhere to medications.	LOE: V. The study used relevant high-quality studies and obtained stronger evidence on nonadherence among hypertensive patients and its relation to gender, race, and the presence of comorbidities. However, there were high levels of heterogeneity across studies. The study showed that the level of nonadherence among hypertensive patients was high. The study is feasible since is identifies the scope of the problem with hypertensive patients. The study recommends to implement interventions increasing adherence and develop new methods of monitoring adherence.
Corrao, G., Rea, F., Monzio Compagnoni, M., Merlino, L., & Mancia, G. (2017). Protective effects of antihypertensive treatment in patients aged 85 years or older. Journal of Hypertension, 35(7), 1432-1441. Web.	To evaluate the reduction of risks of cardiovascular events in 85-year-old and older individuals associated with adherence to medications	Adherence to antihypertensive drugs reduces the risk of cardiovascular events in patients aged 85 and older	A nested case-control study	A cohort of 85-year-old and older patients, who were newly treated with antihypertensive drugs in 2007- 2009. The setting was Lombardy (Italy).	Adherence to medications; the risk of cardiovascular events	Adherence was measured by the number of days covered by medication prescription.	The chi-square was applied to explore differences between groups. The Statistical Analysis System Software was used for the analyses	Adherence to antihypertensive drugs reduced the risk of cardiovascular events in elderly and very elderly patients compared to patients with very low adherence.	LOE: IV. The study used a large unselected population, and the drug prescription data was highly accurate. However, the sample size was not large enough to make generalized conclusions, and the level of adherence was derived from drug prescriptions. The study concluded that adherence to antihypertension drugs significantly reduced the risk of cardiovascular events in older adults. Recommendations are to increase adherence in older patients.
Kim, J., Bushnell, C. D., Lee, H. S., & Han, S. W. (2018). Effect of adherence to antihypertensive medication on the long-term outcome after hemorrhagic stroke in Korea. Hypertension, 72(2), 391-398. Web.	To evaluate adherence to drugs in patients with acute hemorrhagic stroke and its impact on long-term outcomes	Adherence to antihypertensive drugs after acute hemorrhagic stroke improves long-term patient outcomes	Retrospective cohort study	1872 hypertensive patients admitted with acute hemorrhagic stroke between2002 and 2013 in South Korea	Adherence, patient outcomes	Adherence was measured as the number of days covered by the prescribed medication. Outcomes were defined as the recurrent stroke, myocardial infarction, or all-cause mortality.	Time-dependent Cox proportional hazard regression analyses	The proportion of patients with good adherence was only 46.8% at 1 year, 43.2% at 3 years, and 41.7% at 5 years of follow-up. Poor adherence to drugs after stroke led to adverse events.	LOE: IV. The strength of the study is that it evaluates the long-term outcomes of adherence after acute hemorrhagic stroke. However, since the study was retrospective, the causal relationship between poor adherence and an increased risk of cardiovascular events could not be proved. The conclusion was that adherence to medications after stroke improved patient outcomes. The recommendation was for healthcare professionals to improve patients adherence to drugs after acute hemorrhagic stroke.

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