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Current Medical Research and Opinion Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/icmo20
Non-compliance and therapeutic inertia: two unanswered questions in clinical practice ab
V. Pallarés-Carratalá
& R. Pascual Pérez
c
a
Surveillance Health Unit, Unión de Mutuas CastellónSpain
b
Department of Medicine, Jaume I University CastellónSpain
c
Department of Medicine, Miguel Hernández University ElcheSpain Published online: 26 May 2015.
Click for updates To cite this article: V. Pallarés-Carratalá & R. Pascual Pérez (2014) Non-compliance and therapeutic inertia: two unanswered questions in clinical practice, Current Medical Research and Opinion, 30:5, 839-840 To link to this article: http://dx.doi.org/10.1185/03007995.2013.879442
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Current Medical Research & Opinion 0300-7995 doi:10.1185/03007995.2013.879442
Vol. 30, No. 5, 2014, 839–840
Article ST-0471/879442 All rights reserved: reproduction in whole or part not permitted
py Un t rig au fo t ht di hor r S sp ize a la d le © y, u s 20 vi e o ew p r 14 r C o an h d p ibi om In rin ted m fo rm t a . Au e si th rc aU ng or i le is al K co ed D py us is Lim fo ers tr ite rp c i b a er n d so d ut na ow io l u nl n se oa d,
Editorial Non-compliance and therapeutic inertia: two unanswered questions in clinical practice
Surveillance Health Unit, Unio´n de Mutuas, Castello´n, Spain Department of Medicine, Jaume I University, Castello´n, Spain
R. Pascual Pe´rez
Department of Medicine, Miguel Herna´ndez University, Elche, Spain
Address for correspondence: Vicente Pallare´s-Carratala´ MD PhD, Surveillance Health Unit, Unio´n de Mutuas, Avda. Lledo´ 67, 12004-Castello´n, Spain. Tel: +34 964231212; [email protected]
Keywords: Blood pressure – Clinical inertia – Hypertension – Non-compliance
Accepted: 23 December 2013; published online: 22 January 2014 Citation: Curr Med Res Opin 2014; 30:839–40
No
Co
Downloaded by [UNSW Library] at 00:48 11 August 2015
V. Pallare´s-Carratala´
! 2014 Informa UK Ltd www.cmrojournal.com
Non-compliance and clinical inertia are the main causes of poorly controlled blood pressure in hypertensive patients. Non-compliance fundamentally depends on the patient’s decision not to adhere to the prescribed medication regularly. Therapeutic inertia occurs when physicians do not intensify or modify therapy despite knowing that their patients are poorly controlled. Forgetfulness is the main cause for lack of adherence and the main reason physicians adopt a conservative attitude is because of the acceptance of borderline figures as adequate, leading to failure to intensify therapeutic treatment1,2. The Spanish working group on compliance and clinical inertia, funded by the Spanish Society of Hypertension (SEH.LELHA), has been researching these issues in clinical practice for over 20 years3. Their findings indicated that good controlled hypertension targets do not exceed 50% in Spain, lack of adherence is around 50% and lifestyle modification compliance is between 80 and 95%. They also observed that the percentages of clinical inertia vary between 30 and 85%, depending on the study design. Guidelines emphasize that early control based on overcoming clinical inertia and patient non-compliance is necessary in order to achieve the benefits of therapy, especially in patients at high cardiovascular risk. Today, many research studies4 are carried out to analyze difficulties in clinical practice to overcome both problems. Mainly, they are performed with polymedicated patients with multiple diseases as therapeutic complexity may influence medication adherence and physicians accept borderline figures to avoid complicating treatment. Ma´rquez-Contreras et al.5 provide relevant information to health professionals about the control of hypertensive patients at high vascular risk. Their methodological strengths lie in the study design, a prospective longitudinal 6 month follow-up study, and in the sample size, 3600 patients from 585 primary healthcare centers throughout Spain. Their findings show that blood pressure control was associated with the combination of therapeutic compliance and clinical inertia. During the follow-up of this study, blood pressure control increased and clinical inertia decreased resulting in an unexpected non-compliance increase. Possibly, the reason for this was that physicians modified treatment, increasing therapeutic complexity, and as a result more patients failed to comply with their treatment. Reduction of clinical inertia might influence blood pressure control more than non-compliance, as these patients partially comply with treatment. This study also showed that clinical inertia was associated with the number of diseases suffered and the number of antihypertensive agents taken, and non-compliance was related to the number of antihypertensive agents taken by patients. As the study progressed, it was expected that the percentage of compliant patients would decrease in patients taking more than one drug. However, the most striking result was the fact that the decrease in
Non-compliance and therapeutic inertia Pallare´s-Carratala´ & Pascual Pe´rez
839
Downloaded by [UNSW Library] at 00:48 11 August 2015
Current Medical Research & Opinion Volume 30, Number 5
May 2014
compliant patients taking one drug was greater, a fact observed by Armario and Waeber6 recently. To achieve recommended blood pressure targets it is necessary to take medication correctly and if the compliant patient does not meet the targets, the physician should intensify treatment. An intervention to consider may be the incorporation of protocols which aim to identify non-compliant patients and to select the most effective strategies to modify their behavior. These protocols should suggest questions which make physicians think about the necessity of modifying treatment when patients do not achieve appropriate blood pressure figures. The protocols would have to dismiss other causes that may influence lack of adherence, e.g. drug interactions, white coat adherence7,8. Blackwell9 stated that much time, effort and money was invested in drugs but nobody asked whether patients take the medication. Excellent treatments are not useful if the patient does not take them and if physicians do not intensify treatment of poorly controlled patients they will not achieve the proper targets. The exhaustive study by Marquez et al.5 shows that non-compliance and clinical inertia are not isolated problems and new strategies, which provide solutions for both problems, are needed in clinical practice to achieve good control in hypertensive patients.
Transparency Declaration of funding This editorial was not funded.
840
Non-compliance and therapeutic inertia Pallare´s-Carratala´ & Pascual Pe´rez
Declaration of financial/other relationships V.P.-C. and R.P.P. have disclosed that they have no significant relationships with or financial interests in any commercial companies related to this study or article.
References 1. Redo´n J, Coca A, La´zaro P, et al. Factors associated with therapeutic inertia in hypertension: validation of a predictive model. J Clin Hypertens 2010;12:335-44 2. Gil-Guille´n V, Orozco-Beltra´n D, Pe´rez RP, et al. Clinical inertia in diagnosis and treatment of hypertension in primary care: quantification and associated factors. Blood Press 2010;19:3-10 3. Ma´rquez-Contreras E, Martell-Claros N, Gil-Guille´n V, et al. Compliance Group of the Spanish Society of Hypertension. Efficacy of a home blood pressure monitoring programme on therapeutic compliance in hypertension: the EAPACUM-HTA study. J Hypertens 2006;24:169-75 4. Ma´rquez-Contreras E, de la Figuera-Von Wichmann M, Franch-Nadal J, et al. Do patients with high vascular risk take antihypertensive medication correctly? Cumple-MEMS Study. Rev Esp Cardiol 2012;65:544-50 5. Ma´rquez-Contreras E, Gil-Guille´n V, de la Figuera-Von Wichmann M, et al. Non-compliance and inertia in hypertensive Spaniards at high cardiovascular risk. CUMPLE Study. Curr Med Res Opin 2013;30:11-17 6. Armario P, Waeber B. Therapeutic strategies to improve control of hypertension. J Hypertens 2013;31(Suppl 1):S9-12 7. Ma´rquez Contreras E, Martel Claros N, Gil Guille´n V, et al. Nonpharmacological intervention as a strategy to improve antihypertensive treatment compliance. Aten Primaria 2009;41:501-10 8. Ma´rquez Contreras E, Martel Claros N, Gil Guille´n V, et al. Control of therapeutic inertia in the treatment of arterial hypertension by using different strategies. Aten Primaria 2009;41:315-23 9. Blackwell B. Patient compliance. N Engl J Med 1973;289:249-52
www.cmrojournal.com ! 2014 Informa UK Ltd
Current Medical Research and Opinion Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/icmo20
Non-compliance and therapeutic inertia: two unanswered questions in clinical practice ab
V. Pallarés-Carratalá
& R. Pascual Pérez
c
a
Surveillance Health Unit, Unión de Mutuas CastellónSpain
b
Department of Medicine, Jaume I University CastellónSpain
c
Department of Medicine, Miguel Hernández University ElcheSpain Published online: 26 May 2015.
Click for updates To cite this article: V. Pallarés-Carratalá & R. Pascual Pérez (2014) Non-compliance and therapeutic inertia: two unanswered questions in clinical practice, Current Medical Research and Opinion, 30:5, 839-840 To link to this article: http://dx.doi.org/10.1185/03007995.2013.879442
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Current Medical Research & Opinion 0300-7995 doi:10.1185/03007995.2013.879442
Vol. 30, No. 5, 2014, 839–840
Article ST-0471/879442 All rights reserved: reproduction in whole or part not permitted
py Un t rig au fo t ht di hor r S sp ize a la d le © y, u s 20 vi e o ew p r 14 r C o an h d p ibi om In rin ted m fo rm t a . Au e si th rc aU ng or i le is al K co ed D py us is Lim fo ers tr ite rp c i b a er n d so d ut na ow io l u nl n se oa d,
Editorial Non-compliance and therapeutic inertia: two unanswered questions in clinical practice
Surveillance Health Unit, Unio´n de Mutuas, Castello´n, Spain Department of Medicine, Jaume I University, Castello´n, Spain
R. Pascual Pe´rez
Department of Medicine, Miguel Herna´ndez University, Elche, Spain
Address for correspondence: Vicente Pallare´s-Carratala´ MD PhD, Surveillance Health Unit, Unio´n de Mutuas, Avda. Lledo´ 67, 12004-Castello´n, Spain. Tel: +34 964231212; [email protected]
Keywords: Blood pressure – Clinical inertia – Hypertension – Non-compliance
Accepted: 23 December 2013; published online: 22 January 2014 Citation: Curr Med Res Opin 2014; 30:839–40
No
Co
Downloaded by [UNSW Library] at 00:48 11 August 2015
V. Pallare´s-Carratala´
! 2014 Informa UK Ltd www.cmrojournal.com
Non-compliance and clinical inertia are the main causes of poorly controlled blood pressure in hypertensive patients. Non-compliance fundamentally depends on the patient’s decision not to adhere to the prescribed medication regularly. Therapeutic inertia occurs when physicians do not intensify or modify therapy despite knowing that their patients are poorly controlled. Forgetfulness is the main cause for lack of adherence and the main reason physicians adopt a conservative attitude is because of the acceptance of borderline figures as adequate, leading to failure to intensify therapeutic treatment1,2. The Spanish working group on compliance and clinical inertia, funded by the Spanish Society of Hypertension (SEH.LELHA), has been researching these issues in clinical practice for over 20 years3. Their findings indicated that good controlled hypertension targets do not exceed 50% in Spain, lack of adherence is around 50% and lifestyle modification compliance is between 80 and 95%. They also observed that the percentages of clinical inertia vary between 30 and 85%, depending on the study design. Guidelines emphasize that early control based on overcoming clinical inertia and patient non-compliance is necessary in order to achieve the benefits of therapy, especially in patients at high cardiovascular risk. Today, many research studies4 are carried out to analyze difficulties in clinical practice to overcome both problems. Mainly, they are performed with polymedicated patients with multiple diseases as therapeutic complexity may influence medication adherence and physicians accept borderline figures to avoid complicating treatment. Ma´rquez-Contreras et al.5 provide relevant information to health professionals about the control of hypertensive patients at high vascular risk. Their methodological strengths lie in the study design, a prospective longitudinal 6 month follow-up study, and in the sample size, 3600 patients from 585 primary healthcare centers throughout Spain. Their findings show that blood pressure control was associated with the combination of therapeutic compliance and clinical inertia. During the follow-up of this study, blood pressure control increased and clinical inertia decreased resulting in an unexpected non-compliance increase. Possibly, the reason for this was that physicians modified treatment, increasing therapeutic complexity, and as a result more patients failed to comply with their treatment. Reduction of clinical inertia might influence blood pressure control more than non-compliance, as these patients partially comply with treatment. This study also showed that clinical inertia was associated with the number of diseases suffered and the number of antihypertensive agents taken, and non-compliance was related to the number of antihypertensive agents taken by patients. As the study progressed, it was expected that the percentage of compliant patients would decrease in patients taking more than one drug. However, the most striking result was the fact that the decrease in
Non-compliance and therapeutic inertia Pallare´s-Carratala´ & Pascual Pe´rez
839
Downloaded by [UNSW Library] at 00:48 11 August 2015
Current Medical Research & Opinion Volume 30, Number 5
May 2014
compliant patients taking one drug was greater, a fact observed by Armario and Waeber6 recently. To achieve recommended blood pressure targets it is necessary to take medication correctly and if the compliant patient does not meet the targets, the physician should intensify treatment. An intervention to consider may be the incorporation of protocols which aim to identify non-compliant patients and to select the most effective strategies to modify their behavior. These protocols should suggest questions which make physicians think about the necessity of modifying treatment when patients do not achieve appropriate blood pressure figures. The protocols would have to dismiss other causes that may influence lack of adherence, e.g. drug interactions, white coat adherence7,8. Blackwell9 stated that much time, effort and money was invested in drugs but nobody asked whether patients take the medication. Excellent treatments are not useful if the patient does not take them and if physicians do not intensify treatment of poorly controlled patients they will not achieve the proper targets. The exhaustive study by Marquez et al.5 shows that non-compliance and clinical inertia are not isolated problems and new strategies, which provide solutions for both problems, are needed in clinical practice to achieve good control in hypertensive patients.
Transparency Declaration of funding This editorial was not funded.
840
Non-compliance and therapeutic inertia Pallare´s-Carratala´ & Pascual Pe´rez
Declaration of financial/other relationships V.P.-C. and R.P.P. have disclosed that they have no significant relationships with or financial interests in any commercial companies related to this study or article.
References 1. Redo´n J, Coca A, La´zaro P, et al. Factors associated with therapeutic inertia in hypertension: validation of a predictive model. J Clin Hypertens 2010;12:335-44 2. Gil-Guille´n V, Orozco-Beltra´n D, Pe´rez RP, et al. Clinical inertia in diagnosis and treatment of hypertension in primary care: quantification and associated factors. Blood Press 2010;19:3-10 3. Ma´rquez-Contreras E, Martell-Claros N, Gil-Guille´n V, et al. Compliance Group of the Spanish Society of Hypertension. Efficacy of a home blood pressure monitoring programme on therapeutic compliance in hypertension: the EAPACUM-HTA study. J Hypertens 2006;24:169-75 4. Ma´rquez-Contreras E, de la Figuera-Von Wichmann M, Franch-Nadal J, et al. Do patients with high vascular risk take antihypertensive medication correctly? Cumple-MEMS Study. Rev Esp Cardiol 2012;65:544-50 5. Ma´rquez-Contreras E, Gil-Guille´n V, de la Figuera-Von Wichmann M, et al. Non-compliance and inertia in hypertensive Spaniards at high cardiovascular risk. CUMPLE Study. Curr Med Res Opin 2013;30:11-17 6. Armario P, Waeber B. Therapeutic strategies to improve control of hypertension. J Hypertens 2013;31(Suppl 1):S9-12 7. Ma´rquez Contreras E, Martel Claros N, Gil Guille´n V, et al. Nonpharmacological intervention as a strategy to improve antihypertensive treatment compliance. Aten Primaria 2009;41:501-10 8. Ma´rquez Contreras E, Martel Claros N, Gil Guille´n V, et al. Control of therapeutic inertia in the treatment of arterial hypertension by using different strategies. Aten Primaria 2009;41:315-23 9. Blackwell B. Patient compliance. N Engl J Med 1973;289:249-52
www.cmrojournal.com ! 2014 Informa UK Ltd
