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Barriers to effective outpatient hypertension treatment: a view of physicians and patients

Aim. To study the opinion of primary care physicians and hypertensive (HTN) outpatients with different compliance rate on factors preventing effective antihypertensive therapy (AHT). Material and methods. Primary physicians and HTN were questioned. a confidence interval and almost equivalent factors were the need for lifestyle change — 5,6±3,3 (95% CI: 4,53-6,71), the need for regular visits — 5,6±3,1 (95% CI: 4,53-6,58) and the need for self-management — 5,6±2,8 (95% CI: 4,63-6,48). Conclusion. The results obtained make it possible to fore-cast the compliance rate of patients with HTN, and, there-fore, direct more efforts to those with a low rate, thereby increasing the effectiveness of AHT. Relationships and Activities: not.

Achieving a target level of blood pressure (BP) is critical to reducing the risk of cardiovascular events (CVE) and improving the prognosis in patients for hypertension (HTN) [1]. However, in actual clinical practice, only about a third of patients receiving antihypertensive therapy (AHT) reach BP <140/90 mm Hg and a little more than 10% -<130/80 mm Hg. [2]. Inadequate control of BP may be due to medical influence (irrational AHT, insufficient dosing, low frequency of using fixed-dose combinations (FDC), etc.), as well as factors related to patients. First of all, this regards to a low adherence to treatment, expressed in non-compliance or incomplete compliance with prescribed AHT, which, in turn, is influenced by various aspects of pharmacotherapy and personal characteristics of patients [3]. The present work is devoted to the study and evaluation of these factors.
The aim was to study the opinion of primary care physicians and HTN outpatients with different compliance rate on factors preventing effective AHT.

Material and methods
The multicenter (18 ambulatory clinics of Volgograd and Volzhsky) open-label observational study was performed. A voluntary, anonymous survey of primary care physicians, cardiologists and HTN outpatients was conducted. Doctors completed the questionnaire independently. Questioning of patients was carried out by doctors in the same health facilities after completing the informed consent. The questionnaires were based on questions similar to those used in the previous studies [4]. The questionnaire for medical practitioners consisted of two sections. The first was informational in nature and consisted of questions about demographics (sex and age) and work experience. In the second section, a list of possible factors lowing patient compliance with the prescribed treatment was proposed. Respondents were asked to determine the level of significance of each of them. Evaluation of these factors was carried out using visual analogue scale (VAS), where 0 was considered as the minimum and 10 as the maximum value. The content of this section corresponded to the same section in the patient questionnaire. The questionnaire for patients with HTN consisted of three sections. The first included questions about socio-demographic data (sex, age, education, marital status, social status, financial standing, presence/ absence of disability, and questions on the AHT). These questions were clarified, if necessary, by the questioning doctors. The second section included the eight-item Morisky Medication Adherence Scale [5,6], which is necessary for assessing medication adherence. The results of this test were evaluated as follows: 1 point was awarded for each negative answer, except for the question of taking all drugs yester-day -1 point was given for a positive answer to this question. In the question, how often do you have difficulty remembering to take all your medications, 1 point was awarded only for the answer "never". Patients who scored 8 points had high adherence, those with 6-7 points -medium adherence, and those with 5 or less points -low adherence. In the third section of the questionnaire, it was proposed to evaluate the significance of factors that, in the opinion of patients, prevent medication compliance. The assessment was carried out using VAS, in which 0 was taken as the minimum, and 10 as the maximum value. This section for patients corresponded in content to the second section for doctors and was intended to assess the agreement between the opinions of practitioners and patients regarding the main issues of HTN treatment. The inclusion criteria were as follows: signed informed consent; age >18 years; verified HTN and taking AHT. There were following exclusion criteria: not signed informed consent; age <18 years; hospitalization due to cardiovascular disease over the past 3 months (including revascularization), severe clinical course and/or severe decompensated heart failure (HF), chronic kidney disease, liver failure, cognitive impairment, symptomatic hyperuricemia/gout, pregnancy, lactation. The data of patients as a whole and in subgroups with different medication adherence rates were analyzed. For data assessing, descriptive statistics were used: proportions (%), mean (M), standard deviation (σ). The calculation was carried out with a 95% confidence interval (CI). Assessment of the normality of the distribution was carried out using the Kolmogorov-Smirnov test. For the normally distributed traits, independentsamples Student's t-test was used to assess the statistical significance of differences. For the non-normally distributed traits, the nonparametric Mann-Whitney U-test was used. To assess the statistical significance of differences in qualitative traits, the Pearson's chi-squared test was used. Statistical processing was performed using the software package BIOSTAT and SPSS 16.0.

Results
The survey involved 298 primary care physicians (112 men and 186 women) with mean age 45,6±11,6 years (95% CI: 43,28-47,87) and mean work experience 21,5±11,9 years (95% CI: 19,13-23,89). The study also included data of 517 patients (176 men and 341 women) who met the inclusion criteria. The mean age of the patients was 61,8±12,3 (95% CI: 59,53-64,15) years. Table 1 presents data for the studied population of HTN patients as a whole and in groups with different medication compliance rate. Groups were comparable with respect to age and sex (p>0,05). The results of a survey using MMAS-8 are presented in Table 2; an analysis of the data obtained is shown in Table 3. It was found that the proportion of patients with a high medication adherence was about 1% (n=5). Medium adherence was noted in 34% (n=176) of patients. The remaining 65% (n=336) of patients had a low medication adherence. Most patients had an intermediate vocational training. In the group with a low adherence, the proportion of patients with higher education was 1,5% (n=5), which is significantly lower compared to other groups  I  II  III  I  II  III  I  II  III  I  II  III -14,5   (p<0,01), while the proportion of basic general education was significantly greater (40,3%; n=133) than in other groups (p<0,01). All groups were dominated by married persons. In the studied population, unemployed pensioners prevailed -47,6% (n=246). There were no significant differences in relation to this parameter between groups. There were 17,4% of patients with disabilities, and their largest proportion (21,2%; n=70) was noted in the low adherence group (p<0,05). None of the groups revealed individuals with category I disability. There were no disabled patients in high adherence group. Majority of respon-dents rated their financial standing as average (84,5%), however, in the low adherence group, the percentage of people who rated their financial situation as lower than average was significantly higher -19,3% (n=64) than in other groups (p<0,05). To assess the possible effect on the opinion of patients, characteristics of AHT was studied, which did not have significant differences in the groups. Dual and triple AHT was most frequently prescribed -38,1% (n=197) and 35,0% (n=181), respectively. The prevalence of FDC was extremely low in all groups. These drugs have been used in less than a third of patients. Assessment of factors affecting AHT, according to physicians and patients, is presented in Table 4. According to physicians, the most significant and equivalent are the economic aspects of treatment -7,9±2,1 (95% CI: 7,51-8,38), the need for lifestyle change -7,9±2,4 (95% CI: 7,37-8,38) and, to a slightly lesser extent, psychological aspects 6,8±2,2 (95% CI: 5,43-6,43). The lowest meaning had insufficient knowledge of patients about their disease -5,5±2,3 points (95% CI: 5.05-6.01). The economic aspects of treatment and need for lifestyle change were also most significant factors according to patients with high (8,8±1,8 (95% CI: 7,23-10,37) and 8,4±1,7 (95% CI: 6,93-9,87), respectively) and low (95% CI: 6,4±3,0 (5,65-7,07) and 6,2±2,8 (95% CI: 5,5-6,82) respectively) compliance rates. For patients with moderate compliance rate, the most significant and almost equivalent factors were the need for life-  Patients of all groups rated the insufficient knowledge about their disease and psychological aspects as the least significant factors. Groups with low and medium medication adherence had significant difference regarding the value of need for lifestyle change (χ 2 =11,012 2 ; d.f.=9; p<0,05). No significant intergroup differences with respect to other factors were found.

Discussion
The practitioners participated in this study mainly had a long-term work experience, which gives reason to consider the information obtained as objective. The demographics of patients in subgroups with different adherence rates did not significantly differ. In all compared groups of patients, AHT did not have significant differences. Dual and triple AHT were prescribed most frequently, at the same time, the prevalence of using FDC was extremely low. Noteworthy is the quantitative dis-proportion of groups with high and low medication adherence (1% and 65%, respectively). This is probably due to the fact that the majority of HTN participants had features that did not allow them to achieve a high adherence. This may be due to low level of education, which can lead to a misunderstanding of the need to comply with medical recommendations, reassessment of one's own knowledge in medicine, and, consequently, propensity to selfmedication. Perhaps these factors explain the unexpected low number of patients with high adherence and the significant socio-economic differences in low adherence group (lower level of education, lower financial standing, higher number of disabled patients). The dependence of adherence rate on the level of education (the higher the level of education, the higher the medication adherence rate) was demonstrated in earlier studies [7]. According to physicians, the most significant factors preventing effective therapy were the economic aspects of treatment and, equally, the need for lifestyle change, as well as the mental problems. According to patients, economic aspects of treatment and, equally, the need for lifestyle change were the most significant factors. The value of these factors in the subgroups had significant, as well as the need for lifestyle changes. Thus, at present, the opinion of doctors and patients on AHT have become more consolidated.

Conclusion
According to most physicians and patients, the economic aspects of treatment and the need for lifestyle change are the most significant factors preventing effective AHT. Most patients had a low medication adherence rate. Among them, the smallest proportion of people with higher education was noted; one fifth of these patients rated their financial standing below the average level and the same proportion were disabled. In addition, psychological problems were considered by physicians as one of the most significant factors of ineffective treatment. However, patients rated this factor as the least significant. The results obtained make it possible to form a preliminary judgment on the expected level of adherence of patients with AH, and, therefore, direct more efforts to work with patients with a low level of adherence, thereby increasing the effectiveness of AHT.
Relationships and Activities: not. some differences. For patients with medium medication adherence, the most significant were the need for lifestyle change and for self-monitoring during treatment and, to a lesser extent, the need for regular physician office visit. The economic aspects of treatment were in fourth place. In patients with low adherence, economic aspects of treatment were the most important, followed by the need for lifestyle change and for regular physician office visit. Perhaps it is precisely the socio-economic vulnerability of these patients that affected the results of the study. In contrast to the physicians' opinion regarding the importance of psychological aspects, patients themselves, regardless of the adherence rate, rated this factor as the least significant. The inf luence of psychological factors on medication adherence was noted in other studies [8]. Both among practitioners and patients, insufficient knowledge about the disease had a low value. In previous studies [4], dissociation was revealed regarding the importance of economic aspects, which physicians considered the most significant, and patients put them only in the 5 th place. In our study, both physicians and most patients rated this factor as the most