Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA.
Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA.
Am J Hypertens. 2021 Sep 22;34(9):895-909. doi: 10.1093/ajh/hpab046.
Interventions targeting traditional barriers to antihypertensive medication adherence have been developed and evaluated, with evidence of modest improvements in adherence. Translation of these interventions into population-level improvements in adherence and clinical outcomes among older adults remains suboptimal. From the Cohort Study of Medication Adherence among Older adults (CoSMO), we evaluated traditional barriers to antihypertensive medication adherence among older adults with established hypertension (N = 1,544; mean age = 76.2 years, 59.5% women, 27.9% Black, 24.1% and 38.9% low adherence by proportion of days covered (i.e., PDC <0.80) and the 4-item Krousel-Wood Medication Adherence Scale (i.e., K-Wood-MAS-4 ≥1), respectively), finding that they explained 6.4% and 14.8% of variance in pharmacy refill and self-reported adherence, respectively. Persistent low adherence rates, coupled with low explanatory power of traditional barriers, suggest that other factors warrant attention. Prior research has investigated explicit attitudes toward medications as a driver of adherence; the roles of implicit attitudes and time preferences (e.g., immediate vs. delayed gratification) as mechanisms underlying adherence behavior are emerging. Similarly, while associations of individual-level social determinants of health (SDOH) and medication adherence are well reported, there is growing evidence about structural SDOH and specific pathways of effect. Building on published conceptual models and recent evidence, we propose an expanded conceptual framework that incorporates implicit attitudes, time preferences, and structural SDOH, as emerging determinants that may explain additional variation in objectively and subjectively measured adherence. This model provides guidance for design, implementation, and assessment of interventions targeting sustained improvement in implementation medication adherence and clinical outcomes among older women and men with hypertension.
针对降压药物治疗依从性的传统障碍已经开发并评估了干预措施，这些干预措施在提高依从性方面有适度的改善。将这些干预措施转化为人口层面的改善以及老年人群中依从性和临床结局的改善仍然不理想。从老年人药物依从性队列研究（CoSMO）中，我们评估了患有已确诊高血压的老年患者（N=1544；平均年龄为 76.2 岁，59.5%为女性，27.9%为黑人，分别有 24.1%和 38.9%的患者依据药物覆盖比例（即 PDC＜0.80）和 4 项 Krousel-Wood 药物依从性量表（即 K-Wood-MAS-4≥1）测量的低依从性）的降压药物治疗依从性的传统障碍，发现这些障碍分别解释了药房配药和自我报告的依从性差异的 6.4%和 14.8%。持续的低依从率，再加上传统障碍的解释力较低，表明其他因素值得关注。先前的研究已经调查了对药物的明确态度作为依从性的驱动因素；而作为依从行为背后机制的内隐态度和时间偏好（例如，即时与延迟满足）的作用正在出现。同样，虽然个体层面的社会决定因素（SDOH）和药物依从性之间的关联已有大量报道，但关于结构 SDOH 和特定影响途径的证据也在不断增加。在已发表的概念模型和最近的证据基础上，我们提出了一个扩展的概念框架，该框架纳入了内隐态度、时间偏好和结构 SDOH，将其作为新兴的决定因素，可能可以解释在客观和主观测量的依从性方面的额外变化。该模型为设计、实施和评估干预措施提供了指导，旨在改善高血压老年男女患者的药物治疗依从性和临床结局。
