Uncontrolled hypertension - the role of medication adherence and clinical inertia

描述(由申请人提供)：伊恩·克罗尼什，医学博士，公共卫生硕士，西奈山医学院医学系普通内科医生和助理教授。候选人的长期目标是成为行为心脏病学领域独立的、以患者为导向的研究人员，研究医生和患者的行为影响慢性心血管疾病预后和管理的因素。更具体地说，候选人对开发、测试和传播行为干预措施感兴趣，这些干预措施可以提高对推荐的心血管行为的依从性。这位候选人在他担任普通医学研究员期间开始涉足这一领域，当时他研究了急性冠脉综合征后患者抑郁与不坚持治疗的关系，以及急性冠脉综合征后不坚持治疗对临床结果的影响。拟议的职业发展计划将密切指导的、以患者为中心的研究经验与多学科的教学培训结合在一起，内容包括1)临床试验设计、2)生物统计学、3)健康行为理论和4)专门的高血压培训。普通内科医生遇到的最常见的心血管问题之一是无法控制的高血压。高血压失控的两个重要原因与行为因素有关，包括：1)临床医生治疗强化不足，也称为临床惰性；2)患者不坚持用药。在健康心理学家Karina Davidson博士和普通内科医生Thomas McGinn医学博士和公共卫生硕士Thomas McGinn的指导下，这位候选人的目标是测试向临床医生提供有关他们的患者遵守药物治疗的客观信息是否可以改善临床医生对无法控制的高血压的管理。为了实现这一目标，候选人将首先登记并随机选择30名初级保健临床医生。随机接受干预的临床医生稍后将收到总结患者对降压药物依从性的报告。被随机分配到对照组的临床医生将继续进行常规护理。然后，他将从与临床医生相同的诊所招募300名未受控制的高血压患者。这些患者将接受为期一个月的电子血压药物依从性监测。然后，这些患者将回到他们之前参加研究的临床医生那里就诊。在患者访问时，干预组的临床医生将收到一份量化报告，总结他们的患者在前一个月坚持服用降压药的情况。对照组的临床医生将不会收到这份报告，并将按照通常的护理来治疗他们的患者。然后，候选人将评估收到依从性信息的临床医生是否更有可能1)加强对血压未得到控制的依从性患者的治疗(即：增加剂量或药物数量)，以及2)建议依从性较差的患者。这些数据将被用来计算更大规模、更具决定性的试验的功率。这项拟议研究的另一个目标将是评估患者相关、提供者相关和健康系统因素，这些因素可能是在1个月的磨合期内药物依从性较差的预测因素，并使用这些因素来开发预测不遵守降压药的模型。 公共卫生相关性：如果向临床医生提供他们的患者对电子监测的血压药物依从性的报告可以改善高血压的管理，那么电子监测依从性可能是减少血压不受控制的患者比例的有用工具。此外，能够预测血压药物依从性差的模型的成功开发，可能有助于指导针对依从性差的患者的干预设计，并有助于识别无法获得电子药物监测的依从性差的患者。

DESCRIPTION (provided by applicant): Ian Kronish, MD, MPH is a general internist and Assistant Professor in the Department of Medicine at the Mount Sinai School of Medicine. The candidate's long-term goal is to become and independent patient- oriented researcher in the field of behavioral cardiology, examining factors by which physician and patient behavior impact the prognosis and management of chronic cardiovascular illnesses. More specifically, the candidate is interested in developing, testing, and disseminating behavioral interventions that can improve adherence to recommended cardiovascular behaviors. The candidate became involved in this area during his fellowship in general medicine when he studied the association of depression with non-adherence among patients after acute coronary syndromes as well as the impact of non-adherence on clinical outcomes after acute coronary syndromes. The proposed career development plan combines a closely mentored patient- oriented research experience with multidisciplinary, didactic training in 1) clinical trial design, 2) biostatistics, 3) health behavior theory, and 4) specialized hypertension training. One of the most commonly encountered cardiovascular problems encountered by general internists is uncontrolled hypertension. Two important causes of uncontrolled hypertension relate to behavioral factors and include: 1) inadequate therapy intensification by clinicians, also known as clinical inertia and 2) patient non-adherence to medications. Under the mentorship of health psychologist Karina Davidson, PhD, and general internist Thomas McGinn, MD, MPH, the candidate aims to test whether providing clinicians with objective information about their patients' adherence to medications can improve clinician management of uncontrolled hypertension. To achieve this aim, the candidate will first enroll and randomize 30 primary care clinicians. Clinicians randomized to the intervention will later receive reports that summarize their patients' adherence to blood pressure medications. Clinicians randomized to the control arm will continue with usual care. He will then enroll 300 patients with uncontrolled hypertension from the same practice as the clinicians. These patients will have their adherence to blood pressure medications electronically monitored for one month. These patients will then return for visits with their clinicians who were previously enrolled in the study. At the time of the patient visit, clinicians in the intervention group will receive a quantitative report summarizing their patients' adherence to blood pressure medications in the prior month. Clinicians in the control arm will not receive this report and will treat their patients according to usual care. The candidate will then assess whether clinicians who receive the adherence information are more likely to 1) intensify treatment in adherent patients with uncontrolled blood pressure (i.e: increase dose or number of medications) and 2) counsel poorly adherent patients. These data will be used to calculate power for a larger, more definitive trial. Another goal of the proposed research will be to assess patient-related, provider-related, and health system factors that may be predictors of poor adherence to medication during the 1-month run-in period and to use these factors to develop a model for predicting non-adherence to blood pressure medications. PUBLIC HEALTH RELEVANCE: If providing clinicians with reports of their patients' electronically monitored adherence to blood pressure medications improves the management of hypertension, then electronically monitoring adherence may be a useful tool to reduce the proportion of patients with uncontrolled blood pressure. Further, the successful development of a model that can predict poor adherence to blood pressure medications may be helpful for informing the design of interventions targeted at patients with poor adherence and for identifying poorly adherent patients who do not have access to electronic medication monitoring.