THE DIMATCH-HTA STUDY             DETERMINANTS AND IMPACT OF             MEDICATION ADHERENCE AND             THERAPEUTIC ...
INDEXSUMMARY …………………………………………………………………….. 3RESUMO ………………………………………………………………………. 4BACKGROUND ……………………..........................
SUMMARYINTRODUCTION: Hypertension is a serious problem of public health since it affects more then 50% of thePortuguese po...
RESUMOINTRODUÇÃO: A hipertensão arterial (HTA) é uma doença crónica que atinge mais de 50% da populaçãoportuguesa acima do...
BACKGROUNDCardiovascular diseases are the main cause of death in Portugal, with a mortality rateamong the highest in Europ...
(BP) and for having a higher risk of developing complications from coronary heart disease.7, 15The best available estimate...
with health care services, are major determinants for the control of a chronic disease, suchas hypertension. Some of the f...
Studying only African migrants is a limitation, but we believe that our findings could contribute forrelevant insights con...
SPECIFIC AIMSWe will follow two cohorts of medicated hypertensive patients attending primary health careclinics, one of im...
STUDY POPULATION AND ELIGIBILITY CRITERIAStudy participants will:   1) have a clinical record at Primary Health Care Centr...
b. Within PHCC sampling of eligible subjectsFor each PHCC, a list of all eligible users will be obtained from SINUS inform...
TABLE 1. Data collection sources and periods.               DATA COLLECTION                         VERIFICATION       AT ...
(baseline and follow-up period). BP will be measured as a continuous variable and itsclassification will be according to 2...
b. Predictors variablesThe role of several variables – socioeconomic, health system and health care team, high BP,treatmen...
A questionnaire applied to the enrolled physicians will collect information concerning training andpractice in hypertensio...
STATISTICAL METHODSDescriptive and inferential statistics will be performed. 95% confidence intervals will beestimated for...
more than one level and are known to be a good very general framework to discover how   differences between studies in tre...
Hypertension awareness, prevalence, control and treatment in Immigrants*       Furthermore, also in 2007, our research tea...
Study Timeline and Human Resources                                                                         Month          ...
BUDGET AND MATERIAL RESOURCESFor an expected sample size of 2180 subjects (see sample size calculation), we anticipate the...
EXPECTED RESULTS, PUBLICATIONS AND PRESENTATIONSIt is expected to communicate the research’s potential contributions throu...
that, in the course of this study, we will be able to make collaborations with other          researchers, so that we and ...
9                                                                    26   Direcção-Geral de Saúde. Programa Nacional de Pr...
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Hypertension study

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Hypertension study

  1. 1. THE DIMATCH-HTA STUDY DETERMINANTS AND IMPACT OF MEDICATION ADHERENCE AND THERAPEUTIC CHANGE IN THE CONTROL OF ARTERIAL HYPERTENSION AMONG COHORTS OF IMMIGRANTS AND NON-IMMIGRANTS AT THE PRIMARY CARE LEVELPrincipal Investigator: Evangelista Casimiro RochaResearch team: Paulo Nicola, Mário Carreira, Violeta Alarcão, Paulo Nogueira, Milene Fernandes, Maria Alves Cortes, Marta GodinhoScientific consultants: Charles Agyemang, José Pereira Miguel Unidade de Epidemiologia Instituto de Medicina Preventiva Faculdade de Medicina de Lisboa June 2008
  2. 2. INDEXSUMMARY …………………………………………………………………….. 3RESUMO ………………………………………………………………………. 4BACKGROUND ……………………............................................................. 5SPECIFIC AIMS ……….............................................................................. 9METHODS ……………............................................................................. 9 Study Design ……………………………………………………………………... 9 Study Population and Eligibility Criteria ……………………………………. 10 Sampling Process ……………………………………………………………….. 10 Data Collection Process ………………………………………………………... 11 Variables Definition ……………………………………………………………... 12 Measurements and Data Sources …………………………………………….. 15 Sample Size ………………………………………………………………………. 15 Statistical Methods ……………………………………………………………… 16PRELIMINARY DATA ………………………………………………………….. 17EXPECTED RESULTS ................................................................................ 20STUDY TIMELINE AND HUMAN RESOURCES ................................................ 19ETHICAL ISSUES ....................................................................................... 19BUDGET AND MATERIAL RESOURCES ……………………………………….. 20EXPECTED PUBLICATION AND PRESENTATIONS …………………………….. 21BIBLIOGRAPHIC REFERENCES ……………………………………………….. 22 2
  3. 3. SUMMARYINTRODUCTION: Hypertension is a serious problem of public health since it affects more then 50% of thePortuguese population above 45 years. Lack of hypertension control is strongly associated with strokemortality and acute myocardial infarction, two leading causes of death and morbidity in Portugal. Amongthe determinants of failure to control blood pressure, non-adherence and clinical inertia assume majorrelevance. Cultural and socio-economic factors and health services access and utilization are criticalaspects underlying non-adherence and clinical inertia. These issues become even more complex when itcomes to hypertensive immigrants, due to the specifics involved in social integration, the migrationphenomenon and the own ethnicity. Both migrant and non-migrant populations are followed at primarycare level, where a strong patient-physician relationship and an integrated management of multiplechronic diseases are a challenge to physicians. Longitudinal studies are the best approach to evaluatemedication adherence and therapeutic inertia dynamics, providing a better understanding on determinantsable to be intervened.SPECIFIC AIMS: a) examine potential determinants of medication adherence and therapeutic adjustment;b) identify multidirectional relations between adherence, inertia and the blood pressure control; c) identifysub-groups, in each cohort, with high risk of uncontrolled hypertension related to poor adherence and/orclinical inertia.STUDY DESIGN: Observational, population-based prospective cohort study of medicated hypertensivepatients, followed at Primary Care Health Centres (PHCC) of the Lisbon Health Region, will be stratified totwo different cohorts, according to their status as immigrants or native.METHODS: The sampling process will follow a multistage approach, by clusters, aiming to draw arepresentative sample from the native and immigrant population who accesses primary care centres inLisbon, and their physicians. The final sample will be constituted by 1090 immigrants’ patients from AfricanPortuguese Speaking Countries and 1090 native medicated hypertensive patients. The inclusion criteriawill be verified through SINUS information system, by asking their physicians and during a phone interviewwith the patient. The follow-up period will last for 18 months, and data collection will be performed by face-to-face and phone interviews. The enrolled participants’ physicians will be asked to fulfil a questionnaireafter each medical appointment. Data collected will allow a longitudinal analysis by using the softwareSPSS and R.EXPECTED CONTRIBUTIONS: With a prospective evaluation of medication adherence and clinicalinertia, it will be identified the impact of key factors such as access and continuity of health care, thepatient beliefs regarding hypertension and antihypertensive medication and the patient-physicianrelationship, and of key moments, such as a new medical appointment and time between appointments.All these results will provide evidence for interventions and recommendations on hypertensionmanagement. Also, by assessing both patients and physicians and their relationships, this study will beable to examine the value of continuity and personalized care, which are specific values of Primary HealthCare. As we have preliminary results, we will be particularly interested in proposing and testinginterventions aiming to improve high blood pressure control and anti-hypertensive adherence.KEYWORDS: Hypertension, Medication adherence, Clinical inertia, Migration 3
  4. 4. RESUMOINTRODUÇÃO: A hipertensão arterial (HTA) é uma doença crónica que atinge mais de 50% da populaçãoportuguesa acima dos 45 anos. O não controlo da HTA está fortemente associado ao acidente vascularcerebral e ao enfarte agudo do miocárdio, identificados como as principais causas de morte e morbilidadeno nosso país. A não adesão e a inércia terapêutica têm sido apontadas como dois determinantes major donão controlo da HTA. Sendo multi-dimensionais, ambas estão relacionadas com factores culturais e sócio-económicos e com o acesso e utilização dos serviços de saúde, entre outros determinantes. Estes factorestornam-se ainda mais complexos nos imigrantes hipertensos, devido às características próprias daintegração social, do fenómeno migratório e da própria etnia. Os cuidados de saúde primários acompanhamambas as populações, imigrante e não-imigrante, colocando exigências ao nível da relação médico-doentee continuidade de cuidados, bem como na adequação dos cuidados de saúde para as várias doençascrónicas que o doente apresenta. Para compreender o impacto destes factores no controlo da HTA sãorecomendados estudos longitudinais sobre a dinâmica da adesão e a inércia terapêutica. Da identificaçãodestes factores poderão surgir estratégias de intervenção para melhoria do controlo da HTA.OBJECTIVOS: a) descrever os determinantes da dinâmica da adesão terapêutica e da mudançaterapêutica; b) analisar a relação multidireccional entre adesão, inércia terapêutica e controlo da HTA; c)identificar sub-grupos, em cada coorte, com elevado risco de não controlo da HTA relacionado com a nãoadesão e/ou inércia terapêutica.DESENHO DE ESTUDO: observacional analítico, prospectivo e de base populacional, de 2 coortes deimigrantes e não imigrantes, com HTA medicada e seguidos nos Cuidados de Saúde Primários da Regiãode Saúde de Lisboa.MÉTODO: O processo de amostragem será multi-etápico, por conglomerados, pretendendo-se umaamostra representativa da população imigrante e não imigrante que acede aos cuidados de saúdeprimários, bem como dos seus médicos de clínica geral e medicina familiar. A amostra final seráconstituída por 1090 doentes imigrantes oriundos dos Países Africanos de Língua Oficial Portuguesa epor 1090 doentes de naturalidade portuguesa com HTA medicada. Os critérios de inclusão serãoverificados através da informação obtida no sistema de informação SINUS, por questionário aplicado aosmédicos e durante uma entrevista telefónica com cada potencial participante. Os doentes de ambas ascoortes serão seguidos durante 18 meses, com recolha de informação por realização de entrevistaspresenciais e telefónicas. Será pedido aos médicos que preencham um formulário depois de cadaconsulta com um dos doentes participantes no estudo. A análise dos dados recolhidos será feita comrecurso a modelos de estatística adequados, utilizando os softwares estatísticos SPSS e R.CONTRIBUTOS ESPERADOS: A avaliação prospectiva da adesão e inércia terapêutica irá permitir aidentificação de factores-chave que possam ser alvo de intervenção, como o acesso e a continuidade decuidados de saúde, as crenças sobre a HTA e sobre a medicação e a relação médico-doente; e eventos-chave, como uma nova consulta médica e o tempo entre consultas. Os resultados do estudo darãosuporte científico para estabelecer recomendações no controlo da HTA. Além disso, na medida em que oestudo recolhe informação do doente, do médico e da relação entre ambos, será possível avaliar o valorde cuidados de saúde continuados e personalizados, como defendido para os Cuidados de SaúdePrimários. Na presença de resultados preliminares, é de particular interesse propôr e testar intervençõesque melhorem a adesão à terapêutica e controlo da HTA.PALAVRAS-CHAVE: Hipertensão, Adesão à terapêutica, Inércia terapêutica, Imigração e saúde. 4
  5. 5. BACKGROUNDCardiovascular diseases are the main cause of death in Portugal, with a mortality rateamong the highest in Europe and the World1. Furthermore, ischemic heart diseases andcerebrovascular are the third and fifth highest causes for potential years of life lost in Portugal.2Moreover, international studies showed immigrants are more vulnerable to the effects ofhypertension, in particular with higher prevalence, severity and risk of premature hypertensionby ethnic group, which has been reflected in the differences in morbidity and mortality.3, 4After age, hypertension is the highest attributable risk factor for cardiovascular diseases,and it presents a very high prevalence in Portugal. In 2003, a national population-based studydetected hypertensive blood pressure levels in 42.1% of the 5023 adults examined.5 It has beenestimated that 40% of acute myocardial infarction or stroke is attributable to hypertension6. Evenmild or borderline hypertension has been showed to increase stroke’s incidence7. In contrastwith age, hypertension is amiable to prevention and control. This fact justifies the emphasisgiven by the Portuguese National Health Plan (NHP) for its prevention and control.8Also, given the high prevalence of hypertension in the Portuguese population, the NationalProgram for Prevention and Control of Cardiovascular Diseases recognizes that the control ofhigh blood pressure is a major objective for the improvement of cardiovascular mortality.9 Theseobjectives should be achieved by improving the “(…) diagnosis, treatment, follow-up ofhypertensive patients, medication adherence, self-care and self-control of hypertension andassociated risk factors”,10 and by recommending that “(…) scientific studies concerning theprevalence, treatment and control of hypertension in Portugal should be developed.”11Although effective antihypertensive treatments have been developed in the last decades, studieshave showed that 60-80% of medicated hypertensive patients do not achieve normal bloodpressure levels.12 A 2003 population-based national study showed that, among the Portuguesemedicated hypertensive patients, only 28.7% had normal blood pressure levels. This value is inagreement with other international studies and surveys.13Medication adherence and clinical inertia are key factors for hypertension controlAmong the causes of failure to control hypertension, poor adherence and clinical inertia aretop high because of their impact and frequency.14 Adherence has been defined as “the extentto which a person’s behaviour - taking a medication, following a diet (…) corresponds withagreed recommendations from a health care provider”. Studies on medication-taking behaviourhave identified low adherence as a primary cause of inadequate control of blood pressure 5
  6. 6. (BP) and for having a higher risk of developing complications from coronary heart disease.7, 15The best available estimates are that poor adherence to therapy contributes to lack of goodblood pressure control in more than two-thirds of people living with hypertension.7Also, "medication adherence is a dynamic parameter that is not stable over time".16 For instance,patients with variable adherence often improve compliance around the time of a scheduled clinicvisit but declines thereafter.17 Other key events related to adherence dynamic are acceptance,representing if whether or not the patient ever starts the dosing regimen, and persistence,defined as the time between the first and the last dose. Non-acceptance is less studied but it isrecognized by clinical experience,15 while studies on short persistence have pointed out that,within first year prescription, up to half of newly diagnosed patients quit their antihypertensivemedication.16 All these medication taking parameters will be comprehensively examined duringthis study. 18Antihypertensive medication intensity is another main determinant of blood pressurecontrol.19 An interest finding is that, in chronic diseases, the problem isnt usually prescribing thewrong drug but “failure to initiate or titrate medications until important evidence-based clinicalgoals are reached”.20 This failure may lead to potentially preventable adverse events, disability,death, and excess medical care costs.21 Regarding high blood pressure control, it is pointed outthe need to (1) recognize lack of control and (2) initiate and/or intensify treatment untiltherapeutic goals are reached.22 Also, hypertension management guidelines reinforces that “theeffective and timely titration to BP control requires frequent visits in order to timely modify thetreatment regimen in relation to BP changes”.23 Despite these recommendations, clinical inertia,defined as “an office visit at which no therapeutic move was made to lower blood pressure of apatient with uncontrolled hypertension”24 has a major impact on blood pressure control inhypertensive patients receiving regular care: a recent cohort study concluded that reducingclinical inertia would allow to control increased blood pressure in additionally 20% ofhypertensive patients.19 To better evaluate clinical inertia, a sufficient time window should beconsidered, to encompass several clinical visits. Furthermore, factors related to physician,patient and the clinical visit should be considered, such as insufficient time with the patient andlack of physician training and proactive care.25 Our study will include such design andlongitudinal data collection, to be able to examine and interpret these factors.Migration, cultural and socio-economic characteristics as challenging factors forhypertension controlControl and adherence to hypertension medication are complex and multidimensional. Wehypothesize that cultural and socio-economical factors, crucial to the understanding ofhypertension and adherence to anti-hypertensive treatment, and well to the two-way interaction 6
  7. 7. with health care services, are major determinants for the control of a chronic disease, suchas hypertension. Some of the factors associated to the nature and complexity of migration –such as individual lifestyle and cultural and environmental conditions – may influence theadherence to medication in immigrants. We aim to understand how these possible differencesaffect the adherence to hypertensive medication, blood pressure control and clinical inertia, bycomparing eventual inequalities among immigrants to non-immigrants.26 Nevertheless, little isknown about migration as a health determinant and this topic has been neglected in thescientific literature. In Portugal, we have found no published studies about adherence andcontrol of hypertension in immigrants.It has been demonstrated that African Americans were more likely to have inadequate bloodpressure control when compared to whites.27, 28 Moreover, African were more aware of theirhypertension and more likely to be on treatment if aware of their diagnosis but among thosetreated for hypertension, they were less likely to have their blood pressure controlled.29 Thereasons given to explain the poorer hypertension control in different races include geneticfactors, lower aggressiveness of treatment, factors related to lifestyle, diet and stress, sideeffects acceptance and access and use of health care.29Regarding medication adherence, African Americans were more likely to be non-adherent, toperceive hypertension as more serious and to report increased side effects than whites, withthese factors being related to poorer blood pressure control.27 Non-adherence was shown to beassociated with a lack of a primary care physician and having blood pressure checked in anemergency room.30 Adherence WHO Report states that race is frequently a predictor ofadherence, regardless of whether the members of a particular race are living in their country oforigin or elsewhere as immigrants. Often, cultural beliefs, fear of discrimination or beingdistrusted by medical profession are the reason behind these racial differences.7All these factors challenge hypertension control, health care and clinical practice. By comparingimmigrants and non-immigrants with high blood pressure, we will be able to betterunderstand the impact of socio-cultural characteristics, health care utilization and otherimportant factors in blood pressure control and medication adherence.Our cohort of immigrant will be restricted to Portuguese Speaking African Countries. Regardingthe lately national migration statistic (with age information by country of origin),31 only migrantsfrom the Portuguese Speaking African Countries present a considerable number of individualsabove 40 years of age (25%). The great majority of migrants from Brazil and Ukraine (two of theten top origin countries) have less than 40 years of age. In fact, migration flows from these twocountries are more recent than from the African Countries. 7
  8. 8. Studying only African migrants is a limitation, but we believe that our findings could contribute forrelevant insights concerning barriers to blood pressure control in other minority groups and in thegeneral population. As we stated, the prevalence, severity and impact of hypertension areincreased in blacks, and therefore studying African migrants will allow us to better understandthose elevated risks.Purpose and advantages of the current study proposalHypertension, as a paradigm of a chronic disease with enormous public heath impact, is aparticularly important social, disease and health care model to understand chronic diseasecontrol and management. Including disadvantageous populations, such as immigrants, willemphasize disease care areas that are fundamental to chronic disease control andmanagement.This study will closely follow, for 18th months, a cohort of immigrants and non-immigrants,allowing measuring and characterizing complex and dynamic phenomena which aremajor determinants of blood pressure control, such as patient adherence to medication,health care utilization and clinical inertia. Moreover, this study will characterize the care ofhypertension at the primary-care level, which will provide fundamentals data and insightsregarding the impact of primary care in the control of chronic diseases, such as hypertension.Our team encompasses experienced and knowledgeable researchers, which have lead andparticipated in community and primary-care based studies on cardiovascular disease,medication adherence and health of migrants. This study will allow our country to participate ininternational forums and networks were research, clinical care and public health policies forchronic diseases, primary care, public health, health of immigrants and hypertension. 8
  9. 9. SPECIFIC AIMSWe will follow two cohorts of medicated hypertensive patients attending primary health careclinics, one of immigrants and the other of non-immigrants, in order: 1. To compare migrants and non-migrants concerning the prevalence of controlled hypertension, antihypertensive medication adherence, patterns of health services utilization and approaches to hypertension control, adjusted for age, comorbidities, socio- cultural and economical characteristics. 2. To examine potential determinants of medication adherence and therapeutic adjustment. In particular, these will be related to: a. Hypertensive disease, including severity and co-morbidities b. Therapy, namely pharmacological and non-pharmacological approaches c. Health Services, including access, patient-physician relationship and health system utilization d. Socio-economic aspects e. Patient beliefs and attitudes towards hypertension and therapy 3. To identify multidirectional relations between adherence, therapeutic change, and blood pressure (BP) control. We will identify situations of clinical inertia. We will test the following hypotheses: a. Therapeutic change is associated with medication adherence b. Low adherent patients have a higher probability of uncontrolled BP, inducing cyclic therapeutic change until higher dosages compensate non-adherence c. Therapeutic change is determinant to BP control in high adherent patients, but not much so in low adherent patients 4. To identify sub-groups in each cohort with high risk of uncontrolled BP related to poor adherence and/or clinical inertia.METHODSSTUDY DESIGNThis is an observational population-based prospective cohort study. Medicated hypertensivepatients, followed at Primary Care Health Centres of the Lisbon Health Region, will be stratified totwo different cohorts, according to their status as immigrants or native. 9
  10. 10. STUDY POPULATION AND ELIGIBILITY CRITERIAStudy participants will: 1) have a clinical record at Primary Health Care Centres from the administrative health region of Lisbon; 2) have a clinical diagnosis of high blood pressure, as stated by the physician, or recorded in the clinical medical record; 3) currently be taking antihypertensive medication, as indicated in the clinical medical record, and confirmed during a visit to the participant; 4) have had their last clinical visit at least six months ago; 5) be aged between 40 and 80 years, included; 6) be responsible for taking their medication; 7) be able to be contacted, with an active phone number and address registered in the primary health care centre information system; 8) be able to and consent in participate on the study.We will exclude from this study subjects who are: 1) Institutionalized or those who depend on others to take the medication; 2) Patients with cognitive disorders such as dementia and schizophrenia, as indicated in the clinical record or perceived during the interview. 3) Having plans to move from the Lisbon Health Region for more than consecutive 4 months within a 18th months period. 4) Patients unable to be contacted by telephone, after 10 attempts, in alternate days, at different periods of the day.In this study, immigrants are defined as subjects who were born in Portuguese Speaking AfricanCountries (Angola, Cape Verde, Guinea Bissau, Mozambique or Sao Tome and Prince), andhave arrived to Portugal after 1980. For the non-immigrants’ cohort, patients must have beenborn in Portugal.SAMPLING PROCESSThe sampling process will follow a multistage approach, by clusters, aiming to draw arepresentative sample from the native and immigrant population who accesses primary carecentres in Lisbon Health Region. a. Sampling of Primary Health Care Centres (PHCC)Ten, out of 45 PHCC from Lisbon’s Health Region will be randomly selected. All selected PHCC’sdirectors will be invited to participate, and any eventual refusal will be replaced by a new PHCCrandomly selected by the same process. 10
  11. 11. b. Within PHCC sampling of eligible subjectsFor each PHCC, a list of all eligible users will be obtained from SINUS information systemmanaged by The National Health System Central Administration (ACSS). All eligible users willbe stratified in two lists (natives and non-natives) according to the location of birth (Portugal vs.Portuguese Speaking African Countries). c. Within PHCC sampling of participating physiciansIndividual will be sequentially drawn from both lists. First 5 physicians reaching 75 users in eachof both cohorts will be selected and invited to participate in the study. Any eventual refusal ofparticipation by the physician will lead to the next physician reaching the same criteria. d. Identification of medicated hypertensive patientsPotential medicated hypertensive patients will be identified by asking theirs physicians toindicate those among the selected subjects. We have shown this identification process to besuperior, when comparing to telephone interview or reviewing the medical record32. Furtherselection criteria will be assessed by phone interview.DATA COLLECTION PROCESSData will be collected from following sources and times indicated in table 1.The follow-up period will last for 18 months, during which it is expected to establish a continuousrelationship between the study participants and the research team by: (1) Face-to-face interviews each 6 month (4 by participant in 1.5 years of follow-up); (2) Phone interviews at 3, 9 and 15 months (3 by participant in 1.5 years of follow-up).This frequency is expected to contribute to keep participants committed during the study and toclarify any question that may arise by the participants. 11
  12. 12. TABLE 1. Data collection sources and periods. DATA COLLECTION VERIFICATION AT FOLLOW-UP INSTRUMENTS AND SOURCES OF ELEGIBILITY BASELINE 3M 6M 9M 12M 15M 18MPatients’ eligibility form (to be fulfilled by thephysician) XPatients’ eligibility questionnaire (to be fulfilledduring phone interview) XPhysician’s questionnaire X X XPatients’ baseline questionnaire (face-to-face) XPatients’ baseline questionnaire – immigrant cohort(face-to-face) XClinical records’ form XSocial Support Questionnaire (SSQ6) X X XHospital Anxiety and Depression Scale (HAD) –Portuguese version X X XEUROPEP – Portuguese version X XBeliefs about Medicine Questionnaire – Generaland Specific (BMQ) – Portuguese version X XIllness Perception Questionnaire (IPQ) –Portuguese version X XPatients’ follow-up questionnaire (face-to-face) X X XPatients’ follow-up questionnaire (telephoneinterview) X X XPhysicians’ follow-up form During each appointment.Patients’ BP self-measurement and medicationadherence diary X X X XPhysicians’ participation consists in fulfilling (1) A formulary per visit of the enrolled patients, with information about BP values and changes in therapy. a. The questionnaires will be annexed to clinical processes and collected monthly. (2) A mid and final questionnaire regarding attendance to training courses and congresses related to hypertension, as well as knowledge, attitudes and decision making regarding management and experience with hypertensive patients.VARIABLES DEFINITION a. Outcome measuresBlood pressure (BP)Blood pressure record will be collected by three sources of information: (1) patients’ clinicalrecords and (1.a) form filled by its physicians at each visit, (2) ambulatory BP, in a subgroup ofrandomly selected patients, and (3) home BP, performed at all the face-to-face interviews 12
  13. 13. (baseline and follow-up period). BP will be measured as a continuous variable and itsclassification will be according to 2007 ESH-ESC Practice Guidelines for the Management ofArterial Hypertension.Adherence to antihypertensive pharmacological therapyAdherence will be evaluated as a time-changing parameter, which includes (1) acceptance (innaïve medicated patients), (2) compliance and (3) persistence. A patient will be classified asadherent if he accepts to take the prescribed medication, maintains the treatment during thestudy period and presents compliance level of 80% or higher. (1) Acceptance is defined has a dichotomous variable, assuming that a naïve medicated patient accepts medication when it continues taking it for more than one month. (2) Persistence is also defined as a dichotomous variable, assuming that a patient persists with its medication when that is taken until the physician suspends it or the end of study period. (3) A multi-method approach will be taken in order to access compliance, based on pharmacy record and self-report: • At the baseline interview, all the non-naïve patients will be submitted to the following questions33: “People miss taking their medications for many reasons. Do you have medicines for which you sometimes miss taking a dose? (..) How many doses might you have missed in the past 10 days?” (Portuguese) “As pessoas podem falhar os seus medicamentos por muitas razões. Há medicamentos para os quais, por vezes, falte a toma de um ou mais comprimidos?” (....) “Nos últimos 10 dias, quantas tomas deve ter faltado?” These questions had a specificity of 69.8% and a sensitivity of 80%, giving an overall accuracy of 74.5%, when compared to pill count.33 • All participants will be requested to keep their pharmacy receipts for the duration of the study period (18 months). This is usual practice as they allow taxes return. Compliance will be defined as Medication Possession Ratio: sum of the days supply of medication divided by the number of days between the first fill and the last refill plus the days supply of the last refill. The accuracy of this methodological approach will be defined in a previous validation study, assuming pill-count as the gold-standard.Clinical inertiaWe will use the O’Connor PJ et al. definition of clinical inertia. Newly added antihypertensivetherapy and increase in the dose of current antihypertensive therapy will be consideredtherapeutic changes. Target blood pressure is assumed to be <140/90 mmHg (or <130/80 indiabetic patients), according to 2007 ESH-ESC Practice Guidelines for the Management ofArterial Hypertension. Therapeutic change is designated as timely when it occurs within 6 monthfrom the date of a clinical visit. 13
  14. 14. b. Predictors variablesThe role of several variables – socioeconomic, health system and health care team, high BP,treatment and patient-related factors – as determinants of adherence dynamic and therapeuticchange will be collected at baseline and throughout the study. This research team isexperienced in collecting such data and applying these questionnaires, as it has been happeningin other studies.Socioeconomic-related factorsPatients’ baseline questionnaire will allow collecting information regarding socio-demographiccharacterization (age, sex, ethnicity, Graffar scale), professional status and income, socialsupport networks (assessed with Social Support Questionnaire SSQ6), marital status,educational degree (number of school years concluded). For immigrants, the level ofacculturation will be assessed through the Vancouver index.Hypertension-related factorsFrom the patients’ clinical medical record, data will be collected regarding the time since thediagnosis of hypertension, its aetiology and grade (according to European Guidelines); co-morbidities included in Charlson Co-morbidity Index34 and lipid disorders. At the baseline 35interview, the Portuguese version of the Hospital Anxiety and Depression Scale (HAD) will beapplied to all patients enrolled in the study. Cardiovascular risk factors will also be identified atthe baseline interview: alcohol consumption, smoking habits and physical activity practice will bemeasured according to Portuguese National Health Survey methodology; height and weight willallow the calculation of the body mass index.Treatment-related factorsAntihypertensive medication will be assessed each medical appointment throughout the study bymeans of a simple, one-page form that the physician will fulfil at the end of each appointment.Data will be also collected / confirmed at each face-to-face or telephone interview. These datawill pertain to prescription details and allow the computation of the medication’s expenditure.During face-to-face interview, further information will be collected regarding the patientinvolvement in decision’s making, perceived self-efficacy and side-effects, use of over-the-counter medicines and non-pharmacological treatments.Health system and health care team-related factorsDuring the patients’ baseline interview, the Portuguese version of EUROPEP will be applied toaccess the patients’ satisfaction with primary health care system, including the patient-physicianrelationship.36 14
  15. 15. A questionnaire applied to the enrolled physicians will collect information concerning training andpractice in hypertension control, such as, years of clinical practice, enrolment in trainingprograms on hypertension management, the physician criteria for initiating and intensifying anti-hypertensive medication and the adoption of guidelines. Other information as needs oninformation concerning the management of hypertension, and problems faced when prescribingantihypertensive medication will also be accessed.Patient-related factorsPatients’ knowledge, attitudes, and lay beliefs about hypertension will be obtained during a face-to-face interview with the application of Beliefs about Medicine Questionnaire – General andSpecific (BMQ)37 – and Illness Perception Questionnaire (IPQ)38.MEASUREMENT AND DATA SOURCESInstruments will be pretested and interviewers will have specific training to avoid systematicerrors. Test-retest reliability will be performed in a group of randomly selected patients, beingexpected an inter-ratter agreement statistic (Kappa) ≥ 0.85. Adjustment and new testing processwill be conducted to those variables/questions in which Kappa < 0.85. A Manual of Procedures(or Operations Manual), including definitions and quality control procedures, will be developedand tested during the pilot study.SAMPLE SIZEAssuming medication adherence as 80% or more of expected drug intake, a difference of ± 5%may be detected with a sample size of 907 among the two cohorts (total sample size of 1814).With this sample size, 907 participants per cohort, and given a statistical power of 80%, it will bepossible to detect relative’s risks of 1.18 or more, or 0.85 or less. For this sample size adifference among two continuous pair of variables will allow a high power to detect differences.For instance, to detect differences of blood pressure levels among two groups we will be able todetect 2 mmHg among two groups (assuming a standard deviation of 5mmHg in each group) in98.9% of the times. Therefore this samples size will allow powerful multivariate models, evenmore as repeated measures will be taken.To account for lost to follow-up during the study, the total calculated sample size will beincreased in 20%. Therefore, the final sample size will be of 2180 subjects, that is, 1090 percohort. 15
  16. 16. STATISTICAL METHODSDescriptive and inferential statistics will be performed. 95% confidence intervals will beestimated for parameters of interest and a 5% significance level will be adopted for all statisticalhypotheses tests. Analysis will be performed using SPSS and R software. A careful datainspection, cleaning and quality assurance phase will precede statistical analysis.Accordingly to the study main objectives:1) TO COMPARE MIGRANTS AND NON-MIGRANTS CONCERNING THE PREVALENCE OF CONTROLLED HYPERTENSION, ANTIHYPERTENSIVE MEDICATION ADHERENCE, PATTERNS OF HEALTH SERVICES UTILIZATION AND APPROACHES TO HYPERTENSION CONTROL, a description of both cohort will be done, using categorical, parametric and non-parametric descriptive statistics, as appropriate. Prevalence of controlled hypertension will be described according to relevant socio- demographic variables (age, sex, education, economic status) for both groups and 95% confidence intervals will be computed according to the F distribution. Relevant socio- demographic and economical aspects, comorbidities scores and other clinical information (for instance, number of years with hypertension), will be compared among migrants and non- migrants, using chi-square tests for categorical variables, student t-test for parametric or Wilcoxon rank sum test for non-parametric continuous variables, as appropriate. Non-migrants and migrants will be compared regarding dichotomous variables, such as frequency of controlled hypertension, percentage of subjects adherent to antihypertensive medication, etc., using logistic regression modelling, adjusted for age, comorbidities, socio-cultural and economical aspects.2) TO EXAMINE POTENTIAL DETERMINANTS OF MEDICATION ADHERENCE AND THERAPEUTIC ADJUSTMENT bivariate and multivariate methods will be used. Bivariated association will be tested using chi-square tests, Fisher Exact Test and binary logistic regression. Multivariated binary logistic regression will be performed to check which factors simultaneously relate with outcome variables.3) TO IDENTIFY MULTIDIRECTIONAL RELATIONS BETWEEN ADHERENCE, THERAPEUTIC CHANGE, AND BLOOD PRESSURE CONTROL bivariate and multivariated data analysis will be performed. In bivariated analysis, when adherence or therapeutic chance is considered an dependent variable, the analysis is identical to the recommended above for potential determinants determination. Of particular interest here is the situation when blood pressure is considered as the variable to be explained (as dependent variable): in such case t-tests and ANOVA will be used, as well as their non-parametric equivalent Mann-Whitney and Kruskal-Wallis tests. Multivariated approaches, aiming at identifying multiple factors and variables simultaneous associated with blood pressure will consist of multifactorial ANOVA (General Linear Models) and Multilevel Models. In fact, Multilevel Models (also known as hierarchical linear models, generalized linear mixed models, nested models, mixed models, random coefficient, random-effects models, random parameter models, or split-plot designs) are statistical models of parameters that vary at 16
  17. 17. more than one level and are known to be a good very general framework to discover how differences between studies in treatment implementations, research methods, subject characteristics, and contexts related to treatment effect estimates within studies39. These models can be seen as generalizations of linear models, although they can also extend non- linear models. Multilevel models are known to be very flexible but are also known to be sensible to presence of missing data and low number of information waves (number of time points at which time points were collected). In our study a high number of missing values is not expected. If number of records with missing information is small, listwise selection/deletion will be considered; otherwise data imputation or multiple imputation standard techniques will be considered. In this latter case, sensibility analysis will be performed (analysis with and without imputation) and reported.4) TO IDENTIFY SUB-GROUPS IN EACH COHORT WITH HIGH RISK OF UNCONTROLLED BLOOD PRESSURE RELATED TO POOR ADHERENCE AND/OR CLINICAL INERTIA profiles will be generated using multivariate exploratory data techniques: Cluster Analysis and Q Factor Analysis will be conducted.PRELIMINARY DATAOur research team has experience in working with the primary care setting; examiningantihypertensive medication adherence; and studying immigrants’ health. In this section wedescribe preliminary work and results relevant to demonstrate our proficiency and how this studybuilds on previous studies.Immigrants access to primary health care40 There is a lack of studies concerning the health, health care access and equity for the immigrant communities. In 2007, our research team developed a study about the "Evaluation of Health and Health Assessment of African and Brazilian Immigrants in Portugal" with the objectives of characterizing the health, the access to health care and the health determinants of the African and Brazilian communities living in Lisbon and Setubal Districts, and comparing theses data with the data available from the general population with the 4th National Health Survey. Individuals were selected through a process of random simple cluster geographical sampling with the help of GIS software (ArcGIS 9.1). The data collection was obtained by teams of interviewers, most of them from the communities in study. A total sample of 4508 individuals was surveyed, aged between 0 and 87 years old, 51% were women. This population used mainly the National Health Service (86%). Within the last three months, 24% have consulted once a doctor, 14% consulted 2-3 times, and 5% consulted more than three times. The last consultation was mainly in the PHCC (61%). 17
  18. 18. Hypertension awareness, prevalence, control and treatment in Immigrants* Furthermore, also in 2007, our research team conducted a study intituled: "Comparison Between Self-Referred Hypertension and Blood Pressure Measurement in African Immigrants and Brazilians", based on a sub-sample from the study described above. Blood pressure measurements were obtained by trained observers using a validated OMROM M6C sphygmomanometer. Additional information’s concerning hypertension and its treatment was collected through a specific questionnaire, during an interview with an interviewer from the same community. The final sample was constituted by a total of 317 individuals, aged between 30 and 83 years old, 61% were women. Overall 45.6% had hypertension. Prevalence of hypertension was higher among African (52.7%) than Brazilian (24.3%) (p<0.001). Overall, 42% of hypertensive patients were aware of their diagnosis. Around 47% of those with hypertension were medicated. Mean years of diagnosis is 11±10.8 and of medication, 10±9.6. Only 19% of hypertensive and 59.7% of hypertensive medicated achieved blood pressure control.Regarding our approach to study adherence the antihypertensive medication in the immigrant’scohort, these preliminary results show that hypertensive immigrants seem not to have limitedaccess to health care as they have frequent consultations in the PHCC (a great number hadconsultations in the previously 3 months of the inquiry). This supports that sampling theimmigrant participants may be carried out in the same way as that for the non-immigrants.How to identify medicated hypertensive patients at Primary Care Health Centres?The answer to this question was possible with a previous study32 of 250 subjects followed at aprimary care centre of Lisbon’s Region, with age ≥ 40 years. To compare advantages and lossesof information, independent processes were applied: (1) physicians were asked to identify theirpatients as with/without hypertension under medication, by answering a brief questionnaire, (2)clinical records were consulted and (3) phone interviews were driven. With the study conclusion,48% (120 patients) have medicated hypertension identified by, at least, one of the above processes.The physician’s questionnaire allowed the identification of a larger number of medicatedhypertensive patients (74.2% of all medicated hypertensive patients) with fewer loss of information.* Unpublished data. 18
  19. 19. Study Timeline and Human Resources Month Human Task 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Resources0. Study protocol and Research team choice of measures1. Ethical Committee and administrative Research team permissions2. Interviewers selection 2 Field and training coordinators3. Pilot study 2 Field4. Database construction Coordinators5. Validation of 2 Interviewers compliance measure by 1 Informatic pharmacy claims 1 Study6. Sampling Process Coordinator7. Recruitment of medicated hypertensive 2 Field participants Coordinators8. Recruitment of primary 6 Interviewers care physicians9. Follow-up period 2 Field (face-to-face interviews or Coordinators telephone interviews each 4 Interviewers 3 months)10.Data analysis Research team11.Publications and divulgation of the study Research team results ETHICAL ISSUES We will take in consideration the following ethical issues: 1. Health care data is sensible personal information. We will de-identify data such as name, birthday, address and telephone contact. Patients and health care providers will be coded with a unique non-identifying number. The database will have protected access (restricted access, password-protected), and servers will be protected with state-of-art software firewalls and anti-virus. 2. Written informed consent will be requested to all participants: a copy of the signed informed consent will remain with the participant. The right to leave the study at any time, and to have all data erased, will be recognized. In order to infer external validity from the data analysis, a small set of non-identifying data (e.g., gender, year of birth) will be used to compare consenting and non- consenting subjects. 3. A permission from Protection Data Portuguese Authority (CNPD) will be required to use centralized databases with individual data. This permission is particularly relevant since we will collect sensible personal and clinical data. This research group is experienced in submitting similar requests to CNPD. A cross-sectional version of this study has already been approved by the Ethical Committee from the Medical School of the University of Lisbon. Currently, it is pending a request for the modifications related to the longitudinal design. 19
  20. 20. BUDGET AND MATERIAL RESOURCESFor an expected sample size of 2180 subjects (see sample size calculation), we anticipate thefollowing budget and material resources: Amount Material Item (Eur) Resources Description Start-up costs Consultant revision (including travel expenses). Consultants 2500 Travel expenses Includes 2 visits of 3 days. Submission to the Ethical Committee and Portuguese Ethical Approval 250 Data Protection Authority Office material Pilot study for the validation of study methodology, testing of the data collection and of the procedures Pilot study 1500 Phone credits manual, in 100 participants (50 per cohort), only at Travel expenses baseline and one follow-visit at 3 months. Database construction and testing, storage and Database management 800 Server protection. Office material Contacts with the PCHCs and general physicians: Implementation at Primary Care invitation to the PCHC directors; debriefing; invitation 500 Travel expenses Health Centres (PCHC) to the physicians. Estimation of 4 visits for 2 persons Phone credits to 14 PCHC at 4.5 Euros per visit. Participant-related costs Telephone contacts with GPs, during all study Physicians contacts 500 Phone credits phases (110 GPs, 3 visits per GP, 3 phone calls per visit, 0,5 Euros per phone call) Post expenses Appointment of face-to-face interviews + telephone interviews (2180 participants, 4 visits per participant, Participants contacts 30000 3 phone interviews per participant, 3 phone calls per Phone credits contact, 0.5 Euros per phone call) (2 letters per participant, 0.5 Euros per letter) Documentation 5500 Office material Paper questionnaires (~2.5 Euro/participant) Staff and Analysis costs Public transportation cards for 5 interviewers for 25 Traveling expenses 5000 Travel expenses months, at 40 Euros per month. 5 part-time interviewers, working a mean of 6 Interviewers part-time stipend 66000 Stipend hours/day, for 22 months, at 600 Euros per month. Statistical analysis performed by a team member and Statistical Analysis & Report 2500 revised by an expert in longitudinal data analysis 30% time of a study coordinator, for 24 months, for a Study coordinator 15000 full-time stipend of 2000 Euros/month. 30% time of a filed coordinator, for 24 months, for a Field coordinator 10000 full-time stipend of 1400 Euros/month. Participation and presentation in national and Travel expenses Publications and divulgation of international meetings; 2500 results Publications and divulgation of the study results in Meeting registration international and national peer-review journals. sub-total 1 142550 Unexpected expenditures (15%) 21382.5 sub-total 2 163932.5 AIDFM (8%) 16000 Institution overheads. IMP (10%) 18400 Institution overheads. Total 198333 200 000 20
  21. 21. EXPECTED RESULTS, PUBLICATIONS AND PRESENTATIONSIt is expected to communicate the research’s potential contributions through publications ininternational and national peer-review journals, and in international and national meetingsrelated to areas such as Public Health and Epidemiology, Cardiology, and Immigrant’s Health. Inthese areas, the research’s foreseen contributions are 1- Clinical, Public Health, Care for Hypertensive patients, Primary-Care: (1) prevalence of hypertension control, adherence to antihypertensive medication and clinical inertial; (2) determinants of hypertension control, adherence dynamic and therapeutic change; (3) implementation and compliance with current guidelines and recommendations; (4) profile of the hypertensive patients at the primary-care; We will be able to describe the dynamics of medication adherence according to important key moments and factors concerning a chronic disease with major public health impact. These key moments are, for example, a new appointment, attending the emergency care or an adverse event. We will measure the impact of key factors, such as patient-doctor relationship and continuity of care, time between appointments, and the physicians’ criteria for intensifying therapy. All these results will provide insights to elements which may be intervened, in order to improve the control of high blood pressure. The importance of these results may be extended to other chronic diseases. This study will be innovative since it will incorporate the information of both patients and physicians. We will be able to understand how these two perspectives integrate each other: for instance, we will be able to examine if a physician who easily intensifies therapy associates with a more adherent patient; if physicians who like to treat hypertensive patients are associated with patients who belief their antihypertensive medication is effective; if physician who evaluate medication adherence and adverse effects are more likely to have adherent patients. Moreover, this insight is of more value as we will be including primary-care physicians, who are more likely to have long-term relations with their patients, and to care about other chronic diseases of the same subjects. 2- Epidemiology: (4) discussion of cohort studies methodology for multiple measurements in chronic diseases; (5) measurement issues in medication adherence and clinical inertia research; (6) measuring health care quality, equity to health care access, and ethnicity as a variable in epidemiological research; In Portugal it is not common to have longitudinal prospective studies, particularly at the primary care level. These studies require a high level of organization and professional management, along with a high-motivated team who will create and maintain a strong commitment and relation with all participants and everyone else involved. We expect 21
  22. 22. that, in the course of this study, we will be able to make collaborations with other researchers, so that we and other may take further scientific and clinical advantage with this effort. Therefore, we expect that new projects will be created from these opportunities. As we have additional preliminary results, we will be particularly interested in proposing and testing interventions aiming to improve high blood pressure control and anti-hypertensive adherence. 3- Immigrant’s health: (7) equity to health care access among immigrants and non- immigrants; (8) discussion of the inclusion of ethnic minorities in health outcomes research; (9) ethnic inequality in health status; (10) acculturation and health and determinants for adherence in immigrants. In Portugal there are few studies about migration and health and none about medication or control of a chronic disease in migrants. As far as we know, this will be the first longitudinal study with a prospective cohort of adult immigrants. A recent cohort study was conduct with children with the objective of defining the prevalence of immigrant children and to assess the children in their first months of life morbidity and mortality.41 We expect a better understand of changes in health related to migration status, which may lead to evidence-based measures regarding health services organization and specific intervention programs.We expect, during the next 2-3 years, to publish about 2 to 4 papers per year (total of 9-10papers), both at national and international peer-reviewed journals. We estimate a similar numberof presentations at national and international meetings. This research unit is responsible for theMaster Degree in Epidemiology at the Lisbon’s University Medical School. This project shouldprovide enough scientific material for 2 master theses. Therefore, we anticipate the opportunityto interest students in project and to present, during the next 2-3 years, about 1 seminar per yearconcerning this study.BIBLIOGRAPHIC REFERENCES1 Rocha E, Pereira Miguel JM. Epidemiologia da hipertensão factors in different ethnic groups in south London Heartarterial em Portugal: Uma actualização; In: Hipertensão Arterial – 1997;78:555–563Tomo I, edit. por Braz Nogueira J.. Biblioteca Cardiológica do 5Clínico Geral, edit. por Soares-Costa J T S. Permanyer Portugal Macedo ME, Lima MJ, Silva AO, et al. Prevalence, awareness,2003 treatment and control of hypertension in Portugal: the PAP study. J Hypertens. 2005 Sep;23(9):1661-6.2 Santana P, Alves I, Couceiro L, Andreozzi V, Nicola PJ, 6Machado MC. Anos de Vida Potencial Perdidos, por causas de Thompson DW, Furlan AJ. Clinical epidemiology of stroke.morte seleccionadas, em Portugal Continental no período 2003 a Neurologic Clinics 1996; 14:309-315.2005. Congresso Português de Epidemiologia. 2007. 7 World Health Organization. Adherence to Long Term Therapies:[http://epidemiologia2007.com.pt, accessed in 2008-03-28] Evidence for Action. WHO Geneva, 20033 Smith GD, Chaturvedi N, Harding S, Nazroo J, Williams R. 8 Direcção-Geral da Saúde. Plano Nacional de Saúde 2004-Ethnic inequalities in health: a review of UK epidemiological 2010: mais saúde para todos. - Lisboa: Direcção-Geral daevidence. Critical Public Health,Vol. 10, No. 4, 2000 Saúde, 2004. - 2 v. - Vol. I – Prioridades; Vol. II - Orientações estratégicas [http://www.dgs.pt/, accessed in 2007-10-19]4 Cappuccio FP, Cook DG, Atkinson RW, Strazzullo P.Prevalence, detection, and management of cardiovascular risk 22
  23. 23. 9 26 Direcção-Geral de Saúde. Programa Nacional de Prevenção e Fernandes, A., Carballo, M., Malheiros, J., J., Miguel, J.PControlo das Doenças Cardiovasculares. Despacho n.o (Eds), Challenges for health in the age of migration. Health and16415/2003, DR, II Série, de 22 de Agosto., page 4. migration in the European Union, Report presented in the[http://www.dgs.pt/, accessed in 2007-10-19] Conference: Health and Migration in the EU: Better health for all in an inclusive society – Lisbon: 200710 Direcção-Geral de Saúde. Programa Nacional de Prevenção e 27Controlo das Doenças Cardiovasculares. Despacho n.o Bosworth HB, Dudley T, Olsen MK, et al. Racial differences in16415/2003, DR, II Série, de 22 de Agosto., page 12. blood pressure control: potential explanatory factors. Am J Med.[http://www.dgs.pt/, accessed in 2007-10-19] 2006;119(1):709-71511 28 Direcção-Geral de Saúde. Programa Nacional de Prevenção e Kramer H, Han C, Post W, et al. 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Therapeutic inertia is an impediment to achieving Mar;12(2):225-35the Healthy People 2010 blood pressure control goals.Hypertension. 2006 Mar;47(3):345-51 36 Grol R, Wensing M, Mainz J, Ferreira P, Hearnshaw H,20 Hjortdahl P, Olesen F, Ribacke M, Spenser T, Szécsényi J. O’Connor P. Overcome Clinical Inertia to Control Systolic Patients priorities with respect to general practice care: anBlood Pressure. Arch Intern Med 2003; 163:2677-8 international comparison. European Task Force on Patient21 Evaluations of General Practice (EUROPEP). Fam Pract. 1999 Fine LJ, Cutler JA. Hypertension and the Treating Physician: Feb;16(1):4-11.Understanding and Reducing Therapeutic Inertia.Hypertension2006 47: 319-320 37 Horne R, Weinman J. Patients beliefs about prescribed22 medicines and their role in adherence to treatment in chronic Phillips LS, Branch WT, Cook CB, Doyle JP, El-Kebbi IM, physical illness. J Psychosom Res. 1999 Dec;47(6):555-67.Gallina DL, Miller CD, Ziemer DC, Barnes CS. Clinical inertia.Ann Intern Med. 2001 Nov 6;135(9):825-34 38 Weinman J, Petrie KJ, Moss-Morris R, Horne R. The Illness23 Perception Questionnaire: A new method for assessing illness ESH-ESC Task Force on the Management of Arterial perceptions. Psychology and HElath. 2006; 11: 431-446.Hypertension. 2007 ESH-ESC Practice Guidelines for theManagement of Arterial Hypertension. J Hypertension 2007; 39 SW Rausdenbush, AS Bryk (2002) Hierarchical linear models.25:1751–1762 Applications and data analysis methods. - Advanced Quantitative24 Techniques in the Social Sciences Series. SAGE publications. O’Connor PJ. Overcome Clinical Inertia to Control SystolicBlood Pressure – editorial. Arch Intern Med 2003;163:2677-2678 40 Carreira M, Alarcão M, Abukumail N, Portugal R. Nível de25 Saúde e Acesso aos Cuidados de Saúde nas Comunidades O’Connor PJ, Sperl-Hillen JM, Johnson PE, Rush WA, Blitz G. Imigrantes de Origem Africana e Brazileira. Conferência “Saúde,Clinical inertia and outpatient medical errors. Advances in Patient Migrações e Desenvolvimento”. Fundação Calouste Gulbenkian,Safety. 2005;2:293–308. in Lisboa, Setembro de 2007.www.ahrq.gov/downloads/pub/advances/vol2/OConnor.pdf[accessed 41 Machado MC, Santana AP, Carreiro MH, Nogueira H, Barrosowww.ahrq.gov/downloads/pub/advances/vol2/OConnor.pdf, MR, Dias A. Iguais ou diferentes? Cuidados de saúde materno-Acedido em 26 de Março de 2008] infantil a uma população de imigrantes, Laboratórios BIAL, Lisboa, 2007. 23

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