New insights into the role primary care providers (PCPs) play in their patient's likeliness of medication adherence and into the use of ambulatory blood pressure (ABP) and office blood pressure (OBP) for predicting the risk of cardiovascular events come from two recently published studies. Both studies highlight the necessity for cardiovascular team members to look at the full picture of patient care to ensure better long-term outcomes.

Results from an observational research study published in Circulation: Cardiovascular Quality and Outcomes found that the less PCPs centered discussions on the patient, addressed social-demographic circumstances or antihypertensive medications, the more likely patients with hypertension were to exhibit poor medication adherence. Antoinette Schoenthaler, EDD, et al., analyzed 92 patients and 27 providers in three safety-net primary care practices across New York, NY. After audiotaping clinic visits and analyzing them using the Medical Interaction Process System, the researchers collected follow-up data using an electronic monitoring device for three months. Patients were also asked to keep diaries.

Majority of patients were black, women and seeing the same PCP for a minimum of one year, while most PCPs were white, women and had been practicing for nearly six years. The mean age was 60 years for patients and 36 years for PCPs.

On average, clinic visits lasted 25 minutes (range, 8-52 minutes). Of the 37,257 total utterances audiotaped, slightly more were spoken by PCPS than patients (54 percent vs. 46 percent). Half of the PCP utterances and 82 percent of patient utterances focused on giving the other person information. Asking open-ended questions made up only 1 percent of PCP utterances and only 3 percent of patient utterances.

A three-fold increase in the risk for poor medication adherence was noted among those whose interactions were characterized by lower patient centeredness, a focus on biomedical issues and more PCP directedness. The odds were six-fold higher when social-demographic circumstances or antihypertensive medication regimens were not fully addressed. The researchers note several reasons for the potential association between social-demographic circumstances and medical adherence. They suggest "that such discussion signals to the patient genuine caring and concern by the provider, which strengthens [a] patient's ability to cope with their life and illness, along with motivation and confidence related to self-management of their disease."

Most affected by a lack in social-demographic dialogue was black patients, who saw an eight-fold increase in poor medical adherence when their providers did not inquire about these circumstances. "The interaction with race suggests an intriguing possibility that this expression of caring might be particularly important for Black patients where social distance is great," write the authors.

Schoenthaler and colleagues recommend improving patient-centered communication training for both medical students and practicing providers. "Encouraging trainees and primary care providers to ask about patients' social circumstances represents a potential means for improving adherence and for identifying adherence barriers...," they state. A total population health impact "will require a new system of care delivery that integrates effective screening and referral for patient's unmet social needs into standard practice."

A study led by Rikke Nørmark Mortensen, PhD, et al., and published in the European Heart Journal analyzed data from 12 general population studies. They found that ABP and OBP provided similar predictive value for 10-year person-specific absolute risk of fatal and non-fatal cardiovascular events. Blood pressure taken at night did not show any improvement in predicting risk over daytime measurements.

Researchers used the International Database on Ambulatory Blood Pressure Monitoring in Relation to Cardiovascular Outcomes to gather follow-up information on 7,927 participants from six cohorts: Copenhagen, Denmark (n = 2,097); Ohasama, Japan (n = 1,310); Noorderkempen, Belgium (n = 1,425); Uppsala, Sweden (n = 1,091); Montevideo, Uruguay (n = 1,443) and Maracaibo, Venezuela (n = 561).

OBP measurements were taken with a standard mercury sphygmomanometer or automatic device, whereas ABP measurements were recorded by portable blood pressure monitors. Night-time was defined as midnight to 6 a.m. in all cohorts except Ohasama (10 p.m. to 4 a.m.).

During the 10-year follow-up period (median period 9-17 years), 563 patients died from cardiovascular events, 758 patients died from non-cardiovascular events and 1,173 were diagnosed with a fatal or non-fatal cardiovascular event. For 90 percent of the patient population, the 10-year predicted risk based on ambulatory risk changed by less than 2.5 percent.

"To understand the discrepancy with the current study it is important to note that the studies reporting superiority of ambulatory [blood pressure] BP and night-time BP did only evaluate statistical significance of hazard ratios and not accuracy of long-term person-specific predictions," state the authors. "The results of the current study have implications for requirements to ambulatory BP monitoring. For the purpose of screening an otherwise healthy population sufficient accuracy can be achieved with office BP."

Keywords: Blood Pressure Monitoring, Ambulatory, Antihypertensive Agents, Blood Pressure, Medication Adherence, Mercury, Motivation, Self Care, Empathy, Research Personnel, Students, Medical, Psychological Distance, Sweden, Uruguay, Venezuela, Follow-Up Studies, Japan, New York, Belgium, Blood Pressure Monitors, Hypertension, European Continental Ancestry Group, African Americans, Blood Pressure Determination, Primary Health Care, Ambulatory Care, Demography, Referral and Consultation, Denmark

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