Faculty Bibliography

BACKGROUND:Non-adherence to medications is common and leads to suboptimal outcomes. Non-adherence can be intentional (e.g., deciding to skip dosages) or unintentional (e.g., forgetting), yet few studies have distinguished these reasons. An improved understanding of the reasons for non-adherence could inform the development of effective interventions. METHODS AND RESULTS/RESULTS:We analyzed data from African Americans in the Jackson Heart Study who were prescribed medications for one or more chronic conditions. Participants were grouped by patient-reported adherence with non-adherence categorized as being intentional, unintentional or both. We used modified Poisson regression models to examine the factors associated with types of non-adherence. Of 2933 participants taking medication, 2138 (72.9%) reported non-adherence with 754 (35.3%) reporting only unintentional non-adherence, 263 (12.3%) only intentional non-adherence, and 1121 (52.4%) both. Factors independently associated with intentional non-adherence included female sex and depressive symptoms while factors associated with unintentional non-adherence included younger age and separated relationship status. Unintentional and intentional non-adherence was more common among participants taking anti-arrhythmic and anti-asthmatic medications, respectively. Higher levels of global perceived stress was associated with both types of non-adherence. The adjusted models for intentional and unintentional non-adherence had c-statistics of 0.65 and 0.66, respectively, indicating modest discrimination. CONCLUSION/CONCLUSIONS:Specific patient factors and individual medication classes were associated with distinct patterns of intentional and unintentional non-adherence, yet the overall modest discrimination of the models suggests contributions from other unmeasured factors. These findings provide a construct for understanding reasons for non-adherence and provide rationale to assess whether personalized interventions can improve adherence.

BACKGROUND AND PURPOSE/OBJECTIVE:Epilepsy is a chronic neurological disease that represents a tremendous burden on both patients and society in general. Studies have addressed how demographic variables, socioeconomic variables, and psychological comorbidity are related to the quality of life (QOL) of people with epilepsy (PWE). However, there has been less focus on how these factors may differ between patients who exhibit varying degrees of seizure control. This study utilized data from the Managing Epilepsy Well (MEW) Network of the Centers for Disease Control and Prevention with the aim of elucidating differences in demographic variables, depression, and QOL between adult PWE. METHODS:Demographic variables, depression, and QOL were compared between PWE who experience clinically relevant differences in seizure occurrence. RESULTS:Gender, ethnicity, race, education, income, and relationship status did not differ significantly between the seizure-frequency categories (p>0.05). People with worse seizure control were significantly younger (p=0.039), more depressed (as assessed using the Patient Health Questionnaire) (p=0.036), and had lower QOL (as determined using the 10-item Quality of Life in Epilepsy for Adults scale) (p<0.001). CONCLUSIONS:The present results underscore the importance of early screening, detection, and treatment of depression, since these factors relate to both seizure occurrence and QOL in PWE.

It is unclear whether black patients with chronic kidney disease (CKD) vs those without CKD who take antihypertensive medication have an increased risk for apparent treatment-resistant hypertension (aTRH). The authors analyzed 1741 Jackson Heart Study participants without aTRH taking antihypertensive medication at baseline. aTRH was defined as uncontrolled blood pressure while taking three antihypertensive medication classes or taking four or more antihypertensive medication classes, regardless of blood pressure level. CKD was defined as an albumin to creatinine ratio >/=30 mg/g or estimated glomerular filtration rate <60 mL/min/1.73 m2 . Over 8 years, 20.1% of participants without CKD and 30.5% with CKD developed aTRH. The multivariable-adjusted hazard ratio for aTRH comparing participants with CKD vs those without CKD was 1.45 (95% CI, 1.12-1.86). Participants with an albumin to creatinine ratio >/=30 vs <30 mg/g (hazard ratio, 1.44; 95% CI, 1.04-2.00) and estimated glomerular filtration rate of 45 to 59 mL/min/1.73 m2 and <45 vs >/=60mL/min/1.73 m2 (hazard ratio, 1.60 [95% CI, 1.16-2.20] and 2.05 [95% CI, 1.28-3.26], respectively) were more likely to develop aTRH.

The purpose of this study was to test the association between a self-report measure of 24-hour adherence to antihypertensive medication and blood pressure (BP) among African Americans. The primary analysis included 3558 Jackson Heart Study participants taking antihypertensive medication who had adherence data for at least one study examination. Nonadherence was defined by self-report of not taking one or more prescribed antihypertensive medications, identified during pill bottle review, in the past 24 hours. Nonadherence and clinic BP were assessed at Exam 1 (2000-2004), Exam 2 (2005-2008), and Exam 3 (2009-2013). Associations of nonadherence with clinic BP and uncontrolled BP (systolic BP >/= 140 mm Hg or diastolic BP >/= 90 mm Hg) were evaluated using unadjusted and adjusted linear and Poisson repeated measures regression models. The prevalence of nonadherence to antihypertensive medications was 25.4% at Exam 1, 28.7% at Exam 2, and 28.5% at Exam 3. Nonadherence was associated with higher systolic BP (3.38 mm Hg) and diastolic BP (1.47 mm Hg) in fully adjusted repeated measures analysis. Nonadherence was also associated with uncontrolled BP (prevalence ratio = 1.26; 95% confidence interval = 1.16-1.37). This new self-report measure may be useful for identifying nonadherence to antihypertensive medication in future epidemiologic studies.

Background -Data from before the 2000s indicate the majority of incident cardiovascular disease (CVD) events occur among US adults with systolic and diastolic blood pressure (SBP/DBP)>/=140/90 mmHg. Over the past several decades, BP declined and hypertension control has improved. Methods -We estimated the percentage of incident CVD events that occur at SBP/DBP<140/90 mmHg in a pooled analysis of three contemporary US cohorts: the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, the Multi-Ethnic Study of Atherosclerosis (MESA), and the Jackson Heart Study (JHS) (n=31,856; REGARDS=21,208; MESA=6,779; JHS=3,869). Baseline study visits were conducted in 2003-2007 for REGARDS, 2000-2002 for MESA, and 2000-2004 for JHS. BP was measured by trained staff using standardized methods. Antihypertensive medication use was self-reported. The primary outcome was incident CVD, defined by the first occurrence of fatal or non-fatal stroke, non-fatal myocardial infarction, fatal coronary heart disease, or heart failure. Events were adjudicated in each study. Results -Over a mean follow-up of 7.7 years, 2,584 participants had incident CVD events. Overall, 63.0% (95%CI: 54.9%-71.1%) of events occurred in participants with SBP/DBP<140/90 mmHg; 58.4% (95%CI: 47.7%-69.2%) and 68.1% (95%CI: 60.1%-76.0%) among those taking and not taking antihypertensive medication, respectively. The majority of events occurred in participants with SBP/DBP<140/90 mmHg among those <65 years (66.7%; 95%CI: 60.5%-73.0%) and >/=65 years (60.3%; 95%CI: 51.0%-69.5%), women (61.4%; 95%CI: 49.9%-72.9%) and men (63.8%; 95%CI: 58.4%-69.1%), and for whites (68.7%; 95%CI: 66.1%-71.3%), blacks (59.0%; 95%CI: 49.5%-68.6%), Hispanics (52.7% 95%CI: 45.1%-60.4%) and Chinese-Americans (58.5%; 95%CI: 45.2%-71.8%). Among participants taking antihypertensive medication with SBP/DBP<140/90 mmHg, 76.6% (95% CI: 75.8%-77.5%) were eligible for statin treatment but only 33.2% (95%CI: 32.1%-34.3%) were taking one and 19.5% (95%CI: 18.5%-20.5%) met the Systolic Blood Pressure Intervention Trial eligibility criteria and may benefit from a SBP target goal of 120 mmHg. Conclusions -While higher BP levels are associated with increased CVD risk, in the modern era, the majority of incident CVD events occur in US adults with SBP/DBP<140/90 mmHg. Although absolute risk and cost-effectiveness should be considered, additional CVD risk reduction measures for adults with SBP/DBP<140/90 mmHg at high risk for CVD may be warranted.

Several modifiable health behaviors and health factors that comprise the Life's Simple 7-a cardiovascular health metric-have been associated with hypertension risk. We determined the association between cardiovascular health and incident hypertension in JHS (the Jackson Heart Study)-a cohort of blacks. We analyzed participants without hypertension or cardiovascular disease at baseline (2000-2004) who attended >/=1 follow-up visit in 2005 to 2008 or 2009 to 2012 (n=1878). Body mass index, physical activity, diet, cigarette smoking, blood pressure (BP), total cholesterol, and fasting glucose were assessed at baseline and categorized as ideal, intermediate, or poor using the American Heart Association's Life's Simple 7 definitions. Incident hypertension was defined at the first visit wherein a participant had systolic BP >/=140 mm Hg, diastolic BP >/=90 mm Hg, or self-reported taking antihypertensive medication. The percentage of participants with