• No results found

PP 19: Adults who commence pharmacotherapy should have their medication adjusted as required and response assessed regularly (approximately 6-12 weekly) until sufficient improvement has been achieved or maximum tolerated

3.2 Patient adherence

Failure to take prescribed medication is a major barrier to optimal prevention of CVD, however the literature concerning interventions to improve adherence to medications remains surprisingly weak. One Cochrane review involving 78 trials found only modest effects for interventions to improve adherence to medications across a range of populations and settings. Conflicting evidence for short-term interventions on compliance was found and very few studies reported changes in patient outcomes.313 Almost all of the interventions that were effective for long-term compliance were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counselling, family therapy, psychological therapy, crisis intervention, telephone follow-up and sfollow-upportive care.

One recent Cochrane review (72 trials) assessed different interventions to improve BP control in hypertensive adults in a primary care, outpatient or community setting.314 Organisational interventions (nine trials) to enable regular review in tandem with a rigorous stepped-care approach to antihypertensive drug treatment were found to be the

most effective, but this finding was dominated by findings from a single large trial – the Hypertension Detection and Follow-Up study. Self-monitoring (18 trials) was associated with a reduction in SBP (2.5 mmHg) and DBP (1.8 mmHg) and may be a useful adjunct strategy. Other interventions assessed in this systematic review did not produce clear results. Educational interventions directed at physicians (10 trials) did not change BP control, but education for patients (20 trials) may have a modest effect although heterogeneity was noted. Use of health care professionals such as nurses and pharmacists (12 trials) demonstrated generally favourable but heterogeneous results. Lastly, reminders (postal, computer or telephone) improved follow-up and control of patients, but produced heterogeneous results in terms of BP reduction.

Another Cochrane review (38 trials) specific to BP-lowering therapy in an ambulatory setting suggested that simplifying dosing regimens was the most consistently effective intervention (seven out of nine studies).

Motivational strategies (e.g. financial incentives or reminder packages/aids) and complex interventions involving

more than one technique were less consistent. Effects were generally modest and patient education alone was largely ineffective.315 Further, in a systematic review of 11 trials investigating the effects of home BP monitoring on medication adherence, six of the 11 trials reported a statistically significant improvement in medication

adherence; 84% of these were complex interventions using home BP monitoring in combination with other adherence-enhancing strategies such as patient counselling by nurses, pharmacists or telephone-linked systems, patient education and the use of timed medication reminders.316 Two

moderate quality reviews of simplifying doses by using fixed-dose combinations to improve adherence for raised BP reported improved compliance with combination treatment (24% decrease risk of non-compliance in one review).317, 318 Another systematic review (11 trials) found strategies for patient re-enforcement and reminding (e.g. telephone reminders or pharmacist review) to have the most consistent benefits in improving adherence for lipid-lowering therapy (four of six trials were positive with absolute improvement in adherence of 6–24%).319 Other strategies found to increase adherence, included simplification of the drug regimen (11% improvement) and patient information and education (13% improvement), although results were inconsistent and the quality of some studies was low. One high-quality systematic review (21 trials) in people with type 2 diabetes failed to find clear benefits for various strategies including nurse-led interventions, home aids, diabetes education, pharmacy led interventions, adaptation of dosing and frequency of medication taking.320 The evidence is difficult to interpret due to heterogeneity; however overall there seems to be a modest improvement in adherence from the more complex interventions.

The guidelines development process was coordinated by the National Stroke Foundation on behalf of the National Vascular Disease Prevention Alliance (NVDPA) with partner agencies represented on the advisory and/or expert working group committees as appropriate. The guidelines have been developed according to the processes outlined in the document NHMRC Standards and Procedures for Externally Developed Guidelines (2007).

Project Committees

Three groups were established in the development of the guidelines.

Advisory Committee

The Advisory Committee had 17 representatives from a wide range of backgrounds including diabetes,

nephrology, stroke, cardiology, Indigenous health, general practice, economics, a consumer and the Pharmaceutical Benefits Advisory Committee (PBAC). The Committee was responsible for:

• overseeing operational aspects of the guidelines development

• determining the topics and questions to be addressed in the guidelines

• advising on a plan for communication, dissemination and implementation

• assisting the EWG as needed (particularly in regard to responding to consultation where significant difference in opinion exists)

• developing recommendations for periodically updating the guidelines

• regular reporting to the full committee of the NVDPA.

Members of the Advisory Committee included:

Dr Erin Lalor (Chair) Chief Executive Officer, National Stroke Foundation Chair of NVDPA

Dr Andrew Boyden (until February 2011) National Director-Clinical Issues,

National Heart Foundation Dr Dominique Cadilhac Head, Public Health Division, National Stroke Research Institute Professor Stephen Colagiuri Diabetologist,

Boden Institute of Obesity, Nutrition, Exercise and Eating Disorders,

The University of Sydney

Professor Jennifer Doust (PBAC representative until August 2010)

Epidemiology and Public Health, Bond University

Ms Dianne Fraser

Assistant Director, Chronic Disease Branch, Department of Health and Ageing

Professor Mark Harris (RACGP representative) General Practitioner,

Centre for Primary Health Care and Equity, The University of New South Wales

Dr Nancy Huang (until March 2010) National Manager Clinical Programs, National Heart Foundation

Appendix 1:

Guidelines development groups and terms of reference

Professor David Johnson Nephrologist,

Princess Alexandra Hospital and University of Queensland

Professor Greg Johnson (from November 2010) Chief Executive Officer,

Diabetes Australia – Victoria

Dr Nadia Lusis (NACCHO representative) Public Health Medical Officer,

Victorian Aboriginal Community Controlled Health Organisation (VACCHO)

Associate Professor Timothy Mathew National Medical Director,

Kidney Health Australia

Mr Noel Muller (Consumer Health Forum representative) Consumer

Dr Rashmi Sharma (PBAC representative from December 2010)

General Practitioner,

Isabella Plains Medical Centre, ACT

Associate Professor Jonathan Shaw (Baker IDI guideline development group representative)

Associate Director,

Baker IDI Heart and Diabetes Institute Dr Ian White (until December 2010) National Policy Manager,

Diabetes Australia

Ms Jinty Wilson (from March 2011) National Manager Clinical Programs, National Heart Foundation

Expert Working Group

The EWG had 12 members including endocrinologists, cardiologists, nephrologists, general practitioners,

geriatricians, a consumer and a PBAC representative. The EWG was responsible for:

• assisting as required with the appraisal and grading of identified research

• using the evidence base to develop the guidelines recommendations

• assisting with the drafting of the guidelines document

• linking with members of the corresponding group where relevant

• assisting with the consultation process

• assisting with the response to feedback gained during the consultation process.

The NVDPA is grateful to the members of the EWG who provided their time and expertise to develop these guidelines.

Members of the EWG included:

Professor Stephen Colagiuri (Chair) Diabetologist,

Boden Institute of Obesity, Nutrition, Exercise and Eating Disorders,

The University of Sydney Professor Andrew Tonkin

Cardiologist, Cardiovascular Research Unit, Monash University

Professor Leonard Arnolda Cardiologist,

Canberra Hospital and Australian National University Professor Alex Brown Indigenous Health,

Executive Director and Margaret Ross Chair of Indigenous Health,

Baker IDI Central Australia Professor Terry Campbell, AM Cardiologist (PBAC representative), University of New South Wales Professor Derek Chew

Cardiologist,

Dr David Dunbabin

Stroke Specialist/Geriatrician, Royal Hobart Hospital and University of Tasmania Professor Mark Harris General Practitioner,

Centre for Primary Health Care and Equity, University of New South Wales

Professor David Johnson Nephrologist,

Princess Alexandra Hospital and University of Queensland

Mr Richard McCluskey Consumer representative Professor Mark Nelson General Practitioner,

Menzies Research Institute of Tasmania, University of Tasmania

Associate Professor David Sullivan Clinical Biochemistry,

Royal Prince Alfred Hospital and University of Sydney

Corresponding Group

The Corresponding Group had 22 members with wide representation across all of the previously identified groups and also broad representation across the lifestyle issues such as smoking, physical activity, nutrition, depression and alcohol. This group was responsible for:

• assisting as required with the appraisal and grading of identified research

• assisting with the drafting of the guidelines document (including recommendations)

• linking with members of the EWG where relevant

• assisting with the consultation process

• assisting with the response to feedback gained during the consultation process.

The NVDPA wishes to thank the members of the

Corresponding Group for their input to the development of the guidelines.

Members of the Corresponding Group included:

Professor Philip Barter Lipid management, University of Sydney Professor Adrian Bauman

Behavioural Epidemiology and Health Promotion, University of Sydney

Dr Dominique Cadilhac Head, Public Health Division, National Stroke Research Institute Professor David Clarke

Psychology, Beyondblue, Monash University Professor Peter Clifton Nutrition,

Australian Atherosclerosis Society Dr Emil Djakic

General Practitioner,

Australian General Practice Network Dr Martin Gallagher

Nephrologist,

Caring for Australians with Renal Impairment Dr Melina Gattellari

Public Health,

Stroke Society of Australasia Associate Professor Timothy Gill Public health nutrition,

National Heart Foundation Professor Leonard Kritharides Cardiologist,

Concord Hospital and The University of Sydney Dr Alasdair MacDonald General practitioner,

Internal Medicine Society of Australia and New Zealand Associate Professor Arduino Mangoni

Cardiologist, Flinders University

Professor Manny Noakes Nutrition,

CSIRO

Professor Caryl Nowson Nutrition,

Deakin University

Associate Professor Anushka Patel Cardiologist,

The George Institute for Global Health Ms Adriana Platona

The Australian Government, Department of Health and Ageing Professor Vlado Perkovic

Nephrologist,

The George Institute for Global Health Professor Prasuna Reddy

Psychologist, Deakin University Professor Jo Salmon Nutrition,

Deakin University

Associate Professor Markus Schlaich Renal Physician,

High Blood Pressure Research Council of Australia Dr Lynn Weekes

Pharmaceutical,

National Prescribing Service Associate Professor Margarite Vale Nutrition,

Cardiac Society of Australia and New Zealand

Editorial Independence

The EWG was responsible for the content of the guidelines with independence from the funding source. A DOHA representative formed part of the Advisory Committee to oversee the process of the guidelines development.

Conflict of Interest

A policy regarding disclosure and management of potential conflicts of interest (COI) was implemented. All Advisory Committee and EWG members completed COI forms and a COI register was maintained and updated regularly.

COI were managed in the following manner:

• Open disclosure of all COI to all members of the committee and public declaration of all COI in guidelines

• If the COI is deemed significant, individuals may be restricted from involvement in discussions and decisions on related topics. This is determined by the chair of the relevant committee and has occurred once

• If the COI is considered exclusionary, the individual will be excluded from membership of the relevant committee or from employment in the guidelines team. This will be determined by the chair of the relevant committee and the CEO of the NSF, the lead agency for this project.

This level of COI has been experienced and the relevant member resigned from the committee.

A copy of the Conflict of Interest Policy can be supplied on request.

National Stroke Foundation Guidelines Project Team

Ms Ruth Friedman

Senior Project Manager, CVD Guidelines, National Stroke Foundation

Mr Kelvin Hill

Manager, Guidelines Program, National Stroke Foundation Ms Diana Reddan

Senior Administration Assistant, National Stroke Foundation

External Consultants

medScript Mr Brad Dalton Medical writer

International Centre for Allied Health Evidence (iCAHE) University of South Australia

Dr Susan Hillier

Systematic Review Lead Kylie Johnson

Evidence Review

Janine Dizon, Valentin Dones, Karly Hayman, Jonathan Ucinek

Data Extraction Alexandra Young Database Searching

Centre for Burden of Disease and Cost Effectiveness University of Queensland

Professor Theo Vos

Health Economic Modelling Project Lead Dr Linda Cobiac

Health Economic Modelling Deakin Health Economics

Strategic Research Centre - Population Health Deakin University

Professor Rob Carter Health Economic Modelling Ms Anne Magnus

Health Economics Literature Synthesis