Hypertensive Patient Compliance with Pharmacist Intervention: A Systematic Review

Background: Pharmacists and physicians can work together to improve patient compliance especially for the management of hypertension. Medication adherence leads to advance health and reduces hospitalizations (morbidity), death (mortality) and healthcare costs. Objectives: Involvement of pharmacist in treatment intervention can result in improved understanding about hypertension and it can increase medication adherence to antihypertensive therapy which ultimately advance overall quality of life. Study design and methods: A comprehensive research study was conducted using two eminent databases i.e. PUBMED and EMBASE. The research articles from 1996 to 2015 were analyzed. All the selected articles were about pharmacist intervention, hypertensive patient compliance and hypertension medication adherence. Results: Some studies show no control in BP; however, there was significant difference in the systolic and diastolic BP pre and post pharmacist intervention (Systolic from 158.1±14.4 to 143.8 ± 10.7, Diastolic from 100.6 ±11.5 to 89.8 ± 9.7). Conversely, in some studies BP was controlled in about 29.9% of control group and in 63% of the intervention group. Systematic Review Alshahrani et al.; JPRI, 33(39B): 85-97, 2021; Article no.JPRI.71895 86 Conclusion: Results showed many methods can improve medication adherence and blood pressure including counseling patients in person, collaboration between pharmacists and physicians, and using technology like telecommunication to intensify patients counseling. Pharmacist intervention can significantly increase disease-related knowledge, blood pressure control and medication adherence in patients with hypertension.


INTRODUCTION
Hypertension is a non-communicable chronic disease frequently asymptomatic or sometimes with minor symptoms [1]. When there is no obvious underlying cause of hypertension it can be classified as essential hypertension, secondary hypertension, Cushing syndrome and malignant hypertension [2].
Hypertension disease is the major risk factor for cardiovascular disease and affects approximately 20% of adults in North America [3]. Hypertension is defined as blood pressure at 140/90 mmHg or greater. In the United States, 29% of the population, 85.4 million individuals have been diagnosed with hypertension [4].
Hypertension is a well-known risk factor for many chronic diseases including cardiocerebrovascular, metabolic and kidney diseases and a leading risk factor for mortality due to these complications [5].
Due to poor medication adherence and compliance to current therapeutic guidelines, hypertension is poorly managed [6].
Pharmacists can play an important role in helping patients with hypertension to manage their condition. Helping as a partner and instructor, pharmacists can provide medication therapy management services and can educate patients about Hypertension [7].
Pathophysiologicaly, hypertension can be stated in terms of systolic blood pressure, which replicates the blood pressure when the heart is contracted (systole), and diastolic blood pressure, which replicates the blood pressure during relaxation (diastole). Hypertension can be diagnosed when whichever systolic pressure, diastolic pressure, or both are elevated New guidelines issued by the National Committee on Prevention, Detection, Evaluation, and Treatment of Blood Pressure (JNC 7) encourage health providers to help those who have uncontrolled blood pressure. Moreover, guidelines have been issued by American Diabetes Association (ADA) and World Health Organization-International Society of Hypertension (WHO-ISH) that emphasize the need to control blood pressure [9]. Complications, such as renal failure [10], myocardial infarction, heart failure and stroke, can occur as a result of uncontrolled hypertension. [11] A study was conducted where the pharmacist and the physician worked together to improve patient compliance especially for patients diagnosed with hypertension and showed that there was a significant improvement from baselines of the mean BP [12][13][14].
Furthermore, medication adherence leads to improved health and reduced hospitalizations (morbidity), death (mortality), and the healthcare costs. Addressing factors that positively affect medications adherence for hypertension patients is very important to reduce the burden of hypertension disease and other diseases that may be caused by hypertensions such as chronic kidney diseases [15].

Information Sources
A comprehensive research study has been conducted by using two databases; PUBMED and EMBASE (1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015). Search terms that had been used in PUBMED were "pharmacist intervention" and "hypertensive patient compliance" and using MeSH terms to do the advanced research for each term and then combined them by using AND coin to include the two terms in the research. After that, searching on EMBASE was performed by using "hypertension medication adherence" and to narrow the research, it was joined to pharmacist intervention and the language that has been used was the English for both databases.

Inclusion Criteria
The inclusion criteria are hypertensive patients with other comorbidities, including cardiovascular diseases, kidney diseases or diabetes mellitus Pharmacist intervention was defined as counseling the patients in person using technology (telecommunications, emails, etc.).
Blood pressure is the primary outcome.

Data Collection & Study Selection
The abstracts with titles were reviewed to determine if the article met predetermined inclusion criteria (see Fig. 1). Some of them were eliminated if they did not include an intervention where the pharmacist interacted with patients to improve high blood pressure and medication adherence/compliance as outcomes.

Study Selection
Based on the eligibility criteria and removing the duplicate citations a total of 60 articles were diabetes mellitus. Pharmacist intervention was defined as counseling the patients in person or technology (telecommunications, emails, ).
Blood pressure is the primary

Study Selection
The abstracts with titles were reviewed to determine if the article met predetermined 1). Some of them were eliminated if they did not include an intervention where the pharmacist interacted with patients to d pressure and medication adherence/compliance as outcomes.
MeSH Hypertension patient MeSH Pharmacist intervention MeSH hypertension patient compliance Text word: hypertension medication intervention

Fig. 1. Process for Eligible Articles
Based on the eligibility criteria and removing the duplicate citations a total of 60 articles were found (see Fig. 1). Then, titles and abstracts were examined and 17 were selected for full text review. There were 10 articles that showed a statistical significant in reducing the blood pressure. Six articles were identified that mentioned a significant improvement in medication adherence. Finally, a one article showed both a statistically significant improvement in blood pressure and medication adherence. Table 1 provides a summary of 17 studie met the eligible criteria that mentioned above. These studies differ from one another according to the sample size, sample population, study design, duration, studies sites, and intervention and control groups description. Sample size in 17 studies ranged from forty to five hundred and eighty-four patients. The length of duration was from one month and eleven days to thirty months. Regarding to the sites, places of studies, there were six international studies. Randomized control trials were the most common study design [8,9,3,18,21]. Other study designs included case control study [2], qausi experimental study with a control group [10], prospective and controlled design randomized cross-over design [7,20], nonrandomized retrospective comparison [17]. All studies focused on adult patients who are over 55 years. Table 2 shows the medications adherence and blood pressure levels in all studies at the baselines and at the end of each study. There are fluctuations and wide range of mean baselines of blood pressure and medications adherence according to various study design. For most of them, to detect medication adherence, qualitative methods like interviewers or self reported surveys were used to determine whether the patient was more adher pharmacist and physician instructions for medications adherence.

Study Characteristics & Results of Individual Studies
Physical measuring blood pressure as a directly to detect blood pressure included in [8,3,17,19]. However, indirect methods like self-report using a questionnaire or Morisky method to medication adherence along with measuring blood pressure was also used [21].
; Article no.JPRI.71895 found (see Fig. 1). Then, titles and abstracts were examined and 17 were selected for full text review. There were 10 articles that showed a statistical significant in reducing the blood pressure. Six articles were identified that improvement in medication adherence. Finally, a one article showed both a statistically significant improvement in blood pressure and medication Table 1 provides a summary of 17 studies that met the eligible criteria that mentioned above. These studies differ from one another according to the sample size, sample population, study design, duration, studies sites, and intervention and control groups description. Sample size in 17 ranged from forty to five hundred and four patients. The length of duration was from one month and eleven days to thirty-six months. Regarding to the sites, places of studies, there were six international studies. Randomized most common study design [8,9,3,18,21]. Other study designs included case control study [2], qausiexperimental study with a control group [10], prospective and controlled design [19], nonover design [7,20], mparison [17]. All studies focused on adult patients who are Table 2 shows the medications adherence and blood pressure levels in all studies at the baselines and at the end of each study. There are fluctuations and wide range of mean lines of blood pressure and medications adherence according to various study design. For most of them, to detect medication adherence, qualitative methods like interviewers or self reported surveys were used to determine whether the patient was more adherent to pharmacist and physician instructions for medications adherence.

Study Characteristics & Results of
Physical measuring blood pressure as a directly to detect blood pressure included in [8,3,17,19]. However, report using a questionnaire or Morisky method to detect the medication adherence along with measuring blood pressure was also used [21].