Improving prescribing: a feasibility study of pharmacogenetic testing with clinical decision support in primary healthcare in Singapore.

BACKGROUND: The study of genetic variation as a factor influencing drug safety, efficacy, and effectiveness has brought about significant breakthroughs in understanding the clinical application of gene-drug interactions to better manage drug therapy. OBJECTIVE: This study was designed to assess the feasibility of collecting buccal samples by general practitioners (GPs) at private practices in Singapore within a usual consultation, incorporating use of a pharmacogenetics-based medical decision support system to guide subsequent drug dosing. METHODS: We used a prospective cohort study design, with GPs recruiting 189 patients between October 2020 and March 2021. The genotypes of 51 biallelic SNPs were determined using Illumina Infinium Global Screening Array. RESULTS: Seven GPs from 6 private practices recruited and obtained buccal samples from a total of 189 patients. All patients had at least one actionable variant. The prevalence of patients having 2, 3, or 4 variants was 37.0%, 32.8%, and 12.7%, respectively. Potential alterations to medications were identified using the Clinical Decision Support System. Patients were accepting and the GPs were enthusiastic about the potential of pharmacogenetics to personalize medicine for their patients. CONCLUSION: This is the first study in Singapore to demonstrate the feasibility of pharmacogenetic testing in primary care. The high prevalence of genetic variants underscores the potential use of pharmacogenetics in this setting.

Determining the communicable period of SARS-CoV-2: A rapid review of the literature, March to September 2020.

IntroductionStandard testing for infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is based on RT-PCR tests, but detection of viral genetic material alone does not indicate ongoing infectious potential. The ability to isolate whole virus represents a better proxy for infectivity.AimThe objective of this study was to gain an understanding of the current literature and compare the reported periods of positive SARS-CoV-2 detection from studies that conducted RT-PCR testing in addition to experiments isolating whole virus.MethodsUsing a rapid review approach, studies reporting empirical data on the duration of positive RT-PCR results and/or successful viral isolation following SARS-CoV-2 infection in humans were identified through searches of peer-reviewed and pre-print health sciences literature. Articles were screened for relevance, then data were extracted, analysed, and synthesised.ResultsOf the 160 studies included for qualitative analysis, 84% (n = 135) investigated duration of positive RT-PCR tests only, 5% (n = 8) investigated duration of successful viral isolations, while 11% (n = 17) included measurements on both. There was significant heterogeneity in reported data. There was a prolonged time to viral clearance when deduced from RT-PCR tests compared with viral isolations (median: 26 vs 9 days).DiscussionFindings from this review support a minimum 10-day period of isolation but certain cases where virus was isolated after 10 days were identified. Given the extended time to viral clearance from RT-PCR tests, future research should ensure standard reporting of RT-PCR protocols and results to help inform testing policies aimed at clearance from isolation.

Pharmacogenetics in primary care.

The use of pharmacogenetic information is becoming mainstream with insurance companies and others starting to pay for widescale implementation of this new technology starting with patients who have anxiety and depression. It has been introduced in response to the unpredictability of medication, the high number of adverse drug events, and lack of drug effectiveness. Greater than one-third of patients are identified as having one or more pharmacogenetic variants. Each pharmacogenetic variant may affect the metabolism of several medications used in primary care, in addition to the antidepressant and anti-anxiolytic medications. Pharmacogenetic information is evolving with major international working groups providing continuous updates. It is challenging to incorporate this new information along with all the other variables needed to identify safe and effective drug options within a normal consultation. Medication decision support software is one solution that can help address this.

A systematic review of evidence for older adults' sedentary behavior and physical activity after hip fracture.

OBJECTIVE: To synthesize evidence on older adults' sedentary behavior and physical activity during rehabilitation and recovery for hip fracture (1) across the care continuum and (2) from clinical interventions. DESIGN: We conducted a systematic review of peer-reviewed publications using CINAHL, Embase, Ovid MEDLINE, PsycINFO, and SportDiscus (last search: 17 October 2017). STUDY SELECTION: We included studies that measured sedentary behavior and physical activity of older adults with hip fracture using activity monitors (e.g. accelerometers). We identified literature at Level 1 (title and abstract) and Level 2 (full text), and conducted forward and backward searches. We assessed observational studies' adherence to reporting guidelines and intervention studies' risk of bias. RESULTS: We included 14 studies (882 participants). Four studies reported sedentary behavior data, while all studies reported information on physical activity. Settings included hospital, rehabilitation centers, and the community. Nine studies were observational; five were experimental design. Older adults had excessive sedentary time (>10 hours/day) and low physical activity. Participants' average upright time differed across settings. During hospital stay, it ranged 16-52 minutes/day, while in the community, it ranged 51-261 minutes/day. Data from five interventions reported on physical activity change: two studies increased between 14 and 27 minutes/day. Another study reported participants accumulated 6994 steps/day at the end of the intervention, but for two other interventions, activity was below 5000 steps/day. CONCLUSION: Based on available evidence, older adults with hip fracture engage in prolonged sedentary behavior and have low levels of physical activity during rehabilitation and recovery.

Attending to power differentials: How NP-led group medical visits can influence the management of chronic conditions.

OBJECTIVE: In Canada, primary care reform has encouraged innovations, including nurse practitioners (NPs) and group medical visits (GMVs). NP-led GMVs provide an opportunity to examine barriers and enablers to implementing this innovation in primary care. DESIGN: An instrumental case study design (n=3): two cases where NPs were using GMVs and one case where NPs were not using GMVs, was completed. In-depth interviews with patients and providers (N=24) and 10 hours of direct observation were completed. Interpretive descriptive methods were used to analyse data. RESULTS/FINDINGS: Two main themes were identified: (i) acquisition of knowledge and (ii) GMVs help shift relationships between patients and health-care providers. Participants discussed how patients and providers learn from one another to facilitate self-management of chronic conditions. They also discussed how the GMV shifts inherent power differentials between providers and between patients and providers. DISCUSSION: NP-led GMVs are a method of care delivery that harness NPs' professional agency through increased leadership and interprofessional collaboration. GMVs also facilitate an environment that is patient-centred and interprofessional, providing patients with increased confidence to manage their chronic conditions. The GMV provides the opportunity to meet both team-based and patient-centred health-care objectives and may disrupt inherent power differentials that exist in primary care.

How do family physicians measure blood pressure in routine clinical practice? National survey of Canadian family physicians.

OBJECTIVE: To describe the techniques currently used by family physicians in Canada to measure blood pressure (BP) for screening for, diagnosing, and treating hypertension. DESIGN: A Web-based cross-sectional survey distributed by e-mail. SETTING: Stratified random sample of family physicians in Canada. PARTICIPANTS: Family physician members of the College of Family Physicians of Canada with valid e-mail addresses. MAIN OUTCOME MEASURES: Physicians' self-reported routine methods for recording BP in their practices to screen for, diagnose, and manage hypertension. RESULTS: A total of 774 valid responses were received, for a response rate of 16.2%. Respondents were similar to nonrespondents except for underrepresentation of male physicians. Of 769 respondents, 417 (54.2%) indicated that they used manual office BP measurement with a mercury or aneroid device and stethoscope as the routine method to screen patients for high BP, while 42.9% (330 of 769) reported using automated office BP (AOBP) measurement. The method most frequently used to make a diagnosis of hypertension was AOBP measurement (31.1%, 240 of 771), followed by home BP measurement (22.4%, 173 of 771) and manual office BP measurement (21.4%, 165 of 771). Ambulatory BP monitoring (ABPM) was used for diagnosis by 14.4% (111 of 771) of respondents. The most frequently reported method for ongoing management was home BP monitoring (68.7%, 528 of 769), followed by manual office BP measurement (63.6%, 489 of 769) and AOBP measurement (59.2%, 455 of 769). More than three-quarters (77.8%, 598 of 769) of respondents indicated that ABPM was readily available for their patients. CONCLUSION: Canadian family physicians exhibit overall high use of electronic devices for BP measurement, However, more efforts are needed to encourage practitioners to follow current Canadian guidelines, which advocate the use of AOBP measurement for hypertension screening, ABPM and home BP measurement for making a diagnosis, and both AOBP and home BP monitoring for ongoing management.

Complexities of Introducing Group Medical Visits With Nurse Practitioners in British Columbia.

In Canada, increasing numbers of people with chronic conditions have prompted calls for innovative approaches to delivering primary care. These approaches may include group medical visits (GMVs) and the introduction of nurse practitioners (NPs). We examined why NPs in the province of British Columbia were not using GMVs. This case study is part of a larger research project that examined the impact of GMVs with NPs for patients with chronic conditions. We completed open-ended interviews with seven NPs working in primary care. Interviews were audiotaped and transcribed. Data were analyzed using interpretive descriptive approaches. Three major themes emerged: (a) advantages of GMVs, (b) questioning the fit of GMVs in current practice contexts, and (c) navigating scope of practice and role constraints that affect NPs' ability to use GMVs. Power dynamics and hierarchies may influence NPs' ability to adapt to GMVs. Consideration of practice environments and structures that enable the NPs ability to diffuse and utilize health-care innovative care delivery methods is needed.

Genotype-guided drug prescribing: a systematic review and meta-analysis of randomized control trials.

AIM: Adverse drug events lead to increased morbidity, mortality and health care costs. Pharmacogenetic testing that guides drug prescribing has the potential to reduced adverse drug events and increase drug effectiveness. Our aim was to quantify the clinical effectiveness of genotype-guided prescribing. METHODS: Three electronic databases were searched from January 1980 through December 2013. Studies were eligible if they were RCTs comparing genotype-guided prescribing with non-genetic informed prescribing, reported drug specific adverse drug events and clinical effectiveness outcomes. Two reviewers independently screened titles and abstracts, extracted data and assessed study quality. Meta-analyses of specific outcomes were conducted where data allowed. RESULTS: Fifteen studies, involving 5688 patients and 19 drugs, met the inclusion and exclusion criteria. Eight studies had statistically significant results for their primary outcome in favour of genotype-guided prescribing. Nine studies evaluated genotype-guided warfarin dosing. Analysis of percentage of time in therapeutic international normalized ratio range (1952 individuals) showed a statistically significant benefit in favour of genotype-guided warfarin dosing (mean difference = 6.67; 95% CI 1.34, 12.0, I(2) = 80%). There was a statistically significant reduction in numbers of warfarin-related minor bleeding, major bleeding and thromboembolisms associated with genotype guided warfarin dosing, relative risk 0.57 (95% CI 0.33, 0.99; I(2) = 60%). It was not possible to meta-analyze genotype-guided dosing for other drugs. Of the six non-warfarin genotype-guided trials, two demonstrated a statistically significant benefit for their primary outcome, odds ratio 0.03 (95% CI 0.00, 0.62, P < 0.001) for abacavir. CONCLUSIONS: There is evidence of improved clinical effectiveness associated with genotype-guided warfarin dosing.

MEthods of ASsessing blood pressUre: identifying thReshold and target valuEs (MeasureBP): a review & study protocol.

Despite progress in automated blood pressure measurement (BPM) technology, there is limited research linking hard outcomes to automated office BPM (OBPM) treatment targets and thresholds. Equivalences for automated BPM devices have been estimated from approximations of standardized manual measurements of 140/90 mmHg. Until outcome-driven targets and thresholds become available for automated measurement methods, deriving evidence-based equivalences between automated methods and standardized manual OBPM is the next best solution. The MeasureBP study group was initiated by the Canadian Hypertension Education Program to close this critical knowledge gap. MeasureBP aims to define evidence-based equivalent values between standardized manual OBPM and automated BPM methods by synthesizing available evidence using a systematic review and individual subject-level data meta-analyses. This manuscript provides a review of the literature and MeasureBP study protocol. These results will lay the evidenced-based foundation to resolve uncertainties within blood pressure guidelines which, in turn, will improve the management of hypertension.

Diagnosing hypertension: Evidence supporting the 2015 recommendations of the Canadian Hypertension Education Program.

OBJECTIVE: To highlight the 2015 Canadian Hypertension Education Program (CHEP) recommendations for the diagnosis and assessment of hypertension. QUALITY OF EVIDENCE: A systematic search was performed current to August 2014 by a Cochrane Collaboration librarian using the MEDLINE and PubMed databases. The search results were critically appraised by the CHEP subcommittee on blood pressure (BP) measurement and diagnosis, and evidence-based recommendations were presented to the CHEP Central Review Committee for independent review and grading. Finally, the findings and recommendations were presented to the Recommendations Task Force for discussion, debate, approval, and voting. The main recommendations are based on level II evidence. MAIN MESSAGE: Based on the most recent evidence, CHEP has made 4 recommendations in 2 broad categories for 2015 to improve BP measurement and the way hypertension is diagnosed. A strong recommendation is made to use electronic BP measurement in the office setting to replace auscultatory BP measurement. For patients with elevated office readings, CHEP is recommending early use of out-of-office BP measurement, preferably ambulatory BP measurement, in order to identify early in the process those patients with white-coat hypertension. CONCLUSION: Improvements in diagnostic accuracy are critical to optimizing hypertension management in Canada. The annual updates provided by CHEP ensure that practitioners have up-to-date evidence-based information to inform practice.

Development of a survey instrument to investigate the primary care factors related to differences in cancer diagnosis between international jurisdictions.

BACKGROUND: Survival rates following a diagnosis of cancer vary between countries. The International Cancer Benchmarking Partnership (ICBP), a collaboration between six countries with primary care led health services, was set up in 2009 to investigate the causes of these differences. Module 3 of this collaboration hypothesised that an association exists between the readiness of primary care physicians (PCP) to investigate for cancer - the 'threshold' risk level at which they investigate or refer to a specialist for consideration of possible cancer - and survival for that cancer (lung, colorectal and ovarian). We describe the development of an international survey instrument to test this hypothesis. METHODS: The work was led by an academic steering group in England. They agreed that an online survey was the most pragmatic way of identifying differences between the jurisdictions. Research questions were identified through clinical experience and expert knowledge of the relevant literature.A survey comprising a set of direct questions and five clinical scenarios was developed to investigate the hypothesis. The survey content was discussed and refined concurrently and repeatedly with international partners. The survey was validated using an iterative process in England. Following validation the survey was adapted to be relevant to the health systems operating in other jurisdictions and translated into Danish, Norwegian and Swedish, and into Canadian and Australian English. RESULTS: This work has produced a survey with face, content and cross cultural validity that will be circulated in all six countries. It could also form a benchmark for similar surveys in countries with similar health care systems. CONCLUSIONS: The vignettes could also be used as educational resources. This study is likely to impact on healthcare policy and practice in participating countries.

Automated office blood pressure measurement in primary care.

OBJECTIVE: To provide FPs with detailed knowledge of automated office blood pressure (AOBP) measurement, its potential role in primary care, and its proper use in the diagnosis and management of hypertension. SOURCES OF INFORMATION: Comprehensive monitoring and collection of scientific articles on AOBP by the authors since its introduction. MAIN MESSAGE: Automated office blood pressure measurement maintains a role for blood pressure (BP) readings taken in the office setting. Clinical research studies have reported a substantially stronger relationship between awake ambulatory BP measurement and AOBP measurement compared with manual BP recorded during routine visits to the patient's physician. Automated office blood pressure measurement produces mean BP values comparable to awake ambulatory BP and home BP values. Compared with routine manual office BP measurement, AOBP correlates more strongly with awake ambulatory BP measurement, shows less digit preference, is more consistent from visit to visit, is similar both within and outside of the physician's office, virtually eliminates office-induced hypertension, and is associated with less masked hypertension. It is estimated that more than 25% of Canadian primary care physicians are now using AOBP measurement in their office practices. The use of AOBP to diagnose hypertension has been recommended by the Canadian Hypertension Education Program since 2010. CONCLUSION: There is now sufficient evidence to incorporate AOBP measurement into primary care as an alternative to manual BP measurement.

Screening for lifestyle and mental health risk factors in the waiting room: feasibility study of the Case-finding Health Assessment Tool.

OBJECTIVE: To assess the feasibility and acceptability of administering the validated Case-finding Health Assessment Tool (CHAT) in Canadian family practice waiting rooms to identify risk factors for depression, anxiety, anger control,smoking, drinking, other drug use, gambling, exposure to abuse, and physical inactivity. DESIGN: Cross-sectional survey. SETTING: One urban academic family practice and one inner-city community health centre in British Columbia. PARTICIPANTS: Convenience sample of consecutive adult patients (19 years of age or older) and their attending family physicians. MAIN OUTCOME MEASURES: Rates of completion; positive responses to and wanting help with identified lifestyle and mental health risk factors; rates of objections to any questions; and positive and negative comments about the CHAT by participating physicians and patients. RESULTS: A total of 265 eligible adults presented in the waiting rooms over 5 full days and 3 half-days, 176 (66%) of whom enrolled in the study; 161(91%) completed the CHAT, and 107 (66%) completed acceptability feedback forms. The prevalence of risk factors among patients in the academic and inner-city practice samples was different, with 20% and 63%, respectively,recording positive responses to both depression screening questions,34% and 60% positive for anxiety, 11% and 71% currently smoking, 6%and 22% feeling they needed to cut down on alcohol, 1% and 48% having used recreational drugs in the past year, and 11% and 65% with problems controlling anger. While many requested help with reducing risk factors,such as smoking (20%) and mental health symptoms (25% to 27%), a total of 35% (57 of 161) wanted help with an identified issue that day. Patients and physicians found the CHAT acceptable, with no patients objecting to any question except the alcohol question (2 objected). Most comments were positive. CONCLUSION: The CHAT allowed efficient identification of 9 risk factors, as well as identification of those wanting help. It could be used to screen all or targeted adult Canadian primary care patients in waiting rooms.

Home Blood Pressure Telemonitoring Technology for Patients With Asymptomatic Elevated Blood Pressure Discharged From the Emergency Department: Pilot Study.

BACKGROUND: Hypertension affects 1 in 5 Canadians and is the leading cause of morbidity and mortality globally. Hypertension control is declining due to multiple factors including lack of access to primary care. Consequently, patients with hypertension frequently visit the emergency department (ED) due to high blood pressure (BP). Telehealth for Emergency-Community Continuity of Care Connectivity via Home-Telemonitoring Blood Pressure is a pilot project that implements and evaluates a comprehensive home blood pressure telemonitoring (HBPT) and physician case management protocol designed as a postdischarge management strategy to support patients with asymptomatic elevated BP as they transition from the ED to home. OBJECTIVE: Our objective was to conduct a feasibility study of an HBPT program for patients with asymptomatic elevated BP discharged from the ED. METHODS: Patients discharged from an urban, tertiary care hospital ED with asymptomatic elevated BP were recruited in Vancouver, British Columbia, Canada, and provided with HBPT technology for 3 months of monitoring post discharge and referred to specialist hypertension clinics. Participants monitored their BP twice in the morning and evenings and tele-transmitted readings via Bluetooth Sensor each day using an app. A monitoring clinician received these data and monitored the patient's condition daily and adjusted antihypertensive medications. Feasibility outcomes included eligibility, recruitment, adherence to monitoring, and retention rates. Secondary outcomes included proportion of those who were defined as having hypertension post-ED visits, changes in mean BP, overall BP control, medication adherence, changes to antihypertensive medications, quality of life, and end user experience at 3 months. RESULTS: A total of 46 multiethnic patients (mean age 63, SD 17 years, 69%, n=32 women) found to have severe hypertension (mean 191, SD 23/mean 100, SD 14 mm Hg) in the ED were recruited, initiated on HBPT with hypertension specialist physician referral and followed up for 3 months. Eligibility and recruitment rates were 40% (56/139) and 88% (49/56), respectively. The proportion of participants that completed ≥80% of home BP measurements at 1 and 3 months were 67% (31/46) and 41% (19/46), respectively. The proportion of individuals who achieved home systolic BP and diastolic BP control at 3 months was 71.4% (30/42) and 85.7% (36/42) respectively. Mean home systolic and diastolic BP improved by -13/-5 mm Hg after initiation of HBPT to the end of the study. Patients were prescribed 1 additional antihypertensive medication. No differences in medication adherence from enrollment to 3 months were noted. Most patients (76%, 25/33) were highly satisfied with the HBPT program and 76% (25/33) found digital health tools easy to use. CONCLUSIONS: HBPT intervention is a feasible postdischarge management strategy and can be beneficial in supporting patients with asymptomatic elevated BP from the ED. A randomized trial is underway to evaluate the efficacy of this intervention on BP control.

Health of China's rural-urban migrants and their families: a review of literature from 2000 to 2012.

BACKGROUND: Socioeconomic transformation in China at the beginning of the twenty-first century has led to rapid urbanization and accelerated rural-urban migration. As a result, the concerns about public health problems triggered by increasing internal population mobility have been more widely studied in recent years. SOURCES OF DATA: Published data in Chinese and English on health of migrants and their families in mainland China from 2000 to 2012. AREAS OF AGREEMENT: The shifting patterns of disease distribution due to rural-urban migration, health equity and health reform strategies that cater for this specific yet substantial subpopulation are outstanding concerns. Infectious diseases, mental health, occupational health and women's health are emerging public health priorities related to migration. AREAS OF CONTROVERSY: The high mobility and large numbers of Chinese rural-urban migrants pose challenges to research methods and the reliability of evidence gained. GROWING POINTS: While the theme of working migrants is common in the literature, there have also been some studies of health of those left behind but who often remain unregistered. Migration within China is not a single entity and understanding the dynamics of new and emerging societies will need further study. AREAS TIMELY FOR DEVELOPING RESEARCH: Social, economic, emotional, environmental and behavioural risk factors that impact on health of migrants and their families call for more attention from health policy-makers and researchers in contemporary China.

Effectiveness of group medical visits for improving diabetes care: a systematic review and meta-analysis.

BACKGROUND: Group medical visits, whereby health care professionals meet with groups of patients who have the same disease, have been introduced in primary care as a way to meet the increasing demand for health care delivery to patients with chronic diseases. We performed a systematic review and meta-analysis of the evidence on the effectiveness of such visits for patients with diabetes. METHODS: We conducted a systematic review of all relevant studies published from 1947 to February 2012 identified in a search of electronic databases and grey literature. We included randomized controlled trials (RCTs) and observational studies published in English that included patients aged 16-80 years with type 1 or 2 diabetes and that had group medical visits as the intervention. These studies were assessed for methodologic quality. We included data only from the RCTs in the meta-analysis. RESULTS: Of the 94 studies identified, we selected 26 that met our inclusion criteria, 13 of which were RCTs. Group medical visits had a positive effect on clinical and patient-reported outcomes, with significant reductions in glycated hemoglobin (HbA1c reduction -0.46%, 95% confidence interval -0.80% to -0.31%). We were unable to assess the effect of group medical visits on processes of care because of an insufficient number of RCTs that reported on this outcome. INTERPRETATION: Group medical visits for patients with diabetes were found to be effective in terms of reducing HbA1c. The results of our meta-analysis suggest that wider implementation of group medical visits for patients with diabetes will have a positive effect on patient outcomes.

Effectiveness of disseminating consensus management recommendations for ulcer bleeding: a cluster randomized trial.

BACKGROUND: International guidelines for the management of nonvariceal upper gastrointestinal bleeding have not been widely adopted in clinical practice. We sought to determine whether a national, multifaceted intervention could improve adherence to guidelines, especially for patients at high risk of nonvariceal upper gastrointestinal bleeding. METHODS: In this randomized trial, we stratified hospitals by region and size and allocated sites to either the control or experimental group. Health care workers in the experimental group were given published guidelines, generic algorithms, stratification scoring systems and written reminders and attended multidisciplinary guideline education groups and case-based workshops. These interventions were implemented over a 12-month period after randomization, with performance feedback and benchmarking. The primary outcome of adherence rates to key guidelines in endoscopic and pharmacologic management, determined by chart review, was adjusted according to site characteristics and possible within-site dependencies. We also report the rates of adherence to other recommendations. RESULTS: Forty-three sites were randomized to the experimental (n=21) or control (n=22) groups. In our primary analysis, we compared patients before (experimental group: n=402 patients; control group: n=424 patients) and after (experimental group: n=361 patients; control group: n=389 patients) intervention. Patient-level analysis revealed no significant difference in adherence rates to the guidelines after the intervention (experimental group: 9.8%; control group: 4.8%; p=0.99) after adjustment for the rate of adherence before the intervention (experimental group: 13.2%; control group: 7.1%). The adherence rates to other guidelines were similar and decreased over time, varying between 5% and 93%. INTERPRETATION: This national knowledge translation-based trial suggests poor adherence to guidelines on nonvariceal upper gastrointestinal bleeding. Adherence was not improved by an educational intervention, which highlights both the complexity and poor predictability of attempting to alter the behaviour of health care providers (Trial registration: ClinicalTrials.gov, no. MCT-88113).