Jurisdictional Guidance on DOAC Use-Will It Affect Practice? A Comparison of European, American, and Canadian Product Monographs.

Objective: To identify clinically relevant areas of concordance and discordance between product monographs for 4 direct oral anticoagulants (DOACs) approved by regulatory authorities in Europe, the United States, and Canada. Data Sources: For each DOAC (apixaban, dabigatran, edoxaban, rivaroxaban), manufacturer product monographs were retrieved from the European Medicines Database, US Food and Drug Administration, and Health Canada Drug Product Database. Data Extraction: Monographs for each DOAC were independently reviewed by 2 investigators to identify areas of concordance and discordance. Discordance existed if it was deemed that a potentially clinically relevant difference existed. A heat map summarizing the data was created to identify areas of complete concordance, partial concordance (concordance between 2 of 3 monographs), and complete discordance. Data Synthesis: The areas of concordance were indications for use, use in extremes of weight, and switching to/from the DOAC. Areas of discordance included the following: differing recommendations for use/dosing with renal dysfunction; contraindication or use with caution with drug interactions, pregnancy, and hepatic/renal dysfunction; and timing of DOAC with spinal/epidural anesthesia after a procedure or traumatic puncture. Relevance to Patient Care and Clinical Practice: Concordance was most evident for uncomplicated patients with atrial fibrillation or venous thromboembolism, whereas discordance emerged for those having characteristics/factors wherein clinicians may seek clarification within product monographs (eg, impaired renal/hepatic function, drug interactions). As such, clinicians must be familiar with product information within their country of practice. Conclusion: Variability between jurisdictions was evident, and variability of DOAC use is likely to increase with expanding worldwide uptake.

Use of low-dose acetylsalicylic acid for cardiovascular disease prevention: A practical, stepwise approach for pharmacists.

Low-dose acetylsalicylic acid (ASA) is recommended in patients with established cardiovascular disease. However, the role of ASA in those without cardiovascular disease (i.e., primary prevention) is less clear, which has led to discordance among Canadian guidelines. In 2018, 3 double-blind, randomized controlled trials were published that evaluated ASA 100 mg daily versus placebo in patients without established cardiovascular disease. In the ASPREE trial, ASA did not reduce the risk of all-cause death, dementia, or persistent physical disability in patients ≥70 years of age but increased the risk of major bleeding. In the ARRIVE trial, ASA failed to lower the risk of a composite of cardiovascular events but increased any gastrointestinal bleeding in patients at intermediate risk of cardiovascular disease. In the ASCEND trial, ASA significantly reduced the primary composite cardiovascular outcome in patients with diabetes for a number needed to treat of 91 over approximately 7.4 years. Yet major bleeding was increased with ASA for a number needed to harm of 112. Therefore, in most situations, ASA should not be recommended for primary cardiovascular prevention. However, there are additional indications for ASA beyond cardiovascular disease. Thus, a sequential algorithm was developed based on contemporary evidence to help pharmacists determine the suitability of ASA in their patients and play an active role in educating their patients about the potential benefits (or lack thereof) and risks of ASA. Can Pharm J (Ott) 2020;153:xx-xx.

Development of clinical pharmacy key performance indicators for hospital pharmacists using a modified Delphi approach.

BACKGROUND: Key performance indicators (KPIs) are quantifiable measures of quality. There are no published, systematically derived clinical pharmacy KPIs (cpKPIs). OBJECTIVE: A group of hospital pharmacists aimed to develop national cpKPIs to advance clinical pharmacy practice and improve patient care. METHODS: A cpKPI working group established a cpKPI definition, 8 evidence-derived cpKPI critical activity areas, 26 candidate cpKPIs, and 11 cpKPI ideal attributes in addition to 1 overall consensus criterion. Twenty-six clinical pharmacists and hospital pharmacy leaders participated in an internet-based 3-round modified Delphi survey. Panelists rated 26 candidate cpKPIs using 11 cpKPI ideal attributes and 1 overall consensus criterion on a 9-point Likert scale. A meeting was facilitated between rounds 2 and 3 to debate the merits and wording of candidate cpKPIs. Consensus was reached if 75% or more of panelists assigned a score of 7 to 9 on the consensus criterion during the third Delphi round. RESULTS: All panelists completed the 3 Delphi rounds, and 25/26 (96%) attended the meeting. Eight candidate cpKPIs met the consensus definition: (1) performing admission medication reconciliation (including best-possible medication history), (2) participating in interprofessional patient care rounds, (3) completing pharmaceutical care plans, (4) resolving drug therapy problems, (5) providing in-person disease and medication education to patients, (6) providing discharge patient medication education, (7) performing discharge medication reconciliation, and (8) providing bundled, proactive direct patient care activities. CONCLUSIONS: A Delphi panel of hospital pharmacists was successful in determining 8 consensus cpKPIs. Measurement and assessment of these cpKPIs will serve to advance clinical pharmacy practice and improve patient care.

Anticoagulation Interventions by Pharmacists in Acute Care.

Background: Clinical pharmacy key performance indicators (cpKPIs) relate to activities performed by pharmacists that have been shown to improve patient outcomes. Within Saskatchewan Health Authority (SHA) Regina, most cpKPIs are incorporated into the organization's clinical practice standards, which provide guidance in prioritizing care, especially for high-risk medications, including anticoagulants. To track pharmacists' interventions associated with clinical practice standards, a locally developed electronic data-capture system (known as AIM High) was implemented. Objectives: To quantify and describe pharmacists' anticoagulation interventions on 16 wards with dedicated ward-based clinical pharmacists and to compare intervention rates between the cardiology and internal medicine wards to further evolve the organization's practice model. Methods: Data from the electronic data-capture system were retrospectively analyzed for a 5-year period (January 2016 to December 2020). Results: A total of 94 201 interventions were recorded in the AIM High system (average 362 interventions per week or 26 interventions per pharmacist per week). Of these, 15 661 (16.6%) cited the anticoagulation standard (average 60 anticoagulation interventions per week or 4 anticoagulant interventions per pharmacist per week). For the cardiology and internal medicine wards, 4183 of 11 888 (35.2%) and 9034 of 54 843 (16.5%) interventions cited the anticoagulation standard, respectively. The top 4 types of anticoagulation interventions were dose changed (n = 4372 or 27.9%), drug started or restarted (n = 3867 or 24.7%), patient education (n = 3094 or 19.8%), and drug discontinued (n = 2944 or 18.8%). Conclusion: Dedicated ward-based clinical pharmacists were following clinical practice standards incorporating the majority of cpKPIs to complete anticoagulation interventions. The types of anticoagulation interventions evolved over time and were influenced by the patient population.

Contexte: Les indicateurs clés de performance en pharmacie clinique (ICPEPC) se rapportent à des activités exécutées par des pharmaciens qui ont fait leurs preuves dans l'amélioration des résultats pour les patients. À la Saskatchewan Health Authority (SHA) Regina, la plupart des ICPEPC sont intégrés aux normes de pratique clinique de l'organisme. Celles-ci fournissent des conseils pour hiérarchiser les soins liés aux médicaments, en particulier ceux associés aux médicaments à haut risque, notamment les anticoagulants. Un système électronique de saisie de données développé localement, le « AIM High ¼, a été mis en place afin de suivre les interventions des pharmaciens associées aux normes de pratique clinique. Objectifs: Quantifier et décrire les interventions des pharmaciens en matière d'anticoagulation dans 16 services avec des pharmaciens cliniciens dédiés et comparer les taux d'intervention entre les services de cardiologie et de médecine interne en vue de faire évoluer davantage le modèle de pratique de l'organisation. Méthodes: Les données du système électronique de saisie des données ont été analysées rétrospectivement sur une période de 5 ans (de janvier 2016 à décembre 2020). Résultats: Au total, 94 201 interventions ont été enregistrées dans le système (moyenne de 362 interventions par semaine ou 26 interventions par pharmacien par semaine). Parmi celles-ci, 15 661 (16,6 %) citent la norme d'anticoagulation (moyenne de 60 interventions d'anticoagulation par semaine ­ soit 4 interventions d'anticoagulation par pharmacien par semaine). Pour les services de cardiologie et de médecine interne, 4183 (35,2%) des 11 888 et 9034 (16,5 %) des 54 843 interventions citent respectivement la norme d'anticoagulation. Les 4 principaux types d'interventions d'anticoagulation étaient le changement de dose (n = 4372 ou 27,9 %), le traitement commencé ou redémarré (n = 3867 ou 24,7 %), l'éducation du patient (n = 3094 ou 19,8 %) et l'arrêt du médicament (n = 2944 ou 18,8 %). Conclusion: Les pharmaciens cliniques dédiés au service suivaient les normes de pratique clinique incorporant la majorité des ICPEPC pour mener à bien les interventions d'anticoagulation. Les types d'interventions d'anticoagulation ont évolué au fil du temps et ont été influencés par la population de patients.

Prevention and treatment of venous thromboembolism in patients with cancer.

BACKGROUND: Many patients who experience a venous thromboembolic event have cancer, and thrombosis is much more prevalent in patients with cancer than in those without it. Thrombosis is the second most common cause of death in cancer patients and cancer is associated with a high rate of recurrence of venous thromboembolism (VTE), bleeding, requirement for long-term anticoagulation and poorer quality of life. METHODS: A literature review was conducted to identify guidelines and evidence pertaining to anticoagulation prophylaxis and treatment for patients with cancer, with the goal of identifying opportunities for pharmacists to advocate for and become more involved in the care of this population. RESULTS: Many clinical trials and several guidelines providing guidance to clinicians in the treatment and prevention of VTE in patients with cancer were identified. Current clinical evidence and guidelines suggest that cancer patients receiving care in hospital with no contraindications should receive VTE prophylaxis with unfractionated heparin (UFH), a low-molecular-weight heparin (LMWH) or fondaparinux. Patients who require surgery for their cancer should receive prophylaxis with UFH, LMWH or fondaparinux. Cancer patients who have experienced a VTE event should receive prolonged anticoagulant therapy with LMWH (at least 3 months to 6 months). No routine prophylaxis is required for the majority of ambulatory patients with cancer who have not experienced a VTE event. Most publicly funded drug plans in Canada have developed criteria for funding of LMWH therapy for patients with cancer. CONCLUSIONS: Evidence suggests that LMWH for 3 to 6 months is the preferred strategy for most cancer patients who have experienced a thromboembolic event and for hospital inpatients, but this is often not implemented in practice. Concerns about adherence with injectable therapy should not prevent use of these agents. Pharmacists should assess cancer patients for their risk of VTE and should advocate for optimal VTE pharmacotherapy as appropriate. If LMWH is the preferred agent, on the basis of the evidence, the pharmacist should educate the patients appropriately and work with the prescriber to ensure best care.

Use of Direct Oral Anticoagulants Versus Traditional Therapies for Acute Venous Thromboembolism After Direct Discharge From the Emergency Department or After Hospitalization: An Audit of 16 Canadian Hospitals.

PURPOSE: This study compares and describes the use of direct oral anticoagulants (DOACs) versus traditional therapies (parenteral anticoagulant with or without warfarin) for acute venous thromboembolism (VTE) between individuals discharged directly from the emergency department (ED) versus those hospitalized. This study also reports patterns based on discharge from an academic, community, or rural-based site. METHODS: This retrospective medical records study included patients discharged with acute VTE (2015-2016) from 16 institutions across 4 provinces. Patients with atypical clots, other indications for anticoagulants, or an anticipated lifespan <3 months or those who were pregnant or breastfeeding were excluded. FINDINGS: Overall, 590 individuals (30.0%) discharged from the ED and 809 (53.8%) discharged after hospitalization were studied. Hospitalized patients were significantly older, had more comorbidities (cancer, pulmonary disease, and heart failure), and were more likely to have pulmonary embolism than deep vein thrombosis. DOAC use was significantly higher in the ED cohort versus the hospitalized cohort (51.4% vs 44.3%; P < 0.004) and more common for those having lower risk of pulmonary embolisms (simplified Pulmonary Embolism Severity Index score of 0 compared with ≥1) in the ED (58.0% and 26.5%; P < 0.0001) and hospitalized cohorts (57.1% and 35.7%; P < 0.0001). Use of DOACs was lowest in academic settings (46.2%) and highest in rural sites (56.7%). Follow-up patterns were different, with specialists and VTE clinics being most common in academic sites and family physicians being most common in rural practices. IMPLICATIONS: DOACs were used in less than half of all patients, with more use in EDs and rural sites. Follow-up patterns (VTE clinic or specialist vs family physician) varied and likely contributed to therapy selection. Over time, use of DOACs is likely to increase, and patient factors (eg, those younger with fewer comorbidities) and health care contact (eg, place of discharge or availability of an ambulatory VTE clinic) will likely continue to influence practice patterns.

Retrospective observational assessment of statin adherence among subjects patronizing different types of community pharmacies in Canada.

BACKGROUND: Community pharmacies vary widely in terms of ownership structures, location, and dispensing policies. It is unknown if an association exists between the type of community pharmacy and the degree of medication adherence exhibited by patrons-patients. OBJECTIVE: To describe adherence to statin therapy among subjects patronizing different types of community pharmacy categories (department- mass merchandise, chain-franchise, and independent-banner) in Saskatchewan, Canada, between 2000 and 2005. METHODS: Study data were obtained from the Saskatchewan Drug Plan and Extended Benefits database, which is maintained by the government of Saskatchewan, Canada. The study included all subjects who (a) filled a statin prescription within selected community pharmacies between January 1, 2000, and December 31, 2005; (b) had no record of statin prescriptions during the year prior to the first statin prescription, according to the records of the Saskatchewan Drug Plan and Extended Benefits; and (c) demonstrated active utilization in the drug plan database for at least 1 year after the first statin prescription. The proxy criterion for activity was any dispensing record for statin or nonstatin medications at least 1 year following the index claim. Statin adherence level was estimated as tablets per day, defined as the total number of tablets dispensed divided by the total number of days of observation. Each subject's observation period began on the index date and ended on the earlier of (a) 30 days after the last recorded fill for any type of prescription medication (statin or nonstatin), or (b) December 31, 2005. The primary end point was the proportion of subjects within each pharmacy category who maintained an adherence level of 80% or greater during their individual observation period. Additional adherence calculations were performed for each of 3 time periods, beginning on the index date and ending on days 365, 729, and 1094 (i.e., 1, 2, and 3 years). Patients were included in the analysis for each time period if they met a proxy criterion for availability for observation, defined as the dispensing of any drug at least 1 day after the end date of each period. Pearson chi square tests were used to assess the significance of differences in baseline characteristics and adherence proportions, comparing pharmacy categories. Logistic regression analysis estimated the odds of an adherence level of at least 80% during the individual observation period, adjusting for pharmacy category, sex, age 65 years or older, known low-income drug coverage, number of distinct drug classes filled concurrently during the first year of observation, loyalty to index pharmacy, and length of observation. Using similar methods, we also estimated "pharmacy loyalty" by calculating the proportion of subjects who refilled 75% or more of their statin prescriptions at the pharmacy that dispensed their first statin prescription. RESULTS: From an initial sample of 12,818 subjects who had at least 1 pharmacy claim for a statin in the period from January 1, 2000, through December 31, 2005, 8699 subjects met the inclusion criteria. Subjects were observed for a mean (SD, range) of 3.7 (1.7, 1.0-7.0) years after the index statin prescription. During the first year following the index claim, statin adherence rates were at least 80% for 1799 of 3761 (47.8%) patrons of department-mass merchandise, 1778 of 3235 (55.0%) patrons of chain-franchise, and 921 of 1703 (54.1%) patrons of independent-banner stores (P < 0.001). Measured from the index date through day 1094, 869 of 2292 (37.9%), 874 of 1887 (46.3%), and 457 of 975 (46.9%) subjects in the department-mass merchandise, chain-franchise, and independent banner categories, respectively, had a statin adherence level of at least 80% (P < 0.001). In logistic regression analysis, pharmacy category type was significantly associated with statin adherence; subjects in the chain franchise and independent-banner categories were more likely to be adherent to their statin medications during their observation periods than were those in the department-mass merchandise category (adjusted odds ratio [OR] = 1.36, 95% CI = 1.23-1.50, P < 0.001 and OR = 1.39, 95% CI = 1.24-1.57, P < 0.001, respectively). From the index date through day 1094, 1752 of 2292 (76.4%), 1475 of 1887 (78.2%), and 795 of 975 (81.5%) subjects remained pharmacy-loyal in the department-mass merchandise, chain franchise, and independent-banner categories, respectively (P = 0.006). Controlling for several potential confounders using logistic regression, independent-banner pharmacy patrons were more likely to remain pharmacy- loyal during their observation periods than were those patronizing department-mass merchandise (adjusted OR = 1.34, 95% CI = 1.16-1.54, P < 0.001) or chain-franchise stores (adjusted OR = 1.22, 95% CI = 1.06-1.42, P = 0.009). CONCLUSION: One year after their first statin fill, subjects demonstrated low rates of adherence, ranging from 48% to 55%, regardless of the type of pharmacy they patronized. Although the differences by type of pharmacy reached statistical significance, their clinical importance is not evident, reinforcing the fact that the problem of nonadherence appears to exist among all types of community pharmacies, regardless of their categorization.

Measuring Competency of Pharmacy Residents: A Survey of Residency Programs' Methods for Assessment and Evaluation.

BACKGROUND: The Canadian Pharmacy Residency Board (CPRB) specifies the competencies that pharmacy residents must attain and the need for assessment and evaluation. Methods of assessment and evaluation are left to the discretion of individual programs. There is a scarcity of published literature compiling and comparing the strategies used by Canadian residency programs. OBJECTIVES: To determine curricular components used for assessment and evaluation; to describe the tools used by programs; to characterize the scheduling, frequency, and repetition of curricular components; and to determine the individuals or groups involved. METHODS: Coordinators of hospital pharmacy residency programs with CPRB accreditation or accreditation pending were surveyed to collect information about the assessment and evaluation of select CPRB standards. RESULTS: From the 37 eligible residency programs, 20 unique responses (54%) were received. All respondents were general practice programs (100%) in predominantly multicentre organizations (70%). Programs were similar in terms of assessment components used, with all respondents citing care plan review, direct observation of patient care, journal clubs, creation of project timelines, and ethics submission. The predominant evaluation components were within-department presentations (100%), written manuscripts (95%), drug information rotations (85%), and longitudinal evaluations (75%). Standardized forms (70%-100%) defined by Bloom's taxonomy (65%) and the CPRB "levels and ranges" document (60%) were the principle means used. Assessments for patient care and for provision of education were generally carried out immediately (80% and 95%, respectively), whereas project management skills were assessed predominantly at final evaluation (75%). Self-assessment and assessment by pharmacy team members occurred for every competency, whereas patients (0%-10%) and allied health professionals (5%) were less frequently involved. CONCLUSIONS: The assessment and evaluation strategies reported by programs were congruent. The results provide a summary of national practices and will allow existing and developing programs to examine their approach to assessment and evaluation for alignment with national standards.

CONTEXTE: Le Conseil canadien de résidence en pharmacie (CCRP) précise les compétences que les résidents en pharmacie doivent acquérir ainsi que le besoin d'observation et d'évaluation. Les méthodes d'observation et d'évaluation sont laissées à la discrétion de chacun des programmes. La littérature publiée qui compile et compare les stratégies utilisées par les programmes en résidence canadiens est rare. OBJECTIFS: Déterminer les composantes des programmes utilisés pour l'observation et l'évaluation des normes; décrire les outils utilisés par ces programmes; établir l'horaire, la fréquence et la répétition des éléments qui constituent ces programmes et déterminer les personnes ou les groupes concernés. MÉTHODES: Les coordinateurs des programmes de résidence en pharmacie hospitalière ayant un agrément ou dont l'agrément est en cours de procédure ont été interrogés afin qu'ils fournissent des informations concernant l'observation et l'évaluation des normes CCRP sélectionnées. RÉSULTATS: Des 37 programmes de résidence admissibles, 20 réponses individuelles (54 %) sont parvenues aux investigateurs. Tous les répondants représentaient des programmes de pratique générale (100 %) dans des organismes majoritairement multicentriques (70 %). Les programmes étaient similaires en termes de points à observer : tous les répondants citaient l'examen des plans de soins, l'observation directe des soins aux patients, les clubs de journaux, la création d'échéanciers pour la réalisation de projets et la proposition de documents sur l'éthique. Les critères d'évaluation prédominants consistaient en des présentations au sein du département (100 %), la rédaction de manuscrits (95 %), des rotations reliées au service d'information pharmacothérapeutique (85 %) et les évaluations longitudinales (75 %). Les formulaires standardisés (70 %­100 %) définis par la taxonomie de Bloom (65 %) et le document Levels and ranges (niveaux de performance des compétences) du CCRP (60 %) étaient les ressources de base utilisées. L'observation des soins aux patients et de la formation avait généralement lieu immédiatement (respectivement 80 % et 95 %,), tandis que les compétences en matière de gestion de projet étaient majoritairement évaluées en dernier (75 %). L'auto-observation et l'observation effectué par des membres de l'équipe de pharmacie portaient sur chaque compétence, tandis que les patients (0 % ­ 10 %) et les autres professionnels de la santé (5 %) participaient plus rarement à cette observation. CONCLUSIONS: Les stratégies d'observation et d'évaluation rapportées par les programmes concordaient. Les résultats fournissent un résumé des pratiques nationales et permettront aux responsables des programmes existants et en cours d'élaboration d'étudier l'approche de l'observation et de l'évaluation pour l'aligner sur les normes nationales.

Anticoagulant therapies for acute venous thromboembolism: a comparison between those discharged directly from the emergency department versus hospital in two Canadian cities.

OBJECTIVE: To compare the characteristics/management of acute venous thromboembolism (VTE) for patients either discharged directly from the emergency department (ED) or hospitalised throughout a year within two urban cities in Canada. DESIGN: Retrospective medical record review. SETTING: Hospitals in Edmonton, Alberta (n=4) and Regina, Saskatchewan (n=2) from April 2014 to March 2015. PARTICIPANTS: All patients discharged from the ED or hospital with acute deep vein thrombosis or pulmonary embolism (PE). Those having another indication for anticoagulant therapy, pregnant/breast feeding or anticipated lifespan <3 months were excluded. PRIMARY AND SECONDARY OUTCOMES: Primarily, to compare proportion of patients receiving traditional therapy (parenteral anticoagulant±warfarin) relative to a direct oral anticoagulant (DOAC) between the two cohorts. Secondarily, to assess differences with therapy selected based on clot burden and follow-up plans postdischarge. RESULTS: 387 (25.2%) and 665 (72.5%) patients from the ED and hospital cohorts, respectively, were included. Compared with the ED cohort, those hospitalised were older (57.3 and 64.5 years; p<0.0001), more likely to have PE (35.7% vs 83.8%) with a simplified Pulmonary Embolism Severity Index (sPESI) ≥1 (31.2% vs 65.2%), cancer (14.7% and 22.3%; p=0.003) and pulmonary disease (10.1% and 20.6%; p<0.0001). For the ED and hospital cohorts, similar proportions of patients were prescribed traditional therapies (72.6% and 71.1%) and a DOAC (25.8% and 27.4%, respectively). For the ED cohort, DOAC use was similar between those with a sPESI score of 0 and ≥1 (35.1% and 34.9%, p=0.98) whereas for those hospitalised lower risk patients were more likely to receive a DOAC (31.4% and 23.8%, p<0.055). Follow-up was most common with family physicians for those hospitalised (51.5%), while specialists/VTE clinic was most common for those directly discharged from the ED (50.6%). CONCLUSIONS: Traditional and DOAC therapies were proportionately similar between the ED and hospitalised cohorts, despite clear differences in patient populations and follow-up patterns in the community.

Anticoagulant therapies for acute venous thromboembolism among a cohort of patients discharged from Canadian urban and rural hospitals.

OBJECTIVE: To determine anticoagulant therapy at hospital discharge for patients with acute venous thromboembolism (VTE) and secondarily, to describe factors affecting choice of therapy. DESIGN: A retrospective chart review. SETTING: Canadian hospitals in Edmonton, Alberta (n=4), Regina, Saskatchewan (n=2) and rural Alberta (n=3) from April 2014 to March 2015. PARTICIPANTS: All patients discharged with an acute VTE were screened. Those with atypical clots, another indication for anticoagulation, pregnancy/breast feeding or lifespan <3 months were excluded. PRIMARY AND SECONDARY OUTCOMES: Primarily, we identified the proportion of patients discharged from hospital with acute VTE that were prescribed either traditional therapy (parenteral anticoagulant±warfarin) or a direct oral anticoagulant (DOAC). Secondarily, management based on setting, therapy choice based on deep vein thrombosis (DVT) versus pulmonary embolism (PE), clot burden and renal function was compared. DOAC dosing was assessed (when prescribed), length of hospital stay based on therapy was compared and planned follow-up in the community was described. RESULTS: Among the 695 patients included, most were discharged following a diagnosis of PE (82.9%) on traditional therapy (parenteral anticoagulant±warfarin) (70.2%) with follow-up by either a family doctor (51.5%) or specialist/clinic (46.9%) postdischarge. Regional variation was most evident between urban and rural sites. Of those prescribed a DOAC (28.3%), the majority were dosed appropriately (85.8%). DOAC use did not differ between those with DVT and PE, was proportionately higher for less severe clots and declined with worsening renal function. Patients prescribed DOACs versus traditional therapy had a shorter length of stay (4 vs 7 days, respectively). CONCLUSIONS: Uptake of DOAC therapy for acute VTE was modest and may have been influenced by the timing of the audit in relation to the approval of these agents for this indication. Future audits should occur to assess temporal changes and ongoing appropriateness of care delivery.

Management of acute venous thromboembolism among a cohort of patients discharged directly from the emergency department.

OBJECTIVE: To report the proportion of patients discharged directly from the emergency department (ED) on traditional therapy (parenteral anticoagulant±warfarin) or a direct oral anticoagulant (DOAC) for the management of acute venous thromboembolism (VTE). DESIGN: Retrospective medical record review across four EDs in Edmonton, Alberta, two in Regina, Saskatchewan and three in rural Alberta. SETTING: EDs from April 2014 through March 2015. PARTICIPANTS: Discharged directly from the ED with acute VTE. Patients were excluded if they had another indication for anticoagulants, were pregnant/breastfeeding or anticipated lifespan <3 months. PRIMARY AND SECONDARY OUTCOME MEASURES: Primarily, the proportion of patients discharged directly from the ED that were prescribed traditional therapy or a DOAC, with comparisons between Edmonton, Regina and rural Alberta. Secondarily, therapy selection was compared based on deep vein thrombosis (DVT) versus pulmonary embolism (PE) and clot burden. Dosing of DOACs was assessed (when applicable) and follow-up in the community was compared. RESULTS: After screening 1723 patients, 417 (24.2%) were included with DVT and PE occurring in 65.5% and 34.5%, respectively. More patients with PE were discharged from EDs in Edmonton (43%) than Regina (7%). Overall, the majority of patients were discharged on traditional therapy (70.7%), with 27.8% receiving a DOAC. Uptake of DOAC use was highest in rural Alberta (53.3%) compared with Edmonton (29.6%) and Regina (12.1%). DOACs were more commonly prescribed for PE (34.0%) than DVT (24.5%) (p=0.04), proximal versus distal DVT (28.4% and 17.3%; p<0.001), and when prescribed were appropriately dosed in 79.3%. Follow-up most commonly occurred via a VTE clinic in Edmonton or family physician in Regina and rural Alberta. CONCLUSIONS: Regional variation in discharging patients directly from the ED with PE is evident. While traditional therapy is most common, uptake of DOACs was modest given the timing of indication approval.

Community Pharmacists Assisting in Total Cardiovascular Health (CPATCH): A Cluster-Randomized, Controlled Trial Testing a Focused Adherence Strategy Involving Community Pharmacies.

STUDY OBJECTIVE: To test a brief intervention for preventing statin nonadherence among community pharmacy patrons. DESIGN: Prospective, cluster-randomized, controlled trial (the Community Pharmacists Assisting in Total Cardiovascular Health [CPATCH] trial). SETTING: Thirty community pharmacies in Saskatchewan, Canada. PATIENTS: Participating pharmacies were randomized to 15 intervention pharmacies where a brief statin adherence intervention was delivered by pharmacists (intervention group [907 patients]) or 15 usual care pharmacies where no statin adherence intervention was delivered (usual care group [999 patients]) to new users of statins (defined as less than 1 yr of statin therapy). INTERVENTION: Staff (pharmacy managers, staff pharmacists, and technicians) from intervention pharmacies attended a 2.5-hour workshop on the CPATCH program that prepared pharmacists to deal with the adherence barriers most likely associated with statin use (e.g., safety, cost, patient-provider relationship, and tolerability). Intervention pharmacists screened for new statin users and assessed these adherence barriers. Pharmacists were then instructed to tailor their follow-up plan based on the individual patient's situation. Investigators contacted the intervention pharmacies monthly to assess their compliance with the protocol and to offer additional support to motivate ongoing participation. MEASUREMENTS AND MAIN RESULTS: The primary outcome was mean difference in statin adherence between the intervention and usual care groups. Adherence was measured by the proportion of days covered (PDC) between 6 and 12 months following the original prescription fill date. General estimating equations were used to evaluate the difference in mean adherence between groups. Secondary outcomes included the percentage of new statin users exhibiting optimal adherence (defined as PDC of 80% or higher) and the percentage exhibiting nonpersistence (defined as the cessation of all statin dispensations within 3 mo of the first dispensation). Among 1906 eligible patients, no significant differences in mean adherence were observed between those receiving the intervention and those receiving usual care (71.6% vs 70.9%, p=0.64), the percentage of patients achieving optimal adherence (57.3% vs 55.9%, p=0.51), or the percentage exhibiting nonpersistence (9.4% vs 8.3%, p=0.41). However, compliance to the study protocol was extremely low in several intervention pharmacies. In a post hoc analysis, a higher level of protocol compliance among intervention pharmacies was significantly associated with higher adherence (p<0.01 for trend). Pharmacies falling in the highest tertile of compliance to the study protocol exhibited higher mean adherence among their patients compared with those in the usual care group (ß = 0.056, 95% confidence interval [CI] 0.010-0.101, p=0.01), and a significantly higher percentage of patients achieving optimal adherence (odds ratio 1.32, 95% CI 1.08-1.61; p<0.01); however, nonpersistence did not significantly differ between the two groups (5.5% vs 8.3%, p=0.27). CONCLUSION: The CPATCH intervention was ineffective for improving patient adherence to statin therapy in community pharmacies. However, poor effectiveness may have resulted from a failure to deliver the protocol consistently in several intervention pharmacies.

Adherence to statins, beta-blockers and angiotensin-converting enzyme inhibitors following a first cardiovascular event: a retrospective cohort study.

BACKGROUND: Population studies of statin adherence are generally restricted to one to two years of follow-up and do not analyze adherence to other drugs. OBJECTIVES: To report long-term adherence rates for statins, angiotensin-converting enzyme (ACE) inhibitors and beta-blockers in patients who recently experienced a first cardiovascular event. METHODS: Linked administrative databases in the province of Saskatchewan were used in this retrospective cohort study. Eligible patients received a new statin prescription within one year of their first cardiovascular event between 1994 and 2001. Adherence to statins, beta-blockers and ACE inhibitors was assessed from the first statin prescription to a subsequent cardiovascular event. RESULTS: Of 1221 eligible patients, the proportion of patients adherent to statin medications dropped to 60.3% at one year and 48.8% at five years. The decline in the proportion of adherent patients was most notable during the first two years (100% to 53.7%). Several factors were associated with statin adherence, including age (P = 0.012), number of physician service days (P = 0.037), chronic disease score (P = 0.032), beta-blocker adherence (P < 0.001) and ACE inhibitor adherence (P < 0.001). Adherence to beta-blockers and ACE inhibitors was very similar to adherence to statin medications at each year of follow-up. CONCLUSIONS: Patients who exhibit optimal adherence over one to two years after their initial cardiovascular event generally remain adherent over subsequent years. Also, adherence to beta-blockers and ACE inhibitors is significantly associated with statin adherence in a subset of patients; however, overall adherence to all three drugs was similarly poor.

Management of stroke prevention in canadian patients with atrial fibrillation at moderate to high risk of stroke.

BACKGROUND: Many patients with atrial fibrillation who are at moderate to high risk of stroke do not receive anticoagulation with vitamin K antagonists (VKAs) in accordance with recommendations. OBJECTIVE: To determine (1) why Canadian patients with atrial fibrillation who are potentially eligible for VKA do not receive this therapy, (2) why Canadian primary care physicians discontinue VKA therapy, and (3) why VKA therapy is perceived as difficult to manage. METHODS: The study involved a chart review of 3 cohorts of patients with nonvalvular atrial fibrillation at moderate to high risk of stroke: patients who had never received VKA treatment (VKA-naive), those whose treatment had been discontinued, and those whose VKA treatment was considered difficult to manage. RESULTS: Charts for 187 patients (mean age 78.4 years, standard deviation 8.9 years) treated at 39 primary care sites were reviewed (62 treatment-naive, 42 with therapy discontinued, and 83 whose therapy was considered difficult to manage). Atrial fibrillation was paroxysmal in 82 (44%) of the patients, persistent in 47 patients (25%), and permanent in 58 (31%). One patient in each of the 3 cohorts had experienced a stroke during the 6 months before study participation. Bleeding events were more frequent among patients who had discontinued VKA therapy than in the other 2 groups. Among those whose therapy was discontinued and those whose therapy was difficult to manage, the mean time in the therapeutic range was 46.3% and 56.4%, respectively. The most common reason for not initiating VKA therapy in treatment-naive patients was the transient nature of atrial fibrillation (25/62 [40%]). The most common reason for discontinuation of VKA therapy was a bleeding event (10/42 [24%]). The presence of a concomitant chronic disease was the most common reason that a patient's therapy was considered difficult to manage (46/83 [55%]). CONCLUSIONS: VKA therapy was not initiated or was discontinued for various reasons. Multiple comorbid conditions made management of VKA therapy more difficult. These findings reflect the challenges that primary care physicians experience in managing the care of patients with atrial fibrillation.

CONTEXTE: De nombreux patients atteints d'une fibrillation auriculaire (FA) et présentant un risque d'accident vasculaire cérébral (AVC) modéré ou élevé ne reçoivent pas d'anticoagulothérapie par un antagoniste de la vitamine K, conformément aux recommandations. OBJECTIF: Déterminer 1) pourquoi les patients canadiens atteints d'une FA et qui sont des candidats potentiels à l'anticoagulothérapie par un antagoniste de la vitamine K ne reçoivent pas ce traitement, 2) pourquoi les médecins canadiens de soins primaires interrompent l'anticoagulothérapie par un antagoniste de la vitamine K, et 3) pourquoi la prise en charge d'un tel traitement est considérée comme difficile. MÉTHODES: Cette étude comportait une analyse des dossiers médicaux des patients de trois cohortes atteints d'une FA non valvulaire et considérés comme présentant un risque modéré ou élevé d'AVC : patients qui n'avaient jamais reçu d'anticoagulothérapie par un antagoniste de la vitamine K, patients chez qui ce traitement avait été interrompu et patients chez qui la prise en charge de ce traitement était considérée comme difficile. RÉSULTATS: Les dossiers médicaux de 187 patients (âge moyen de 78,4 ans, écart-type de 8,9 ans) traités dans 39 établissements de soins primaires ont été analysés (62 : jamais traités, 42 : traitement interrompu et 83 : prise en charge considérée comme difficile). On a répertorié 82 (44 %) cas de FA paroxystique, 47 (25 %) cas de FA persistante et 58 (31 %) cas de FA permanente. Un patient dans chacune des trois cohortes a eu un AVC durant les six mois précédant sa participation à cette étude. Les saignements étaient plus fréquents parmi les patients chez qui on avait interrompu le traitement par l'antagoniste de la vitamine K que chez ceux des deux autres groupes. Parmi les patients chez qui le traitement avait été interrompu ou sa prise en charge était considérée comme difficile, le temps moyen dans l'écart thérapeutique était respectivement de 46,3 % et de 56,4 %. La raison la plus souvent évoquée pour ne pas instaurer le traitement par un antagoniste de la vitamine K chez les patients n'ayant jamais reçu un tel traitement était la nature passagère de la FA (25/62 [40 %]). La raison la plus souvent évoquée pour interrompre ce traitement était les saignements (10/42 [24%]). La présence d'une comorbidité chronique était la raison la plus souvent évoquée pour expliquer la prise en charge difficile de ce traitement (46/83 [55 %]). CONCLUSIONS: L'anticoagulothérapie par un antagoniste de la vitamine K n'était pas instaurée ou était interrompue pour diverses raisons. La présence de multiples comorbidités rendait sa prise en charge plus difficile. Ces résultats reflètent les difficultés des médecins de soins primaires dans la prise en charge des patients atteints de fibrillation auriculaire. [Traduction par l'éditeur].

Changes in adherence to evidence-based medications in the first year after initial hospitalization for heart failure: observational cohort study from 1994 to 2003.

BACKGROUND: The use of evidence-based medications in patients with heart failure has increased over the past 10 years. We aimed to determine whether adherence to these medications has also increased during this time. METHODS AND RESULTS: A retrospective cohort was created using administrative databases from the province of Saskatchewan, Canada. Subjects discharged alive from their first hospitalization for heart failure between 1994 and 2003 were eligible. Those filling a prescription for a beta-blocker (BB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB) within 6 months of discharge were followed for 1 year after the initial prescription. Of 8805 eligible patients, 67% of BB users (941/1414) and 74% of ACEI/ARB users (4441/5991) exhibited optimal adherence at 1 year (defined as >or=80% adherence calculated from pharmacy refill records). When grouped by year of initial heart failure hospitalization, the proportion of optimally adherent patients improved from 54% to 75% with BB and from 67% to 80% with ACEI/ARBs between 1994/1995 and 2002/2003 (P for trend <0.001 for both). Mean 1-year adherence improved from 71% to 83% for BB and 80% to 88% for ACEI/ARBs. After adjustment using multivariable logistic regression, subjects discharged in 2003 were significantly more likely to exhibit optimal adherence to a BB (odds ratio, 2.04; 95% CI, 1.21 to 3.44) or an ACEI/ARB (odds ratio, 1.65; 95% CI, 1.30 to 2.08) than those prescribed therapy in 1994/1995. CONCLUSIONS: One-year adherence to BB and ACEI/ARB is improving over time in patients discharged after first heart failure hospitalization. Patients taking multiple cardiac medications were not any less likely to exhibit optimal adherence than patients taking only 1 medication.