The role and impact of the pharmacist in long-term care settings: A systematic review.

OBJECTIVE: Older adults in long-term care (LTC) are often frail and comorbid and have multiple medications. Although medication review by pharmacists has been integrated into LTC practice in many countries through policy and reimbursement models, the impact is variable in the literature. The purpose of our study was to review the literature regarding the impact of the pharmacist in LTC. DATA SOURCES: Four databases were searched from inception to September 2017, including Ovid MEDLINE, Ovid Embase, Ovid Evidence-Based Medicine Reviews (Cochrane Library), and Ovid International Pharmaceutical Abstracts. STUDY SELECTION: Studies in any language were included if they met the following criteria: (1) pharmacist involved in care, (2) quasi-experimental or experimental design, and (3) conducted in LTC. DATA EXTRACTION: Two reviewers independently reviewed the titles, abstracts, and full-text articles to determine if they met inclusion criteria, with a third researcher resolving discrepancies. Data of included studies were independently abstracted by 2 reviewers and confirmed by a third researcher. RESULTS: Twenty-six studies (total N = 20,228, median study duration = 12 months) met the inclusion criteria. Medication review was the most common intervention, evaluated in 24 studies (92%). Eleven studies (42%) reported on the total number of medications per patient, with 7 studies finding a statistically significant reduction in medication usage. Six studies focused on psychotropic medications, with 4 of those leading to a reduction in medication. Explicit medication appropriateness criteria showed improvement in 5 studies. Medication and health care costs were evaluated in 14 studies (54%), with 4 reporting a statistically significant reduction. Studies reporting hospitalizations (10, 38%) were moderately heterogeneous (I2 = 59%) and failed to demonstrate an impact. Studies reporting mortality (8, 31%) were less heterogeneous (I2 = 0%), but they also failed to show a change. CONCLUSION: There is evidence to support pharmacist intervention, primarily through medication review, to improve measures in medication appropriateness.

Interaction Between Low-Dose Methotrexate and Nonsteroidal Anti-inflammatory Drugs, Penicillins, and Proton Pump Inhibitors.

OBJECTIVE: To review the potential drug interactions between low-dose methotrexate (LD-MTX) and nonsteroidal anti-inflammatory drugs (NSAIDs), penicillins, and proton-pump inhibitors (PPIs) given the disparity between interactions reported for high-dose and low-dose MTX to help guide clinicians. DATA SOURCES: A literature search was performed in MEDLINE (1946 to September 2016), EMBASE (1974 to September 2016), and International Pharmaceutical Abstracts (1970 to January 2015) to identify reports describing potential drug interactions between LD-MTX and NSAIDS, penicillins, or PPIs. Reference lists of included articles were reviewed to find additional eligible articles. STUDY SELECTION AND DATA EXTRACTION: All English-language observational, randomized, and pharmacokinetic (PK) studies assessing LD-MTX interactions in humans were analyzed to determine clinical relevance in making recommendations to clinicians. Clinical case reports were assigned a Drug Interaction Probability Scale score. DATA SYNTHESIS: A total of 32 articles were included (28 with NSAIDs, 3 with penicillins, and 2 with PPIs [1 including both PPI and NSAID]). Although there are some PK data to describe increased LD-MTX concentrations when NSAIDs are used concomitantly, the clinical relevance remains unclear. Based on the limited data on LD-MTX with penicillins and PPIs, no clinically meaningful interaction was identified. CONCLUSION: Given the available evidence, the clinical importance of the interaction between LD-MTX and NSAIDs, penicillins, and PPIs cannot be substantiated. Health care providers should assess the benefit and risk of LD-MTX regardless of concomitant drug use, including factors known to predispose patients to MTX toxicity, and continue to monitor clinical and laboratory parameters per guideline recommendations.

Effect of calcium-based versus non-calcium-based phosphate binders on mortality in patients with chronic kidney disease: an updated systematic review and meta-analysis.

BACKGROUND: Phosphate binders (calcium-based and calcium-free) are recommended to lower serum phosphate and prevent hyperphosphataemia in patients with chronic kidney disease, but their effects on mortality and cardiovascular outcomes are unknown. We aimed to update our meta-analysis on the effect of calcium-based versus non-calcium-based phosphate binders on mortality in patients with chronic kidney disease. METHODS: We did a systematic review of articles published in any language after Aug 1, 2008, up until Oct 22, 2012, by searching Medline, Embase, International Pharmaceutical Abstracts, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature. We included all randomised and non-randomised trials that compared outcomes between patients with chronic kidney disease taking calcium-based phosphate binders with those taking non-calcium-based binders. Eligible studies, determined by consensus with predefined criteria, were reviewed, and data were extracted onto a standard form. We combined data from randomised trials to assess the primary outcome of all-cause mortality using the DerSimonian and Laird random effects model. FINDINGS: Our search identified 847 reports, of which eight new studies (five randomised trials) met our inclusion criteria and were added to the ten (nine randomised trials) included in our previous meta-analysis. Analysis of the 11 randomised trials (4622 patients) that reported an outcome of mortality showed that patients assigned to non-calcium-based binders had a 22% reduction in all-cause mortality compared with those assigned to calcium-based phosphate binders (risk ratio 0·78, 95% CI 0·61-0·98). INTERPRETATION: Non-calcium-based phosphate binders are associated with a decreased risk of all-cause mortality compared with calcium-based phosphate binders in patients with chronic kidney disease. Further studies are needed to identify causes of mortality and to assess whether mortality differs by type of non-calcium-based phosphate binder. FUNDING: None.

Multidisciplinary approaches to the management of high blood pressure.

PURPOSE OF REVIEW: Studies on collaborative and multidisciplinary approaches to the management of hypertension published in the past 2 years are summarized. Expanding scopes of practice for nonphysician health professionals, a need to build capacity in the healthcare system, and a movement toward multidisciplinary care warrant an examination of the evidence in this area. RECENT FINDINGS: Multidisciplinary care for hypertension management, across the majority of studies identified, resulted in improved blood pressure (BP) outcomes and the timeliness of achieving treatment targets. Interventions involving therapeutic decision-making by nonphysician health professionals consistently resulted in significant BP improvements compared with usual care, whereas more passive approaches, such as education and lifestyle monitoring programs, were unable to significantly benefit participants' BP. SUMMARY: Our findings support recent efforts to integrate collaborative care approaches into chronic disease management, with the strongest evidence for pharmacist care. Expanding scopes of practice and clinical decision-making protocols for nurses, pharmacists, dietitians, and physiotherapists have the potential to further improve hypertension care.

Paying pharmacists for patient care: A systematic review of remunerated pharmacy clinical care services.

BACKGROUND: Expansion of scope of practice and diminishing revenues from dispensing are requiring pharmacists to increasingly adopt clinical care services into their practices. Pharmacists must be able to receive payment in order for provision of clinical care to be sustainable. The objective of this study is to update a previous systematic review by identifying remunerated pharmacist clinical care programs worldwide and reporting on uptake and patient care outcomes observed as a result. METHODS: Literature searches were performed in several databases, including MEDLINE, Embase and International Pharmaceutical Abstracts, for papers referencing remuneration, pharmacy and cognitive services. Searches of the grey literature and Internet were also conducted. Papers and programs were identified up to December 2012 and were included if they were not reported in our previous review. One author performed data abstraction, which was independently reviewed by a second author. All results are presented descriptively. RESULTS: Sixty new remunerated programs were identified across Canada, the United States, Europe, Australia and New Zealand, ranging in complexity from emergency contraception counseling to minor ailments schemes and comprehensive medication management. In North America, the average fee provided for a medication review is $68.86 (all figures are given in Canadian dollars), with $23.37 offered for a follow-up visit and $15.16 for prescription adaptations. Time-dependent fees were reimbursed at $93.60 per hour on average. Few programs evaluated uptake and outcomes of these services but, when available, indicated slow uptake but improved chronic disease markers and cost savings. DISCUSSION: Remuneration for pharmacists' clinical care services is highly variable, with few programs reporting program outcomes. Programs and pharmacists are encouraged to examine the time required to perform these activities and the outcomes achieved to ensure that fees are adequate to sustain these patient care activities.

"You're just one of the group when you're embedded": report from a mixed-method investigation of the research-embedded health librarian experience.

OBJECTIVE: Embedded librarianship has received much attention in recent years. A model of embeddedness rarely discussed to date is that of research-embedded health librarians (REHLs). This study explores the characteristics of Canadian REHLs and the situations in which they are employed. METHODS: The authors employed a sequential, mixed-method design. An online survey provided descriptive statistics about REHLs' positions and work experiences. This informed a series of focus group interviews that expanded upon the survey. Through constant comparison, we conducted qualitative descriptive analysis of the interviews. RESULTS: Based on twenty-nine survey responses and four group interviews, we created a portrait of a "typical" REHL and discovered themes relevant to REHL work. REHLs may identify more strongly as researchers than as librarians, with corresponding professional needs and rewards. REHLs value "belonging" to the research team, involvement in full project lifecycles, and in-depth relationships with nonlibrarian colleagues. Despite widely expressed job satisfaction, many REHLs struggle with isolation from library and information science peers and relative lack of job security. CONCLUSIONS: REHLs differ from non-embedded health librarians, as well as from other types of embedded librarians. REHLs' work also differs from just a decade or two ago, prior to widespread Internet access to digital resources. IMPLICATIONS: Given that research-embedded librarianship appears to be a distinct and growing subset of health librarianship, libraries, master's of library and information science programs, and professional associations will need to respond to the support and education needs of REHLs or risk losing them to the health research field.

PharmGuide: your guide to free online drug information.

PharmGuide < http://goo.gl/f14Me >is an annotated directory of high quality, freely available, online drug information resources intended for use by librarians, pharmacists, and the public. Given the plethora of drug information websites with varying levels of authoritativeness and accuracy, PharmGuide is intended to facilitate the search for resources by providing links to only those sources that have been critically appraised and that meet specific quality criteria. Methods used in developing the site, evidence of its utility based on usage statistics, and examples of its application in practice are presented within the context of the drug information landscape.

Publicly funded remuneration for the administration of injections by pharmacists: An international review.

BACKGROUND: The administration of injections has become an increasingly common addition to pharmacists' scope of practice. Four Canadian provinces, all US states and a number of other countries have regulations allowing pharmacists to administer injections. However, the extent to which such services are remunerated is unknown. METHODS: We contacted regulatory and advocacy organizations within those jurisdictions where pharmacists are authorized to administer injections to identify publicly funded programs that pay pharmacists for these services, as well as details of the eligible drugs/vaccines. Patient or private insurer payment programs were excluded. RESULTS: Of the 281 organizations we contact-ed, 104 provided information on a total of 34 pharmacist vaccination programs throughout Canada, the United States, England, Wales and Ireland. Converted to 2013 Canadian dollars, remuneration averages $13.12 (SD $4.63) per injection (range, $4.14-$21.21). All regions allow pharmacists to bill for administration of the influenza vaccine, while some states allow for a number of other vaccines. Alberta has the broadest range of injections eligible for remuneration. DISCUSSION: Despite evidence of increased vaccination rates in areas allowing pharmacist administration of injections, the availability of publicly funded remuneration programs and the fee offered vary by more than 5-fold across North America and the United Kingdom. CONCLUSION: Pharmacist-administered injections have great public health potential. The range of injections eligible for remuneration should be expanded to include a wide range of vaccines and other injectable drugs, and remuneration should be sufficient to encourage more pharmacists to provide this service.

Utilisation of search filters in systematic reviews of prognosis questions.

BACKGROUND: Search filters are designed to increase efficiency of information retrieval and can be particularly useful in limiting the large numbers of articles retrieved for systematic reviews (SRs). Existing published prognosis search filters (or hedges) have lower sensitivity and precision values than their therapy counterparts. OBJECTIVES: Taking into account the relatively poor performance of prognosis filters, this study seeks to identify which methods of limiting search results to prognostic studies are most often used by SR teams. METHODS: One hundred and three SRs of prognostic studies published in 2009 and indexed in MEDLINE were retrieved. Each review's search strategy was reviewed and prognosis-related search terms were extracted. RESULTS: Forty-seven of 103 studies used prognosis-related terms to limit the search. Six SRs of 103 did not specify their search terms, and the remaining 50 SRs used content terms only (no terms related to methodology or prognosis). Of the 47 strategies using prognosis-related terms, only six used a published filter. Many SRs used few or poorly selected prognosis-related search terms which are unlikely to provide the sensitivity generally sought for SRs. CONCLUSIONS: Published prognosis search filters are used in only a small minority of prognosis SRs.

Health information support provided by professional associations in Canada.

BACKGROUND: Healthcare practitioners in Alberta and across Canada have varying levels of access to information resources depending on their institutional and professional affiliations, yet access to current health information is critical for all. OBJECTIVES: To determine what information resources and services are provided by Albertan and Canadian professional health associations to their members. METHODS: Representatives of professional colleges and associations were interviewed regarding information resources and services offered to members and perceptions of their members' information needs. RESULTS: National-level associations are more likely to provide resources than provincial ones. There is a clear distinction between colleges and associations in terms of information offered: colleges provide regulatory information, while associations are responsible for provision of clinical information resources. Only half of the associations interviewed provide members with access to licensed databases, with cost being a major barrier. CONCLUSIONS: There is considerable variation in the number of electronic resources and the levels of information support provided by professional health associations in Alberta and Canada. Access and usage vary among the health professions. National licensing of resources or creation of a portal linking to freely available alternatives are potential options for increasing access and awareness.

Measuring Disease Activity and Damage with Validated Metrics: A Systematic Review on Mortality and Damage in Systemic Lupus Erythematosus.

OBJECTIVE: To identify the effect of disease activity and damage, measured by validated indices, on mortality and damage accrual, in order to inform upcoming Canadian systemic lupus erythematosus (SLE) recommendations. METHODS: Following GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology to fill in evidence-to-decision tables to create recommendations for "minimal investigations needed to monitor SLE patients at baseline and subsequent visits," a systematic literature review was performed. The effect of disease activity and damage, measured by validated metrics, on mortality and damage was systematically reviewed, with metaanalyses performed when available. RESULTS: A title/abstract screen of 5599 articles identified 816 articles for full paper review, with 102 meeting inclusion criteria and 53 with extractable data. Thirty-three articles describing outcomes related to disease activity and 20 articles related to damage were identified. Mortality was associated with higher SLE Disease Activity Index-2000 scores in 6 studies (HR 1.14, 95% CI 1.06-1.22) and higher Systemic Lupus International Collaborating Clinics/ACR Damage Index scores in 6 studies (HR 1.53, 95% CI 1.28-1.83). Higher SLE Activity Measure scores were associated with increased risk of damage in 3 studies (OR 1.06, 95% CI 1.04-1.08). British Isles Lupus Assessment Group was associated with mortality in 1 study with HR of 1.15. CONCLUSION: Active SLE disease and damage are associated with and predict greater mortality and damage. The use of validated disease activity and damage metrics is important in the assessment of disease activity and damage and will inform upcoming Canadian recommendations for the assessment of SLE.

Evaluating the content and development of decision aid tools for the management of menopause: A scoping review.

OBJECTIVE: Decision-making during menopause (especially surgical menopause) can be complex given the variability in risk-benefit perceptions of menopausal treatments. Decision aid tools (DATs) help women participate in decision-making about options. Our objective is to identify and evaluate the content and development of DATs for managing menopause, with a special focus on surgical menopause. METHODS: We systematically searched electronic databases, including MEDLINE and EMBASE, from inception to March 2017 for relevant records. The principal inclusion criterion was that papers reported studies on DATs for managing menopause. Search terms were derived from two concepts: menopause and DATs. Data extracted were presented in written evidence tables and narrative summaries. RESULTS: Our search yielded 18,801 records. Of these, 26 records met our inclusion criteria, which gave rise to 12 DATs from peer-reviewed literature and 6 from grey literature. Seventeen DATs were focused on natural menopause and two targeted surgical menopause, both identified from grey literature. More than half were published before the Women's Health Initiative (WHI) publication and 70% before the release of the International Patient Decision Aid Standards (IPDAS). Very few studies reported the full development of the DAT involved, and less than half of DATs were informed by a needs assessment to identify the decisional needs of their target population. Most DATs focused on hormone therapy as a treatment option and did not provide a comprehensive overview of other options. None of the DATs reported the steps involved in finding, appraising and summarizing scientific content of the tool. CONCLUSION: This review highlights several limitations in the content and development of DATs for managing menopause. No peer-reviewed DATs were identified for surgical menopause. A need for a complete, evidence-based DAT in the context of surgical menopause is identified.

Effectiveness of Multifaceted Care Approach on Adverse Clinical Outcomes in Nondiabetic CKD: A Systematic Review and Meta-analysis.

INTRODUCTION: The risk of major adverse events associated with chronic kidney disease (CKD) could potentially be reduced with effective medical interventions. The impact of multifaceted interventions as compared with usual care in patients with nondiabetic CKD is unclear. We performed a systematic review to analyze the impact of multifaceted interventions on reducing the risk of major adverse events in this population. METHODS: Systematic review and meta-analysis. We searched MEDLINE, EMBASE, CINAHL and the Cochrane Library databases for medical literature published up to November 2016. Published original studies and abstracts were reviewed that reported on adult patients in a community or specialty care setting, with 2 or more CKD risk factors, treated with a combination of more than 2 interventions. We included randomized controlled trials, observational studies, and systematic reviews. Studies focused on diabetic patients were excluded. The intervention was defined as a treatment with a combination of 2 or more interventions compared with the usual care. The outcomes were defined as a reduction in the risk of adverse clinical outcomes (renal replacement therapy, all-cause hospitalizations, all-cause and cardiovascular mortality, cardiovascular events) as primary outcomes. Secondary outcomes were optimal risk factor control (attaining guideline concordant blood pressure, reduction of proteinuria, smoking cessation). RESULTS: Five of the 5846 unique citations from our initial literature search met our study criteria. All identified studies reported on patients with CKD and their management. In comparison with usual care, multifaceted interventions tended to reduce all-cause mortality (risk ratio: 0.81, 95% confidence interval: 0.63-1.03) and were associated with a lower risk of progression to kidney failure requiring dialysis (risk ratio: 0.57, 95% confidence interval: 0.35-0.94). Multifaceted interventions were not associated with reducing risk of all-cause hospitalizations (risk ratio: 0.93, 95% confidence interval: 0.71-1.23) or improved blood pressure control (mean difference: -0.48, range: -2.5 to 1.55 mm Hg). DISCUSSION: Multifaceted interventions targeting multiple risk factors tended to reduce the risk of all-cause mortality and reduced the risk to progress to end-stage kidney failure in patients with CKD. There is a need for high-quality studies that can rigorously evaluate a set of interventions targeting multiple domains of CKD management in the population with nondiabetic CKD due to paucity of data in the current published literature.

Learning to detect, categorize, and identify skin lesions: a meta-analysis.

IMPORTANCE: Educators use a variety of practices to train laypersons, medical students, residents, and primary care providers to diagnose skin lesions. Researchers have described these methods for decades, but there have been few attempts to catalog their scope or effectiveness. OBJECTIVE: To determine the scope and effectiveness of educational practices to improve the detection, categorization, and identification of skin lesions. DATA SOURCES: Literature indexed in MEDLINE, EMBASE, CINAHL, ERIC, PsycINFO, and BIOSIS Previews from inception until April 1, 2014, using terms cognate with skin disease, diagnosis, and education. STUDY SELECTION: Studies in which the educational objective was operationalized as the ability to detect, categorize, or identify skin lesions, and the intervention was evaluated through comparisons of participants' abilities before and after the intervention. DATA EXTRACTION AND SYNTHESIS: Information about trainees, educational practices, educational outcomes, and study quality was extracted; it was synthesized through meta-analysis using a random effects model. Effect sizes were calculated by dividing the differences between preintervention and postintervention means by the pooled standard deviation (ie, standardized mean difference [SMD]). Heterogeneity was assessed using an I2 statistic. MAIN OUTCOMES AND MEASURES: Pooled effect size across all studies and separate effect sizes for each of the educational practices. RESULTS: Thirty-seven studies reporting 47 outcomes from 7 educational practices met our inclusion criteria. The pooled effect of the practices on participants' abilities was large, with an SMD of 1.06 (95% CI, 0.81-1.31) indicating that posttest scores were approximately 1 SD above pretest scores. Effect sizes varied categorically between educational practices: the dermatology elective (SMD = 1.64; 95% CI, 1.17-2.11) and multicomponent interventions (SMD = 2.07; 95% CI, 0.71-3.44) had large effects; computer-based learning (SMD = 0.64; 95% CI, 0.36-0.92), lecture (SMD = 0.59; 95% CI, 0.28-0.90), pamphlet (SMD = 0.47; 95% CI, -0.11 to 1.05), and audit and feedback (SMD = 0.58; 95% CI, 0.10-1.07) had moderate effects; and moulage had a small effect (SMD = 0.15; 95% CI, -0.26 to 0.57). CONCLUSIONS AND RELEVANCE: A number of approaches are used to improve participants' abilities to diagnose skin lesions; some are more effective than others. The most effective approaches engage participants in a number of coordinated activities for an extended period, providing learners with the breadth of knowledge and practice required to change the mechanisms underlying performance.

A meta-narrative review of recorded patient-pharmacist interactions: exploring biomedical or patient-centered communication?

BACKGROUND: Pharmacists worldwide require improved patient-centered communication skills as they transition from a dispensing role to enhanced involvement in patient care. Researchers have studied pharmacist communication through audio and video recordings of patient-pharmacist encounters. A meta-narrative review of research using these recordings will offer insight into the extent of biomedical vs. patient-centered communication in patient-pharmacist exchanges. OBJECTIVES: This review aimed to characterize research on patient-pharmacists interactions using audio or video recordings and explore the 1) focus of research questions, 2) study design, 3) data analysis methods, 4) main findings and 5) presence of patient-centered vs. biomedical models of interaction. METHODS: Drawing on the principles of meta-narrative systematic review, a literature search was performed to identify studies published in English. No publication date limits were implemented. Key search terms included: "audio recording", "video recording", "communication", "patient counseling", "patient interaction", "discourse analysis", "conversation analysis", "narrative analysis", and "content analysis". The search was conducted in five databases: Medline, Embase, International Pharmaceutical Abstracts (IPA), Web of Science, and Academic Search Complete. RESULTS: Forty-one articles met the inclusion criteria and represent 32 unique collections of patient-pharmacist recordings. The 23 quantitative studies focused on "what" was in the interaction, whereas the 5 qualitative studies characterized specialized pharmacy practice and 13 studies used conversational analysis to describe "how" patients and pharmacists interact. The majority of research described the content of recorded interactions in community pharmacies. Twenty-three studies presented evidence of a biomedical model, whereas 8 studies characterized a patient-centered focus. CONCLUSIONS: A developing body of research used recordings to describe the content of patient-pharmacist communication and explore the quality of the interactions, validation of coding tools, impact of an intervention, and patient-pharmacist power asymmetry. Study findings, particularly the identification of biomedical vs. patient-centered communication, were guided by the quantitative, qualitative, or conversational analysis research paradigm.

Do calcium channel blockers increase the diagnosis of heart failure in patients with hypertension?

Calcium channel blockers (CCBs) are widely used to control hypertension. Previous work suggested that their use could increase heart failure (HF), which is 1 of the consequences of uncontrolled hypertension. Information about the effect of CCBs on incident HF in patients with hypertension is scarce. A systematic review was conducted to evaluate patients with hypertension treated with CCBs and incident HF. An electronic search of publications was conducted using 8 major databases. Studies were eligible if they (1) were randomized clinical trials, (2) performed comparisons of CCBs versus active control, (3) randomized >200 patients, (4) had follow-up periods >6 months, and (5) provided data regarding incident HF. Trials of renal transplantation patients, placebo-controlled trials, and HF trials were excluded. A total of 156,766 patients were randomized to CCBs or control, with a total of 5,049 events. The analysis indicated a significant increase in the diagnosis of HF in patients allocated to CCBs (odds ratio 1.18, 95% confidence interval 1.07 to 1.31). The effect observed was independent of incident myocardial infarction. Subgroup analyses indicated that patients with diabetes were at higher risk for developing HF (odds ratio 1.71, 95% confidence interval 1.21 to 2.41). In conclusion, the results suggest that patients with hypertension treated with CCBs have increased incident HF.

Effect of fish oil on arrhythmias and mortality: systematic review.

OBJECTIVE: To synthesise the literature on the effects of fish oil-docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA)-on mortality and arrhythmias and to explore dose response and formulation effects. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Medline, Embase, the Cochrane Library, PubMed, CINAHL, IPA, Web of Science, Scopus, Pascal, Allied and Complementary Medicine, Academic OneFile, ProQuest Dissertations and Theses, Evidence-Based Complementary Medicine, and LILACS. Studies reviewed Randomised controlled trials of fish oil as dietary supplements in humans. DATA EXTRACTION: The primary outcomes of interest were the arrhythmic end points of appropriate implantable cardiac defibrillator intervention and sudden cardiac death. The secondary outcomes were all cause mortality and death from cardiac causes. Subgroup analyses included the effect of formulations of EPA and DHA on death from cardiac causes and effects of fish oil in patients with coronary artery disease or myocardial infarction. DATA SYNTHESIS: 12 studies totalling 32 779 patients met the inclusion criteria. A neutral effect was reported in three studies (n=1148) for appropriate implantable cardiac defibrillator intervention (odds ratio 0.90, 95% confidence interval 0.55 to 1.46) and in six studies (n=31 111) for sudden cardiac death (0.81, 0.52 to 1.25). 11 studies (n=32 439 and n=32 519) provided data on the effects of fish oil on all cause mortality (0.92, 0.82 to 1.03) and a reduction in deaths from cardiac causes (0.80, 0.69 to 0.92). The dose-response relation for DHA and EPA on reduction in deaths from cardiac causes was not significant. CONCLUSIONS: Fish oil supplementation was associated with a significant reduction in deaths from cardiac causes but had no effect on arrhythmias or all cause mortality. Evidence to recommend an optimal formulation of EPA or DHA to reduce these outcomes is insufficient. Fish oils are a heterogeneous product, and the optimal formulations for DHA and EPA remain unclear.