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1.
Diabet Med ; 32(7): 899-906, 2015 Jul.
Article in English | MEDLINE | ID: mdl-25594919

ABSTRACT

BACKGROUND: Adding pharmacists to primary care teams significantly improved blood pressure control and reduced predicted 10-year cardiovascular risk in patients with Type 2 diabetes. This pre-specified sub-study evaluated the economic implications of this cardiovascular risk reduction strategy. METHODS: One-year outcomes and healthcare utilization data from the trial were used to determine cost-effectiveness from the public payer perspective. Costs were expressed in 2014 Canadian dollars and effectiveness was based on annualized risk of cardiovascular events derived from the UKPDS Risk Engine. RESULTS: The 123 evaluable trial patients included in this analysis had a mean age of 62 ( ± 11) years, 38% were men, and mean diabetes duration was 6 ( ± 7) years. Pharmacists provided 3.0 ( ± 1.9) hours of additional service to each intervention patient, which cost $226 ( ± $1143) per patient. The overall one-year per-patient costs for healthcare utilization were $190 lower in the intervention group compared with usual care [95% confidence interval (CI): -$1040, $668). Intervention patients had a significant 0.3% greater reduction in the annualized risk of a cardiovascular event (95% CI: 0.08%, 0.6%) compared with usual care. In the cost-effectiveness analysis, the intervention dominated usual care in 66% of 10,000 bootstrap replications. At a societal willingness-to-pay of $4000 per 1% reduction in annual cardiovascular risk, the probability that the intervention was cost-effective compared with usual care reached 95%. A sensitivity analysis using multiple imputation to replace missing data produced similar results. CONCLUSIONS: Within a randomized trial, adding pharmacists to primary care teams was a cost-effective strategy for reducing cardiovascular risk in patients with Type 2 diabetes. In most circumstances, this intervention may also be cost saving.


Subject(s)
Cardiovascular Diseases/prevention & control , Diabetes Mellitus, Type 2/economics , Diabetes Mellitus, Type 2/therapy , Diabetic Angiopathies/prevention & control , Diabetic Cardiomyopathies/prevention & control , Patient Care Team , Pharmacists , Aged , Canada/epidemiology , Cardiovascular Diseases/complications , Cardiovascular Diseases/economics , Cardiovascular Diseases/therapy , Combined Modality Therapy/economics , Cost-Benefit Analysis , Diabetes Mellitus, Type 2/complications , Diabetic Angiopathies/economics , Diabetic Angiopathies/epidemiology , Diabetic Angiopathies/therapy , Diabetic Cardiomyopathies/economics , Diabetic Cardiomyopathies/epidemiology , Diabetic Cardiomyopathies/therapy , Drug Monitoring/economics , Female , Follow-Up Studies , Health Care Costs , Humans , Male , Middle Aged , Patient Acceptance of Health Care , Patient Care Team/economics , Pharmacists/economics , Primary Health Care , Risk Factors
2.
Diabet Med ; 29(11): 1433-9, 2012 Nov.
Article in English | MEDLINE | ID: mdl-22486226

ABSTRACT

AIM: To determine the impact of adding pharmacists to primary care teams on predicted 10-year risk of cardiovascular events in patients with Type 2 diabetes without established cardiovascular disease. METHODS: This was a pre-specified secondary analysis of randomized trial data. The main study found that, compared with usual care, addition of a pharmacist resulted in improvements in blood pressure, dyslipidaemia, and hyperglycaemia for primary care patients with Type 2 diabetes. In this sub-study, predicted 10-year risk of cardiovascular events at baseline and 1 year were calculated for patients free of cardiovascular disease at enrolment. The primary outcome was change in UK Prospective Diabetes Study (UKPDS) risk score; change in Framingham risk score was a secondary outcome. RESULTS: Baseline characteristics were similar between the 102 intervention patients and 93 control subjects: 59% women, median (interquartile range) age 57 (50-64) years, diabetes duration 3 (1-6.5) years, systolic blood pressure 128 (120-140) mmHg, total cholesterol 4.34 (3.75-5.04) mmol/l and HbA(1c) 54 mmol/mol (48-64 mmol/mol) [7.1% (6.5-8.0%)]. Median baseline UKPDS risk score was 10.2% (6.0-16.7%) for intervention patients and 9.5% (5.8-15.1%) for control subjects (P = 0.80). One-year post-randomization, the median absolute reduction in UKPDS risk score was 1.0% greater for intervention patients compared with control subjects (P = 0.032). Similar changes were seen with the Framingham risk score (median reduction 1.2% greater for intervention patients compared with control subjects, P = 0.048). The two risk scores were highly correlated (rho = 0.83; P < 0.001). CONCLUSION: Adding pharmacists to primary care teams for 1 year significantly reduced the predicted 10-year risk of cardiovascular events for patients with Type 2 diabetes without established cardiovascular disease.


Subject(s)
Cardiovascular Diseases/drug therapy , Diabetes Mellitus, Type 2/drug therapy , Diabetic Angiopathies/drug therapy , Dyslipidemias/drug therapy , Hyperglycemia/drug therapy , Patient Care Team , Pharmacists , Primary Health Care/organization & administration , Adult , Aged , Blood Glucose/drug effects , Blood Pressure/drug effects , Cardiovascular Diseases/physiopathology , Cost-Benefit Analysis , Diabetes Mellitus, Type 2/complications , Diabetes Mellitus, Type 2/physiopathology , Diabetic Angiopathies/physiopathology , Diabetic Angiopathies/prevention & control , Female , Glycated Hemoglobin/drug effects , Humans , Hypoglycemic Agents/administration & dosage , Male , Middle Aged , Patient Care Team/organization & administration , Prospective Studies , Risk Factors
3.
Osteoporos Int ; 21(3): 391-8, 2010 Mar.
Article in English | MEDLINE | ID: mdl-19499272

ABSTRACT

SUMMARY: This study evaluated the effect of a multifaceted intervention (screening and patient education) by community pharmacists on testing or treatment of osteoporosis. One hundred and twenty-nine patients randomized to receive the intervention were compared to 133 patients who did not receive the intervention. Twice as many patients who got the intervention received further testing or treatment for osteoporosis. INTRODUCTION: The objective of this study was to determine the effect of a community pharmacist screening program on testing and treatment of osteoporosis. METHODS: In this randomized, controlled trial, 262 patients meeting bone mineral density (BMD) testing guidelines [men or women aged > or = 65 years or 50-64 years with one major risk factor including previous fracture, family history of osteoporosis, glucocorticoids for > 3 months, or early menopause] were allocated to intervention (129) or control (133). Intervention consisted of printed materials, education, and quantitative ultrasound. Primary outcome was a composite endpoint of BMD or prescription for osteoporosis medication within 4 months. RESULTS: Primary endpoint of BMD or osteoporosis treatment was achieved by 28 intervention patients (22%) compared with 14 controls (11%) (RR 2.1, 95% CI 1.1-3.7). This was driven by BMD testing (28 (22%) vs. 13 (10%) for controls, p = 0.011). Calcium intake increased more among intervention patients than controls (30% vs. 19%, RR 1.6, 95% CI 1.0-2.5). There was no effect on knowledge or quality of life. CONCLUSION: A pharmacist screening program doubled the number of patients tested for osteoporosis. Nevertheless, many patients eligible for BMD did not receive appropriate care suggesting more intensive interventions are needed.


Subject(s)
Community Pharmacy Services/organization & administration , Osteoporosis/diagnosis , Absorptiometry, Photon/statistics & numerical data , Aged , Alberta , Bone Density , Bone Density Conservation Agents/therapeutic use , Calcium/therapeutic use , Female , Humans , Male , Mass Screening/methods , Mass Screening/organization & administration , Middle Aged , Osteoporosis/drug therapy , Osteoporosis/etiology , Outcome Assessment, Health Care/methods , Patient Education as Topic/methods , Risk Factors , Single-Blind Method , Vitamin D/therapeutic use
4.
Emerg Med J ; 26(5): 371-6, 2009 May.
Article in English | MEDLINE | ID: mdl-19386880

ABSTRACT

INTRODUCTION: In ST elevation myocardial infarction (STEMI), prehospital management (PHM) may improve clinical outcomes through a reduction in reperfusion delay. The purpose of this study was to evaluate perceptions among healthcare stakeholder groups relating to the barriers and facilitators of implementing a PHM programme. METHODS: A 25-question cross-sectional survey, using a four-point Likert scale assessing barriers and facilitators of PHM, was distributed to paramedics, cardiologists, emergency physicians and emergency nurses within the Edmonton region, where prehospital STEMI treatment is established. The proportion of responses on each question was compared and differences between groups were determined using chi(2) and Fisher's exact tests. RESULTS: 57% (355/619) of subjects responded: 69% paramedics, 50% cardiologists, 54% emergency physicians and 45% emergency nurses. A majority believed PHM reduced treatment delays in both rural (96-100%) and urban (86-96%) areas, while decreasing patient mortality (paramedics 97%, cardiologists 74%, emergency physicians 85%, emergency nurses 88%). Regarding the capability of paramedics to deliver PHM, paramedics 25%, cardiologists 33%, emergency physicians 67%, and emergency nurses 47% stated that urban paramedics are better equipped and trained than rural paramedics. Although 81% of paramedics supported the possibility of PHM delivery without physician overview, 0% of cardiologists, 98% of emergency physicians and 95% emergency nurses agreed. A majority (71-88%) favoured mandatory signed informed consent. CONCLUSIONS: While stakeholders agreed on the benefits of PHM, perceptual differences existed on paramedics' ability to deliver PHM without physician overview. Addressing real and perceived barriers through communication and educational programmes may enhance PHM within this healthcare region and facilitate the implementation of PHM programmes.


Subject(s)
Attitude of Health Personnel , Emergency Medical Services/organization & administration , Myocardial Infarction/diagnosis , Alberta , Allied Health Personnel , Cross-Sectional Studies , Delivery of Health Care/organization & administration , Emergency Nursing , Humans , Informed Consent , Myocardial Infarction/therapy , Rural Health Services/organization & administration , Urban Health Services/organization & administration
5.
Int J Clin Pract ; 62(9): 1397-402, 2008 Sep.
Article in English | MEDLINE | ID: mdl-18793376

ABSTRACT

BACKGROUND: Trials evaluating angiotensin-receptor blockers in heart failure (HF) have shown inconsistent results. OBJECTIVE: To evaluate the effect of angiotensin II (AII) receptor blockers in HF patients on total mortality and HF hospitalisations. METHODS: Systematic search of the literature through MEDLINE (1980-2007) and abstracts of major cardiovascular congresses from 2002 to 2007. ELIGIBILITY CRITERIA: (i) randomised controlled trials with more than 500 patients and follow up > 6 months, (ii) availability of total mortality and/or (iii) availability of hospital admission because of worsening HF. Data retrieved by two independent reviewers. DerSimonian random effects model was used. RESULTS: Mortality data were available from 27,495 patients. When AII receptor blockers plus angiotensin-converting enzyme inhibitors (ACE-I) were compared with ACE-I in chronic HF trials, the relative risk (RR) for death was 0.98 (95% CI: 0.84-1.15). When AII receptor blockers were compared with ACE-I the RR for death was 1.06 (95% CI: 0.56-1.62). Similar results were found for postmyocardial infarction trials. The effects on hospital admission revealed a RR of 0.83 (95% CI: 0.71-0.97) and 1.09 (95% CI: 0.74-1.60) respectively. CONCLUSION: Angiotensin II receptor blockers did not show any beneficial effect on mortality when used in combination with ACE-I or when compared with ACE-I alone. A 17% reduction in hospital admissions was observed.


Subject(s)
Angiotensin II Type 1 Receptor Blockers/therapeutic use , Heart Failure/mortality , Aged , Angiotensin-Converting Enzyme Inhibitors/therapeutic use , Chronic Disease , Clinical Trials as Topic , Drug Combinations , Heart Failure/drug therapy , Hospitalization , Humans , Middle Aged
6.
Aliment Pharmacol Ther ; 25(9): 1017-28, 2007 May 01.
Article in English | MEDLINE | ID: mdl-17439502

ABSTRACT

BACKGROUND: Although reversal of pretransplant renal dysfunction in hepatorenal syndrome reduces post-transplant complications, the overall impact on morbidity and mortality requires clarification. AIM: To review trials of pharmacologic interventions in hepatorenal syndrome, with specific assessment of trial quality and study endpoints, including patient survival and renal outcome measures. METHODS: Literature search and selection was carried out by a single reviewer. Data extraction and quality analysis were carried out by two independent reviewers. RESULTS: Of 848 identified articles, 36 were eligible for inclusion. Twenty-one were full-text. Only 19% were randomized-controlled trials. About 50% of studies included only Type 1 hepatorenal syndrome patients. Serum creatinine, urine output and urine sodium were the most common renal outcome measures. Only 42% defined a primary renal endpoint. About 88% of articles reported mortality rates. CONCLUSIONS: Existing literature of pharmacologic agents for use in hepatorenal syndrome is limited by poor study design, including non-randomization, heterogeneous study populations, lack of power, and limited use of clinically relevant outcomes. There is insufficient information in most trials to judge the impact of pharmacologic therapy on mortality or rates of transplantation. The validity of renal outcome measures as surrogate markers of more clinically relevant endpoints has not been established.


Subject(s)
Hepatorenal Syndrome/drug therapy , Female , Hepatorenal Syndrome/complications , Hepatorenal Syndrome/mortality , Humans , Male , Multicenter Studies as Topic , Prospective Studies , Randomized Controlled Trials as Topic , Retrospective Studies , Survival Analysis
7.
Circulation ; 100(10): 1056-64, 1999 Sep 07.
Article in English | MEDLINE | ID: mdl-10477530

ABSTRACT

BACKGROUND: We investigated the effects of candesartan (an angiotensin II antagonist) alone, enalapril alone, and their combination on exercise tolerance, ventricular function, quality of life (QOL), neurohormone levels, and tolerability in congestive heart failure (CHF). METHODS AND RESULTS: Seven hundred sixty-eight patients in New York Heart Association functional class (NYHA-FC) II to IV with ejection fraction (EF) <0.40 and a 6-minute walk distance (6MWD) <500 m received either candesartan (4, 8, or 16 mg), candesartan (4 or 8 mg) plus 20 mg of enalapril, or 20 mg of enalapril for 43 weeks. There were no differences among groups with regard to 6MWD, NYHA-FC, or QOL. EF increased (P=NS) more with candesartan-plus-enalapril therapy (0.025+/-0.004) than with candesartan alone (0.015+/-0.004) or enalapril alone(0.015+/-0.005). End-diastolic (EDV) and end-systolic (ESV) volumes increased less with combination therapy (EDV 8+/-4 mL; ESV 1+/-4 mL; P<0.01) than with candesartan alone (EDV 27+/-4 mL; ESV 18+/-3 mL) or enalapril alone (EDV 23+/-7 mL; ESV 14+/-6 mL). Blood pressure decreased with combination therapy (6+/-1/4+/-1 mm Hg) compared with candesartan or enalapril alone (P<0.05). Aldosterone decreased (P<0.05) with combination therapy (23.2+/-5.3 pg/mL) at 17 but not 43 weeks compared with candesartan (0.7+/-7.8 pg/mL) or enalapril (-0.8+/-11. 3 pg/mL). Brain natriuretic peptide decreased with combination therapy (5.8+/-2.7 pmol/L; P<0.01) compared with candesartan (4. 4+/-3.8 pmol/L) and enalapril alone (4.0+/-5.0 pmol/L). CONCLUSIONS: Candesartan alone was as effective, safe, and tolerable as enalapril. The combination of candesartan and enalapril was more beneficial for preventing left ventricular remodeling than either candesartan or enalapril alone.


Subject(s)
Angiotensin-Converting Enzyme Inhibitors/therapeutic use , Benzimidazoles/therapeutic use , Enalapril/therapeutic use , Heart Failure/drug therapy , Tetrazoles/therapeutic use , Aged , Biphenyl Compounds , Blood Pressure/drug effects , Creatinine/blood , Drug Combinations , Female , Heart Failure/physiopathology , Heart Rate/drug effects , Hormones/blood , Humans , Male , Middle Aged , Pilot Projects , Potassium/blood , Ventricular Dysfunction, Left/drug therapy , Ventricular Dysfunction, Left/physiopathology , Ventricular Function
8.
Arch Intern Med ; 161(11): 1405-10, 2001 Jun 11.
Article in English | MEDLINE | ID: mdl-11386889

ABSTRACT

BACKGROUND: Some of the benefit of statins for the prevention of cardiovascular disease may be due to their antithrombotic properties. Little is known about the effect of these drugs on the development of deep vein thrombosis. MATERIALS AND METHODS: We conducted a retrospective cohort study over an 8-year period by linking Ontario provincial health care administrative databases covering more than 1.4 million Ontario residents aged 65 years or older. We excluded those with a documented history of atherosclerosis, venous thromboembolism, or cancer within 36 months prior to study enrollment, as well as those prescribed warfarin sodium within 12 months before enrollment. In the primary cohort, we evaluated the subsequent risk of deep vein thrombosis (DVT) among men and women prescribed thyroid replacement therapy, nonstatin lipid-lowering agents, or statins. A second cohort of women only was evaluated in a similar fashion, but estrogen use was added as a third comparison drug group. RESULTS: There were 125 862 men and women in the primary cohort. After adjusting for age; sex; prior hospitalization; newly diagnosed cancer; or prescribed aspirin, warfarin, or estrogen, statin users (n = 77 993) had an associated decreased risk of DVT relative to those prescribed thyroid replacement therapy (n = 35 978) (adjusted hazard ratio [HR], 0.78; 95% confidence interval [CI], 0.69-0.87). Compared with thyroid replacement therapy, users of nonstatin lipid-lowering agents (n = 11 891) did not seem to be at lower risk for deep vein thrombosis (HR, 0.97; 95% CI, 0.79-1.18). In the secondary cohort of 89 508 women, after adjusting for age, prior hospitalization, newly diagnosed cancer, or prescribed aspirin or warfarin, estrogen users (n = 29 165) had an associated increased risk for DVT compared with those receiving thyroid replacement therapy (n = 22 118) (HR, 1.16; 95% CI, 1.01-1.33), while statin users had an associated decreased risk (HR, 0.68; 95% CI, 0.59-0.79). Nonstatin lipid-lowering agents (n = 5155) were not associated with a reduced risk of DVT compared with thyroid replacement therapy (HR, 0.84; 95% CI, 0.63-1.12). CONCLUSION: Among selected individuals aged 65 years or older, statins were associated with a 22% relative risk reduction in the risk of DVT. A randomized clinical trial is needed to evaluate the efficacy of statins for the primary and secondary prevention of DVT.


Subject(s)
Anticholesteremic Agents/therapeutic use , Lovastatin/therapeutic use , Venous Thrombosis/prevention & control , Aged , Cohort Studies , Estrogens/therapeutic use , Female , Humans , Male , Multivariate Analysis , Retrospective Studies , Risk Factors , Thyroid Hormones/therapeutic use
9.
Arch Intern Med ; 160(1): 41-6, 2000 Jan 10.
Article in English | MEDLINE | ID: mdl-10632303

ABSTRACT

Atrial fibrillation (AF) is a growing public health problem associated with significant morbidity and mortality. Numerous randomized controlled trials of warfarin have conclusively demonstrated that long-term anticoagulation therapy can reduce the risk for stroke by approximately 68% per year in patients with nonvalvular AF, and even more in patients with valvular AF. However, available data show that of those patients with AF and no contraindication to warfarin therapy, only 15% to 44% are prescribed warfarin. Our literature review has identified patient-, physician-, and health care system-related barriers to warfarin prescription. However, the relative importance of these specific barriers remains unknown. Further work is needed to understand the discrepancy between the randomized controlled trial evidence and clinical practice patterns.


Subject(s)
Anticoagulants/therapeutic use , Atrial Fibrillation/complications , Stroke/prevention & control , Warfarin/therapeutic use , Evidence-Based Medicine , Humans , Practice Patterns, Physicians' , Randomized Controlled Trials as Topic , Risk , Stroke/etiology
10.
Arch Intern Med ; 161(19): 2337-42, 2001 Oct 22.
Article in English | MEDLINE | ID: mdl-11606149

ABSTRACT

BACKGROUND: Few studies have prospectively and systematically explored the factors that acutely precipitate exacerbation of congestive heart failure (CHF) in patients with left ventricular dysfunction. Knowledge of such factors is important in designing measures to prevent deterioration of clinical status. The objective of this study was to prospectively describe the precipitants associated with exacerbation of CHF status in patients enrolled in the Randomized Evaluation of Strategies for Left Ventricular Dysfunction Pilot Study. METHODS: We conducted a 2-stage, multicenter, randomized trial in 768 patients with CHF who had an ejection fraction of less than 40%. Patients were randomly assigned to receive enalapril maleate, candesartan cilexetil, or both for 17 weeks, followed by randomization to receive metoprolol succinate or placebo for 26 weeks. Investigators systematically documented information on clinical presentation, management, and factors associated with the exacerbation for any episode of acute CHF during follow-up. RESULTS: A total of 323 episodes of worsening of CHF occurred in 180 patients during 43 weeks of follow-up; 143 patients required hospitalization, and 5 died. Factors implicated in worsening of CHF status included noncompliance with salt restriction (22%); other noncardiac causes (20%), notably pulmonary infectious processes; study medications (15%); use of antiarrhythmic agents in the past 48 hours (15%); arrhythmias (13%); calcium channel blockers (13%); and inappropriate reductions in CHF therapy (10%). CONCLUSIONS: A variety of factors, many of which are avoidable, are associated with exacerbation of CHF. Attention to these factors and patient education are important in the prevention of CHF deterioration.


Subject(s)
Heart Failure/drug therapy , Heart Failure/mortality , Metoprolol/analogs & derivatives , Tetrazoles , Ventricular Dysfunction, Left/drug therapy , Ventricular Dysfunction, Left/mortality , Adrenergic beta-Antagonists/therapeutic use , Aged , Antihypertensive Agents/therapeutic use , Benzimidazoles/therapeutic use , Biphenyl Compounds/therapeutic use , Disease Progression , Double-Blind Method , Drug Therapy, Combination , Enalapril/therapeutic use , Female , Hospitalization , Humans , Male , Metoprolol/therapeutic use , Middle Aged , Patient Compliance , Precipitating Factors , Prospective Studies , Severity of Illness Index , Stroke Volume/drug effects , Treatment Outcome
11.
Drugs ; 61(14): 2021-33, 2001.
Article in English | MEDLINE | ID: mdl-11735631

ABSTRACT

Congestive heart failure (CHF) is associated with substantial morbidity and mortality, and is the only major cardiovascular disease increasing in prevalence. Despite abundant evidence to support their efficacy and cost-effectiveness, angiotensin-converting enzyme (ACE) inhibitors are sub-optimally used in patients with CHF. This paper reviews the evidence for the sub-optimal use of ACE inhibitors in patients with CHF, the factors contributing to this, and its implications for health systems. A systematic review of all articles assessing practice patterns (specifically the use of ACE inhibitors in CHF) identified by MEDLINE, search of bibliographies, and contact with content experts was undertaken. 37 studies have documented the use of ACE inhibitors in patients with CHF. Studies assessing use among all patients with CHF document 33% to 67% (median 51%) of all patients discharged from hospital and 10% to 36% (median 26%) of community dwelling patients were prescribed ACE inhibitors. Rates of ACE inhibitor use range from 43% to 90% (median of 71%) amongst those discharged from hospital having known systolic dysfunction, and from 67% to 95% (median of 86%) for those monitored in specialty clinics. Moreover, the dosages used in the 'real world' are substantially lower than those proven efficacious in randomised, controlled trials, with evaluations reporting only a minority of patients achieving target doses and/or an overall mean dose achieved to be less than one-half of the target dose. Factors predicting the use and optimal dose administration of ACE inhibitors are identified, and include variables relating to the setting (previous hospitalisation, specialty clinic follow-up), the physician (cardiology specialty versus family practitioner or general internist, board certification), the patient (increased severity of symptoms, male, younger), and the drug (lower frequency of administration). In light of the substantial evidence for reductions in morbidity and mortality, clearly, the prescription of ACE inhibitors is sub-optimal. Wide variability in ACE inhibitor use is noted, with higher rates consistently reported among patients having systolic dysfunction confirmed by an objective assessment--an apparent minority of the those having CHF. Optimisation of the prescription of proven efficacious therapies has the potential to confer a substantial reduction in the total cost of care for patients with CHF by reducing hospitalisations and lengths of hospital stays. It is likely that only multifaceted programs targeted toward the population at large will yield benefits to the healthcare system, given the widespread nature of the sub-optimal prescription of therapies proven effective in the management of patients with CHF.


Subject(s)
Angiotensin-Converting Enzyme Inhibitors/therapeutic use , Heart Failure/drug therapy , Dose-Response Relationship, Drug , Drug Administration Schedule , Evidence-Based Medicine , Heart Failure/mortality , Humans , Morbidity , Patient Selection , Practice Patterns, Physicians'
12.
Chest ; 105(6): 1687-92, 1994 Jun.
Article in English | MEDLINE | ID: mdl-7911417

ABSTRACT

OBJECTIVE: To define contemporary age- and sex-related mortality risks and patterns of medical practice in acute myocardial infarction (AMI). DESIGN: Retrospective comparison of demographic and clinical variables, including the use of proven effective AMI medical therapy, among AMI patients cohorts from 1987 to 1992. PATIENTS/SETTING: Of a total of 2,070 AMI patients, 629 were women and 1,441, men; 951 patients were managed in university hospitals, 641 in a regional hospital, and 478 in community hospitals. INTERVENTIONS: No direct study interventions; results of practice patterns and risk analyses of the earlier (1987-90) AMI cohorts, however, were published concurrently with the actual practices of the more recent (1991-92) cohorts and may have had some indirect effect on the recent practice patterns. RESULTS: Univariate analysis showed that mortality was higher (p < 0.0001) and use of thrombolysis, beta blockers, and acetylsalicylic acid was lower (p < 0.0001) in patients 70 years of age and older, compared with younger patients, and in women, compared with men. Multivariate analysis of the entire patient sample revealed age of 75 years or older (154 percent) and age 70 to 74 years (141 percent) to be associated with the highest relative risk of death in hospital. The increased relative risk associated with previous AMI was 45 percent. Acetylsalicylic acid use was associated with the greatest decrease in relative risk of death (-69 percent), followed by beta blockers (-36 percent) and thrombolysis (-31 percent). These patterns of relative risk were the same for men and women. CONCLUSIONS: Among contemporary AMI patients, advanced age and female sex are associated with relative under-utilization of proven effective medical therapy and increased risk of dying in the hospital. Although the contribution of age to AMI risk appears greater than that of gender, survival in any high risk group would likely be improved by increased use of proven medical therapy.


Subject(s)
Hospital Mortality , Myocardial Infarction/mortality , Outcome and Process Assessment, Health Care/statistics & numerical data , Practice Patterns, Physicians'/statistics & numerical data , Adrenergic beta-Antagonists/therapeutic use , Age Factors , Aged , Aspirin/therapeutic use , Canada/epidemiology , Cohort Studies , Female , Humans , Male , Middle Aged , Multivariate Analysis , Myocardial Infarction/drug therapy , Retrospective Studies , Risk Factors , Sex Factors , Thrombolytic Therapy
13.
J Am Geriatr Soc ; 47(7): 811-8, 1999 Jul.
Article in English | MEDLINE | ID: mdl-10404924

ABSTRACT

OBJECTIVES: To review the evidence for clinical efficacy and cost-effectiveness of proven medications in the treatment and prevention of myocardial infarction (MI) in older patients; to summarize Canadian data on treatment patterns and clinical outcomes for younger and older patients with coronary heart disease; to explore the reasons for gaps between best care, based on the evidence of efficacy from trials, and usual care, based on the population effectiveness audits; and to explore potential approaches to closing the care gaps. DESIGN: Review of the recent clinical trial literature on the management of MI, highlighting results in older patients. Review of medication utilization and outcomes data from a series of large, consecutively enrolled patient cohorts with acute MI (N = 7070) in a variety of cardiac care settings (10 centers in five Canadian provinces, including university-based teaching hospitals, community hospitals, cardiologist and family physician out-patient clinics) from 1987 to 1996. RESULTS: There is no qualitative interaction of cardiac therapies: thrombolytics, beta-blockers, acetylsalicylic acid (ASA), and statins are efficacious in all clinically relevant patient subgroups, including older people. However, there are consistent gaps between usual care and best care, particularly among older patients (in whom there is also a concomitantly higher mortality risk). Repeated multivariate analyses confirm older age to be an independent contributor to increased risk. Use of efficacious medications is, in contrast, consistently associated with increased survival. Analysis of temporal trends suggests beneficial changes in practice patterns and outcomes are possible to achieve. However, "best care" has not been rapidly or completely achieved. Review of strategies to close these care gaps suggests that audit and feedback, critical pathways, and multifactorial interventions involving patients and other members of the healthcare team as well as physicians may be the most efficacious strategies for change. CONCLUSIONS: Despite equal or enhanced efficacy, there is consistently less prescription of proven drugs among older cardiac patients. These care patterns may contribute to their enhanced risk. The causes underlying these practice patterns are complex, and their population impact may be undervalued by clinicians and managers. Improvement of these patterns is difficult, but ultimately it would be beneficial for this presently disadvantaged, readily identified, high risk patient population.


Subject(s)
Coronary Disease/therapy , Health Services for the Aged/standards , Practice Patterns, Physicians'/standards , Quality of Health Care , Aged , Aged, 80 and over , Benchmarking , Canada/epidemiology , Cohort Studies , Coronary Disease/complications , Coronary Disease/mortality , Cost-Benefit Analysis , Evidence-Based Medicine , Humans , Multivariate Analysis , Practice Patterns, Physicians'/economics , Risk Factors , Survival Analysis , Treatment Outcome
14.
Pharmacotherapy ; 21(5): 576-82, 2001 May.
Article in English | MEDLINE | ID: mdl-11349746

ABSTRACT

All articles assessing adherence to hypolipidemic drugs were reviewed and categorized by patient population (clinical trial, unselected) and reported as rates of nonadherence and discontinuation. Overall, levels of discontinuation reported in clinical trials (6-31%) and lipid clinics (2-38%) are similar, with unselected populations consistently reporting higher rates (15-78%). Rates of nonadherence in clinical trials and lipid clinics also are comparable, with unselected populations having the highest rates. Across all settings, rates of discontinuation and nonadherence are consistently reported to be poorer with resins and niacin than with hydroxy-6-methylglutamate coenzyme A reductase inhibitors. Adherence to hypolipidemic agents appears to decrease in parallel with level of follow-up. Data evaluating mechanisms of poor adherence are limited. While the search for new, efficacious therapies must continue, efforts focused on improving adherence to proven therapy may have a greater overall impact on health than any single new agent.


Subject(s)
Clinical Trials as Topic/statistics & numerical data , Hypercholesterolemia/drug therapy , Hypolipidemic Agents/therapeutic use , Treatment Refusal , Aged , Ambulatory Care Facilities/statistics & numerical data , Clinical Trials as Topic/methods , Follow-Up Studies , Humans , Randomized Controlled Trials as Topic , Treatment Refusal/statistics & numerical data
15.
Pharmacotherapy ; 21(7): 807-17, 2001 Jul.
Article in English | MEDLINE | ID: mdl-11444577

ABSTRACT

Hypercholesterolemia is a major risk factor for coronary heart disease, and data indicate that aggressive cholesterol reduction decreases mortality and morbidity associated with this disease. Many patients with hypercholesterolemia, however, are not screened, prescribed appropriate lipid-lowering therapy, or treated to target cholesterol levels. Practice patterns are particularly inadequate for those patients at highest risk for having a cardiac event. We performed a literature search to identify studies of practice patterns in the management of patients with hypercholesterolemia with regard to screening, implementing lipid-lowering therapy, and treating to lipid goals. The findings highlight the potential for substantial opportunities to improve patient outcomes. Future studies should evaluate reasons for suboptimal cholesterol management as well as provide steps to improve management.


Subject(s)
Evidence-Based Medicine/methods , Hypercholesterolemia , Practice Guidelines as Topic , Animals , Anticholesteremic Agents/economics , Anticholesteremic Agents/therapeutic use , Clinical Trials as Topic/statistics & numerical data , Humans , Hypercholesterolemia/drug therapy , Hypercholesterolemia/economics , Risk Factors
16.
Pharmacotherapy ; 21(5): 627-35, 2001 May.
Article in English | MEDLINE | ID: mdl-11349751

ABSTRACT

The Study of Cardiovascular Risk Intervention by Pharmacists, a randomized, controlled trial in over 50 community pharmacies in Alberta and Saskatchewan, Canada, demonstrated that a pharmacist intervention program improved cholesterol risk management in patients at high risk for cardiovascular disease. In a substudy, costs and consequences were analyzed to describe the economic impact of the program. Two perspectives were taken: a government-funded health care system and a pharmacy manager. Costs were reported in 1999 Canadian dollars. Incremental costs to a government payor and community pharmacy manager were $6.40/patient and $21.76/patient, respectively, during the 4-month follow-up period. The community pharmacy manager had an initial investment of $683.50. The change in Framingham risk function for the intervention group from baseline also was reported. The 10-year risk of cardiovascular disease decreased from 17.3% to 16.4% (p<0.0001) during the 4 months. The intervention program in this study led to a significant reduction in cardiovascular risk in the intervention group during the 4-month follow-up period. The incremental cost to provide the program appeared minimal from both government and pharmacy manager perspectives. It is hoped that these results could support negotiations for reimbursement of clinical pharmacy services with payors.


Subject(s)
Cardiovascular Diseases/economics , Cardiovascular Diseases/prevention & control , Cholesterol , Community Pharmacy Services/economics , Pharmacists/economics , Aged , Anticholesteremic Agents/economics , Anticholesteremic Agents/therapeutic use , Blood Pressure , Canada/epidemiology , Cardiovascular Diseases/epidemiology , Chi-Square Distribution , Cholesterol/blood , Community Pharmacy Services/statistics & numerical data , Costs and Cost Analysis/economics , Costs and Cost Analysis/statistics & numerical data , Humans , Hypercholesterolemia/drug therapy , Hypercholesterolemia/economics , Hypercholesterolemia/epidemiology , Hypertension/drug therapy , Hypertension/economics , Hypertension/epidemiology , Middle Aged , Pharmacists/statistics & numerical data , Risk Assessment , Risk Factors , Statistics, Nonparametric
17.
Pharmacotherapy ; 20(9): 1060-5, 2000 Sep.
Article in English | MEDLINE | ID: mdl-10999498

ABSTRACT

STUDY OBJECTIVE: To evaluate the adequacy of anticoagulation in patients with atrial fibrillation (AF) coming to a hospital. DESIGN: Retrospective medical record review. SETTING: Tertiary care hospital. PATIENTS: Consecutive patients with a history of AF who had been prescribed warfarin and who had the international normalized ratio (INR) measured when they arrived at the hospital. Those who developed AF as a complication during hospitalization were excluded. MEASUREMENTS AND MAIN RESULTS: Of 1085 patients, 375 (mean age 73 yrs, 56.3% men) were eligible for further evaluation. Most had nonvalvular AF; in 44.5% the INR was subtherapeutic, in 36.5% it was therapeutic, and in 18.9% it was supratherapeutic. Patients admitted for any thromboembolic event and for ischemic stroke were significantly more likely to have subtherapeutic INRs. CONCLUSION: It is well documented in the literature that warfarin is underprescribed, but our results suggest that even in treated patients, about half are inadequately protected from thromboembolism.


Subject(s)
Anticoagulants/administration & dosage , Atrial Fibrillation/drug therapy , International Normalized Ratio/statistics & numerical data , Stroke/prevention & control , Thromboembolism/prevention & control , Warfarin/administration & dosage , Aged , Analysis of Variance , Chi-Square Distribution , Female , Humans , Male , Middle Aged , Patients/statistics & numerical data , Retrospective Studies
18.
Pharmacotherapy ; 20(4): 387-93, 2000 Apr.
Article in English | MEDLINE | ID: mdl-10772368

ABSTRACT

Despite strong evidence that inhaled corticosteroids are beneficial in treating asthma, a number of small studies suggest a use rate of only 34-56%. The primary objective of this study was to determine patterns of prescribing inhaled corticosteroids for high-risk patients with asthma. Secondary objectives were to assess patterns of practice with respect to other agents prescribed before and at hospital discharge, and to determine if an emergency room asthma care map at one of the study hospitals was being followed. We retrospectively reviewed charts of 1022 patients with an acute attack of asthma treated in the emergency rooms of the Royal Alexandra Hospital and University of Alberta Hospital from January 1, 1996, to March 31, 1997. A forward stepwise logistic regression analysis was performed with the dependent variable defined as whether or not the patient was using an inhaled or oral corticosteroid during the index visit, and the independent variable being all major demographic variables. Inhaled corticosteroids were prescribed for 460 patients (52.0%) at the index visit. Overall, antiinflammatory drugs were prescribed for 548 patients (62.1%). An asthma care map was followed for 107 (16.8%) patients treated at the Royal Alexandra Hospital at the index visit. Logistic regression analysis showed that women and patients with more than one emergency room visit most likely were to be using inhaled or inhaled plus oral corticosteroids at the index visit. Documentation of drug therapy at discharge was poor for 42% of patients; therefore, analysis of practice patterns in this group was not attempted. This study shows that inhaled corticosteroids were prescribed for only about one-half of patients with an acute asthma attack. Given this low use by high-risk patients, the need for programs designed to improve asthma therapy is evident.


Subject(s)
Adrenal Cortex Hormones/therapeutic use , Asthma/drug therapy , Administration, Inhalation , Adolescent , Adult , Aged , Aged, 80 and over , Animals , Cricetinae , Drug Prescriptions/statistics & numerical data , Female , Humans , Logistic Models , Male , Middle Aged , Office Visits/statistics & numerical data , Practice Patterns, Physicians'/statistics & numerical data , Primary Health Care/statistics & numerical data , Referral and Consultation , Retrospective Studies
19.
Pharmacotherapy ; 20(7): 823-9, 2000 Jul.
Article in English | MEDLINE | ID: mdl-10907972

ABSTRACT

STUDY OBJECTIVE: To explore barriers to adherence to drug therapy identified by patients with congestive heart failure (CHF). SETTING: University-associated heart failure clinic and a family practice clinic. PATIENTS: Twenty-six patients with CHF. INTERVENTION: Four focus group sessions. MEASUREMENTS AND MAIN RESULTS: Participants were asked to describe how their lives changed as a result of developing CHF and the challenges they face when taking drugs for the condition. In the second half of each session, participants were asked for their opinions regarding various teaching and memory aids for improving adherence with therapy. They recognized the value of these aids and often created their own when health care professionals did not supply them. Transcripts were reviewed and comments grouped to identify patient-perceived barriers to adherence. The disease placed significant limitations on lifestyle. Furosemide had dramatic effects on daily activities, and some patients altered the dosing schedule to accommodate their plans. Influences on adherence were generalized into five themes: confidence in health care providers; their own knowledge regarding the disease and drugs used to treat it; previous experience with drugs; support from family and friends; and ease of communication with health care professionals. CONCLUSION: Focus groups are an effective and efficient method to explore patients opinions of barriers to drug therapy adherence. Such information can have a direct impact on management of patients with CHF. Information gathered in this study will be used to construct a survey to measure barriers to drug adherence and design interventions to improve adherence.


Subject(s)
Cardiovascular Agents/therapeutic use , Communication Barriers , Focus Groups , Heart Failure/drug therapy , Patient Compliance , Aged , Family Practice , Female , Heart Failure/complications , Heart Failure/epidemiology , Humans , Male , Middle Aged , Patient Education as Topic , Social Support
20.
Pharmacotherapy ; 21(6): 731-9, 2001 Jun.
Article in English | MEDLINE | ID: mdl-11401185

ABSTRACT

We designed this project to determine community pharmacists' opinions regarding the challenges and motivations of their recent participation in a pharmacy practice-based research study At the conclusion of a randomized, multicenter study, 87 community pharmacist-investigators were sent a questionnaire that explored four areas: motivating factors to participate, barriers to participation, communication tools used by study coordinators, and design issues for future studies. Fifty-eight (67%) completed questionnaires were returned. Key factors motivating participation in the study were desire to improve the profession and opportunity to learn. Time was the greatest barrier to participation. Pharmacy practice-based research has two distinct advantages. First, it translates clinical knowledge into direct application in the community. Second, it provides needed data to demonstrate the value of enhanced pharmacy practice. Thorough understanding of pharmacists' opinions is necessary to optimize the design of future studies.


Subject(s)
Attitude of Health Personnel , Community Pharmacy Services/statistics & numerical data , Health Services Research , Pharmacists/psychology , Surveys and Questionnaires , Cardiovascular Diseases/drug therapy , Cardiovascular Diseases/prevention & control , Humans , Patient Selection , Population Surveillance , Research Design , Risk Factors
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