Evaluation of a training program for medicines-oriented policymakers to use a database of systematic reviews.

BACKGROUND: Suboptimal prescribing and medications use is a problem for health systems globally. Systematic reviews are a comprehensive resource that can help guide evidence-informed decision-making and implementation of interventions addressing such issues; however, a barrier to the use of systematic reviews is their inaccessibility (due to both dispersion across journals and inaccessibility of content). Publicly available databases, such as Rx for Change, provide quick access to summaries of appraised systematic reviews of professional and consumer-oriented interventions to improve prescribing behaviour and appropriate medication use, and may help maximise the use of evidence to inform decisions. The present study aims to evaluate a training program to improve attitudes towards, confidence in skills, intentions to use, and use of systematic review evidence contained within Rx for Change. METHODS: Guided by the Knowledge to Action framework, a training program with content customised to local provider and consumer contexts was developed with knowledge user input. The training program consisted of a 6 minute information video, a 1 hour workshop with hands-on, interactive and didactic components, and two post-training reminders. Forty-nine people from five medicines-focused organisations in Canada and Australia attended one of six workshops. Participants were surveyed immediately pre and post and 3 months after training to evaluate their attitudes towards, confidence in skills, intentions to use, and use of Rx for Change, and attitudes towards and confidence in skills for using evidence for decision-making. Analyses for differences for each of the outcomes at three time points (pre, post and 3 months after training) was performed using a random effects model. RESULTS: Immediately post-training, there were higher respondent attitudes towards Rx for Change (mean increase = 0.54 out of 5, 95% CI, 0.18-0.83, P < 0.005); intention to use Rx for Change (0.53, 95% CI, 0.21-0.86, P < 0.005); confidence in skills for using Rx for Change (2.08, 95% CI, 1.74-2.42, P < 0.005); and confidence in skills for using evidence in policy decision-making (0.50, 95% CI, 0.22-0.77, P < .005) compared to pre-training. Confidence in skills for using both Rx for Change and evidence were maintained 3 months after training (both P < 0.005). CONCLUSIONS: Participants of this training program reported sustained improvements in their confidence in skills for using evidence in policy decision-making. This may have important implications for uptake of systematic review evidence promoting improved prescribing and medication use.

"Fishing" for the origins of the "Eskimos and heart disease" story: facts or wishful thinking?

During the 1970s, 2 Danish investigators, Bang and Dyerberg, on being informed that the Greenland Eskimos had a low prevalence of coronary artery disease (CAD) set out to study the diet of this population. Bang and Dyerberg described the "Eskimo diet" as consisting of large amounts of seal and whale blubber (ie, fats of animal origin) and suggested that this diet was a key factor in the alleged low incidence of CAD. This was the beginning of a proliferation of studies that focused on the cardioprotective effects of the "Eskimo diet." In view of data, which accumulated on this topic during the past 40 years, we conducted a review of published literature to examine whether mortality and morbidity due to CAD are indeed lower in Eskimo/Inuit populations compared with their Caucasian counterparts. Most studies found that the Greenland Eskimos and the Canadian and Alaskan Inuit have CAD as often as the non-Eskimo populations. Notably, Bang and Dyerberg's studies from the 1970s did not investigate the prevalence of CAD in this population; however, their reports are still routinely cited as evidence for the cardioprotective effect of the "Eskimo diet." We discuss the possible motives leading to the misinterpretation of these seminal studies.

What is the feasibility of implementing effective sodium reduction strategies to treat hypertension in primary care settings? A systematic review.

OBJECTIVE: To evaluate whether efficacious counseling methods on sodium restriction can be successfully incorporated into primary care models for the management of hypertension. METHODS: We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects and Health Technology Assessment to identify randomized controlled trials of dietary counseling for salt intake reduction that reported significant reduction in 24-h urinary sodium and blood pressure levels among adults with untreated hypertension. Data extraction and assessment of reproducibility and feasibility were done in duplicate and any disagreements were resolved by consensus. RESULTS: Six trials were included for assessment of methods as they were efficacious in reducing sodium intake (24-h urinary sodium excretion) by 73 to 93 mmol/day (intervention) vs. 3.2 to 12.5 mmol/day (control). This was paralleled with a reduction in blood pressure (-4 to -27  mmHg) between groups. In four of the six trials, the methods were described in sufficient detail to be reproducible, but in none of these trials were the 'counseling methods' feasible for application in primary care settings. Apart from multiple sessions of counseling, the reported interventions were supplemented with provision of prepared food, community cooking classes, and intensive inpatient training sessions. CONCLUSION: Despite the availability of efficacious counseling methods for the reduction of sodium intake among newly diagnosed hypertensive patients (feasible within a clinical trial setting), none of these methods, in their present form, are suitable for incorporation into existing primary care settings in countries such as Canada, United States, and UK.

Population-based versus high-risk strategies for the prevention of cardiovascular diseases in low- and middle-income countries.

Cardiovascular diseases (CVD) are now the number one cause of death in low- and middle-income countries (LMIC), such as those in South East Asia (SEA). It is projected that SEA countries will have the greatest total number of deaths due to non-communicable diseases (NCDs) by 2020. In low resource countries, the rising burden of CVDs imposes severe economic consequences that range from impoverishment of families to high health system costs and the weakening of country economies. There are two possible options to be considered for addressing this issue: a "population-based strategy" and/or a "high risk" strategy. The question is, what is the optimal way to reduce the excessive burden of these diseases in the LMICs. We believe that by applying systematic policy and smoking cessation programs with proven effectiveness, there is a chance that the high smoking prevalence, particularly among SEA.

A cross-national comparative study of blood pressure levels and hypertension prevalence in Canada and Hungary.

PURPOSE: Hungary has one of the highest cardiovascular (CV) mortality and stroke rates compared to other countries in Europe and North America. Data from two recent blood pressure (BP) screening projects in Hungary and Canada provided us with the opportunity to compare potential differences in the prevalence of hypertension between these countries. METHODS: From the Ontario Blood Pressure Survey, 880 white Canadians between 20 and 62 years old with white-collar occupation were selected and compared with a total of 1000 Hungarian bank employees in the same age range. Identical methods were employed for CV risk factor screening and BP measurements using the BpTRU instrument. Hypertension was defined by elevated BP measurement (SBP ≥140  mmHg and/or DBP ≥90  mmHg) or current intake of antihypertensive medication. RESULTS: Canadian participants were on average 10 years older with a higher rate of obesity, diabetes and high cholesterol. Smoking was more prevalent among Hungarians (29.4 vs. 22.5%, P  <  0.001). Despite being younger, Hungarians exhibited significantly higher SBP (121.3  ±  4.3 vs. 111.6  ±â€Š 14.1, P  <  0.001) and DBP (78.5  ±â€Š 10.5 vs. 70.8  ±â€Š 9.5, P  <  0.001), which remained significant after adjustment for age and use of antihypertensive medication as well as sex and CV risk factors. Age-adjusted prevalence of hypertension was significantly higher and poorly controlled among Hungarians (P  <  0.001). CONCLUSION: The increased prevalence of hypertension among young and middle-aged Hungarians compared with Canadians could represent an essential contributor to the high CV mortality and stroke rates in Hungary. BP awareness, treatment and control require improved medical attention and should be addressed early among young Hungarians.

High prevalence of prehypertension and hypertension in a working population in Hungary.

BACKGROUND: Hungary has one of the highest mortality rates due to strokes among the European Union countries. As elevated blood pressure (BP) is the principal risk factor for strokes, we assessed BP levels, as well as awareness and treatment status of hypertension and prehypertension in a working population sample in Hungary. METHODS: Worksite employees in Budapest and Szeged were screened for their BP using an automated BP measuring instrument (BpTRU). BpTRU readings of heart rate (HR) were also recorded. Respondents were classified as normotensives (NT), prehypertensives (PHTN) and hypertensives (HTN) according to their BP levels, as defined by the JNC 7 guidelines. Body height and body weight were measured and body mass index (BMI) was calculated. Self-reported information regarding smoking was collected. RESULTS: In total, 2,012 respondents were recruited (1,000 white collar; 1,012 blue-collar workers), with a mean (±s.d.) age of 34.8 (±9.9) years. Of all respondents, 22.6% were identified as HTN and 39.8% as PHTN. Among HTN, 40% were unaware of their condition and only 18.5% were adequately treated. PHTN were similar in age as NT, but showed significantly higher HR. CONCLUSIONS: A high proportion of relatively young and apparently healthy Hungarian employees were diagnosed with prehypertension and hypertension. Only a small proportion of HTN had their BP controlled. BMI and HR were significantly higher among individuals with prehypertension compared to NT. Whether the high rates of hypertension, prehypertension, and low levels of control explain the high stroke mortality and unfavorable cardiovascular disease (CVD) profile of Hungary needs further study.

Time trends in cardiovascular and all-cause mortality in the 'old' and 'new' European Union countries.

AIMS: There are large differences in all-cause and cardiovascular disease (CVD) mortality between eastern and western countries in Europe. We reviewed the development of these mortality trends in countries of the European Union (EU) over the past 40 years and evaluated available data regarding possible determinants of these differences. METHODS AND RESULTS: We summarized all-cause mortality and specific cardiovascular mortality for two country groups - 10 countries that joined the European Union (EU) after 2004 (East), and 15 countries that joined before 2004 (West). Standardized mortality rates were retrieved from the World Health Organization "European Health for All" database for each country between 1970 and 2007. Currently (in the 2000s), mortality due to circulatory system disease, ischemic heart disease (IHD), cerebrovascular disease (CBVD), and all-causes in the 'new' EU countries (East) is approximately twice that in the 'old' EU countries (West). These differences were much smaller in the 1970s. The increasing gap in mortality between West and East is primarily the result of a continuous and rapid improvement in the West. CONCLUSION: Differences in lifestyle (i.e. diet, alcohol consumption, physical activity, and smoking) provide insufficient explanation for the observed mortality gap in these two groups of EU countries. Higher expenditures on health, better access to invasive and acute cardiac care, and better pharmacological control of hypertension and hypercholesterolemia in the West are well documented. Socioeconomic and psychosocial factors may also contribute to the changes in mortality trends.

Lifestyle changes and blood pressure control: a community-based cross-sectional survey (2006 Ontario Survey on the Prevalence and Control of Hypertension).

To evaluate lifestyle changes and their impact on hypertension control in a sample of hypertensive respondents in Ontario, Canada, diet, physical activity, and other nonpharmacologic measures were recorded using a structured questionnaire during the 2006 Ontario Survey on the Prevalence and Control of Hypertension. Responses were weighted to the total adult population of 7,996,653 in Ontario. The prevalence of hypertension was 21%; 42% of hypertensive persons received therapy with antihypertensive drugs and lifestyle changes, and 41% received therapy with drugs only. Blood pressure was controlled in 85% of respondents who used only drugs and in 78% of those who stated that they received therapy with combined drug treatment and lifestyle changes. Fewer than half of hypertensive respondents practiced lifestyle changes (in combination with drug treatment) for blood pressure control. Lifestyle measures in addition to medication use did not result in better control of hypertension compared to only medication use.

2006 Ontario Survey on the Prevalence and Control of Hypertension (ON-BP): rationale and design of a community-based cross-sectional survey.

BACKGROUND: The presently available Canadian data, based on direct measurements of blood pressure (BP) from the Canadian Heart Health Surveys, are more than 15 years old. In view of major changes in the demographics and health status of the Ontario population, there is an urgent need to update this information. On the initiative of the Heart and Stroke Foundation of Ontario, the University of Ottawa Heart Institute, jointly with Statistics Canada, designed and implemented a population-based cross-sectional survey of hypertension in the Province of Ontario: the 2006 Ontario Survey on the Prevalence and Control of Hypertension (ON-BP). OBJECTIVES: To establish the prevalence of hypertension in the Ontario adult population between the ages of 20 and 79 years; to assess the awareness, current status and management of hypertension; and to gather respondent information about sex, age, physical measurements, personal health practices, socioeconomic measures, ethnicity and comorbidities. METHODS: The present paper describes the background history and the successive steps undertaken during the implementation of this project. CONCLUSIONS: The authors' experiences from the ON-BP indicate that close co-operation between research scientists, statisticians, governmental and nongovernmental organizations -- in the present case, the Heart and Stroke Foundation of Ontario -- is essential to conduct a successful, large-scale survey of BP distribution.