Using the theoretical domains framework to identify barriers and enablers to pediatric asthma management in primary care settings.

OBJECTIVES: This study aimed to apply a theory-based approach to identify barriers and enablers to implementing the Alberta Primary Care Asthma Pediatric Pathway (PCAPP) into clinical practice. Phase 1 included an assessment of assumptions underlying the intervention from the perspectives of the developers. Phase 2 determined the perceived barriers and enablers for: 1) primary care physicians' prescribing practices, 2) allied health care professionals' provision of asthma education to parents, and 3) children and parents' adherence to their treatment plans. METHODS: Interviews were conducted with 35 individuals who reside in Alberta, Canada. Phase 1 included three developers. Phase 2 included 11 primary care physicians, 10 allied health care professionals, and 11 parents of children with asthma. Phase 2 interviews were based on the 14 domains of the Theoretical Domains Framework (TDF). Transcribed interviews were analyzed using a directed content analysis. Key assumptions by the developers about the intervention, and beliefs by others about the barriers and enablers of the targeted behaviors were identified. RESULTS: Eight TDF domains mapped onto the assumptions of the pathway as described by the intervention developers. Interviews with health care professionals and parents identified nine TDF domains that influenced the targeted behaviors: knowledge, skills, beliefs about capabilities, social/professional role and identity, beliefs about consequences, environmental context and resources, behavioral regulation, social influences, and emotions. CONCLUSIONS: Barriers and enablers perceived by health care professionals and parents that influenced asthma management will inform the optimization of the PCAPP prior to its evaluation.

Plasma essential fatty acid on hospital admission is a marker of COVID-19 disease severity.

It is important for allocation of resources to predict those COVID patients at high risk of dying or organ failure. Early signals to initiate cellular events of host immunity can be derived from essential fatty acid metabolites preceding the cascade of proinflammatory signals. Much research has focused on understanding later proinflammatory responses. We assessed if remodelling of plasma phospholipid content of essential fatty acids by the COVID-19 virus provides early markers for potential death and disease severity. Here we show that, at hospital admission, COVID-19 infected subjects who survive exhibit higher proportions of C20:4n-6 in plasma phospholipids concurrent with marked proinflammatory cytokine elevation in plasma compared to healthy subjects. In contrast, more than half of subjects who die of this virus exhibit very low C18:2n-6 and C20:4n-6 content in plasma phospholipids on hospital admission compared with healthy control subjects. Moreover, in these subjects who die, the low level of primary inflammatory signals indicates limited or aberrant stimulation of host immunity. We conclude that COVID-19 infection results in early fundamental remodelling of essential fatty acid metabolism. In subjects with high mortality, it appears that plasma n-6 fatty acid content is too low to stimulate cellular events of host immunity.

A De Novo Pharmacist-Family Physician Collaboration Model in a Family Medicine Clinic in Alberta, Canada.

Collaborative practice in health-care has proven to be an effective and efficient method for the management of chronic diseases. This study describes a de novo collaborative practice between a pharmacist and a family physician. The primary objective of the study is to describe the collaboration model between a pharmacist and family physician. The secondary objective is to describe the pharmacist workload. A list of patients who had at least one interaction with the pharmacist was generated and printed from the electronic medical record. There were 389 patients on the patient panel. The pharmacist had at least one encounter with 159 patients. There were 83 females. The most common medical condition seen by the pharmacist was hypertension. A total of 583 patient consultations were made by the pharmacist and 219 of those were independent visits. The pharmacist wrote 1361 prescriptions. The expanded scope of practice for pharmacists in Alberta includes additional prescribing authority. The pharmacists' education and clinical experience gained trust from the family physician. These, coupled with the family physician's previous positive experience working with pharmacists made the collaboration achievable.

Effective Asthma Management: Is It Time to Let the AIR out of SABA?

For years, standard asthma treatment has included short acting beta agonists (SABA), including as monotherapy in patients with mild asthma symptoms. In the Global Initiative for Asthma 2019 strategy for the management of asthma, the authors recommended a significant departure from the traditional treatments. Short acting beta agonists (SABAs) are no longer recommended as the preferred reliever for patients when they are symptomatic and should not be used at all as monotherapy because of significant safety concerns and poor outcomes. Instead, the more appropriate course is the use of a combined inhaled corticosteroid-fast acting beta agonist as a reliever. This paper discusses the issues associated with the use of SABA, the reasons that patients over-use SABA, difficulties that can be expected in overcoming SABA over-reliance in patients, and our evolving understanding of the use of "anti-inflammatory relievers" in our patients with asthma.

Validating a case definition for adult asthma in primary care electronic medical records.

Although asthma is one of the most common chronic conditions affecting Canadians, its epidemiologic characteristics and burden in primary care contexts are poorly understood. The aim of this study was to develop and validate a case definition to identify adults with asthma who consult family physicians and to estimate the prevalence of asthma in that setting in Canada. This validation study utilized a database of electronic medical records (EMRs) from the Southern Alberta Primary Care Research Network, a node of the Canadian Primary Care Sentinel Surveillance Network (SAPCReN-CPCSSN). The population included patients over age 17y of any gender and health status who had visited an SAPCReN-CPCSSN primary care provider during the period December 1, 2014-December 31, 2016. The validation of the case definition involved comparing a case-finding algorithm to caseness determined by an expert physician review of the records of 1000 patient in the CPCSSN database. The case definition, which included the ICD-9 code 493 and asthma-related text words, had 83.33% sensitivity (95% CI: 63.61-93.88%), 99.28% specificity (95% CI: 98.51-99.67%), a positive predictive value of 74.07% (95% CI: 55.03-87.14%), and a negative predictive value of 99.59% (95% CI: 98.93-99.86%). The prevalence of adult asthma in CPCSSN primary care practices in southern Alberta was 4.20% (95% CI: 4.09-4.31). The strong validation metrics suggest that this case definition is valid for both clinical and research purposes. The validated case definition may be used to improve patient care and improve understanding of the prevalence and burden of asthma in primary care in Canada.

Hypertension treatment and control rates: chart review in an academic family medicine clinic.

OBJECTIVE: To characterize hypertension management in an academic family medicine clinic. DESIGN: Cross-sectional chart review. SETTING: Academic family medicine clinic in Edmonton, Alta. PARTICIPANTS: A total of 210 patients with 1 or more visits for hypertension during the previous 3 years. MAIN OUTCOME MEASURES: Patient characteristics, current antihypertensive therapies, most recent blood pressure measurements, and compelling indications according to the 2006 Canadian Hypertension Education Program recommendations. RESULTS: A total of 185 subjects (88%) were prescribed antihypertensive medications, and 89 (42%) had controlled hypertension. Younger subjects, people with diabetes, and people not receiving antihypertensive medication therapy appeared less likely to have controlled hypertension. There were 76 subjects (36%) prescribed 1 antihypertensive medication, 65 subjects (31%) prescribed 2 antihypertensive medications, and 44 (21%) prescribed 3 or more antihypertensive medications. Angiotensin-converting enzyme inhibitors were prescribed for 51% of the subjects, diuretics for 47%, beta-blockers for 27%, calcium channel blockers for 23%, angiotensin receptor blockers for 20%, and alpha-blockers for 1%. CONCLUSION: Hypertension treatment and control rates in this academic family medicine clinic appear to be better than those in the general population. Following the principles of a continuous quality improvement process, this information will serve as an important foundation for identifying areas to improve hypertension management in the clinic.

The Impact of a Training Program on Clinical Pharmacists on Pharmacy Clinical Services in a Tertiary Hospital in Hunan China.

BACKGROUND: Prior to 2015, clinical consultation was the only clinical service provided by clinical pharmacists in Changsha Second Hospital. Between 2015 and 2017, a train-the-trainer program was implemented to train clinical pharmacists to provide pharmaceutical care and to conduct clinical research. The objective of the study is to examine the impact on the clinical services provided by pharmacists after the implementation of the train-the-trainer program. PATIENTS AND METHODS: Between 2004 and 2014, all completed clinical consultation activities were tallied and summarized. The results from the tallied consultation activities were used as a baseline for clinical activities provided by pharmacists prior to the training. A structured training program was implemented between 2015 and 2017 to train clinical pharmacists to provide pharmaceutical care. After the implementation of the training program was completed, all clinical activities provided by pharmacists between January 2017 and December 2017 were documented in the clinical workload form. The clinical activities completed by each pharmacist were tallied and summarized. RESULTS: Between 2004 and 2014, a total of 6569 (average 657 per year) pharmacy consultations were requested and completed from a total of 44 departments. In 2017, a total of 15,078 hrs of clinical activities were logged. The pharmacists completed 3481 consultations in 2017 (an increase of 430%), averaging 316 consultations for each pharmacist and 271.8 hr per pharmacist. Over 2000 hrs (of the 15,078 hrs) were spent on direct patient care by the pharmacists. CONCLUSION: This study shows that there was a 430% increase in clinical pharmacy consultation services provided by the clinical pharmacists after the implementation of the training program. This is directly related to the number of well-trained pharmacists available. After the implementation of the train-the-trainer program, the range of services as well as the number of clinical services and clinical hours spent on providing pharmaceutical care have significantly increased.

Papanicolaou smears: to swab or not to swab.

OBJECTIVE: To determine whether cleaning the cervix with a cotton swab affects the quality of the conventional Papanicolaou smear. DESIGN: Prospective, single-blinded randomized case-control study. SETTING: Two academic family medicine teaching units and 1 community family practice site. PARTICIPANTS: Female patients, 18 to 65 years of age, who presented for a routine Pap smear in the family practice setting were randomized into the Swab Group (n = 300) or the No Swab Group (n = 316). INTERVENTION: Before the Pap smear, the cervix of patients in the Swab Group was wiped with a cotton swab until visibly free of mucus. In the No Swab Group, the cervix was not cleaned with a cotton swab before the Pap smear. MAIN OUTCOME MEASURES: The quality of the conventional Pap smear was determined by the presence or absence of endocervical cells noted on the pathology report. RESULTS: There was no major difference in the quality of the Pap smear in terms of the adequacy of endocervical cells between the Swab and No Swab Group. CONCLUSION: Cleaning the cervix with a cotton swab does not appear to affect the quality of the conventional Pap smear in terms of adequacy of endocervical cells. This implies that the practice of wiping or not wiping the mucus from the cervix before taking the Pap smear can be employed at the discretion of the clinician.

Should We be Worried About QTc Prolongation Using Citalopram? A Review.

PURPOSE: Summarize available information regarding clinical impact of citalopram on the QTc interval. METHODS: A literature search was conducted in Pubmed, EMBASE, and Cochrane databases using the MeSH term "long QT syndrome" and key word "citalopram" on July 11, 2014. RESULTS: Thirty-one studies were evaluated with 4 included in this review. Studies were excluded if they reported acute overdoses of citalopram or did not report on patient-specific risk factors for long QT syndrome (eg, hypokalemia, bradycardia, and increased age). The majority of the available data is derived from case reports. A number of confounders complicate the determination of a causal link between QTc prolongation and citalopram. Of the 4 studies included for review, none identified significant QTc prolongation in patients taking citalopram 20 to 60 mg daily without the patients having one or more patient-specific risk factors for prolonged QTc. CONCLUSION: There is insufficient evidence to establish a causal link between citalopram 20 to 60 mg orally daily and increased risk of TdP. Further research is required to determine the clinical impact and association between citalopram 20 to 60 mg daily and QTc prolongation.

Development of a validated algorithm for the diagnosis of paediatric asthma in electronic medical records.

An accurate estimation of the prevalence of paediatric asthma in Alberta and elsewhere is hampered by uncertainty regarding disease definition and diagnosis. Electronic medical records (EMRs) provide a rich source of clinical data from primary-care practices that can be used in better understanding the occurrence of the disease. The Canadian Primary Care Sentinel Surveillance Network (CPCSSN) database includes cleaned data extracted from the EMRs of primary-care practitioners. The purpose of the study was to develop and validate a case definition of asthma in children 1-17 who consult family physicians, in order to provide primary-care estimates of childhood asthma in Alberta as accurately as possible. The validation involved the comparison of the application of a theoretical algorithm (to identify patients with asthma) to a physician review of records included in the CPCSSN database (to confirm an accurate diagnosis). The comparison yielded 87.4% sensitivity, 98.6% specificity and a positive and negative predictive value of 91.2% and 97.9%, respectively, in the age group 1-17 years. The algorithm was also run for ages 3-17 and 6-17 years, and was found to have comparable statistical values. Overall, the case definition and algorithm yielded strong sensitivity and specificity metrics and was found valid for use in research in CPCSSN primary-care practices. The use of the validated asthma algorithm may improve insight into the prevalence, diagnosis, and management of paediatric asthma in Alberta and Canada.

Primary Care Pathway for Childhood Asthma: Protocol for a Randomized Cluster-Controlled Trial.

BACKGROUND: Asthma is the most common chronic condition in children. For many, the disease is inadequately controlled, which can burden the lives of children and their families as well as the health care system. Improved use of the best available scientific evidence by primary care practitioners could reduce the need for hospital care and improve quality of life and asthma control, thereby reducing overall costs to society and families. OBJECTIVE: The Primary Care Pathway for Childhood Asthma aims to improve the management of children with asthma by (1) providing primary care practitioners with an electronic guide (a clinical pathway) incorporated into the patient's electronic medical record, and (2) providing train-the-trainer education to chronic disease management health professionals to promote the provision of asthma education in primary care. METHODS: The research will utilize a pragmatic cluster-controlled design, quantitative and qualitative research methodologies, and economic evaluation to assess the implementation of a pathway and education intervention in primary care. The intervention will be analyzed for effectiveness, and if the results are positive, a strategy will be developed to implement delivery to all primary care practices in Alberta. RESULTS: The research has been successfully funded and ethics approvals have been obtained. Practice recruitment began fall 2015, and we expect all study-related activities to be concluded by March 2018. CONCLUSIONS: The proposed pathway and education intervention has the potential to improve pediatric asthma management in Alberta. The intervention is anticipated to result in better quality of care for equal or lesser cost. CLINICALTRIAL: ClinicalTrials.gov NCT02481037; https://clinicaltrials.gov/ct2/show/NCT02481037 (Archived by WebCite at http://www.webcitation.org/6fPIQ02Ma).

Self-reported osteoporosis prevention in inhaled corticosteroid users in community pharmacy setting.

OBJECTIVES: The use of inhaled corticosteroids is the standard maintenance therapy in asthma therapy and as adjunct therapy in moderate to severe chronic obstructive pulmonary disease. A dose-related increase in fracture risk is associated with inhaled corticosteroid use; there is an inverse relationship between bone mineral density and duration and cumulative dose of inhaled corticosteroid. Adequate intake of calcium and vitamin D are cornerstones of osteoporosis prevention. The objectives are to assess whether the proportion of patients receiving inhaled corticosteroids are taking calcium and vitamin D; the association between long-term inhaled corticosteroid use and abnormal bone mineral density or fractures; and how many qualified patients received bone mineral density scans. METHODS: Patients who filled a prescription for inhaled corticosteroids at selected community pharmacies across Alberta were recruited for a survey of their osteoporosis prevention activities. RESULTS: A total of 256 patients from 12 community pharmacies were included. The average age was 60 ± 17.4 years with 65% female. There were 21%, 51%, and 28% of patients on high, medium, and low dose inhaled corticosteroids, respectively. Only 17% of patients >50 years old received recommended calcium and vitamin D supplementation and 87 (73%) of the qualified patients received bone mineral density scan. CONCLUSION: Osteoporosis prevention in inhaled corticosteroid users is currently poorly addressed. More promotion is needed to raise pharmacist awareness of the risks of inhaled corticosteroids.

The relative importance of barriers to the prescription of warfarin for nonvalvular atrial fibrillation.

BACKGROUND AND PURPOSE: Despite the publication of a number of randomized, controlled trials demonstrating a substantial reduction in stroke with anticoagulation in patients with nonvalvular atrial fibrillation, the 'real world' use of warfarin is sub-optimal. Previous surveys have attempted to explain this problem but have significant limitations. The purpose of this study was to assess the relative importance of various barriers that may influence the prescription of warfarin in patients with nonvalvular atrial fibrillation. METHODS: This cross-sectional survey was mailed to all practising cardiologists, neurologists and internists, as well as a random sample of family physicians within Alberta. Physicians caring for patients with NVAF rated the relative importance of potential barriers using a Likert scale. RESULTS: Sixty-seven per cent of all physicians returned the survey. Overall, barriers pertaining to the patient's clinical characteristics were rated to be more important than those pertaining to the physician or to the organization required when prescribing these therapies. Specifically, an ongoing history of falls, a history of bleeding within the previous year and an inability to comply with therapy were rated as important barriers by 64%, 55% and 53% of physicians, respectively. Most physicians strongly believed that patients should receive information on the benefits and risks of warfarin (96%) and that patients should have a say in whether warfarin is prescribed (86%). IMPLICATIONS: This study suggests that most of the barriers to warfarin use pertain to patient clinical characteristics and the need for patients to be involved in the decision to initiate therapy. The use of decision support technologies would facilitate involvement of the patient and serve to educate both the patient and physician on the risks and benefits of warfarin therapy.

Evaluation of a Nurse-run asthma clinic in general practice.

BACKGROUND: Since 1985, nurse-run asthma clinics have been developing and are now widespread in the United Kingdom, having been greatly stimulated by the New Contract for General Practice (1990). To date, there have been few definitive studies evaluating such clinics. This study, in two adjacent general practices in semi-rural Somerset, evaluates the effect of nurse-run clinics on patients' symptoms, pulmonary function, and healthcare utilisation over a four-month period. METHODS: One hundred and twenty-nine subjects, aged 2-79 years, were recruited from the two practices over a one-year period (1991-1992). All patients identified in either practice who had used preventive therapy in the preceding 12 months were eligible and were included if they had a positive exercise or reversibility (20%) test and had not previously received formal asthma education. A pre- and post-experimental study design was used. Subjects' symptoms, pulmonary function, and health care in the preceding eight weeks were assessed at intake and at 16 weeks; the nurse education being delivered at intake, one and four weeks. RESULTS: Both mean number of days off work/school and mean number of nights on which waking occurred fell (p < 0.001). Peak expiratory flow rates and forced expiratory volumes improved during the study period (p < 0.001 and p < 0.01 respectively). Use of antibiotics, oral steroids, and rescue bronchodilator use all improved significantly (p < 0.001). Physician attendances were also reduced. CONCLUSIONS: A nurse-run asthma clinic in general practice is an effective way to improve symptoms, pulmonary function, and health care utilisation for asthmatic patients.

A Screening Instrument to Identify Adults with Nutritional Risks in a Family Medicine Practice.

Family practice is the point of entry for many individuals seeking medical attention in the community. It is an ideal site for instituting preventative measures aimed at risk management. The objective of this study was to develop a valid, reliable instrument to screen adults for risk of suboptimal nutrition in a family practice population. A self-administered nutrition questionnaire was developed and sent to 50 registered dietitians in Alberta to establish face validity. The ability of the tool to identify nutritional risk was established by comparing the results of the screen to a dietitian's full assessment, that would include weight, weight changes, body mass index, adequacy of nutrition intake, available laboratory data, and medical and social factors that influence nutrition status. A score of 12 or higher on the screen was found to have an 80% sensitivity and defined the high-risk individuals who required immediate nutrition intervention (14% of our study population). At a score of seven, the screening instrument had a sensitivity of 67% and a specificity of 77%. This score was used to define moderate risk individuals, who required some nutrition advice. Screen scores below seven corresponded with individuals who were not at nutritional risk. The study has shown that a simple, self-administered screening tool can effectively identify the nutritional risk of adults in a family medicine practice.

Asthma in preschool children: a review of the diagnostic challenges.

Family physicians face many challenges when diagnosing asthma in preschool children. These diagnostic challenges are compounded by variations in the natural history of early stage asthma, which are not fully understood, since early childhood wheezing and asthma are heterogeneous disorders with many phenotypic and variable expressions. Since no standard definition for the type, severity, or frequency of symptoms exist for this age group, clear evidence-based recommendations are lacking. Without adequate guidance, family physicians are left to make diagnostic and treatment decisions, which can lead to undertreatment of asthmatics and overtreatment of transient wheezers. New guidelines that specifically address the challenges of diagnosing asthma in this particular age group (Global Initiative for Asthma, British Thoracic Society/Scottish Intercollegiate Guidelines Network) have recently been published, and researchers are actively seeking new methods and techniques through epidemiological studies to assist primary care clinicians in the diagnostic process. This review has wide application in primary care. By recognizing the diagnostic challenges and understanding the related best practices, family physicians will be better placed to treat, manage, and control asthma symptoms, resulting in lower morbidity rates and reduced health system costs, as well as enhancing the overall quality of life and well-being of the children affected.

Feasibility of a self-administered survey to identify primary care patients at risk of medication-related problems.

BACKGROUND AND OBJECTIVES: Pharmacists working in primary care clinics are well positioned to help optimize medication management of community-dwelling patients who are at high risk of experiencing medication-related problems. However, it is often difficult to identify these patients. Our objective was to test the feasibility of a self-administered patient survey, to facilitate identification of patients at high risk of medication-related problems in a family medicine clinic. METHODS: We conducted a cross-sectional, paper-based survey at the University of Alberta Hospital Family Medicine Clinic in Edmonton, Alberta, which serves approximately 7,000 patients, with 25,000 consultations per year. Adult patients attending the clinic were invited to complete a ten-item questionnaire, adapted from previously validated surveys, while waiting to be seen by the physician. Outcomes of interest included: time to complete the questionnaire, staff feedback regarding impact on workflow, and the proportion of patients who reported three or more risk factors for medication-related problems. RESULTS: The questionnaire took less than 5 minutes to complete, according to the patient's report on the last page of the questionnaire. The median age (and interquartile range) of respondents was 57 (45-69) years; 59% were women; 47% reported being in very good or excellent health; 43 respondents of 100 had three or more risk factors, and met the definition for being at high risk of a medication-related problem. CONCLUSIONS: Distribution of a self-administered questionnaire did not disrupt patients, or the clinic workflow, and identified an important proportion of patients at high risk of medication-related problems.

Assessment of COPD wellness tools for use in primary care: an IPCRG initiative.

COPD is considered a complex disease and global problem that is predicted to be the third most common cause of death by 2030. While managing this chronic condition, primary health care practitioners are faced with the ongoing challenge of achieving good quality of life and overall "wellness" for those affected. As such, a practical tool for monitoring quality of life in a clinical setting is required. However, due to the wide variety of general and disease-specific tools from which to choose, primary health care practitioners are given minimal guidance as to which tool may be most appropriate. To address these challenges, the International Primary Care Respiratory Group (IPCRG) proposed the creation of a user's guide for primary health care practitioners to assess "wellness" in COPD patients in an everyday clinical setting. This short report outlines the process by which the IPCRG Users' Guide to COPD "Wellness" Tools was developed. It also describes why this guide has the potential to be of great value in guiding primary health care practitioners to improve patient wellness.