Alfred J. Remillard

Effectiveness of contact-based education for reducing mental illness-related stigma in pharmacy students

BackgroundA strategy for reducing mental illness-related stigma in health-profession students is to include contact-based sessions in their educational curricula. In such sessions students are able to interact socially with a person that has a mental illness. We sought to evaluate the effectiveness of this strategy in a multi-centre study of pharmacy students.MethodsThe study was a randomized controlled trial conducted at three sites. Because it was necessary that all students receive the contact-based sessions, the students were randomized either to an early or late intervention, with the late intervention group not having participated in the contact-based education at the time when the primary outcome was assessed. The primary outcome, stigma, was assessed using an attitudes scale called the Opening Minds Survey for Health Care Providers (OMS-HC).ResultsWe initially confirmed that outcomes were homogeneous across study centres, centre by group interaction, p = 0.76. The results were pooled across the three study centres. A significant reduction in stigma was observed in association with the contact-based sessions (mean change 4.3 versus 1.5, t=2.1, p=0.04). The effect size (Cohen’s d) was 0.45. A similar reduction was seen in the control group when they later received the intervention.ConclusionsContact-based education is an effective method of reducing stigma during pharmacy education. These results add to a growing literature confirming the effectiveness of contact-based strategies for stigma reduction in health profession trainees.

Diabetes and Cardiovascular Disease Interventions by Community Pharmacists: A Systematic Review

Objective: To systematically review and assess the quality of studies evaluating community pharmacist interventions for preventing or managing diabetes or cardiovascular disease (CVD) and/or their major risk factors. Data Sources: A comprehensive literature search was performed using MEDLINE (1950-February 2011), EMBASE (1980-February 2011), International Pharmaceutical Abstracts (1970-February 2011), Cumulative Index to Nursing and Allied Health Literature (1982-June 2007), and Cochrane Central Register of Controlled Trials (1898-February 2011). Search terms included: community pharmacy(ies), community pharmacist(s), cardiovascular, diabetes, and intervention. The grey literature was searched using the ProQuest Dissertations and Theses, Theses Canada, and OAlster databases. Study Selection and Data Extraction: Articles published in English or French with all study designs were considered for the review. Studies were included if they contained interventions designed to reduce the incidence, risk, or mortality of CVD or diabetes; affect clinical indicators of CVD or diabetes mellitus (including hypertension, dyslipidemia, or hemoglobin A1c); and/or improve adherence to treatment strategies. Only studies involving interventions carried out primarily by pharmacists in community pharmacy settings were included. Study quality was assessed using a checklist validated for both randomized and nonrandomized studies. Data Synthesis: A total of 4142 studies were initially identified, with 40 meeting our inclusion criteria. Eleven studies were randomized controlled trials, 4 were cluster randomized trials, and 2 studies had randomized before-after designs. The remaining studies were controlled before-after (n = 2), cohort (n = 4), and uncontrolled before-after (n = 17) designs. Interventions focused on diabetes (n = 12), hypertension (n = 9), medication adherence (n = 9), lipids (n = 5), evidence-based medication initiation or optimization (n = 3), risk factor prediction scores (n = 1), and body mass index (n = 1). All studies contained interventions focused at the patient level and the majority of studies (34/40) involved interventions directed at both the physician and patient. No specific intervention emerged as superior, and study quality was generally poor, making it difficult to determine the true effect of the interventions. Conclusions: Poor study quality, time-intensive interventions, and unproven clinical significance warrant the need for further high-quality studies of community pharmacist interventions for preventing or managing diabetes or CVD and/or their major risk factors.

First-Fill Medication Discontinuations and Nonadherence to Antihypertensive Therapy: An Observational Study

BACKGROUND Medication nonadherence is a barrier to successfully managing hypertension, but little is known about the contribution that immediate discontinuations have on antihypertensive (AHT) nonadherence. The purpose of this study was to determine the proportion of new AHT users who discontinue after a single dispensation, and to examine potential predictors of these discontinuations. METHODS This retrospective cohort study utilizing linked administrative data from Saskatchewan, Canada. Subjects were ≥40 years of age and received a new AHT between 1994-2002. The primary end point was the proportion of subjects who discontinued their AHT after the first dispensation (first-fill discontinuation). The proportion of nonadherence attributed to first-fill discontinuations was then calculated. Multivariate regression identified factors associated with first-fill discontinuations. RESULTS 52,039 subjects were included in the analyses. Mean age was 59.4 (s.d. 12.5) years, and 42% were male. Overall, 25,812/52,039 (50%) subjects were nonadherent at 1 year; first-fill discontinuations accounted for 39.1% (10,081/25,812) of this nonadherence. Approximately 20% (10,081/52,039) of all subjects discontinued all AHT therapy after the first fill. A higher chronic disease score (adjusted odds ratio (OR) 1.09, 95% confidence interval (CI) 1.08-1.11) and antidepressant medication usage during the observation year (adjusted OR 1.17, 95% CI 1.09-1.26) was associated with increased risk for first-fill discontinuations. Older age, starting AHT therapy after 1994, frequent physician visits, or use of a statin, acetylsalicylic acid, warfarin or antihyperglycemic during the observation year was associated with a lower risk for first-fill discontinuations. CONCLUSION A substantial proportion of nonadherence to AHT medications is due to discontinuations after only a single dispensation.

Integration of a primary healthcare pharmacist

Pharmacists have been encouraged to enhance their role on primary healthcare teams; but, the profession has yet to be involved to the degree in which a substantial impact can be made. The objective of this study was to provide guidance on how to integrate a pharmacist into an already established primary healthcare team. Using action research, a panel of established primary healthcare pharmacists identified clinical activities for a primary healthcare pharmacist tailored for the project site. The results were presented to the primary healthcare team, who then collaborated with the pharmacist and researchers to define the role of the pharmacist. Once an agreement was reached, a pharmacist provided eight weeks of full-time clinical services. Upon completion, focus groups were used to evaluate the pharmacists clinical services. The focus group data, along with the pharmacists suggestions, formed a step-wise guide for integration. The template consists of eight steps which highlight the importance of selecting a collaborative process and team, defining the role of the pharmacist, determining the logistics of providing care, establishing credibility, re-evaluating the role as it evolves, and obtaining patient feedback. Pharmacists desiring to be involved in primary healthcare teams can follow this template to assist them with integration.

A pharmacoepidemiological evaluation of anticholinergic prescribing patterns in the elderly.

The elderly are high consumers of both prescription and over‐the‐counter medications. As a result of age‐related changes in drug pharmacokinetics and pharmacodynamics, they experience twice the number of adverse effects than in the general population. Using the health insurance data bases of the province of Saskatchewan, the prescribing pattern of drugs which have anticholinergic properties, was studied in the elderly. Of patients less than or equal to (≤) 64 years of age 3.8% compared to 11.3% of patients greater than or equal to (≥) 65 years of age were prescribed an anticholinergic medication. In the elderly group, 9.3% of the ambulatory subjects and 43.8% of the special care home (SCH) residents received a prescription for an anticholinergic drug. The concurrent prescribing of two or more anticholinergic medications was also higher in the elderly (0.16% of patients ≤ 64 versus 0.54% of patients ≥ 65). All differences between patients ≤ 64 and those ≥ 65, as well as between the ambulatory elderly subjects and the SCH elderly residents, were statistically significant. Approximately 25% of all anticholinergic medications were prescribed in the high to excessive dosage range. The study also looked at prescribing patterns for individuals with a diagnosis of dementia. Despite the potential detrimental adverse effect of anticholinergic therapy in that patient group, 35.5% received a prescription for anticholinergic medication. These data confirm that the elderly are at high risk for receiving a prescription for anticholinergic medications. The high prevalence of anticholinergic prescribing in a patient population known to be sensitive to anticholinergic side‐effects has the potential to cause significant adverse clinical consequences.

A pragmatic cluster randomized trial evaluating the impact of a community pharmacy intervention on statin adherence: rationale and design of the Community Pharmacy Assisting in Total Cardiovascular Health (CPATCH) study

BackgroundTraditional randomized controlled trials are considered the gold standard for evaluating the efficacy of a treatment. However, in adherence research, limitations to this study design exist, especially when evaluating real-world applicability of an intervention. Although adherence interventions by community pharmacists have been tested, problems with internal and external validity have limited the usefulness of these studies, and further well-designed and well-conducted research is needed. We aimed to determine the real-world effectiveness of a community pharmacy adherence intervention using a robust study design. This novel design integrates cluster randomization and an outcome evaluation of medication adherence using a population-based administrative data source in the province of Saskatchewan, Canada.Methods/DesignCommunity pharmacies from across the province of Saskatchewan, Canada were randomized to deliver an adherence intervention to their patients or usual care. Intervention pharmacies were trained to employ a practical adherence strategy targeted at new users of statin medications. While randomization and implementation of the intervention occurred at the community pharmacy level, the outcome analysis will occur at the level of the individual subjects. The primary outcome is the mean statin adherence among all eligible new users of statin medications. Secondary outcomes include the proportion of new statin users who exhibit adherence ≥80%, and persistence with statin use.DiscussionThis novel study design was developed to combine the rigor of a randomized trial with a pragmatic approach to implementing and capturing the results in a real-world fashion. We believe this approach can serve as an example for future study designs evaluating practice-based adherence interventions.Trial RegistrationClinicalTrials.gov no. NCT00971412.

A pilot project to assess the association of anticholinergic symptoms with anticholinergic serum levels in the elderly.

Study Objective. To evaluate whether serum anticholinergic drug activity would be a useful clinical tool in helping to predict anticholinergic toxicity.

The Association Between Market Availability and Adherence to Antihypertensive Medications: An Observational Study

BACKGROUND High adherence to angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) reported in observational studies has frequently been attributed to improved tolerability. However, these agents are also relatively new to the market compared to other antihypertensive medications. We aimed to determine if an association exists between adherence and market availability of a specific antihypertensive agent. METHODS This retrospective cohort study used administrative data from Saskatchewan, Canada. Subjects were ≥40 years of age and received a new antihypertensive medication between 1994 and 2002. The primary outcome was the proportion of subjects achieving optimal adherence (≥80%) at 1 year, stratified by antihypertensive medication class and the year of availability. Adherence was measured using the cumulative mean gap ratio. RESULTS A total of 36,214 subjects met the inclusion criteria. Optimal adherence was observed in 4987 of 8623 (57.8%) subjects receiving ACEIs and 1013 of 1600 (63.3%) subjects receiving ARBs, but adherence appeared inconsistent when examined within each antihypertensive class. A pattern of increasing mean adherence was observed according to availability in the ACEI subgroup (Spearman r = 0.82; P = 0.007) but not the ARB subgroup (Spearman r = 0.41; P = 0.49). However, the association between availability and optimal adherence converged when ARB and ACEI users were combined (Spearman r = 0.85, P < 0.001). CONCLUSIONS Optimal adherence with ACEIs and ARBs compared to other antihypertensive agents may be associated with their relative availability. To what extent optimal adherence is also associated with improved tolerability, as currently believed, remains to be determined.

Intravenous Clomipramine and Obsessive-Compulsive Disorder

A 62 year old woman presented with a long history of obsessive-compulsive disorder, the symptoms of which were not adequately controlled by oral clomipramine. The patient was started on intravenous clomipramine. Drug levels of both clomipramine and its active metabolite desmethylclomipramine were measured. Symptoms were controlled during her hospital stay. A three year follow-up report indicated the patient is doing well with no evidence of obsessive-compulsive or depressive symptoms. A discussion of the blood levels obtained and the caution to be exercised during intravenous administration is presented.

Deuterium-labelled p-tyramine challenge test and phenolsulfotransferase activity in depressed patients--failure to replicate decreased p-tyramine conjugation in depression.

1. Depressed and normal subjects were challenged with deuterium-labelled p-tyramine and urine was collected for 3 h. 2. Urinary excretion of conjugated p-tyramine was not significantly different between normal, melancholic and non-melancholic depressed subjects. 3. Platelet phenolsulfotransferase activity to p-tyramine (p less than 0.05) and to phenol (p less than 0.005) were significantly lower in the depressed patients.