Darcy A. Lamb

Changes in Adherence to Evidence-Based Medications in the First Year After Initial Hospitalization for Heart Failure Observational Cohort Study From 1994 to 2003

Background—The use of evidence-based medications in patients with heart failure has increased over the past 10 years. We aimed to determine whether adherence to these medications has also increased during this time. Methods and Results—A retrospective cohort was created using administrative databases from the province of Saskatchewan, Canada. Subjects discharged alive from their first hospitalization for heart failure between 1994 and 2003 were eligible. Those filling a prescription for a &bgr;-blocker (BB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB) within 6 months of discharge were followed for 1 year after the initial prescription. Of 8805 eligible patients, 67% of BB users (941/1414) and 74% of ACEI/ARB users (4441/5991) exhibited optimal adherence at 1 year (defined as ≥80% adherence calculated from pharmacy refill records). When grouped by year of initial heart failure hospitalization, the proportion of optimally adherent patients improved from 54% to 75% with BB and from 67% to 80% with ACEI/ARBs between 1994/1995 and 2002/2003 (P for trend <0.001 for both). Mean 1-year adherence improved from 71% to 83% for BB and 80% to 88% for ACEI/ARBs. After adjustment using multivariable logistic regression, subjects discharged in 2003 were significantly more likely to exhibit optimal adherence to a BB (odds ratio, 2.04; 95% CI, 1.21 to 3.44) or an ACEI/ARB (odds ratio, 1.65; 95% CI, 1.30 to 2.08) than those prescribed therapy in 1994/1995. Conclusions—One-year adherence to BB and ACEI/ARB is improving over time in patients discharged after first heart failure hospitalization. Patients taking multiple cardiac medications were not any less likely to exhibit optimal adherence than patients taking only 1 medication.

Atenolol as initial antihypertensive therapy: an observational study comparing first-line agents

Objective The role of atenolol in the management of patients with hypertension is currently under scrutiny. Our aim was to evaluate the real-world consequences of recent clinical trial findings. Methods We conducted a retrospective, cohort study using linked administrative data from the province of Saskatchewan, Canada. Eligible subjects were first-ever users of antihypertensive medications between 1 January 1994 and 31 December 2003 and were grouped into four cohorts: atenolol, angiotensin-converting enzyme inhibitors (ACEI), thiazide diuretics, or calcium antagonists. Patients remained eligible during monotherapy only. Results We identified 19 249 eligible individuals (mean age 60.6 years) who were followed for a mean of 2.3 years (SD 2.0). The rate of myocardial infarction, unstable angina, stroke, or death occurred in similar frequencies among all cohorts: atenolol (2.3%), ACEI (3.6%), thiazide diuretics (2.9%), and calcium antagonists (3.9%). After adjustment for potential confounders, atenolol therapy was not associated with higher event rates than the other first-line agents, with hazard ratios ranging between 1.03 [95% confidence intervals (CI) 0.72–1.46] and 1.24 (95% CI 0.91–1.68) for all cohorts compared with atenolol. Similar results were observed upon stratifying the sample into subjects above and below 60 years of age. Conclusion The low event rates for all cohorts suggest that atenolol has not been associated with a significant burden of cardiovascular morbidity or mortality in its traditional role for uncomplicated hypertension. Further study is needed to identify the specific types of patients that should avoid atenolol as an antihypertensive agent.

Practice Change Challenges and Priorities: A National Survey of Practising Pharmacists

Background: Vision and action plans have been created to address the future of pharmacy and help pharmacists progress into expanded roles in order to provide more patient-centred care. To assess the thoughts and perceptions of pharmacists in these new roles, a survey was conducted among practising pharmacists in Canada. Methods: A Web-based survey, developed as part of the Canadian Pharmacists Associations Moving Forward initiative, was open to all practising pharmacists in September and October of 2007. This survey educated pharmacists on potential future roles and sought to gain feedback on the human resource challenges and priorities that might result from the proposed practice changes. Results: From the 1003 respondents, it was found that the majority of pharmacist time is spent on dispensing duties. However, over 60% of pharmacists felt that it was time to begin taking on new responsibilities and over 70% of pharmacists want to be performing expanded clinical duties within 5 years. Discussion: It is encouraging to see that most pharmacists are open to new expanded clinical roles in the near future. Despite the challenges identified, such as the need for additional training, increases in workload and stress and expected poor physician acceptance, it was felt that changes would result in improved patient health outcomes and better personal job satisfaction. Conclusion: Pharmacists have responded positively to the proposed vision for the future of pharmacy and are eager to move away from the traditional dispensing role to an expanded clinical role that more fully utilizes their unique skills and knowledge.

Integrating a brief pharmacist intervention into practice: Osteoporosis pharmacotherapy assessment.

Pharmacy practice is in the midst of a change that is both necessary and long overdue. This change is driven by evidence that medication mismanagement and preventable adverse drug events occur at an alarming rate and the fact that pharmacists have the potential to positively impact these patient outcomes if their expertise were fully utilized.1–3 Unfortunately, some pharmacist interventions proven effective in the literature have not been integrated into practice. For example, the SCRIP study was terminated early after the intervention was associated with improvements in cholesterol management, deeming it unethical not to treat the control group.4 Despite this evidence, the SCRIP intervention has not been widely implemented. Several barriers that limit the integration of new interventions have been identified, including lack of time, disruption of workflow, requirement of additional training and lack of reimbursement. 5–8 Lengthy or intensive pharmacist interventions are particularly difficult to integrate, as they are impacted by all of these barriers. Alternatively, brief and focused interventions may be more readily integrated into practice. Unfortunately, we identified no examples in the literature describing these types of brief interventions. The purpose of this paper is to provide an example of how a brief intervention can be integrated into a contemporary pharmacist practice without disrupting workflow or requiring training, by describing an intervention that was piloted at West Winds Primary Health Centre in Saskatoon, Saskatchewan. The goal is not to evaluate this intervention, but rather to use it as an illustration. Ethics approval was unnecessary, as no formal evaluation was performed and no patient data were used.

Cardiovascular risk reduction strategies in community pharmacy settings need real world angle

It is well established that cardiovascular risk reduction strategies are often not successful in primary care settings and several organizations suggest that community pharmacists should play a more active role. As a result, several studies have attempted to examine the benefits of involving community pharmacists in the management of cardiovascular-risk patients. While many have reported positive results, real-world implementation has been minimal at best. In our view, 3 major barriers to widespread implementation of published protocols exist: generalizability, efficiency, and strategic focus.

Heart Failure: Back to Basics for Pharmacists:

Heart failure is a clinical syndrome associated with poor quality of life, frequent hospital admissions, and high mortality rates. Since the number of people with heart failure is continuing to ris...