Lyne Lalonde

Better adherence to antihypertensive agents and risk reduction of chronic heart failure.

Aims.  Antihypertensive (AH) agents have been shown to reduce the risk of major cardiovascular events including chronic heart failure (CHF). However, the impact of changes in patterns of AH agents use on CHF is unknown. Our objective was to estimate to which different patterns of AH agent use is associated with the occurrence of CHF in a population‐based study.

The Impact of a Multidisciplinary Information Technology–Supported Program on Blood Pressure Control in Primary Care

Background—Hypertension is a leading mortality risk factor yet inadequately controlled in most affected subjects. Effective programs to address this problem are lacking. We hypothesized that an information technology–supported management program could help improve blood pressure (BP) control. Methods and Results—This randomized controlled trial included 223 primary care hypertensive subjects with mean 24-hour BP >130/80 and daytime BP >135/85 mm Hg measured with ambulatory monitoring (ABPM). Intervention subjects received a BP monitor and access to an information technology–supported adherence and BP monitoring system providing nurses, pharmacists, and physicians with monthly reports. Control subjects received usual care. The mean (±SD) follow-up was 348 (±78) and 349 (±84) days in the intervention and control group, respectively. The primary end point of the change in the mean 24-hour ambulatory BP was consistently greater in intervention subjects for both systolic (−11.9 versus −7.1 mm Hg; P<0.001) and diastolic BP (−6.6 versus −4.5 mm Hg; P=0.007). The proportion of subjects that achieved Canadian Guideline target BP (46.0% versus 28.6%) was also greater in the intervention group (P=0.006). We observed similar BP declines for ABPM and self-recorded home BP suggesting the latter could be an alternative for confirming BP control. The intervention was associated with more physician-driven antihypertensive dose adjustments or changes in agents (P=0.03), more antihypertensive classes at study end (P=0.007), and a trend toward improved adherence measured by prescription refills (P=0.07). Conclusions—This multidisciplinary information technology–supported program that provided feedback to patients and healthcare providers significantly improved blood pressure levels in a primary care setting.

Development and preliminary testing of a patient decision aid to assist pharmaceutical care in the prevention of cardiovascular disease.

Study Objective. To develop and test a decision aid for patients with hypertension and/or dyslipidemia because a decision aid may assist in pharmaceutical care by providing relevant evidence‐based information.

Evaluation of a decision aid and a personal risk profile in community pharmacy for patients considering options to improve cardiovascular health: the OPTIONS pilot study

Objective In a pilot study, to assess the feasibility and relevance of providing a community pharmacist consultation supplemented by a decision aid (DA) or a personal risk profile (PRP) to patients on lipid‐lowering or antihypertensive pharmacotherapy. Preliminary data on the clinical effectiveness of these interventions were collected.

Effectiveness of a medication discharge plan for transitions of care from hospital to outpatient settings

PURPOSE The effect of a medication discharge plan (MDP) on the rate of medication discrepancies between hospital and outpatient settings was evaluated. METHODS In a pragmatic, open, randomized, controlled trial, MDPs were completed for all patients before discharge from the hospital. Patients were then assigned to either an MDP group, for whom MDPs were sent to community pharmacies and treating physicians, or a usual care group, for whom an MDP was not sent. Discrepancies between MDPs and community pharmacy dispensing records and medication use reported by patients during a telephone interview were documented. The percentage of patients with discrepancies and the mean percentage of medications with discrepancies were compared between the two groups. The clinical severity of discrepancies was blindly evaluated. RESULTS A total of 83 patients agreed to participate in the study. The percentage of patients with at least one discrepancy was high and similar in both groups when MDPs were compared with pharmacy dispensing records and patient self-reports. Comparison of MDPs to pharmacy dispensing records revealed discrepancies for 13-15% of medications; more than a third were clinically significant. Comparison of MDPs to patient self-reports revealed discrepancies for 10-12% of medications; 48% were clinically significant. No significant differences were observed between the two groups. CONCLUSION The rate of medication discrepancies was not decreased in patients whose MDP was provided to their community pharmacy and physician at the time of hospital discharge compared with the rate in patients who received usual care.

A cluster randomized controlled Trial to Evaluate an Ambulatory primary care Management program for patients with dyslipidemia: the TEAM study

Background: Few studies have reported the efficacy of collaborative care involving family physicians and community pharmacists for patients with dyslipidemia. Methods: We randomly assigned clusters consisting of at least two physicians and at least four pharmacists to provide collaborative care or usual care. Under the collaborative care model, pharmacists counselled patients about their medications, requested laboratory tests, monitored the effectiveness and safety of medications and patients’ adherence to therapy, and adjusted medication dosages. After 12 months of follow-up, we assessed changes in low-density lipoprotein (LDL) cholesterol (the primary outcome), the proportion of patients reaching their target lipid levels and changes in other risk factors. Results: Fifteen clusters representing a total of 77 physicians and 108 pharmacists were initially recruited, and a total of 51 physicians and 49 pharmacists were included in the final analyses. The collaborative care teams followed a total of 108 patients, and the usual care teams followed a total of 117 patients. At baseline, mean LDL cholesterol level was higher in the collaborative care group (3.5 v. 3.2 mmol/L, p = 0.05). During the study, patients in the collaborative care group were less likely to receive high-potency statins (11% v. 40%), had more visits with health care professionals and more laboratory tests, were more likely to have their lipid-lowering treatment changed and were more likely to report lifestyle changes. At 12 months, the crude incremental mean reduction in LDL cholesterol in the collaborative care group was −0.2 mmol/L (95% confidence interval [CI] −0.3 to −0.1), and the adjusted reduction was −0.05 (95% CI −0.3 to 0.2). The crude relative risk of achieving lipid targets for patients in the collaborative care group was 1.10 (95% CI 0.95 to 1.26), and the adjusted relative risk was 1.16 (95% CI 1.01 to 1.34). Interpretation: Collaborative care involving physicians and pharmacists had no significant clinical impact on lipid control in patients with dyslipidemia. International Standard Randomized Controlled Trial register no. ISRCTN66345533.

Health-related quality of life in cardiac patients with dyslipidemia and hypertension

Background: Hypertension is associated with lower health-related quality of life (HRQOL). Similar association may be found for dyslipidemia. However, controversies exist regarding the HRQOL with dyslipidemia. We evaluated the HRQOL of cardiac patients with and without dyslipidemia and hypertension. Methods: In a cross-sectional study, 284 cardiac patients rated their HRQOL using SF-36 Health Survey (SF-36), and three preference-based measures (Rating Scale, Time Trade-off and Standard Gamble). Results: Compared to those without dyslipidemia, those with dyslipidemia reported better HRQOL on all preference-based measures and most SF-36 scales particularly on the physical health scales. Adjusted mean differences and 95% confidence interval (95% CI) were equal to 4.5 (0.5, 8.5), 10.8 (2.8, 18.8), and 2.2 (0.2, 4.2) on the Physical Functioning, the Role-Physical and the Physical Component Summary scales, respectively. Exactly the opposite trends were observed among patients with hypertension. The adjusted mean differences (95% CI) were equal to −2.7 (−6.7, 1.4), −10.9 (−19.1, −2.8), and −2.9 (−4.9, −0.9) on the Physical Functioning, the Role-Physical and the Physical Component Summary scales, respectively. Conclusion: Cardiac patients with hypertension reported lower physical health than those without hypertension while cardiac patients with dyslipidemia reported better physical health than those without dyslipidemia. The reason for these different trends is not known. Possible explanations are discussed.

Community Pharmacists’ Interventions in Asthma Care: A Descriptive Study

BACKGROUND Factors influencing community pharmacists’ interventions have been identified, but little information is available regarding these factors in asthma care. OBJECTIVE To describe the type and frequency of pharmacists’ asthma care interventions and to identify factors influencing those interventions. METHODS A pretested, self-administered questionnaire was mailed to all community pharmacists registered with the Ordre des pharmaciens du Québec in 2006. The form included questions about the pharmacists’ interventions in asthma care in the community setting (21 questions), factors influencing the provision of those interventions (13 questions), and the responders’ characteristics (17 questions). RESULTS A total of 4587 questionnaires were sent; 917 pharmacists returned the questionnaires (response rate 20%), and 877 were eligible for analysis. Overall, community pharmacists who completed the questionnaire appeared to intervene frequently when the initial prescription for asthma medication was filled. About 98% of responders reported providing verbal information always or often on new asthma medication prescriptions. Furthermore, checking for overuse of rescue medication and underuse of maintenance therapy always or often was reported by 91% and 85.8% of responders, respectively. Other interventions at follow-up were not as frequently reported. For example, only 8.4% of pharmacists reported reassessing inhalation technique always or often. Lack of time was reported to be an important barrier to the type and frequency of intervention, while interest on the part of the patient appeared to be a significant facilitator. About 99% of pharmacists agreed with the statement that they have an important role in asthma care. CONCLUSIONS Community pharmacists appear to intervene with patients with asthma mostly at the initiation of treatment, but some interventions at follow-up are not frequently done, which could be attributed to organizational factors.

Development and Validation of the PAIR (Pharmacotherapy Assessment in Chronic Renal Disease) Criteria to Assess Medication Safety and Use Issues in Patients With CKD

BACKGROUND Explicit criteria for judging medication safety and use issues in patients with chronic kidney disease (CKD) are lacking. STUDY DESIGN Quality improvement report. SETTING & PARTICIPANTS Nephrologists (n = 4), primary care physicians (n = 2), hospital pharmacists with expertise in nephrology (n = 4), and community pharmacists (n = 2). The PAIR (Pharmacotherapy Assessment in Chronic Renal Disease) criteria were applied retrospectively to 90 patients with CKD in a randomized study. QUALITY IMPROVEMENT PLAN Development of an explicit set of criteria to enable rapid and systematic detection of drug-related problems (DRPs). Using a RAND method, experts judged the clinical significance of DRPs and the appropriateness of a community pharmacist intervention. The PAIR criteria include 50 DRPs grouped into 6 categories. OUTCOMES DRPs detected using the PAIR criteria compared with implicit clinical judgment by nephrology pharmacists. MEASUREMENTS Prevalence of DRPs and reliability, validity, and responsiveness of the PAIR criteria. RESULTS A mean of 2.5 DRPs/patient (95% CI, 2.0-3.1) was identified based on the PAIR criteria compared with 3.9 DRPs/patient (95% CI, 3.4-4.5) based on clinical judgment of nephrology pharmacists. Inter-rater reliability coefficients (κ) by PAIR category varied from 0.80-1.00, with an intraclass correlation coefficient (ICC) of 0.93 (95% CI, 0.89-0.95) for total DRPs per patient. Test-retest reliability coefficients by category varied from 0.74-1.00, with an ICC of 0.91 (95% CI, 0.82-0.96) for total DRPs per patient. During the study, the mean number of DRPs per patient did not change significantly when assessed using the PAIR criteria and clinical judgment. LIMITATION The prevalence of PAIR DRPs may be underestimated due to the retrospective nature of the validation. CONCLUSION The prevalence of DRPs requiring the intervention of community pharmacists is high in patients with CKD. The PAIR criteria are reliable, but their responsiveness remains to be shown.

Costs of moderate to severe chronic pain in primary care patients – a study of the ACCORD Program

Background The economic burden of chronic noncancer pain (CNCP) remains insufficiently documented in primary care. Purpose To evaluate the annual direct health care costs and productivity costs associated with moderate to severe CNCP in primary care patients taking into account their pain disability. Materials and methods Patients reporting noncancer pain for at least 6 months, at a pain intensity of 4 or more on a 0 (no pain) to 10 (worst possible pain) intensity scale, and at a frequency of at least 2 days a week, were recruited from community pharmacies. Patients’ characteristics, health care utilization, and productivity losses (absenteeism and presenteeism) were documented using administrative databases, pharmacies’ renewal charts, telephone, and self-administered questionnaires. Patients were stratified by tertile of pain disability measured by the Brief Pain Inventory questionnaire. Results Patients (number =483) were, on average, 59 years old, mainly women (67.5%), and suffered from CNCP for a mean of 12 years at an average pain intensity of 6.5±1.9. The annual direct health care costs and productivity costs averaged CAD