Mark Makowsky

A Randomized Trial of the Effect of Community Pharmacist and Nurse Care on Improving Blood Pressure Management in Patients With Diabetes Mellitus: Study of Cardiovascular Risk Intervention by Pharmacists–Hypertension (SCRIP-HTN)

BACKGROUND Blood pressure (BP) control in patients with diabetes mellitus is difficult to achieve and current patterns are suboptimal. Given increasing problems with access to primary care physicians, community pharmacists and nurses are well positioned to identify and observe these patients. This study aimed to determine the efficacy of a community-based multidisciplinary intervention on BP control in patients with diabetes mellitus. METHODS We performed a randomized controlled trial in 14 community pharmacies in Edmonton, Alberta, Canada, of patients with diabetes who had BPs higher than 130/80 mm Hg on 2 consecutive visits 2 weeks apart. Care from a pharmacist and nurse team included a wallet card with recorded BP measures, cardiovascular risk reduction education and counseling, a hypertension education pamphlet, referral to the patients primary care physician for further assessment or management, a 1-page local opinion leader-endorsed evidence summary sent to the physician reinforcing the guideline recommendations for the treatment of hypertension and diabetes, and 4 follow-up visits throughout 6 months. Control-arm patients received a BP wallet card, a pamphlet on diabetes, general diabetes advice, and usual care by their physician. The primary outcome measure was the difference in change in systolic BP between the 2 groups at 6 months. RESULTS A total of 227 eligible patients were randomized to intervention and control arms between May 5, 2005, and September 1, 2006. The mean (SD) patient age was 64.9 (12.1) years, 59.9% were male, and the mean (SD) baseline systolic/diastolic BP was 141.2 (13.9)/77.3 (8.9) mm Hg at baseline. The intervention group had an adjusted mean (SE) greater reduction in systolic BP at 6 months of 5.6 (2.1) mm Hg compared with controls (P = .008). In the subgroup of patients with a systolic BP greater than 160 mm Hg at baseline, BP was reduced by an adjusted mean (SE) of 24.1 (1.9) mm Hg more in intervention patients than in controls (P < .001). CONCLUSION Even in patients who have diabetes and hypertension that are relatively well controlled, a pharmacist and nurse team-based intervention resulted in a clinically important improvement in BP. Trial Registration clinicaltrials.gov Identifier: NCT00374270.

Capturing Outcomes of Clinical Activities Performed by a Rounding Pharmacist Practicing in a Team Environment: The Collaborate Study [nct00351676]

Background:Medical inpatients are at risk for suboptimal health outcomes from adverse drug events and under-use of evidence-based therapies. We sought to determine whether collaborative care including a team-based clinical pharmacist improves the quality of prescribed drug therapy and reduces hospital readmission. Methods:Multicenter, quasi-randomized, controlled clinical trial. Consecutive patients admitted to 2 internal and 2 family medicine teams in 3 teaching hospitals between January 30, 2006 and February 2, 2007 were included. Team care patients received proactive clinical pharmacist services (medication history, patient-care round participation, resolution of drug-related issues, and discharge counseling). Usual care patients received traditional reactive clinical pharmacist services. The primary outcome was the overall quality score measured retrospectively by a blinded chart reviewer using 20 indicators targeting 5 conditions. Secondary outcomes included 3- and 6-month readmission. Results:A total of 452 patients (220 team care, 231 usual care, mean age: 74 years, 46% male) met eligibility criteria. Team care patients were more likely than usual care patients to receive care specified by the indicators overall (56.4% vs. 45.3%; adjusted mean difference: 10.4%; 95% confidence interval [CI]: 4.9%, 15.7%) and for each targeted disease state except for heart failure. Team care patients experienced fewer readmissions at 3 months (36.2% vs. 45.5%; adjusted OR: 0.63; 95% CI: 0.42, 0.94) but not at 6 months (50.7% vs. 56.3%; adjusted OR; 0.78; 95% CI: 0.53, 1.15). Conclusions:In patients admitted to internal and family medicine teams, team-based care including a clinical pharmacist, improved the overall quality of medication use and reduced rates of readmission.

Lower extremity peripheral arterial disease in individuals with coronary artery disease: Prognostic importance, care gaps, and impact of therapy

BACKGROUND Our objective was to examine the effect of concomitant lower extremity peripheral arterial disease (PAD) on long-term prognosis and pharmacotherapy in patients with coronary artery disease (CAD). METHODS Prospective cohort study enrolling all patients with angiographically proven CAD between April 1, 2000, and December 31, 2004, in Alberta, Canada. RESULTS Of 28,649 patients (mean age 64 years) with CAD, 2509 (9%) had a physician-assigned diagnosis of lower extremity PAD. Mortality was higher in the patients with CAD and PAD over a mean follow-up of 3.1 years, even after adjusting for the fact that patients with PAD had more severe CAD and more comorbidities (adjusted hazard ratio [HR] 1.41, 95% CI 1.28-1.55). Fewer patients with CAD and PAD received antiplatelet agents (83% vs 86%, odds ratio 0.86, 95% CI 0.77-0.97) or beta-blockers (63% vs 67%, odds ratio 0.89, 95% CI 0.82-0.98), but users of these agents exhibited lower mortality (adjusted HR 0.68, 95% CI 0.60-0.77, for antiplatelet agents and adjusted HR 0.72, 95% CI 0.64-0.80, for beta-blockers). Approximately half of these patients were prescribed statins or angiotensin-converting enzyme inhibitors, and 27% were using all 3 evidence-based anti-atherosclerotic therapies (antiplatelets, statin, and angiotensin-converting enzyme inhibitor). CONCLUSIONS In patients with CAD, lower extremity PAD is independently associated with poorer outcomes. Although all evidence-based therapies are underused in patients with CAD, patients with concomitant PAD are less likely to be prescribed antiplatelet agents or beta-blockers--both agents are associated with improved survival in patients with CAD and PAD.

A systematic review of the evidence for pharmacist care of patients with dyslipidemia.

To evaluate the effect of pharmacist care on patients with dyslipidemia.

Factors influencing pharmacists’ adoption of prescribing: qualitative application of the diffusion of innovations theory

BackgroundIn 2007, Alberta became the first Canadian jurisdiction to grant pharmacists a wide range of prescribing privileges. Our objective was to understand what factors influence pharmacists’ adoption of prescribing using a model for the Diffusion of Innovations in healthcare services.MethodsPharmacists participated in semi-structured telephone interviews to discuss their prescribing practices and explore the facilitators and barriers to implementation. Pharmacists working in community, hospital, PCN, or other settings were selected using a mix of random and purposive sampling. Two investigators independently analyzed each transcript using an Interpretive Description approach to identify themes. Analyses were informed by a model explaining the Diffusion of Innovations in health service organizations.ResultsThirty-eight participants were interviewed. Prescribing behaviours varied from non-adoption through to product, disease, and patient focused use of prescribing. Pharmacists’ adoption of prescribing was dependent on the innovation itself, adopter, system readiness, and communication and influence. Adopting pharmacists viewed prescribing as a legitimization of previous practice and advantageous to instrumental daily tasks. The complexity of knowledge required for prescribing increased respectively in product, disease and patient focused prescribing scenarios. Individual adopters had higher levels of self-efficacy toward prescribing skills. At a system level, pharmacists who were in practice settings that were patient focused were more likely to adopt advanced prescribing practices, over those in product-focused settings. All pharmacists stated that physician relationships impacted their prescribing behaviours and individual pharmacists’ decisions to apply for independent prescribing privileges.ConclusionsDiffusion of Innovations theory was helpful in understanding the multifaceted nature of pharmacists’ adoption of prescribing. The characteristics of the prescribing model itself which legitimized prior practices, the model of practice in a pharmacy setting, and relationships with physicians were prominent influences on pharmacists’ prescribing behaviours.

Paradoxically lower prevalence of peripheral arterial disease in South Asians: a systematic review and meta-analysis

Background While people of South Asian (SA) descent have higher rates of cardiovascular disease compared with people of White European (WE) descent, a lower prevalence of lower extremity peripheral arterial disease (PAD) has been suggested in SA. Our intent was to systematically review the literature on PAD prevalence in people of SA descent and to conduct a meta-analysis to identify differences in PAD prevalence between SA and WE. Methods Standard Cochrane systematic review methodology was used for conducting a literature review of published research. Population prevalence studies of PAD in SA with a WE comparison group were included. Full text studies were selected and reviewed by two authors with independent data extraction. Prevalence differences between SA and WE were analysed using ORs. Findings 129 studies were initially identified and ultimately 15 (n=240 003 patients) studies were included. Only one study reported direct comparative general PAD prevalence between SA and WE (OR=0.26, 95%CI 0.17 to 0.38, p<0.001, n=77 855). Fourteen studies with comparative prevalence data between SA and WE in high-risk populations confirm significantly lower odds of PAD in SA with coronary artery disease (CAD) (OR=0.47, 95%CI 0.39 to 0.56, p<0.001, n=139 313) and diabetes (OR=0.44; 95% CI 0.30 to 0.63, p<0.001, n=22 835). Interpretation Reported PAD prevalence is significantly lower in SA than WE for both the CAD and diabetes populations. Explanations for these findings, if true, are unclear. These results underscore the need for further study to clarify mechanisms of ethnic divergence in PAD prevalence.

Prevalence and Treatment Patterns of Lower Extremity Peripheral Arterial Disease Among Patients at Risk in Ambulatory Health Settings

BACKGROUND Lower extremity peripheral arterial disease (PAD) is underdiagnosed and undertreated in Canada, although data are limited. We sought to measure PAD prevalence and treatment patterns in ambulatory settings. METHODS Five trained undergraduate pharmacy students screened subjects > 50 years of age in 10 community pharmacies and 4 physician offices in northern and central Alberta. We assessed cardiovascular risk factors, cardiovascular disease (CVD), and use of evidence-based therapies; administered the Edinburgh Claudication Questionnaire; and measured the ankle-brachial index (ABI). Patients with definite claudication but ABI > 0.90, or patients with ABI > 1.30 were referred to the study vascular medicine physician for further assessment. PAD was defined as an ABI ≤ 0.90 at the initial community screening or an exercise ABI of ≤ 0.90 and 20% lower than the resting ABI, or toe-brachial index of ≤ 0.70. RESULTS We recruited 361 patients (65.1 ± 9.5 years old, 55% female, 85% white) between July 1 and November 30, 2008. Sixteen subjects had PAD (prevalence 4.4%; 95% confidence interval [CI], 2.3-6.5), and all were previously unaware that they had PAD. Nine patients (2.5%) had PAD only, 7 (1.9%) had both PAD and CVD, 87 (24%) had CVD only, and 259 (72%) had neither PAD nor CVD. Use of antiplatelet agents (44%), angiotensin blockade (56%), or statins (44%) was low in patients with newly diagnosed PAD and without other CVD. CONCLUSIONS About 1 in 20 ambulatory persons > 50 years of age screened had PAD. All cases of PAD that we found were previously undiagnosed, and there was a large treatment gap for those without concomitant CVD.

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.

Survey of pharmacist prescribing practices in Alberta

PURPOSE Results of a survey to characterize pharmacist prescribing in the Canadian province of Alberta are reported. METHODS A cross-sectional survey of a random sample of pharmacists registered with the Alberta College of Pharmacists was conducted. The survey was developed in four stages, with evidence of reliability and construct validity compiled. Analysis of variance and chi-square testing were used to compare prescribing behaviors. RESULTS Three hundred fifty of 692 invited pharmacists (51%) completed the survey, with 76.9% and 11.1% indicating that they practiced in community and hospital settings, respectively, and 12.0% practicing in a consultant role (i.e., on a primary care team or in a long-term care setting). Overall, 93.4% of the pharmacists had prescribed. The most common practices were renewing prescriptions for continuity of therapy (92.3%), altering doses (74.3%), and substituting a medication due to a shortage (80.6%). Twenty-three pharmacists (6.6%) indicated that they did not prescribe because they were on an interprofessional team, had a consulting role, or preferred to fax physicians to request orders. Pharmacists with additional prescribing authorization (6.3% of the total survey population) were more likely to prescribe to adjust ongoing medications (63.6%) than to initiate a new medication (18.2%). CONCLUSION A survey showed that Alberta pharmacists prescribed in a manner that mirrored their practice environment. Compared with other groups, hospital and consultant pharmacists were more likely to adapt prescriptions, and community pharmacists were more likely to renew medications. Pharmacists in rural areas were prescribing most frequently.

Pharmacists on primary care teams: Effect on antihypertensive medication management in patients with type 2 diabetes

OBJECTIVE To identify which activities produced a significant improvement in blood pressure control in patients with type 2 diabetes when pharmacists were added to primary care teams. METHODS This prespecified, secondary analysis evaluated medication management data from a randomized controlled trial. The primary outcome was a change in treatment, defined as addition, dosage increase, or switching of an antihypertensive medication during the 1-year study period. The secondary outcome was a change in antihypertensive medication adherence using the medication possession ratio (MPR). RESULTS The 200 evaluable trial patients had a mean age of 59 (SD, 11) years, 44% were men, and mean blood pressure was 130 (SD, 16)/74 (SD, 10) mm Hg at baseline. Treatment changes occurred in 45 (42%) of 107 patients in the intervention group and 24 (26%) of 93 patients in the control group (RR, 1.63; 95% CI, 1.08-2.46). Addition of a new medication was the most common type of change, occurring in 34 (32%) patients in the intervention group and 17 (18%) patients in the control group (P = 0.029). Adherence to antihypertensive medication was high at baseline (MPR, 93%). Although medication adherence improved in the intervention group (MPR, 97%) and declined in the control group (MPR, 91%), the difference between groups was not significant (P = 0.21). CONCLUSION The observed improvement in blood pressure control when pharmacists were added to primary care teams was likely achieved through antihypertensive treatment changes and not through improvements in antihypertensive medication adherence.