Miriam Fradette

Association between frailty and 30-day outcomes after discharge from hospital

Background: Readmissions after hospital discharge are common and costly, but prediction models are poor at identifying patients at high risk of readmission. We evaluated the impact of frailty on readmission or death within 30 days after discharge from general internal medicine wards. Methods: We prospectively enrolled patients discharged from 7 medical wards at 2 teaching hospitals in Edmonton. Frailty was defined by means of the previously validated Clinical Frailty Scale. The primary outcome was the composite of readmission or death within 30 days after discharge. Results: Of the 495 patients included in the study, 162 (33%) met the definition of frailty: 91 (18%) had mild, 60 (12%) had moderate, and 11 (2%) had severe frailty. Frail patients were older, had more comorbidities, lower quality of life, and higher LACE scores at discharge than those who were not frail. The composite of 30-day readmission or death was higher among frail than among nonfrail patients (39 [24.1%] v. 46 [13.8%]). Although frailty added additional prognostic information to predictive models that included age, sex and LACE score, only moderate to severe frailty (31.0% event rate) was an independent risk factor for readmission or death (adjusted odds ratio 2.19, 95% confidence interval 1.12–4.24). Interpretation: Frailty was common and associated with a substantially increased risk of early readmission or death after discharge from medical wards. The Clinical Frailty Scale could be useful in identifying high-risk patients being discharged from general internal medicine wards.

Impact of a patient decision aid on care among patients with nonvalvular atrial fibrillation: a cluster randomized trial

Background: Too few patients with nonvalvular atrial fibrillation (NVAF) receive appropriate antithrombotic therapy. We tested the short-term (primary outcome) and long-term (secondary outcome) effect of a patient decision aid on the appropriateness of antithrombotic therapy among patients with NVAF. Methods: We conducted a cluster randomized trial with blinded outcome assessment involving 434 NVAF patients from 102 community-based primary care practices. Patients in the intervention group received a self-administered booklet and audiotape decision aid tailored to their personal stroke risk profile. Patients in the control group received usual care. The primary outcome measure was change in antithrombotic therapy at 3 months. Appropriateness of therapy was defined using the American College of Chest Physicians (ACCP) recommendations. Results: The mean patient age was 72 years, and the median duration of NVAF was 5 years. In the control group, there was a 3% decrease over 3 months in the number of patients receiving therapy appropriate to their risk of stroke (40% [85/215] at baseline v. 37% [79/215] at 3 months). In the intervention group, the number of patients receiving therapy appropriate to their stroke risk increased by 9% (32% [69/219] at baseline v. 41% [89/219] at 3 months). Although the proportion of patients whose therapy met the ACCP treatment recommendations did not differ between study arms at baseline (p = 0.11) or 3 months (p = 0.44), there was a 12% absolute improvement in the number of patients receiving appropriate care in the intervention group compared with the control group at 3 months (p = 0.03). The beneficial effect of the decision aid did not persist (p = 0.44 for differences between study arms after 12 months). Interpretation: There was short-term improvement in the appropriateness of antithrombotic care among patients with NVAF who were exposed to a decision aid, but the improvement did not persist.

Case management for blood pressure and lipid level control after minor stroke: PREVENTION randomized controlled trial

Background: Optimization of systolic blood pressure and lipid levels are essential for secondary prevention after ischemic stroke, but there are substantial gaps in care, which could be addressed by nurse- or pharmacist-led care. We compared 2 types of case management (active prescribing by pharmacists or nurse-led screening and feedback to primary care physicians) in addition to usual care. Methods: We performed a prospective randomized controlled trial involving adults with recent minor ischemic stroke or transient ischemic attack whose systolic blood pressure or lipid levels were above guideline targets. Participants in both groups had a monthly visit for 6 months with either a nurse or pharmacist. Nurses measured cardiovascular risk factors, counselled patients and faxed results to primary care physicians (active control). Pharmacists did all of the above as well as prescribed according to treatment algorithms (intervention). Results: Most of the 279 study participants (mean age 67.6 yr, mean systolic blood pressure 134 mm Hg, mean low-density lipoprotein [LDL] cholesterol 3.23 mmol/L) were already receiving treatment at baseline (antihypertensives: 78.1%; statins: 84.6%), but none met guideline targets (systolic blood pressure ≤ 140 mm Hg, fasting LDL cholesterol ≤ 2.0 mmol/L). Substantial improvements were observed in both groups after 6 months: 43.4% of participants in the pharmacist case manager group met both systolic blood pressure and LDL guideline targets compared with 30.9% in the nurse-led group (12.5% absolute difference; number needed to treat = 8, p = 0.03). Interpretation: Compared with nurse-led case management (risk factor evaluation, counselling and feedback to primary care providers), active case management by pharmacists substantially improved risk factor control at 6 months among patients who had experienced a stroke. Trial registration: ClinicalTrials.gov, no. NCT00931788

The Enhancing Secondary Prevention in Coronary Artery Disease trial

Background: Proven efficacious therapies are sometimes underused in patients with chronic cardiac conditions, resulting in suboptimal outcomes. We evaluated whether evidence summaries, which were either unsigned or signed by local opinion leaders, improved the quality of secondary prevention care delivered by primary care physicians of patients with coronary artery disease. Methods: We performed a randomized trial, clustered at the level of the primary care physician, with 3 study arms: control, unsigned statements or opinion leader statements. The statements were faxed to primary care physicians of adults with coronary artery disease at the time of elective cardiac catheterization. The primary outcome was improvement in statin management (initiation or dose increase) 6 months after catheterization. Results: We enrolled 480 adults from 252 practices. Although statin use was high at baseline (n = 316 [66%]), most patients were taking a low dose (mean 32% of the guideline-recommended dose), and their low-density lipoprotein (LDL) cholesterol levels were elevated (mean 3.09 mmol/L). Six months after catheterization, statin management had improved in 79 of 157 patients (50%) in the control arm, 85 of 158 (54%) patients in the unsigned statement group (adjusted odds ratio [OR] 1.18, 95% CI 0.71–1.94, p = 0.52) and 99 of 165 (60%) patients in the opinion leader statement group (adjusted OR 1.51, 95% CI 0.94–2.42, p = 0.09). The mean fasting LDL cholesterol levels after 6 months were similar in all 3 study arms: 2.35 (standard deviation [SD] 0.86) mmol/L in the control arm compared with 2.24 (SD 0.73) among those in the opinion leader group (p = 0.48) and 2.19 (SD 0.68) in the unsigned statement group (p = 0.32). Interpretation: Faxed evidence reminders for primary care physicians, even when endorsed by local opinion leaders, were insufficient to optimize the quality of care for adults with coronary artery disease. ClinicalTrials.gov trial register no. NCT00175240.

Medication Discrepancies Associated With a Medication Reconciliation Program and Clinical Outcomes After Hospital Discharge

To identify the frequency of unintended medication discrepancies 30 days postdischarge from medicine wards with interprofessional medication reconciliation processes and clinical import.

Case management reduces global vascular risk after stroke: Secondary results from the The preventing recurrent vascular events and neurological worsening through intensive organized case-management randomized controlled trial

BACKGROUND Survivors of ischemic stroke/transient ischemic attack (TIA) are at high risk for other vascular events. We evaluated the impact of 2 types of case management (hard touch with pharmacist or soft touch with nurse) added to usual care on global vascular risk. METHODS This is a prespecified secondary analysis of a 6-month trial conducted in outpatients with recent stroke/TIA who received usual care and were randomized to additional monthly visits with either nurse case managers (who counseled patients, monitored risk factors, and communicated results to primary care physicians) or pharmacist case managers (who were also able to independently prescribe according to treatment algorithms). The Framingham Risk Score [FRS]) and the Cardiovascular Disease Life Expectancy Model (CDLEM) were used to estimate 10-year risk of any vascular event at baseline, 6 months (trial conclusion), and 12 months (6 months after last trial visit). RESULTS Mean age of the 275 evaluable patients was 67.6 years. Both study arms were well balanced at baseline and exhibited reductions in absolute global vascular risk estimates at 6 months: median 4.8% (Interquartile range (IQR) 0.3%-11.3%) for the pharmacist arm versus 5.1% (IQR 1.9%-12.5%) for the nurse arm on the FRS (P = .44 between arms) and median 10.0% (0.1%-31.6%) versus 12.5% (2.1%-30.5%) on the CDLEM (P = .37). These reductions persisted at 12 months: median 6.4% (1.2%-11.6%) versus 5.5% (2.0%-12.0%) for the FRS (P = .83) and median 8.4% (0.1%-28.3%) versus 13.1% (1.6%-31.6%) on the CDLEM (P = .20). CONCLUSIONS Case management by nonphysician providers is associated with improved global vascular risk in patients with recent stroke/TIA. Reductions achieved during the active phase of the trial persisted after trial conclusion.

Cholesterol End Points Predict Outcome in Patients With Coronary Disease: Quality Improvement Metrics from The Enhancing Secondary Prevention in Coronary Artery Disease (ESP-CAD) Trial

BACKGROUND Achievement of target low-density lipoprotein (LDL) levels for secondary prevention is endorsed in Canadian guidelines but has been de-emphasized in the 2013 American College of Cardiology/American Heart Association coronary artery disease (CAD) guidelines in favor of initiation of statins or triple therapy (antiplatelet agent, angiotensin converting enzyme inhibitor/angiotensin II receptor blocker, and statins). Our objective was to determine which of these 3 process-of-care metrics achieved within 6 months would be associated with 5-year rates of death, myocardial infarction, or stroke and thus be suitable as an end point for quality improvement studies in patients with CAD. METHODS This was a cohort study that followed 448 participants for 5 years after their involvement in a 6-month secondary prevention trial. RESULTS Over 5 years, 37 patients died, 23 had myocardial infarction, and 20 had stroke. Six months after randomization, 125 (27.9%) had achieved the LDL target (≤ 2.0 mmol/L), 399 (89.1%) received statins, and 256 (57.1%) received triple therapy. The 5-year composite event rate was significantly lower in patients who achieved the LDL target during the 6-month trial than in those who did not (8.8% vs 17.3%; adjusted hazard ratio [aHR], 0.52; 95% confidence interval [CI], 0.27-0.99), even accounting for statin use (adjusted P = 0.038). Conversely, 5-year event rates were not lower in patients taking statins at 6 months compared with those who were not (14.8% vs 16.3%; aHR, 1.23; 95% CI, 0.58-2.61) or in those receiving triple therapy and those who were not (14.5% vs 15.6%; aHR, 1.17; 95% CI, 0.71-1.94). CONCLUSIONS Achievement of LDL targets at 6 months is suitable as a metric for CAD quality-improvement studies; medication use alone was not independently associated with longer term outcomes.

Dabigatran in atrial fibrillation: New kid on the block

In Canada, atrial fibrillation (AF) is the most prevalent cardiac arrhythmia.1 It is associated with an increase in morbidity and mortality, with cardioembolic stroke being one of the most feared complications.2 Anticoagulation is an effective means of reducing the risk of stroke. Currently, warfarin is the preferred agent in patients at high risk of stroke.3,4 However, maintaining warfarin therapy within its narrow therapeutic window is challenging, even for specialized anticoagulation clinics.5 Many factors contribute to the variable dose response of warfarin, such as inter-individual variability, comorbidities and drug and food interactions.5 Dabigatran is a novel therapeutic alternative that provides more predictable anticoagulation with less laboratory monitoring, and it is poised to take over some of warfarins role in AF stroke prophylaxis. While other novel agents, such as rivaroxaban and apixaban, have proven to be beneficial in stroke prophylaxis in AF, discussion of their roles is beyond the scope of this article.

Usability and Acceptability of a Home Blood Pressure Telemonitoring Device Among Community-Dwelling Senior Citizens With Hypertension: Qualitative Study

Background Hypertension is a major cause of cardiovascular disease in older individuals. To ensure that blood pressure (BP) levels are within the optimal range, accurate BP monitoring is required. Contemporary hypertension clinical practice guidelines strongly endorse the use of home BP measurement as a preferred method of BP monitoring for individuals with hypertension. The benefits of home BP monitoring may be optimized when measurements are telemonitored to care providers; however, this may be challenging for older individuals with less technological capabilities. Objective The objective of this qualitative study was to examine the usability and acceptability of a home BP telemonitoring device among senior citizens. Methods We conducted a qualitative descriptive study. Following a 1-week period of device use, individual, semistructured interviews were conducted. Interview audio recordings were anonymized, de-identified, and transcribed verbatim. We performed thematic analysis on interview transcripts. Results Seven senior citizens participated in the usability testing of the home BP telemonitoring device. Participants comprised females (n=4) and males (n=3) with a mean age of 86 years (range, 70-95 years). Overall, eight main themes were identified from the interviews: (1) positive features of the device; (2) difficulties or problems with the device; (3) device was simple to use; (4) comments about wireless capability and components; (5) would recommend device to someone else; (6) would use device in future; (7) suggestions for improving the device; and (8) assistance to use device. Additional subthemes were also identified. Conclusions Overall, the home BP telemonitoring device had very good usability and acceptability among community-dwelling senior citizens with hypertension. To enhance its long-term use, few improvements were noted that may mitigate some of the relatively minor challenges encountered by the target population.