Valérie Santschi

Improving Blood Pressure Control Through Pharmacist Interventions: A Meta-Analysis of Randomized Controlled Trials

Background Control of blood pressure (BP) remains a major challenge in primary care. Innovative interventions to improve BP control are therefore needed. By updating and combining data from 2 previous systematic reviews, we assess the effect of pharmacist interventions on BP and identify potential determinants of heterogeneity. Methods and Results Randomized controlled trials (RCTs) assessing the effect of pharmacist interventions on BP among outpatients with or without diabetes were identified from MEDLINE, EMBASE, CINAHL, and CENTRAL databases. Weighted mean differences in BP were estimated using random effect models. Prediction intervals (PI) were computed to better express uncertainties in the effect estimates. Thirty‐nine RCTs were included with 14 224 patients. Pharmacist interventions mainly included patient education, feedback to physician, and medication management. Compared with usual care, pharmacist interventions showed greater reduction in systolic BP (−7.6 mm Hg, 95% CI: −9.0 to −6.3; I2=67%) and diastolic BP (−3.9 mm Hg, 95% CI: −5.1 to −2.8; I2=83%). The 95% PI ranged from −13.9 to −1.4 mm Hg for systolic BP and from −9.9 to +2.0 mm Hg for diastolic BP. The effect tended to be larger if the intervention was led by the pharmacist and was done at least monthly. Conclusions Pharmacist interventions – alone or in collaboration with other healthcare professionals – improved BP management. Nevertheless, pharmacist interventions had differential effects on BP, from very large to modest or no effect; and determinants of heterogeneity could not be identified. Determining the most efficient, cost‐effective, and least time‐consuming intervention should be addressed with further research.

Monitoring compliance in resistant hypertension: an important step in patient management.

Poor compliance with antihypertensive drug regimens is one recognized cause of inadequate blood pressure control. Compliance is difficult to measure, so poor adherence to treatment remains largely undiagnosed in clinical practice. When the therapeutic response to a drug is not the one expected, it is a major challenge for many physicians to decide whether the patient is a non-responder or a non-complier. Poor compliance is therefore often incorrectly interpreted as a lack of response to treatment. Not detecting non-compliance can lead to the wrong measures being taken. Electronic monitoring of compliance provides important longitudinal information about drug-intake behaviour that cannot be obtained in the clinic. Such monitoring can improve both compliance and blood pressure control, and help physicians to make more rational therapeutic decisions. A reliable assessment of compliance could have a great impact on medical costs by preventing unnecessary investigations or dose adaptations in patients who are not taking their drugs adequately, or potentially reducing the number of hospitalizations. Side-effects and lack of effectiveness are two frequent causes of poor compliance. The right choice of antihypertensive drug can therefore contribute to compliance. In this respect, it is important to find a drug regimen that is effective, long-acting and well tolerated. Long-acting antihypertensive drugs that provide good blood pressure control beyond the 24-h dosing period should perhaps be considered as drugs of choice in non-compliant patients with hypertension because they help to prevent the consequences of occasional drug omissions.

Pharmacist Interventions to Improve Cardiovascular Disease Risk Factors in Diabetes: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE This systematic review and meta-analysis of randomized controlled trials (RCTs) assesses the effect of pharmacist care on cardiovascular disease (CVD) risk factors among outpatients with diabetes. RESEARCH DESIGN AND METHODS MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials were searched. Pharmacist interventions were classified, and a meta-analysis of mean changes of blood pressure (BP), total cholesterol (TC), LDL cholesterol, HDL cholesterol, and BMI was performed using random-effects models. RESULTS The meta-analysis included 15 RCTs (9,111 outpatients) in which interventions were conducted exclusively by pharmacists in 8 studies and in collaboration with physicians, nurses, dietitians, or physical therapists in 7 studies. Pharmacist interventions included medication management, educational interventions, feedback to physicians, measurement of CVD risk factors, or patient-reminder systems. Compared with usual care, pharmacist care was associated with significant reductions for systolic BP (12 studies with 1,894 patients; −6.2 mmHg [95% CI −7.8 to −4.6]); diastolic BP (9 studies with 1,496 patients; −4.5 mmHg [−6.2 to −2.8]); TC (8 studies with 1,280 patients; −15.2 mg/dL [−24.7 to −5.7]); LDL cholesterol (9 studies with 8,084 patients; −11.7 mg/dL [−15.8 to −7.6]); and BMI (5 studies with 751 patients; −0.9 kg/m2 [−1.7 to −0.1]). Pharmacist care was not associated with a significant change in HDL cholesterol (6 studies with 826 patients; 0.2 mg/dL [−1.9 to 2.4]). CONCLUSIONS This meta-analysis supports pharmacist interventions—alone or in collaboration with other health care professionals—to improve major CVD risk factors among outpatients with diabetes.

Drug adherence in chronic kidney diseases and dialysis

Poor long-term adherence and persistence to drug therapy is universally recognized as one of the major clinical issues in the management of chronic diseases, and patients with renal diseases are also concerned by this important phenomenon. Chronic kidney disease (CKD) patients belong to the group of subjects with one of the highest burdens of daily pill intake with up to >20 pills per day depending on the severity of their disease. The purpose of the present review is to discuss the difficulties encountered by nephrologists in diagnosing and managing poor adherence and persistence in CKD patients including in patients receiving maintenance dialysis. Our review will also attempt to provide some clues and new perspectives on how drug adherence could actually be addressed and possibly improved. Working on drug adherence may look like a long and tedious path, but physicians and healthcare providers should always be aware that drug adherence is in general much lower than what they may think and that there are many ways to improve and support drug adherence and persistence so that renal patients obtain the full benefits of their treatments.

Cost-effectiveness of pharmacist care for managing hypertension in Canada:

Background: More than half of all heart disease and stroke are attributable to hypertension, which is associated with approximately 10% of direct medical costs globally. Clinical trial evidence has demonstrated that the benefits of pharmacist intervention, including education, consultation and/or prescribing, can help to reduce blood pressure; a recent Canadian trial found an 18.3 mmHg reduction in systolic blood pressure associated with pharmacist care and prescribing. The objective of this study was to evaluate the economic impact of such an intervention in a Canadian setting. Methods: A Markov cost-effectiveness model was developed to extrapolate potential differences in long-term cardiovascular and renal disease outcomes, using Framingham risk equations and other published risk equations. A range of values for systolic blood pressure reduction was considered (7.6-18.3 mmHg) to reflect the range of potential interventions and available evidence. The model incorporated health outcomes, costs and quality of life to estimate an overall incremental cost-effectiveness ratio. Costs considered included direct medical costs as well as the costs associated with implementing the pharmacist intervention strategy. Results: For a systolic blood pressure reduction of 18.3 mmHg, the estimated impact is 0.21 fewer cardiovascular events per person and, discounted at 5% per year, 0.3 additional life-years, 0.4 additional quality-adjusted life-years and

Public health surveillance with electronic medical records: at risk of surveillance bias and overdiagnosis

6,364 cost savings over a lifetime. Thus, the intervention is economically dominant, being both more effective and cost-saving relative to usual care. Discussion: Across a range of one-way and probabilistic sensitivity analyses of key parameters and assumptions, pharmacist intervention remained both effective and cost-saving. Conclusion: Comprehensive pharmacist care of hypertension, including patient education and prescribing, has the potential to offer both health benefits and cost savings to Canadians and, as such, has important public health implications.

Meta-analyses: with confidence or prediction intervals?

ARTICLE Public health surveillance consists in the systematic collection, analysis and interpretation of data, closely integrated with the timely dissemination and use of these data to help prevent and control diseases and injuries.1 Surveillance is traditionally conducted with data tailored to address a specific health problem, for instance, data on risk behaviours from periodic health surveys or data on cancers collected in dedicated registries. These data and methods of collection are ‘designed’ for specific surveillance activities.2 In the past two decades, methods of surveillance have radically changed with the development of information technology, making easier the collection of data for public health surveillance.3 In particular, data from health care providers have become highly accessible through electronic medical records (EMRs), which offers fantastic opportunities for the surveillance of several conditions. EMR is a digital record of patient’s health and health care from hospitals, nursing homes, physician’s offices or pharmacies.3 All kinds of medical events are recorded in EMRs, being diagnoses, laboratory results, treatments, drug prescriptions, vital signs or clinical outcomes. EMRs increase the availability of clinical information, can help decision making and improve quality and efficiency of care. Furthermore, shared EMRs are cardinal for the evolution of health professionals’ …

Secular trends in blood pressure in children: A systematic review

In meta-analyses, when data are pooled and analyzed using random effect models, it is standard to report a confidence interval (CI) around the effect estimate [1–3], as reported in several meta-analyses published in the European Journal of Epidemiology [4–6]. Nevertheless, when heterogeneity is substantial, some authors have proposed to report a prediction interval (PI) rather than a CI to have a better appreciation of the uncertainty around the effect estimate [7–9]. What is the meaning of confidence and prediction intervals? Using results from a meta-analysis demonstrating the impact of pharmacist interventions on blood pressure [10], we explain how to use each of these intervals. In a recent systematic review with meta-analyses of randomized controlled trials, we showed that pharmacist interventions improve the management of major cardiovascular disease risk factors in outpatients, including hypertension, dyslipidemia, and smoking [10]. Interventions were led by the pharmacist alone or in collaboration with other health professionals (e.g., physicians or nurses) and included patient educational interventions, measurement of blood pressure, medication management and feedback to physician, or educational interventions to healthcare professionals. Heterogeneity in the effect of interventions was expected and random effects models were used to estimate mean changes in blood pressure [2]. Out of 30 trials included in this review, blood pressure was the outcome in 19 studies including 10,479 patients. Pharmacist interventions were associated with clinically and statistically significant reductions of systolic (-8.1 mmHg [95 % CI -10.2 to -5.9]) (Fig. 1) and diastolic blood pressure (-3.8 mmHg [95 % CI -5.3 to -2.3]) (Fig. 2) compared with usual care. Nevertheless, a substantial heterogeneity was observed in the effect of pharmacist interventions for both systolic (I = 76 %; I is a measure of between study heterogeneity not due to chance [2]) and diastolic blood pressure (I = 85 %). Differences between studies in terms of type and intensity of interventions may explain this heterogeneity [10, 11]. We computed PI and CI for the effect estimate of pharmacist interventions on blood pressure (Table 1). For both systolic and diastolic blood pressure, PI was much wider than CI. It is critical to realize that CI and PI do not estimate the same thing [8, 9]. CI quantifies the accuracy of the mean and indicates where the mean effect is likely to be [8]. More particularly in our meta-analysis, CI indicates the uncertainty around the estimate of the average effect of pharmacist interventions. Since CI for systolic and CI for diastolic blood pressure do not contain the null value (Table 1), we are confident that the effect on blood pressure is on average beneficial [2]. PI quantifies the dispersion (or distribution) of effect estimates of the interventions [8]. It means that in 95 % of cases the true effect of a new and unique study (from the same family of studies assessing the impact of a pharmacist intervention) will fall within the PI values. In our case, the PI contains values close to 0 mmHg for systolic blood pressure and above 0 mmHg for diastolic blood pressure (Table 1). This means that, although pharmacists’ interventions are effective on average to decrease A. Chiolero (&) V. Santschi B. Burnand Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, Biopôle 2, route de la Corniche 10, 1010 Lausanne, Switzerland e-mail: arnaud.chiolero@chuv.ch; valerie.santschi@gmail.com

Community-based pharmacies: an opportunity to recruit patients?

Blood pressure (BP) is expected to have increased over time in children in most countries due to the increasing prevalence of childhood obesity worldwide. The authors conducted a systematic review of studies assessing secular trends in BP in children and adolescents. Of 1739 citations screened, the authors identified 18 studies including 2 042 470 participants examined between 1963 and 2012. Thirteen studies were conducted in high‐income countries, five in middle‐income countries, and none in low‐income countries. The prevalence of overweight or obesity increased in 17 studies and decreased in one study. BP decreased over time in 13 studies, increased in four, and did not change in one. These findings suggest that secular trends in BP do not mirror secular trends in overweight. This implies that other factors mitigate the effect of overweight on BP in children and adolescents.

Evidence for pharmacist care in the management of hypertension

Recruiting representative population groups with a specific disease is a challenge. In jurisdictions with no existing or no access to a database including individual disease diagnoses (e.g., electronic medical records), there are few satisfying strategies. Usually, population health surveys do not provide enough diagnostic information and may not allow recruiting large enough samples to study a specific disease. Registries or clinical cohorts may exist for specific diseases, but are often not truly population-based. Recruitment from patients’ associations and physicians’ practices may also be selective. In addition, the latter is difficult to run in busy primary care clinics. Finally, the type of information and the possibility to access health insurances’ databases may preclude their use. For diseases that require treatment involving pharmacies regularly, we propose to recruit patients in community pharmacies; this has been seldom described (Knoester et al. 2005; Van Wieren-de Wijer et al. 2009). In the canton of Vaud, Switzerland (*700,000 residents), we have applied such an approach to conduct a survey designed to describe the current population of diabetic patients and to assess the quality of their care. This survey was developed within the framework of a regional diabetes program that started in the summer of 2010 (Hagon-Traub et al. 2010), as one of many such programs implemented to tackle the chronic diseases epidemic (Nolte et al. 2008). The aim of this Hints and Kinks is to present a pharmacy-based approach of recruiting diabetic patients.