Yazid N. Al Hamarneh

Pharmacist intervention for glycaemic control in the community (the RxING study)

Objective To determine the effect of a community pharmacist prescribing intervention on glycaemic control in patients with poorly controlled type 2 diabetes. Design Pragmatic, before–after design. Setting 12 community pharmacies in Alberta, Canada. Participants Type 2 diabetes receiving oral hypoglycaemic medications and with glycated haemoglobin (HbA1c) of 7.5–11%. Intervention Pharmacists systematically identified potential candidates by inviting patients with type 2 diabetes to test their HbA1c using validated point-of-care technology. Pharmacists prescribed 10 units of insulin glargine at bedtime, adjusted by increments of 1 unit daily to achieve a morning fasting glucose of ≤5.5 mmol/L. The patients were followed up at 2, 4, 8, 14, 20 and 26 weeks. Primary outcome Change in HbA1c from baseline to week 26. Secondary outcomes Proportion of patients achieving target HbA1c, changes in oral hypoglycaemic agents, quality of life and patient satisfaction, persistence on insulin glargine, number of insulin dosage adjustments per patient and number of hypoglycaemic episodes. Results We screened 365 patients of whom 111 were eligible. Of those, 100 (90%) were enrolled in the study; all 11 patients who did not consent refused to use insulin. Average age was 64 years (SD 10.4), while average diabetes duration was 10.2 years (SD 7). HbA1c was reduced from 9.1% (SD 1) at baseline to 7.3% (SD 0.9); a change of 1.8% (95% CI 1.4 to 2, p<0.001). Fasting plasma glucose was reduced from 11 (SD 3.3) to 6.9 mmol/L (SD 1.8); a change of 4.1 mmol/L (95% CI of 3.3 to 5, p=0.007). Fifty-one per cent of the patients achieved the target HbA1c of ≤7% at the end of the study. Conclusions This is the first completed study of independent prescribing by pharmacists. Our results showed similar improvements in glycaemic control as previous physician-led studies. RxING provides further evidence for the benefit of pharmacist care in diabetes. Trial registration clinicaltrials.gov; Identifier: NCT01335763.

Public knowledge and awareness of cardiovascular disease and its risk factors: a cross-sectional study of 1000 Jordanians

Objective  To assess the level of the current knowledge and understanding of cardiovascular disease (CVD) among Jordans general public, their behaviour towards CVD and the factors associated with different CVD knowledge levels.

Community pharmacist targeted screening for chronic kidney disease

More than 1 in 10 adults in Canada is living with chronic kidney disease (CKD),1 defined as a reduction in kidney function (estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m2) or markers of kidney damage (albuminuria ≥3 mg/mmol or abnormalities in urine sediment or renal imaging) for more than 3 months.2 Individuals with CKD require more intensive follow-up due to their reduced renal function, increased cardiovascular risk and multiple associated comorbidities.3 Early detection can help optimize the treatment, prevent or slow the progression of the disease and ultimately improve the quality of life of patients with CKD.4-6 Early stages of CKD are often asymptomatic, making preventive efforts difficult. Indeed, Mitra and Bradley7 identified that a large proportion of patients in the community are underdiagnosed and undertreated for CKD. As such, the use of comprehensive evidence-based guidelines to aid in targeted screening, early detection and management of such patients has been recommended.1 The CKD Clinical Pathway was developed to provide guidance on these issues in this high-risk population.8 The CKD Clinical Pathway is an online tool modeled after the successful National Institute for Health and Care Excellence (NICE) clinical pathways. It was developed by a team of stakeholders that included nephrologists, pharmacists, primary care physicians, nurses, other health care professionals, information technology specialists, web developers and designers to aid in the diagnosis, management and referral of adults with CKD in the community. The content in the CKD Clinical Pathway is evidence based and combines a group of national and international guidelines.2,9-14 This ensures that the recommendations are relevant and harmonized across Canada. More information on the CKD Clinical Pathway is available at www.ckdpathway.ca. Pharmacists are frontline health care professionals who see patients with, and at risk of, CKD frequently and therefore could systematically identify these individuals and assist in their management. Moreover, pharmacists’ scope of practice has expanded in Alberta, allowing them to order and view laboratory tests. As such, we undertook this study to evaluate pharmacists’ application of the CKD Clinical Pathway in the screening and identification of patients with CKD, particularly those with previously unrecognized CKD.

Pharmacists' perceptions of their practice: a comparison between Alberta and Northern Ireland

Objective  To explore how community pharmacists from Alberta, Canada, and Northern Ireland, UK, describe what a pharmacist does and to compare their responses.

Online clinical pathway for managing adults with chronic kidney disease

Around one-tenth of the adults in Canada are affected by chronic kidney disease (CKD), which is defined as estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m2.1 Early recognition of CKD is important, since timely implementation of lifestyle and pharmacological interventions can prevent it or slow its progression.2-4 Such interventions can also reduce the incidence of cardiovascular disease (CVD)5,6—the primary cause of death in these patients.7 However, patients with CKD are often not recognized and do not receive optimal treatment because of complexities in care and failure to disseminate best practices.8-10 The Kidney Disease Improving Global Outcomes (KDIGO) CKD clinical practice guidelines provide evidence for the evaluation and management of CKD.11 While clinical practice guidelines summarize evidence and provide recommendations, they are often difficult to apply in routine daily clinical activities. Clinical pathways are often derived from clinical practice guidelines but differ by providing more explicit and practical information about the sequence, timing and provision of interventions.12 A clinical pathway can be an effective tool to increase uptake of evidence-based health care by pharmacists and other primary care professionals in the community, who care for the majority of patients with CKD.13-15 Pharmacists in Canada have an expanding scope of practice; pharmacists can order laboratory tests, adapt new prescriptions, perform therapeutic substitutions, issue prescriptions for continuity of care and prescribe in emergency situations.16 In Alberta, pharmacists who have Additional Prescribing Authorization can prescribe at initial access or manage ongoing therapy based on their own assessment or in collaboration with another regulated health care professional.17 An integral part of pharmacists’ practice is working collaboratively and communicating with physicians and other health care providers.17 As pharmacists’ expanded scope of practice develops,16 tools such as the CKD Clinical Pathway (Figure 1) can assist pharmacists to implement evidence-based guidelines into their daily practice. This manuscript provides an overview of the clinical pathway for diagnosis, management and referral of adults with CKD and its potential clinical use for pharmacists. Figure 1 Overview of the adult CKD Clinical Pathway Development of the adult CKD Clinical Pathway The CKD Clinical Pathway is an online tool/guideline modeled after the successful National Institute for Health and Clinical Excellence (NICE) clinical pathways (http://pathways.nice.org.uk). It was developed by a team of stakeholders that included pharmacists, nephrologists, primary care physicians, nurses, other health care professionals, IT specialists, web developers and designers. Usability and heuristic testing with primary care professionals has been completed, and the CKD Clinical Pathway has been available online since November 4, 2014 (www.CKDpathway.ca). The content in the CKD Clinical Pathway is evidence based and uses international and national guidelines, including the KDIGO CKD guidelines,11 KDIGO Lipid guidelines,18 C-CHANGE,19 Canadian Diabetes Association (CDA) guidelines,20 Canadian Cardiovascular Society Lipid and Antiplatelet guidelines21,22 and Canadian Hypertension Education Program guidelines.23 This ensures that the recommendations are relevant and harmonized across Canada. Some of the content, such as the specialist referral form, is tailored to practice in Alberta. Users of the pathway should be aware that their local laboratory may report different reference ranges and units of measure than the laboratories in Alberta. Currently, laboratories in Alberta report estimated GFR using the CKD-EPI equation.24

Glycemic control in community-dwelling patients with type 2 diabetes.

Nearly 25% of Canadians have either diabetes or prediabetes, with diabetes-associated health care costs reaching

Public perceptions of coronary events risk factors: a discrete choice experiment

12.2 billion in 2010.1 It has been reported that glycemic control in primary care is poor. Harris and colleagues2 conducted a study across the 10 provinces of Canada to assess the quality of care and treatment of type 2 diabetes patients in primary care settings. They reported that almost half of the patients with type 2 diabetes in primary care settings did not achieve their glycemic target (HbA1c ≤7%).2 Poor glycemic control puts diabetes patients at high risk of suffering from diabetes complications.3 Glycemic control testing plays an essential role not only in diabetes diagnosis,4 but it is also considered the first step in diabetes management.2 There are 3 different ways to measure glycemic control: Fasting plasma glucose (FPG) Oral glucose tolerance test (OGTT), in which the blood glucose concentration is measured 2 hours after taking a glucose solution (75 g anhydrous glucose dissolved in water) Glycated hemoglobin (HbA1c) (the 2008 Canadian Diabetes Association Guidelines recommend diabetes patients to have HbA1c ≤7%)4

After the diabetes care trial ends, now what? A 1-year follow-up of the RxING study

Objectives To assess public perceptions of coronary heart disease (CHD) risk factors. Design Discrete choice experiment questionnaire. Setting Six provincial centres in Northern Ireland. Participants 1000 adults of the general public in Northern Ireland. Primary and secondary outcomes The general publics perception of CHD risk factors. The effect of having risk factor(s) on that perception. Results Two multinomial logit models were created. One was a basic model (no heterogeneity permitted), while the other permitted heterogeneity based on respondents’ characteristics. In both models individuals with very high cholesterol were perceived to be at the highest risk of having a coronary event. Respondents who reported having high cholesterol perceived the risk contribution of very high cholesterol to be greater than those who reported having normal cholesterol. Similar findings were observed with blood pressure and smoking. Respondents who were male and older perceived the contribution of age and gender to be lower than respondents who were female and younger. Conclusions Respondents with different risk factors perceived such factors differently. These divergent perceptions of CHD risk factors could be a barrier to behavioural change. This brings into focus the need for more tailored health promotion campaigns to tackle CHD.

Hypertension Canada’s 2017 guidelines for diagnosis, risk assessment, prevention and treatment of hypertension in adults for pharmacists: An update:

Introduction There is strong evidence that pharmacist care improves patients’ glycaemic control. However, the sustainability and durability of such interventions beyond the research period is not known. RxING was the first trial of pharmacist prescribing in diabetes and it showed an improvement in glycated haemoglobin (HbA1c) of 1.8% over 6 months. Objective 1° objective: To evaluate glycaemic control in the RxING study patients 12 months after the end of the formal study follow-up. 2° objective: To assess the patients’ risk of cardiovascular events in the next 10 years. Methods We contacted the participating pharmacists to check if the patients who participated in the RxING study are still taking insulin, the dose of insulin they are taking, and their HbA1c. There were no mandated follow-up visits with the pharmacist after the study completion. Results A total of 100 patients with poorly controlled type 2 diabetes were enrolled in the original RxING study; 93 of them completed the study, while 83 participated in the 12-month follow-up. Seventy-five patients were still taking insulin, with the average dose increasing from 31.1 units (SD 18.4) at study completion to 37.4 units (SD 30.8) (95% CI −13.3 to 0.88, p=0.085). HbA1c was reduced from 9.1% (SD 1) at baseline to 7.3% (SD 0.9) at study completion (95% CI 1.4 to 2, p <0.001), and increased to 8.1% (SD 1.3) 12 months later (95% CI −1.1 to −0.5, p <0.001 vs study completion). Conclusions Twelve months after completing the intervention, approximately half of the glycaemic control gains were lost. This highlights the importance of structured follow-up with the pharmacist in this patient population. Trial registration number clinicaltrials.gov; Identifier: NCT01335763.

Prevalence of non-adherence among psychiatric patients in Jordan, a cross sectional study

Hypertension Canada (formerly the Canadian Hypertension Education Program, CHEP) has been publishing evidence-based guidelines for the diagnosis and management of hypertension since 1999. The 2017 guidelines, released earlier this year, denote the 19th annual synthesis and update of evidence to date in hypertension. These guidelines, together with knowledge translation programs for health care professionals, have helped to improve the levels of detection and management of hypertension in Canada and reduced associated cardiovascular mortality. Indeed, the proportion of patients with controlled blood pressure in Canada has significantly increased from 13.2% in 1992 to 68.1% in 2012-2013. A multidisciplinary expert panel is responsible for the synthesis and dissemination of Hypertension Canada’s guidelines. To date, the panel has consisted of physicians, nurses and pharmacists, among other disciplines. Pharmacists are well positioned to manage hypertension, as they see patients with chronic conditions more frequently than any other health care professional. Furthermore, the growing body of evidence supporting pharmacist interventions is indisputable. As such, Hypertension Canada has recognized pharmacists’ expanded scope of practice as one approach to improve the detection and management of hypertension in Canada. The Canadian Pharmacists Journal has regularly published pharmacist-specific hypertension guidelines, with the most recent full set of guidelines published in 2011 and regular updates thereafter. This article highlights updates that have been integrated into the current 2017 Hypertension Canada guidelines, in addition to elements that the authors feel are still important from previous publications. Readers requiring Hypertension Canada’s full guidelines are encouraged to refer to the Canadian Journal of Cardiology, www.hypertension.ca or previous versions of pharmacist-specific publications in the Canadian Pharmacists Journal.