Philip A McFarlane

Christus St. Michaels' Hospital, 텍사캐나, Arkansas, United States

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Publications (66)328.25 Total impact

  • Philip A McFarlane
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    ABSTRACT: Routine quantification of urinary albumin levels is recommended for all Canadians with diabetes, yet many controversies remain when interpreting these tests. Elevated levels of albuminuria have traditionally been labeled as either microalbuminuria, representing 30 to 300 mg of albuminuria per day (a range not reliably picked up by conventional urine dipsticks), or as overt nephropathy, representing more than 300 mg per day and usually identifiable by dipstick. The random urine albumin-to-creatinine ratio is a convenient test that can predict reliably the total daily protein excretion. The 30 mg per day upper limit of normal was selected to be a threshold far above the normal albumin excretion seen in healthy people. However, recent studies have shown that elevations of albumin excretion below the microalbuminuria threshold are associated with increased cardiorenal risk, suggesting that the 30 mg per day level may be set too high. Recently, the Canadian Diabetes Association Clinical Practice Guidelines changed the threshold for abnormal urine albumin-to-creatinine ratios to be 2.0 mg/mmol for both men and women. As a result, more women will be identified as having abnormal levels of albuminuria. However, these women will be correctly identified as having increased cardiorenal risk. It is important to note that people with diabetes who have abnormal levels of albuminuria are among patients at the highest risk for cardiorenal disease. These risks can be reduced by using the strategies outlined in the guidelines put forth by the Canadian Diabetes Association.
    Canadian Journal of Diabetes 10/2014; 38(5):372-375. DOI:10.1016/j.jcjd.2014.07.221 · 0.46 Impact Factor
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    ABSTRACT: Over 40% of patients with end stage renal disease in the United States were treated with home hemodialysis (HHD) in the early 1970's. However, this number declined rapidly over the ensuing decades so that the overwhelming majority of patients were treated in-centre 3 times per week on a 3-4 hour schedule. Poor outcomes for patients treated in this fashion led to a renewed interest in home hemodialysis, with more intensive dialysis schedules including short daily (SDHD) and nocturnal (NHD). The relative infancy of these treatment schedules means that there is a paucity of data on 'how to do it'. We undertook a systematic survey of home hemodialysis programs in Canada to describe current practice patterns. Development and deployment of a qualitative survey instrument. Community and academic HHD programs in Canada. Physicians, nurses and technologists. Programmatic approaches to patient selection, delivery of dialysis, human resources available, and follow up. We developed the survey instrument in three phases. A focus group of Canadian nephrologists with expertise in NHD or SDHD discussed the scope the study and wrote questions on 11 domains. Three nephrologists familiar with all aspects of HHD delivery reviewed this for content validity, followed by further feedback from the whole group. Multidisciplinary teams at three sites pretested the survey and further suggestions were incorporated. In July 2010 we distributed the survey electronically to all renal programs known to offer HHD according to the Canadian Organ Replacement Registry. We compiled the survey results using qualitative and quantitative methods, as appropriate. Of the academic and community programs that were invited to participate, 80% and 63%, respectively, completed the survey. We observed wide variation in programmatic approaches to patient recruitment, human resources, equipment, water, vascular access, patient training, dialysis prescription, home requirements, patient follow up, medications, and the approach to non-adherent patients. Cross-sectional survey, unable to link variation to outcomes. Competition for patients between HHD and home peritoneal dialysis means that case mix for HHD may also vary between centres. There is wide variation between programs in all domains of HHD delivery in Canada. We plan further study of the extent to which differences in approach are related to outcomes.
    06/2014; 1(1):11. DOI:10.1186/2054-3581-1-11
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    ABSTRACT: AimThe financial burden of the increasing dialysis population challenges healthcare resources internationally. Home haemodialysis offers many benefits over conventional facility dialysis including superior clinical, patient-centered outcomes and reduced cost. This review updates a previous review, conducted a decade prior, incorporating contemporary home dialysis techniques of frequent and nocturnal dialysis.We sought comparative cost-effectiveness studies of home versus facility haemodialysis (HD) for people with end-stage kidney failure (ESKF).Methods We conducted a systematic review of literature from January 2000 – March 2014. Studies were included if they provided comparative information on the costs, health outcomes and cost-effectiveness ratios of home HD and facility HD. We searched medical and health economic databases using MeSH headings and text words for economic evaluation and haemodialysis.ResultsSix studies of economic evaluations that compared home to facility HD were identified. Two studies compared home nocturnal HD, one home nocturnal and daily home HD, and three compared contemporary home HD to facility HD. Overall these studies suggest that contemporary home HD modalities are less costly and more effective than facility HD. Home HD start-up costs tend to be higher in the short term, but these are offset by cost savings over the longer term.Conclusions Contemporaneous dialysis modalities including nocturnal and daily home haemodialysis are cost-effective orcost-saving compared to facility-based haemodialysis. This result is largely driven by lower staff costs, and better health outcomes for survival and quality of life. Expanding the proportion of haemodialysis patients managed at home is likely to produce cost savings.
    Nephrology 04/2014; 19(8). DOI:10.1111/nep.12269 · 1.86 Impact Factor
  • Value in Health 11/2013; 16(7):A634. DOI:10.1016/j.jval.2013.08.1891 · 2.89 Impact Factor
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    ABSTRACT: Practices in vascular access management with intensive hemodialysis may differ from those used in conventional hemodialysis. We conducted a systematic review to inform clinical practice guidelines for the provision of intensive hemodialysis. Adult patients receiving maintenance (>3 months) intensive hemodialysis (frequent [≥5 hemodialysis treatments per week] and/or long [>5.5 hours per hemodialysis treatment]). We searched EMBASE and MEDLINE (1990-2011) for randomized and observational studies. We also searched conference proceedings (2007-2011). (1) Central venous catheter (CVC) versus arteriovenous (AV) access, (2) buttonhole versus rope-ladder cannulation, (3) topical antimicrobial cream versus none in buttonhole cannulation, and (4) closed connector devices among CVC users. Access-related infection, survival, hospitalization, patency, access survival, intervention rates, and quality of life. We included 23, 7, and 5 reports describing effectiveness by access type, buttonhole cannulation, and closed connector device, respectively. No study directly compared CVC with AV access. On average, bacteremia and local infection rates were higher with CVC compared with AV access. Access intervention rates were higher with more frequent hemodialysis, but access survival did not differ. Buttonhole cannulation was associated with bacteremia rates similar to those seen with CVCs in some series. Topical mupirocin seemed to attenuate this effect. No direct comparisons of closed connector devices versus standard luer-locking devices were found. Low rates of actual or averted (near misses) air embolism and bleeding were reported with closed connector devices. Overall, evidence quality was very low. Limited direct comparisons addressing main review questions, small sample sizes, selective outcome reporting, publication bias, and residual confounding were major factors. This review highlights several differences in the management of vascular access in conventional and intensive hemodialysis populations. We identify a need for standardization of vascular access outcome reporting and a number of priorities for future research.
    American Journal of Kidney Diseases 07/2013; 62(1):112-31. DOI:10.1053/j.ajkd.2013.03.028 · 5.76 Impact Factor
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    ABSTRACT: AIM: To investigate the cardiometabolic risk assessment and management patterns for individuals with and without type 2 diabetes mellitus (T2DM) in Canadian primary care practices. METHODS: Between April 2011 and March 2012, physicians from 9 primary care teams and 88 traditional non-team practices completed a practice assessment on the management of 2461 patients >40 years old with no clinical evidence of cardiovascular disease and diagnosed with at least one of the following risk factor - T2DM, dyslipidemia or hypertension. RESULTS: There were 1304 individuals with T2DM and 1157 without. Pharmacotherapy to manage hyperglycemia, dyslipidemia and hypertension was widely prescribed. Fifty-eight percent of individuals with T2DM had an HbA1c ≤7.0%. Amongst individuals with dyslipidemia, median LDL-C was 1.8 mmol/L for those with T2DM and 2.8 mmol/L for those without. Amongst individuals with hypertension, 30% of those with T2DM achieved the <130/80 mmHg target while 60% of those without met the <140/90 mmHg target. The composite glycemic, LDL-C and blood pressure (BP) target outcome was achieved by 12% of individuals with T2DM. Only 17% of individuals with T2DM and 11% without were advised to increase their physical activity. Dietary modifications were recommended to 32% and 10% of those with and without T2DM respectively. CONCLUSIONS: Patients at elevated cardiometabolic risk were sub-optimally managed in the primary care practices surveyed. There was low attainment of recommended therapeutic glycemic, lipid and BP targets. Advice on healthy lifestyle changes was infrequently dispensed, representing a missed opportunity to educate patients on the long-term benefits of lifestyle modification.
    Diabetes Obesity and Metabolism 05/2013; 15(12). DOI:10.1111/dom.12134 · 5.46 Impact Factor
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    ABSTRACT: BACKGROUND: Patients treated with conventional hemodialysis (HD) develop disorders of mineral metabolism that are associated with increased morbidity and mortality. More frequent and longer HD has been associated with improvement in hyperphosphatemia that may improve outcomes. STUDY DESIGN: Systematic review and meta-analysis to inform the clinical practice guideline on intensive dialysis for the Canadian Society of Nephrology. SETTING & POPULATION: Adult patients receiving outpatient long (≥5.5 hours/session; 3-4 times per week) or long-frequent (≥5.5 hours/session, ≥5 sessions per week) HD. SELECTION CRITERIA FOR STUDIES: We included clinical trials, cohort studies, case series, case reports, and systematic reviews. INTERVENTIONS: Dialysate calcium concentration ≥1.5 mmol/L and/or phosphate additive. OUTCOMES: Fragility fracture, peripheral arterial and coronary artery disease, calcific uremic arteriolopathy, mortality, intradialytic hypotension, parathyroidectomy, extraosseous calcification, markers of mineral metabolism, diet liberalization, phosphate-binder use, and muscle mass. RESULTS: 21 studies were identified: 2 randomized controlled trials, 2 reanalyses of data from the randomized controlled trials, and 17 observational studies. Dialysate calcium concentration ≥1.5 mmol/L for patients treated with long and long-frequent HD prevents an increase in parathyroid hormone levels and a decline in bone mineral density without causing harm. Both long and long-frequent HD were associated with a reduction in serum phosphate level of 0.42-0.45 mmol/L and a reduction in phosphate-binder use. There was no direct evidence to support the use of a dialysate phosphate additive. LIMITATIONS: Almost all the available information is related to changes in laboratory values and surrogate outcomes. CONCLUSIONS: Dialysate calcium concentration ≥1.5 mmol/L for most patients treated with long and long-frequent dialysis prevents an increase in parathyroid hormone levels and decline in bone mineral density without increased risk of calcification. It seems prudent to add phosphate to the dialysate for patients with a low predialysis phosphate level or very low postdialysis phosphate level until more evidence becomes available.
    American Journal of Kidney Diseases 04/2013; 62(1). DOI:10.1053/j.ajkd.2013.02.357 · 5.76 Impact Factor
  • PharmacoEconomics 04/2013; 31(5). DOI:10.1007/s40273-013-0046-5 · 3.34 Impact Factor
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    ABSTRACT: Intensive (longer and more frequent) hemodialysis has emerged as an alternative to conventional hemodialysis for the treatment of patients with end-stage renal disease. However, given the differences in dialysis delivery and models of care associated with intensive dialysis, alternative approaches to patient management may be required. The purpose of this work was to develop a clinical practice guideline for the Canadian Society of Nephrology. We applied the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach for guideline development and performed targeted systematic reviews and meta-analysis (when appropriate) to address prioritized clinical management questions. We included studies addressing the treatment of patients with end-stage renal disease with short daily (≥5 days per week, <3 hours per session), long (3-4 days per week, ≥5.5 hours per session), or long-frequent (≥5 days per week, ≥5.5 hours per session) hemodialysis. We included clinical trials and observational studies with or without a control arm (1990 and later). Based on a prioritization exercise, 6 interventions of interest included optimal vascular access type, buttonhole cannulation, antimicrobial prophylaxis for buttonhole cannulation, closed connector devices, and dialysate calcium and dialysate phosphate additives for patients receiving intensive hemodialysis. We developed 6 recommendations addressing the interventions of interest. Overall quality of the evidence was very low and all recommendations were conditional. We provide detailed commentaries to guide in shared decision making. The main limitation was the very low overall quality of evidence that precluded strong recommendations. Most included studies were small single-arm observational studies. Three randomized controlled trials were applicable, but provided only indirect evidence. Published information for patient values and preference was lacking. In conclusion, we provide 6 recommendations for the practice of intensive hemodialysis. However, due to very low-quality evidence, all recommendations were conditional. We therefore also highlight priorities for future research.
    American Journal of Kidney Diseases 04/2013; 62(1). DOI:10.1053/j.ajkd.2013.02.351 · 5.76 Impact Factor
  • Canadian Journal of Diabetes 04/2013; 37:S129–S136. DOI:10.1016/j.jcjd.2013.01.037 · 0.46 Impact Factor
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    ABSTRACT: We updated the evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in adults for 2013. This year's update includes 2 new recommendations. First, among nonhypertensive or stage 1 hypertensive individuals, the use of resistance or weight training exercise does not adversely influence blood pressure (BP) (Grade D). Thus, such patients need not avoid this type of exercise for fear of increasing BP. Second, and separately, for very elderly patients with isolated systolic hypertension (age 80 years or older), the target for systolic BP should be < 150 mm Hg (Grade C) rather than < 140 mm Hg as recommended for younger patients. We also discuss 2 additional topics at length (the pharmacological treatment of mild hypertension and the possibility of a diastolic J curve in hypertensive patients with coronary artery disease). In light of several methodological limitations, a recent systematic review of 4 trials in patients with stage 1 uncomplicated hypertension did not lead to changes in management recommendations. In addition, because of a lack of prospective randomized data assessing diastolic BP thresholds in patients with coronary artery disease and hypertension, no recommendation to set a selective diastolic cut point for such patients could be affirmed. However, both of these issues will be examined on an ongoing basis, in particular as new evidence emerges.
    The Canadian journal of cardiology 03/2013; DOI:10.1016/j.cjca.2013.01.005 · 3.94 Impact Factor
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    ABSTRACT: BACKGROUND: We evaluated the risk assessment and management patterns employed by primary care physicians in patients at elevated cardiometabolic risk. METHODS: Between April 2011 and March 2012, multiple physicians from 9 Primary Care Teams (PCTs) and 88 physicians from traditional nonteam (Solo) practices completed a practice assessment on the management of 2461 patients > 40 years old with no clinical evidence of cardiovascular disease and diagnosed with at least 1 of the following: dyslipidemia, type 2 diabetes mellitus (T2DM), or hypertension. RESULTS: Individuals with dyslipidemia, T2DM, or hypertension tended to have a body mass index ≥ 25 kg/m2. Waist circumference measurements, obtained for only 392/829 (47.0%) Solo patients, revealed that 88.9% of these individuals were abdominally obese and that at least 52.2% of Solo patients had metabolic syndrome. Cardiovascular risk, determined by the physicians for 83.5% of all patients without T2DM and typically performed using traditional risk engines, was often miscalculated (43.2% PCTs, 58.8% Solo; P = 0.0007). Healthy behavioural modifications were infrequently recommended (< 50%). Pharmacotherapy was widely used (> 70%) but treatment targets were infrequently met. The composite outcome of guideline-recommended low-density lipoprotein cholesterol, glycemic, and blood pressure targets was met by 9.0% and 8.1% of patients managed by PCT and Solo physicians respectively. CONCLUSIONS: Obesity and cardiovascular risk were underassessed and the latter often underestimated. Patients were infrequently counselled on the benefits of healthy behavioural changes. A paradigm change in assessing and managing obesity and cardiovascular risk via aggressive lifestyle interventions is warranted in individuals at elevated cardiometabolic risk.
    The Canadian journal of cardiology 02/2013; 29(8). DOI:10.1016/j.cjca.2012.12.001 · 3.94 Impact Factor
  • 01/2013; 33(1):96-9. DOI:10.3747/pdi.2012.00022
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    ABSTRACT: BackgroundSTARRT recently demonstrated that many patients experience suboptimal dialysis starts (defined as initiation as an inpatient and/or with a central venous catheter), even when followed by a nephrologist for >12 months (NDT 2011). However, STARRT did not identify the factors associated with suboptimal initiation of dialysis. The objectives of this study were to extend the results of STARRT by ascertaining the factors leading to suboptimal initiation of dialysis in patients who were referred at least 12 months prior to commencement of dialysis.Methods At each of the three Toronto centers, charts of consecutive incident RRT patients were identified from 1 January 2009 to 31 December 2010, with predetermined data extracted.ResultsA total of 436 incident RRT patients were studied; 52.4% were followed by a nephrologist for >12 months prior to the initiation of dialysis. Suboptimal starts occurred in 56.4% of these patients. No attempt at arteriovenous fistula (AVF) or arteriovenous graft (AVG) prior to initiation was made in 65% of these starts. Factors contributing to suboptimal starts despite early referral included patient-related delays (31.25%), acute-on-chronic kidney disease (31.25%), surgical delays (16.41%), late decision-making (8.59%) and others (12.50%). The percentage of optimal starts with early referral among 14 nephrologists ranged from 33 to 72%.Conclusions Most patients started dialysis in a suboptimal manner, despite an extended period of pre-dialysis care. Nephrologists should take responsibility for suboptimal initiation of dialysis despite early referral and test methods that attempt to prevent this.
    Nephrology Dialysis Transplantation 12/2012; DOI:10.1093/ndt/gfs431 · 3.49 Impact Factor
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    ABSTRACT: Cardiometabolic risk (CMR) refers to the collective consideration of traditional and emerging risk factors that amplify the potential of developing atherogenic cardiovascular disease, as well as the emergence of type 2 diabetes mellitus. Cumulative data suggest that the metabolic syndrome confers a 5-fold increase in risk for type 2 diabetes mellitus and also increases the cardiovascular risk calculated by conventional algorithms by an additional 1.5- to 2.0-fold. This article is a summary of the recently published position article on cardiometabolic risk by the nationally represented inter-disciplinary Cardiometabolic Risk Working Group (Can J Cardiol. 2011;27:e1–e33). The objective of this article is to review what the emerging risk factors are, how to determine if individuals at risk for or with type 2 diabetes mellitus have elevated CMR and the steps that should be taken to optimally manage and reduce CMR in these patients.
    Canadian Journal of Diabetes 12/2012; 36(6):320-326. DOI:10.1016/j.jcjd.2012.08.009 · 0.46 Impact Factor
  • Canadian Journal of Diabetes 10/2012; 36(5):S39-S40. DOI:10.1016/j.jcjd.2012.07.340 · 0.46 Impact Factor
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    ABSTRACT: In many jurisdictions, cost-effectiveness analysis (CEA) plays an important role in determining drug coverage and reimbursement and, therefore, has the potential to impact patient access. Health economic guidelines recommend the inclusion of future costs related to the intervention of interest within CEAs but provide little guidance regarding the definition of 'related'. In the case of CEAs of therapies that extend the lives of patients with chronic kidney disease (CKD) on dialysis but do not impact the need for or the intensity of dialysis, the determination of the relatedness of future dialysis costs to the therapy of interest is particularly ambiguous. The uncertainty as to whether dialysis costs are related or unrelated in these circumstances has led to inconsistencies in the conduct of CEAs for such products, with dialysis costs included in some analyses while excluded in others. Due to the magnitude of the cost of dialysis, whether or not dialysis costs are included in CEAs of such therapies has substantial implications for the results of such analyses, often meaning the difference between a therapy being deemed cost effective (in instances where dialysis costs are excluded) or not cost effective (in instances where dialysis costs are included). This paper explores the issues and implications surrounding the inclusion of dialysis costs in CEAs of therapies that extend the lives of dialysis patients but do not impact the need for dialysis. Relevant case studies clearly demonstrate that, regardless of the clinical benefits of a life-extending intervention for dialysis patients, and due to the high cost of dialysis, the inclusion of dialysis costs in the analysis essentially eliminates the possibility of obtaining a favourable cost-effectiveness ratio. This raises the significant risk that dialysis patients may be denied access to interventions that are cost effective in other populations due solely to the high background cost of dialysis itself. Finally, the paper presents a case for excluding dialysis costs in CEAs of therapies that extend the lives of patients receiving dialysis but do not impact the need for dialysis. The argument is founded on the following: (i) health economic guidelines imply that dialysis costs are unrelated to such therapies and therefore should not be included in CEAs of such therapies; (ii) the high cost and cost-effectiveness ratio associated with dialysis place an unreasonable and insurmountable barrier to demonstrating the cost effectiveness of such therapies, particularly since the decision to fund dialysis has already been made; and (iii) current clinical and reimbursement practices include the use of such therapies for patients with CKD receiving dialysis. We conclude that the exclusion of dialysis costs in such cases is methodologically correct given current health economic guidelines and is consistent with current practices regarding the treatment of dialysis patients.
    PharmacoEconomics 09/2012; 30(11):981-9. DOI:10.2165/11599390-000000000-00000 · 3.34 Impact Factor
  • The Canadian journal of cardiology 09/2012; 28(5):S182-S183. DOI:10.1016/j.cjca.2012.07.233 · 3.94 Impact Factor
  • The Canadian journal of cardiology 09/2012; 28(5):S387. DOI:10.1016/j.cjca.2012.07.677 · 3.94 Impact Factor
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    ABSTRACT: We updated the evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in adults for 2012. The new recommendations are: (1) use of home blood pressure monitoring to confirm a diagnosis of white coat syndrome; (2) mineralocorticoid receptor antagonists may be used in selected patients with hypertension and systolic heart failure; (3) a history of atrial fibrillation in patients with hypertension should not be a factor in deciding to prescribe an angiotensin-receptor blocker for the treatment of hypertension; and (4) the blood pressure target for patients with nondiabetic chronic kidney disease has now been changed to < 140/90 mm Hg from < 130/80 mm Hg. We also reviewed the recent evidence on blood pressure targets for patients with hypertension and diabetes and continue to recommend a blood pressure target of less than 130/80 mm Hg.
    The Canadian journal of cardiology 05/2012; 28(3):270-87. DOI:10.1016/j.cjca.2012.02.018 · 3.94 Impact Factor

Publication Stats

1k Citations
328.25 Total Impact Points

Institutions

  • 2008–2014
    • Christus St. Michaels' Hospital
      텍사캐나, Arkansas, United States
  • 2003–2014
    • St. Michael's Hospital
      Toronto, Ontario, Canada
  • 2003–2013
    • University of Toronto
      • • Division of Neurology
      • • Department of Medicine
      Toronto, Ontario, Canada
  • 2012
    • McGill University
      • Division of General Internal Medicine
      Montréal, Quebec, Canada
    • Queens University of Charlotte
      New York, United States
    • McMaster University
      • Department of Clinical Epidemiology and Biostatistics
      Hamilton, Ontario, Canada
  • 2010
    • The University of Western Ontario
      • Department of Clinical Neurological Sciences
      London, Ontario, Canada