[Show abstract][Hide abstract] ABSTRACT: A reporting and learning system is a method of monitoring the occurrence of incidents that affect patient safety. This cross-sectional survey asked pediatric chiropractors about factors that may limit their participation in such a system. The list of potential barriers for participation was developed using a systematic approach. All members of the 2 pediatric councils associated with US national chiropractic organizations were invited to complete the survey (N = 400). The cross-sectional survey was created using an online survey tool (REDCap) and sent directly to member emails addressed by the respective executive committees. Of the 400 potential respondents, 81 responded (20.3%). The most common limitations to participating were identified as time pressure (96%) and patient concerns (81%). Reporting and learning systems have been utilized to increase safety awareness in many high-risk industries. To be successful, future patient safety studies with pediatric chiropractors need to ensure these barriers are understood and addressed.
[Show abstract][Hide abstract] ABSTRACT: 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.
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.
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.
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).
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.
clinicaltrials.gov; Identifier: NCT01335763.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
[Show abstract][Hide abstract] ABSTRACT: Background:
Pharmacy practice research is one avenue through which new pharmacy services can be integrated into daily pharmacy practice. However, pharmacists' participation in this research has not been well characterized. Drawing from the literature on work performance and personality traits, 4 hypotheses were developed to gain insight into pharmacists' performance in a pharmacy practice research trial.
This study was an observational, cross-sectional survey of pharmacists participating in a research trial. All pharmacists were asked to complete the Big Five Inventory (BFI), a validated, reliable instrument of personality traits. These results were then compared with measures of pharmacists' performance in the trial.
Thirty pharmacists expressed interest in participating in the trial; 23 completed the BFI and 14 actively participated in the pharmacy practice research trial. No statistically significant differences were identified in the examination of the predetermined hypotheses. Exploratory analyses revealed significant relationships between the BFI trait of extroversion and pharmacists' participation in the study, obtaining prescribing authority for the study and the number of patients lost to follow-up.
In addition to identifying a number of personality traits that have been shared by other samples of pharmacists, this work suggests the possibility of an interaction between pharmacists' personality traits and their performance in a pharmacy practice research trial.
Future research should better characterize the relationship between pharmacists' personality traits and participation in pharmacy practice research trials to gain insight into the context of pharmacy practice and how pharmacists are integrating this research into their practices.
No preview · Article · Jul 2015 · Canadian Pharmacists Journal
[Show abstract][Hide abstract] ABSTRACT: -Hypertension control rates remain suboptimal. Pharmacists' scope of practice is evolving and their position in the community may be ideal for improving hypertension care. We aimed to study the impact of pharmacist prescribing on blood pressure (BP) control in community-dwelling patients.
-We designed a patient-level randomized controlled trial, enrolling adults with above-target BP (as defined by Canadian guidelines), through community pharmacies, hospitals, or primary care teams in 23 communities in Alberta. Intervention group patients received an assessment of BP and cardiovascular risk, education on hypertension, prescribing of antihypertensive medications, laboratory monitoring, and monthly follow-up visits for 6 months (all by their pharmacist). Control group patients received a wallet card for BP recording, written hypertension information, and usual care from their pharmacist and physician. Primary outcome was the change in systolic BP at 6 months. A total of 248 patients (mean age 64 years, 49% male) were enrolled. Baseline mean (SD) systolic/diastolic BP was 150(14)/84(11) mm Hg. The intervention group had a mean (SE) reduction in systolic BP at 6 months of 18.3 (1.2) compared with 11.8 (1.9) in the control group, an adjusted difference of 6.6 (1.9) mmHg (p=0.0006). The adjusted odds of patients achieving BP targets was 2.32 (95% CI 1.17, 4.15 in favor of the intervention).
-Pharmacist prescribing for patients with hypertension resulted in a clinically important and statistically significant reduction in BP. Policymakers should consider an expanded role for pharmacists, including prescribing, to address the burden of hypertension. Clinical Trial Registration Information-clinicaltrials.gov; Identifier: NCT00878566.
[Show abstract][Hide abstract] ABSTRACT: 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.
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).
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).
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.
Full-text · Article · Apr 2015 · Journal of the American Pharmacists Association
[Show abstract][Hide abstract] ABSTRACT: Natural health products (NHPs), including melatonin, are widely used products. Despite the widespread assumption that all NHPs are safe, they contain pharmacologically active substances and can therefore have adverse effects and/or interact with pharmaceuticals.
To investigate the mechanism underlying NHP interactions identified through the Pharmacy SONAR active surveillance study.
Active surveillance was undertaken in community pharmacies to identify adverse events in patients who had recently taken NHPs together with conventional pharmaceuticals. For suspected NHP-pharmaceutical interactions, the possible mechanism of action was explored by in vitro analysis of samples of different products to identify cytochrome P450 enzyme (CYP) inhibition potential.
Active surveillance identified a 19-year-old male taking citalopram, nortriptyline and oxycodone concomitantly and who experienced severe sedation when melatonin was added to this regimen. In vitro analysis involving several melatonin products showed product-dependent inhibition of CYP1A2, CYP2C19 and CYP3A7.
The adverse event was likely due to a primary pharmacokinetic interaction between melatonin and citalopram; although mechanistically, interactions affecting cytochrome P450-mediated metabolism may have occurred with all of these health products. A pharmacodynamic interaction may also be possible, but beyond the capacity of this study to establish.Key words: Melatonin, citalopram, nortriptyline, oxycodone, drug interaction. This article is open to POST-PUBLICATION REVIEW. Registered readers (see "For Readers") may comment by clicking on ABSTRACT on the issue's contents page.
Full-text · Article · Apr 2015 · Journal of Pharmacy and Pharmaceutical Sciences
[Show abstract][Hide abstract] ABSTRACT: Evidence for the value of pharmacists' interventions in the care of patients is strong and continues to grow, but the rate at which these new practice opportunities are being integrated into daily practice has not kept pace. The knowledge translation literature suggests that before effective change strategies can be implemented, a better understanding of the current environment must be obtained. Two important factors within the practice environment are the professional culture and personality traits of group members.
To gain insight, at a national level, into the culture of hospital pharmacy, using the Organizational Culture Profile, and into hospital pharmacists' personality traits, using the Big Five Inventory.
A cross-sectional survey of hospital pharmacists from across Canada was conducted intermittently over the period August 2012 to September 2013. The online survey contained questions about demographic characteristics and practice setting, as well as questions from the Organizational Culture Profile and Big Five Inventory. The survey link was distributed directly to hospital pharmacists or made available through provincial monthly newsletters. All data were analyzed descriptively and inferentially.
In total, 401 surveys were returned. Descriptive analyses from the Organizational Culture Profile revealed that most respondents perceived value in the factors of supportiveness, competitiveness, and stability. Descriptive analyses from the Big Five Inventory revealed that respondents may have been more likely to exhibit behaviours in line with the trait of conscientiousness. Several significant subgroup differences were noted in relation to levels of education, regions of practice within Canada, years in practice, and proportion of time spent conducting clinical duties.
The results from this survey provide preliminary insight into the professional culture and personality traits of Canadian hospital pharmacists. It will be important to explore these findings in more depth to maximize the success of any future practice change initiatives.
No preview · Article · Mar 2015 · The Canadian journal of hospital pharmacy
[Show abstract][Hide abstract] ABSTRACT: Frailty is a multidimensional syndrome characterized by loss of physiologic reserve that gives rise to vulnerability to poor outcomes. We aimed to examine the association between frailty and long-term health-related quality-of-life among survivors of critical illness.
Prospective multicenter observational cohort study.
ICUs in six hospitals from across Alberta, Canada.
Four hundred twenty-one critically ill patients who were 50 years or older.
Frailty was operationalized by a score of more than 4 on the Clinical Frailty Scale. Health-related quality-of-life was measured by the EuroQol Health Questionnaire and Short-Form 12 Physical and Mental Component Scores at 6 and 12 months. Multiple logistic and linear regression with generalized estimating equations was used to explore the association between frailty and health-related quality-of-life. In total, frailty was diagnosed in 33% (95% CI, 28-38). Frail patients were older, had more comorbidities, and higher illness severity. EuroQol-visual analogue scale scores were lower for frail compared with not frail patients at 6 months (52.2 ± 22.5 vs 64.6 ± 19.4; p < 0.001) and 12 months (54.4 ± 23.1 vs 68.0 ± 17.8; p < 0.001). Frail patients reported greater problems with mobility (71% vs 45%; odds ratio, 3.1 [1.6-6.1]; p = 0.001), self-care (49% vs 15%; odds ratio, 5.8 [2.9-11.7]; p < 0.001), usual activities (80% vs 52%; odds ratio, 3.9 [1.8-8.2]; p < 0.001), pain/discomfort (68% vs 47%; odds ratio, 2.0 [1.1-3.8]; p = 0.03), and anxiety/depression (51% vs 27%; odds ratio, 2.8 [1.5-5.3]; p = 0.001) compared with not frail patients. Frail patients described lower health-related quality-of-life on both physical component score (34.7 ± 7.8 vs 37.8 ± 6.7; p = 0.012) and mental component score (33.8 ± 7.0 vs 38.6 ± 7.7; p < 0.001) at 12 months.
Frail survivors of critical illness experienced greater impairment in health-related quality-of-life, functional dependence, and disability compared with those not frail. The systematic assessment of frailty may assist in better informing patients and families on the complexities of survivorship and recovery.
No preview · Article · Jan 2015 · Critical Care Medicine
[Show abstract][Hide abstract] ABSTRACT: Background
Adding pharmacists to primary care teams significantly improved blood pressure control and reduced predicted 10–year cardiovascular risk in patients with Type 2 diabetes. This pre-specified sub-study evaluated the economic implications of this cardiovascular risk reduction strategy.Methods
One-year outcomes and healthcare utilization data from the trial were used to determine cost-effectiveness from the public payer perspective. Costs were expressed in 2014 Canadian dollars and effectiveness was based on annualized risk of cardiovascular events derived from the UKPDS Risk Engine.ResultsThe 123 evaluable trial patients included in this analysis had a mean age of 62 (± 11) years, 38% were men, and mean diabetes duration was 6 (± 7) years. Pharmacists provided 3.0 (± 1.9) hours of additional service to each intervention patient, which cost $226 (± $1143) per patient. The overall one-year per-patient costs for healthcare utilization were $190 lower in the intervention group compared with usual care [95% confidence interval (CI): $1040, $668). Intervention patients had a significant 0.3% greater reduction in the annualized risk of a cardiovascular event (95% CI: 0.08%, 0.6%) compared with usual care. In the cost-effectiveness analysis, the intervention dominated usual care in 66% of 10 000 bootstrap replications. At a societal willingness-to-pay of $4000 per 1% reduction in annual cardiovascular risk, the probability that the intervention was cost-effective compared with usual care reached 95%. A sensitivity analysis using multiple imputation to replace missing data produced similar results.Conclusions
Within a randomized trial, adding pharmacists to primary care teams was a cost-effective strategy for reducing cardiovascular risk in patients with Type 2 diabetes. In most circumstances, this intervention may also be cost saving.This article is protected by copyright. All rights reserved.
No preview · Article · Jan 2015 · Diabetic Medicine
[Show abstract][Hide abstract] ABSTRACT: Background: Despite evidence of benefit for pharmacist involvement in chronic disease management, the provision of these services in community pharmacy has been suboptimal. The Promoting Action on Research Implementation in Health Services (PARiHS) framework suggests that for knowledge translation to be effective, there must be evidence of benefit, a context conducive to implementation, and facilitation to support uptake. We hypothesize that while the evidence and context components of this framework are satisfied, that uptake into practice has been insufficient because of a lack of facilitation. This protocol describes the rationale and methods of a feasibility study to test a facilitated pharmacy practice intervention based on the PARiHS framework, to assist community pharmacists in increasing the number of formal and documented medication management services completed for patients with diabetes, dyslipidemia, and hypertension.
Methods: A cluster-randomized before-after design will compare ten pharmacies from within a single organization, with the unit of randomization being the pharmacy. Pharmacies will be randomized to facilitated intervention based on the PARiHS framework or usual practice. The Alberta Context Tool will be used to establish the context of practice in each pharmacy. Pharmacies randomized to the intervention will receive task-focused facilitation from an external facilitator, with the goal of developing alternative team processes to allow the greater provision of medication management services for patients with diabetes, hypertension, and dyslipidemia. The primary outcome will be a process evaluation of the needs of community pharmacies to provide more clinical services, the acceptability and uptake of modifications made, and the willingness of pharmacies to participate. Secondary outcomes will include the change in the number of formal and documented medication management services in the aforementioned chronic conditions provided 6 months before, versus after, the intervention between the two groups, and identification of feasible quantitative outcomes for evaluating the effect of the intervention on patient care outcomes.
Results: To date, the study has identified and enrolled the ten pharmacies required and initiated the intervention process.
Conclusion: This study will be the first to examine the role of facilitation in pharmacy practice, with the goal of scalable and sustainable practice change.
Trial registration: Clinicaltrials.gov identifier NCT02191111.
Keywords: Pharmacy; Facilitation; Knowledge translation; Knowledge implementation
[Show abstract][Hide abstract] ABSTRACT: Background
Hemodialysis patients experience poor outcomes associated with the presence of atherosclerosis, particularly lower-extremity peripheral artery disease (PAD). Prevalence of PAD is known to vary between ethnic groups; however, no information on ethnic-specific PAD prevalence in a hemodialysis cohort is available.
Data from the Canadian Kidney Dialysis Cohort Study was used in a secondary analysis of 1293 adults starting hemodialysis in three major Canadian centres. PAD diagnosis was determined through structured interview and supplemented by clinical record. Ethnicity was self-reported.
Overall PAD prevalence was 19.1 % with no significant difference between ethnic groups. Ethnic differences observed in diabetes prevalence in the full hemodialysis group were not present in the subset of PAD patients.
The prevalence of PAD in patients undergoing hemodialysis is high, however we found no apparent ethnic differences in prevalence between ethnic groups.