To learn more about the health services and products that patients use after receiving a diagnosis of knee osteoarthritis (OA), as well as the trajectory of their health-related quality of life (HRQOL).
Using a simple screening survey, community pharmacists identified 194 participants with previously undiagnosed knee OA. Of these participants, 190 were confirmed to have OA on further investigation. At baseline and 1, 3, and 6 months after diagnosis, a survey was administered to assess health services, product use, and HRQOL, including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Medical Outcomes Study Short Form 36 (SF-36) health survey, the Paper Adaptive Test (PAT-5D-QOL), and the Health Utilities Index Mark 3.
With a mean age of 63 years, participants were mostly women, white, and overweight. By 6 months, more than 90% of the participants had visited their family physician to discuss their OA, and more than 50% of participants took either prescription or nonprescription analgesics. In addition, three-quarters of the participants started exercising, one-third initiated activity aids, and one-third had started natural medicine products. At 6 months compared with baseline, significant improvements were seen in the SF-36 physical component summary (P = 0.001) and bodily pain domain scores (P = 0.02), the PAT-5D-QOL overall, pain, and usual daily activities scores (P
To develop an economic model based on the use of pharmacy-based blood pressure kiosks for case finding of remunerable medication therapy management (MTM) opportunities.
Descriptive, exploratory, nonexperimental study.
Ontario, Canada, between January 2010 and September 2011.
More than 7.5 million blood pressure kiosk readings were taken from 341 pharmacies.
A model was developed to estimate revenues achievable by using blood pressure kiosks for 1 month to identify a cohort of patients with blood pressure of 130/80 mm Hg or more and caring for those patients during 1 year.
Revenue generated from MTM programs.
Pharmacies could generate an average of $12,270 (range $4,523-24,420) annually in revenue from billing for MTM services.
Blood pressure kiosks can be used to identify patients with elevated blood pressure who may benefit from reimbursable pharmacist cognitive services. Revenue can be reinvested to purchase automated dispensing technology or offset pharmacy technician costs to free pharmacists to provide pharmaceutical care. Improved patient outcomes, increased patient loyalty, and improved adherence are additional potential benefits.
Canadian Cardiovascular Society Consensus Conference guidelines on heart failure, update 2009: diagnosis and management of right-sided heart failure, myocarditis, device therapy and recent important clinical trials.
The Canadian Cardiovascular Society published a comprehensive set of recommendations on the diagnosis and management of heart failure in January 2006. Based on feedback obtained through a national program of heart failure workshops and through active solicitation of stakeholders, several topics were identified because of their importance to the practicing clinician. Topics chosen for the present update include best practices for the diagnosis and management of right-sided heart failure, myocarditis and device therapy, and a review of recent important or landmark clinical trials. These recommendations were developed using the structured approach for the review and assessment of evidence adopted and previously described by the Society. The present update has been written from a clinical perspective to provide a user-friendly and practical approach. Specific clinical questions that are addressed include: What is right-sided heart failure and how should one approach the diagnostic work-up? What other clinical entities may masquerade as this nebulous condition and how can we tell them apart? When should we be concerned about the presence of myocarditis and how quickly should patients with this condition be referred to an experienced centre? Among the myriad of recently published landmark clinical trials, which ones will impact our standards of clinical care? The goals are to aid physicians and other health care providers to optimally treat heart failure patients, resulting in a measurable impact on patient health and clinical outcomes in Canada.
Notes
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Canadian Cardiovascular Society Consensus Conference recommendations on heart failure update 2007: Prevention, management during intercurrent illness or acute decompensation, and use of biomarkers.
Heart failure is common, yet it is difficult to treat. It presents in many different guises and circumstances in which therapy needs to be individualized. The Canadian Cardiovascular Society published a comprehensive set of recommendations in January 2006 on the diagnosis and management of heart failure, and the present update builds on those core recommendations. Based on feedback obtained through a national program of heart failure workshops during 2006, several topics were identified as priorities because of the challenges they pose to health care professionals. New evidence-based recommendations were developed using the structured approach for the review and assessment of evidence adopted and previously described by the Society. Specific recommendations and practical tips were written for the prevention of heart failure, the management of heart failure during intercurrent illness, the treatment of acute heart failure, and the current and future roles of biomarkers in heart failure care. Specific clinical questions that are addressed include: which patients should be identified as being at high risk of developing heart failure and which interventions should be used? What complications can occur in heart failure patients during an intercurrent illness, how should these patients be monitored and which medications may require a dose adjustment or discontinuation? What are the best therapeutic, both drug and nondrug, strategies for patients with acute heart failure? How can new biomarkers help in the treatment of heart failure, and when and how should BNP be measured in heart failure patients? The goals of the present update are to translate best evidence into practice, to apply clinical wisdom where evidence for specific strategies is weaker, and to aid physicians and other health care providers to optimally treat heart failure patients to result in a measurable impact on patient health and clinical outcomes in Canada.
Notes
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Changes in adherence to evidence-based medications in the first year after initial hospitalization for heart failure: observational cohort study from 1994 to 2003.
The use of evidence-based medications in patients with heart failure has increased over the past 10 years. We aimed to determine whether adherence to these medications has also increased during this time.
A retrospective cohort was created using administrative databases from the province of Saskatchewan, Canada. Subjects discharged alive from their first hospitalization for heart failure between 1994 and 2003 were eligible. Those filling a prescription for a beta-blocker (BB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB) within 6 months of discharge were followed for 1 year after the initial prescription. Of 8805 eligible patients, 67% of BB users (941/1414) and 74% of ACEI/ARB users (4441/5991) exhibited optimal adherence at 1 year (defined as >or=80% adherence calculated from pharmacy refill records). When grouped by year of initial heart failure hospitalization, the proportion of optimally adherent patients improved from 54% to 75% with BB and from 67% to 80% with ACEI/ARBs between 1994/1995 and 2002/2003 (P for trend
Validity of Heart Failure (HF) diagnoses from administrative records has not been extensively evaluated, especially with respect to small / unselected hospitals.
To determine the positive predictive value of a primary / most responsible diagnosis of HF among a general population of subjects discharged from Saskatchewan hospitals.
Using administrative health records from the Province of Saskatchewan, Canada, we identified subjects experiencing their first HF hospitalization between 1994 and 2003. From this cohort, we randomly selected 500 subjects for individual validation using Framingham and Carlson criteria.
The 466 charts available for analysis, 74% (345/466) and 63.9% (298/466) of subjects met criteria for a clinical diagnosis of HF based on Framingham or Carlson criteria, respectively; 57.5% (268/466) met both criterion. Provincial hospitals (located in the largest urban centres) were associated with the highest proportion of confirmed HF diagnoses (87.8% by Framingham criteria) compared to progressively smaller hospitals (regional 77.9%; district 64.2%; and community 60.0%). Accuracy also differed when stratified by physician category. Cardiologists and internists were associated with the highest rates of confirmed diagnoses [(97.5% (39 / 40) and 85.0% (34 / 40)]) compared to general practitioners [(73.1% (95 / 130)]) and other physicians [(69.1% (177 / 256)]), by Framingham criteria.
Hospital discharge abstracts indicating HF are frequently inaccurate. These findings have important implications for the epidemiologic study of HF as well as the clinical management of patients.
Congestive heart failure (CHF) is associated with high morbidity and mortality; however, there is little contemporary Canadian data to quantify the burden of this illness.
To report the impact of CHF in Canada, as measured by hospitalizations.
Data were obtained from the Canadian Institute for Health Information on patients hospitalized with CHF as a most responsible, primary or complication diagnosis during fiscal year 2000/01.
There were a total of 106,130 discharges for 85,679 CHF patients in the fiscal year 2000/01. Total in-hospital mortality was 15.8%. In terms of total discharges for CHF, 32.7% were readmissions. On an individual patient basis, 19.9% of patients were rehospitalized once or more during 2000. In terms of burden of illness of CHF compared with other major illnesses, CHF is associated with the second highest total number of hospital days and third highest number of patients affected.
Hospitalization for CHF occurs frequently and accounts for a large number of hospital bed-days in Canada. These figures should signal a call to action for researchers, administrators and health care providers regarding the need for more efficacious therapies, better application of already-proven therapies and patient education.
Scot H. Simpson, Pharm.D., M.Sc., Jeffrey A. Johnson, Ph.D., Karen B. Farris, Ph.D., and Ross T. Tsuyuki, Pharm.D., M.Sc. Objective. To report the development of and initial experience with a survey designed to assess patient-perceived barriers to drug use in ambulatory patients with heart failure. Methods. The Barriers to Medication Use (BMU) survey, developed from previous qualitative work by our group, was administered to 128 consecutive patients attending an outpatient heart failure clinic. The first 42 patients to return the survey were mailed a second survey to evaluate response stability over time. The survey contained 31 questions in five barrier domains (knowledge, previous drug therapy experiences, social support, communication, and relationship with health care professionals). Patients also completed the Minnesota Living with Heart Failure (MLHF) questionnaire and a self-reported drug use scale. Frequency of drug refills was used to estimate adherence. Reliability and construct validity of the BMU survey were assessed using correlation coefficients. Results. Response rates were 89% and 93% for the first and retest surveys, respectively The BMU survey showed modest internal consistency in the overall survey and in two of the five barrier domains. Responses to the first and retest surveys showed good stability over time in the overall survey and in four of the five barrier domains. Patients with good adherence reported few barriers; however, the association was not strong (Pearson correlation coefficient r = -0.14, p=0.14). Patients who reported few barriers also reported better MLHF scores (r = 0.42, p
Congestive heart failure (CHF) is the most common cause of cardiovascular hospital admission. A significant proportion of the costs of CHF is due to hospitalizations. The present study evaluated the economic impact of a modest increase in the use of angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, spironolactone and digoxin on CHF hospitalizations. Patients with CHF were identified through the Canadian Institute for Health Information (CIHI) database. The efficacy of ACE inhibitors, beta-blockers, spironolactone and digoxin in the first year of treatment were retrieved from the Survival and Ventricular Enlargement (SAVE) trial, a meta-analysis, the Randomized Aldactone Evaluation Study (RALES) and the Digitalis Investigation Group (DIG) trial, respectively. Cost of CHF hospitalization was based on the National List of Provincial Costs. Costs of drug treatment were based on the 2002 Alberta Health and Wellness Drug Benefit list. Physician visits for drug titration were also included in the model. A total of 85,679 patients with CHF were identified with a total of 106,130 hospital discharges. A 10% increase in use of ACE inhibitors, beta-blockers, spironolactone and digoxin would incur in a total cost due to avoidable hospital admissions of 0.4 million dollars, 1.3 million dollars, 3.7 million dollars and 1.2 million dollars, respectively. Similarly, the costs of drug treatment would be 2.2 million dollars, 1.3 million dollars, 0.3 million dollars and 0.5 million dollars, respectively. An increase in the use of the above medications would save 6.6 million dollars due to avoidable hospital admissions. The total cost of drug treatment was 4.3 million dollars, giving a net savings of 2.3 million dollars in the first year. The implementation of evidence-based therapy for CHF treatment is not only clinically efficacious, but also economically attractive.
The pathogenesis of refractory ascites (RA) is linked to splanchnic vasodilation. We hypothesized that a combination of midodrine, octreotide long-acting release (LAR) and albumin would result in increased natriuresis, better control of ascites and an improvement in renal function in patients with RA+/-Type 2 hepatorenal syndrome.
A prospective pilot study in patients with RA as defined by the International Ascites Club. Consecutive patients received an intramuscular injection of octreotide-LAR, 50 g of albumin three times per week and midodrine titrated to increase the systolic blood pressure for 1 month.
Ten patients with RA were enrolled and eight with complete data to 1 month post-treatment were included in the analysis. There was no change in renal function but there was a trend towards a reduction in the volume of ascites removed by paracentesis (P=0.08) and a significant reduction in the plasma renin (P=0.01) and aldosterone concentrations (P=0.01). Interestingly, there was a transient worsening in the model for end-stage liver disease (MELD) score (P=0.01). The deterioration in MELD was completely reversible after discontinuation of therapy.
To our knowledge, this is the first study of prolonged midodrine, octreotide and albumin therapy in RA. We observed a significant reduction in the plasma renin and aldosterone concentrations and a trend towards a reduction in the volume of ascites removed by paracentesis without an effect on renal function. The beneficial effects are at the expense of a reversible deterioration in the MELD score. Large controlled trials are needed before this therapy can be routinely recommended.
