Frailty is a multidimensional syndrome characterized by loss of physiologic and cognitive reserves that confers vulnerability to adverse outcomes. We determined the prevalence, correlates and ...outcomes associated with frailty among adults admitted to intensive care.
We prospectively enrolled 421 critically ill adults aged 50 or more at 6 hospitals across the province of Alberta. The primary exposure was frailty, defined by a score greater than 4 on the Clinical Frailty Scale. The primary outcome measure was in-hospital mortality. Secondary outcome measures included adverse events, 1-year mortality and quality of life.
The prevalence of frailty was 32.8% (95% confidence interval CI 28.3%-37.5%). Frail patients were older, were more likely to be female, and had more comorbidities and greater functional dependence than those who were not frail. In-hospital mortality was higher among frail patients than among non-frail patients (32% v. 16%; adjusted odds ratio OR 1.81, 95% CI 1.09-3.01) and remained higher at 1 year (48% v. 25%; adjusted hazard ratio 1.82, 95% CI 1.28-2.60). Major adverse events were more common among frail patients (39% v. 29%; OR 1.54, 95% CI 1.01-2.37). Compared with nonfrail survivors, frail survivors were more likely to become functionally dependent (71% v. 52%; OR 2.25, 95% CI 1.03-4.89), had significantly lower quality of life and were more often readmitted to hospital (56% v. 39%; OR 1.98, 95% CI 1.22-3.23) in the 12 months following enrolment.
Frailty was common among critically ill adults aged 50 and older and identified a population at increased risk of adverse events, morbidity and mortality. Diagnosis of frailty could improve prognostication and identify a vulnerable population that might benefit from follow-up and intervention.
Summary Background Phosphate binders (calcium-based and calcium-free) are recommended to lower serum phosphate and prevent hyperphosphataemia in patients with chronic kidney disease, but their ...effects on mortality and cardiovascular outcomes are unknown. We aimed to update our meta-analysis on the effect of calcium-based versus non-calcium-based phosphate binders on mortality in patients with chronic kidney disease. Methods We did a systematic review of articles published in any language after Aug 1, 2008, up until Oct 22, 2012, by searching Medline, Embase, International Pharmaceutical Abstracts, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature. We included all randomised and non-randomised trials that compared outcomes between patients with chronic kidney disease taking calcium-based phosphate binders with those taking non-calcium-based binders. Eligible studies, determined by consensus with predefined criteria, were reviewed, and data were extracted onto a standard form. We combined data from randomised trials to assess the primary outcome of all-cause mortality using the DerSimonian and Laird random effects model. Findings Our search identified 847 reports, of which eight new studies (five randomised trials) met our inclusion criteria and were added to the ten (nine randomised trials) included in our previous meta-analysis. Analysis of the 11 randomised trials (4622 patients) that reported an outcome of mortality showed that patients assigned to non-calcium-based binders had a 22% reduction in all-cause mortality compared with those assigned to calcium-based phosphate binders (risk ratio 0·78, 95% CI 0·61–0·98). Interpretation Non-calcium-based phosphate binders are associated with a decreased risk of all-cause mortality compared with calcium-based phosphate binders in patients with chronic kidney disease. Further studies are needed to identify causes of mortality and to assess whether mortality differs by type of non-calcium-based phosphate binder. Funding None.
Despite the cardiovascular disease (CVD) risk associated with hypertension, diabetes, dyslipidemia, and smoking, these risk factors remain poorly identified and controlled.
The study sought to ...evaluate the effectiveness of a community pharmacy-based case finding and intervention on cardiovascular risk.
The RxEACH (Alberta Vascular Risk Reduction Community Pharmacy Project) study was a randomized trial conducted in 56 community pharmacies. Participants were recruited by their pharmacist, who enrolled adults at high risk for CVD. Patients were randomized to usual care (usual pharmacist care with no specific intervention) or intervention, comprising a Medication Therapy Management review from their pharmacist and CVD risk assessment and education. Pharmacists prescribed medications and ordered laboratory tests as per their scope of practice to achieve treatment targets. Subjects received monthly follow-up visits for 3 months. The primary outcome was difference in change in estimated CVD risk between groups at 3 months. CVD risk was estimated using the greater of the Framingham, International, or United Kingdom Prospective Diabetes Study risk scores.
We enrolled 723 patients (mean 62 years of age; 58% male, and 27% smokers). After adjusting for baseline values and center effect, there was a 21% difference in change in risk for CVD events (p < 0.001) between the intervention and usual care groups. The intervention group had greater improvements in low-density lipoprotein cholesterol (-0.2 mmol/l; p < 0.001), systolic blood pressure (-9.37 mm Hg; p < 0.001), glycosylated hemoglobin (-0.92%; p < 0.001), and smoking cessation (20.2%; p = 0.002).
The RxEACH study was the first large randomized trial of CVD risk reduction by community pharmacists, demonstrating a significant reduction in risk for CVD events. Engagement of community pharmacists with an expanded scope of practice could have significant public health implications. (The Alberta Vascular Risk Reduction Community Pharmacy Project: RxEACH RxEACH; NCT01979471).
Table 1 Literature review Study author Date Setting/country Disease Frequency of pharmacist contact with patient per year (median, IQR) Comparison group (median, IQR) McNamara et al.1 2012 ...Wimmera/Australia N = 694 patients CVD (or risk factors for) Overall: (2, 0-10) Overall: (GPs) (3, 1-6) Age <65 years Age 25-44 years (1, 0-3) n = 94Age 45-54 years (2, 0-6) n = 161Age 55-64 years (2, 0-10) n = 162 Age <65 years (GPs) Age 25-44 years (2, 1-4) n = 94Age 45-54 years (2, 1-5) n = 161Age 55-64 years (3, 1-5) n = 162 Age >65 years Age 65-74 years (6, 0-10) n = 161Age 75-84 years (10, 1-12) n = 116 Age >65 years (GPs) Age 65-74 years (4, 2-6) n = 161Age 75-84 years (5, 3-8) n = 116 Shiu et al.2 2006 Saskatchewan/Canada N = 36,493 patients Diabetes (15, 9-24) GPs (7, 4-13) Jose et al.3 2015 Oman N = 390 patients General 56.9% of the participants visited the pharmacy at least 6 times a year No comparator 2008 Pharmacy Satisfaction Digest4 2008 United States N = 34,454 patients General 30 (mean) GPs, 2.9 (mean) Unverified* Reports Campbell5 1993 Unknown Unknown States that pharmacists see patients at least 5 times more than any other health professional Kroon et al.6 1997 Unknown Diabetes States that people with diabetes see their pharmacist 7 times more than their family physician Moose et al.7 2014 Unknown Unknown 35 (mean) GP, 4 (mean) CVD, cardiovascular disease; GP, general practitioner; IQR, interquartile range. * No data or citation provided. Areas for future research should look at various age groups and by specific disease states (e.g., hypertension, asthma, mental health, etc.). ...the evidence suggests that pharmacists play a major primary care role that is enhanced by their accessibility.
AbstractObjectiveTo determine the relative effectiveness of dietary macronutrient patterns and popular named diet programmes for weight loss and cardiovascular risk factor improvement among adults ...who are overweight or obese.DesignSystematic review and network meta-analysis of randomised trials.Data sourcesMedline, Embase, CINAHL, AMED, and CENTRAL from database inception until September 2018, reference lists of eligible trials, and related reviews.Study selectionRandomised trials that enrolled adults (≥18 years) who were overweight (body mass index 25-29) or obese (≥30) to a popular named diet or an alternative diet.Outcomes and measuresChange in body weight, low density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol, systolic blood pressure, diastolic blood pressure, and C reactive protein at the six and 12 month follow-up.Review methodsTwo reviewers independently extracted data on study participants, interventions, and outcomes and assessed risk of bias, and the certainty of evidence using the GRADE (grading of recommendations, assessment, development, and evaluation) approach. A bayesian framework informed a series of random effects network meta-analyses to estimate the relative effectiveness of the diets.Results121 eligible trials with 21 942 patients were included and reported on 14 named diets and three control diets. Compared with usual diet, low carbohydrate and low fat diets had a similar effect at six months on weight loss (4.63 v 4.37 kg, both moderate certainty) and reduction in systolic blood pressure (5.14 mm Hg, moderate certainty v 5.05 mm Hg, low certainty) and diastolic blood pressure (3.21 v 2.85 mm Hg, both low certainty). Moderate macronutrient diets resulted in slightly less weight loss and blood pressure reductions. Low carbohydrate diets had less effect than low fat diets and moderate macronutrient diets on reduction in LDL cholesterol (1.01 mg/dL, low certainty v 7.08 mg/dL, moderate certainty v 5.22 mg/dL, moderate certainty, respectively) but an increase in HDL cholesterol (2.31 mg/dL, low certainty), whereas low fat (−1.88 mg/dL, moderate certainty) and moderate macronutrient (−0.89 mg/dL, moderate certainty) did not. Among popular named diets, those with the largest effect on weight reduction and blood pressure in comparison with usual diet were Atkins (weight 5.5 kg, systolic blood pressure 5.1 mm Hg, diastolic blood pressure 3.3 mm Hg), DASH (3.6 kg, 4.7 mm Hg, 2.9 mm Hg, respectively), and Zone (4.1 kg, 3.5 mm Hg, 2.3 mm Hg, respectively) at six months (all moderate certainty). No diets significantly improved levels of HDL cholesterol or C reactive protein at six months. Overall, weight loss diminished at 12 months among all macronutrient patterns and popular named diets, while the benefits for cardiovascular risk factors of all interventions, except the Mediterranean diet, essentially disappeared.ConclusionsModerate certainty evidence shows that most macronutrient diets, over six months, result in modest weight loss and substantial improvements in cardiovascular risk factors, particularly blood pressure. At 12 months the effects on weight reduction and improvements in cardiovascular risk factors largely disappear.Systematic review registrationPROSPERO CRD42015027929.
There is robust evidence from randomized trials that pharmacist involvement in patient care can provide benefit. Favourable disease-specific outcomes have been documented for the management of ...hypertension, dyslipidemia, heart failure, anticoagulation therapy, asthma and diabetes. A systematic review of 19 randomized trials of pharmacist care for hypertension showed a reduction in systolic blood pressure of 8.1/3.8 (95% confidence interval CI 5.9-10.2/ 2.3-5.3) mm Hg compared with usual care.10 Pharmacist care for dyslipidemia reduced lowdensity lipoprotein cholesterol by 0.28 (95% CI 0.12-0.44) mmol/L and helped achieve target lipid values.11 A systematic review of pharmacist care in patients with heart failure showed a reduction in hospital admission for heart failure of 31% (95% CI 6%-49%), compared with usual physician and nurse care.12 Collaborative care by nonspecialist pharmacists working with family doctors to manage the treatment of patients with heart failure also improved prescribing of disease-modifying medications, but showed no difference in death or hospital admission for worsening heart failure.13 Improved control of inter national normalized ratios and patient satisfaction have been consistently reported in pharmacist-led anticoagulation clinics.14 Asthma and diabetes care by pharmacists can result in improvements in pulmonary function tests and glycated hemoglobin.15-18 Services provided by pharmacists in community or ambulatory outpatient settings have been shown to improve medication management and adherence.19,20 Whether pharmacist care is cost-effective remains to be determined. Trials are currently ongoing in Canada and elsewhere to determine where added value can best be derived to improve patient outcomes.21 Evidence already shows that pharmacists' provision of vaccination services increases vaccination rates and is safe and well received by patients.8,9 As with physicians, pharmacists must exercise all prescribing and other activities within the practice framework developed by the regulatory bodies in each province and must hold liability insurance. For instance, pharmacists in Alberta and Quebec are required to have a minimum of $2 million dollars in personal liability coverage. All pharmacists are required to participate in ongoing professional development and to participate in their college's competency program. The Blueprint for Pharmacy initiative developed by the Canadian Pharmacists Association aims to augment training opportunities for practising pharmacists and to increase the rate of enrolment of pharmacy students into residency programs. The National Association of Pharmacy Regulatory Authorities is currently seeking to standardize training programs and oversight for pharmacists' activities across the country. Programs that teach pharmacists how to administer injections, and accreditation procedures for vaccination delivery in concert with public health requirements for appropriate places to store and administer vaccines are mandatory. Trusting relationships between physicians and pharmacists may take time to develop, similar to the relationships that develop between family practitioners and specialists. Investing time and effort in such relationships and getting to know pharmacists' competencies and the tasks they wish to share is worthwhile. Asking pharmacists to perform medication reviews for patients with complex illnesses and acknowledging useful suggestions is an excellent place to start. Once established, collaborative care with pharmacists will likely yield tremendous benefits to both patients and physicians. The expanding scope of pharmacists' practice offers many opportunities to improve patient care. However, it is also an ongoing process that must be evaluated as regulated activities change, new pharmacists enter practice and scopes of activities continue to expand.
Abstract Objective To evaluate the relation between adherence to drug therapy, including placebo, and mortality. Design Meta-analysis of observational studies. Data sources Electronic databases, ...contact with investigators, and textbooks and reviews on adherence. Review methods Predefined criteria were used to select studies reporting mortality among participants with good and poor adherence to drug therapy. Data were extracted for disease, drug therapy groups, methods for measurement of adherence rate, definition for good adherence, and mortality. Results Data were available from 21 studies (46 847 participants), including eight studies with placebo arms (19 633 participants). Compared with poor adherence, good adherence was associated with lower mortality (odds ratio 0.56, 95% confidence interval 0.50 to 0.63). Good adherence to placebo was associated with lower mortality (0.56, 0.43 to 0.74), as was good adherence to beneficial drug therapy (0.55, 0.49 to 0.62). Good adherence to harmful drug therapy was associated with increased mortality (2.90, 1.04 to 8.11). Conclusion Good adherence to drug therapy is associated with positive health outcomes. Moreover, the observed association between good adherence to placebo and mortality supports the existence of the “healthy adherer” effect, whereby adherence to drug therapy may be a surrogate marker for overall healthy behaviour.
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