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Ross T Tsuyuki

Publications and source records attributed to Ross T Tsuyuki.

At least 19 recordsLinked to original sources
PubMed2007

Impact of opinion leader-endorsed evidence summaries on the quality of prescribing for patients with cardiovascular disease: a randomized controlled trial.

BACKGROUND: Local opinion leaders are educationally and socially influential physicians. Although they can accelerate the adoption of new evidence in hospitals, their impact on the quality of prescribing for outpatients has only been examined by a few studies. We hypothesized that an intervention consisting of patient-specific one-page evidence summaries, generated and endorsed by local opinion leaders, would improve prescribing of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in heart failure (HF) and that of statins in ischemic heart disease (IHD). METHODS: We conducted a community-based randomized controlled trial in patients with HF (not receiving ACE inhibitors or ARBs) and those with IHD (not receiving statins) who were recruited from 40 pharmacies and allocated either to the opinion leader intervention or to usual care based on randomization of their primary care physician. The primary outcome was an increase in the use of efficacious therapies (ACE inhibitors or ARBs in HF and statins in IHD) within 6 months; the secondary outcomes were prescribing changes for HF or IHD. RESULTS: A total of 171 patients participated in the study; 87 were allocated to the intervention, whereas 84 were assigned to the control group. The median age of the participants was 75 years; 103 (60%) were female, 54 (32%) had HF, and 117 (68%) had IHD. Overall, 21 (24%) intervention patients started receiving an efficacious medication within 6 months, as compared with 15 (18%) control subjects (relative risk of improvement 1.32, 95% CI 0.73-2.40, P = .31). In the HF subgroup, 38% of the intervention patients started receiving an ACE inhibitor or ARB therapy, as compared with 20% of control subjects (relative risk of improvement 1.90, 95% CI 0.76-4.72, P = .15). In the IHD subgroup, 17% of the intervention patients and 17% of the control subjects started receiving statin therapy (P = .97). CONCLUSIONS: The influence of local opinion leaders may be useful for improving the quality of cardiovascular prescribing in the community, but the benefits are likely modest and may be disease specific. Further studies on this method are warranted.

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PubMed2006

Revascularization in patients with heart failure.

BACKGROUND: Although practice guidelines recommend coronary revascularization for patients with heart failure, the evidence to support this recommendation is weak. The objective of our study was to determine the association of coronary revascularization with survival in patients who have had heart failure. METHODS: Data were obtained from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH), a clinical outcome-monitoring initiative that has captured data on all patients undergoing cardiac catheterization in the province of Alberta since 1995. Our study included data from patients with a history of heart failure and with documented coronary artery disease; patients with normal coronary arteries or prior coronary artery bypass grafting (CABG) were excluded. We constructed survival curves and adjusted them by the corrected group prognosis method (incorporating all clinical variables in APPROACH). Propensity scores were used to account for clinical characteristics that could influence the decision to revascularize. RESULTS: A total of 2538 patients (mean age 68 yr, standard deviation [SD] 11 yr, 31% female) underwent revascularization; 1690 patients (mean age 69 [SD 11] yr, 34% female) did not. Crude 1-year mortality was 11.8% among patients who underwent revascularization, compared with 21.6% among those who did not. Adjusted survival curves diverged early and continued up to 7 years of follow-up (hazard ratio 0.50, 95% confidence interval 0.44-0.57). Propensity scores showed improved survival with revascularization across all quintiles of likelihood of revascularization. INTERPRETATION: This new evidence lends support to practice guidelines, which recommend revascularization in patients with heart failure and coronary disease.

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PubMed2006

A meta-analysis of the association between adherence to drug therapy and mortality.

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.

Drug Therapy↗
PubMed2006

A randomized trial to assess the impact of opinion leader endorsed evidence summaries on the use of secondary prevention strategies in patients with coronary artery disease: the ESP-CAD trial protocol [NCT00175240].

BACKGROUND: Although numerous therapies have been shown to be beneficial in the prevention of myocardial infarction and/or death in patients with coronary disease, these therapies are under-used and this gap contributes to sub-optimal patient outcomes. To increase the uptake of proven efficacious therapies in patients with coronary disease, we designed a multifaceted quality improvement intervention employing patient-specific reminders delivered at the point-of-care, with one-page treatment guidelines endorsed by local opinion leaders ("Local Opinion Leader Statement"). This trial is designed to evaluate the impact of these Local Opinion Leader Statements on the practices of primary care physicians caring for patients with coronary disease. In order to isolate the effects of the messenger (the local opinion leader) from the message, we will also test an identical quality improvement intervention that is not signed by a local opinion leader ("Unsigned Evidence Statement") in this trial. METHODS: Randomized trial testing three different interventions in patients with coronary disease: (1) usual care versus (2) Local Opinion Leader Statement versus (3) Unsigned Evidence Statement. Patients diagnosed with coronary artery disease after cardiac catheterization (but without acute coronary syndromes) will be randomly allocated to one of the three interventions by cluster randomization (at the level of their primary care physician), if they are not on optimal statin therapy at baseline. The primary outcome is the proportion of patients demonstrating improvement in their statin management in the first six months post-catheterization. Secondary outcomes include examinations of the use of ACE inhibitors, anti-platelet agents, beta-blockers, non-statin lipid lowering drugs, and provision of smoking cessation advice in the first six months post-catheterization in the three treatment arms. Although randomization will be clustered at the level of the primary care physician, the design effect is anticipated to be negligible and the unit of analysis will be the patient. DISCUSSION: If either the Local Opinion Leader Statement or the Unsigned Evidence Statement improves secondary prevention in patients with coronary disease, they can be easily modified and applied in other communities and for other target conditions.

Journal Article↗
PubMed2006

Dose-response relation between sulfonylurea drugs and mortality in type 2 diabetes mellitus: a population-based cohort study.

BACKGROUND: Over the past 30 years, the relation between use of sulfonylureas to treat type 2 diabetes and the risk of cardiovascular events has been vigorously debated. The purpose of this study was to determine if the risk of death changes with level of exposure to sulfonylurea drugs. METHODS: This was a retrospective, inception cohort study using administrative data from Saskatchewan Health (1991-1999). The 5795 subjects, identified by their first-ever dispensation for an oral antidiabetic agent, were grouped according to their use of such agents during follow-up. Potential subjects using insulin or combination therapy were excluded. Exposure level was defined by daily dose and degree of adherence. Separate multivariate Cox proportional-hazard models were constructed for each monotherapy group and used to calculate the risk of death associated with higher versus lower exposure category. Disease severity indicators were identified among the administrative data and entered as covariates in each model. The main outcomes were all-cause mortality and death from an acute ischemic event. RESULTS: The mean age of the cohort members was 66.3 (standard deviation [SD] 13.4) years; 43.4% were female; and their mean duration of follow-up was 4.6 (SD 2.1) years. First-generation sulfonylureas were used exclusively by 120 subjects; glyburide, by 4138; and metformin, by 1537. A greater risk of death was associated with higher daily doses of the first-generation sulfonylureas (adjusted hazard ratio [HR] 2.1, 95% confidence interval [CI] 1.0-4.7) and glyburide (HR 1.3, 95% CI 1.2-1.4), but not metformin (HR 0.8, 95% CI 0.7-1.1). Similar associations were observed for death caused by an acute ischemic event. INTERPRETATION: Higher exposure to sulfonylureas was associated with increased mortality among patients newly treated for type 2 diabetes. The same relation was not observed with metformin. This implies that the manner in which blood glucose concentration is lowered may be as important as achieving recommended glucose targets.

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PubMed2006

Canadian Cardiovascular Society consensus conference recommendations on heart failure 2006: diagnosis and management.

Heart failure remains a common diagnosis, especially in older individuals. It continues to be associated with significant morbidity and mortality, but major advances in both diagnosis and management have occurred and will continue to improve symptoms and other outcomes in patients. The Canadian Cardiovascular Society published its first consensus conference recommendations on the diagnosis and management of heart failure in 1994, followed by two brief updates, and reconvened this consensus conference to provide a comprehensive review of current knowledge and management strategies. New clinical trial evidence and meta-analyses were critically reviewed by a multidisciplinary primary panel who developed both recommendations and practical tips, which were reviewed by a secondary panel. The resulting document is intended to provide practical advice for specialists, family physicians, nurses, pharmacists and others who are involved in the care of heart failure patients. Management of heart failure begins with an accurate diagnosis, and requires rational combination drug therapy, individualization of care for each patient (based on their symptoms, clinical presentation and disease severity), appropriate mechanical interventions including revascularization and devices, collaborative efforts among health care professionals, and education and cooperation of the patient and their immediate caregivers. The goal is to translate best evidence-based therapies into clinical practice with a measureable impact on the health of heart failure patients in Canada.

Canada↗
PubMed2006

Treatment and blood pressure control in 47,964 people with diabetes and hypertension: a systematic review of observational studies.

BACKGROUND: Many patients with diabetes also have hypertension, greatly increasing their risk for cardiovascular disease. It has been suggested that hypertension is poorly treated in those with diabetes. OBJECTIVE: To examine treatment and control of hypertension in people with diabetes. DATA SOURCES: Data sources included MEDLINE, EMBASE, HealthSTAR, CINAHL, Web of Science, clinical evidence and government health and statistical Web sites. METHOD: Databases were systematically reviewed and hand searches of the bibliographies of relevant studies (1990 to 2004) were conducted. Two investigators selected studies and extracted the data independently. RESULTS: A total of 44 studies (77,649 subjects with diabetes, 47,964 [62%] of whom also had hypertension) were included. While 83% (range 32% to 100%) of patients with hypertension received drug therapy, only 12% (range 6% to 30%) had their blood pressure (BP) controlled to 130/85 mmHg or less. While BP control rates differed by definition of control (those studies with the least stringent definitions for BP control--160/90 mmHg or less--reported mean control rates of 37%), treatment and control rates did not differ appreciably between countries or health care settings. CONCLUSIONS: Fewer than one in eight people with diabetes and hypertension have adequately controlled BP, with remarkable uniformity across studies conducted in a variety of settings. There is an urgent need for multidisciplinary, community-based approaches to manage these high-risk patients.

Antihypertensive Agents↗
PubMed2006

Effect of a prior authorization process on antiplatelet therapy and outcomes in patients prescribed clopidogrel following coronary stenting.

BACKGROUND: Alberta Blue Cross (ABC) provides copayment-based coverage for residents older than 65 years. A prior authorization (PA) process for patients prescribed clopidogrel following stent insertion was changed to an authorized prescriber (AP) list process in March 2002. OBJECTIVE: To determine the effect of a policy change in medication coverage for clopidogrel on patients' filling of prescriptions and outcomes following stent insertion. METHODS: Consecutive patients who received a coronary stent between September 1, 2001, and August 31, 2002, at the University of Alberta Hospital and were eligible for ABC coverage were identified. Data were obtained from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease and ABC databases. RESULTS: One hundred twelve patients (45 in the PA period and 67 in the AP period) who received a coronary stent were eligible for ABC coverage during the study period. The two cohorts of patients were similar with respect to demographics. Fewer patients in the PA period than in the AP period had their prescription filled on the day of discharge (31% versus 54%; P=0.02), and the median time to fill was four days versus zero days in the PA and AP periods, respectively (Wilcoxon P=0.04). There was no significant difference in the proportion of patients filling their prescriptions after 28 days from discharge (67% versus 75%, P = not significant) or in the overall comparison of time to fill (log rank P=0.22). Two repeat revascularization procedures were necessary within six weeks after stent placement; both were in PA period patients who delayed or failed to fill their prescription. CONCLUSIONS: The PA process may have delayed patients filling clopidogrel prescriptions following hospital discharge and has the potential to contribute to negative clinical consequences.

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PubMed2005

Angiotensin receptor blockers and risk of myocardial infarction: systematic review.

OBJECTIVE: To evaluate the effect of angiotensin receptor blockers on the risk of myocardial infarction in patients at risk for cardiovascular events. DESIGN: Systematic review of controlled trials of angiotensin receptor blockers. DATA SOURCES: Medline, Embase, Cochrane central register of controlled trials, hand search, and contact with investigators. SELECTION OF STUDIES: Predefined criteria were used to select controlled clinical trials comparing use of angiotensin receptor blockers with angiotensin converting enzyme (ACE) inhibitors or placebo in patients at risk for cardiovascular events. Data were extracted for patients' characteristics, interventions, quality of trials, and rates of myocardial infarction. RESULTS: 19 studies with 31,569 patients were included in the analysis. Two studies investigated the use of angiotensin receptor blockers in hypertensive patients, four studies in patients with diabetes and nephropathy, 10 studies in patients with heart failure, and three in patients with recent myocardial infarction or ischaemic syndrome. 11 studies of 21,062 patients allowed for comparison between angiotensin receptor blockers and placebo; nine studies of 10,625 patients allowed for comparison between angiotensin receptor blockers and ACE inhibitors. Use of angiotensin receptor blockers was not associated with increased risk of myocardial infarction compared with placebo (odds ratio 0.94, 95% confidence interval 0.75 to 1.16) nor with increased risk of myocardial infarction compared with ACE inhibitors (1.01, 0.87 to 1.16). CONCLUSIONS: Treatment with angiotensin receptor blockers was not associated with a significantly increased risk of myocardial infarction. The 95% confidence intervals do, however, not exclude an increase of up to 16% in the risk of myocardial infarction or a reduction in risk of up to 25%. Until further information specifically dealing with this issue is available from large prospective trials, our findings may alleviate recent concerns over the safety of this class of medications.

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PubMed2005

Relation of T-axis abnormalities to coronary artery disease and survival after cardiac catheterization.

We investigated the association of an abnormal T axis with angiographic indicators of coronary artery disease and mortality. In univariate analysis, no significant association was observed between an abnormal T axis and extent of coronary artery disease (p = 0.928). An abnormal T axis was a significant predictor of overall mortality (p = 0.035) for death at any time in our unadjusted survival analysis, and a trend toward poorer survival persisted after adjustment for clinical covariates.

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PubMed2005

Utilization of evidence-based therapies for heart failure in the institutionalized elderly.

OBJECTIVES: Heart failure (HF) is a major source of morbidity and mortality in elderly populations. A significant proportion of the elderly with HF are living in long-term care facilities. Little is known about their management. The aim of this study was to evaluate the use of evidence-based therapies in institutionalized elderly patients with HF. DESIGN, SETTING AND PARTICIPANTS: Retrospective chart review conducted at 15 long-term care facilities in the Capital Health Region (Edmonton, Alberta). Residents > or =65 years of age with HF were identified using a pharmacy database. RESULTS: Overall prevalence of HF was 15% (313/2062 residents). Mean age was 87 years, median duration of residence was 1.8 years. Utilization of ACE-inhibitors, beta-blockers and spironolactone was 51%, 16% and 10%, respectively. Use of these medications was not significantly different between subgroups of those with and without contraindications to the therapies, different advance directive levels, gender or age. Sodium and fluid restricted diets were prescribed in only 11.0% and 3.8% of residents. Weight was not regularly monitored. Influenza and pneumococcal vaccination were administered to 60.4% and 81.2% of the residents. CONCLUSION: The use of evidence-based therapies in institutionalized elderly patients with HF is low, and unexplained by contraindications or advance directives. Efforts to increase the utilization of evidence-based therapies and improve monitoring are warranted.

Adrenergic beta-Antagonists↗
PubMed2005

Pharmaceutical care in community pharmacies: practice and research in Canada.

OBJECTIVE: To discuss the provision of pharmaceutical care in community pharmacies in Canada including the following topics: organization and delivery of health services, health service policy, methods of payment, types of pharmacy services provided, types of cognitive pharmacy services, research in community pharmacy, and future plans for community pharmacy services. DATA SYNTHESIS: The implementation of pharmaceutical care in Canadian community pharmacies continues to become more widespread. However, barriers to the provision of pharmaceutical care still exist, including the current shortage of pharmacists and lack of reimbursement systems for cognitive services. Evidence of the value of pharmaceutical care in Canadian community pharmacies has been supported by several pharmacy practice research projects. The pharmacist's role in patient care is expected to continue to expand. CONCLUSIONS: Although Canadian pharmacists' capabilities are not yet universally recognized and applied to their full potential, there is reason to be optimistic about the future of pharmaceutical care in the community setting in Canada.

Canada↗
PubMed2005

A cluster randomized trial to assess the impact of opinion leader endorsed evidence summaries on improving quality of prescribing for patients with chronic cardiovascular disease: rationale and design [ISRCTN26365328].

BACKGROUND: Although much has been written about the influence of local opinion leaders on clinical practice, there have been few controlled studies of their effect, and almost none have attempted to change prescribing in the community for chronic conditions such as heart failure (HF) or ischemic heart disease (IHD). These two conditions are common and there is very good evidence about how to best prevent morbidity and mortality - and good evidence that quality of care is, in general, suboptimal. Practice audits have demonstrated that about one-half of eligible HF patients are prescribed ACE inhibitors (with fewer still reaching appropriate target doses) and less than one-third of patients with established IHD are prescribed statins (with many fewer reaching recommended cholesterol targets). It is apparent that interventions to improve quality of prescribing are urgently needed. We hypothesized that an intervention that consisted of patient-specific one-page evidence summaries, generated and then endorsed by local opinion leaders, would be able to change prescribing practices of community-based primary care physicians. METHODS (STUDY DESIGN): A pragmatic single-centre cluster randomized controlled trial comparing an opinion leader-based intervention to usual care for patients with HF or IHD. Randomization will be clustered at the level of the primary care physician; as the design effect is anticipated to be negligible, the unit of analysis will be the patient. Patients with HF or IHD (not receiving ACE inhibitors or statins, respectively) will be recruited from community pharmacies and allocated to intervention or usual care based on the randomization status of their primary care physician. The primary outcome is improvement in prescription of proven efficacious therapies for HF (ACE inhibitors) or IHD (statins) within 6 months of the intervention. CONCLUSION: If the methods used in this intervention are found to improve prescribing practices, similar interventions could be designed for other chronic conditions dealt with in the outpatient setting.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed2005

A cohort study found the RAND-12 and Health Utilities Index Mark 3 demonstrated construct validity in high-risk primary care patients.

OBJECTIVE: The Short Form 12 (SF-12) is widely used in primary care settings. The RAND-12 Health Status Inventory (HSI) and the Health Utilities Index Mark 3 (HUI3) have not been as widely used in such settings. The objective of this study was to examine the construct validity of the RAND-12 and HUI3 in the context of high-risk primary care patients. STUDY DESIGN AND SETTING: The SF-12, HUI2, and HUI3 were administered to a cohort of high-risk primary care patients. RAND-12 summary scores for physical and mental health were generated. Single-attribute utility scores for each dimension of health status and overall health in HUI3 were computed. A priori hypotheses were specified. RESULTS: In general, the relationships among RAND-12 and HUI3 scores were consistent with construct validity. Twelve of 24 a priori predictions were confirmed. However, predictions about the correlations between the number of medical conditions and the number of medications and the measures of health-related quality of life were, in general, not confirmed. CONCLUSIONS: The RAND-12 and HUI3 seem to be useful among primary care patients with diverse chronic conditions. Further investigation is warranted.

Cohort Studies↗
PubMed2005

Long-term impact of a community pharmacist intervention on cholesterol levels in patients at high risk for cardiovascular events: extended follow-up of the second study of cardiovascular risk intervention by pharmacists (SCRIP-plus).

STUDY OBJECTIVE: To determine the effect of a community pharmacist intervention in patients at high risk for coronary heart disease on low-density lipoprotein cholesterol (LDL) levels 1 year after completion of the Second Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP- plus ). METHODS: Patients who completed the original study were invited to make a single return visit to their community pharmacy so that the pharmacist could measure their fasting LDL level using a point-of-care device. The primary outcome was change in LDL level from the 6-month (final) visit to the extended follow-up evaluation. RESULTS: Of the 359 patients who completed the original 6-month visit, data were collected for 162 (45%) patients. The mean +/- SD LDL level at completion of the original study was 107.9 +/- 33.6 mg/dl (2.79 +/- 0.96 mmol/L) (an increase of 2.7 mg/dl [0.07 mmol/L], 95% confidence interval -19.3-7.3 [-0.5-0.19]). Sixty-one (38%) patients were at the target LDL level (< 96.7 mg/dl [< 2.50 mmol/L]). CONCLUSION: The LDL reduction was maintained 1 year after completion of the extended follow-up. Since most patients were still not at the target LDL level, this finding suggests that continuing intervention is necessary to help patients reach this target.

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