Rural community pharmacy: a feasible site for a health promotion and screening service for cardiovascular risk factors

ABSTRACT: A pharmacist-delivered health promotion and screening service for cardiovascular risk factors in rural community pharmacy was implemented in the Upper Hunter Valley, New South Wales (NSW). We describe the development of the service and profile 204 participants at their initial screening. A standardised clinical protocol guided the pharmacist through delivery of the service. The mean age of participants was 44 years ( SD ± 13 ). Over half (54%) had a Body Mass Index (BMI) > 25, 54% had cholesterol > 5.0 mmol L^-1 and 18% a systolicBP > 140 mmHg and/or diastolicBP > 90 mmHg. Most (80%) received lifestyle information (dietary, exercise or smoking cessation). One third required referral to a general practitioner. Provision of the service through community pharmacy increased the community's access to screening, 28% reported that they had never had their cholesterol measured. Since this new service was able to identify, educate and refer people at risk of cardiovascular disease in a rural community, we recommend a broader adoption through rural pharmacies.     

Atypical Alliances: The Potential for Social Work and Pharmacy Collaborations in Primary Health Care Delivery

The growing prevalence of chronic conditions is a cause for concern globally, both in terms of its impact on the health of populations and also the strain it is predicted to place on health resources. There is a push to adopt more holistic and collaborative approaches to health care, and for the education of health care professionals to be reformed if these efforts are to be successful. A research project was undertaken in New Zealand in 2010–2011 aimed at exploring the perceptions of health care professionals on competencies in the field of chronic care. This article aims to highlight learning from the project regarding the “atypical alliance” between social work and pharmacy. Based on this, the authors argue that, with the growing expectations for interprofessional collaboration, effective primary and community health care delivery is increasingly dependent on relationships between educators in different health disciplines, between health professionals-in-training, and between education providers and health organizations.     

Rethinking prevention in primary care: applying the chronic care model to address health risk behaviors

This study examines the Chronic Care Model (CCM) as a framework for preventing health risk behaviors such as tobacco use, risky drinking, unhealthy dietary patterns, and physical inactivity. Data were obtained from primary care practices participating in a national health promotion initiative sponsored by the Robert Wood Johnson Foundation. Practices owned by a hospital health system and exhibiting a culture of quality improvement were more likely to offer recommended services such as health risk assessment, behavioral counseling, and referral to community-based programs. Practices that had a multispecialty physician staff and staff dieticians, decision support in the form of point-of-care reminders and clinical staff meetings, and clinical information systems such as electronic medical records were also more likely to offer recommended services. Adaptation of the CCM for preventive purposes may offer a useful framework for addressing important health risk behaviors.     

Narrative reports to monitor and evaluate the integration of pharmacists into family practice settings

PURPOSE Narratives can capture unfolding events and negotiation of roles and thus can help to evaluate interventions in interdisciplinary health care teams. We describe a practical qualitative method, the narrative report, and its role in evaluating implementation research.METHODS We used narrative reports as a means to evaluate an intervention to integrate pharmacists into group family practices. The pharmacists submitted 63 written narrative reports during a 1-year period. Our interdisciplinary research team analyzed these reports to monitor the progress of the implementation, to identify pharmacists’ needs, and to capture elements of the integration process.RESULTS The monthly narrative reports allowed the research team to document early learning and calibrate the program in terms of clinical support, adapting roles, and realigning expectations. The reports helped the research team stay in tune with practice-related implementation challenges, and the preliminary summary of narrative findings provided a forum for sharing innovations among the integrating pharmacists.CONCLUSION The narrative report can be a successful qualitative tool to track and evaluate the early stages of an intervention in the context of evolving primary health care teams.     

Self-rated cardiovascular risk and 15-year cardiovascular mortality

PURPOSE Many individuals perceive their cardiovascular disease (CVD) risk to be lower than established clinical tools would estimate, yet little is known about the long-term consequences of holding such optimistic beliefs. We evaluated whether lower self-ratings of CVD risk are associated with lower rates of CVD death after addressing potential confounding by an extensive set of social and biologic CVD risk factors.METHODS We conducted a 15-year mortality surveillance study of adults aged 35 to 75 years from southeastern New England (n = 2,816) who had no history of myocardial infarction. Baseline evaluation in 1990–1992 included household interview, anthropomorphic measures, and laboratory analyses. Outcomes were obtained using the National Death Index records through December 2005.RESULTS Rating oneself to be at lower-than-average risk for one’s age and sex was associated with lower rates of CVD mortality among men (hazard ratio [HR]=0.3; 95% confidence interval [CI], 0.2–0.7) but not among women (HR = 0.9; 95% CI, 0.5–1.7). None of the following weakened the findings among men: adjustment for baseline Framingham Risk Score, propensity score adjustment for both social and biologic factors, and censoring the first 2 years of surveillance.CONCLUSIONS Lower self-ratings of CVD risk are independently associated with lower rates of CVD death among men.     

Impact of the sustained control of cardiovascular risk factors on first episode heart failure: The relevant role of primary care

Background: The role of cardiovascular risk factor control in the development of heart failure (HF) has not yet been clearly established.

Objective: To determine the effect of cardiovascular risk factor control on the occurrence of a first episode of hospital admission for HF.

Methods: A case-control study using propensity score-matching was carried out to analyse the occurrence of first hospital admission for HF taking into account the degree of cardiovascular risk factor control over the previous 24 months. All patients admitted to the cardiology unit of the Hospital del Mar between 2008 and 2011 because of a first episode of HF were considered cases. Controls were selected from the population in the hospital catchment area who were using primary care services. Cardiovascular risk factor measurements in the primary healthcare electronic medical records prior to the first HF episode were analysed.

Results: After the matching process, 645 participants were analysed (129 HF cases and 516 controls). Patients suffering a first HF episode had modest increments in body mass index and blood pressure levels during the previous two years. Adjusted odds ratio for experiencing a first HF hospital admission episode according to systolic blood pressure levels and body mass index was (OR: 1.031, 95% CI: 1.001–1.04), and (OR: 1.09, 95% CI: 1.03–1.15), respectively.

Conclusion: Increased levels of body mass index and systolic blood pressure during the previous 24 months may determine a higher risk of having a first HF hospital admission episode.     

Ethnic group differences in cardiovascular risk assessment scores: national cross-sectional study

Objectives. There are marked inequalities in cardiovascular disease (CVD) incidence and outcomes between ethnic groups. CVD risk scores are increasingly used in preventive medicine and should aim to accurately reflect differences between ethnic groups. Ethnicity, as an independent risk factor for CVD, can be accounted for in CVD risk scores primarily using two methods, either directly incorporating it as a risk factor in the algorithm or through a post hoc adjustment of risk. We aim to compare these two methods in terms of their prediction of CVD across ethnic groups using representative national data from England.

Design. A cross-sectional study using data from the Health Survey for England. We measured ethnic group differences in risk estimation between the QRISK2, which includes ethnicity and Joint British Societies 2 (JBS2) algorithm, which uses post hoc risk adjustment factor for South Asian men.

Results. The QRISK2 score produces lower median estimates of CVD risk than JBS2 overall (6.6% [lower quartile–upper quartile (LQ-UQ) = 4.0–18.6] compared with 9.3% [LQ-UQ = 2.3–16.9]). Differences in median risk scores are significantly greater in South Asian men (7.5% [LQ-UQ = 3.6–12.5]) compared with White men (3.0% [LQ-UQ = 0.7–5.9]). Using QRISK2, 19.1% [95% confidence interval (CI) = 16.2–22.0] fewer South Asian men are designated at high risk compared with 8.8% (95% CI = 5.9–7.8) fewer in White men. Across all ethnic groups, women had a lower median QRISK2 score (0.72 [LQ-UQ = ? 0.6 to 2.13]), although relatively more (2.0% [95% CI = 1.4–2.6]) were at high risk than with JBS2.

Conclusions. Ethnicity is an important CVD risk factor. Current scoring tools used in the UK produce significantly different estimates of CVD risk within ethnic groups, particularly in South Asian men. Work to accurately estimate CVD risk in ethnic minority groups is important if CVD prevention programmes are to address health inequalities.     

A classification and regression tree analysis for the evaluation of the role of nutritional services on cardiovascular disease risk status of older people living in Greek islands and Cyprus

Introduction: The purpose of this study was to evaluate, with classification–regression tree analysis, the structure of the associations between nutritional and health care services and the cumulative prevalence of the classical cardiovascular disease (CVD) risk factors of older individuals living in Greek islands and Cyprus. Methods: During 2005–2009, 744 men and 742 women (>65 years) from nine Greek islands and Cyprus Republic were voluntarily enrolled in the Mediterranean Islands study; various socio-demographic, clinical and lifestyle characteristics were recorded. Moreover, information regarding practising dieticians (n = 88) and nutritional services provided in these islands was also recorded. Results: Both medical and nutrition services act more effectively to elders' cardiovascular health. For example, older individuals living in areas with nutritional services' support for at least five years, with collaboration between dieticians and physicians, reduced the CVD risk factors (CVD RF) burden by 42%. Whereas, in areas with dietetic support less than five years, but more than two, the presence of advanced health care system seemed to control the CVD RF burden to the population average. Conclusions: Despite the fact that the present work shares some limitations mainly because of its cross-sectional design, the classification and regression tree approach has clearly demonstrated the interrelation between nutritional services and the health care system towards achieving benefits among the elders' quality of life.     

Evaluation of a workplace cardiovascular health promotion programme in the Republic of Ireland

This paper describes a comprehensive evaluation of the organizational impact of a workplace health promotion programme, in the context of a framework devised by Nutbeam in 1998. The Happy Heart at Work programme, sponsored by the Irish Heart Foundation, has been in existence for 10 years and aims to promote a healthy lifestyle through specially devised modular materials. A postal census survey of 785 valid registered sites expressing any level of initial interest in the programme yielded a 40% response rate (n = 311). Of these, 194 (63%) were currently active and 114 were not. Active organizations were less likely to be Irish owned (54.5% versus 71.4%, p < 0.05), and more likely to operate in shifts (72.3% versus 51.1%, p < 0.05) or to have an occupational physician amongst the staff (36.9% versus 31%). Programme impact within active organizations, based on pre-defined Health Promoting Workplace parameters, was documented. There was agreement in the questionnaire responses that participating organizations promote a smoke-free environment (mean rating on five-point scale = 4.42), employee health and well-being (4.21) and good nutritional practice (4.11). Triangulation of research methods, including a telephone survey of gatekeepers from within organizations (n = 18), focus groups with participant employees (n = 42) and a review of the staff opinions of the facilitating organization on the programme, all showed strong concordance with respect to the strengths and weaknesses of Happy Heart at Work. The programme was felt to help improve employees' lifestyle habits and morale, as well as the company's public image. The main drawbacks of the programme were its relatively low profile, even in actively participating organizations, and the fact that it was not seen to be independently sustainable without intensive and ongoing support.     

Absolute cardiovascular disease risk and shared decision making in primary care: a randomized controlled trial

PURPOSE We wanted to determine the effect of promoting the effective communication of absolute cardiovascular disease (CVD) risk and shared decision making through disseminating a simple decision aid for use in family practice consultations.METHODS The study was based on a pragmatic, cluster randomized controlled trial (phase III) with continuing medical education (CME) groups of family physicians as the unit of randomization. In the intervention arm, 44 physicians (7 CME groups) consecutively recruited 550 patients in whom cholesterol levels were measured. Forty-seven physicians in the control arm (7 CME groups) similarly included 582 patients. Four hundred sixty patients (83.6%) of the intervention arm and 466 patients (80.1%) of the control arm were seen at follow-up. Physicians attended 2 interactive CME sessions and received a booklet, a paper-based risk calculator, and individual summary sheets for each patient. Control physicians attended 1 CME-session on an alternative topic. Main outcome measures were patient satisfaction and participation after the index consultation, change in CVD risk status, and decisional regret at 6 months’ follow-up.RESULTS Intervention patients were significantly more satisfied with process and result (Patient Participation Scale, difference 0.80, P<.001). Decisional regret was significantly lower at follow-up (difference 3.39, P = .02). CVD risk decreased in both groups without a significant difference between study arms.CONCLUSION A simple transactional decision aid based on calculating absolute individual CVD risk and promoting shared decision making in CVD prevention can be disseminated through CME groups and may lead to higher patient satisfaction and involvement and less decisional regret, without negatively affecting global CVD risk.     

Social determinants of health: the how,who, and where screenings are occurring; a systematic review

Screening for social determinants of health allows health care teams to assess and address social factors that influence one’s health, mental health, and access to care. These social factors include poverty, health literacy, social support, exposure to trauma, food insecurity, and housing instability. The objective of this study was to examine what screening tools for social determinants of health are being used, in what contexts, and with what populations. Findings suggest that health literacy is the most commonly screened for, followed by trauma history, social support, food insecurity and housing across diverse contexts and populations. Results from this study can be used to inform providers of available screening tools and resources that can be readily utilized in practice.     

A controlled trial of dissemination and implementation of a cardiovascular risk reduction strategy in small primary care practices

ObjectiveTo assess the effect of dissemination and implementation of an intervention consisting of practice facilitation and a risk‐stratified, population management dashboard on cardiovascular risk reduction for patients at high risk in small, primary care practices.Study SettingA total of 219 small primary care practices (≤10 clinicians per site) across North Carolina with primary data collection from electronic health records (EHRs) from the fourth quarter of 2015 through the second quarter of 2018.Study DesignWe performed a stepped‐wedge, stratified, cluster randomized trial of a one‐year intervention consisting of practice facilitation utilizing quality improvement techniques coupled with a cardiovascular dashboard that included lists of risk‐stratified adults, aged 40‐79 years and their unmet treatment opportunities. The primary outcome was change in 10‐Year ASCVD Risk score among all patients with a baseline score ≥10 percent from baseline to 3 months postintervention.Data Collection/ Extraction MethodsData extracts were securely transferred from practices on a nightly basis from their EHR to the research team registry.Principle FindingsASCVD risk scores were assessed on 437 556 patients and 146 826 had a calculated 10‐year risk ≥10 percent. The mean baseline risk was 23.4 percent (SD ± 12.6 percent). Postintervention, the absolute risk reduction was 6.3 percent (95% CI 6.3, 6.4). Models considering calendar time and stepped‐wedge controls revealed most of the improvement (4.0 of 6.3 percent) was attributable to the intervention and not secular trends. In multivariate analysis, male gender, age >65 years, low‐income (<$40 000), and Black race (P < .001 for all variables) were each associated with greater risk reductions.ConclusionA risk‐stratified, population management dashboard combined with practice facilitation led to substantial reductions of 10‐year ASCVD risk for patients at high risk. Similar approaches could lead to effective dissemination and implementation of other new evidence, especially in rural and other under‐resourced practices.Registration: ClinicalTrials.Gov 15‐0479.     

Principles of the Patient-Centered Medical Home and Preventive Services Delivery

PURPOSE Limited research exists examining the principles of the patient-centered medical home (PCMH) and improved outcomes. We examined whether PCMH principles (personal physician, physician-directed team, whole-person orientation, coordination of care, quality and safety, and enhanced access) are associated with receipt of preventive services.METHODS We undertook cross-sectional analyses using baseline patient and practice member surveys and chart audits from a quality improvement trial in 24 primary care offices. Association of PCMH principles with preventive services (receipt of cancer screening, lipid screening, influenza vaccination, and behavioral counseling) was examined using hierarchical linear modeling.RESULTS Higher global PCMH scores were associated with receipt of preventive services (β=2.3; P <.001). Positive associations were found with principles of personal physician (β=3.7; P <.001), in particular, continuity with the same physician (β=4.4; P = .002) and number of visits within 2 years (15% higher for patients with 13 or more visits; P <.001); and whole-person orientation (β=5.6; P <.001), particularly, having a well-visit within 5 years (β=12.3; P <.001) and being treated for chronic diseases (6% higher if more than 3 chronic diseases; P = .002). Having referral systems to link patients to community programs for preventive counseling (β = 8.0; P <.001) and use of clinical decision-support tools (β = 5.0; P = .04) were also associated with receipt of preventive services.CONCLUSIONS Relationship-centered aspects of PCMH are more highly correlated with preventive services delivery in community primary care practices than are information technology capabilities. Demonstration projects and tools that measure PCMH principles should have greater emphasis on these key primary care attributes.     

A primary care cardiovascular risk reduction clinic in Canada was more effective and no more expensive than usual on-demand primary care – a randomised controlled trial

The objective of this randomised controlled trial was to compare the effects and expense of three approaches to care (1) proactive cardiovascular risk reduction (CaRR) clinic; (2) nurse telephone calls; or (3) usual care for people with cardiovascular risk factors in a Primary Care, Health Service Organisation (HSO) in Ontario, Canada. Subjects included consenting patients with an identified cardiovascular disease (CVD) risk factor identified from the HSO computerised patient information system in 2004. Patients were excluded if they were mentally incompetent, <18 years of age, in a nursing home, or not English speaking. Of 1570 eligible subjects, 523 (33.3%) verbally declined, 145 (9.2%) could not be contacted, and 249 (15.9%) were not needed. The final sample size was 653 (41.6%), 634 completed the follow-up (97%). The Cardiovascular Risk Score, Health and Social Service Utilisation, Montgomery-Asberg Depression Rating, Billings and Moos Indices of Coping, Personal Resource and Self-Efficacy Questionnaires were measured at baseline and 1-year follow-up by clinical examination and telephone interview. Cardiovascular risk scores were reduced in all treatment groups after 1 year. The proportions of subjects showing reduction in risk score greater than or equal to 10% was greatest in the CaRR group (69.2%) compared with Nurse Phone intervention (57.8%) and Usual Care (59.0%) ( M - H χ² = 4.33, df = 1, P  = 0.037, CaRR-Usual Care). Self-efficacy scores showed the greatest improvements in the CaRR clinic. This effect was achieved with no significant difference in total person per annum costs for direct and indirect health and social service utilisation between all three groups. A CaRR clinic is more effective in reducing CVD risk after 1 year compared with nurse phone intervention and usual care with no additional expense found.     

Prevalence of cardiovascular risk factors of the smokers and non-smokers in the city of Debrecen, Hungary

The aim of our study was to compare the major cardiovascular disease (CVD) risk factors of smokers and non-smokers. Risk screening of CVD was estimated by a questionnaire, via interview. Random samples of 20 000 inhabitants of Debrecen, Hungary, aged 30-65 y, took part in the study. 19 922 questionnaires were considered appropriate for further evaluation. 32.2% of the participants (n=6410) were smokers, whose data were compared to those of the 68.8% of non-smokers (n=13 512). There were more male smokers than female (39.3% vs 27.7%), (P<0.001). 36.5% of males and 58.9% of females had not previously smoked regularly (P<0.001). 24.2% of males and only 13.3% of females were able to stop smoking (P<0.001). 8.7% of the participants smoked more than 20 cigarettes per day (14.8% of males, 5.0% of females), (P<0.001). Smokers were younger, with a mean age of 43.4 y vs 47.1 y for non-smokers (P<0.01). The ex-smokers and non-smokers had a higher body mass index than light, moderate and heavy smokers (26. 75+/-4.1 kg/m2 and 26.09+/-4.3 kg/m2 vs 24.87+/-3.9 kg/m2 and 24. 89+/-4.2 kg/m2 and 25.32+/-4.3 kg/m2, respectively), (P<0.001). The results of the last measured blood pressures did not differ between the two groups. 94.8% of smokers and 93.6% of non-smokers did not perform any regular leisure time exercises (P<0.01). 39.8% of smokers regularly ate fatty food, in comparison to 28.0% of non-smokers (P<0.001). 30.6% of smokers vs 28.6% of non-smokers were factory workers while 69.4% of smokers vs 71.4% of non-smokers did sedentary jobs (P<0.001). 2.3% of smokers vs 0.9% of non-smokers admitted regular consumption of alcohol (P<0.001). Amongst the parents and brothers/sisters of smokers the prevalence of heart attack was higher 19.7% vs 18.7%, than for those of non-smokers (P<0. 05). We observed an accumulation of cardiovascular risk factors in the case of smokers, which indicates the higher susceptibility of smokers to CVD.