General practitioners' and pharmacists' perceptions of the role of community pharmacists in delivering clinical services

BackgroundBecause community pharmacists are encouraged to provide clinical services, there is a need to determine the role perceptions of both community pharmacists and general practitioners (primary care physicians). Differing role perceptions are likely to result in barriers to pharmacists expanding their roles in health care.ObjectivesThe purpose of this study was to investigate whether community pharmacists' and general practitioner's perceptions of the role of community pharmacists may be a barrier to pharmacists increasing their role in medication management. Other potential barriers were also explored that could provide a framework for future research.MethodsA postal survey to 900 and 1000 randomly selected community pharmacists and general practitioners, respectively, elicited the perceptions of these groups toward the role of community pharmacists. Likert scales were used to quantify the results.ResultsThe results revealed a gap in perceptions regarding the role of the community pharmacist, with general acceptance of the technical roles but less acceptance of clinical roles by general practitioners. Barriers to increased involvement of community pharmacists in clinical services included a perceived lack of mandate, legitimacy, adequacy, and effectiveness by both groups. Also observed was a lack of readiness to change by community pharmacists.ConclusionsThis study suggests that there are significant barriers to community pharmacists increasing clinical services, both from the community pharmacists themselves and from the general practitioners. Attention to change management in a complex environment will be necessary if community pharmacists are to change their role toward more clinical services.     

CLINICAL Review # : low body weight mediates the relationship between HIV infection and low bone mineral density: a meta-analysis

CONTEXT: HIV infection has been associated with low bone mineral density (BMD) in many cross-sectional studies, although longitudinal studies have not demonstrated accelerated bone loss. The cross-sectional studies may have been confounded by the failure to control for low body weight in HIV-infected patients. OBJECTIVE: Our objective was to determine whether low body weight might explain the association of HIV infection with low BMD. DATA SOURCES: MEDLINE and EMBASE were searched for English language studies published from 1966 to March 2007, and conference abstracts prior to 2007 were hand-searched. STUDY SELECTION: All studies reporting BMD and weight or body mass index in adult patients with HIV and a healthy age- and sex-comparable control group were included. Nine of 40 identified studies and one of 68 identified abstracts were eligible. DATA SYNTHESIS: We adjusted for the between-groups weight differences using regression coefficients from published cohorts of healthy men and women. On average, HIV-infected patients were 5.1 kg [95% confidence interval (CI), -6.8, -3.4; P < 0.001] lighter than controls. At all skeletal sites, unadjusted BMD was lower by 4.4-7.0% in the HIV-infected groups than the controls (P < 0.01). After adjustment for body weight, residual between-groups differences in BMD were small (2.2-4.7%) [lumbar spine, -0.02 (95% CI, -0.05, 0.01) g/cm2; P = 0.12; total hip, -0.02 (95% CI, -0.04, 0.00) g/cm2; P = 0.031; femoral neck, -0.04 (95% CI, -0.07, -0.01) g/cm2; P = 0.013; and total body, -0.03 (95% CI, -0.07, 0.01) g/cm2, P = 0.11]. CONCLUSION: HIV-infected patients are lighter than controls and low body weight may largely account for the high prevalence of low BMD reported in HIV-infected patients. However, in the setting of current treatment practice, HIV infection per se is not a risk factor for low BMD.     

Addition of monofluorophosphate to estrogen therapy in postmenopausal osteoporosis: a randomized controlled trial

INTRODUCTION: Treatment of osteoporosis with high-dose fluoride alone does not reduce fracture risk. We hypothesized that the antifracture efficacy of fluoride could be optimized by its use in low doses combined with an antiresorptive agent. EXPERIMENTAL SUBJECTS: Subjects included 80 women with postmenopausal osteoporosis who had been taking estrogen for at least 1 yr. METHODS: Subjects were randomized to receive monofluorophosphate (MFP) (fluoride content of 20 mg/d) or placebo over 4 yr in a double-blind trial. RESULTS AND DISCUSSION: There were progressive increases in lumbar spine bone density over the duration of the study (MFP, 22%; placebo, 6%; P < 0.0001). In the trabecular bone of L3, these increases were even greater (MFP, 49%; placebo, 2.5%; P < 0.0001). In the proximal femur, there were smaller but significant treatment effects (P = 0.015). Total body scans and their subregions also showed significantly greater increases in the MFP group. Bone formation markers increased significantly in the MFP group at yr 1. Hyperosteoidosis was present in biopsies from five of seven MFP subjects, with osteomalacia in two of seven. The hazards ratio for vertebral fractures was 0.20 (95% confidence interval, 0.05-1.30), and the incidence rate ratio was 0.12 (95% confidence interval, 0.06-0.23; P < 0.01). The hazards ratio for nonvertebral fractures was 3.3 (95% confidence interval, 0.8-12.0). CONCLUSIONS: We conclude that fluoride at 20 mg/d produces substantial increases in bone mineral density but still interferes with bone mineralization. This indicates that most previous studies with this ion have used toxic doses and that much lower doses should be assessed to find a safe dose window for the use of this powerful anabolic agent.     

Crystalline silica and lung cancer: a critical review of the occupational epidemiology literature of exposure-response studies testing this hypothesis

IARC (2009; Metals, Particles and Fibres. IARC Monographs on the Evaluaton of Carcinogenic Risks to Humans. Volume 100C. Lyon, France: IARC) concluded that crystalline silica in occupational settings is a lung carcinogen. This conclusion is based primarily on studies with exposure-response (E-R) analyses and a pooled analysis of 10 major studies with about 1000 lung cancer cases. The purpose of this review is to critically assess this cancer classification based on E-R analyses in 18 studies from eight countries with about 2000 lung cancer cases and the same database used by IARC (2009) . The most appropriate exposure-response analysis is selected from latest study with least effect from bias, confounding, and presented graphically to assist individual assessment of the weight of evidence. Strength of association is consistently weak in the majority of studies. At the highest exposure level the mean relative risk (RR) is 1.5; four studies have strong associations (RRs?>?2), three have moderate strong associations (RRs 1.5-2.0), six have weak-negligible associations (RRs 1-1.5), and five have no associations (RRs ≤1.0). Biological gradients were an inconsistent finding. Three studies had clear positive E-R trends; 3 had suggestive trends; and 12 had no E-R trends, 9 of which were flat or negative. There was a negative ER slope using RRs at the highest exposure of each study. Consistent findings of weak associations and lack of E-R trends does not support a causal association. Weight of evidence from occupational epidemiology does not support a causal association of lung cancer and silica exposure, which is contrary to the IARC conclusion using essentially the same data.     

Admission Hypoglycemia and Increased Mortality in Patients Hospitalized with Pneumonia

Background

The relationship between spontaneous admission hypoglycemia and mortality in patients hospitalized with community-acquired pneumonia is unclear.

Methods

From 2000 to 2002, clinical data were prospectively collected on all patients with community-acquired pneumonia who were admitted to all 6 hospitals in Edmonton, Alberta, Canada. Patients with admission glucose greater than 6.1 mmol/L (n = 1996) were excluded; the remaining patients were categorized as having admission hypoglycemia (<4.0 mmol/L [n = 54]) or normoglycemia (4.0 to ≤ 6.1 mmol/L [n = 902]). Multivariable Cox proportional hazards models were used to examine the relationship between hypoglycemia and all-cause mortality in-hospital, at 30 days, and at 1 year.

Results

The mean age was 65 (standard deviation = 20) years, 48% were female, 8% had diabetes, and 56% had severe pneumonia. Overall, admission hypoglycemia was present in 2% (54/2990) of the entire cohort and 6% of those with glucose of 6.1 mmol/L or less. Total deaths were 89 (9%) in-hospital, 96 (10%) at 30 days, and 247 (26%) at 1 year. In-hospital mortality was higher among patients with admission hypoglycemia (11 [20%] deaths) compared with those with normoglycemia (78 [9%]; adjusted hazards ratio [aHR] 2.96; 95% confidence interval [CI], 1.39-6.31; P = .005). An increased risk of mortality was observed at 30 days (11 [20%] vs 85 [10%]; aHR 2.89; 95% CI, 1.32-6.29) and remained elevated at 1 year (19 [35%] vs 228 [25%]; aHR1.80; 95% CI, 1.02-3.17). These results were not influenced by treatment for diabetes (P > .4 for interaction).

Conclusion

In a population-based sample of patients with community-acquired pneumonia, spontaneous admission hypoglycemia was independently associated with increased mortality during hospitalization that persisted to 1 year. Patients with hypoglycemia are an easily identified group that may warrant more intensive inpatient and postdischarge follow-up.     

The Darkening Cloud of Diabetes: Do trends in cardiovascular risk management provide a silver lining?

OBJECTIVE—We aimed to evaluate the changes in cardiovascular-related health care utilization (drug therapies, hospitalizations) and mortality for the diabetic population during a 9-year period in Saskatchewan, Canada.RESEARCH DESIGN AND METHODS—We identified annual diabetes prevalence rates for people aged ≥30 years between 1993 and 2001 from the administrative databases of Saskatchewan Health. Annual rates of evidence-based drug therapies (antihypertensives, ACE inhibitors, β-blockers, calcium channel blockers, 3-hydroxy-3-metaglutaryl coenzyme A reductase inhibitors [statins]), hospitalizations for cerebrovascular and cardiac events, and all-cause mortality were estimated. Rates were direct age and sex standardized using the 2001 Canadian population, and trends over time were assessed using Joinpoint regression.RESULTS—From 1993 to 2001, diabetes prevalence increased 34% (4.7–6.5%, P < 0.001) with the highest rates in men and those aged ≥65 years. The rate of increase in diabetes prevalence appeared to slow in those aged <65 years (P < 0.01 for trend). Significant increased use of evidence-based drug therapies was observed (41% increase in antihypertensive agents, 97% increase in ACE inhibitors, 223% increase in statin therapies; all P < 0.05 for trend). During this period, both cerebrovascular and cardiac-related hospitalizations declined by 36% (9.5 vs. 6.1 per 1,000) and 19% (38.0 vs. 30.6 per 1,000) (P < 0.05 for trends), respectively, with similar reductions regardless of sex. No change in all-cause mortality was observed (17.7 vs. 17.8 deaths per 1,000; P > 0.05).CONCLUSIONS—During our period of study, there was an increase in the utilization of evidenced-based drug therapies in people with diabetes and reductions in cardiovascular-related hospitalizations. Despite this, we observed no change in all-cause mortality.Diabetes represents a major public health burden, both locally and globally (1). From 1985 to 2000, the number of people living with diabetes globally rose from 30 million to ∼171 million (1). Future projections have estimated the prevalence of diabetes to exceed 300 million cases by 2030, with the majority of growth occurring in developing countries (1). Recent estimates, however, suggest that these projections may grossly underestimate the true prevalence (2).It is well known that diabetes is associated with significant morbidity and mortality. It is estimated that there are six deaths every minute attributable to the complications of diabetes, with cardiovascular disease being responsible for the vast majority (3). Not surprisingly, diabetes and its complications place an enormous burden on both patients and the health care system, with direct health care costs ranging from 2.5 to 15% of annual health care budgets (4). Given the expected rise in diabetes cases, this economic burden will also increase.For these reasons, considerable resources have been invested to improve diabetes management. In addition to lifestyle changes, a cornerstone of this management scheme has been the use of evidence-based drug therapies for vascular protection (5). Large trials have demonstrated that aggressive pharmacologic management of cardiovascular risks can reduce both morbidity and mortality in patients with diabetes (5). It would also appear that the diabetic community is incorporating this evidence into the daily management of diabetic patients. Several studies (6–9) have reported significant increases in the use of evidence-based drug therapies in people with diabetes. However, previous studies have largely focused on antihyperglycemic management (7,8) or have been restricted to specific subpopulations of patients with diabetes (e.g., aged ≥65 years) (6,9).The increased prevalence of diabetes has been attributed not only to an increase in incidence but also to reduced mortality rates (2,10). A decrease in mortality rates over time in people with diabetes has been reported in both Canada and the U.S. (2,10–14). It remains uncertain, however, whether concurrent changes in utilization rates of evidence-based drug therapies over time has resulted in substantial improvements in the health of people with diabetes at the population level. We are unaware of studies that have simultaneously evaluated the trends in health care utilization and subsequent changes in mortality in people with diabetes. Therefore, our objective was to explore both health care utilization patterns (i.e., evidence-based drug therapies and hospitalizations) and mortality rates over a 9-year period in an unselected population of patients with diabetes.     

An encouraging assessment of methods to inform priorities for updating systematic reviews

ObjectiveTo consider the use of statistical methods that aim to prioritize the updating of a collection of systematic reviews based on preliminary literature searches.Study Design and SettingA new simulation-based method estimating statistical power and the ratio of the weights assigned to the predicted new and old evidence, and the existing Barrowman n approach is considered. Using only information on the numbers of subjects randomized in the “new” trials, these were applied retrospectively, by removing recent studies, to existing systematic reviews from the Cochrane Infectious Diseases Group.ResultsTwelve systematic reviews were included. When the removed studies were reinstated, inferences changed in five of them. These reviews were ranked, in order of update priority, 1, 2, 3, 4, and 11 and 1, 2, 3, 4, and 12 by the Barrowman n and simulation-based power approaches, respectively. The low ranking of one significant meta-analysis by both methods was due to unexpectedly favorable results in the reinstated study.ConclusionThis study demonstrates the feasibility of the use of analytical methods to inform update prioritization strategies. Under conditions of homogeneity, Barrowman's n and simulated power were in close agreement. We encourage further, prospective, evaluation of these methods.