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Hypertension Canada provides annually updated, evidence-based guidelines for the diagnosis, assessment, prevention, and treatment of hypertension in adults and children. This year, the adult and pediatric guidelines are combined in one document. The new 2018 pregnancy-specific hypertension guidelines are published separately. For 2018, 5 new guidelines are introduced, and 1 existing guideline on the blood pressure thresholds and targets in the setting of thrombolysis for acute ischemic stroke is revised. The use of validated wrist devices for the estimation of blood pressure in individuals with large arm circumference is now included. Guidance is provided for the follow-up measurements of blood pressure, with the use of standardized methods and electronic (oscillometric) upper arm devices in individuals with hypertension, and either ambulatory blood pressure monitoring or home blood pressure monitoring in individuals with white coat effect. We specify that all individuals with hypertension should have an assessment of global cardiovascular risk to promote health behaviours that lower blood pressure. Finally, an angiotensin receptor-neprilysin inhibitor combination should be used in place of either an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in individuals with heart failure (with ejection fraction < 40%) who are symptomatic despite appropriate doses of guideline-directed heart failure therapies. The specific evidence and rationale underlying each of these guidelines are discussed., (Copyright © 2018 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Objective: The Goal Oriented controL of Diabetes in the Elderly populatioN (GOLDEN) Program assessed the management of older persons with type 2 diabetes in Canadian primary care., Methods: Data were extracted from the records of 833 consecutively identified persons 65 years of age or older who had type 2 diabetes and were taking 1 antihyperglycemic agent or more; they were managed by 64 physicians from 36 Ontario clinics., Results: More than half (53%) had glycated hemoglobin (A1C) levels of 7.0% or lower, 41% had blood pressure levels below 130/80 mm Hg, and 73% had low-density lipoprotein levels of 2.0 mmol/L or lower; 19% met all 3 criteria. Over the past year, 11% had been assessed for frailty, 16% for cognitive dysfunction and 19% for depression; 88% were referred for eye checkups, and 83% had undergone foot examinations. One-tenth were taking 4 or more antihyperglycemic agents, 87% statins and 52% an angiotensin-converting enzyme inhibitor. More than half of those with high clinical complexity had A1C levels of 7.0% or lower; of these, one-third were taking a sulfonylurea, and one-fifth were taking insulin. In the patients with A1C levels of 7.0% or above and low clinical complexity, there was often no up-titration or initiation of additional antihyperglycemic agents., Conclusions: Older persons with type 2 diabetes often have multiple comorbidities. Unlike eye and foot examinations, there was less emphasis on evaluating for frailty, cognitive dysfunction and depression. The GOLDEN patients had generally well-controlled glycemic, blood pressure and cholesterol profiles, but whether these would be reflected in a "sicker" population is not known. Personalized strategies are necessary to avoid undertreatment of "healthy" older patients and overtreatment of the frail elderly., (Copyright © 2017 Diabetes Canada. Published by Elsevier Inc. All rights reserved.)

The COMmunity Pharamcists ASSist for Blood Pressure (COMPASS-BP) study aimed to assess the effectiveness of lifestyle support programs administered in community pharmacies on hypertension control. This open-label, two-armed parallel group, cluster-randomized controlled trial included 73 pharmacies (clusters) in Japan randomized to a control or intervention group. Eligible hypertensive patients (n = 125), aged 20-75 years, received the intervention (n = 64) or the control treatment (n = 61), as dictated by their pharmacy randomization. Patients in the intervention group received brochures and healthy lifestyle advice from pharmacists using motivational interviewing methods during pharmacy visits over a 12-week period, with their usual pharmacy care. Conversely, the control group just received usual care. The main outcome measure was a change in morning systolic blood pressure (SBP) from baseline to week 12. The intervention group exhibited a decrease in morning SBP that was 6.0 mmHg greater than that of the control group (95% confidence interval [CI]: -11.0 to -0.9, p = 0.021). In a mixed-effect model for repeated measures analysis, the intergroup difference in morning SBP decrease was -4.5 mmHg (95% CI: -8.5 to -0.6, p = 0.024). Our findings indicate that implementation of a lifestyle advice program in pharmacies is feasible and may lead to reduced blood pressure.

Background: Affecting a substantial proportion of adults, chronic kidney disease (CKD) is considered a major risk factor for cardiovascular (CV) events. It has been reported that patients with CKD are underserved when it comes to CV risk reduction efforts., Study Design: Prespecified subgroup analysis of a randomized controlled trial., Setting & Participants: Adults with CKD and at least 1 uncontrolled CV risk factor were enrolled from 56 pharmacies across Alberta, Canada., Intervention: Patient, laboratory, and individualized CV risk assessments; treatment recommendations; prescription adaptation(s) and/or initiation as necessary; and regular monthly follow-up for 3 months., Outcomes: The primary outcome was change in estimated CV risk from baseline to 3 months after randomization. Secondary outcomes were change between baseline and 3 months after randomization in individual CV risk factors (ie, low-density lipoprotein cholesterol, blood pressure, and hemoglobin A 1c ), risk for developing end-stage renal disease, and medication use and dosage; tobacco cessation 3 months after randomization for those who used tobacco at baseline; and the impact of rural versus urban residence on the difference in change in estimated CV risk., Measurements: CV risk was estimated using the Framingham, UK Prospective Diabetes Study, and international risk assessment equations depending on the patients' comorbid conditions., Results: 290 of the 723 participants enrolled in R x EACH had CKD. After adjusting for baseline values, the difference in change in CV risk was 20% (P<0.001). Changes of 0.2mmol/L in low-density lipoprotein cholesterol concentration (P=0.004), 10.5mmHg in systolic blood pressure (P<0.001), 0.7% in hemoglobin A 1c concentration (P<0.001), and 19.6% in smoking cessation (P=0.04) were observed when comparing the intervention and control groups. There was a larger reduction in CV risk in patients living in rural locations versus those living in urban areas., Limitations: The 3-month follow-up period can be considered relatively short. It is possible that larger reduction in CV risk could have been observed with a longer follow up period., Conclusions: This subgroup analysis demonstrated that a community pharmacy-based intervention program reduced CV risk and improved control of individual CV risk factors. This represents a promising approach to identifying and managing patients with CKD that could have important public health implications., (Copyright © 2017 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Cardiovascular disease (CVD) is the leading cause of death among patients with diabetes. Management and control of CV risk factors in those with diabetes are generally poor. Pharmacists are frontline primary healthcare providers who see patients with chronic diseases frequently. As such, they are in a prime position to systematically identify patients with diabetes, assess their CV risk and assist in their disease management and preventive measures., Objective: to evaluate the effect of pharmacist case finding and intervention program on estimated CV risk in patients with diabetes., Methods: Sub-group analysis of a randomized controlled trial (RxEACH). Patients were randomized to receive intervention or usual care for 3 months. Those who were randomized to the intervention group received a Medication Therapy Management consultation which included patient assessment, laboratory assessment, individualized CV risk assessment. Treatment regimen adjustment, as needed, in order to meet treatment targets., Results: Estimated CV risk was reduced from 26.9 +/- 21% to 26.5 +/- 21.3% in the control group and from 25.8 +/- 19.4% to 20.1 +/- 17.2% in the intervention group over the 3-month follow up period (an absolute reduction of 5.38; 95% confidence interval (CI) 4.24 to 6.52; p <0.001)., Discussion and Conclusion: Community pharmacy-based case finding and intervention program reduced the risk for major CV events by 21% when compared to usual practice. This represents a promising approach to help tackle the major public health problem of diabetes in Canada., (Copyright © 2017 Diabetes Canada. Published by Elsevier Inc. All rights reserved.)

Background: Patient safety performance can be assessed with several systems, including passive and active surveillance. Passive surveillance systems provide opportunity for health care personnel to confidentially and voluntarily report incidents, including adverse events, occurring in their work environment. Active surveillance systems systematically monitor patient encounters to seek detailed information about adverse events that occur in work environments; unlike passive surveillance, active surveillance allows for collection of both numerator (number of adverse events) and denominator (number of patients seen) data. Chiropractic manual therapy is commonly used in both adults and children, yet few studies have been done to evaluate the safety of chiropractic manual therapy for children. In an attempt to evaluate this, this study will compare adverse event reporting in passive versus active surveillance systems after chiropractic manual therapy in the pediatric population., Methods/design: This cluster randomized controlled trial aims to enroll 70 physicians of chiropractic (unit of randomization) to either passive or active surveillance system to report adverse events that occur after treatment for 60 consecutive pediatric (13 years of age and younger) patient visits (unit of analysis). A modified enrollment process with a two-phase consent procedure will be implemented to maintain provider blinding and minimize dropouts. The first phase of consent is for the provider to confirm their interest in a trial investigating the safety of chiropractic manual therapy. The second phase ensures that they understand the specific requirements for the group to which they were randomized. Percentages, incidence estimates, and 95% confidence intervals will be used to describe the count of reported adverse events in each group. The primary outcome will be the number and quality of the adverse event reports in the active versus the passive surveillance group. With 80% power and 5% one-sided significance level, the sample size was calculated to be 35 providers in each group, which includes an 11% lost to follow-up of chiropractors and 20% of patient visits., Discussion: This study will be the first direct comparison of adverse event reporting using passive versus active surveillance. It is also the largest prospective evaluation of adverse events reported after chiropractic manual therapy in children, identified as a major gap in the academic literature., Trial Registration: ClinicalTrials.gov, ID: NCT02268331 . Registered on 10 October 2014.

Background: Atrial fibrillation (AF) is a common arrhythmia associated with significant morbidity, mortality, and healthcare resource use. The prevalence of AF is increasing with a growing and aging population, and timely access to care for these patients is a concern. Nontraditional models of care delivery, such as nurse practitioner (NP)-led clinics, may improve access to care and quality of care, but they require formal assessment. The objective of this study is to assess the effect of NP-led care on the health-related quality of life (HRQoL) of adult patients with AF., Methods/design: We plan a randomized controlled trial comparing NP-led care vs. standard care. Inclusion criteria are ≥18 years of age, documented nonvalvular AF, willingness to give informed consent, and capacity to complete questionnaires. Patients referred for electrophysiological intervention who are clinically unstable or unable to attend follow-up visits will not be eligible to participate. Patients will be asked for verbal consent during the initial triage phone call from the nurse. Randomization will occur via a secure website. The intervention includes an NP consult, including medical history, physical examination, patient teaching, treatment plan, and follow-up at 3 and 6 months. The control arm involves usual cardiologist consultation with follow-up determined by the cardiologist's practice pattern. The primary outcome will be the difference in change in Atrial Fibrillation Effect on Quality of Life Survey scores at 6 months between groups. Secondary outcomes will include difference in change of EQ-5D scores at 6 months between groups, difference in composite outcomes of death resulting from cardiovascular cause, hospitalizations and emergency department visits between groups, and satisfaction with NP-led care measured by the Consultant Satisfaction Questionnaire. A sample size of 70 per group will ensure adequate power despite a potential 10% loss to follow-up., Discussion: Our study will determine the effect of NP-led AF care on HRQoL in patients with AF, as well as measure its impact on relevant outcomes such as death, hospitalization, and emergency department visits. Our findings may have implications for delivery of care to patients with AF., Trial Registration: ClincalTrials.gov, NCT02745236 . Registered on 16 April 2016.

Competing Interests: Declaration of Conflicting Interests:The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Competing Interests: Declaration of Conflicting Interests:A. Cresswell-Melville is an employee of the Eczema Society of Canada (ESC), a registered Canadian charity, and has no conflict of interest or funding disclosure related to this publication. The Eczema Society of Canada receives funding from private citizen donations and foundations and funds, as well as from corporate partners, including Actelion Pharmaceuticals Ltd, Astellas Pharma, Beiersdorf Canada, Galderma Canada, Glaxo SmithKline Canada, Johnson & Johnson Inc., L’Oreal Canada Inc., Pediapharm Inc., Pierre Fabre Dermo-Cosmétique Canada Inc., Sanofi Canada, Skin Fix Inc., Valeant Canada and Wellspring Pharmaceuticals. A. M. Drucker is an investigator for Sanofi and Regeneron and a consultant for Sanofi. Dr. Drucker has received honoraria from Astellas Canada, Prime Inc. and Spire Learning.

Hypertension Canada provides annually updated, evidence-based guidelines for the diagnosis, assessment, prevention, and treatment of hypertension. This year, we introduce 10 new guidelines. Three previous guidelines have been revised and 5 have been removed. Previous age and frailty distinctions have been removed as considerations for when to initiate antihypertensive therapy. In the presence of macrovascular target organ damage, or in those with independent cardiovascular risk factors, antihypertensive therapy should be considered for all individuals with elevated average systolic nonautomated office blood pressure (non-AOBP) readings ≥ 140 mm Hg. For individuals with diastolic hypertension (with or without systolic hypertension), fixed-dose single-pill combinations are now recommended as an initial treatment option. Preference is given to pills containing an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in combination with either a calcium channel blocker or diuretic. Whenever a diuretic is selected as monotherapy, longer-acting agents are preferred. In patients with established ischemic heart disease, caution should be exercised in lowering diastolic non-AOBP to ≤ 60 mm Hg, especially in the presence of left ventricular hypertrophy. After a hemorrhagic stroke, in the first 24 hours, systolic non-AOBP lowering to < 140 mm Hg is not recommended. Finally, guidance is now provided for screening, initial diagnosis, assessment, and treatment of renovascular hypertension arising from fibromuscular dysplasia. The specific evidence and rationale underlying each of these guidelines are discussed., (Copyright © 2017 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: More than half of all heart disease and stroke are attributable to hypertension, which is associated with approximately 10% of direct medical costs globally. Clinical trial evidence has demonstrated that the benefits of pharmacist intervention, including education, consultation and/or prescribing, can help to reduce blood pressure; a recent Canadian trial found an 18.3 mmHg reduction in systolic blood pressure associated with pharmacist care and prescribing. The objective of this study was to evaluate the economic impact of such an intervention in a Canadian setting., Methods: A Markov cost-effectiveness model was developed to extrapolate potential differences in long-term cardiovascular and renal disease outcomes, using Framingham risk equations and other published risk equations. A range of values for systolic blood pressure reduction was considered (7.6-18.3 mmHg) to reflect the range of potential interventions and available evidence. The model incorporated health outcomes, costs and quality of life to estimate an overall incremental cost-effectiveness ratio. Costs considered included direct medical costs as well as the costs associated with implementing the pharmacist intervention strategy., Results: For a systolic blood pressure reduction of 18.3 mmHg, the estimated impact is 0.21 fewer cardiovascular events per person and, discounted at 5% per year, 0.3 additional life-years, 0.4 additional quality-adjusted life-years and $6,364 cost savings over a lifetime. Thus, the intervention is economically dominant, being both more effective and cost-saving relative to usual care., Discussion: Across a range of one-way and probabilistic sensitivity analyses of key parameters and assumptions, pharmacist intervention remained both effective and cost-saving., Conclusion: Comprehensive pharmacist care of hypertension, including patient education and prescribing, has the potential to offer both health benefits and cost savings to Canadians and, as such, has important public health implications., Competing Interests: Declaration of Conflicting Interests:The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Background: The RxEACH trial was a randomized trial to evaluate the efficacy of community pharmacy-based case finding and intervention in patients at high risk for cardiovascular (CV) events. Community-dwelling patients with poorly controlled risk factors were identified and their CV risk reduced through patient education, prescribing and follow-up by their pharmacist. Perspectives of patients, family physicians and community pharmacists were obtained regarding pharmacists' identification and management of patients at high risk for CV events, to identify strategies to facilitate implementation of the pharmacist's expanded role in routine patient care., Methods: We used a qualitative methodology (individual semistructured interviews) with conventional qualitative content analysis to describe perceptions about community pharmacists' care of patients at high risk for CV events. Perceptions were categorized into macro (structure), meso (institution) and micro (practice) health system levels, based on a conceptual framework of care for optimizing scopes of practice., Results: We interviewed 48 participants (14 patients, 13 family physicians and 21 community pharmacists). Patients were supportive of the expanded scope of practice of pharmacists. All participant groups emphasized the importance of communication, ability to share patient information, trust and better understanding of the roles, responsibilities, accountabilities and liabilities of the pharmacist within their expanded role., Interpretation: Despite support from patients and changes to delivery of care in primary care settings, ongoing efforts are needed to understand how to best harmonize family physician and community pharmacist roles across the health system. This will require collaboration and input from professional associations, regulatory bodies, pharmacists, family physicians and patients., Competing Interests: Competing interests: None declared.

Background: The provision of medication management (MM) services by community pharmacists has not been as widely implemented as expected. The Promoting Action on Research Implementation in Health Services framework proposes that in addition to evidence of benefit and a practice context conducive to change, health professionals benefit from facilitation to support their efforts. However, the impact of facilitation on patient care services in community pharmacy has not been studied., Objective: The primary objective of this study was to explore the needs of community pharmacists in improving the provision of MM services to patients, and secondarily to use external facilitation to support pharmacies in increasing the number of MM services provided., Methods: Ten community pharmacies in Alberta, Canada were randomized to external task-focused facilitation or usual practice. Facilitators interviewed staff of each intervention pharmacy to determine current workflow and barriers and facilitators to service provision, and collaborated to address these site-specific barriers over 6 months., Results: Barriers identified by all intervention sites related to the impact of MM on dispensing, lengthy documentation, inefficient use of follow-up opportunities to address lower-priority concerns, and inconsistent patient identification. Strategies to address these barriers were generally well received by sites, which noted that facilitation improved staff communication and encouraged reflection on current practices; however, MM counts across both groups decreased over the intervention versus baseline. This decline was likely due to the unanticipated effect of the influenza vaccination season occurring concurrently with the intervention period., Conclusions: External facilitation appears to be a feasible and acceptable method to support community pharmacy provision of MM services. However, as the scope of pharmacists' practice increases, serious consideration of how, and when, these services can be consistently offered must be made. Relevant stakeholders should consider strategies to mitigate the barriers identified in this study when introducing new services or evaluating existing programs to ensure their uptake within existing workflow demands., Clinical Trial Registration: Clinicaltrials.gov identifier NCT02191111., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Childhood cancer survivors experience adverse drug events leading to lifelong health issues. The Applying Biomarkers to Minimize Long-Term Effects of Childhood/Adolescent Cancer Treatment (ABLE) team was established to validate and apply biomarkers of cancer treatment effects, with a goal of identifying children at high risk of developing cancer treatment complications associated with thrombosis, graft-versus-host disease, hearing loss, and kidney damage. Cisplatin is a chemotherapy well known to cause acute and chronic nephrotoxicity. Data on biomarkers of acute kidney injury (AKI) and late renal outcomes in children treated with cisplatin are limited., Objective: To describe the design and methods of the pan-Canadian ABLE Nephrotoxicity study, which aims to evaluate urine biomarkers (neutrophil gelatinase-associated lipocalin [NGAL] and kidney injury molecule-1 [KIM-1]) for AKI diagnosis, and determine whether they predict risk of long-term renal outcomes (chronic kidney disease [CKD], hypertension)., Design: This is a 3-year observational prospective cohort study., Setting: The study includes 12 Canadian pediatric oncology centers., Patients: The target recruitment goal is 150 patients aged less than 18 years receiving cisplatin. Exclusion criteria : Patients with an estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m 2 or a pre-existing renal transplantation at baseline., Measurements: Serum creatinine (SCr), urine NGAL, and KIM-1 are measured during cisplatin infusion episodes (pre-infusion, immediate post-infusion, discharge sampling). At follow-up visits, eGFR, microalbuminuria, and blood pressure are measured and outcomes are collected., Methods: Outcomes: AKI is defined as per SCr criteria of the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. CKD is defined as eGFR <90 mL/min/1.73m2 or albumin-to-creatinine ratio≥3mg/mmol. Hypertension is defined as per guidelines. Procedure: Patients are recruited before their first or second cisplatin cycle. Participants are evaluated during 2 cisplatin infusion episodes (AKI biomarker validation) and at 3, 12, and 36 months post-cisplatin treatment (late outcomes)., Limitations: The study has a relatively moderate sample size and short follow-up duration. There is potential for variability in data collection since multiple sites are involved., Conclusions: ABLE will provide a national platform to study biomarkers of late cancer treatment complications. The Nephrotoxicity study is a novel study of AKI biomarkers in children treated with cisplatin that will greatly inform on late cisplatin renal outcomes and follow-up needs., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To determine the benefits of diabetes nurse practitioner (DNP) intervention on glycemic control, quality of life and diabetes treatment satisfaction in patients with type 2 diabetes (T2DM) admitted to cardiology inpatient services at a tertiary centre., Patients and Methods: Patients admitted to the cardiology service with T2DM who had suboptimal control (HbA1c >6.5%) were approached for the study. Diabetes care was optimized by the DNP through medication review, patient education and discharge care planning. Glycemic control was evaluated with 3-month post-intervention HbA1c. Secondary outcomes of lipid profiles, quality of life and treatment satisfaction were evaluated at baseline and at 3 months with fasting lipids, Audit of Diabetes-Dependent Quality of Life questionnaires (ADDQoL) and Diabetes Treatment Satisfaction Questionnaires (DTSQ) respectively., Results: With almost 49% of patients admitted to the Mazankowski Alberta Heart Institute having HbA1c <6.5%, only 23 patients completed the study over a 12-month period. We found a significant decrease in HbA1c values at 3 months post-intervention from 8.0% (SD=1. 2) to 6.9% (SD=0.7), p=0.002. LDL showed a significant decrease at 3 months from 1.7 mmol/L (SD=0.7) to 1.1 mmol /L (SD=0.6), p=0.011. Overall median ADDQoL impact scores improved at follow up, from -1.4 to -0.4, p = 0.0003. Overall no significant changes in DTSQ scores were seen., Conclusions: Short-term DNP intervention in T2DM patients admitted to the inpatient cardiology service was associated with benefits in areas of glycemic control and various domains of QoL. Our study provides support for the involvement of DNP in the care of cardiology inpatients at tertiary centres., (Copyright © 2016 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.)

Background: To identify those characteristics of self-management interventions in patients with heart failure (HF) that are effective in influencing health-related quality of life, mortality, and hospitalizations., Methods and Results: Randomized trials on self-management interventions conducted between January 1985 and June 2013 were identified and individual patient data were requested for meta-analysis. Generalized mixed effects models and Cox proportional hazard models including frailty terms were used to assess the relation between characteristics of interventions and health-related outcomes. Twenty randomized trials (5624 patients) were included. Longer intervention duration reduced mortality risk (hazard ratio 0.99, 95% confidence interval [CI] 0.97-0.999 per month increase in duration), risk of HF-related hospitalization (hazard ratio 0.98, 95% CI 0.96-0.99), and HF-related hospitalization at 6 months (risk ratio 0.96, 95% CI 0.92-0.995). Although results were not consistent across outcomes, interventions comprising standardized training of interventionists, peer contact, log keeping, or goal-setting skills appeared less effective than interventions without these characteristics., Conclusion: No specific program characteristics were consistently associated with better effects of self-management interventions, but longer duration seemed to improve the effect of self-management interventions on several outcomes. Future research using factorial trial designs and process evaluations is needed to understand the working mechanism of specific program characteristics of self-management interventions in HF patients., Competing Interests: The authors declare the following interests: this work was supported by a grant from The Netherlands Organisation for Health Research and Development, ZonMw (grant number 520001002). DAD reports grants from NIH during the conduct of the study, outside the submitted work. MH reports grants from MDRTC during the conduct of the study, outside the submitted work. RTT reports investigator-initiated grants from Merck Canada Inc., AstraZeneca Canada, and personal fees from Merck Canada Inc., all outside the submitted work. The other authors declare no conflict of interest., (Copyright © 2016 The Author(s). Published by Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of Conflicting Interests:The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Background: To be sustainable, pharmacists providing direct patient care must receive appropriate payment for these services. This prespecified substudy of the RxACTION trial (a randomized trial of pharmacist prescribing vs usual care in patients with above-target blood pressure [BP]) aimed to determine if BP reduction achieved differed between patients whose pharmacist was paid by pay-for-performance (P4P) vs fee-for-service (FFS)., Methods: Within RxACTION, patients with elevated BP assigned to the pharmacist prescribing group were further randomized to P4P or FFS payment for the pharmacist. In FFS, pharmacists received $150 for the initial visit and $75 for follow-up visits. P4P included FFS payments plus incentives of $125 and $250 for each patient who reached 50% and 100% of the BP target, respectively. The primary outcome was difference in change in systolic BP between P4P and FFS groups., Results: A total of 89 patients were randomized to P4P and 92 to the FFS group. Patients' average (SD) age was 63.0 (13.2) years, 49% were male and 76% were on antihypertensive drug therapy at baseline, taking a median of 2 (interquartile range = 1) medications. Mean systolic BP reductions in the P4P and FFS groups were 19.7 (SD = 18.4) vs 17.0 (SD = 16.4) mmHg, respectively ( p = 0.47 for the comparison of deltas and p = 0.29 after multivariate adjustment)., Conclusions: This trial of pharmacist prescribing found substantial reductions in systolic BP among poorly controlled hypertensive individuals but with no appreciable difference when pharmacists were paid by P4P vs FFS., Competing Interests: Declaration of Conflicting Interests:The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Background: Dyslipidemia is an important risk factor for cardiovascular disease but is suboptimally managed. Pharmacists are accessible primary care professionals and with expanded scopes of practice (including prescribing), could identify and manage patients with dyslipidemia. We sought to evaluate the effect of pharmacist prescribing of dyslipidemia medications on the proportion of participants achieving target LDL-cholesterol (LDL-c) levels., Methods: We conducted a randomized controlled trial in 14 community pharmacies in Alberta, Canada. We enrolled adults with uncontrolled dyslipidemia as defined by the 2009 Canadian Dyslipidemia Guidelines. Intervention was pharmacist-directed dyslipidemia care, including assessment of cardiovascular risk, review of LDL-c, prescribing of medications, health behaviour interventions and follow-up every 6 weeks for 6 months. Usual care patients received their lipid results and a pamphlet on cardiovascular disease and usual care from their physician and pharmacist. Primary outcome was the proportion of participants achieving their target LDL-c (<2 mmol/L or ≥50% reduction) at 6 months between groups., Results: We enrolled 99 patients with a mean (SD) age of 63 (13) years, 49% male and baseline LDL-c of 3.37 mmol/L (0.98). Proportion of patients achieving LDL-c target was 43% intervention versus 18% control ( p = 0.007). Adjusted odds of achieving target LDL-c were 3.3 times higher for the intervention group ( p = 0.031), who also achieved greater reduction in LDL-c (1.12 mmol/L, SE = 0.112) versus control (0.42 mmol/L, SE = 0.109), for an adjusted mean difference of 0.546 mmol/L (SE = 0.157), p < 0.001., Conclusion: Pharmacist prescribing resulted in >3-fold more patients achieving target LDL-c levels. This could have major public health implications., Competing Interests: Declaration of Conflicting Interests:The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Background: Despite the cardiovascular disease (CVD) risk associated with hypertension, diabetes, dyslipidemia, and smoking, these risk factors remain poorly identified and controlled., Objectives: The study sought to evaluate the effectiveness of a community pharmacy-based case finding and intervention on cardiovascular risk., Methods: 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., Results: 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)., Conclusions: 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)., (Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Conducted in Alberta, the RxING study examined the effect of a community pharmacist prescribing intervention on glycemic control in patients with uncontrolled type 2 diabetes mellitus (T2DM) using insulin glargine. The objective of this study was to assess the cost-effectiveness of pharmacists' prescribing of insulin glargine as an early intervention in uncontrolled patients with T2DM vs usual clinical practice., Methods: The IMS CORE diabetes Markov model was used to project long-term clinical outcomes, costs and cost-effectiveness of interventions. The efficacy of insulin glargine, in terms of hemoglobin A1c reduction and hypoglycemia rates, was obtained from the RxING study. Health utility and cost data were found in Canadian publications. The base-case analyses examined the economic and clinical effects of having pharmacists initiate insulin therapy in patients with uncontrolled T2DM in comparison to a physician initiate it up to 3 years later., Results: Insulin initiation by pharmacists with uncontrolled T2DM patients is cost-effective. Having pharmacists prescribe insulin 1 year earlier than usual clinical practice resulted in an incremental cost savings of $805 (CDN$) and a gain of 0.048 QALYs per patient. Pharmacists prescribing insulin 2 years earlier resulted in an incremental cost savings of $624 (CDN$) per year and a gain of 0.075 quality-adjusted life-years (QALYs). Prescribing 3 years earlier allowed for a minor increase of $26 and a gain of 0.086 QALYs., Conclusion: Earlier initiation of insulin by pharmacists, in uncontrolled T2DM patients, resulted in cost savings and delays in the development of diabetes-related complications, leading to an improved quality of life and increased survival rates.

A reporting and learning system is a method of monitoring the occurrence of incidents that affect patient safety. This cross-sectional survey asked pediatric chiropractors about factors that may limit their participation in such a system. The list of potential barriers for participation was developed using a systematic approach. All members of the 2 pediatric councils associated with US national chiropractic organizations were invited to complete the survey (N = 400). The cross-sectional survey was created using an online survey tool (REDCap) and sent directly to member emails addressed by the respective executive committees. Of the 400 potential respondents, 81 responded (20.3%). The most common limitations to participating were identified as time pressure (96%) and patient concerns (81%). Reporting and learning systems have been utilized to increase safety awareness in many high-risk industries. To be successful, future patient safety studies with pediatric chiropractors need to ensure these barriers are understood and addressed., (© The Author(s) 2015.)

Background: Self-management interventions are widely implemented in the care for patients with heart failure (HF). However, trials show inconsistent results, and whether specific patient groups respond differently is unknown. This individual patient data meta-analysis assessed the effectiveness of self-management interventions in patients with HF and whether subgroups of patients respond differently., Methods and Results: A systematic literature search identified randomized trials of self-management interventions. Data from 20 studies, representing 5624 patients, were included and analyzed with the use of mixed-effects models and Cox proportional-hazard models, including interaction terms. Self-management interventions reduced the risk of time to the combined end point of HF-related hospitalization or all-cause death (hazard ratio, 0.80; 95% confidence interval [CI], 0.71-0.89), time to HF-related hospitalization (hazard ratio, 0.80; 95% CI, 0.69-0.92), and improved 12-month HF-related quality of life (standardized mean difference, 0.15; 95% CI, 0.00-0.30). Subgroup analysis revealed a protective effect of self-management on the number of HF-related hospital days in patients <65 years of age (mean, 0.70 versus 5.35 days; interaction P=0.03). Patients without depression did not show an effect of self-management on survival (hazard ratio for all-cause mortality, 0.86; 95% CI, 0.69-1.06), whereas in patients with moderate/severe depression, self-management reduced survival (hazard ratio, 1.39; 95% CI, 1.06-1.83, interaction P=0.01)., Conclusions: This study shows that self-management interventions had a beneficial effect on time to HF-related hospitalization or all-cause death and HF-related hospitalization alone and elicited a small increase in HF-related quality of life. The findings do not endorse limiting self-management interventions to subgroups of patients with HF, but increased mortality in depressed patients warrants caution in applying self-management strategies in these patients., Competing Interests: Disclosures: The other authors have no conflict of interest to declare., (© 2016 American Heart Association, Inc.)

Background: Legislative changes are affording pharmacists the opportunity to provide more advanced pharmacy services. However, many pharmacists have not yet been able to provide these services sustainably. Research from implementation science suggests that before sustained change in pharmacy can be achieved an improved understanding of pharmacy context, through the professional culture of pharmacy and pharmacists' personality traits, is required., Objective: The primary objective of this study was to investigate possible relationships between cultural factors, and personality traits, and the uptake of advanced practice opportunities by pharmacists in British Columbia, Canada., Methods and Materials: The study design was a cross-sectional survey of registered, and practicing, pharmacists from one Canadian province. The survey gauged respondents' characteristics, practice setting, and the provision of advanced pharmacy services, and contained the Organizational Culture Profile (OCP), a measure of professional culture, as well as the Big Five Inventory (BFI), a measure of personality traits., Results: A total of 945 completed survey instruments were returned. The majority of respondents were female (61%), the average age of respondents was 42 years (SD: 12), and the average number of years in practice was 19 (SD: 12). A significant positive relationship was identified for respondents perceiving greater value in the OCP factors competitiveness and innovation and providing a higher number of all advanced services. A positive relationship was observed for respondents scoring higher on the BFI traits extraversion and the immunizations provided, and agreeableness and openness and medication reviews completed., Conclusion: This is the first work to identify statistically significant relationships between the OCP and BFI, and the provision of advanced pharmacy services. As such, this work serves as a starting place from which to develop more detailed insight into how the professional culture of pharmacy and pharmacists personality traits may influence the adoption of advanced pharmacy services., (Copyright © 2016 Elsevier Inc. All rights reserved.)