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Zhu A, Rajendran S, Hajian H, Aitken S. Patient Factors Influencing Prescription of Antithrombotic Medication After Lower Limb Endovascular Intervention. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00461-1. [PMID: 38802038 DOI: 10.1016/j.ejvs.2024.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 04/21/2024] [Accepted: 05/22/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVE There is significant practice variation in the use of antithrombotic therapy after endovascular intervention for lower limb peripheral arterial disease, with differences in medication choice and duration. Prescriber decision making is complex, and patient factors have been shown to substantially contribute to prescribing variation. To determine the influence of patient factors on antithrombotic prescribing, a discrete choice experiment was distributed to vascular surgeons and trainees across Australia and Aotearoa New Zealand. METHODS After pilot testing, the discrete choice experiment questionnaire was distributed to 300 vascular surgeons and trainee members of the Australian and New Zealand Society for Vascular Surgery. Multinomial logistic regression models were used to analyse patient factors that had the most influence on decisions to prescribe a second antithrombotic agent, and the preferred choice of antithrombotic (clopidogrel 75 mg daily or rivaroxaban 2.5 mg twice daily) in addition to aspirin 100 mg daily. The odds ratio (OR) with 95% confidence interval (CI) reported preference strength. RESULTS A total of 44 questionnaires were completed between September and October 2023, reaching the 15% targeted response rate. Prescribing a second antithrombotic was more likely after femoropopliteal stenting compared with angioplasty (OR 1.89, 95% CI 1.20 - 2.13), and in chronic limb threatening ischaemia compared with intermittent claudication (OR 1.58, 95% CI 1.20 - 2.13). Most respondents preferred clopidogrel over rivaroxaban (62%), with over a third of respondents exclusively prescribing clopidogrel. Patients with stents (OR 1.77, 95% CI 1.32 - 2.37) or moderate bleeding risk (OR 1.38, 95% CI 0.97 - 1.84) were more likely to receive clopidogrel than rivaroxaban. CONCLUSION This study demonstrates that vascular surgeons primarily prioritise antithrombotic prescribing decisions by procedure type. Clopidogrel is more likely to be prescribed than rivaroxaban as a second agent in combination with aspirin, especially after stenting. Knowing these clinician preferences can target implementation strategies towards supporting decision making in subgroups of patients according to individual risk profiles.
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Affiliation(s)
- Alison Zhu
- Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia; Department of Vascular Surgery, Concord Institute of Academic Surgery, Concord Repatriation General Hospital, Concord West, NSW, Australia.
| | - Saissan Rajendran
- Department of Vascular Surgery, Concord Institute of Academic Surgery, Concord Repatriation General Hospital, Concord West, NSW, Australia
| | - Hamid Hajian
- Department of Vascular Surgery, Concord Institute of Academic Surgery, Concord Repatriation General Hospital, Concord West, NSW, Australia
| | - Sarah Aitken
- Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia; Department of Vascular Surgery, Concord Institute of Academic Surgery, Concord Repatriation General Hospital, Concord West, NSW, Australia; Centre for PAD Research, Heart Research Institute, Camperdown, NSW, Australia
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Shaw L, Briscoe S, Nunns MP, Lawal HM, Melendez-Torres GJ, Turner M, Garside R, Thompson Coon J. What is the quantity, quality and type of systematic review evidence available to inform the optimal prescribing of statins and antihypertensives? A systematic umbrella review and evidence and gap map. BMJ Open 2024; 14:e072502. [PMID: 38401904 PMCID: PMC10895245 DOI: 10.1136/bmjopen-2023-072502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 01/31/2024] [Indexed: 02/26/2024] Open
Abstract
OBJECTIVES We aimed to map the systematic review evidence available to inform the optimal prescribing of statins and antihypertensive medication. DESIGN Systematic umbrella review and evidence and gap map (EGM). DATA SOURCES Eight bibliographic databases (Cochrane Database of Systematic Reviews, CINAHL, EMBASE, Health Management Information Consortium, MEDLINE ALL, PsycINFO, Conference Proceedings Citation Index-Science and Science Citation Index) were searched from 2010 to 11 August 2020. Update searches conducted in MEDLINE ALL 2 August 2022. We searched relevant websites and conducted backwards citation chasing. ELIGIBILITY CRITERIA FOR SELECTING STUDIES We sought systematic reviews of quantitative or qualitative research where adults 16 years+ were currently receiving, or being considered for, a prescription of statin or antihypertensive medication. Eligibility criteria were applied to the title and abstract and full text of each article independently by two reviewers. DATA EXTRACTION AND SYNTHESIS Quality appraisal was completed by one reviewer and checked by a second. Review characteristics were tabulated and incorporated into an EGM based on a patient care pathway. Patients with lived experience provided feedback on our research questions and EGM. RESULTS Eighty reviews were included within the EGM. The highest quantity of evidence focused on evaluating interventions to promote patient adherence to antihypertensive medication. Key gaps included a lack of reviews synthesising evidence on experiences of specific interventions to promote patient adherence or improve prescribing practice. The evidence was predominantly of low quality, limiting confidence in the findings from individual reviews. CONCLUSIONS This EGM provides an interactive, accessible format for policy developers, service commissioners and clinicians to view the systematic review evidence available relevant to optimising the prescribing of statin and antihypertensive medication. To address the paucity of high-quality research, future reviews should be conducted and reported according to existing guidelines and address the evidence gaps identified above.
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Affiliation(s)
- Liz Shaw
- Exeter Policy Research Programme Evidence Review Facility, Faculty of Health and Life Sciences, St Luke's Campus, University of Exeter, EX1 2LU, Exeter, UK
| | - Simon Briscoe
- Exeter Policy Research Programme Evidence Review Facility, Faculty of Health and Life Sciences, St Luke's Campus, University of Exeter, EX1 2LU, Exeter, UK
| | - Michael P Nunns
- Exeter Policy Research Programme Evidence Review Facility, Faculty of Health and Life Sciences, St Luke's Campus, University of Exeter, EX1 2LU, Exeter, UK
| | - Hassanat Mojirola Lawal
- Exeter Policy Research Programme Evidence Review Facility, Faculty of Health and Life Sciences, St Luke's Campus, University of Exeter, EX1 2LU, Exeter, UK
| | - G J Melendez-Torres
- Exeter Policy Research Programme Evidence Review Facility, Faculty of Health and Life Sciences, St Luke's Campus, University of Exeter, EX1 2LU, Exeter, UK
| | - Malcolm Turner
- Exeter Policy Research Programme Evidence Review Facility, Faculty of Health and Life Sciences, St Luke's Campus, University of Exeter, EX1 2LU, Exeter, UK
- NIHR ARC South West Peninsula Patient and Public Engagement Group, University of Exeter, Exeter, UK
| | - Ruth Garside
- Exeter Policy Research Programme Evidence Review Facility, Faculty of Health and Life Sciences, St Luke's Campus, University of Exeter, EX1 2LU, Exeter, UK
- European Centre for Environment and Health, University of Exeter, Exeter, UK
| | - Jo Thompson Coon
- Exeter Policy Research Programme Evidence Review Facility, Faculty of Health and Life Sciences, St Luke's Campus, University of Exeter, EX1 2LU, Exeter, UK
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Tu Q, Hyun K, Hafiz N, Knight A, Hespe C, Chow CK, Briffa T, Gallagher R, Reid CM, Hare DL, Zwar N, Woodward M, Jan S, Atkins ER, Laba TL, Halcomb E, Usherwood T, Billot L, Redfern J. Age-Related Variation in the Provision of Primary Care Services and Medication Prescriptions for Patients with Cardiovascular Disease. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10761. [PMID: 36078474 PMCID: PMC9518583 DOI: 10.3390/ijerph191710761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/20/2022] [Accepted: 08/24/2022] [Indexed: 06/15/2023]
Abstract
As population aging progresses, demands of patients with cardiovascular diseases (CVD) on the primary care services is inevitably increased. However, the utilisation of primary care services across varying age groups is unknown. The study aims to explore age-related variations in provision of chronic disease management plans, mental health care, guideline-indicated cardiovascular medications and influenza vaccination among patients with CVD over differing ages presenting to primary care. Data for patients with CVD were extracted from 50 Australian general practices. Logistic regression, accounting for covariates and clustering effects by practices, was used for statistical analysis. Of the 14,602 patients with CVD (mean age, 72.5 years), patients aged 65-74, 75-84 and ≥85 years were significantly more likely to have a GP management plan prepared (adjusted odds ratio (aOR): 1.6, 1.88 and 1.55, respectively, p < 0.05), have a formal team care arrangement (aOR: 1.49, 1.8, 1.65, respectively, p < 0.05) and have a review of either (aOR: 1.63, 2.09, 1.93, respectively, p < 0.05) than those < 65 years. Patients aged ≥ 65 years were more likely to be prescribed blood-pressure-lowering medications and to be vaccinated for influenza. However, the adjusted odds of being prescribed lipid-lowering and antiplatelet medications and receiving mental health care were significantly lowest among patients ≥ 85 years. There are age-related variations in provision of primary care services and pharmacological therapy. GPs are targeting care plans to older people who are more likely to have long-term conditions and complex needs.
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Affiliation(s)
- Qiang Tu
- Faculty of Medicine and Health, School of Health Sciences, The University of Sydney, Sydney 2050, Australia
| | - Karice Hyun
- Faculty of Medicine and Health, School of Health Sciences, The University of Sydney, Sydney 2050, Australia
- Department of Cardiology, Concord Hospital, Sydney 2139, Australia
| | - Nashid Hafiz
- Faculty of Medicine and Health, School of Health Sciences, The University of Sydney, Sydney 2050, Australia
| | - Andrew Knight
- The Primary and Integrated Care Unit, South Western Sydney Local Health District, Sydney 2170, Australia
- School of Population Health, University of New South Wales, Sydney 2052, Australia
| | - Charlotte Hespe
- School of Medicine, The University of Notre Dame, Sydney 2010, Australia
| | - Clara K. Chow
- Research Education Network, Western Sydney Local Health District, Sydney 2151, Australia
- Westmead Applied Research Centre, Faculty of Medicine and Health, The University of Sydney, Westmead 2154, Australia
| | - Tom Briffa
- School of Population and Global Health, The University of Western Australia, Perth 6009, Australia
| | - Robyn Gallagher
- Faculty of Medicine and Health, Sydney Nursing School, University of Sydney, Sydney 2006, Australia
| | - Christopher M. Reid
- School of Population Health, Curtin University, Perth 6102, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne 3004, Australia
| | - David L. Hare
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne 3010, Australia
- Department of Cardiology, Austin Health, Heidelberg 3084, Australia
| | - Nicholas Zwar
- School of Population Health, University of New South Wales, Sydney 2052, Australia
- Faculty of Health Sciences & Medicine, Bond University, Gold Coast 4226, Australia
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Sydney 2046, Australia
- The George Institute for Global Health, School of Public Health, Imperial College London, London NW9 7PA, UK
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney 2046, Australia
| | - Emily R. Atkins
- Westmead Applied Research Centre, Faculty of Medicine and Health, The University of Sydney, Westmead 2154, Australia
- The George Institute for Global Health, University of New South Wales, Sydney 2046, Australia
| | - Tracey-Lea Laba
- Pharmacy Program, Clinical and Health Sciences Unit, University of South Australia, Adelaide 5001, Australia
| | - Elizabeth Halcomb
- School of Nursing, University of Wollongong, Wollongong 2522, Australia
| | - Tim Usherwood
- Westmead Applied Research Centre, Faculty of Medicine and Health, The University of Sydney, Westmead 2154, Australia
- The George Institute for Global Health, University of New South Wales, Sydney 2046, Australia
| | - Laurent Billot
- The George Institute for Global Health, University of New South Wales, Sydney 2046, Australia
| | - Julie Redfern
- Faculty of Medicine and Health, School of Health Sciences, The University of Sydney, Sydney 2050, Australia
- The George Institute for Global Health, University of New South Wales, Sydney 2046, Australia
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Pereira VC, Silva SN, Carvalho VKS, Zanghelini F, Barreto JOM. Strategies for the implementation of clinical practice guidelines in public health: an overview of systematic reviews. Health Res Policy Syst 2022; 20:13. [PMID: 35073897 PMCID: PMC8785489 DOI: 10.1186/s12961-022-00815-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 01/10/2022] [Indexed: 01/08/2023] Open
Abstract
Abstract
Background
As a source of readily available evidence, rigorously synthesized and interpreted by expert clinicians and methodologists, clinical guidelines are part of an evidence-based practice toolkit, which, transformed into practice recommendations, have the potential to improve both the process of care and patient outcomes. In Brazil, the process of development and updating of the clinical guidelines for the Brazilian Unified Health System (Sistema Único de Saúde, SUS) is already well systematized by the Ministry of Health. However, the implementation process of those guidelines has not yet been discussed and well structured. Therefore, the first step of this project and the primary objective of this study was to summarize the evidence on the effectiveness of strategies used to promote clinical practice guideline implementation and dissemination.
Methods
This overview used systematic review methodology to locate and evaluate published systematic reviews regarding strategies for clinical practice guideline implementation and adhered to the PRISMA guidelines for systematic review (PRISMA).
Results
This overview identified 36 systematic reviews regarding 30 strategies targeting healthcare organizations, healthcare providers and patients to promote guideline implementation. The most reported interventions were educational materials, educational meetings, reminders, academic detailing and audit and feedback. Care pathways—single intervention, educational meeting—single intervention, organizational culture, and audit and feedback—both strategies implemented in combination with others—were strategies categorized as generally effective from the systematic reviews. In the meta-analyses, when used alone, organizational culture, educational intervention and reminders proved to be effective in promoting physicians' adherence to the guidelines. When used in conjunction with other strategies, organizational culture also proved to be effective. For patient-related outcomes, education intervention showed effective results for disease target results at a short and long term.
Conclusion
This overview provides a broad summary of the best evidence on guideline implementation. Even if the included literature highlights the various limitations related to the lack of standardization, the methodological quality of the studies, and especially the lack of conclusion about the superiority of one strategy over another, the summary of the results provided by this study provides information on strategies that have been most widely studied in the last few years and their effectiveness in the context in which they were applied. Therefore, this panorama can support strategy decision-making adequate for SUS and other health systems, seeking to positively impact on the appropriate use of guidelines, healthcare outcomes and the sustainability of the SUS.
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George NE, Shukkoor AA, Joseph N, Palanimuthu R, Kaliappan T, Gopalan R. Implementation of clinical audit to improve adherence to guideline-recommended therapy in acute coronary syndrome. Egypt Heart J 2022; 74:4. [PMID: 35020077 PMCID: PMC8755862 DOI: 10.1186/s43044-021-00237-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 12/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite global consensus on the management of acute coronary syndrome (ACS), implementation of strategies to improve adherence of guideline-directed medical therapy (GDMT) remains sub-optimal, especially in developing countries. Thus, we aimed to assess the effect of clinical pharmacist-led clinical audit to improve the compliance of discharge prescriptions in patients admitted with ACS. It is a prospective clinical audit of ACS patients which was carried out for 12 months. The discharge prescriptions were audited by clinical pharmacists for the appropriateness in the usage of statins, dual antiplatelet therapy (DAPT), beta-blockers, and angiotensin-converting enzyme inhibitors (ACE-I)/angiotensin receptor blocker (ARB). A feedback report was presented every month to the cardiologists involved in the patient care, and the trend in the adherence to GDMT was analyzed over 12 months. RESULTS The discharge prescriptions of 1072 ACS patients were audited for the justifiable and non-justifiable omissions of mandated drugs. The first-month audit revealed unreasonable omissions of DAPT, statin, ACE-I/ARB, and beta-blockers in 1%, 0%, 14%, and 11% respectively, which reduced to nil by the end of the 11th month of the audit-feedback program. This improvement remained unchanged until the end of the 12th month. CONCLUSIONS The study revealed that periodic clinical audit significantly improves adherence to GDMT in patients admitted with ACS.
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Affiliation(s)
- Nimmy Elizabeth George
- Department of Cardiology, PSG Institute of Medical Sciences and Research, Coimbatore, India
| | - Aashiq Ahamed Shukkoor
- Department of Cardiology, PSG Institute of Medical Sciences and Research, Coimbatore, India
| | - Noel Joseph
- Department of Cardiology, PSG Institute of Medical Sciences and Research, Coimbatore, India
| | - Ramasamy Palanimuthu
- Department of Cardiology, PSG Institute of Medical Sciences and Research, Coimbatore, India.
| | - Tamilarasu Kaliappan
- Department of Cardiology, PSG Institute of Medical Sciences and Research, Coimbatore, India
| | - Rajendiran Gopalan
- Department of Cardiology, PSG Institute of Medical Sciences and Research, Coimbatore, India
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Sparrow RT, Khan AM, Ferreira-Legere LE, Ko DT, Jackevicius CA, Goodman SG, Anderson TJ, Stacey D, Tiszovszky I, Farkouh ME, Tu JV, Udell JA. Effectiveness of Interventions Aimed at Increasing Statin-Prescribing Rates in Primary Cardiovascular Disease Prevention: A Systematic Review of Randomized Clinical Trials. JAMA Cardiol 2020; 4:1160-1169. [PMID: 31461127 DOI: 10.1001/jamacardio.2019.3066] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Statins are a cornerstone medication in cardiovascular disease prevention, but their use in clinical practice remains suboptimal, with less than half of people who are indicated for statins actually taking the medication. Objective To perform a systematic review and synthesis of the literature on patient-oriented and physician-oriented interventions aimed at increasing statin-prescribing rates in adults without a history of cardiovascular disease. Evidence Review PubMed, Embase, and the Cochrane Library were searched for randomized clinical trials published between January 2000 and May 2019. Data abstraction was performed using the Cochrane Public Health Review Group's data collection template, and a narrative synthesis of study results was conducted. The risk of bias in each study was qualitatively assessed, and a funnel plot was created to further evaluate the risk of publication bias. Findings Among 7948 citations and 128 full-text articles reviewed, 20 studies (of 109 807 patients) were included in the review. Eight trials reported a statistically significant increases in statin-prescribing rates. Among the effective trials, absolute effect sizes ranged from 4.2% (95% CI, 2.2%-6.4%) to 23% (95% CI, 7.3%-38.9%) and odds ratios from 1.29 (95% CI, 1.01-1.66) to 11.8 (95% CI, 8.8-15.9). Patient-education initiatives were the most commonly effective intervention, with 4 of 7 trials indicating increases in statin-prescribing rates. Two trials combined electronic decision-support tools with audit-and-feedback systems, both of which were effective overall. Physician-education programs without dynamic input regarding patient risk or updated treatment recommendations were generally found to be less effective. Conclusions and Relevance While heterogeneous in their interventions and outcomes, a number of interventions have demonstrated increases in statin-prescribing rates, with patient-education initiatives demonstrating more promising results than those focused on physician education alone. As opposed to more education about generic recommendations, tailored patient-focused and physician-focused interventions were more effective when they provided personalized cardiovascular risk information, dynamic decision-support tools, or audit-and-feedback reports in a multicomponent program. There are a number of modestly successful approaches to implement increases in rates of statin prescribing, a proven yet underused cardiovascular disease prevention class of therapy.
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Affiliation(s)
- Robert T Sparrow
- Faculty of Medical Science, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Anam M Khan
- ICES, Toronto, Ontario, Canada.,School of Public Health, University of Michigan, Ann Arbor
| | | | - Dennis T Ko
- ICES, Toronto, Ontario, Canada.,Schulich Heart Centre, Sunnybrook Health Services Centre, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Cynthia A Jackevicius
- ICES, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Western University of Health Sciences, Pomona, California
| | - Shaun G Goodman
- University of Toronto, Toronto, Ontario, Canada.,St. Michael's Hospital, Toronto, Ontario, Canada
| | - Todd J Anderson
- Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada
| | - Dawn Stacey
- Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Ildiko Tiszovszky
- Patient Partnership, Community Heart Outcomes Improvement and Cholesterol Education Study (CHOICES) Trial at ICES, Toronto, Ontario, Canada
| | - Michael E Farkouh
- University of Toronto, Toronto, Ontario, Canada.,Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Jack V Tu
- ICES, Toronto, Ontario, Canada.,Schulich Heart Centre, Sunnybrook Health Services Centre, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Jacob A Udell
- ICES, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada.,Women's College Hospital, Toronto, Ontario, Canada
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Sparrow RT, Ferreira-Legere L, Udell JA, Waters DD. Improving Statin Noncompliance: If You Build It, Will They Come? Can J Cardiol 2019; 35:813-815. [PMID: 31292077 DOI: 10.1016/j.cjca.2019.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 05/09/2019] [Indexed: 11/26/2022] Open
Affiliation(s)
- Robert T Sparrow
- Faculty of Medical Science, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | | | - Jacob A Udell
- ICES, Toronto, Ontario, Canada; University of Toronto, the Cardiovascular Division, Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - David D Waters
- Division of Cardiology, Zuckerberg San Francisco General Hospital, and the Department of Medicine, University of California, San Francisco, California, USA.
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