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Roy LM, Neill A, Swampy K, Auger J, Campbell SM, Chatwood S, Al Sayah F, Johnson JA. Preference-based measures of health-related quality of life in Indigenous people: a systematic review. Qual Life Res 2024; 33:317-333. [PMID: 37715878 PMCID: PMC10850204 DOI: 10.1007/s11136-023-03499-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2023] [Indexed: 09/18/2023]
Abstract
PURPOSE In many countries, there are calls to address health inequalities experienced by Indigenous people. Preference-based measures (PBMs) provide a measurement of health-related quality of life and can support resource allocation decisions. This review aimed to identify, summarize, and appraise the literature reporting the use and performance of PBMs with Indigenous people. METHODS Eleven major databases were searched from inception to August 31, 2022. Records in English that (1) assessed any measurement property of PBMs, (2) directly elicited health preferences, (3) reported the development or translation of PBMs for Indigenous people, or (4) measured health-related quality of life (HRQL) using PBMs were included. Ethically engaged research with Indigenous people was considered as an element of methodological quality. Data was synthesized descriptively (PROSPERO ID: CRD42020205239). RESULTS Of 3139 records identified, 81 were eligible, describing psychometric evaluation (n = 4), preference elicitation (n = 4), development (n = 4), translation (n = 2), and HRQL measurement (n = 71). 31 reported ethically engaged research. Reports originated primarily from Australia (n = 38), New Zealand (n = 20), USA (n = 9) and Canada (n = 6). Nearly all (n = 73) reported indirect, multi-attribute PBMs, the most common of which was the EQ-5D (n = 50). CONCLUSION A large number of recent publications from diverse disciplines report the use of PBMs with Indigenous people, despite little evidence on measurement properties in these populations. Understanding the measurement properties of PBMs with Indigenous people is important to better understand how these measures might, or might not, be used in policy and resource decisions affecting Indigenous people. (Funding: EuroQoL Research Foundation).
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Affiliation(s)
- Lilla M Roy
- School of Public Health, University of Alberta, Edmonton, AB, Canada
- School of Nursing, Cape Breton University, Sydney, NS, Canada
| | - Aidan Neill
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Kristen Swampy
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | | | - Sandra M Campbell
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, Canada
| | - Susan Chatwood
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Fatima Al Sayah
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Jeffrey A Johnson
- School of Public Health, University of Alberta, Edmonton, AB, Canada.
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Karavasili C, Babaee S, Kutty S, Chu JN, Min S, Fitzgerald N, Morimoto J, Inverardi N, Traverso G. Modular Titratable Polypills for Personalized Medicine and Simplification of Complex Medication Regimens. Adv Healthc Mater 2023; 12:e2301101. [PMID: 37526266 PMCID: PMC10836191 DOI: 10.1002/adhm.202301101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Indexed: 08/02/2023]
Abstract
Simplification of complex medication regimens in polypharmacy positively contributes to treatment adherence and cost-effective improved health outcomes. Even though fixed dose combination (FDC) drug products are the only currently available single dose poly-pill regimens, the lack of flexibility in dose adjustment of a single drug in the combination limits their efficacy. To fill the existing gap in drug dose personalization and simplification of complex medication regimens commonly encountered in the treatment of cardiovascular disease, tuberculosis, and tapering of corticosteroid therapy, a modular titratable polypill approach that simultaneously addresses both aspects is proposed. The polypill consists of modular units that contain different drugs at incremental or decremental doses to be assembled in a single titratable polypill at the required dose for each drug through a stacking or interlocking process. The variable dose (VD) modular tablets are subjected to quality control tests and found to comply to pharmacopeia's acceptance criteria and requirements specified in the respective drug monographs. A cost-effectiveness analysis is conducted supporting the VD strategy as cost-effective compared to the FDC strategy and more effective and less expensive than standard of care. The VD approach stands to enable pill burden reduction, ease of administration, enhancement of treatment adherence, and potential cost-saving benefits.
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Affiliation(s)
- Christina Karavasili
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
- Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Sahab Babaee
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
- Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Shruti Kutty
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Jacqueline N Chu
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
- Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
- Integrated Gastroenterology Consultants, N. Chelmsford, MA, 01863, USA
| | - Seokkee Min
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Nina Fitzgerald
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Joshua Morimoto
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Nicoletta Inverardi
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Giovanni Traverso
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
- Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
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Gnanenthiran SR, Agarwal A, Patel A. Frontiers of cardiovascular polypills: From atherosclerosis and beyond. Trends Cardiovasc Med 2023; 33:182-189. [PMID: 34973412 PMCID: PMC10424636 DOI: 10.1016/j.tcm.2021.12.013] [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: 08/09/2021] [Revised: 12/24/2021] [Accepted: 12/24/2021] [Indexed: 11/24/2022]
Abstract
Fixed-dose combination (FDC) therapies (also known as polypills) remain underutilized in clinical practice despite over two decades of evidence from randomized controlled trials demonstrating increased adherence to multidrug therapy, improved cardiovascular disease (CVD) risk factor control, and lower incidence of cardiovascular events. Evidence demonstrates that FDC-based implementation strategies can substantially complement and augment current strategies for CVD risk prevention globally. The next decade is likely to extend the frontier of cardiovascular FDC therapies, particularly given expected advances in FDC manufacturing technology and accessibility. FDC-based anti-hypertensive therapies are emerging as integral components of a pragmatic blood pressure lowering strategy. Cardiovascular FDCs are rapidly approaching its coming of age, transforming from heavily hyped research tools to pragmatic clinical instruments. This review evaluates the current evidence for cardiovascular FDCs, barriers to current use, and potential next generation advances.
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Affiliation(s)
- Sonali R Gnanenthiran
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia.
| | - Anubha Agarwal
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Anushka Patel
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
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Fixed-Dose Combination (Polypill) for Cardiovascular Disease Prevention: A Meta-Analysis. Am J Prev Med 2022; 63:440-449. [PMID: 35613977 DOI: 10.1016/j.amepre.2022.03.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION This meta-analysis was performed to assess the efficacy of fixed-dose combination (polypill) in reducing the risk of mortality and cardiovascular events. METHODS Medline, Scopus, Web of Science, and Cochrane Central were searched during May 2021. All randomized trials investigating the efficacy of antihypertensive and lipid-lowering ± antiplatelet drug combinations in patients at cardiovascular risk were included. Outcomes were presented as risk ratios or standardized mean differences with 95% CIs. RESULTS A total of 16 trials (N = 26,567 participants) were included. The risk reduction for all-cause mortality (risk ratio = 0.90; 95% CI = 0.79, 1.01; I2 = 0%; moderate certainty) and major adverse cardiac events (risk ratio=0.84; 95% CI=0.68, 1.04; I2=51%; very low certainty) did not reach statistical significance in comparison with those of the control group. Subgroup analysis of studies that used an active control yielded similar results. However, significant reductions in major adverse cardiac event risk were observed in studies that exclusively targeted primary prevention, followed patients for ≥4 years, and had a low risk of bias. The polypill group had significantly higher adherence (risk ratio=1.18; 95% CI=1.06, 1.32; I2=96%; very low certainty) and comprable rates of adverse side effects (risk ratio=1.10; 95% CI=0.98, 1.23; I2=58%; moderate certainty) with those of the control group. Patients randomized to the polypill had significant reductions in systolic and diastolic blood pressure as well as in total and low-density lipoprotein cholesterol. DISCUSSION Despite reductions in cardiovascular risk factors, the observed mortality benefit for the polypill did not reach statistical significance. Further studies are needed to validate its clinical benefits and determine the patient populations likely to achieve such benefits.
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Fowler-Woods A, Smolik I, Anaparti V, O’Neil L, El-Gabalawy H. Can Studying Genetically Predisposed Individuals Inform Prevention Strategies for RA? Healthcare (Basel) 2021; 9:1301. [PMID: 34682981 PMCID: PMC8544392 DOI: 10.3390/healthcare9101301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/09/2021] [Accepted: 09/21/2021] [Indexed: 12/29/2022] Open
Abstract
Rheumatoid arthritis (RA) is a prevalent autoimmune disorder in which complex genetic predisposition interacts with multiple environmental factors to precipitate chronic and progressive immune-mediated joint inflammation. Currently, in most affected individuals, ongoing suppression of the inflammation is required to prevent irreversible damage and functional loss. The delineation of a protracted preclinical period in which autoimmunity is initially established and then evolves to become pathogenic provides unprecedented opportunities for interventions that have the potential to prevent the onset of this lifelong disease. Clinical trials aimed at assessing the impact of specific prevention strategies require the identification of individuals who are at high risk of future RA development. Currently, these risk factors include a strong family history of RA, and the detection of circulating RA-associated autoantibodies, particularly anti-citrullinated protein antibodies (ACPA). Yet, even in such individuals, there remains considerable uncertainty about the likelihood and the timeframe for future disease development. Thus, individuals who are approached to participate in such clinical trials are left weighing the risks and benefits of the prevention measures, while having large gaps in our current understanding. To address this challenge, we have undertaken longitudinal studies of the family members of Indigenous North American RA patients, this population being known to have a high prevalence of RA, early age of onset, and familial clustering of cases. Our studies have indicated that the concepts of "risk" and "prevention" need to be communicated in a culturally relevant manner, and proposed prevention interventions need to have an appropriate balance of effectiveness, safety, convenience, and cultural acceptability. We have focused our proposed prevention studies on immunomodulatory/anti-inflammatory nutritional supplements that appear to strike such a complex balance.
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Affiliation(s)
- Amanda Fowler-Woods
- Ongomiizwin Indigenous Institute of Health and Healing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3W 0W3, Canada;
| | - Irene Smolik
- Rheumatic Diseases Unit, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3A 1M4, Canada;
| | - Vidyanand Anaparti
- Manitoba Center for Proteomics and Systems Biology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 3P4, Canada; (V.A.); (L.O.)
| | - Liam O’Neil
- Manitoba Center for Proteomics and Systems Biology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 3P4, Canada; (V.A.); (L.O.)
| | - Hani El-Gabalawy
- Manitoba Center for Proteomics and Systems Biology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 3P4, Canada; (V.A.); (L.O.)
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Cross AJ, Elliott RA, Petrie K, Kuruvilla L, George J. Interventions for improving medication-taking ability and adherence in older adults prescribed multiple medications. Cochrane Database Syst Rev 2020; 5:CD012419. [PMID: 32383493 PMCID: PMC7207012 DOI: 10.1002/14651858.cd012419.pub2] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Older people taking multiple medications represent a large and growing proportion of the population. Managing multiple medications can be challenging, and this is especially the case for older people, who have higher rates of comorbidity and physical and cognitive impairment than younger adults. Good medication-taking ability and medication adherence are necessary to ensure safe and effective use of medications. OBJECTIVES To evaluate the effectiveness of interventions designed to improve medication-taking ability and/or medication adherence in older community-dwelling adults prescribed multiple long-term medications. SEARCH METHODS We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, CINAHL Plus, and International Pharmaceutical Abstracts from inception until June 2019. We also searched grey literature, online trial registries, and reference lists of included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs. Eligible studies tested interventions aimed at improving medication-taking ability and/or medication adherence among people aged ≥ 65 years (or of mean/median age > 65 years), living in the community or being discharged from hospital back into the community, and taking four or more regular prescription medications (or with group mean/median of more than four medications). Interventions targeting carers of older people who met these criteria were also included. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data, and assessed risk of bias of included studies. We conducted meta-analyses when possible and used a random-effects model to yield summary estimates of effect, risk ratios (RRs) for dichotomous outcomes, and mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, along with 95% confidence intervals (CIs). Narrative synthesis was performed when meta-analysis was not possible. We assessed overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were medication-taking ability and medication adherence. Secondary outcomes included health-related quality of life (HRQoL), emergency department (ED)/hospital admissions, and mortality. MAIN RESULTS We identified 50 studies (14,269 participants) comprising 40 RCTs, six cluster-RCTs, and four quasi-RCTs. All included studies evaluated interventions versus usual care; six studies also reported a comparison between two interventions as part of a three-arm RCT design. Interventions were grouped on the basis of their educational and/or behavioural components: 14 involved educational components only, 7 used behavioural strategies only, and 29 provided mixed educational and behavioural interventions. Overall, our confidence in results regarding the effectiveness of interventions was low to very low due to a high degree of heterogeneity of included studies and high or unclear risk of bias across multiple domains in most studies. Five studies evaluated interventions for improving medication-taking ability, and 48 evaluated interventions for improving medication adherence (three studies evaluated both outcomes). No studies involved educational or behavioural interventions alone for improving medication-taking ability. Low-quality evidence from five studies, each using a different measure of medication-taking ability, meant that we were unable to determine the effects of mixed interventions on medication-taking ability. Low-quality evidence suggests that behavioural only interventions (RR 1.22, 95% CI 1.07 to 1.38; 4 studies) and mixed interventions (RR 1.22, 95% CI 1.08 to 1.37; 12 studies) may increase the proportions of people who are adherent compared with usual care. We could not include in the meta-analysis results from two studies involving mixed interventions: one had a positive effect on adherence, and the other had little or no effect. Very low-quality evidence means that we are uncertain of the effects of educational only interventions (5 studies) on the proportions of people who are adherent. Low-quality evidence suggests that educational only interventions (SMD 0.16, 95% CI -0.12 to 0.43; 5 studies) and mixed interventions (SMD 0.47, 95% CI -0.08 to 1.02; 7 studies) may have little or no impact on medication adherence assessed through continuous measures of adherence. We excluded 10 studies (4 educational only and 6 mixed interventions) from the meta-analysis including four studies with unclear or no available results. Very low-quality evidence means that we are uncertain of the effects of behavioural only interventions (3 studies) on medication adherence when assessed through continuous outcomes. Low-quality evidence suggests that mixed interventions may reduce the number of ED/hospital admissions (RR 0.67, 95% CI 0.50 to 0.90; 11 studies) compared with usual care, although results from six further studies that we were unable to include in meta-analyses indicate that the intervention may have a smaller, or even no, effect on these outcomes. Similarly, low-quality evidence suggests that mixed interventions may lead to little or no change in HRQoL (7 studies), and very low-quality evidence means that we are uncertain of the effects on mortality (RR 0.93, 95% CI 0.67 to 1.30; 7 studies). Moderate-quality evidence shows that educational interventions alone probably have little or no effect on HRQoL (6 studies) or on ED/hospital admissions (4 studies) when compared with usual care. Very low-quality evidence means that we are uncertain of the effects of behavioural interventions on HRQoL (1 study) or on ED/hospital admissions (2 studies). We identified no studies evaluating effects of educational or behavioural interventions alone on mortality. Six studies reported a comparison between two interventions; however due to the limited number of studies assessing the same types of interventions and comparisons, we are unable to draw firm conclusions for any outcomes. AUTHORS' CONCLUSIONS Behavioural only or mixed educational and behavioural interventions may improve the proportion of people who satisfactorily adhere to their prescribed medications, but we are uncertain of the effects of educational only interventions. No type of intervention was found to improve adherence when it was measured as a continuous variable, with educational only and mixed interventions having little or no impact and evidence of insufficient quality to determine the effects of behavioural only interventions. We were unable to determine the impact of interventions on medication-taking ability. The quality of evidence for these findings is low due to heterogeneity and methodological limitations of studies included in the review. Further well-designed RCTs are needed to investigate the effects of interventions for improving medication-taking ability and medication adherence in older adults prescribed multiple medications.
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Affiliation(s)
- Amanda J Cross
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Rohan A Elliott
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
- Pharmacy Department, Austin Health, Heidelberg, Australia
| | - Kate Petrie
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Lisha Kuruvilla
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
- Pharmacy Department, Barwon Health, North Geelong, Australia
| | - Johnson George
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
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Selak V, Webster R, Stepien S, Bullen C, Patel A, Thom S, Arroll B, Bots ML, Brown A, Crengle S, Dorairaj P, Elley CR, Grobbee DE, Harwood M, Hillis GS, Laba TL, Neal B, Peiris D, Rafter N, Reid C, Stanton A, Tonkin A, Usherwood T, Wadham A, Rodgers A. Reaching cardiovascular prevention guideline targets with a polypill-based approach: a meta-analysis of randomised clinical trials. Heart 2018; 105:42-48. [DOI: 10.1136/heartjnl-2018-313108] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 05/17/2018] [Accepted: 05/24/2018] [Indexed: 01/11/2023] Open
Abstract
ObjectiveThe aim of this study was to determine the effect of polypill-based care on the achievement of 2016 European Society of Cardiology (ESC) guideline targets for blood pressure (BP), low-density lipoprotein (LDL) cholesterol and antiplatelet therapy.MethodsWe conducted an individual participant data meta-analysis of three randomised clinical trials that compared a strategy using a polypill containing aspirin, statin and antihypertensive therapy with usual care in patients with a prior cardiovascular disease (CVD) event or who were at high risk of their first event. Overall, the trials included 3140 patients from Australia, England, India, Ireland, the Netherlands and New Zealand (75% male, mean age 62 years and 76% with a prior CVD event). The primary outcome for this study was the proportion of people achieving ESC guideline targets for BP, LDL and antiplatelet therapy.ResultsThose randomised to polypill-based care were more likely than those receiving usual care to achieve recommended targets for BP (62% vs 58%, risk ratio (RR) 1.08, 95% CI 1.02 to 1.15), LDL (39% vs 34%, RR 1.13, 95% CI 1.02 to 1.25) and all three targets for BP, LDL and adherence to antiplatelet therapy (the latter only applicable to those with a prior CVD event) simultaneously (24% vs 19%, RR 1.27, 95% CI 1.10 to 1.47) at 12 months. There was no difference between groups in antiplatelet adherence (96% vs 96%, RR 1.00, 95% CI 0.98 to 1.01). There was heterogeneity by baseline treatment intensity such that treatment effects increased with the fewer the number of treatments being taken at baseline: for patients taking 3, 2 and 0–1 treatment modalities the RRs for reaching all three guideline goals simultaneously were 1.10 (95% CI 0.94 to 1.30, 22% vs 20%), 1.62 (95% CI 1.09 to 2.42, 27% vs 17%) and 3.07 (95% CI 1.77 to 5.33, 35% vs 11%), respectively.ConclusionsPolypill-based therapy significantly improved the achievement of all three ESC targets for BP, LDL and antiplatelet therapy compared with usual care, particularly among those undertreated at baseline.
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Bahiru E, de Cates AN, Farr MRB, Jarvis MC, Palla M, Rees K, Ebrahim S, Huffman MD. Fixed-dose combination therapy for the prevention of atherosclerotic cardiovascular diseases. Cochrane Database Syst Rev 2017; 3:CD009868. [PMID: 28263370 PMCID: PMC6464321 DOI: 10.1002/14651858.cd009868.pub3] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death and disability worldwide, yet ASCVD risk factor control and secondary prevention rates remain low. A fixed-dose combination of blood pressure- and cholesterol-lowering and antiplatelet treatments into a single pill, or polypill, has been proposed as one strategy to reduce the global burden of ASCVD. OBJECTIVES To determine the effect of fixed-dose combination therapy on all-cause mortality, fatal and non-fatal ASCVD events, and adverse events. We also sought to determine the effect of fixed-dose combination therapy on blood pressure, lipids, adherence, discontinuation rates, health-related quality of life, and costs. SEARCH METHODS We updated our previous searches in September 2016 of CENTRAL, MEDLINE, Embase, ISI Web of Science, and DARE, HTA, and HEED. We also searched two clinical trials registers in September 2016. We used no language restrictions. SELECTION CRITERIA We included randomised controlled trials of a fixed-dose combination therapy including at least one blood pressure-lowering and one lipid-lowering component versus usual care, placebo, or an active drug comparator for any treatment duration in adults 18 years old or older, with no restrictions on presence or absence of pre-existing ASCVD. DATA COLLECTION AND ANALYSIS Three review authors independently selected studies for inclusion and extracted the data for this update. We evaluated risk of bias using the Cochrane 'Risk of bias' assessment tool. We calculated risk ratios (RR) for dichotomous data and mean differences (MD) for continuous data with 95% confidence intervals (CI) using fixed-effect models when heterogeneity was low (I2 < 50%) and random-effects models when heterogeneity was high (I2 ≥ 50%). We used the GRADE approach to evaluate the quality of evidence. MAIN RESULTS In the initial review, we identified nine randomised controlled trials with a total of 7047 participants and four additional trials (n = 2012 participants; mean age range 62 to 63 years; 30% to 37% women) were included in this update. Eight of the 13 trials evaluated the effects of fixed-dose combination (FDC) therapy in populations without prevalent ASCVD, and the median follow-up ranged from six weeks to 23 months. More recent trials were generally larger with longer follow-up and lower risk of bias. The main risk of bias was related to lack of blinding of participants and personnel, which was inherent to the intervention. Compared with the comparator groups (placebo, usual care, or active drug comparator), the effects of the fixed-dose combination treatment on mortality (FDC = 1.0% versus control = 1.0%, RR 1.10, 95% CI 0.64 to 1.89, I2 = 0%, 5 studies, N = 5300) and fatal and non-fatal ASCVD events (FDC = 4.7% versus control = 3.7%, RR 1.26, 95% CI 0.95 to 1.66, I2 = 0%, 6 studies, N = 4517) were uncertain (low-quality evidence). The low event rates for these outcomes and indirectness of evidence for comparing fixed-dose combination to usual care versus individual drugs suggest that these results should be viewed with caution. Adverse events were common in both the intervention (32%) and comparator (27%) groups, with participants randomised to fixed-dose combination therapy being 16% (RR 1.16, 95% CI 1.09 to 1.25, 11 studies, 6906 participants, moderate-quality evidence) more likely to report an adverse event . The mean differences in systolic blood pressure between the intervention and control arms was -6.34 mmHg (95% CI -9.03 to -3.64, 13 trials, 7638 participants, moderate-quality evidence). The mean differences (95% CI) in total and LDL cholesterol between the intervention and control arms were -0.61 mmol/L (95% CI -0.88 to -0.35, 11 trials, 6565 participants, low-quality evidence) and -0.70 mmol/L (95% CI -0.98 to -0.41, 12 trials, 7153 participants, moderate-quality evidence), respectively. There was a high degree of statistical heterogeneity in comparisons of blood pressure and lipids (I2 ≥ 80% for all) that could not be explained, so these results should be viewed with caution. Fixed-dose combination therapy improved adherence to a multidrug strategy by 44% (26% to 65%) compared with usual care (4 trials, 3835 participants, moderate-quality evidence). AUTHORS' CONCLUSIONS The effects of fixed-dose combination therapy on all-cause mortality or ASCVD events are uncertain. A limited number of trials reported these outcomes, and the included trials were primarily designed to observe changes in ASCVD risk factor levels rather than clinical events, which may partially explain the observed differences in risk factors that were not translated into differences in clinical outcomes among the included trials. Fixed-dose combination therapy is associated with modest increases in adverse events compared with placebo, active comparator, or usual care but may be associated with improved adherence to a multidrug regimen. Ongoing, longer-term trials of fixed-dose combination therapy will help demonstrate whether short-term changes in risk factors might be maintained and lead to expected differences in clinical events based on these changes.
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Affiliation(s)
- Ehete Bahiru
- Northwestern UniversityInternal Medicine; Division of Cardiology201 E. Huron St. Galter 19‐100ChicagoIllinoisUSA60611
| | - Angharad N de Cates
- Warwick Medical School, University of WarwickDivision of Health SciencesCoventryUKCV4 7AL
| | - Matthew RB Farr
- Warwick Medical School, University of WarwickDivision of Health SciencesCoventryUKCV4 7AL
| | - Morag C Jarvis
- Warwick Medical School, University of WarwickDivision of Health SciencesCoventryUKCV4 7AL
| | - Mohan Palla
- Wayne State UniversityDepartment of Medicine540 E Canfield StDetroitMichiganUSA48201
| | - Karen Rees
- Warwick Medical School, University of WarwickDivision of Health SciencesCoventryUKCV4 7AL
| | - Shah Ebrahim
- London School of Hygiene & Tropical MedicineDepartment of Non‐communicable Disease EpidemiologyKeppel StreetLondonUKWC1E 7HT
| | - Mark D Huffman
- Northwestern University Feinberg School of MedicineDepartments of Preventive Medicine and Medicine (Cardiology)680 N. Lake Shore Drive, Suite 1400ChicagoILUSA60611
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Selak V, Bullen C, Stepien S, Arroll B, Bots M, Bramley D, Cass A, Grobbee D, Hillis GS, Molanus B, Neal B, Patel A, Rafter N, Rodgers A, Thom S, Tonkin A, Usherwood T, Wadham A, Webster R. Do polypills lead to neglect of lifestyle risk factors? Findings from an individual participant data meta-analysis among 3140 patients at high risk of cardiovascular disease. Eur J Prev Cardiol 2016; 23:1393-400. [PMID: 26945024 DOI: 10.1177/2047487316638216] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 02/17/2016] [Indexed: 11/15/2022]
Abstract
AIM The aim of this study was to investigate whether polypill-based care for the prevention of cardiovascular disease (CVD) is associated with a change in lifestyle risk factors when compared with usual care, among patients with CVD or high calculated cardiovascular risk. METHODS We conducted an individual participant data meta-analysis of three trials including patients from Australia, England, India, Ireland, the Netherlands and New Zealand that compared a strategy using a polypill containing aspirin, statin and antihypertensive therapy with usual care in patients with a prior CVD event or who were at high risk of their first event. Analyses investigated any differential effect on anthropometric measures and self-reported lifestyle behaviours. RESULTS Among 3140 patients (75% male, mean age 62 years and 76% with a prior CVD event) there was no difference in lifestyle risk factors in those randomised to polypill-based care compared with usual care over a median of 15 months, either across all participants combined, or in a range of subgroups. Furthermore, narrow confidence intervals (CIs) excluded any major effect; for example differences between the groups in body mass index was -0.1 (95% CI -0.2 to 0.1) kg/m(2), in weekly duration of moderate intensity physical activity was -2 (-26 to 23) minutes and the proportion of smokers was 16% vs 17% (RR 0.98, 0.84 to 1.15) at the end of trial. DISCUSSION This analysis allays concern that polypill-based care may lead to neglect of lifestyle risk factors, at least among high-risk patients. Maximally effective preventive approaches should address lifestyle factors alongside pharmaceutical interventions, as recommended by major international guidelines.
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Affiliation(s)
- Vanessa Selak
- Department of Epidemiology and Biostatistics, University of Auckland, New Zealand
| | - Chris Bullen
- National Institute for Health Innovation, University of Auckland, New Zealand
| | - Sandrine Stepien
- The George Institute for Global Health, University of Sydney, Australia
| | - Bruce Arroll
- Department of General Practice and Primary Health Care, University of Auckland, New Zealand
| | - Michiel Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | | | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, Australia
| | - Diederick Grobbee
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | | | - Barbara Molanus
- South Australian Health and Medical Research Institute, Australia
| | - Bruce Neal
- The George Institute for Global Health, University of Sydney, Australia
| | - Anushka Patel
- The George Institute for Global Health, University of Sydney, Australia
| | - Natasha Rafter
- National Institute for Health Innovation, University of Auckland, New Zealand Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Ireland
| | - Anthony Rodgers
- The George Institute for Global Health, University of Sydney, Australia
| | - Simon Thom
- International Centre for Circulatory Health, Imperial College London, UK
| | - Andrew Tonkin
- Department of Epidemiology and Preventive Medicine, Monash University, Australia
| | - Tim Usherwood
- Department of General Practice, University of Sydney Westmead, Australia
| | - Angela Wadham
- National Institute for Health Innovation, University of Auckland, New Zealand
| | - Ruth Webster
- The George Institute for Global Health, University of Sydney, Australia
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11
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Barrios V, Escobar C. Improving cardiovascular protection: focus on a cardiovascular polypill. Future Cardiol 2016; 12:181-96. [DOI: 10.2217/fca.15.80] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Lack of adherence may explain, at least in part, the poor cardiovascular risk factors control observed in patients with ischemic heart disease, increasing the risk of developing new events. Polypill improves medication adherence, which may actually reduce blood pressure and LDL cholesterol compared with the drugs given separately. The fixed combination of acetylsalicylic acid 100 mg + ramipril 2.5, 5, or 10 mg + either simvastatin 40 mg or atorvastatin 20 mg is the unique cardiovascular polypill that has been registered in 22 countries worldwide. The polypill-containing simvastatin has been specifically tested in a clinical trial including only patients with ischemic heart disease. The FOCUS study showed that patients treated with the polypill showed a higher adherence compared with those receiving separate medications.
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Affiliation(s)
- Vivencio Barrios
- Department of Cardiology, University Hospital Ramon y Cajal, School of Medicine. University of Alcalá, Madrid, Spain
| | - Carlos Escobar
- Cardiology Department, University Hospital La Paz, Madrid, Spain
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12
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Webster R, Patel A, Selak V, Billot L, Bots ML, Brown A, Bullen C, Cass A, Crengle S, Raina Elley C, Grobbee DE, Neal B, Peiris D, Poulter N, Prabhakaran D, Rafter N, Stanton A, Stepien S, Thom S, Usherwood T, Wadham A, Rodgers A. Effectiveness of fixed dose combination medication ('polypills') compared with usual care in patients with cardiovascular disease or at high risk: A prospective, individual patient data meta-analysis of 3140 patients in six countries. Int J Cardiol 2015; 205:147-156. [PMID: 26736090 DOI: 10.1016/j.ijcard.2015.12.015] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 11/26/2015] [Accepted: 12/12/2015] [Indexed: 11/25/2022]
Abstract
AIMS To conduct a prospective, individual participant data (IPD) meta-analysis of randomised controlled trials comparing a polypill-based approach with usual care in high risk individuals. METHODS AND RESULTS Three trials comparing polypill-based care with usual care in individuals with CVD or high calculated cardiovascular risk contributed IPD. Primary outcomes were self-reported adherence to combination therapy (anti-platelet, statin and ≥ two blood pressure (BP) lowering agents), and difference in mean systolic BP (SBP) and LDL-cholesterol at 12 months. Analyses used random effects models. Among 3140 patients from Australia, England, India, Ireland, New Zealand and The Netherlands (75% male, mean age 62 years), median follow-up was 15 months. At baseline, 84%, 87% and 61% respectively were taking a statin, anti-platelet agent and at least two BP lowering agents. At 12 months, compared to usual care, participants in the polypill arm had higher adherence to combination therapy (80% vs. 50%, RR 1.58; 95% CI, 1.32 to 1.90; p < 0.001), lower SBP (-2.5 mmHg; 95% CI, -4.5 to -0.4; p = 0.02) and lower LDL-cholesterol (-0.1 mmol/L; 95% CI, -0.2 to 0.0; p = 0.04). Baseline treatment levels were a major effect modifier for adherence and SBP (p-homog < 0.0001 and 0.02 respectively) with greatest improvements seen among those under-treated at baseline. CONCLUSIONS Polypill therapy significantly improved adherence, SBP and LDL-cholesterol in high risk patients compared with usual care, especially among those who were under-treated at baseline.
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Affiliation(s)
- Ruth Webster
- The George Institute for Global Health, University of Sydney, PO Box M201, Missenden Rd, Camperdown, NSW 2050, Australia.
| | - Anushka Patel
- The George Institute for Global Health, University of Sydney, PO Box M201, Missenden Rd, Camperdown, NSW 2050, Australia
| | - Vanessa Selak
- National Institute for Health Innovation, School of Population Health, The University of Auckland, Private Bag 92019, Auckland Mail Centre, Auckland 1142, New Zealand
| | - Laurent Billot
- The George Institute for Global Health, University of Sydney, PO Box M201, Missenden Rd, Camperdown, NSW 2050, Australia
| | - Michiel L Bots
- The Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Alex Brown
- South Australian Health and Medical Research Institute, PO Box 11060, Adelaide, SA 5001, Australia
| | - Chris Bullen
- National Institute for Health Innovation, School of Population Health, The University of Auckland, Private Bag 92019, Auckland Mail Centre, Auckland 1142, New Zealand
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, NT 0811, Australia
| | - Sue Crengle
- Invercargill Medical Centre, 160 Don St, Invercargill 9810, New Zealand
| | - C Raina Elley
- Department of General Practice and Primary Health Care, The University of Auckland, Auckland, New Zealand
| | - Diederick E Grobbee
- The Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Bruce Neal
- The George Institute for Global Health, University of Sydney, PO Box M201, Missenden Rd, Camperdown, NSW 2050, Australia
| | - David Peiris
- The George Institute for Global Health, University of Sydney, PO Box M201, Missenden Rd, Camperdown, NSW 2050, Australia
| | - Neil Poulter
- Imperial College, 59/61 North Wharf Road, St Mary's Campus, London, United Kingdom
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, 4th Floor, Plot no. 47, Sector 44, Near Metro Huda City Center, Gurgaon, Haryana 122002, India
| | - Natasha Rafter
- National Institute for Health Innovation, School of Population Health, The University of Auckland, Private Bag 92019, Auckland Mail Centre, Auckland 1142, New Zealand
| | - Alice Stanton
- Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin 2, Ireland
| | - Sandrine Stepien
- The George Institute for Global Health, University of Sydney, PO Box M201, Missenden Rd, Camperdown, NSW 2050, Australia
| | - Simon Thom
- Imperial College, 59/61 North Wharf Road, St Mary's Campus, London, United Kingdom
| | - Tim Usherwood
- Sydney Medical School - Westmead, University of Sydney, Sydney, Australia
| | - Angela Wadham
- National Institute for Health Innovation, School of Population Health, The University of Auckland, Private Bag 92019, Auckland Mail Centre, Auckland 1142, New Zealand
| | - Anthony Rodgers
- The George Institute for Global Health, University of Sydney, PO Box M201, Missenden Rd, Camperdown, NSW 2050, Australia
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13
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Truelove M, Patel A, Bompoint S, Brown A, Cass A, Hillis GS, Peiris D, Rafter N, Reid CM, Rodgers A, Tonkin A, Usherwood T, Webster R. The Effect of a Cardiovascular Polypill Strategy on Pill Burden. Cardiovasc Ther 2015; 33:347-52. [DOI: 10.1111/1755-5922.12151] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Michael Truelove
- Sydney Medical School; The University of Sydney; Sydney NSW Australia
| | - Anushka Patel
- The George Institute for Global Health; The University of Sydney; Sydney NSW Australia
| | - Severine Bompoint
- The George Institute for Global Health; The University of Sydney; Sydney NSW Australia
| | - Alex Brown
- South Australian Health and Medical Research Institute; Adelaide SA Australia
| | - Alan Cass
- Menzies School of Health Research; Charles Darwin University; Darwin NT Australia
| | | | - David Peiris
- The George Institute for Global Health; The University of Sydney; Sydney NSW Australia
| | - Natasha Rafter
- Department of Geriatric and Stroke Medicine; Royal College of Surgeons in Ireland; Dublin Ireland
| | - Christopher M. Reid
- Monash Centre of Cardiovascular Research and Education in Therapeutics; School of Public Health and Preventive Medicine; Monash University; Melbourne Vic. Australia
- School of Public Health; Curtin University; Perth WA Australia
| | - Anthony Rodgers
- The George Institute for Global Health; The University of Sydney; Sydney NSW Australia
| | - Andrew Tonkin
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Vic. Australia
| | - Tim Usherwood
- Department of General Practice; Sydney Medical School (Westmead); The University of Sydney; Sydney NSW Australia
| | - Ruth Webster
- The George Institute for Global Health; The University of Sydney; Sydney NSW Australia
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14
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Liu H, Massi L, Eades AM, Howard K, Peiris D, Redfern J, Usherwood T, Cass A, Patel A, Jan S, Laba TL. Implementing Kanyini GAP, a pragmatic randomised controlled trial in Australia: findings from a qualitative study. Trials 2015; 16:425. [PMID: 26399503 PMCID: PMC4581084 DOI: 10.1186/s13063-015-0956-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 09/11/2015] [Indexed: 11/30/2022] Open
Abstract
Background Pragmatic randomised controlled trials (PRCTs) aim to assess intervention effectiveness by accounting for ‘real life’ implementation challenges in routine practice. The methodological challenges of PRCT implementation, particularly in primary care, are not well understood. The Kanyini Guidelines Adherence to Polypill study (Kanyini GAP) was a recent primary care PRCT involving multiple private general practices, Indigenous community controlled health services and private community pharmacies. Through the experiences of Kanyini GAP participants, and using data from study materials, this paper identifies the critical enablers and barriers to implementing a PRCT across diverse practice settings and makes recommendations for future PRCT implementation. Methods Qualitative data from 94 semi-structured interviews (47 healthcare providers (pharmacists, general practitioners, Aboriginal health workers; 47 patients) conducted for the process evaluation of Kanyini GAP was used. Data coded to ‘trial impact’, ‘research motivation’ and ‘real world’ were explored and triangulated with data extracted from study materials (e.g. Emails, memoranda of understanding and financial statements). Results PRCT implementation was facilitated by an extensive process of relationship building at the trial outset including building on existing relationships between core investigators and service providers. Health providers’ and participants’ altruism, increased professional satisfaction, collaboration, research capacity and opportunities for improved patient care enabled implementation. Inadequate research infrastructure, excessive administrative demands, insufficient numbers of adequately trained staff and the potential financial impact on private practice were considered implementation barriers. These were largely related to this being the first experience of trial involvement for many sites. The significant costs of addressing these barriers drew study resources from the task of achieving recruitment targets. Conclusions Conducting PRCTs is crucial to generating credible evidence of intervention effectiveness in routine practice. PRCT implementation needs to account for the particular challenges of implementing collaborative research across diverse stakeholder organisations. Reliance on goodwill to participate is crucial at the outset. However, participation costs, particularly for organisations with little or no research experience, can be substantial and should be factored into PRCT funding models. Investment in a pool to fund infrastructure in the form of primary health research networks will offset some of these costs, enabling future studies to be implemented more cost-effectively. Trial registration ACTRN126080005833347 Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-0956-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hueiming Liu
- The George Institute for Global Health, University of Sydney, PO Box M201, Missenden Road, Camperdown, NSW, 2050, Australia.
| | - Luciana Massi
- The George Institute for Global Health, University of Sydney, PO Box M201, Missenden Road, Camperdown, NSW, 2050, Australia.
| | - Anne-Marie Eades
- The George Institute for Global Health, University of Sydney, PO Box M201, Missenden Road, Camperdown, NSW, 2050, Australia.
| | - Kirsten Howard
- Sydney School of Public Health, University of Sydney, Sydney, NSW, 2006, Australia.
| | - David Peiris
- The George Institute for Global Health, University of Sydney, PO Box M201, Missenden Road, Camperdown, NSW, 2050, Australia.
| | - Julie Redfern
- The George Institute for Global Health, University of Sydney, PO Box M201, Missenden Road, Camperdown, NSW, 2050, Australia.
| | - Tim Usherwood
- Department of General Practice, Sydney Medical School Westmead, University of Sydney, Sydney, NSW, 2006, Australia.
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, Casuarina, NT, 0811, Australia.
| | - Anushka Patel
- The George Institute for Global Health, University of Sydney, PO Box M201, Missenden Road, Camperdown, NSW, 2050, Australia.
| | - Stephen Jan
- The George Institute for Global Health, University of Sydney, PO Box M201, Missenden Road, Camperdown, NSW, 2050, Australia.
| | - Tracey-Lea Laba
- The George Institute for Global Health, University of Sydney, PO Box M201, Missenden Road, Camperdown, NSW, 2050, Australia. .,Faculty of Pharmacy, University of Sydney, Sydney, Australia.
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15
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Liu H, Laba TL, Massi L, Jan S, Usherwood T, Patel A, Hayman NE, Cass A, Eades AM, Lawrence C, Peiris DP. Facilitators and barriers to implementation of a pragmatic clinical trial in Aboriginal health services. Med J Aust 2015; 203:24-7. [PMID: 26126563 DOI: 10.5694/mja14.00581] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 02/05/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To identify facilitators and barriers to clinical trial implementation in Aboriginal health services. DESIGN Indepth interview study with thematic analysis. SETTING Six Aboriginal community-controlled health services and one government-run service involved in the Kanyini Guidelines Adherence with the Polypill (KGAP) study, a pragmatic randomised controlled trial that aimed to improve adherence to indicated drug treatments for people at high risk of cardiovascular disease. PARTICIPANTS 32 health care providers and 21 Aboriginal and Torres Strait Islander patients. RESULTS A fundamental enabler was that participants considered the research to be governed and endorsed by the local health service. That the research was perceived to address a health priority for communities was also highly motivating for both providers and patients. Enlisting the support of Aboriginal and Torres Strait Islander staff champions who were visible to the community as the main source of information about the trial was particularly important. The major implementation barrier for staff was balancing their service delivery roles with adherence to often highly demanding trial-related procedures. This was partially alleviated by the research team's provision of onsite support and attempts to make trial processes more streamlined. Although more intensive support was highly desired, there were usually insufficient resources to provide this. CONCLUSION Despite strong community and health service support, major investments in time and resources are needed to ensure successful implementation and minimal disruption to already overstretched, routine services. Trial budgets will necessarily be inflated as a result. Funding agencies need to consider these additional resource demands when supporting trials of a similar nature.
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Affiliation(s)
- Hueming Liu
- The George Institute for Global Health, Sydney, NSW, Australia.
| | - Tracey-Lea Laba
- The George Institute for Global Health, Sydney, NSW, Australia
| | | | - Stephen Jan
- The George Institute for Global Health, Sydney, NSW, Australia
| | | | - Anushka Patel
- The George Institute for Global Health, Sydney, NSW, Australia
| | | | - Alan Cass
- Menzies School of Health Research, Darwin, NT, Australia
| | | | - Chris Lawrence
- The George Institute for Global Health, Sydney, NSW, Australia
| | - David P Peiris
- The George Institute for Global Health, Sydney, NSW, Australia
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16
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Patel A, Cass A, Peiris D, Usherwood T, Brown A, Jan S, Neal B, Hillis GS, Rafter N, Tonkin A, Webster R, Billot L, Bompoint S, Burch C, Burke H, Hayman N, Molanus B, Reid CM, Shiel L, Togni S, Rodgers A. A pragmatic randomized trial of a polypill-based strategy to improve use of indicated preventive treatments in people at high cardiovascular disease risk. Eur J Prev Cardiol 2015; 22:920-930. [DOI: 10.1177/2047487314530382] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Anushka Patel
- The George Institute for Global Health, University of Sydney, Australia
| | - Alan Cass
- The George Institute for Global Health, University of Sydney, Australia
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - David Peiris
- The George Institute for Global Health, University of Sydney, Australia
| | - Tim Usherwood
- Department of General Practice, Sydney Medical School (Westmead), The University of Sydney, Australia
| | - Alex Brown
- Baker IDI Centre for Indigenous Vascular and Diabetes Research, Alice Springs, Australia
- South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Stephen Jan
- The George Institute for Global Health, University of Sydney, Australia
| | - Bruce Neal
- The George Institute for Global Health, University of Sydney, Australia
| | - Graham S Hillis
- The George Institute for Global Health, University of Sydney, Australia
| | - Natasha Rafter
- National Institute for Health Innovation, School of Population Health, University of Auckland, New Zealand
| | - Andrew Tonkin
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Ruth Webster
- The George Institute for Global Health, University of Sydney, Australia
| | - Laurent Billot
- The George Institute for Global Health, University of Sydney, Australia
| | - Severine Bompoint
- The George Institute for Global Health, University of Sydney, Australia
| | - Carol Burch
- The George Institute for Global Health, University of Sydney, Australia
| | - Hugh Burke
- Maari Ma Aboriginal Corporation, Broken Hill, Australia
| | | | - Barbara Molanus
- Baker IDI Centre for Indigenous Vascular and Diabetes Research, Alice Springs, Australia
| | - Christopher M Reid
- Monash Centre of Cardiovascular Research and Education in Therapeutics, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Louise Shiel
- Monash Centre of Cardiovascular Research and Education in Therapeutics, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Samantha Togni
- Baker IDI Centre for Indigenous Vascular and Diabetes Research, Alice Springs, Australia
| | - Anthony Rodgers
- The George Institute for Global Health, University of Sydney, Australia
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17
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Laba TL, Howard K, Rose J, Peiris D, Redfern J, Usherwood T, Cass A, Patel A, Jan S. Patient Preferences for a Polypill for the Prevention of Cardiovascular Diseases. Ann Pharmacother 2015; 49:528-39. [DOI: 10.1177/1060028015570468] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Polypill-based strategies have improved patient use of preventive cardiovascular disease (CVD) medications in clinical trials. Continued use in real-world settings relies on patients preferring a polypill over current treatment. Objective: Within a clinical trial assessing a CVD polypill-based strategy on patient adherence (Kanyini Guidelines Adherence with the Polypill study [Kanyini GAP]), we used discrete choice experiment (DCE) to assess the influence of polypill-based treatment attributes and patient characteristics on preferences for CVD preventive treatment. Methods: A DCE survey was administered to Kanyini GAP participants, involving choices between 2 hypothetical treatment options and no treatment for CVD prevention. Attributes delineating a polypill from current treatment were assessed: out-of-pocket costs, tablet number, administration, and prescriber visit frequency. The odds ratios (ORs) for preferring treatment, trade-off between treatment-related attributes, and willingness to pay against other attributes were estimated. Results: In all, 332 of 487 (68%) participants completed the survey. Active treatment, compared with no treatment, was chosen by 93%. Treatment preference decreased with increasing out-of-pocket cost (OR = 0.04; 95% CI = 0.03-0.05) and tablet number (OR = 0.69; 95% CI = 0.59-0.81). Out-of-pocket cost was the most important attribute. Respondents were willing to pay $3.45 per month for each tablet reduction. Education and household income significantly influenced treatment preference. Conclusions: Assuming equivalent efficacy and safety of treatment options, the treatment-specific attributes that were assessed and influenced patient preference strongly accord with the posited advantages of the cardiovascular polypill. The study provides promising evidence that improvements in treatment adherence observed in CVD polypill trials may translate to the real world and potentially close treatment gaps in CVD prevention.
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Affiliation(s)
- Tracey-Lea Laba
- The George Institute for Global Health, Camperdown, New South Wales, Australia
| | - Kirsten Howard
- University of Sydney, Camperdown, New South Wales, Australia
| | - John Rose
- University of South Australia, Sydney, New South Wales, Australia
| | - David Peiris
- The George Institute for Global Health, Camperdown, New South Wales, Australia
| | - Julie Redfern
- The George Institute for Global Health, Camperdown, New South Wales, Australia
| | - Tim Usherwood
- Sydney Medical School Westmead Sydney, New South Wales, Australia
| | - Alan Cass
- Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Anushka Patel
- The George Institute for Global Health, Camperdown, New South Wales, Australia
| | - Stephen Jan
- The George Institute for Global Health, Camperdown, New South Wales, Australia
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18
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Checkley W, Ghannem H, Irazola V, Kimaiyo S, Levitt NS, Miranda JJ, Niessen L, Prabhakaran D, Rabadán-Diehl C, Ramirez-Zea M, Rubinstein A, Sigamani A, Smith R, Tandon N, Wu Y, Xavier D, Yan LL. Management of NCD in low- and middle-income countries. Glob Heart 2014; 9:431-43. [PMID: 25592798 PMCID: PMC4299752 DOI: 10.1016/j.gheart.2014.11.003] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 10/31/2014] [Accepted: 11/14/2014] [Indexed: 12/23/2022] Open
Abstract
Noncommunicable disease (NCD), comprising cardiovascular disease, stroke, diabetes, and chronic obstructive pulmonary disease, are increasing in incidence rapidly in low- and middle-income countries (LMICs). Some patients have access to the same treatments available in high-income countries, but most do not, and different strategies are needed. Most research on noncommunicable diseases has been conducted in high-income countries, but the need for research in LMICs has been recognized. LMICs can learn from high-income countries, but they need to devise their own systems that emphasize primary care, the use of community health workers, and sometimes the use of mobile technology. The World Health Organization has identified "best buys" it advocates as interventions in LMICs. Non-laboratory-based risk scores can be used to identify those at high risk. Targeting interventions to those at high risk for developing diabetes has been shown to work in LMICs. Indoor cooking with biomass fuels is an important cause of chronic obstructive pulmonary disease in LMICs, and improved cookstoves with chimneys may be effective in the prevention of chronic diseases.
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Affiliation(s)
- William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Program in Global Disease Epidemiology and Control, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; CRONICAS Center of Excellence for Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Hassen Ghannem
- Department of Epidemiology, Chronic Disease Prevention Research Centre, University Hospital Farhat Hached, Sousse, Tunisia
| | - Vilma Irazola
- Centro de Excelencia en Salud Cardiovascular para el Cono Sur (CESCAS), Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Sylvester Kimaiyo
- AMPATH, Moi University School of Medicine, Eldoret, Kenya; Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Naomi S Levitt
- Chronic Disease Initiative for Africa (CDIA), Cape Town, South Africa; Division of Diabetic Medicine and Endocrinology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - J Jaime Miranda
- CRONICAS Center of Excellence for Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru.
| | - Louis Niessen
- Centre for Control of Chronic Diseases (CCCD), International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Centre for Applied Health Research and Delivery, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, New Delhi, India; Centre of Excellence in Cardio-Metabolic Risk Reduction in South Asia, Public Health Foundation of India, New Delhi, India
| | - Cristina Rabadán-Diehl
- Office of Global Health, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA; Office of Global Affairs, U.S. Department of Health and Human Services, Washington, DC, USA
| | - Manuel Ramirez-Zea
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Adolfo Rubinstein
- Centro de Excelencia en Salud Cardiovascular para el Cono Sur (CESCAS), Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Alben Sigamani
- St. John's Medical College and Research Institute, Bangalore, India
| | - Richard Smith
- Chronic Disease Initiative, UnitedHealth Group, London, United Kingdom.
| | - Nikhil Tandon
- Department of Endocrinology, All India Institute of Medical Sciences, New Delhi, India
| | - Yangfeng Wu
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China; Peking University School of Public Health and Clinical Research Institute, Beijing, China
| | - Denis Xavier
- St. John's Medical College and Research Institute, Bangalore, India
| | - Lijing L Yan
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China; Duke Global Health Institute and Global Heath Research Center, Duke Kunshan University, Kunshan, China
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Panaretto KS, Wenitong M, Button S, Ring IT. Aboriginal community controlled health services: leading the way in primary care. Med J Aust 2014; 200:649-52. [PMID: 24938346 DOI: 10.5694/mja13.00005] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 03/13/2014] [Indexed: 11/17/2022]
Abstract
The national Closing the Gap framework commits to reducing persisting disadvantage in the health of Aboriginal and Torres Strait Islander people in Australia, with cross-government-sector initiatives and investment. Central to efforts to build healthier communities is the Aboriginal community controlled health service (ACCHS) sector; its focus on prevention, early intervention and comprehensive care has reduced barriers to access and unintentional racism, progressively improving individual health outcomes for Aboriginal people. There is now a broad range of primary health care data that provides a sound evidence base for comparing the health outcomes for Indigenous people in ACCHSs with the outcomes achieved through mainstream services, and these data show: models of comprehensive primary health care consistent with the patient-centred medical home model; coverage of the Aboriginal population higher than 60% outside major metropolitan centres; consistently improving performance in key performance on best-practice care indicators; and superior performance to mainstream general practice. ACCHSs play a significant role in training the medical workforce and employing Aboriginal people. ACCHSs have risen to the challenge of delivering best-practice care and there is a case for expanding ACCHSs into new areas. To achieve the best returns, the current mainstream Closing the Gap investment should be shifted to the community controlled health sector.
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Affiliation(s)
- Kathryn S Panaretto
- Queensland Aboriginal and Islander Health Council, Brisbane, QLD, Australia.
| | - Mark Wenitong
- National Aboriginal Community Controlled Health Organisation, Canberra, ACT, Australia
| | - Selwyn Button
- Queensland Aboriginal and Islander Health Council, Brisbane, QLD, Australia
| | - Ian T Ring
- Australian Health Services Research Institute, University of Wollongong, Wollongong, NSW, Australia
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Ong KS, Carter R, Vos T, Kelaher M, Anderson I. Cost-effectiveness of Interventions to Prevent Cardiovascular Disease in Australia's Indigenous Population. Heart Lung Circ 2014; 23:414-21. [DOI: 10.1016/j.hlc.2013.10.084] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 10/16/2013] [Accepted: 10/22/2013] [Indexed: 10/26/2022]
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de Cates AN, Farr MRB, Wright N, Jarvis MC, Rees K, Ebrahim S, Huffman MD. Fixed-dose combination therapy for the prevention of cardiovascular disease. Cochrane Database Syst Rev 2014; 4:CD009868. [PMID: 24737108 PMCID: PMC4083498 DOI: 10.1002/14651858.cd009868.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Cardiovascular disease (CVD) is the leading cause of death and disability worldwide, yet CVD risk factor control and secondary prevention rates remain low. A fixed-dose combination of blood pressure and cholesterol lowering and antiplatelet treatments into a single pill, or polypill, has been proposed as one strategy to reduce the global burden of CVD by up to 80% given its potential for better adherence and lower costs. OBJECTIVES To determine the effectiveness of fixed-dose combination therapy on reducing fatal and non-fatal CVD events and on improving blood pressure and lipid CVD risk factors for both primary and secondary prevention of CVD. We also aimed to determine discontinuation rates, adverse events, health-related quality of life, and costs of fixed-dose combination therapy. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2013, Issue 6), MEDLINE Ovid (1946 to week 2 July 2013), EMBASE Ovid (1980 to Week 28 2013), ISI Web of Science (1970 to 19 July 2013), and the Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment Database (HTA), and Health Economics Evaluations Database (HEED) (2011, Issue 4) in The Cochrane Library. We used no language restrictions. SELECTION CRITERIA We included randomised controlled trials of a fixed-dose combination therapy including at least one blood pressure lowering and one lipid lowering component versus usual care, placebo, or a single drug active component for any treatment duration in adults ≥ 18 years old with no restrictions on presence or absence of pre-existing cardiovascular disease. DATA COLLECTION AND ANALYSIS Three review authors independently selected studies for inclusion and extracted the data. We evaluated risk of bias using the Cochrane risk of bias assessment tool. We sought to include outcome data on all-cause mortality, fatal and non-fatal CVD events, adverse events, changes in systolic and diastolic blood pressure, total and low density lipoprotein (LDL) cholesterol concentrations, discontinuation rates, quality of life, and costs. We calculated risk ratios (RR) for dichotomous data and weighted mean differences (MD) for continuous data with 95% confidence intervals (CI) using fixed-effect models when heterogeneity was low (I(2) < 50%) and random-effects models when heterogeneity was high (I(2) > 50%). MAIN RESULTS We found nine randomised controlled trials with a total of 7047 participants. Seven of the nine trials evaluated the effects of fixed-dose combination therapy on primary CVD prevention, and the trial length ranged from six weeks to 15 months. We found a moderate to high risk of bias in the domains of selection, performance, detection, attrition, and other types of bias in five of the nine trials. Compared with the comparator groups, the effects of the fixed-dose combination treatment on mortality (1.2% versus 1.0%, RR 1.26, 95% CI 0.67 to 2.38, N = 3465) and cardiovascular events (4.0% versus 2.9%, RR 1.38, 95% CI 0.91 to 2.10, N = 2479) were uncertain (low quality evidence). The low event rates for these outcomes, limited availability of data as only two out of nine trials reported on these outcomes, and a high risk of bias in at least one domain suggest that these results should not be viewed with confidence. Adverse events were common in both the intervention (30%) and comparator (24%) groups, with participants randomised to fixed-dose combination therapy being 20% (95% CI 9% to 30%) more likely to report an adverse event. Notably, no serious adverse events were reported. Compared with placebo, the rate of discontinuation among participants randomised to fixed-dose combination was higher (14% versus 11%, RR 1.26 95% CI 1.02 to 1.55). The weighted mean differences in systolic and diastolic blood pressure between the intervention and control arms were -7.05 mmHg (95% CI -10.18 to -3.87) and -3.65 mmHg (95% CI -5.44 to -1.85), respectively. The weighted mean differences (95% CI) in total and LDL cholesterol between the intervention and control arms were -0.75 mmol/L (95% CI -1.05 to -0.46) and -0.81 mmol/L (95% CI -1.09 to -0.53), respectively. There was a high degree of statistical heterogeneity in comparisons of blood pressure and lipids (I(2) ≥ 70% for all) that could not be explained, so these results should be viewed with caution. Fixed-dose combination therapy improved adherence to a multi-drug strategy by 33% (26% to 41%) compared with usual care, but this comparison was reported in only one study. The effects of fixed-dose combination therapy on quality of life are uncertain, though these results were reported in only one trial. No trials reported costs. AUTHORS' CONCLUSIONS Compared with placebo, single drug active component, or usual care, the effects of fixed-dose combination therapy on all-cause mortality or CVD events are uncertain; only few trials report these outcomes and the included trials were primarily designed to observe changes in CVD risk factor levels rather than clinical events. Reductions in blood pressure and lipid parameters are generally lower than those previously projected, though substantial heterogeneity of results exists. Fixed-dose combination therapy is associated with modest increases in adverse events compared with placebo, single drug active component, or usual care but may be associated with improved adherence to a multidrug regimen. Ongoing trials of fixed-dose combination therapy will likely inform key outcomes.
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Affiliation(s)
- Angharad N de Cates
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Matthew RB Farr
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Nicola Wright
- Public Health Department, NHS Warwickshire, Warwick, UK
| | - Morag C Jarvis
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Karen Rees
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Shah Ebrahim
- Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Mark D Huffman
- Departments of Preventive Medicine and Medicine (Cardiology), Northwestern University Feinberg School of Medicine, Chicago, USA
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Sandli OK, Spigset O, Slørdal L. [The polypill as cardiovascular prophylactic: clinical trials]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2014; 134:620-3. [PMID: 24670510 DOI: 10.4045/tidsskr.13.0925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Cardiovascular disease dominates globally as the most common cause of death. This challenge may be countered by employing a combination pill (the «polypill») for prophylaxis by everybody above a certain age. The polypill normally contains two to three low-dose antihypertensives, a statin and aspirin. Clinical trials with the polypill are reviewed. METHOD The databases PubMed and ClinicalTrials.gov were accessed for published, ongoing and planned randomised clinical trials with a polypill, and studies available per June 2013 were identified and evaluated. RESULTS Six randomised clinical trials with different variations of a polypill have been published. In these, the polypill has been compared either with placebo (n = 3) or other cardiovascularly active pharmacotherapeutic strategies (n = 3). So far, no data on hard endpoints such as morbidity and mortality are available. On the basis of reductions in blood pressure and cholesterol levels, estimated risk reductions for ischemic heart disease and stroke were in the 33-72% and 21-64% ranges, respectively. INTERPRETATION Additional studies of longer duration and with larger numbers of patients are required to assess the polypill's proposed effects on cardiovascular morbidity and mortality, as well as safety issues.
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Affiliation(s)
- Oda Kristine Sandli
- Institutt for laboratoriemedisin, barne- og kvinnesykdommer Norges teknisk-naturvitenskapelige universitet
| | - Olav Spigset
- Institutt for laboratoriemedisin, barne- og kvinnesykdommer Norges teknisk-naturvitenskapelige universitet og Avdeling for klinisk farmakologi St. Olavs hospital
| | - Lars Slørdal
- Institutt for laboratoriemedisin, barne- og kvinnesykdommer Norges teknisk-naturvitenskapelige universitet og Avdeling for klinisk farmakologi St. Olavs hospital
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Webster R, Patel A, Billot L, Cass A, Burch C, Neal B, Usherwood T, Thom S, Poulter N, Stanton A, Bots ML, Grobbee DE, Prabhakaran D, Reddy KS, Field J, Bullen C, Elley CR, Selak V, Rafter N, Wadham A, Berwanger O, Rodgers A. Prospective meta-analysis of trials comparing fixed dose combination based care with usual care in individuals at high cardiovascular risk: The SPACE Collaboration. Int J Cardiol 2013; 170:30-5. [DOI: 10.1016/j.ijcard.2013.10.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 08/29/2013] [Accepted: 10/05/2013] [Indexed: 11/15/2022]
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Yusuf S, Attaran A, Bosch J, Joseph P, Lonn E, McCready T, Mente A, Nieuwlaat R, Pais P, Rodgers A, Schwalm JD, Smith R, Teo K, Xavier D. Combination pharmacotherapy to prevent cardiovascular disease: present status and challenges. Eur Heart J 2013; 35:353-64. [PMID: 24288261 DOI: 10.1093/eurheartj/eht407] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Combination pills containing aspirin, multiple blood pressure (BP) lowering drugs, and a statin have demonstrated safety, substantial risk factor reductions, and improved medication adherence in the prevention of cardiovascular disease (CVD). The individual medications in combination pills are already recommended for use together in secondary CVD prevention. Therefore, current information on their pharmacokinetics, impact on the risk factors, and tolerability should be sufficient to persuade regulators and clinicians to use fixed-dose combination pills in high-risk individuals, such as in secondary prevention. Long-term use of these medicines, in a polypill or otherwise, is expected to reduce CVD risk by at least 50-60% in such groups. This risk reduction needs confirmation in prospective randomized trials for populations for whom concomitant use of the medications is not currently recommended (e.g. primary prevention). Given their additive benefits, the combined estimated relative risk reduction (RRR) in CVD from both lifestyle modification and a combination pill is expected to be 70-80%. The first of several barriers to the widespread use of combination therapy in CVD prevention is physician reluctance to use combination pills. This reluctance may originate from the belief that lifestyle modification should take precedence, and that medications should be introduced one drug at a time, instead of regarding combination pills and lifestyle modification as complementary and additive. Second, widespread availability of combination pills is also impeded by the reluctance of large pharmaceutical companies to invest in development of novel co-formulations of generic (or 'mature') drugs. A business model based on 'mass approaches' to drug production, packaging, marketing, and distribution could make the combination pill available at an affordable price, while at the same time providing a viable profit for the manufacturers. A third barrier is regulatory approval for novel multidrug combination pills, as there are few precedents for the approval of combination products with four or more components for CVD. Acceptance of combination therapy in other settings suggests that with concerted efforts by academics, international health agencies, research funding bodies, governments, regulators, and pharmaceutical manufacturers, combination pills for prevention of CVD in those with disease or at high risk (e.g. those with multiple risk factors) can be made available worldwide at affordable prices. It is anticipated that widespread use of combination pills with lifestyle modifications can lead to substantial risk reductions (as much as an 80% estimated RRR) in CVD. Heath care systems need to deploy these strategies widely, effectively, and efficiently. If implemented, these strategies could avoid several millions of fatal and non-fatal CVD events every year worldwide.
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Elley CR, Gupta AK, Webster R, Selak V, Jun M, Patel A, Rodgers A, Thom S. The efficacy and tolerability of 'polypills': meta-analysis of randomised controlled trials. PLoS One 2012; 7:e52145. [PMID: 23284906 PMCID: PMC3526586 DOI: 10.1371/journal.pone.0052145] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Accepted: 11/08/2012] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND To assess the blood pressure and lipid-lowering efficacy and tolerability of 'polypills' used in cardiovascular disease prevention trials. METHODOLOGY/PRINCIPAL FINDINGS Systematic review and meta-analysis. SEARCH STRATEGY The Cochrane Central Register of Controlled Trials, Medline, and PubMed databases were searched for eligible trials. Study inclusion criteria: Randomised controlled trials of at least six weeks duration, which compared a 'polypill' (that included at least one anti-hypertensive and one lipid-lowering medication) with a placebo (or one active component). OUTCOME MEASURES Change from baseline in systolic and diastolic blood pressures, and total and LDL-cholesterol; discontinuation of study medication and reported adverse effects. Of 44 potentially eligible studies, six trials (including 2,218 patients without previous cardiovascular disease) fulfilled the inclusion criteria. Compared with placebo, 'polypills' reduced systolic blood pressure by -9.2 mmHg (95% confidence interval (CI): -13.4, -5.0) diastolic blood pressure by -5.0 mmHg (95%CI: -7.4, -2.6), total cholesterol by -1.22 mmol/L (95%CI: -1.60, -0.84) and LDL-cholesterol by -1.02 mmol/L (95%CI: -1.37, -0.67). However, those taking a 'polypill' (vs. placebo or component) were more likely to discontinue medication (20% vs 14%) (Odds ratio: 1.5 (95% CI: 1.2, 1.9)). There was no significant difference in reported adverse effects amongst those on a 'polypill' (36% vs. 28%) (OR: 1.3 (95%CI: 0.7, 2.5)). There was high statistical heterogeneity in comparisons for blood pressure and lipid-lowering but use of random-effects and quality-effects models produced very similar results. CONCLUSIONS/SIGNIFICANCE Compared with placebo, the 'polypills' reduced blood pressure and lipids. Tolerability was lower amongst those on 'polypills' than those on placebo or one component, but differences were moderate. Effectiveness trials are needed to help clarify the status of 'polypills' in primary care and prevention strategies.
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Affiliation(s)
- C Raina Elley
- School of Population Health, University of Auckland, Auckland, New Zealand.
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26
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Sanz G, Fuster V. Maximizing Therapeutic Envelope for Prevention of Cardiovascular Disease: Role of Polypill. ACTA ACUST UNITED AC 2012; 79:683-8. [DOI: 10.1002/msj.21355] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Peiris D, Brown A, Howard M, Rickards BA, Tonkin A, Ring I, Hayman N, Cass A. Building better systems of care for Aboriginal and Torres Strait Islander people: findings from the Kanyini health systems assessment. BMC Health Serv Res 2012; 12:369. [PMID: 23102409 PMCID: PMC3529689 DOI: 10.1186/1472-6963-12-369] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Accepted: 10/24/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Australian federal and jurisdictional governments are implementing ambitious policy initiatives intended to improve health care access and outcomes for Aboriginal and Torres Strait Islander people. In this qualitative study we explored Aboriginal Medical Service (AMS) staff views on factors needed to improve chronic care systems and assessed their relevance to the new policy environment. METHODS Two theories informed the study: (1) 'candidacy', which explores "the ways in which people's eligibility for care is jointly negotiated between individuals and health services"; and (2) kanyini or 'holding', a Central Australian philosophy which describes the principle and obligations of nurturing and protecting others. A structured health systems assessment, locally adapted from Chronic Care Model domains, was administered via group interviews with 37 health staff in six AMSs and one government Indigenous-led health service. Data were thematically analysed. RESULTS Staff emphasised AMS health care was different to private general practices. Consistent with kanyini, community governance and leadership, community representation among staff, and commitment to community development were important organisational features to retain and nurture both staff and patients. This was undermined, however, by constant fear of government funding for AMSs being withheld. Staff resourcing, information systems and high-level leadership were perceived to be key drivers of health care quality. On-site specialist services, managed by AMS staff, were considered an enabling strategy to increase specialist access. Candidacy theory suggests the above factors influence whether a service is 'tractable' and 'navigable' to its users. Staff also described entrenched patient discrimination in hospitals and the need to expend considerable effort to reinstate care. This suggests that Aboriginal and Torres Strait Islander people are still constructed as 'non-ideal users' and are denied from being 'held' by hospital staff. CONCLUSIONS Some new policy initiatives (workforce capacity strengthening, improving chronic care delivery systems and increasing specialist access) have potential to address barriers highlighted in this study. Few of these initiatives, however, capitalise on the unique mechanisms by which AMSs 'hold' their users and enhance their candidacy to health care. Kanyini and candidacy are promising and complementary theories for conceptualising health care access and provide a potential framework for improving systems of care.
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Affiliation(s)
- David Peiris
- The George Institute for Global Health, University of Sydney, Sydney, Australia
| | - Alex Brown
- The Baker IDI Heart and Diabetes Institute, Alice Springs, Australia
| | | | | | | | - Ian Ring
- University of Wollongong, Wollongong, Australia
| | - Noel Hayman
- Inala Indigenous Health Service, Brisbane, Australia
| | - Alan Cass
- The George Institute for Global Health, University of Sydney, Sydney, Australia
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Thom S, Field J, Poulter N, Patel A, Prabhakaran D, Stanton A, Grobbee DE, Bots ML, Reddy KS, Cidambi R, Rodgers A. Use of a Multidrug Pill In Reducing cardiovascular Events (UMPIRE): rationale and design of a randomised controlled trial of a cardiovascular preventive polypill-based strategy in India and Europe. Eur J Prev Cardiol 2012; 21:252-61. [PMID: 23038750 DOI: 10.1177/2047487312463278] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The use of preventive medications in people at high risk of cardiovascular disease is conceptually straightforward, yet in practice the adoption of such measures is disappointingly low, plus there is wide international variation in preventive therapies. Several barriers might explain this shortfall and variation, but the simplicity and economy of a polypill-based strategy might overcome some barriers. The 'Use of a Multidrug Pill In Reducing cardiovascular Events' (UMPIRE) trial assesses whether a polypill strategy (by combining aspirin, a statin and two blood pressure lowering agents) would improve adherence to guideline-indicated therapies and would lower both blood pressure and cholesterol, in people with established cardiovascular disease. UMPIRE, running in India and three European countries (England, Ireland and the Netherlands), is an open, randomised, controlled trial designed to include 1000 participants in India and 1000 in Europe, with a followup of 12-24 months. Participants were randomised to one of two versions of the polypill or relegated to usual care. The primary study outcomes were the self-reported use of aspirin, a statin and at least two blood pressure lowering agents; as well as changes in blood pressure and cholesterol. Secondary outcomes included: any cardiovascular events, reasons for stopping medications, serious adverse events and perceived changes in quality of life. Interpretation of the study data will be enhanced by health, economic and process-related evaluations. UMPIRE is registered with the European Clinical Trials database, as EudraCT: 2009-016278-34 and the Clinical Trials Registry, India as CTRI/2010/091/000250. The trial was part of the 'Single Pill Against Cardiovascular Events (SPACE)' collaboration, which encompasses the 'IMProving Adherence using Combination Therapy (IMPACT)' and 'Kanyini Guidelines Adherence with the Polypill (Kanyini-GAP)' trials.
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Affiliation(s)
- Simon Thom
- International Centre for Circulatory Health, Imperial College London, UK
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Ong KS, Carter R, Kelaher M, Anderson I. Differences in primary health care delivery to Australia's Indigenous population: a template for use in economic evaluations. BMC Health Serv Res 2012; 12:307. [PMID: 22954136 PMCID: PMC3468365 DOI: 10.1186/1472-6963-12-307] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 08/27/2012] [Indexed: 01/13/2023] Open
Abstract
Background Health economics is increasingly used to inform resource allocation decision-making, however, there is comparatively little evidence relevant to minority groups. In part, this is due to lack of cost and effectiveness data specific to these groups upon which economic evaluations can be based. Consequently, resource allocation decisions often rely on mainstream evidence which may not be representative, resulting in inequitable funding decisions. This paper describes a method to overcome this deficiency for Australia’s Indigenous population. A template has been developed which can adapt mainstream health intervention data to the Indigenous setting. Methods The ‘Indigenous Health Service Delivery Template’ has been constructed using mixed methods, which include literature review, stakeholder discussions and key informant interviews. The template quantifies the differences in intervention delivery between best practice primary health care for the Indigenous population via Aboriginal Community Controlled Health Services (ACCHSs), and mainstream general practitioner (GP) practices. Differences in costs and outcomes have been identified, measured and valued. This template can then be used to adapt mainstream health intervention data to allow its economic evaluation as if delivered from an ACCHS. Results The template indicates that more resources are required in the delivery of health interventions via ACCHSs, due to their comprehensive nature. As a result, the costs of such interventions are greater, however this is accompanied by greater benefits due to improved health service access. In the example case of the polypill intervention, 58% more costs were involved in delivery via ACCHSs, with 50% more benefits. Cost-effectiveness ratios were also altered accordingly. Conclusions The Indigenous Health Service Delivery Template reveals significant differences in the way health interventions are delivered from ACCHSs compared to mainstream GP practices. It is important that these differences are included in the conduct of economic evaluations to ensure results are relevant to Indigenous Australians. Similar techniques would be generalisable to other disadvantaged minority populations. This will allow resource allocation decision-makers access to economic evidence that more accurately represents the needs and context of disadvantaged groups, which is particularly important if addressing health inequities is a stated goal.
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Affiliation(s)
- Katherine S Ong
- Centre for Health Policy, Programs and Economics, School of Population Health, The University of Melbourne, Carlton, Victoria 3010, Australia.
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Jan S, Usherwood T, Brien JA, Peiris D, Rose J, Hayman N, Howard K, Redfern J, Laba T, Cass A, Patel A. What determines adherence to treatment in cardiovascular disease prevention? Protocol for a mixed methods preference study. BMJ Open 2011; 1:e000372. [PMID: 22080542 PMCID: PMC3211054 DOI: 10.1136/bmjopen-2011-000372] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Background Significant gaps exist between guidelines-recommended therapies for cardiovascular disease prevention and current practice. Fixed-dose combination pills ('polypills') potentially improve adherence to therapy. This study is a preference study undertaken in conjunction with a clinical trial of a polypill and seeks to examine the underlying reasons for variations in treatment adherence to recommended therapy. Methods/design A preference study comprising: (1) Discrete Choice Experiment for patients; and (2) qualitative study of patients and providers. Both components will be conducted on participants in the trial. A joint model combining the observed adherence in the clinical trial (revealed preference) and the Discrete Choice Experiment data (stated preference) will be estimated. Estimates will be made of the marginal effect (importance) of each attribute on overall choice, the extent to which respondents are prepared to trade-off one attribute for another and predicted values of the level of adherence given a fixed set of attributes, and contextual and socio-demographic characteristics. For the qualitative study, a thematic analysis will be used as a means of exploring in depth the preferences and ultimately provide important narratives on the experiences and perspectives of individuals with regard to adherence behaviour. Ethics and dissemination Primary ethics approval was received from Sydney South West Area Health Service Human Research Ethics Committee (Royal Prince Alfred Hospital zone). In addition to usual scientific forums, the findings will be reported back to the communities involved in the studies through site-specific reports and oral presentations.
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Affiliation(s)
- Stephen Jan
- George Institute for Global Health, Camperdown, Australia
| | - Tim Usherwood
- Department of General Practice, Western Clinical School, University of Sydney, Westmead, Australia
| | - Jo Anne Brien
- Faculty of Pharmacy, University of Sydney, Sydney, Australia
| | - David Peiris
- George Institute for Global Health, Camperdown, Australia
| | - John Rose
- Inala Indigenous Health Service, Brisbane, Australia
| | - Noel Hayman
- Institute for Transport and Logistics Studies, University of Sydney, Sydney, Australia
| | - Kirsten Howard
- School of Public Health, University of Sydney, Sydney, Australia
| | - Julie Redfern
- George Institute for Global Health, Camperdown, Australia
| | - Tracey Laba
- George Institute for Global Health, Camperdown, Australia
| | - Alan Cass
- George Institute for Global Health, Camperdown, Australia
| | - Anushka Patel
- George Institute for Global Health, Camperdown, Australia
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