Engaging community pharmacists in the primary prevention of cardiovascular disease: protocol for the Pharmacist Assessment of Adherence, Risk and Treatment in Cardiovascular Disease (PAART CVD) pilot study

Health and Wellness Coaching for 5-Year Projected Cardiovascular Health: A Randomized Controlled Trial

Background and Objectives

Evidence of effective multifactorial lifestyle interventions for primary stroke prevention is lacking, despite the significant contribution of lifestyle to stroke burden. We aimed to determine the efficacy of health and wellness coaching (HWC) for primary stroke and cardiovascular disease (CVD) prevention in adults at a moderate-to-high CVD risk.

Methods

This was a parallel, 2-arm, open-label, single-blinded, phase III randomized controlled trial to determine the efficacy of HWC for primary stroke prevention in individuals 30 years and older with a 5-year CVD risk ≥10% as measured by 5-year absolute CVD risk (as measured by the PREDICT tool) at 9 months post-randomization. Eligible participants were those with a 5-year CVD risk ≥10%, with no history of stroke, transient ischemic attack, or myocardial infarction. The relative risk reduction (RRR) and odds ratios (OR) were evaluated separately in those at moderate (10%-14%) 5-year CVD risk and those at high risk (≥15%) at baseline. The Life's Simple 7 (LS7) score for lifestyle-related CVD risk, as the indicator of cardiovascular health, was a key secondary outcome.

Results

Of a total of 320 participants, 161 were randomized to the HWC group and 159 to the usual care (UC) group. HWC resulted in a statistically significant RRR of -10.9 (95% CI -21.0 to -0.9) in 5-year CVD risk in the higher CVD risk group but no change in the moderate risk group. An improvement in the total LS7 score was seen in the HWC group compared with the UC group (absolute difference = 0.485, 95% CI [0.073 to 0.897], p = 0.02). Improvement in blood pressure scores was statistically significantly greater in the HWC group than in the UC group for those at high risk of CVD (OR 2.28 [95% CI 1.12 to 4.63] and 1.55 [0.80 to 3.01], respectively). No statistically significant differences in mood scores, medication adherence, quality of life, and satisfaction with life scores over time or between groups were seen.

Discussion

Health and wellness coaching resulted in a significant RRR in the 5-year CVD risk compared with UC at 9 months post-randomization in patients with a high baseline CVD risk. There was no improvement in CVD risk in the moderate risk group; hence, this study did not meet the primary hypothesis. However, this treatment effect is clinically significant (number needed to treat was 43). The findings suggest that HWC has potential if further refined to improve lifestyle risk factors of stroke.

Knee osteoarthritis and the knowledgeable, trustworthy pharmacist: Patient and pharmacist perceptions of community pharmacy-based education and support

BACKGROUND

Osteoarthritis (OA) clinical guidelines recommend self-management education, but education is often not included in primary care consultations.

OBJECTIVE

To explore pharmacists' and patients' perceptions of a pharmacist-led model of service delivery for knee OA that was integrated within pharmacies' day-to-day workflow.

METHODS

Cross-sectional qualitative design using Thematic Analysis. Community pharmacies were recruited in New Zealand and Australia. Pharmacy patients were screened for knee OA and offered tailored explanations, self-management information and referral for further support. Pharmacist focus groups and patient 1:1 interviews explored perceptions of the service delivery model.

RESULTS

Nineteen pharmacists and 12 patients with knee OA participated. Pharmacist and patient data were analysed separately, with themes compared and contrasted to derive three meta-themes. Meta-theme 1: 'Welcome Engagement' included two pharmacist themes ('putting my broad skill set to use' and 'we're here and happy to help') and two patient themes ('information delivered well' and 'a welcome offer of help'). Meta-theme 2: 'The Knowledgeable and Trustworthy Pharmacist' included two pharmacist themes ('professional knowledge to help all sorts of patients' and 'managing time to help my patients') and one patient theme ('the accessible professional who I know and trust'). Meta-theme 3: 'The Opportunity for More Support' included one pharmacist theme ('this is not the end of the story') and one patient theme ('more help is available').

CONCLUSION

Community pharmacists are well-positioned to provide information and support to people with knee OA. Pharmacists appreciate the opportunity to better use their skills and accessibility for OA care, and patients welcome this engagement.

Nutrition Education and Community Pharmacy: A First Exploration of Current Attitudes and Practices in Northern Ireland

Community pharmacist is one of the most prominent and accessible healthcare professions. The community pharmacists' role in healthcare is evolving, with opportunities being taken to reduce pressure on primary care services. However, the question remains of how well community pharmacists are equipped for this changing role. This was a sequentially designed study using a mix of methods to explore nutrition education among community pharmacists in Northern Ireland. It consisted of two phases. Phase 1 was a cross-sectional exploration to map the attitudes and practice of Northern Ireland (NI) pharmacists towards diet-related health promotion and disease prevention. An online questionnaire with open and closed questions to gain both quantitative and qualitative responses was developed and distributed to community pharmacists practising in NI. A total of 91% considered nutrition important in reducing the global burden of disease. While the majority (89%) believed patients would value nutritional advice from a pharmacist, 74% were not confident in providing advice to a patient with diabetes. From the consensus gained in Phase 1 a nutrition education intervention (Phase 2) for pre-registration pharmacists was developed using the Hardens 10 question system. The training programme was advertised to pre-registration pharmacy students in NI. It was delivered by nutrition experts who have education qualifications. The intervention was evaluated using a before and after questionnaire that assessed knowledge, attitudes, and practice (KAP). Phase 2 did find sustained improvement from the baseline in KAP but there was a decline from immediately post-training to three months post-training. This suggests the need to further embed nutrition education. The education programme was found to be effective for the target population and sets the stage for the development of an implementation strategy for a wider roll-out with evaluation.

Cardiovascular disease as a leading cause of death: how are pharmacists getting involved?

Cardiovascular diseases (CVDs) are a leading cause of death globally. This article explores the evidence surrounding community pharmacist interventions to reduce cardiovascular events and related mortality and to improve the management of CVD risk factors. We summarize a range of systematic reviews and leading randomized controlled trials and provide critical appraisal. Major observations are that very few trials directly measure clinical outcomes, potentially owing to a range of challenges in this regard. By contrast, there is an extensive, high-quality evidence to suggest that improvements can be achieved for key CVD risk factors such as hypertension, dyslipidemia, tobacco use, and elevated hemoglobin A1c. The heterogeneity of interventions tested and considerable variation of the context under which implementation occurred suggest that caution is warranted in the interpretation of meta-analyses. It is highly important to generate evidence for pharmacist interventions in developing countries where a majority of the global CVD burden will be experienced in the near future. A growing capacity for clinical registry trials and data linkage might allow future research to collect clinical outcomes data more often.

The Community Pharmacist's Role in Reducing Cardiovascular Risk Factors in Lebanon: A Longitudinal Study

OBJECTIVE

To assess the role of the pharmacist in modifying risk factors for cardiovascular disease (CVD) among Lebanese adults in urban and rural areas.

METHODS

In a prospective survey, 865 out of 1,000 participants aged ≥45 years, previously interviewed, agreed to be followed at 1 and 2 years time points. Parameters including blood pressure, lipid profile, blood glucose, average number of risk factors, and atherosclerotic CVD (ASCVD) risk were assessed and evaluated at the beginning of the study, then after 1 and 2 years.

RESULTS

During both follow-ups, the mean average body mass index and systolic blood pressure decreased significantly and the lipid profile improved significantly. Further significant improvements in ASCVD risk occurred during the second follow-up. Monitoring parameters revealed significant improvements as well.

CONCLUSION

This study showed that a plan that includes pharmacists, who regularly monitor and follow-up patients, could improve CVD prevention through the reduction of risk factors.

Primary prevention of stroke and cardiovascular disease in the community (PREVENTS): Methodology of a health wellness coaching intervention to reduce stroke and cardiovascular disease risk, a randomized clinical trial

Rationale Stroke is a major cause of death and disability worldwide, yet 80% of strokes can be prevented through modifications of risk factors and lifestyle and by medication. While management strategies for primary stroke prevention in high cardiovascular disease risk individuals are well established, they are underutilized and existing practice of primary stroke prevention are inadequate. Behavioral interventions are emerging as highly promising strategies to improve cardiovascular disease risk factor management. Health Wellness Coaching is an innovative, patient-focused and cost-effective, multidimensional psychological intervention designed to motivate participants to adhere to recommended medication and lifestyle changes and has been shown to improve health and enhance well-being. Aims and/or hypothesis To determine the effectiveness of Health Wellness Coaching for primary stroke prevention in an ethnically diverse sample including Māori, Pacific Island, New Zealand European and Asian participants. Design A parallel, prospective, randomized, open-treatment, single-blinded end-point trial. Participants include 320 adults with absolute five-year cardiovascular disease risk ≥ 10%, calculated using the PREDICT web-based clinical tool. Randomization will be to Health Wellness Coaching or usual care groups. Participants randomized to Health Wellness Coaching will receive 15 coaching sessions over nine months. Study outcomes A substantial relative risk reduction of five-year cardiovascular disease risk at nine months post-randomization, which is defined as 10% relative risk reduction among those at moderate five-year cardiovascular disease risk (10-15%) and 25% among those at high risk (>15%). Discussion This clinical trial will determine whether Health Wellness Coaching is an effective intervention for reducing modifiable risk factors, and hence decrease the risk of stroke and cardiovascular disease.

Impact of changes in pill appearance in the adherence to angiotensin receptor blockers and in the blood pressure levels: a retrospective cohort study

OBJECTIVE

To assess the level of adherence to angiotensin receptor blockers (ARBs) in patients regularly attending a community pharmacy and the influence of a change in patients' adherence to pharmacological treatment.

DESIGN

Retrospective cohort study of a random sample of consecutive patients collecting their medication.

SETTING

40 community pharmacies in Alicante (Southeast Spain).

PARTICIPANTS

602 consecutive ≥18 years old patients following treatment with ARBs at least 3 previous refills were included.

MAIN OUTCOME MEASURES

Prevalence of uncontrolled blood pressure (BP) and adherence to prescribed pharmacological treatment (measured through both the Batalla and the Morisky-Green tests). A multivariate Poisson regression model was used to estimate the adjusted risk ratio (RRa) for non-adherence to pharmacological treatment by the presence of a change in patient's adherence and other significant variables.

RESULTS

161/602 (13.7%) patients presented uncontrolled BP. According to the Morisky test, 410/602 (68.2%) patients were considered adherent to pharmacological treatment and 231/602 (38.4%) patients according to the Batalla test. According to the Morisky-Green test, in the multivariable analysis, patients with a previous change in pill appearance were less likely to be adherent than those patients with no change in their pharmacological treatment (RRa 0.45; CI 95% 0.22 to 0.90; p=0.024). Systolic BP was higher in patients with a change in pill appearance in the previous 3 refills (median BP 142 mm Hg; IQR 136-148) than in those who did not have a change (median BP 127 mm Hg; IQR 118-135; p<0.001).

CONCLUSIONS

There was a low percentage of adherence and nearly 15% of uncontrolled BP in patients who regularly collected their medication. Switching between pills of different appearances was associated with lower patient adherence to pharmacological treatment and a higher uncontrolled BP than no change in pharmacological treatment or change only in package but not in pill appearance.

Prevention of stroke: a strategic global imperative

The increasing global stroke burden strongly suggests that currently implemented primary stroke prevention strategies are not sufficiently effective, and new primary prevention strategies with larger effect sizes are needed. Here, we review the latest stroke epidemiology literature, with an emphasis on the recently published Global Burden of Disease 2013 Study estimates; highlight the problems with current primary stroke and cardiovascular disease (CVD) prevention strategies; and outline new developments in primary stroke and CVD prevention. We also suggest key priorities for the future, including comprehensive prevention strategies that target people at all levels of CVD risk; implementation of an integrated approach to promote healthy behaviours and reduce health disparities; capitalizing on information technology to advance prevention approaches and techniques; and incorporation of culturally appropriate education about healthy lifestyles into standard education curricula early in life. Given the already immense and fast-increasing burden of stroke and other major noncommunicable diseases (NCDs), which threatens worldwide sustainability, governments of all countries should develop and implement an emergency action plan addressing the primary prevention of NCDs, possibly including taxation strategies to tackle unhealthy behaviours that increase the risk of stroke and other NCDs.

Behaviour change techniques: the development and evaluation of a taxonomic method for reporting and describing behaviour change interventions (a suite of five studies involving consensus methods, randomised controlled trials and analysis of qualitative data)

BACKGROUND

Meeting global health challenges requires effective behaviour change interventions (BCIs). This depends on advancing the science of behaviour change which, in turn, depends on accurate intervention reporting. Current reporting often lacks detail, preventing accurate replication and implementation. Recent developments have specified intervention content into behaviour change techniques (BCTs) - the 'active ingredients', for example goal-setting, self-monitoring of behaviour. BCTs are 'the smallest components compatible with retaining the postulated active ingredients, i.e. the proposed mechanisms of change. They can be used alone or in combination with other BCTs' (Michie S, Johnston M. Theories and techniques of behaviour change: developing a cumulative science of behaviour change. Health Psychol Rev 2012;6:1-6). Domain-specific taxonomies of BCTs have been developed, for example healthy eating and physical activity, smoking cessation and alcohol consumption. We need to build on these to develop an internationally shared language for specifying and developing interventions. This technology can be used for synthesising evidence, implementing effective interventions and testing theory. It has enormous potential added value for science and global health.

OBJECTIVE

(1) To develop a method of specifying content of BCIs in terms of component BCTs; (2) to lay a foundation for a comprehensive methodology applicable to different types of complex interventions; (3) to develop resources to support application of the taxonomy; and (4) to achieve multidisciplinary and international acceptance for future development.

DESIGN AND PARTICIPANTS

Four hundred participants (systematic reviewers, researchers, practitioners, policy-makers) from 12 countries engaged in investigating, designing and/or delivering BCIs. Development of the taxonomy involved a Delphi procedure, an iterative process of revisions and consultation with 41 international experts; hierarchical structure of the list was developed using inductive 'bottom-up' and theory-driven 'top-down' open-sort procedures (n = 36); training in use of the taxonomy (1-day workshops and distance group tutorials) (n = 161) was evaluated by changes in intercoder reliability and validity (agreement with expert consensus); evaluating the taxonomy for coding interventions was assessed by reliability (intercoder; test-retest) and validity (n = 40 trained coders); and evaluating the taxonomy for writing descriptions was assessed by reliability (intercoder; test-retest) and by experimentally testing its value (n = 190).

RESULTS

Ninety-three distinct, non-overlapping BCTs with clear labels and definitions formed Behaviour Change Technique Taxonomy version 1 (BCTTv1). BCTs clustered into 16 groupings using a 'bottom-up' open-sort procedure; there was overlap between these and groupings produced by a theory-driven, 'top-down' procedure. Both training methods improved validity (both p < 0.05), doubled the proportion of coders achieving competence and improved confidence in identifying BCTs in workshops (both p < 0.001) but did not improve intercoder reliability. Good intercoder reliability was observed for 80 of the 93 BCTs. Good within-coder agreement was observed after 1 month (p < 0.001). Validity was good for 14 of 15 BCTs in the descriptions. The usefulness of BCTTv1 to report descriptions of observed interventions had mixed results.

CONCLUSIONS

The developed taxonomy (BCTTv1) provides a methodology for identifying content of complex BCIs and a foundation for international cross-disciplinary collaboration for developing more effective interventions to improve health. Further work is needed to examine its usefulness for reporting interventions.

FUNDING

This project was funded by the Medical Research Council Ref: G0901474/1. Funding also came from the Peninsula Collaboration for Leadership in Applied Health Research and Care.

Intervention fidelity for a complex behaviour change intervention in community pharmacy addressing cardiovascular disease risk

Delivery of cardiovascular disease (CVD) prevention programs by community pharmacists appears effective and enhances health service access. However, their capacity to implement complex behavioural change processes during patient counselling remains largely unexplored. This study aims to determine intervention fidelity by pharmacists for behavioural components of a complex educational intervention for CVD prevention. After receiving training to improve lifestyle and medicines adherence, pharmacists recruited 70 patients aged 50-74 years without established CVD, and taking antihypertensive or lipid lowering therapy. Patients received five counselling sessions, each at monthly intervals. Researchers assessed biomedical and behavioural risk factors at baseline and six months. Pharmacists documented key outcomes from counselling after each session. Most patients (86%) reported suboptimal cardiovascular diets, 41% reported suboptimal medicines adherence, and 39% were physically inactive. Of those advised to complete the intervention, 85% attended all five sessions. Pharmacists achieved patient agreement with most recommended goals for behaviour change, and overwhelmingly translated goals into practical behavioural strategies. Barriers to changing behaviours were regularly documented, and pharmacists reported most behavioural strategies as having had some success. Meaningful improvements to health behaviours were observed post-intervention. Findings support further exploration of pharmacists' potential roles for delivering interventions with complex behaviour change requirements.

Improving the prevention of cardiovascular disease in primary health care: the model for prevention study protocol

Background

Cardiovascular disease (CVD) is the leading cause of death globally, and accounted for nearly 31% of all deaths in Australia in 2011. The primary health care sector is at the frontline for addressing CVD, however, an evidence-to-practice gap exists in CVD risk assessment and management. General practice plays a key role in CVD risk assessment and management, but this sector cannot provide ongoing lifestyle change support in isolation. Community-based lifestyle modification services and programs provided outside the general practice setting have a key role in supporting and sustaining health behavior change. Fostering linkages between the health sector and community-based lifestyle services, and creating sustainable systems that support these sectors is important.

Objective

The objective of the study Model for Prevention (MoFoP) is to take a case study approach to examine a CVD risk reduction intervention in primary health care, with the aim of identifying the key elements required for an effective and sustainable approach to coordinate CVD risk reduction across the health and community sectors. These elements will be used to consider a new systems-based model for the prevention of CVD that informs future practice.

Methods

The MoFoP study will use a mixed methods approach, comprising two complementary research elements: (1) a case study, and (2) a pre/post quasi-experimental design. The case study will consider the organizations and systems involved in a CVD risk reduction intervention as a single case. The pre/post experimental design will be used for HeartLink, the intervention being tested, where a single cohort of patients between 45 and 74 years of age (or between 35 and 74 years of age if Aboriginal or Torres Strait Islander) considered to be at high risk for a CVD event will be recruited through general practice, provided with enhanced usual care and additional health behavior change support. A range of quantitative and qualitative data will be collected. This will include individual health and well being data collected at baseline and again at 12 months for HeartLink participants, and systems related data collected over the period of the intervention to inform the case study.

Results

The intervention is currently underway, with results expected in late 2015.

Conclusions

Gaining a better understanding of CVD prevention in primary health care requires a research approach that can capture and express its complexity. The MoFoP study aims to identify the key elements for effective CVD prevention across the health and community sectors, and to develop a model to better inform policy and practice in this key health priority area for Australia.

Development and validation of the Diet Quality Tool for use in cardiovascular disease prevention settings

The aim of this study was to develop and evaluate a dietary screening tool for use in a secondary cardiovascular disease (CVD) prevention setting to identify an individual's overall dietary quality. The Diet Quality Tool (DQT) was validated against a 4-day food diary for 37 individuals with established CVD attending cardiac rehabilitation. Construct validity was demonstrated for % energy from saturated fat (P=0.002, r=-0.500), dietary fibre (P<0.001, r=0.559) and omega-3 fatty acids (P=0.048, r=0.327). Criterion validity was established with a significant difference found between mean (95% CI) dietary intakes of fibre (28.2g, 4.4 to 17.3) and % total energy from saturated fat (10.6%, -4.8 to -0.8) for those with better DQT scores (>60%) versus those with poorer scores (≤60%) when compared with 4-day food diary nutrient values. The usefulness of the DQT was confirmed by both patients (n=25) and cardiac rehabilitation health professionals (n=8). The DQT was found to be a valid and useful dietary assessment tool with potential for use in a secondary CVD prevention setting. The tool has the capacity to be used in a wider variety of settings and further refinement of the tool would enable a greater amount of nutrients to be reliably screened.

The roles of community pharmacists in cardiovascular disease prevention and management

There is ample evidence in the international literature for pharmacist involvement in the prevention and management of cardiovascular disease (CVD) conditions in primary care. Systematic reviews and meta-analyses have confirmed the significant clinical benefits of pharmacist interventions for a range of CVD conditions and risk factors. Evidence generated in research studies of Australian community pharmacist involvement in CVD prevention and management is summarised in this article.Commonwealth funding through the Community Pharmacy Agreements has facilitated research to establish the feasibility and effectiveness of new models of primary care involving community pharmacists. Australian community pharmacists have been shown to effect positive clinical, humanistic and economic outcomes in patients with CVD conditions. Improvements in blood pressure, lipid levels, medication adherence and CVD risk have been demonstrated using different study designs. Satisfaction for GPs, pharmacists and consumers has also been reported. Perceived 'turf' encroachment, expertise of the pharmacist, space, time and remuneration are challenges to the implementation of disease management services involving community pharmacists.