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Development and validation of a patient decision aid to assist pharmaceutical care in the prevention of cardiovascular d

Development and validation of a patient decision aid to assist pharmaceutical care in the prevention of cardiovascular disease. L Lalonde B Pharm, PhD Faculty of Pharmacy University of Montreal Équipe de recherche en soins de première ligne Cité de la Santé de Laval Canadian Stroke Network.

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Development and validation of a patient decision aid to assist pharmaceutical care in the prevention of cardiovascular d

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  1. Development and validation of a patient decision aid to assist pharmaceutical care in the prevention of cardiovascular disease L Lalonde B Pharm, PhD Faculty of Pharmacy University of Montreal Équipe de recherche en soins de première ligne Cité de la Santé de Laval Canadian Stroke Network

  2. CVD prevention • Dyslipidemia and anti-hypertensive pharmacotherapy reduce CVD morbidity and mortality • Treatment guidelines are available • Adherence and persistence to treatment is low

  3. Hypertension • Canadian Heart Health Surveys: • 16% are treated and controlled • 23% are treated and not controlled • 19% are not treated and not controlled • 42% are unaware of their hypertension AJH 1997; 10:1097-1102

  4. Dyslipidemia • Low persistence to lipid-lowering medication • Two-year adherence in elderly: • Recent acute coronary syndrome: 40% • Chronic coronary artery disease: 36% • Primary prevention: 25% JAMA 2002; 288:462-467 • US-Canadian study: • Persistence: 50% after 5 years • Adherence: 66% of the time JAMA 1998;279(18):1458-1462

  5. Pharmaceutical care improves: Risk-factor control Adherence to pharmacotherapy Patient satisfaction Process of care DYSLIPIDEMIA ImPACT J Am Pharm Assoc 2000; 40(2):157-165 IMPROVE Pharmacotherapy 2000:20(12):1508-1516 SCRIP Arch Intern Med 2002;162:1149-1155 HYPERTENSION Circulation 1973:XLVIII:1104-11 J Am Pharma Assoc1996;36(7): 443-451 J Occup Med 1994;36(7):743-6 Pharmacotherapy 1997;17(1):140-147 J Am Pharma Assoc 1998;38:574-585 Pharmaceutical care

  6. Pharmaceutical care • Patient education • Evaluation of CVD risk • Development of a treatment plan • Patient follow-up Complex, time consuming, and therefore not easily implemented. The development of decision support tools for facilitating pharmaceutical care is important.

  7. Objective Development of a Decision Aid for patients with hypertension and dyslipidemia

  8. Development Developed by a panel of five researchers and clinicians Reviewed by experts in the field and linguistic specialist Pretest among patients with hypertension or dyslipidemia Pilot studies with pharmacists

  9. Description of the DECISION AID

  10. Decision Aid Includes: 1) Booklet 2) Personal worksheet

  11. Booklet Provides general information • CVD • Risk factors • Treatment options • Four steps decision-making strategy • Examples of patients

  12. Booklet The language is adapted to a grade-six level

  13. Booklet Provides general evidence-based information

  14. Worksheet Provides personal information to apply the four step strategy

  15. Step One: To evaluate current cardiovascular health

  16. Step One: • Modifiable CVD risk factors

  17. Step One: • Current CVD risk • CVD age

  18. Step Two: To evaluate the benefits of lifestyle changes and medication

  19. Step Two: Estimates of the potential changes in CVD risk with lifestyle changes and medication Lifestyle changes: LDL:  5% HDL:  5% BP (syst/dias):  10 / 5 mm Medication: LDL:  35% HDL:  10% BP (syst/dias):  15 / 10 mm

  20. Step Two: Net reduction in CVD risk if all modifiable risk factors are modified

  21. Step Two: Patient's preferences

  22. Step Three: To define a plan of action for the next three months with their health professional

  23. Step Four: To follow progress over time

  24. PRE-TESTING

  25. Development and Preliminary Testing of a Patient Decision Aid to Assist Pharmaceutical Care in the Prevention of Cardiovascular Disease. L Lalonde, AM O'Connor, SA Grover, P Duguay, A Kayal, E Drake Pharmacotherapy, July 2004

  26. Methods • Convenience sample of hypertensive and dyslipidemic patients from an hypertension clinic and CVD-prevention clinic. • Interviews before and after the decision aid

  27. Participant characteristics

  28. Acceptability of the Decision Aid

  29. Participants knowledge p=0.001* p=0.014* p=0.016* * Wilcoxon signed-rank test

  30. Perception of CVD risk Risk Category 10-year CVD Risk p = 0.031* p = 0.000* * McNemar test (exact versus inexact estimation)

  31. Decisional Conflict p=0.027* p=0.012* p=0.028* p=0.011* p=0.007*

  32. PILOT STUDY

  33. Evaluation of a decision aid to help patients considering treatment options to reduce their cardiovascular risk: OPTION randomized controlled pilot study L Lalonde, AM O'Connor, SA Grover, P Duguay, A Kayal, E Drake

  34. Mélanie Lauzon Evelyne Maher Andrée Martineau Jocelyne Mercier Isabelle Morneau Mélanie Pelletier Francine Perreault-Blake Julie Rousseau Isabelle Salomon Mélina Tsoumis Krystel Beaucage Pierre-Charles Boucher Dominique Chatel Chantal Desgroseillers Anne Drolet Marie Dubois Mélanie Gareau Normand Gauthier Vincent Landry Patrick Lapointe Véronique Laporte Community pharmacists

  35. Objective • To assess the feasibility, relevance and clinical usefulness of using a decision aid or a simpler educational tool (personalized risk profile) to assist pharmaceutical care in community pharmacies.

  36. Patients initiating anti-hypertensive or lipid-lowering medication(< 12 months) Randomisation Telephone interview Decision aid and pharmacist intervention Personal risk profile and pharmacist intervention Telephone interview 3-month follow-up Telephone interview

  37. Personal RiskProfile • Risk factors identification • CVD risk estimate • Benefit of treatment

  38. Patients sollicited by pharmacistsn = 42 Patients refused to participate (n = 10) Patients involved in another study (n = 1) Pharmacotherapy discontinued (n = 2) Never sent their medical information to the research nurse (n = 3) Pre-intervention interview n = 26 Intervention Post-intervention interview n = 24 3 month follow-up interview n = 23

  39. Analysis • No differences were observed between the DA and the PRP groups. • We combined the results of patients in the DA and the PRP groups • We assessed the differences before and after the intervention.

  40. Patients characteristics

  41. Patients characteristics

  42. Patients characteristics

  43. Acceptability

  44. Knowledge of personal risk factors Proportion of adequate assessment before and after the intervention

  45. Perception of CVD risk Risk category 10-year CVD risk Benefits of treatment

  46. Decisional conflict Median decision conflict score before and after the intervention p=0.028 p=0.028 p=0.055

  47. Decisional conflict Proportion of participants with score > 2.5 units 7 / 24 (29%) 15/26 (58%) P = 0.07

  48. Satisfaction pharmacist intervention Median score The Decision Satisfaction Inventory Scale (Barry MJ, Cherkin DC, Chang YC, Fowler FJ, SkatesS. Disease Management and Clinical Outcomes 1997;1:5-12)

  49. Initiation of treatment (n = 15) Continuation of treatment (n = 8)

  50. Stage of change Reducing salt in diet Smoking cessation Physical activity Reducing fat in diet Reducing alcohol Loosing weight

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