development and pre-testing of a patient decision aid to assist ...课件

Developmentandvalidationofapatientdecisionaidtoassistpharmaceuticalcareinthepreventionofcardiovasculardisease LLalondeBPharm PhDFacultyofPharmacyUniversityofMontreal quipederechercheensoinsdepremi religneCit delaSant deLavalCanadianStrokeNetwork CVDprevention Dyslipidemiaandanti hypertensivepharmacotherapyreduceCVDmorbidityandmortalityTreatmentguidelinesareavailableAdherenceandpersistencetotreatmentislow Hypertension CanadianHeartHealthSurveys 16 aretreatedandcontrolled23 aretreatedandnotcontrolled19 arenottreatedandnotcontrolled42 areunawareoftheirhypertension AJH1997 10 1097 1102 Lowpersistencetolipid loweringmedicationTwo yearadherenceinelderly Recentacutecoronarysyndrome 40 Chroniccoronaryarterydisease 36 Primaryprevention 25 JAMA2002 288 462 467US Canadianstudy Persistence 50 after5yearsAdherence 66 ofthetimeJAMA1998 279 18 1458 1462 Dyslipidemia Pharmaceuticalcare Pharmaceuticalcareimproves Risk factorcontrolAdherencetopharmacotherapyPatientsatisfactionProcessofcare DYSLIPIDEMIAImPACTJAmPharmAssoc2000 40 2 157 165IMPROVEPharmacotherapy2000 20 12 1508 1516SCRIPArchInternMed2002 162 1149 1155HYPERTENSIONCirculation1973 XLVIII 1104 11JAmPharmaAssoc1996 36 7 443 451JOccupMed1994 36 7 743 6Pharmacotherapy1997 17 1 140 147JAmPharmaAssoc1998 38 574 585 Pharmaceuticalcare Complex timeconsuming andthereforenoteasilyimplemented Thedevelopmentofdecisionsupporttoolsforfacilitatingpharmaceuticalcareisimportant PatienteducationEvaluationofCVDriskDevelopmentofatreatmentplanPatientfollow up Objective DevelopmentofaDecisionAidforpatientswithhypertensionanddyslipidemia Development Developedbyapaneloffiveresearchersandclinicians Reviewedbyexpertsinthefieldandlinguisticspecialist Pretestamongpatientswithhypertensionordyslipidemia Pilotstudieswithpharmacists DescriptionoftheDECISIONAID DecisionAid Includes 1 Booklet2 Personalworksheet Booklet Providesgeneralinformation CVDRiskfactorsTreatmentoptionsFourstepsdecision makingstrategyExamplesofpatients Booklet Thelanguageisadaptedtoagrade sixlevel Providesgeneralevidence basedinformation Booklet Worksheet Providespersonalinformationtoapplythefourstepstrategy StepOne Toevaluatecurrentcardiovascularhealth StepOne ModifiableCVDriskfactors StepOne CurrentCVDriskCVDage StepTwo Toevaluatethebenefitsoflifestylechangesandmedication StepTwo EstimatesofthepotentialchangesinCVDriskwithlifestylechangesandmedication Lifestylechanges LDL 5 HDL 5 BP syst dias 10 5mmMedication LDL 35 HDL 10 BP syst dias 15 10mm StepTwo NetreductioninCVDriskifallmodifiableriskfactorsaremodified StepTwo Patient spreferences StepThree Todefineaplanofactionforthenextthreemonthswiththeirhealthprofessional StepFour Tofollowprogressovertime PRE TESTING DevelopmentandPreliminaryTestingofaPatientDecisionAidtoAssistPharmaceuticalCareinthePreventionofCardiovascularDisease LLalonde AMO Connor SAGrover PDuguay AKayal EDrakePharmacotherapy July2004 Methods ConveniencesampleofhypertensiveanddyslipidemicpatientsfromanhypertensionclinicandCVD preventionclinic Interviewsbeforeandafterthedecisionaid Participantcharacteristics AcceptabilityoftheDecisionAid Participantsknowledge p 0 014 p 0 016 p 0 001 Wilcoxonsigned ranktest PerceptionofCVDrisk RiskCategory 10 yearCVDRisk p 0 031 p 0 000 McNemartest exactversusinexactestimation DecisionalConflict p 0 027 p 0 012 p 0 028 p 0 011 p 0 007 PILOTSTUDY Evaluationofadecisionaidtohelppatientsconsideringtreatmentoptionstoreducetheircardiovascularrisk OPTIONrandomizedcontrolledpilotstudy LLalonde AMO Connor SAGrover PDuguay AKayal EDrake Communitypharmacists M lanieLauzonEvelyneMaherAndr eMartineauJocelyneMercierIsabelleMorneauM laniePelletierFrancinePerreault BlakeJulieRousseauIsabelleSalomonM linaTsoumis KrystelBeaucagePierre CharlesBoucherDominiqueChatelChantalDesgroseillersAnneDroletMarieDuboisM lanieGareauNormandGauthierVincentLandryPatrickLapointeV roniqueLaporte Objective Toassessthefeasibility relevanceandclinicalusefulnessofusingadecisionaidorasimplereducationaltool personalizedriskprofile toassistpharmaceuticalcareincommunitypharmacies Patientsinitiatinganti hypertensiveorlipid loweringmedication 12months Randomisation Decisionaidandpharmacistintervention Personalriskprofileandpharmacistintervention 3 monthfollow up Telephoneinterview Telephoneinterview Telephoneinterview PersonalRiskProfile RiskfactorsidentificationCVDriskestimateBenefitoftreatment Patientssollicitedbypharmacistsn 42 Pre interventioninterviewn 26 Post interventioninterviewn 24 3monthfollow upinterviewn 23 Patientsrefusedtoparticipate n 10 Patientsinvolvedinanotherstudy n 1 Intervention Pharmacotherapydiscontinued n 2 Neversenttheirmedicalinformationtotheresearchnurse n 3 Analysis NodifferenceswereobservedbetweentheDAandthePRPgroups WecombinedtheresultsofpatientsintheDAandthePRPgroupsWeassessedthedifferencesbeforeandaftertheintervention Patientscharacteristics Patientscharacteristics Patientscharacteristics Acceptability Knowledgeofpersonalriskfactors Proportionofadequateassessmentbeforeandaftertheintervention Riskcategory 10 yearCVDrisk Benefitsoftreatment PerceptionofCVDrisk Mediandecisionconflictscorebeforeandaftertheintervention p 0 028 p 0 028 p 0 055 Decisionalconflict Decisionalconflict Proportionofparticipantswithscore 2 5units 15 26 58 7 24 29 P 0 07 Satisfactionpharmacistintervention Medianscore TheDecisionSatisfactionInventoryScale BarryMJ CherkinDC ChangYC FowlerFJ SkatesS DiseaseManagementandClinicalOutcomes1997 1 5 12 Initiationoftreatment n 15 Continuationoftreatment n 8 Stageofchange Smokingcessation Physicalactivity Reducingfatindiet Reducingsaltindiet Loosingweight Reducingalcohol Limits PilotstudywithoutrealcontrolgroupOnlyonepharmacistvisitPrevalentcasesLackofphysiciancollaboration Discussion Feasibility Barrierstoimplementationperformresearchproceduresobtainpreviouslaboratorytestresultsschedulepatient sappointmentcollaborationwithtreatingphysician Disc