A primary care medical home approach to pulmonary rehabilitation.

BACKGROUND: Pulmonary rehabilitation (PR) is an evidence-based, nonpharmacological intervention aimed to improve quality of life for patients living with Chronic Obstructive Pulmonary Disease (COPD). Unfortunately, in Canada, most PR programs are hospital based and these are few in number; therefore, accessibility to PR programs is limited. METHODS: The Edmonton Southside Primary Care Network implemented an evidence-based PR program within the setting of the patient's medical home. RESULTS: Post-program evaluation demonstrated improvement in 6-minute walk distance, lower body strength, COPD health status, and quality of life, as well as a reduction in emergency department visits 1 year after program completion. CONCLUSION: The results conclude that delivery of a PR program in a primary care setting is effective and can help address the issue of accessibility.

Connection Through Calls: The Impact of a Seniors Center Without Walls on Older Adults' Social Isolation and Loneliness.

The Edmonton Seniors Centre Without Walls program provides free health, psychosocial, and educational telephone programming for older adults who experience multiple barriers to traditional in-person programming. The aim of this program evaluation was to assess outcomes of participation using validated scales of loneliness and psychosocial and health quality of life. Telephone interviews were conducted pre (n = 160) and post (n = 99) with participants. Given the variation in average attendance, results were assessed by level of participation: Low, Moderate, and High Users. There was statistically significant improvement in all participants' attitudes towards their self-realization and towards energy levels, and EQ-5D-5L anxiety/depression scale after participation, along with a significant reduction in feelings of social isolation. The highest rates of improvement were seen within High Users. These findings suggest that telephone-based programs could be a useful intervention to improve the wellbeing and socially connectedness of older adults.

Simplified lipid guidelines: Prevention and management of cardiovascular disease in primary care.

OBJECTIVE: To develop clinical practice guidelines for a simplified approach to primary prevention of cardiovascular disease (CVD), concentrating on CVD risk estimation and lipid management for primary care clinicians and their teams; we sought increased contribution from primary care professionals with little or no conflict of interest and focused on the highest level of evidence available. METHODS: Nine health professionals (4 family physicians, 2 internal medicine specialists, 1 nurse practitioner, 1 registered nurse, and 1 pharmacist) and 1 nonvoting member (pharmacist project manager) comprised the overarching Lipid Pathway Committee (LPC). Member selection was based on profession, practice setting, and location, and members disclosed any actual or potential conflicts of interest. The guideline process was iterative through online posting, detailed evidence review, and telephone and online meetings. The LPC identified 12 priority questions to be addressed. The Evidence Review Group answered these questions. After review of the answers, key recommendations were derived through consensus of the LPC. The guidelines were drafted, refined, and distributed to a group of clinicians (family physicians, other specialists, pharmacists, nurses, and nurse practitioners) and patients for feedback, then refined again and finalized by the LPC. RECOMMENDATIONS: Recommendations are provided on screening and testing, risk assessments, interventions, follow-up, and the role of acetylsalicylic acid in primary prevention. CONCLUSION: These simplified lipid guidelines provide practical recommendations for prevention and treatment of CVD for primary care practitioners. All recommendations are intended to assist with, not dictate, decision making in conjunction with patients.

Cardiovascular nurse practitioner practice: results of a Canada-wide survey.

Despite an increase in the number of nurse practitioners (NPs) practising within the realm of cardiovascular care, roles and responsibilities of cardiovascular NPs in similar areas appear to be vast and variable. With the recent changes in certification and regulation of the NP role by the Canadian Nurses Association, there has been an attempt to standardize patient care practices. In the spring of 2005, the University of Alberta Hospital-based cardiovascular NPs conducted a national survey. This survey was the first formalized attempt to gather information on the practice patterns of cardiovascular NPs and determine if similarities in roles, responsibilities, manpower and patient workload existed across Canada. A survey was mailed out to all centres that were known to have cardiovascular NPs in their employ. An impressive response rate of 63% was obtained. As predicted, survey results reveal that roles and responsibilities of cardiovascular NPs are diverse and unique. One hundred per cent of respondents were Masters-prepared with 88% of cardiovascular NPs practising in a ward and/or outpatient setting. However, reporting structure, patient workload, clinical, educational, administrative, and research responsibilities were more diversified. The results of the survey may facilitate a better understanding of the NP role within the health care setting and in cardiovascular care. In turn, the findings may provide a basis by which to establish a template for developing future NP roles or enhancing existing NP roles in cardiovascular centres across Canada.

Clinical risk scoring beyond initial troponin values: results from a large, prospective, unselected acute chest pain population.

BACKGROUND: Risk stratifying the diverse group of patients who present to hospital with chest discomfort remains challenging. Current clinical risk models, typically derived from selected populations, are limited by their relative complexity and the absence of a well-defined role of troponin. OBJECTIVE: To derive a simple clinical risk score from a large, unselected population of patients with chest discomfort and to delineate the prognostic value of an initial troponin measurement. METHODS: Prospective, consecutive data were collected from patients who presented to a tertiary care hospital. Multivariate analysis was used to identify variables predictive of the primary end point: death, nonfatal myocardial infarction or revascularization at 30 days. Integer values were assigned, generating a risk score to quantify individual patient risk. RESULTS: Among 1054 patients, predictor variables included ST-segment deviation (strongest predictor -- assigned two points), male sex, prior congestive heart failure, three or more cardiac risk factors and prior acetylsalicylic acid use (one point each). There was a progressive increase in events with increasing total score (P<0.0001), with a 15-fold gradient from scores of 0 to 4 and greater. Although a negative troponin measurement was associated with fewer events for all scores, patients with higher scores remained exposed to substantial risk. A negative initial troponin measurement conferred a negative predictive value of 97.3% (95% CI 93.7% to 99.1%) among patients with a risk score of 0. CONCLUSION: Significant 30-day events occurred in patients with elevated risk scores, despite negative initial troponin measurements, emphasizing the importance of clinical risk stratification. This simple clinical risk score, in conjunction with a single troponin I measurement, facilitates triage of patients who present to hospital with chest discomfort.

Can symptom presentation predict unstable angina/non-ST-segment elevation myocardial infarction in a moderate-risk cohort?

BACKGROUND: Accurate recognition of acute coronary syndromes (ACS) on initial presentation is key to minimizing morbidity and mortality. The wide spectrum of symptom presentation in ACS complicates recognition. Unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) may be particularly difficult to diagnose as patients often do not exhibit initial high-risk features, leaving the clinician with symptom presentation alone, on which to base decisions regarding further investigation and treatment. PURPOSE: The aim of this study was to compare typical symptom presentation (classic description of angina) and atypical presentation in a cohort presenting with symptoms suggestive of UA/NSTEMI. METHOD: A prospective cohort design was used to evaluate 100 patients enrolled in an Emergency Department Chest Pain Program. RESULTS: Although patients with typical presentation were more likely to have UA/NSTEMI, atypical presentation did not rule out this diagnosis. Of the 31 patients with UA/NSTEMI, most (n=23, 74.2%) had atypical symptoms. Male gender, symptom location, and history of ischemic heart disease were significantly associated with UA/NSTEMI. Of those with a final diagnosis of UA/NSTEMI, there was no difference in symptom presentation based on age or gender. CONCLUSION: Clinicians should not rely on classic descriptions of angina when evaluating patients suspected of UA/NSTEMI.