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5.  Insulin versus an oral antidiabetic agent as add-on therapy in type 2 diabetes after failure of an oral antidiabetic regimen: a meta-analysis 
Open Medicine  2008;2(2):e26-e38.
Background
Although evidence-based guidelines for the treatment of type 2 diabetes mellitus provide clear recommendations for initial therapy, evidence on an optimal treatment strategy after secondary failure is unclear.
Purpose
To compare the efficacy of add-on therapy using basal insulin versus an additional oral antidiabetic agent in patients with type 2 diabetes and secondary failure.
Data sources
We searched the following electronic databases from inception until June 2007: MEDLINE; EMBASE; Cochrane Central Register of Controlled Trials; Web of Science; Scopus; CINAHL; International Pharmaceutical Abstracts; Academic OneFile; PASCAL; Global Health Database; LILACS; HealthSTAR; PubMed. Reference lists of potentially relevant articles and clinical trial databases were searched, pharmaceutical manufacturers were contacted, and grey literature sources were sought.
Study selection
Randomized controlled trials (RCTs) involving subjects with type 2 diabetes with secondary failure who were randomly assigned to receive additional basal insulin therapy (insulin glargine, detemir, or NPH [neutral protamine Hagedorn]) versus another oral antidiabetic agent from any class.
Data extraction
Two reviewers independently screened articles, extracted data and assessed methodological quality. Our primary outcome was glycemic control measured by change in glycosylated hemoglobin (HbA1C) and the proportion of subjects achieving a HbA1C value of ≤ 7%.
Data synthesis
To compare overall efficacy between the 2 treatment strategies, change in HbA1C was pooled across studies using a random-effects model and weighted mean difference (WMD). Eleven RCTs, involving 757 participants with a median age of 56 and a median known duration of diabetes of 11 years, were included in our analysis. Insulin treatment demonstrated a small but statistically significant improvement in HbA1C compared with the use of an additional oral agent as add-on therapy (WMD -0.17; 95% CI [confidence interval] -0.33 to -0.02).
Limitations
The use of surrogate outcomes and the short duration of the trials makes it impossible to gain information on long-term patient-oriented outcomes. The overall quality of the studies was low, primarily in view of inadequate blinding.
Conclusions
Although add-on therapy using injected insulin shows a slight benefit over an additional oral antidiabetic agent, our results indicate that basal insulin therapy and the use of an oral agent as add-on therapy produce comparable results. Non-therapeutic differences must be considered in the choice of treatment strategies. More high-quality studies with adequate safety data using more aggressive insulin titrations are needed.
PMCID: PMC3090175  PMID: 21602937
6.  Effect of Adding Pharmacists to Primary Care Teams on Blood Pressure Control in Patients With Type 2 Diabetes 
Diabetes Care  2010;34(1):20-26.
OBJECTIVE
To evaluate the effect of adding pharmacists to primary care teams on the management of hypertension and other cardiovascular risk factors in patients with type 2 diabetes.
RESEARCH DESIGN AND METHODS
We conducted a randomized controlled trial with blinded ascertainment of outcomes within primary care clinics in Edmonton, Canada. Pharmacists performed medication assessments and limited history and physical examinations and provided guideline-concordant recommendations to optimize medication management. Follow-up contact was completed as necessary. Control patients received usual care. The primary outcome was a ≥10% decrease in systolic blood pressure at 1 year.
RESULTS
A total of 260 patients were enrolled, 57% were women, the mean age was 59 years, diabetes duration was 6 years, and blood pressure was 129/74 mmHg. Forty-eight of 131 (37%) intervention patients and 30 of 129 (23%) control patients achieved the primary outcome (odds ratio 1.9 [95% CI 1.1–3.3]; P = 0.02). Among 153 patients with inadequately controlled hypertension at baseline, intervention patients (n = 82) were significantly more likely than control patients (n = 71) to achieve the primary outcome (41 [50%] vs. 20 [28%]; 2.6 [1.3–5.0]; P = 0.007) and recommended blood pressure targets (44 [54%] vs. 21 [30%]; 2.8 [1.4–5.4]; P = 0.003). The 10-year risk of cardiovascular disease, based on changes to the UK Prospective Diabetes Study Risk Engine, were predicted to decrease by 3% for intervention patients and 1% for control patients (P = 0.005).
CONCLUSIONS
Significantly more patients with type 2 diabetes achieved better blood pressure control when pharmacists were added to primary care teams, which suggests that pharmacists can make important contributions to the primary care of these patients.
doi:10.2337/dc10-1294
PMCID: PMC3005466  PMID: 20929988
7.  Sex-based disparities in cardioprotective medication use in adults with diabetes 
Objective
The identification of sex-based disparities in the use of effective medications in high-risk populations can lead to interventions to minimize disparities in health outcomes. The objective of this study was to determine sex-specific rates of cardioprotective medication use in a large population-level administrative-health database from a universal-payer environment.
Research design and methods
This observational, population-based cohort study used provincial administrative data to compare the utilization of cardioprotective medications between women and men in the first year following a diabetes diagnosis. Competing risks regression was used to calculate crude and adjusted sub-hazard ratios for time-to-first angiotensin-converting-enzyme inhibitor, angiotensin receptor blocker, or statin dispensations.
Results
There were 15,120 (45.4%) women and 18,174 (54.6%) men with diabetes in the study cohort. Overall cardioprotective medication use was low for both primary and secondary prevention for both women and men. In the year following a diabetes diagnosis, women were less likely to use a statin relative to men (adjusted sub-hazard ratio [aSHR] 0.90, 95% confidence interval [CI] 0.85 to 0.96), angiotensin-converting-enzyme inhibitors (aSHR 0.90, 95% CI 0.86 to 0.94), or any cardioprotective medication (aSHR 0.93, 95% CI 0.90 to 0.97).
Conclusions
Cardioprotective medication use was not optimal in women or men. We also identified a health care gap with cardioprotective medication use being lower in women with diabetes compared to men. Closing this gap has the potential to reduce the impact of cardiovascular disease in women with diabetes.
Electronic supplementary material
The online version of this article (doi:10.1186/1758-5996-6-117) contains supplementary material, which is available to authorized users.
doi:10.1186/1758-5996-6-117
PMCID: PMC4240896  PMID: 25419242
8.  Feasibility of a self-administered survey to identify primary care patients at risk of medication-related problems 
Background and objectives
Pharmacists working in primary care clinics are well positioned to help optimize medication management of community-dwelling patients who are at high risk of experiencing medication-related problems. However, it is often difficult to identify these patients. Our objective was to test the feasibility of a self-administered patient survey, to facilitate identification of patients at high risk of medication-related problems in a family medicine clinic.
Methods
We conducted a cross-sectional, paper-based survey at the University of Alberta Hospital Family Medicine Clinic in Edmonton, Alberta, which serves approximately 7,000 patients, with 25,000 consultations per year. Adult patients attending the clinic were invited to complete a ten-item questionnaire, adapted from previously validated surveys, while waiting to be seen by the physician. Outcomes of interest included: time to complete the questionnaire, staff feedback regarding impact on workflow, and the proportion of patients who reported three or more risk factors for medication-related problems.
Results
The questionnaire took less than 5 minutes to complete, according to the patient’s report on the last page of the questionnaire. The median age (and interquartile range) of respondents was 57 (45–69) years; 59% were women; 47% reported being in very good or excellent health; 43 respondents of 100 had three or more risk factors, and met the definition for being at high risk of a medication-related problem.
Conclusions
Distribution of a self-administered questionnaire did not disrupt patients, or the clinic workflow, and identified an important proportion of patients at high risk of medication-related problems.
doi:10.2147/JMDH.S46910
PMCID: PMC3937182  PMID: 24591839
screening tool; pharmacists; primary care; medication related problems
9.  Effect of Aspirin Dose on Mortality and Cardiovascular Events in People with Diabetes: A Meta-Analysis 
Journal of General Internal Medicine  2011;26(11):1336-1344.
Objectives
Pharmacologic evidence suggests adequate antiplatelet activity in diabetic patients requires >100 mg aspirin daily, yet recent trials have used ≤100 mg daily. This meta-analysis explored the relationship between aspirin dose and prevention of cardiovascular events.
Data Sources
Six electronic databases were searched using database-appropriate terms for aspirin, diabetes, and comparative study from inception until February 2010.
Review Methods
Randomized controlled trials and cohort studies comparing aspirin to no antiplatelet therapy were included if they reported cardiovascular events as pre-specified outcomes, aspirin dose, and number of diabetic patients. Studies were stratified by daily aspirin dose (≤100 mg; 101–325 mg; >325 mg) and pooled risk ratios (RR) were calculated using random effects models. All-cause mortality was the primary outcome of interest. Cardiovascular-related mortality, myocardial infarction, and stroke were secondary outcomes.
Results
Data for diabetic patients were available from 21 studies (n = 17,522). Overall, 1,172 (15.4%) of 7,592 aspirin users and 1,520 (18.4%) of 8,269 controls died (p = 0.31). The pooled RRs were 0.89 (95% CI: 0.72–1.10; p = 0.27) from 13 studies using ≤100 mg (I2 = 64%); 0.89 (95% CI: 0.61–1.30; p = 0.55) from four studies using 101–325 mg (I2 = 83%); and 0.96 (95% CI: 0.85–1.08; p = 0.50) from eight studies using >325 mg (I2 = 0%). Aspirin use was associated with a significantly lower risk of mortality (RR: 0.82; 95% CI: 0.69–0.98; p = 0.03) in 13 secondary prevention studies (I2 = 27%), whereas aspirin use in seven primary prevention studies (I2 = 0%) was not (RR: 1.01; 95% CI 0.85–1.19; p = 0.94). A substantial amount of heterogeneity was observed amongst studies in all outcomes. Although inclusion of cohort studies was a major source of heterogeneity, stratification by study design did not reveal a significant dose-response relationship.
Conclusions/Interpretation
This summary of available data does not support an aspirin dose-response effect for prevention of cardiovascular events in diabetic patients. However, the systematic review identified an important gap in randomized controlled trial evidence for using 101–325 mg aspirin daily in diabetes.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-011-1757-y) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-011-1757-y
PMCID: PMC3208465  PMID: 21647746
aspirin; diabetes; mortality; myocardial infarction; stroke
10.  What elements of the patient–pharmacist relationship are associated with patient satisfaction? 
Background
Optimal medication management requires an effective relationship between the patient and health care professional. As pharmacists move from the traditional dispensing role to become more actively involved in patient care, factors influencing their relationship with patients need to be identified. A better understanding of these factors will facilitate more effective relationships.
Objective
To explore the effect of patient-perceived pharmacist expertise on relationship quality, self-efficacy, patient satisfaction, and relationship commitment.
Methods
This was a cross-sectional study conducted in five community pharmacies within the province of Alberta, Canada. A total of 500 patients were asked to complete a set of validated, self-administered questionnaires that measured perceived pharmacist expertise, relationship quality, self-efficacy, patient satisfaction, and relationship commitment. Hierarchical multiple regression was used to examine the associations between variables.
Results
A total of 112 surveys were returned. Internal consistency ranged from 0.86–0.92, suggesting good reliability, except for the relationship commitment scale. There was a significant, positive correlation between patient-perceived pharmacist expertise and quality of the relationship (0.78; P < 0.001). There were also significant, positive correlations between perceived expertise and patient satisfaction (0.52; P < 0.001) and relationship commitment (0.47; P < 0.001). These associations remained significant but the magnitude of correlation decreased when relationship quality was taken into account (0.55; P < 0.001 and 0.56; P < 0.001, respectively). On the other hand, there was no significant association between either patient-perceived pharmacist expertise or relationship quality and medication self-efficacy (0.06; P = 0.517 and 0.10; P = 0.292, respectively).
Conclusion
Patient-perceived pharmacist expertise is an independent determinant of relationship quality, patient satisfaction, and relationship commitment. Relationship quality also appears to mediate the effect of perceived expertise on patient satisfaction and relationship commitment.
doi:10.2147/PPA.S35688
PMCID: PMC3461603  PMID: 23055699
relationship quality; pharmacist expertise; self-efficacy; relationship commitment; satisfaction
11.  Evaluating the views of paramedics, cardiologists, emergency department physicians and nurses on advanced prehospital management of acute ST elevation myocardial infarction 
The Canadian Journal of Cardiology  2009;25(9):e323-e328.
BACKGROUND:
Although advanced prehospital management (PHM) in ST elevation myocardial infarction (STEMI) reduces reperfusion delay and improves patient outcomes, its use in North America remains uncommon. Understanding perceived barriers to and facilitators of PHM implementation may support the expansion of programs, with associated patient benefit.
OBJECTIVE:
To explore the attitudes and beliefs of paramedics, cardiologists, emergency physicians and nurses regarding these issues.
METHODS:
To maximize the potential to identify unpredictable issues within each of the four groups, focus group sessions were recorded, transcribed and analyzed for themes using the constant comparative method.
RESULTS:
All 18 participants believed that PHM of STEMI decreased time to treatment and improved health outcomes. Despite agreeing that most paramedics were capable of providing PHM, regular maintenance of competence and medical overview were emphasized. Significant variations in perceptions were revealed regarding practical aspects of the PHM process and protocol, as well as ownership and responsibility of the patient. Success and failures of technology were also expressed. Varying arguments against a signed ‘informed consent’ were presented by the majority.
CONCLUSIONS:
Focus group discussions provided key insights into potential barriers to and facilitators of PHM in STEMI. Although all groups were supportive of the concept and its benefits, concerns were expressed and potential barriers identified. This novel body of knowledge will help elucidate future educational programs and protocol development, and identify future challenges to ensure successful PHM of STEMI, thereby reducing reperfusion delay and improving patient outcomes.
PMCID: PMC2780893  PMID: 19746252
Acute myocardial infarction; Myocardial infarction; Percutaneous coronary intervention; Reperfusion; Thrombolysis
12.  The Darkening Cloud of Diabetes 
Diabetes Care  2008;31(11):2136-2142.
OBJECTIVE—We aimed to evaluate the changes in cardiovascular-related health care utilization (drug therapies, hospitalizations) and mortality for the diabetic population during a 9-year period in Saskatchewan, Canada.
RESEARCH DESIGN AND METHODS—We identified annual diabetes prevalence rates for people aged ≥30 years between 1993 and 2001 from the administrative databases of Saskatchewan Health. Annual rates of evidence-based drug therapies (antihypertensives, ACE inhibitors, β-blockers, calcium channel blockers, 3-hydroxy-3-metaglutaryl coenzyme A reductase inhibitors [statins]), hospitalizations for cerebrovascular and cardiac events, and all-cause mortality were estimated. Rates were direct age and sex standardized using the 2001 Canadian population, and trends over time were assessed using Joinpoint regression.
RESULTS—From 1993 to 2001, diabetes prevalence increased 34% (4.7–6.5%, P < 0.001) with the highest rates in men and those aged ≥65 years. The rate of increase in diabetes prevalence appeared to slow in those aged <65 years (P < 0.01 for trend). Significant increased use of evidence-based drug therapies was observed (41% increase in antihypertensive agents, 97% increase in ACE inhibitors, 223% increase in statin therapies; all P < 0.05 for trend). During this period, both cerebrovascular and cardiac-related hospitalizations declined by 36% (9.5 vs. 6.1 per 1,000) and 19% (38.0 vs. 30.6 per 1,000) (P < 0.05 for trends), respectively, with similar reductions regardless of sex. No change in all-cause mortality was observed (17.7 vs. 17.8 deaths per 1,000; P > 0.05).
CONCLUSIONS—During our period of study, there was an increase in the utilization of evidenced-based drug therapies in people with diabetes and reductions in cardiovascular-related hospitalizations. Despite this, we observed no change in all-cause mortality.
doi:10.2337/dc08-1248
PMCID: PMC2571063  PMID: 18840767
13.  Enhancing hypertension awareness and management in the elderly: Lessons learned from the Airdrie Community Hypertension Awareness and Management Program (A-CHAMP) 
BACKGROUND:
High blood pressure (BP) is an established and modifiable cardiovascular risk factor; however, awareness and management of this primarily asymptomatic disease remains suboptimal.
OBJECTIVES:
The Airdrie Community Hypertension Awareness and Management Program (A-CHAMP) was a community-based BP program for seniors designed to improve public and health care provider awareness and management of hypertension.
METHODS:
Volunteer peer health educators (VPHEs) were recruited from the community and trained to manage BP screening sessions in local pharmacies. Airdrie (Alberta) residents 65 years of age and older were invited by their family physicians (FPs) to attend the A-CHAMP sessions. VPHEs identified participants’ cardiovascular risk factors, assessed BP with a validated automated device and implemented a management algorithm. Participants with BP higher than 159/99 mmHg were directed to their pharmacists and FPs. All participants with elevated BP at the initial A-CHAMP session were invited to return to a follow-up session four to six months later.
RESULTS:
Thirty VPHEs were recruited and trained. All 15 FPs and all six pharmacies in Airdrie participated. VPHEs assessed 406 seniors (approximately 40% of Airdrie seniors) during the three-month program. One hundred forty-eight participants (36.5%) had elevated BP at their first session. Of these, 71% returned for the follow-up session four to six months later. The mean (± SD) systolic BP decreased by 16.9±17.2 mmHg (P<0.05, n=105) compared with their first visit, and 56% of participants (59 of 105) reached Canadian targets for BP.
CONCLUSIONS:
A-CHAMP raised awareness, and identified and managed seniors with hypertension. At follow-up, BP showed statistically and clinically significant and sustained improvement. Participating health care providers and VPHEs indicated that A-CHAMP was effective and feasible in improving awareness and control of hypertension.
PMCID: PMC2640333  PMID: 18612498
Blood pressure; Hypertension
14.  Hypertension treatment and control rates 
Canadian Family Physician  2009;55(7):735-741.
ABSTRACT
OBJECTIVE
To characterize hypertension management in an academic family medicine clinic.
DESIGN
Cross-sectional chart review.
SETTING
Academic family medicine clinic in Edmonton, Alta.
PARTICIPANTS
A total of 210 patients with 1 or more visits for hypertension during the previous 3 years.
MAIN OUTCOME MEASURES
Patient characteristics, current antihypertensive therapies, most recent blood pressure measurements, and compelling indications according to the 2006 Canadian Hypertension Education Program recommendations.
RESULTS
A total of 185 subjects (88%) were prescribed antihypertensive medications, and 89 (42%) had controlled hypertension. Younger subjects, people with diabetes, and people not receiving antihypertensive medication therapy appeared less likely to have controlled hypertension. There were 76 subjects (36%) prescribed 1 antihypertensive medication, 65 subjects (31%) prescribed 2 antihypertensive medications, and 44 (21%) prescribed 3 or more antihypertensive medications. Angiotensin-converting enzyme inhibitors were prescribed for 51% of the subjects, diuretics for 47%, β-blockers for 27%, calcium channel blockers for 23%, angiotensin receptor blockers for 20%, and α-blockers for 1%.
CONCLUSION
Hypertension treatment and control rates in this academic family medicine clinic appear to be better than those in the general population. Following the principles of a continuous quality improvement process, this information will serve as an important foundation for identifying areas to improve hypertension management in the clinic.
PMCID: PMC2718609  PMID: 19602664
15.  Treatment and blood pressure control in 47,964 people with diabetes and hypertension: A systematic review of observational studies 
The Canadian Journal of Cardiology  2006;22(10):855-860.
BACKGROUND
Many patients with diabetes also have hypertension, greatly increasing their risk for cardiovascular disease. It has been suggested that hypertension is poorly treated in those with diabetes.
OBJECTIVE
To examine treatment and control of hypertension in people with diabetes.
DATA SOURCES
Data sources included MEDLINE, EMBASE, HealthSTAR, CINAHL, Web of Science, clinical evidence and government health and statistical Web sites.
METHOD
Databases were systematically reviewed and hand searches of the bibliographies of relevant studies (1990 to 2004) were conducted. Two investigators selected studies and extracted the data independently.
RESULTS
A total of 44 studies (77,649 subjects with diabetes, 47,964 [62%] of whom also had hypertension) were included. While 83% (range 32% to 100%) of patients with hypertension received drug therapy, only 12% (range 6% to 30%) had their blood pressure (BP) controlled to 130/85 mmHg or less. While BP control rates differed by definition of control (those studies with the least stringent definitions for BP control – 160/90 mmHg or less – reported mean control rates of 37%), treatment and control rates did not differ appreciably between countries or health care settings.
CONCLUSIONS
Fewer than one in eight people with diabetes and hypertension have adequately controlled BP, with remarkable uniformity across studies conducted in a variety of settings. There is an urgent need for multidisciplinary, community-based approaches to manage these high-risk patients.
PMCID: PMC2569016  PMID: 16957803
Blood pressure; Diabetes mellitus; Hypertension; Systematic review
16.  A meta-analysis of the association between adherence to drug therapy and mortality 
BMJ : British Medical Journal  2006;333(7557):15.
Objective To evaluate the relation between adherence to drug therapy, including placebo, and mortality.
Design Meta-analysis of observational studies.
Data sources Electronic databases, contact with investigators, and textbooks and reviews on adherence.
Review methods Predefined criteria were used to select studies reporting mortality among participants with good and poor adherence to drug therapy. Data were extracted for disease, drug therapy groups, methods for measurement of adherence rate, definition for good adherence, and mortality.
Results Data were available from 21 studies (46 847 participants), including eight studies with placebo arms (19 633 participants). Compared with poor adherence, good adherence was associated with lower mortality (odds ratio 0.56, 95% confidence interval 0.50 to 0.63). Good adherence to placebo was associated with lower mortality (0.56, 0.43 to 0.74), as was good adherence to beneficial drug therapy (0.55, 0.49 to 0.62). Good adherence to harmful drug therapy was associated with increased mortality (2.90, 1.04 to 8.11).
Conclusion Good adherence to drug therapy is associated with positive health outcomes. Moreover, the observed association between good adherence to placebo and mortality supports the existence of the “healthy adherer” effect, whereby adherence to drug therapy may be a surrogate marker for overall healthy behaviour.
doi:10.1136/bmj.38875.675486.55
PMCID: PMC1488752  PMID: 16790458
17.  Dose–response relation between sulfonylurea drugs and mortality in type 2 diabetes mellitus: a population-based cohort study 
Background
Over the past 30 years, the relation between use of sulfonylureas to treat type 2 diabetes and the risk of cardiovascular events has been vigorously debated. The purpose of this study was to determine if the risk of death changes with level of exposure to sulfonylurea drugs.
Methods
This was a retrospective, inception cohort study using administrative data from Saskatchewan Health (1991– 1999). The 5795 subjects, identified by their first-ever dispensation for an oral antidiabetic agent, were grouped according to their use of such agents during follow-up. Potential subjects using insulin or combination therapy were excluded. Exposure level was defined by daily dose and degree of adherence. Separate multivariate Cox proportional-hazard models were constructed for each monotherapy group and used to calculate the risk of death associated with higher versus lower exposure category. Disease severity indicators were identified among the administrative data and entered as covariates in each model. The main outcomes were all-cause mortality and death from an acute ischemic event.
Results
The mean age of the cohort members was 66.3 (standard deviation [SD] 13.4) years; 43.4% were female; and their mean duration of follow-up was 4.6 (SD 2.1) years. First-generation sulfonylureas were used exclusively by 120 subjects; glyburide, by 4138; and metformin, by 1537. A greater risk of death was associated with higher daily doses of the first-generation sulfonylureas (adjusted hazard ratio [HR] 2.1, 95% confidence interval [CI] 1.0–4.7) and glyburide (HR 1.3, 95% CI 1.2–1.4), but not metformin (HR 0.8, 95% CI 0.7–1.1). Similar associations were observed for death caused by an acute ischemic event.
Interpretation
Higher exposure to sulfonylureas was associated with increased mortality among patients newly treated for type 2 diabetes. The same relation was not observed with metformin. This implies that the manner in which blood glucose concentration is lowered may be as important as achieving recommended glucose targets.
doi:10.1503/cmaj.050748
PMCID: PMC1329454  PMID: 16415461
18.  Angiotensin receptor blockers and risk of myocardial infarction: systematic review 
BMJ : British Medical Journal  2005;331(7521):873.
Objective To evaluate the effect of angiotensin receptor blockers on the risk of myocardial infarction in patients at risk for cardiovascular events.
Design Systematic review of controlled trials of angiotensin receptor blockers.
Data sources Medline, Embase, Cochrane central register of controlled trials, hand search, and contact with investigators.
Selection of studies Predefined criteria were used to select controlled clinical trials comparing use of angiotensin receptor blockers with angiotensin converting enzyme (ACE) inhibitors or placebo in patients at risk for cardiovascular events. Data were extracted for patients' characteristics, interventions, quality of trials, and rates of myocardial infarction.
Results 19 studies with 31 569 patients were included in the analysis. Two studies investigated the use of angiotensin receptor blockers in hypertensive patients, four studies in patients with diabetes and nephropathy, 10 studies in patients with heart failure, and three in patients with recent myocardial infarction or ischaemic syndrome. 11 studies of 21 062 patients allowed for comparison between angiotensin receptor blockers and placebo; nine studies of 10 625 patients allowed for comparison between angiotensin receptor blockers and ACE inhibitors. Use of angiotensin receptor blockers was not associated with increased risk of myocardial infarction compared with placebo (odds ratio 0.94, 95% confidence interval 0.75 to 1.16) nor with increased risk of myocardial infarction compared with ACE inhibitors (1.01, 0.87 to 1.16).
Conclusions Treatment with angiotensin receptor blockers was not associated with a significantly increased risk of myocardial infarction. The 95% confidence intervals do, however, not exclude an increase of up to 16% in the risk of myocardial infarction or a reduction in risk of up to 25%. Until further information specifically dealing with this issue is available from large prospective trials, our findings may alleviate recent concerns over the safety of this class of medications.
doi:10.1136/bmj.38595.518542.3A
PMCID: PMC1255791  PMID: 16183653
19.  The cost of major comorbidity in people with diabetes mellitus 
Background
People with diabetes mellitus are more likely to have cardiovascular, renal and ophthalmic comorbidity than those without diabetes. Information on the economic impact of diabetes and its complications on the Canadian health care system is limited.
Methods
To estimate health care expenditures for diabetes and its major complications, we identified people with diabetes in 1996 in Saskatchewan, using the administrative databases of Saskatchewan Health. We grouped utilization and expenditure data for prescription drugs, physician services, hospitalizations, day surgery procedures and dialysis services according to cardiovascular, renal and ophthalmic services, according to billing codes and the American Hospital Formulary Services classification for prescription drugs.
Results
Of the 38 124 people identified (48.5% female and 9.7% registered Indians), 46.6% had cardiovascular-related records, 19.8% ophthalmic-related records and 6.6% renal-related records. Registered Indians had significantly fewer (p < 0.001) cardiovascular-related records than the rest of the diabetic population (35.1% v. 47.9%, respectively) but more renal- related records (11.7% v. 6.0%, respectively). The total 1996 Saskatchewan Health expenditure for the study group, within the observed categories, was estimated to be $134.3 million, of which $35.5 million (26.4%) was for cardiovascular-related services, $10 million (7.5%) for renal-related services and $3.3 million (2.5%) for ophthalmic-related services.
Interpretation
In 1996, 36.4% of health care expenditures for people with diabetes was attributable to major comorbidity. Actions to prevent or control such comorbidity will yield significant cost savings.
PMCID: PMC161611  PMID: 12821619

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