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Background There is growing evidence of harm associated with trazodone and nonbenzodiazepine sedative hypnotics (e.g., zopiclone); however, their comparative risk of harm is unknown. Methods We conducted a retrospective cohort study with linked health administrative data, which enrolled older ( ≥66 years old) nursing home residents living in Alberta, Canada, between December 1, 2009, and December 31, 2018; the last follow-up date was June 30, 2019. We compared the rate of injurious falls and major osteoporotic fractures (primary outcome) and all-cause mortality (secondary outcome) within 180 days of first prescription of zopiclone or trazodone with cause-specific hazard models and inverse probability of treatment weights to control for confounding; primary analysis was intention-to-treat and secondary analysis was per-protocol (i.e., residents censored if dispensed the other exposure drug). Results Our cohort included 1,403 residents newly dispensed trazo-done and 1,599 residents newly dispensed zopiclone. At cohort entry, the mean resident age was 85.7 (standard deviation [SD] 7.4), 61.6% were female, and 81.2% had dementia. New zopi-clone use was associated with similar rates of injurious falls and major osteoporotic fractures (intention-to-treat-weighted hazard ratio 1.15, 95% confidence interval [CI] 0.90-1.48; per-protocol-weighted hazard ratio 0.85, 95% CI 0.60-1.21) and all-cause mortality (intention-to-treat-weighted hazard ratio 0.96, 95% CI 0.79-1.16; per-protocol-weighted hazard ratio 0.90, 95% CI 0.66-1.23) compared to trazodone. Conclusions Zopiclone was associated with a similar rate of injurious falls, major osteoporotic fractures, and all-cause mortality compared to trazodone—suggesting one medication should not be used in lieu of the other. Appropriate prescribing in-itiatives should also target zopiclone and trazodone.

Albumin-to-creatinine ratio (ACR), the preferred method to quantify proteinuria, can be calculated from urine dipstick protein or protein-to-creatinine ratio (PCR). The performance of calculated vs. measured ACR in predicting kidney failure and death without kidney failure in people with chronic kidney disease (CKD) is unknown. Here, we used population-based data from Alberta, Canada, to identify adults with incident moderate-severe CKD (sustained for more than 90 days) from 2008-04-01 to 2017-03-31, who had same-day measures of ACR and urine dipstick (ACR-dipstick cohort) or PCR (ACR-PCR cohort) in the two years before cohort entry. We followed participants until 2019-03-31 and trained competing risk models of kidney failure and death without kidney failure including age, sex, estimated glomerular filtration rate, diabetes, cardiovascular disease, and either measured or calculated ACR. Model performance was tested in cohorts created using the same algorithm in Manitoba, Canada. The ACR-dipstick and ACR-PCR cohorts included 18,731 and 4,542 people (training cohorts) and 821 and 1,831 people (testing cohorts), respectively. In internal and external testing, there was closer agreement between predictions based on measured vs. PCR-calculated ACR than between those based on measured vs. dipstick-calculated ACR. The dipstick-calculated ACR had higher Brier scores than measured ACR from year three for both outcomes, indicating worsening calibration. Models including measured or calculated ACR had similar discrimination: year one-to-five area under the receiver operating characteristic curve of 83-89% for kidney failure and 69-75% for mortality. Thus, if confirmed in different ethnic groups, calculated ACR can be used for risk predictions when the measured ACR is not available. PCR-calculated ACR may have superior performance to dipstick-calculated ACR.

Self-management in chronic kidney disease (CKD) can slow disease progression; however, there are few tools available to support patients with early CKD. My Kidneys My Health is a patient-focused electronic health (eHealth) self-management tool developed by patients and caregivers. This study will investigate the implementation of My Kidneys My Health across primary care and general nephrology clinics. The study aims to: (1) identify and address barriers and facilitators that may impact implementation and sustainability of the website into routine clinical care; (2) evaluate implementation quality to inform spread and scale-up. We will conduct a multi-stage approach using qualitative methods, guided by the Quality Implementation Framework and using a qualitative content analysis approach. First, we will identify perceived barriers and facilitators to implementation and considerations for sustainability through interviews with clinicians, based on the Readiness Thinking Tool and the Long Term Success Tool. Analysis will be guided by the Consolidated Framework for Implementation Research and the Theoretical Domains Framework. Appropriate implementation strategies will be identified using the Expert Recommendations for Implementing Change compilation, and implementation plans will be developed based on Proctor’s recommendations and the Action, Actor, Context, Target, Time framework. Finally, we will explore implementation quality guided by the RE-AIM framework. There is limited literature describing systematic approaches to implementing and sustaining patient-focused self-management tools into clinical care, in addition to employing tailored implementation strategies to promote adoption and sustainability. We aim to generate insights on how My Kidneys My Health can be integrated into clinical care and how to sustain use of patient-centric eHealth tools in clinical settings on a larger scale.

Aims The aim of this study was to determine the comparative effectiveness and safety of direct oral anticoagulants (DOACs) and warfarin in adults with atrial fibrillation (AF) by level of kidney function. Methods and results We pooled findings from five retrospective cohorts (2011–18) across Australia and Canada of adults with; a new dispensation for a DOAC or warfarin, an AF diagnosis, and a measure of baseline estimated glomerular filtration rate (eGFR). The outcomes of interest, within 1 year from the cohort entry date, were: (1) the composite of all-cause death, first hospitalization for ischaemic stroke, or transient ischaemic attack (effectiveness), and (2) first hospitalization for major bleeding defined as an intracranial, upper or lower gastrointestinal, or other bleeding (safety). Cox models were used to examine the association of a DOAC vs. warfarin with outcomes, after 1:1 matching via a propensity score. Kidney function was categorized as eGFR ≥60, 45–59, 30–44, and Conclusion DOAC use, compared with warfarin use, was associated with a lower or similar risk of all-cause death, ischaemic stroke, and transient ischaemic attack and also a lower or similar risk of major bleeding across all levels of kidney function.

People with chronic kidney disease (CKD) are risk-stratified for adverse events based on estimated glomerular filtration rate (eGFR) and albuminuria level. CKD has often a favorable course (CKD regression) regardless of eGFR. Determining whether lower albuminuria is associated with CKD regression may have implications on CKD management.To assess the 5-year probability of CKD regression across albuminuria categories accounting for the competing risks of CKD progression and death in people with newly diagnosed CKD and the association between albuminuria level and CKD regression.This population-based cohort study used administrative and laboratory data from Alberta, Canada, for adults with incident moderate to severe CKD (defined as sustained eGFR of 15-44 mL/min/1.73 m2 for90 days), between April 1, 2008, and March 31, 2017, and albuminuria measures before cohort entry. Data analysis occurred in January to June 2022.Albuminuria categories were defined by albumin to creatinine ratios (ACRs): A1 (ACR,3 mg/mmol), A2 (ACR, 3-29 mg/mmol), A360 (ACR, 30-59 mg/mmol), and A3≥60 (ACR, ≥60 mg/mmol).The main outcome was time to the earliest of CKD regression or progression (sustained change in CKD stage for3 months and ≥25% increase or decrease in eGFR from baseline or kidney failure, respectively), death, or censoring (outmigration or study end date: March 31, 2019). Cumulative incidence functions were used to estimate absolute risks, and cause-specific Cox models were used to assess the association between albuminuria and CKD regression, accounting for age, sex, eGFR, comorbidities, and health services use indicators.Of 58 004 people with moderate to severe CKD (mean [SD] age, 77 [12] years; 31 725 [55%] women), 35 360 had A1 albuminuria (61%), 15 597 had A2 albuminuria (27%), 1527 had A360 albuminuria (3%), and 5520 had A3≥60 albuminuria (10%). Five-year probability of regression was highest with A1 (22.6%), followed by A2 (16.5%), and A360 (11.6%) and lowest with A3≥60 (5.3%). Using A1 albuminuria as the reference group, the hazard of regression was highest for A2 (hazard ratio [HR], 0.75; 95% CI, 0.72-0.79), then A360 (HR, 0.47; 95% CI, 0.40-0.54), and lowest for A3≥60 (HR, 0.27; 95% CI, 0.24-0.30).In this cohort study of people with moderate to severe CKD, albuminuria levels were inversely associated with CKD regression. These findings extend the key prognostic role of albuminuria, offering novel opportunities to discuss both favorable and adverse outcomes in people with CKD and inform CKD management.

Trials in children with chronic kidney disease do not consistently report outcomes that are critically important to patients and caregivers. This can diminish the relevance and reliability of evidence for decision making, limiting the implementation of results into practice and policy. As part of the Standardized Outcomes in Nephrology—Children and Adolescents (SONG-Kids) initiative, we convened 2 consensus workshops in San Diego, California (7 patients, 24 caregivers, 43 health professionals) and Melbourne, Australia (7 patients, 23 caregivers, 49 health professionals). This report summarizes the discussions on the identification and implementation of the SONG-Kids core outcomes set. Four themes were identified; survival and life participation are common high priority goals, capturing the whole child and family, ensuring broad relevance across the patient journey, and requiring feasible and valid measures. Stakeholders supported the inclusion of mortality, infection, life participation, and kidney function as the core outcomes domains for children with chronic kidney disease.

Introduction Information on early, guideline discordant referrals in nephrology is limited. Our objective was to investigate trends in referral patterns to nephrology for patients with chronic kidney disease (CKD). Methods Retrospective cohort study of adults with ≥1 visits to a nephrologist from primary care with ≥1 serum creatinine and/or urine protein measurement 2, persistent albuminuria (ACR ≥ 300 mg/g, PCR ≥ 500 mg/g, or Udip ≥ 2+), or progressive and persistent decline in eGFR until index nephrology visit (≥ 5 mL/min/1.73m2). Results Of 69,372 patients with CKD, 28,518 (41%) were referred in a guideline concordant manner. The overall rate of first outpatient visits to nephrology increased from 2006 to 2019, although guideline discordant referrals showed a greater increase (trend 21.9 per million population/year, 95% confidence interval 4.3, 39.4) versus guideline concordant referrals (trend 12.4 per million population/year, 95% confidence interval 5.7, 19.0). The guideline concordant cohort were more likely to be on renin-angiotensin system blockers or beta blockers (hazard ratio 1.14, 95% confidence interval 1.12, 1.16), and had a higher risk of CKD progression (hazard ratio 1.09, 95% confidence interval 1.06, 1.13), kidney failure (hazard ratio 7.65, 95% confidence interval 6.83, 8.56), cardiovascular event (hazard ratio 1.40, 95% confidence interval 1.35,1.45) and mortality (hazard ratio 1.58, 95% confidence interval 1.52, 1.63). Conclusions A significant proportion nephrology referrals from primary care were not consistent with current guideline-recommended criteria for referral. Further work is needed to identify quality improvement initiatives aimed at enhancing referral patterns of patients with CKD.

This study analyzed patient-described barriers and facilitators related to diabetes management, focusing on how these differ by glycemia and across individual characteristics to facilitate targeted diabetes management strategies. A cross-sectional telephone survey was conducted with adult patients with diabetes in Alberta, Canada, asking two open-ended questions to describe the most helpful and difficult components of their diabetes management. Responses were analyzed using directed content analysis using the Theoretical Domains Framework as a template. The most frequently cited facilitator was care context and information and the most frequently cited barriers were cognitive challenges and structural barriers, with patient-perceived barriers and facilitators varying by individual-level factors.

Data on dissemination strategies that generate awareness of clinical pathways for kidney care are limited.This study reports the application of Google Analytics to describe the reach and use of the Chronic Kidney Disease Pathway (CKD-P) using a multi-faceted dissemination strategy.The design of this study is a retrospective descriptive study.This study was conducted in Alberta, Canada.Individuals who accessed the CKD-P Web site between November 5, 2014, and May 31, 2019.Dissemination activities included print, electronic, in-person meetings, and a laboratory prompt. We used Google Analytics over a 5-year period to evaluate the following CKD-P Web site user metrics: number of sessions, pageviews, visit duration, user path, and bounce rate (when an individual visits a single page of the Web site and leaves the Web site without interacting with additional pages).We plotted dissemination activities alongside Web site metrics using control charts and described the data using means and percentages. We performed chi-square test for trends to evaluate year-over-year usage.There were 83 294 users, 90 805 sessions, and 231 684 pageviews. The overall bounce rate was 45.7%. Each user had an average of 1.5 sessions and a session duration of 2 minutes and 8 seconds. There was a significant positive trend for total annual users (We were unable to confirm if users were primary care providers and if word-of-mouth dissemination among providers/researchers drove people to use the CKD-P.Google Analytics was a useful and accessible tool for evaluating CKD-P reach and use trends. It was challenging to identify how individual dissemination activities contributed to CKD-P reach; however, repeated dissemination appeared to play a role in increasing CKD-P use.Not applicable-observational study design.Il existe peu de données sur les stratégies de diffusion pour sensibiliser les différents intervenants aux plans d’intervention en santé rénale.Cette étude rend compte de l’utilization de Google Analytics pour décrire la portée et l’utilization d’un plan d’intervention en ligne pour l’insuffisance rénale chronique (CKD-P —Étude descriptive rétrospective.Alberta, Canada.Les individus ayant accédé au site Web CKD-P entre le 5 novembre 2014 et le 31 mai 2019.Les activités de diffusion comprenaient des documents imprimés, des documents électroniques, des réunions en personne et un lien internet vers le site web de CKD-P lors de la transmission d’un résultat anormal de laboratoire. Nous avons utilisé Google Analytics pendant cinq ans pour évaluer les mesures suivantes pour les utilisateurs du site Web CKD-P: nombre de sessions, vues de page, durée des visites, chemin d’accès utilisateur et taux de rebond (lorsqu’une personne visite une seule page du site Web et le quitte sans interagir avec d’autres pages).Les activités de diffusion et les paramètres du site Web sont présentés à l’aide de tableaux de contrôle, et les données à l’aide de moyennes et de pourcentages. Un test de Chi-Deux a servi à déterminer les tendances et évaluer l’utilization d’une année sur l’autre.Nous avons répertorié 83 294 utilisateurs, 90 805 sessions et 231 684 pages consultées. Le taux de rebond global était de 45,7 %. En moyenne, chaque utilisateur comptait 1,5 session dont la durée moyenne était de 2 minutes 8 secondes. On a observé une tendance positive significative pour le nombre total annuel d’utilisateurs (Il n’a pas été possible de confirmer si les utilisateurs étaient des fournisseurs de soins primaires et si la diffusion de bouche-à-oreille entre les fournisseurs/chercheurs avait amené les gens à utiliser CKD-P.Google Analytics s’est avéré un outil utile et accessible pour évaluer les tendances de portée et d’utilization de CKD-P. Il est difficile d’établir comment les activités de diffusion individuelles contribuent à la portée de CKD-P; la diffusion répétée semble néanmoins jouer un rôle dans l’augmentation de l’utilization de CKD-P.Sans objet — étude observationnelle.

BackgroundRecommendations for the diagnosis of pulmonary embolism are available for healthcare providers. Yet, real practice data show existing gaps in the translation of evidence-based recommendations. This is a study to assess the effect of a computerised decision support system (CDSS) with an enhanced design based on best practices in content and reasoning representation for the diagnosis of pulmonary embolism.DesignRandomised preclinical pilot study of paper-based clinical scenarios in the diagnosis of pulmonary embolism. Participants were clinicians (n=30) from three levels of experience: medical students, residents and physicians. Participants were randomised to two interventions for the diagnosis of pulmonary embolism: a didactic lecture versus a decision tree via a CDSS. The primary outcome of diagnostic pathway concordance (derived as a ratio of the number of correct diagnostic decision steps divided by the ideal number of diagnostic decision steps in diagnostic algorithms) was measured at baseline (five clinical scenarios) and after either intervention for a total of 10 clinical scenarios.ResultsThe mean of diagnostic pathway concordance improved in both study groups: baseline mean=0.73, post mean for the CDSS group=0.90 (pInterpretationA computerised decision support system designed for both content and reasoning visualisation can improve clinicians’ diagnostic decision-making.

International audience; Outcomes reported in randomized controlled trials in peritoneal dialysis (PD) are diverse, are measured inconsistently, and may not be important to patients, families, and clinicians. The Standardized Outcomes in Nephrology-Peritoneal Dialysis (SONG-PD) initiative aims to establish a core outcome set for trials in PD based on the shared priorities of all stakeholders. We convened an international SONG-PD stakeholder consensus workshop in May 2018 in Vancouver, Canada. Nineteen patients/caregivers and 51 health professionals attended. Participants discussed core outcome domains and implementation in trials in PD. Four themes relating to the formation of core outcome domains were identified: life participation as a main goal of PD, impact of fatigue, empowerment for preparation and planning, and separation of contributing factors from core factors. Considerations for implementation were identified: standardizing patient-reported outcomes, requiring a validated and feasible measure, simplicity of binary outcomes, responsiveness to interventions, and using positive terminology. All stakeholders supported inclusion of PD-related infection, cardiovascular disease, mortality, technique survival, and life participation as the core outcome domains for PD.

The omission of outcomes that are of relevance to patients, clinicians, and regulators across trials in autosomal dominant polycystic kidney disease (ADPKD) limits shared decision making. The Standardized Outcomes in Nephrology-Polycystic Kidney Disease (SONG-PKD) Initiative convened an international consensus workshop on October 25, 2018, to discuss the identification and implementation of a potential core outcome set for all ADPKD trials. This article summarizes the discussion from the workshops and the SONG-PKD core outcome set. Key stakeholders including 11 patients/ caregivers and 47 health professionals (nephrologists, policy makers, industry, and researchers) attended the workshop. Four themes emerged: "Relevance of trajectory and impact of kidney function" included concerns about a patient's prognosis and uncertainty of when they may need to commence kidney replacement therapy and the lack of an early prognostic marker to inform long-term decisions; "Discerning and defining pain specific to ADPKD" highlighted the challenges in determining the origin of pain, adapting to the chronicity and repeated episodes of pain, the need to place emphasis on pain management, and to have a validated measure for pain; "Highlighting ADPKD consequences" encompassed cyst-related complications and reflected patient's knowledge because of family history and the hereditary nature of ADPKD; and "Risk for life-threatening but rare consequences" such as cerebral aneurysm meant considering both frequency and severity of the outcome. Kidney function, mortality, cardiovascular disease, and pain were established as the core outcomes for ADPKD.

Cardiovascular disease is more common in patients with chronic kidney disease (CKD), and traditional risk factors do not adequately predict those at risk for cardiovascular (CV) events. Recent evidence suggests elevated trimethylamine N-oxide (TMAO), created by gut microflora from dietary L-carnitine and choline, is associated with CV events. We investigated the relationship of TMAO levels in patients with stages 3b and 4 CKD to ischemic CV events using the CanPREDDICT cohort, a Canada-wide observational study with prospective 3-year follow-up of adjudicated CV events. Baseline samples were obtained for 2529 CKD patients. TMAO, choline, and L-carnitine levels were measured using tandem mass spectrometry. Baseline median TMAO level was high for the whole cohort (20.41 μM; interquartile range [IQR]: 12.82–32.70 μM). TMAO was independently associated with CV events (hazard ratio 1.23; 95% confidence interval: 1.06–1.42 / 1 SD lnTMAO) after adjusting for all potential CV risk factors. Those in the highest TMAO quartile had significantly higher risk of CV events (adjusted hazard ratio 1.59; 95% confidence interval: 1.04–2.43; P = 0.0351) in the analysis of recurring ischemic events. Among those with stage 3b CKD (hazard ratio 1.45; 95% confidence interval: 1.12–1.87 / 1 SD lnTMAO), independent of kidney function, TMAO levels identified those at highest risk for events. Our results suggest that TMAO may represent a new potentially modifiable CV risk factor for CKD patients. Further studies are needed to determine sources of variability and if lowering of TMAO reduces CV risk in CKD.

There are an estimated 14,000 randomized trials published in chronic kidney disease. The most frequently reported outcomes are biochemical endpoints, rather than clinical and patient-reported outcomes including cardiovascular disease, mortality, and quality of life. While many trials have focused on optimizing kidney health, the heterogeneity and uncertain relevance of outcomes reported across trials may limit their policy and practice impact. The international Standardized Outcomes in Nephrology (SONG) Initiative was formed to identify core outcomes that are critically important to patients and health professionals, to be reported consistently across trials. We convened a SONG Implementation Workshop to discuss the implementation of core outcomes. Eighty-two patients/caregivers and health professionals participated in plenary and breakout discussions. In this report, we summarize the findings of the workshop in two main themes: socializing the concept of core outcomes, and demonstrating feasibility and usability. We outline implementation strategies and pathways to be established through partnership with stakeholders, which may bolster acceptance and reporting of core outcomes in trials, and encourage their use by end-users such as guideline producers and policymakers to help improve patient-important outcomes. ispartof: pages:1053-1068 ispartof: Kidney Int vol:94 issue:6 pages:1053-1068 ispartof: location:United States status: published

International audience; Fatigue is one of the most highly prioritized outcomes for patients and clinicians, but remains infrequently and inconsistently reported across trials in hemodialysis. We convened an international Standardized Outcomes in Nephrology-Hemodialysis (SONG-HD) consensus workshop with stakeholders to discuss the development and implementation of a core outcome measure for fatigue. 15 patients/caregivers and 42 health professionals (clinicians, researchers, policy makers, and industry representatives) from 9 countries participated in breakout discussions. Transcripts were analyzed thematically. 4 themes for a core outcome measure emerged. Drawing attention to a distinct and all-encompassing symptom was explicitly recognizing fatigue as a multifaceted symptom unique to hemodialysis. Emphasizing the pervasive impact of fatigue on life participation justified the focus on how fatigue severely impaired the patient's ability to do usual activities. Ensuring relevance and accuracy in measuring fatigue would facilitate shared decision making about treatment. Minimizing burden of administration meant avoiding the cognitive burden, additional time, and resources required to use the measure. A core outcome measure that is simple, is short, and includes a focus on the severity of the impact of fatigue on life participation may facilitate consistent and meaningful measurement of fatigue in all trials to inform decision making and care of patients receiving hemodialysis.

The purpose of this review is to contribute to the Choosing Wisely Canada campaign and develop a list of 5 items for nephrology health care professionals and patients to re-evaluate based on evidence that they are overused or misused.A working group was formed from the Canadian Society of Nephrology (CSN) Clinical Practice Guidelines Committee. This working group sequentially used a multistage Delphi method, a survey of CSN members, a modified Delphi process, and a comprehensive literature review to determine 10 candidate items representing potentially ineffective care in nephrology. An in-person vote by CSN members at their Annual General Meeting was used to rank each item based on their relevance to and potential impact on patients with kidney disease to derive the final 5 items on the list.One hundred thirty-four of 609 (22%) CSN members responded to the survey, from which the CSN working group identified 10 candidate-misused items. Sixty-five CSN members voted on the ranking of these items. The top 5 recommendations selected for the final list were (1) do not initiate erythropoiesis-stimulating agents in patients with chronic kidney disease (CKD) with hemoglobin levels greater than or equal to 100 g/L without symptoms of anemia; (2) do not prescribe nonsteroidal anti-inflammatory drugs for individuals with hypertension or heart failure or CKD of all causes, including diabetes; (3) do not prescribe angiotensin-converting-enzyme inhibitors in combination with angiotensin II receptor blockers for the treatment of hypertension, diabetic nephropathy or heart failure; (4) do not initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their nephrology health care team; and (5) do not initiate dialysis in outpatients with CKD category G5-ND in the absence of clinical indications.A low survey response rate of both community and academic nephrologists could contribute to sampling bias. However, the purpose of this report is to generate discussion, rather than study practice variation.These 5 evidence-based recommendations aim to improve outcomes and individualize care for patients with kidney disease, while reducing inefficiencies and preventing harm.Contribuer à la campagne nationale Choisir avec soin (Choosing Wisely Canada) et dresser une liste de cinq pratiques à être réévaluées par les professionnels de la santé et par les patients en néphrologie, parce que trop utilisées ou utilisées incorrectement.Un groupe de travail a été constitué au sein du comité de recommandations pour la pratique clinique de la Société canadienne de néphrologie (SCN). Ce groupe de travail a utilisé, de façon séquentielle, la méthode Delphi par paliers, un sondage mené auprès des membres de la SCN, une version modifiée de la méthode Delphi et une revue exhaustive de la littérature pour établir une liste de 10 pratiques candidates identifiant des soins potentiellement inefficaces en néphrologie. Les éléments retenus ont fait l’objet d’un vote auprès des membres de la SCN présents lors de l’assemblée générale annuelle. Ces derniers ont voté sur chacun des éléments pour permettre de les classer en fonction de leur pertinence et de l’impact potentiel qu’ils pouvaient avoir sur les patients atteints d’insuffisance rénale. Cinq éléments ont été retenus au terme de ce processus.Seuls 134 des 609 membres de la SCN (soit 22 %) ont répondu au sondage. Le groupe de travail de la SCN a identifié 10 pratiques candidates pour lesquelles 65 membres de la SCN ont voté en vue de procéder à un classement. Les 5 recommandations retenues dans la liste finale étaient (1) de ne pas entreprendre de traitement avec des agents stimulant l’érythropoïèse (ASE) chez les patients atteints d’insuffisance rénale chronique (IRC) dont le taux d’hémoglobine est supérieur ou égal à 100 g/L sans symptômes d’anémie ; (2) de ne pas prescrire de médicaments anti-inflammatoires non stéroïdiens (AINS) chez les individus souffrant d’hypertension, d’insuffisance cardiaque ou d’IRC peu importe la cause, y compris le diabète ; (3) de ne pas prescrire d’inhibiteurs de l’ECA (enzyme de conversion de l’angiotensine) en combinaison avec des antagonistes des récepteurs de l’angiotensine II (ARA II) pour le traitement de l’hypertension, de la néphropathie diabétique ou de l’insuffisance cardiaque ; (4) de ne pas amorcer d’hémodialyse chronique sans assurer un processus décisionnel partagé entre les patients, leurs familles, et leur équipe de soin de santé en néphrologie ; et (5) de ne pas amorcer l’hémodialyse chez les patients externes atteints d’IRC de catégorie G5-ND en l’absence d’indications cliniques.Le faible taux de réponse au sondage de la part des néphrologues de la communauté et du milieu universitaire a pu contribuer à introduire un biais attribuable à l’échantillonnage. Cependant, le but de ce rapport est de susciter la discussion, plutôt que d’étudier les variations dans la pratique.Ces cinq recommandations fondées sur des données probantes visent à améliorer les résultats des patients atteints d’insuffisance rénale et à individualiser les soins qui leur sont prodigués, tout en réduisant les lacunes et en prévenant les torts qui pourraient en découler.

End-stage kidney disease (ESKD) patients are at increased cardiovascular risk. Vitamin D deficiency is associated with depressed heart rate variability (HRV), a risk factor depicting poor cardiac autonomic tone and risk of cardiovascular death. Vitamin D deficiency and depressed HRV are highly prevalent in the ESKD population. We aimed to determine the effects of oral vitamin D supplementation on HRV ((low frequency (LF) to high frequency (HF) spectral ratio (LF:HF)) in ESKD patients on hemodialysis. Fifty-six subjects with ESKD requiring hemodialysis were recruited from January 2013–March 2015 and randomized 1:1 to either conventional (0.25 mcg alfacalcidol plus placebo 3×/week) or intensive (0.25 mcg alfacalcidol 3×/week plus 50,000 international units (IU) ergocalciferol 1×/week) vitamin D for six weeks. The primary outcome was the change in LF:HF. There was no difference in LF:HF from baseline to six weeks for either vitamin D treatment (conventional: p = 0.9 vs. baseline; intensive: p = 0.07 vs. baseline). However, participants who remained vitamin D-deficient (25-hydroxyvitamin D < 20 ng/mL) after treatment demonstrated an increase in LF:HF (conventional: n = 13, ∆LF:HF: 0.20 ± 0.06, p < 0.001 vs. insufficient and sufficient vitamin D groups; intensive: n = 8: ∆LF:HF: 0.15 ± 0.06, p < 0.001 vs. sufficient vitamin D group). Overall, six weeks of conventional or intensive vitamin D only augmented LF:HF in ESKD subjects who remained vitamin D-deficient after treatment. Our findings potentially suggest that while activated vitamin D, with or without additional nutritional vitamin D, does not appear to improve cardiac autonomic tone in hemodialysis patients with insufficient or sufficient baseline vitamin D levels, supplementation in patients with severe vitamin D deficiency may improve cardiac autonomic tone in this higher risk sub-population of ESKD. Trial Registration: ClinicalTrials.gov, NCT01774812.

Approximately one-third of Canadians' prescription medication costs are paid directly out-of-pocket. This study attempts to determine if out-of-pocket spending greater than 5% of household income on drugs and pharmaceutical products is associated with cost-related prescription non-adherence among people with cardiovascular-related chronic conditions.The data are from the survey on Barriers to Care for People with Chronic Health Conditions. Three categories of out-of-pocket spending on drugs and pharmaceutical products as a percentage of household income were identified: 0%, more than 0% to less than 5%, and 5% or more. Log-binomial regression was used to investigate associations between category of out-of-pocket spending and cost-related non-adherence.In 2012, about 80% of people aged 40 or older who lived in British Columbia, Alberta, Saskatchewan or Manitoba and had cardiovascular-related chronic conditions reported out-of-pocket spending on drugs and pharmaceutical products; 4.8% reported out-of-pocket spending of at least 5% of their household income. These individuals were significantly older, more often lived in households with incomes less than $30,000, and more often reported multiple morbidities than did people whose out-of-pocket spending on drugs and pharmaceutical products was less than 5% of household income. When the results were adjusted for age and sex, people whose spending amounted to 5% or more of household income were almost three times as likely (prevalence rate ratio = 2.6) to report cost-related prescription non-adherence than were those spending less than 5%.Spending at least 5% of household income on drugs and pharmaceutical products was significantly associated with cost-related prescription non-adherence. Additional data are required to determine if even lower levels of spending put individuals at risk of cost related non-adherence.

There are concerns that alternate payment plans for physicians may be associated with erosion of data quality, given that physicians are paid regardless of whether claims are submitted. Our objective was to determine the proportion of claims submitted by physician specialists using fee-for-service and alternative payment plans, and to identify and compare the validity of information coded in physician billing claims submitted by these specialists in Calgary.We conducted a survey of physician specialists to determine their plan status and obtained consent to use physicians' claims data from 4 acute care hospitals in Calgary. Inpatient and emergency department services were identified from the Discharge Abstract Database for Alberta (Canadian Institute for Health Information) and the Alberta Ambulatory Care Classification System database. We linked services to claims by Alberta physicians from 2002 to 2009 by using unique patient and physician identifiers. After identifying the proportion of claims submitted, we reviewed inpatient charts to determine the completeness of submissions as defined by positive predictive value.Of 182 physicians who responded to the survey, 94 (51.6%) used fee-for-service plans exclusively and 51 (28.0%) used alternative payment plans exclusively. Overall completeness of physician submissions for claims was 91.8% for physicians using fee-for-service plans and 90.0% for physicians using alternative payment plans. Submission rate varied by medical specialty (surgery: 92.4% for fee for service v. 88.6% for alternative payment; internal medicine: 94.1% v. 91.3%; neurology: 95.1% v. 91.0%; and pediatrics: 95.1% v. 89.3%). Among claims submitted, the physician accuracies for billing of medical conditions were 87.8% for fee-for-service and 85.0% for alternative payment.Overall submission rates and accuracy in recording diagnoses by physicians who used both plans were high. These findings show that the implementation of alternative payment plan programs in Alberta may not have an impact on the quality of physician claims data.

Background Computer-based clinical decision support aims to improve the quality of patient care. The utility of decision support for improving blood pressure control in hemodialysis patients is unknown. Methods This was a nonrandomized controlled trial of adult patients receiving chronic in-center hemodialysis during the period of April 1, 2005, to September 30, 2006, in 1 of the 2 major university-based renal programs in Alberta, Canada. Physicians in the intervention center were provided with twice-monthly audits and printed management suggestions based on guideline-recommended blood pressure targets. The same data were available to physicians in the control group but without audit and feedback decision support. Results Eight hundred and thirty hemodialysis patients were receiving dialysis treatment at the time the study was initiated. Preintervention and postintervention blood pressure data were available for 361 patients. The primary outcome, the proportion of postdialysis systolic blood pressures at target over 12 months, did not differ between the intervention and the control programs (unadjusted odds ratio 0.59; 95% confidence interval [95% CI], 0.34-1.02, p = 0.06; adjusted odds ratio 0.62; 95% CI, 0.35-1.11, p = 0.11). There was no significant difference between the intervention and control groups in other measures of blood pressure such as the mean change in postdialysis systolic blood pressures (unadjusted mean difference 4 mm Hg, 95% CI, -1 to 9, p = 0.36; adjusted mean difference 2 mm Hg, 95% CI, -1 to 5, p = 0.19). Conclusions In this population of chronic hemodialysis patients, a computer-based clinical decision support system was not associated with improved blood pressure control.

Health-care systems require reliable information on which to base health-care planning and make decisions, as well as to evaluate their policy impact. Administrative data provide important information about health services use, expenditures, clinical outcomes, and may be used to assess quality of care. With increased digitalization and accessibility of administrative databases, these data are more readily available for health service research purposes, aiding evidence-based decision-making. This chapter discusses the utility of administrative data for population-based studies of health and health care.

Background Individuals with chronic diseases may have difficulty optimizing their health and getting the care they need due to a combination of patient, provider, and health system level barriers. Patient navigator programs, in which trained personnel assess and assist patients in overcoming barriers to care, may improve care and outcomes for patients with chronic disease by providing an alternative approach to conventional information and support resources. Methods This systematic review will evaluate the evidence for patient navigator programs, compared to usual care, in patients with chronic disease. We will include RCTs, cluster RCTs, and quasi-randomized RCTs that study the effects of patient navigator programs on clinical outcomes, patient experience, and markers of adherence to care. Studies will be identified by searching MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, PsycINFO, Social Work Abstracts, and the references of included studies. Two authors will screen titles and abstracts independently. Full texts will be reviewed for relevance and data extraction will be done independently by two authors. Studies will be included if they assess patients of any age with one or more chronic diseases. Outcomes will be categorized into groups characterized by their proximity to mechanism of action of the intervention: patient-level outcomes, intermediate outcomes, and process outcomes. Descriptive data about the elements of the patient navigator intervention will also be collected for potential subgroup analyses. Risk of bias will be assessed using the Effective Practice and Organisation of Care Group (EPOC) risk of bias tool. Data will be analyzed using random effects meta-analysis (relative risk for dichotomous data and mean difference for continuous data), if appropriate. Discussion A comprehensive review of patient navigator programs, including a summary of the elements of programs that are associated with a successful intervention, does not yet exist. This systematic review will synthesize the evidence of the effect of patient navigator interventions on clinical and patient-oriented outcomes in populations across a comprehensive set of chronic diseases. Systematic Review Registration PROSPERO CRD42013005857.

Background Survey research in healthcare is an important tool to collect information about healthcare delivery, service use and overall issues relating to quality of care. Unfortunately, physicians are often a group with low survey response rates and little research has looked at response rates among physician specialists. For these reasons, the purpose of this project was to explore survey response rates among physician specialists in a large metropolitan Canadian city. Methods As part of a larger project to look at physician payment plans, an online survey about medical billing practices was distributed to 904 physicians from various medical specialties. The primary method for physicians to complete the survey was via the Internet using a well-known and established survey company (www.surveymonkey.com). Multiple methods were used to encourage survey response such as individual personalized email invitations, multiple reminders, and a draw for three gift certificate prizes were used to increase response rate. Descriptive statistics were used to assess response rates and reasons for non-response. Results Overall survey response rate was 35.0%. Response rates varied by specialty: Neurology/neurosurgery (46.6%); internal medicine (42.9%); general surgery (29.6%); pediatrics (29.2%); and psychiatry (27.1%). Non-respondents listed lack of time/survey burden as the main reason for not responding to our survey. Conclusions Our survey results provide a look into the challenges of collecting healthcare research where response rates to surveys are often low. The findings presented here should help researchers in planning future survey based studies. Findings from this study and others suggest smaller monetary incentives for each individual may be a more appropriate way to increase response rates.

To determine the types of chronic disease management (CDM) programs offered for patients with diabetes in Alberta's primary care networks (PCNs).A survey was administered to PCNs to determine the types of CDM programs offered for patients with diabetes; CDM programs were organized into categories by their resource intensity and effectiveness. Results of the survey were reported using frequencies and percentages.Alberta has recently created PCNs-groups of family physicians who receive additional funds to enable them to support activities that fall outside the typical physician-based fee-for-service model, but which address specified objectives including CDM. It is currently unknown what additional programs are being provided through the PCN supplemental funding.A survey was administered to the individual responsible for CDM in each PCN. This included executive directors, chronic disease managers, and CDM nurses.We determined the CDM strategies used in each PCN to care for patients with diabetes, whether they were available to all patients, and whether the services were provided exclusively by the PCN or in conjunction with other agencies.There was considerable variation across PCNs with respect to the CDM programs offered for people with diabetes. Nearly all PCNs used multidisciplinary teams (which could include nurses, dietitians, and pharmacists) and patient education. Fewer than half of the PCNs permitted personnel other than the primary physician to write or alter prescriptions for medications.Alberta's PCNs have successfully established many different types of CDM programs. Multidisciplinary care teams, which are among the most effective CDM strategies, are currently being used by most of Alberta's PCNs.

Background We hypothesized that the higher mortality for hemodialysis patients who live farther from the closest attending nephrologist compared with patients living closer might be due to lower quality of care. Study Design Population-based longitudinal study. Setting & Participants All adult maintenance hemodialysis patients with measurements of quality-of-care indicators initiating hemodialysis therapy between January 2001 and June 2010 in Northern Alberta, Canada. Predictors Hemodialysis patients were classified into categories based on the distance by road from their residence to the closest nephrologist: ≤50 (referent), 50.1-150, 150.1-300, and >300 km. Outcomes Quality-of-care indicators were based on published guidelines. Measurements Quality-of-care indicators at 90 days following initiation of hemodialysis therapy and, in a secondary analysis, at 1 year. Results Measurements were available for 1,784 patients. At baseline, the proportions of patients residing in each category were 69% for ≤50 km to closest nephrologist; 17%, 50.1-150 km; 7%, 150.1-300 km; and 7%, >300 km. Those who lived farther away from the closest nephrologist were less likely to have seen a nephrologist 90 days prior to the initiation of hemodialysis therapy ( P for trend=0.008) and were less likely to receive Kt/V of 1.2 (adjusted OR, 0.50; 95% CI, 0.30-0.84; P for trend=0.01). Remote location also was associated with suboptimal levels of phosphate control ( P for trend=0.005). There were no differences in the prevalence of arteriovenous fistulas or grafts or hemoglobin levels across distance categories. Limitations Registry data with limited data for non–guideline-based quality indicators. Conclusions Although several quality-of-care indicators were less common in remote-dwelling hemodialysis patients, these differences do not appear sufficient to explain the previously noted disparities in clinical outcomes by residence location.

Many children with ESRD reside far from a kidney transplant center. It is unknown whether this geographical barrier affects likelihood of transplantation. We used data from a national ESRD database. Patients ≤ 18 yr old who started renal replacement in nine Canadian provinces during 1992-2007 were followed until death or last contact. Primary outcome was kidney transplantation (living or deceased donor). Distance between nearest pediatric transplant center and each patient's residence was categorized as:50, 50 to150, 150 to300, and ≥ 300 km. Using survival analysis, we compared likelihood of transplantation between whites and non-whites living in various distance categories. Among 728 patients, 52.2% were males and 62.5% were whites. Compared to white children living50 km from a transplant center, white (HR, 0.73; 95% CI, 0.56-0.95) and non-white (HR, 0.66; 95% CI, 0.48-0.92) children living ≥ 300 km away were less likely to receive a transplant. Non-white children living50 km away (HR, 0.59; 95% CI 0, 45-0.78) were also less likely to receive a transplant compared to otherwise similar whites living50 km away. Although equitable access to transplantation by residence location is observed among remote-dwelling adults with ESRD, white and non-white children with ESRD living ≥ 300 km from a transplant center were less likely to receive transplants.

Objective: The objective of this study was to evaluate the temporal trends in the incidence of acute myocardial infarction (AMI) and receipt of revascularization procedures in people with and without mental illness. Hypothesis: Individuals with mental illness will have higher rates of AMI, and lower rates of revascularization compared to people without mental illness. Methods: We did a population-based study using provincial administrative data from April 1, 1998 until March 31, 2009. We identified individuals 20 years of age and older as having mental illness (psychotic disorder [PD] or mood disorder [MD]) based on physician billing claims and hospitalization data, and compared them to those without mental illness by this definition. We identified incident AMI using a validated algorithm applied to hospitalization data. We used procedure codes to identify receipt of cardiac catheterization, coronary artery bypass grafting (CABG), or percutaneous transluminal coronary angioplasty (PTCA) in those with incident AMI. Rates were age-adjusted using the 2001 Canadian census population to perform direct standardization. Relative change over time was calculated by comparing rates in 2009 to rates in 1998. Results: A total of 3,639,480 subjects were included, of whom 576,411 (15.8%) had a mood disorder only, 38,116 (1.0%) had a psychotic disorder only, and 72,430 (2.0%) had both a MD and PD. People with MD were more likely to be female, whereas those with PD were older, than the other mentally ill and non-mentally ill populations. Incidence of AMI was highest in people with PD (210 per 100,000 in 2009) and lowest in people without mental illness (160 per 100,000 in 2009), however, incidence of AMI decreased over time in all groups. Use of catheterization decreased over time in people with MD (19% relative decrease) and PD (25% relative decrease), while increasing in people without mental illness (10.8% relative increase). Use of PTCA increased in all groups except people with PD (21.1% relative decrease). Conclusions: Incidence of AMI decreased over time in people with and without mental illness, however, people with mental illness consistently had a higher incidence of AMI compared to individuals without mental illness. Use of catheterization and PTCA increased in people without mental illness while decreasing in people with PD over the study period.

Background Screening and early diagnosis has been shown to reduce the morbidity and mortality associated with certain conditions such as cervical cancer. The role of general practitioners in promoting primary prevention of diseases is particularly important given that they have frequent contact with a large proportion of the population. This study assessed the extent to which general practitioners documented recommended preventive screening interventions among eligible patients. Methods We used a retrospective chart audit to assess patient visits to primary care clinics in Calgary, Canada from 2002-2004. We included fee for service physicians who practiced ≥ 2 days per week at their current location and excluded those whose primary practice was at walk-in clinics, community health centers, hospitals or emergency rooms. We included charts of patients who during the study period were age 35 years or older and had at least 2 visits to a clinic. We randomly selected and reviewed charts (N = 600) from 12 primary care clinics and abstracted information on 6 conditions recommended for preventive screening. Opportunities for preventive screening were determined based on recommendations of the Canadian Task Force on Preventive Health Care, the American College of Physicians, and the Canadian Cancer Society. Our main outcome measures included cancer screening (mammography and pap smears), immunization (influenza and pneumococcal), and risk factor assessment (cholesterol measurement and smoking cessation consultation). Results Patient visits to GP clinics present opportunities for preventive screening. However, we found that documentation of interventions was low, ranging from 40.3% (cholesterol measurement) to 0.9% (pneumococcal vaccination) within 1 year, and from 67.4% to 1.8% within the prior 3 years. Conclusions Documentation of preventive screening interventions by general practitioners was relatively low compared to the number of patients eligible for preventive screening. Some physicians opt to screen for PSA and DRE which is not recommended by the Canadian Task Force on Preventive HealthCare.

Few data guide the prescription of dialysate potassium (dK) in hemodialysis, which is usually prescribed empirically on the basis of predialysis serum potassium levels.This was a retrospective cohort study of prospectively collected data. We studied all patients initiating chronic hemodialysis in the Northern Alberta Renal Program (NARP) between January 2001 and December 2006. Data on demographic, clinical and treatment characteristics as well as the dates of death or transplant were extracted from the NARP database. We aimed to examine the relation between dialysate potassium level and all-cause death.During the study, 515/1,267 of patients (41%) died. The frequency of dK of 0 or 1 mEq/L, 2, 3 and 4 mEq/L was 6%, 40%, 51% and 3%, respectively. In our base model, which considered dK as a categorical exposure, the hazard ratios associated with 0 or 1 mEq/L, 2, 3 and 4 mEq/L were 1.13 (95% confidence interval [95% CI], 0.78-1.63), 1 (referent), 1.29 (95% CI, 1.07-1.56) and 1.74 (95% CI, 1.09-2.77), respectively. When markers of inflammation or malnutrition were adjusted for separately, the association between dK and mortality was attenuated but remained significant. After simultaneous adjustment for markers of inflammation and malnutrition, the risk of death associated with the higher dK categories was attenuated, and the overall trend was eliminated. Analyses using dK as a time-varying covariate found similar results.Although unadjusted and partially adjusted models suggested a graded association between higher dK and the risk of all-cause death, this association was apparently due to confounding by factors suggesting malnutrition and inflammation. The relative paucity of data on the association between dK and clinical outcomes despite the biological importance of potassium suggest that further studies are needed.

To quantify the cost-savings that could be realized by switching patients from two separate agents, ACE inhibitor/ARB and thiazide diuretic, to a fixed dose combination product.CompuScript and Longitudinal Rx (LRx) Insights data from IMS Health Canada for Oct 2006-Sept 2007 was used. From the LRx data, the proportion of patients taking both ACE inhibitors/ARBs and thiazide diuretics as two separate products was calculated to determine how many would qualify for a combination product. From the CompuScript data, the total number of prescriptions for ACE inhibitors and ARBs and the actual average dollar value per prescription for thiazide diuretics, ACE inhibitors, ARBs, and ACE inhibitor/ARB with thiazide diuretic combination products was used to determine the potential cost savings of switching from two separate drugs to a combination product. As a sensitivity analysis, the proportion of patients receiving two separate products who could be switched to a combination product was varied from 60-100%. This analysis was done for Alberta and Canada.The conversion of ACE inhibitor/ARB and thiazide diuretic as two separate agents to a combination product could potentially result in a yearly cost-savings of $27 to $45 million for Canada ($1.1 to $1.9 million for Alberta), based on 60-100% conversion to a combination product.The present analysis has shown that a simple intervention of converting patients receiving separate ACE inhibitor/ARB and thiazide diuretic prescriptions to a single combination product prescription will produce substantial cost-savings for the health care system and simplify the medication regimen for patients.

Studies of the risk of motor vehicle crash associated with diabetes have produced conflicting results.To assess whether the use of anti-diabetic drugs among the elderly increases the risk of motor vehicle crash.The computerized databases of the various universal insurance programs of Québec were linked to form a cohort of all 224,734 elderly drivers that was followed from 1990-1993. Using a nested case-control approach, all 5,579 drivers involved in an injurious crash (cases) and a random sample of 13,300 control subjects were identified. Exposure to anti-diabetic drugs was assessed in the year preceding the index date, namely the date of the crash for the cases and a randomly selected date during follow-up for the controls.The adjusted rate ratio of an injurious crash was 1.4 (95% CI: 1.0-2.0) for current users of insulin monotherapy relative to non-users and 1.3 (95% CI: 1.0-1.7) for sulfonylurea and metformin combined. Monotherapy, using either a sulfonylurea or metformin, was not associated with an increased risk. There was a dose-response effect in subjects using high doses of combined oral therapy (RR 1.4; 95% CI: 1.0-2.0). For users of insulin monotherapy or of high doses of combined oral therapy, the increase corresponds to an excess rate of 32 crashes per 10,000 elderly drivers per year.L Elderly drivers treated with insulin monotherapy or a combination of sulfonylurea and metformin, especially at high doses, have a small increased risk of injurious crashes. There is no increased risk associated with any regimen of oral monotherapy.

To provide updated, evidence-based recommendations for the management of hypertension in adults.For patients who require pharmacological therapy for hypertension, a number of antihypertensive agents may be used. Randomized trials evaluating first-line therapy with diuretics, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers (CCBs), alpha-blockers, centrally acting agents or angiotensin receptor antagonists were reviewed. Also, randomized trials evaluating other agents, such as statins or acetylsalicylic acid, in patients with hypertension were reviewed. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. In addition, other relevant outcomes such as development of end-stage renal disease or changes in blood pressure were examined where appropriate.MEDLINE searches were conducted from November 2001 to October 2003 to update the 2001 Recommendations for the management of hypertension. Reference lists were scanned, experts were contacted, and the personal files of the subgroup members and authors were used to identify additional published studies. All relevant articles were reviewed and appraised independently, using prespecified levels of evidence by content and methodology experts.This document contains detailed recommendations and supporting evidence on treatment thresholds, target blood pressures and choice of agents for hypertensive patients with or without comorbidities. Lifestyle modifications are a key component of any antiatherosclerotic management strategy and detailed recommendations are contained in a separate document. Key recommendations for pharmacotherapy include the following: treatment thresholds and targets should take into account each individual's global atherosclerotic risk, target organ damage and comorbidities, with particular attention to systolic blood pressure; blood pressure should be lowered to 140/90 mmHg or less in all patients, and 130/80 mmHg or less in those with diabetes mellitus or renal disease (125/75 mmHg or less in those with nondiabetic renal disease and more than 1 g of proteinuria per day); most adults with hypertension require more than one agent to achieve target blood pressures; for adults without compelling indications for other agents, initial therapy should include thiazide diuretics; other agents appropriate for first-line therapy for diastolic hypertension with or without systolic hypertension include beta-blockers (in those younger than 60 years), ACE inhibitors (in non-Blacks), long-acting dihydropyridine CCBs or angiotensin receptor antagonists; other agents appropriate for first-line therapy for isolated systolic hypertension include long-acting dihydropyridine CCBs or angiotensin receptor antagonists; certain comorbidities provide compelling indications for first-line use of other agents: in patients with angina, recent myocardial infarction or heart failure, beta-blockers and ACE inhibitors are recommended as first-line therapy; in patients with diabetes mellitus, ACE inhibitors or angiotensin receptor antagonists (or thiazides in patients with diabetes mellitus without albuminuria) are appropriate first-line therapies; and in patients with mild to moderate nondiabetic renal disease, ACE inhibitors are recommended; all hypertensive patients should have their fasting lipids screened and those with dyslipidemia should be treated using the thresholds, targets and agents as per the Recommendations for the management of dyslipidemia and the prevention of cardiovascular disease; and selected patients with hypertension should also receive statin and/or acetylsalicylic acid therapy.All recommendations were graded according to the strength of the evidence and voted on by the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. Individuals with irreconcilable competing interests (declared by all members, compiled and circulated before the meeting) relative to any specific recommendation were excluded from voting on that recommendation. Only recommendations achieving at least 70% consensus are reported here. These guidelines will continue to be updated annually.

Health behaviour change is an important component of management for patients with chronic kidney disease (CKD); however, the optimal method to promote health behaviour change for self-management of CKD is unknown. The See Kidney Disease (SeeKD) targeted screening programme screened Canadians at risk for CKD and promoted health behaviour change through individual counselling and goal setting.The objectives of this study are to determine the effectiveness of individual counselling sessions for eliciting behaviour change and to describe participant characteristics associated with behaviour change.This is a cross-sectional, descriptive study.The study setting is the National SeeKD targeted screening programme.The participants are all 'at risk' patients who were screened for CKD and returned a follow-up health behaviour survey (n = 1129).Health behaviour change was defined as a self-reported change in lifestyle, including dietary changes or medication adherence.An individual counselling session was provided to participants by allied healthcare professionals to promote health behaviour change. A survey was mailed to all participants at risk of CKD within 2-4 weeks following the screening event to determine if behaviour changes had been initiated. Descriptive statistics were used to describe respondent characteristics and self-reported behaviour change following screening events. Results were stratified by estimated glomerular filtration rate (eGFR) ( 60 and ≥ 60 mL/min/1.73 m(2)). Log binomial regression analysis was used to determine the predictors of behaviour change.Of the 1129 respondents, the majority (89.8 %) reported making a health behaviour change after the screening event. Respondents who were overweight (body mass index [BMI] 25-29.9 kg/m(2)) or obese (BMI ≥ 30.0 kg/m(2)) were more likely to report a behaviour change (prevalence rate ratio (PRR) 0.66, 95 % confidence interval (CI) 0.44-0.99 and PRR 0.49, 95 % CI 0.30-0.80, respectively). Further, participants with a prior intent to change their behaviour were more likely to make a behaviour change (PRR 0.58, 95 % CI 0.35-0.96). Results did not vary by eGFR category.We are unable to determine the effectiveness of the behaviour change intervention given the lack of a control group. Potential response bias and social desirability bias must also be considered when interpreting the study findings.Individual counselling and goal setting provided at screening events may stimulate behaviour change amongst individuals at risk for CKD. However, further research is required to determine if this behaviour change is sustained and the impact on CKD progression and outcomes.Les changements dans les habitudes de vie sont une composante majeure dans la prise en charge des patients atteints d’insuffisance rénale chronique (IRC). Malgré cela, la méthode pour promouvoir efficacement ces changements auprès de cette clientèle particulière n’est pas connue. Le programme de dépistage précoce et cibléCette étude avait pour objectif de mesurer l’efficacité de séances de consultation individuelle offertes aux patients en vue de susciter des changements comportementaux. L’étude visait également à établir les caractéristiques des patients associées à ces changements de comportement.Il s’agit d’une étude transversale descriptive qui s’est tenue dans le cadre du programme national de dépistage cibléLa cohorte était constituée de tous les patients identifiés « à risque de développer une IRC » par le programmeUne séance de consultation individuelle ayant pour but de promouvoir l’intégration de nouvelles d’habitudes de vie a été offerte aux participants par les professionnels de la santé à la suite de l’activité de dépistage. Entre deux et quatre semaines plus tard, les participants ont également reçu un questionnaire par la poste à l’aide duquel on a pu vérifier s’ils avaient entamé les changements de comportement proposés. Des statistiques descriptives ont été utilisées pour établir les caractéristiques des répondants ainsi que les changements de comportement que ces derniers ont rapporté avoir adoptés à la suite de l’activité de dépistage. Les résultats ont été stratifiés en deux groupes selon les valeurs de DFGe des participants ( 60 mL/min/1.73 mLa grande majorité (89,8 %) des 1129 participants ont rapporté avoir adopté de nouveaux comportements en matière de santé après avoir été déclarés à risque de développer une IRC. Les répondants souffrant d’embonpoint (indice de masse corporelle [IMC] entre 25 et 29,9 kg/mNous n’avons pu déterminer avec précision l’efficacité des changements de comportement adoptés en raison de l’absence d’un groupe contrôle. De plus, un biais dû aux réponses des participants ou par désirabilité sociale est à considérer dans l’interprétation des résultats.L’établissement d’objectifs ainsi que le counselling individuel fourni à la suite de l’activité de dépistage pourraient stimuler l’adoption de nouvelles habitudes de vie chez les patients à risque de développer une IRC. Toutefois, des recherches supplémentaires sont requises afin de déterminer si ces changements de comportement sont maintenus par les patients et s’ils ont une réelle influence sur le pronostic de la maladie.