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Figure 1. Flow diagram of studies assessed and included. CVD indicates cardiovascular disease; RCT, randomized controlled trial.

Figure 1. Flow diagram of studies assessed and included. CVD indicates cardiovascular disease; RCT, randomized controlled trial.

Figure 2. Forest plots of the mean difference in systolic (A) and diastolic (B) blood pressure (BP) with the pharmacist care group compared with the usual care group. CI indicates confidence interval.

Figure 2. Forest plots of the mean difference in systolic (A) and diastolic (B) blood pressure (BP) with the pharmacist care group compared with the usual care group. CI indicates confidence interval.

Figure 3. Forest plot of the mean difference in total cholesterol (TC) (A) and low-density lipoprotein cholesterol (LDL-C) (B) with the pharmacist care group compared with the usual care group. To convert LDL-C to millimoles per liter, multiply by 0.0259.

Figure 3. Forest plot of the mean difference in total cholesterol (TC) (A) and low-density lipoprotein cholesterol (LDL-C) (B) with the pharmacist care group compared with the usual care group. To convert LDL-C to millimoles per liter, multiply by 0.0259.

Figure 4. Forest plot of the relative risk of smoking with the pharmacist care group compared with the usual care group.

Figure 4. Forest plot of the relative risk of smoking with the pharmacist care group compared with the usual care group.

Table 1. Characteristics of Included Studies: Study Setting and Design, Sample Size, and Study Participants
Table 1. Characteristics of Included Studies: Study Setting and Design, Sample Size, and Study Participants
Table 2. Characteristics of Included Studies: Key Componevnts of Pharmacist Interventions, Intervention Frequency, Usual Care Group, and Outcomes
Table 2. Characteristics of Included Studies: Key Componevnts of Pharmacist Interventions, Intervention Frequency, Usual Care Group, and Outcomes
Table 3. Subgroup Analyses for the Difference in Systolic and Diastolic BP With Pharmacist Care Compared With Usual Care Group According to Selected Study Characteristics
Table 3. Subgroup Analyses for the Difference in Systolic and Diastolic BP With Pharmacist Care Compared With Usual Care Group According to Selected Study Characteristics
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Review Article
Health Care Reform
Sep 12, 2011

Impact of Pharmacist Care in the Management of Cardiovascular Disease Risk FactorsA Systematic Review and Meta-analysis of Randomized Trials

Author Affiliations

Author Affiliations: Department of Epidemiology, Biostatistics, and Occupational Health (Drs Santschi, Chiolero, and Paradis) and McGill Library, Life Sciences Library (Ms Colosimo), McGill University, Montreal, Quebec, Canada; Institute of Social and Preventive Medicine, CHUV and University of Lausanne, Lausanne, Switzerland (Drs Santschi, Chiolero, and Burnand); and Research Institute of the McGill University Health Centre, Montreal, and Institut national de santé publique du Québec, Montreal (Dr Paradis).

Arch Intern Med. 2011;171(16):1441-1453. doi:10.1001/archinternmed.2011.399
Abstract

Background Pharmacists may improve the clinical management of major risk factors for cardiovascular disease (CVD) prevention. A systematic review was conducted to determine the impact of pharmacist care on the management of CVD risk factors among outpatients.

Methods The MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials databases were searched for randomized controlled trials that involved pharmacist care interventions among outpatients with CVD risk factors. Two reviewers independently abstracted data and classified pharmacists' interventions. Mean changes in blood pressure, total cholesterol, low-density lipoprotein cholesterol, and proportion of smokers were estimated using random effects models.

Results Thirty randomized controlled trials (11 765 patients) were identified. Pharmacist interventions exclusively conducted by a pharmacist or implemented in collaboration with physicians or nurses included patient educational interventions, patient-reminder systems, measurement of CVD risk factors, medication management and feedback to physician, or educational intervention to health care professionals. Pharmacist care was associated with significant reductions in systolic/diastolic blood pressure (19 studies [10 479 patients]; −8.1 mm Hg [95% confidence interval {CI}, −10.2 to −5.9]/−3.8 mm Hg [95% CI,−5.3 to −2.3]); total cholesterol (9 studies [1121 patients]; −17.4 mg/L [95% CI,−25.5 to −9.2]), low-density lipoprotein cholesterol (7 studies [924 patients]; −13.4 mg/L [95% CI,−23.0 to −3.8]), and a reduction in the risk of smoking (2 studies [196 patients]; relative risk, 0.77 [95% CI, 0.67 to 0.89]). While most studies tended to favor pharmacist care compared with usual care, a substantial heterogeneity was observed.

Conclusion Pharmacist-directed care or in collaboration with physicians or nurses improve the management of major CVD risk factors in outpatients.

Cardiovascular disease (CVD) is the leading cause of mortality and morbidity in adults worldwide1 and accounts for approximately one-third of mortality in Canada2 and in the United States.3 Randomized studies have demonstrated the efficacy of lowering blood pressure (BP) and cholesterol levels or smoking cessation to reduce CVD mortality and morbidity.4 However, control of CVD risk factors is far from optimal in the population5,6 and only a minority of patients with CVD risk factors achieved target goals for low-density lipoprotein cholesterol (LDL-C) levels7 or BP.6 Interventions to improve the management of CVD risk factors are therefore needed.

Because patients have difficulties accessing primary care physicians and health care costs are rapidly rising, greater use of community-based models of care has been proposed.8 Among these models is the greater integration of the pharmacist as a provider of health services and member of the health care team. Pharmacists are highly accessible health care professionals, and because of their knowledge of drug therapy and their computerized records of medications, they are particularly well positioned to provide the necessary medication instructions to patients to improve safe medication use and are in collaboration with primary care physicians to assist in preventive CVD care.9,10 Studies have demonstrated beneficial interventions of pharmacists in medication use,11 identification of patients at high risk of CVD,12 and CVD management.10 Interventions have included pharmacist-only or pharmacist-collaborative care as part of disease management programs, clinical pharmacy cardiac risk services,1315 and community-based programs that focus on modifiable CVD risk factors.10,16,17 Therefore, interventions delivered by pharmacists may be key to improve the management and outcomes among patients with CVD risk factors.10

Previous studies have shown that collaborative care involving pharmacists may help the management of diabetes,16 dyslipidemia,10 hypertension,18,19 heart failure,20 and CVD17 and reduces the risk of all-cause and heart failure hospitalizations.21 To more effectively use the expertise of pharmacists in CVD care, it is necessary to better understand their roles and contributions to patient care. A review of pharmacist interventions suggested that pharmacy-based interventions improve surrogate outcomes of CVD.22 However, this review was not systematic in its coverage and did not aggregate the findings through meta-analysis. Therefore, we conducted a systematic review of randomized studies to determine the impact of pharmacist care on the management of major CVD risk factors among outpatients.

METHODS
DATA SOURCES AND SEARCHES

In collaboration with a medical research librarian (A.L.C.), we conducted a systematic literature search of the electronic databases MEDLINE via PubMed (1950 to November 2010), EMBASE (1980 to November 2010), CINAHL (1937 to November 2010), and the Cochrane Central Register of Controlled Trials (up to November 2010) for randomized controlled trials (RCTs). Inclusion criteria and methods of analysis were specified in advance and documented in a protocol available on request.

The PubMed search syntax served as the basis for all search strategies, using both Medical Subject Headings (MeSH) and text terms with Boolean operators (see eAppendix for the full electronic search strategy). MESH terms included cardiovascular disease-related terms (Cardiovascular Diseases, Dyslipidemias, Diabetes Mellitus, Smoking, and Overweight) and pharmacist-related terms (Pharmacists, Pharmaceutical Services, Pharmacy Service, Hospital, Pharmacies, and Pharmacy). The search was focused on RCTs using the Cochrane Highly Sensitive Search Strategy for identifying randomized trials in MEDLINE. The search strategy was then adapted for EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials. In addition to these automated searches, we conducted a hand search of bibliographies of all relevant articles. We considered publications in any language.

STUDY SELECTION

Two authors (V.S. and A.C.) independently screened titles, abstracts, and full articles from the literature search to determine eligibility (Figure 1). We included studies that (1) had a randomized control design; (2) evaluated the impact of pharmacist care delivered by pharmacist, community pharmacist, hospital pharmacist, or clinical pharmacist; and (3) were conducted among adults outpatients with any modifiable CVD risk factors (hypertension, dyslipidemia, diabetes, smoking, or obesity), irrespective of whether they were receiving CVD pharmacological treatment, compared with a usual care group. Outcomes of interest for this study were systolic and diastolic BP, total cholesterol (TC), LDL-C, or smoking. Studies involving only diabetic patients were not included. Disagreements were resolved by discussion. Based on a recent systematic review on pharmacist care of patients with heart failure,21 the classification of pharmacist interventions was made using a priori–defined categories: pharmacist-directed care (pharmacist initiated and managed interventions) and pharmacist collaborative care (pharmacist collaborated in interventions conducted by a multidisciplinary health care team).

DATA EXTRACTION AND RISK OF BIAS IN INCLUDED STUDIES

Data extraction was independently performed by 2 authors (V.S. and A.C.) using a standardized data collection form. From each included study, information was abstracted on the following: (1) study author, year of the publication, and country where the study was conducted; (2) study characteristics (including study setting and design, duration of follow-up and sample size); (3) characteristics of participants (including sex, age, CVD risk factors, and medications); (4) characteristics of interventions (including description and frequency of the pharmacist intervention); (5) characteristics of usual care group; and (6) types of outcome measure (including change in BP from baseline, BP at follow-up; change in LDL-C and TC levels from baseline, LDL-C and TC levels at follow-up; and prevalence of smoking cessation).

Risk of bias in the adequacy of randomization, concealment of allocation, blinding of outcome assessors, completeness of data, selective outcome reporting, and other bias (eg, important baseline imbalance in patient characteristics) was assessed by 2 authors (V.S. and A.C.) using the Cochrane Risk of Bias Tool.23 For each item, the quality characteristics of each study were rated as (1) low risk of bias; (2) unclear; and (3) high risk of bias. Disagreements between the reviewers (V.S. and A.C.) were resolved by an open dialogue to develop consensus which was reached without the involvement of a third author.

STATISTICAL ANALYSIS

Statistical analyses were conducted following the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions23 and the PRISMA statement.24 Data were analyzed using STATA version 11.0 (StataCorp, College Station, Texas). Average intervention effects were calculated as relative risks with 95% confidence intervals (CIs) for dichotomous data using a random effects model. For continuous data, we used a random effects model to calculate weighted mean differences with 95% CIs. We calculated standard deviations from standard errors or 95% CIs presented in the articles if required. Heterogeneity was quantified using the I2 and the χ2 test of heterogeneity.23 Funnel plots were drawn and Egger tests were computed to explore the possibility of publication bias. To explore possible determinants of heterogeneity, we conducted post hoc subgroup analyses according to selected study characteristics. We did not perform a meta-regression, given the relatively limited number of studies. Sensitivity analyses were conducted by (1) excluding relatively small studies (with fewer than 50 participants per randomization group); (2) excluding the study by Hennesy et al,25 which was the only study in which the pharmacist did not have direct contact with patients; and (3) restricting analysis to studies of good quality.

RESULTS

Searches identified 11 255 potential citations. After initial screening of titles and abstracts, 154 full-text studies were assessed for eligibility and 30 RCTs, all published in the English language, met inclusion criteria (Figure 1).

DESCRIPTION OF STUDIES AND TYPES OF INTERVENTIONS

Table 1 and Table 2 summarize the characteristics of the included studies. The outcome was BP in 19 studies (10 479 patients),18,25,26,3034,36,39,4248,50,51 TC in 9 studies (1121 patients),9,28,29,35,37,38,41,49,52 LDL-C in 7 studies (924 patients)28,29,32,35,41,49,52 and smoking in 2 studies (165 patients).27,40No study reported obe-sity or overweight as outcome. Six cluster RCTs were randomized at pharmacy43 or provider care level.18,25,46,50,52 The remaining trials were randomized at patient level.9,2642,44,45,4749,51

The included studies involved a total of 11 765 participants aged from 52 to 77 years and followed over a mean of 8 months (minimum, 3 months; maximum, 24 months) (Table 1 and Table 2). Overall, 54% of the participants were women. Patients had uncontrolled CVD risk factors in 17 studies and were receiving pharmacological treatment (antihypertensive or lipid-lowering drugs) in 18 studies. In the remaining studies, patients with controlled or uncontrolled CVD risk factors and with or without pharmacological treatment were included.

Most studies (n = 20) were conducted in North America. Other studies were conducted in South America (n = 3), Asia (n = 3), Europe (n = 2), and Australia (n = 2). Participants were most often followed in outpatients clinics (20 studies), eg, primary care center or family medicine clinic. Five studies were conducted in community pharmacies30,33,35,37,43 and 5 in both outpatients clinics and community pharmacies.3941,50,52 One study involved a pharmacist intervention delivered at home outside of a health care setting.38

Eighteen studies were pharmacist-directed care2643 and 12 pharmacist-collaborative care (Table 1 and Table 2).9,18,25,4452 The interventions exclusively delivered by pharmacist or implemented in collaboration with physicians or nurses included (1) educational interventions directed to patients (defined as education and counseling about medications, lifestyle or compliance; distribution or use of educational material; patient educational workshop) in 26 studies9,2527,3045,4752; (2) patient-reminder systems (defined as telephone contact; using Web site; home visit; or drug adherence aids) in 9 studies18,29,31,32,34,38,43,49,50; (3) medication management (defined as medication review from medical records or patient interview; assessment of medication compliance; monitoring of medication therapy such as assessment, adjustment, or change of medications) in 22 studies9,18,26,28,29,3133,35,38,39,41,42,4452; (4) feedback to health care professional (defined as drug-related problems (DRPs) identification; recommendation to physicians regarding medications change; meeting with team to discuss care) in 24 studies9,18,25,28,30,31,3339,41,4352; (5) measurement of CVD risk factors or reviewing of laboratory data by pharmacist during follow-up in 12 studies9,28,30,31,34,35,3840,4345; and (6) an educational intervention directed to health care professional (defined as a training program or distribution of educational material to other health care professionals including physicians) in 2 studies.25,46

METHODOLOGICAL QUALITY OF INCLUDED STUDIES

The studies were of variable methodological quality (see eFigure). Information on allocation concealment or blinding to outcome assessors was not described in most studies. None of the study blinded study participants to the pharmacist intervention. Most of the studies were free of selective outcome reporting.

OUTCOMES
Blood Pressure

The majority of the 19 studies demonstrated beneficial and statistically significant differences in systolic and diastolic BP between pharmacist and usual care groups (Figure 2). No study demonstrated a statistically significant difference in favor of the usual care group. The pooled estimate of the 19 RCTs showed a significant reduction in BP for pharmacist care compared with usual care (weighted mean difference in systolic BP, −8.1 mm Hg [95% CI, −10.2 to −5.9], P < .001; weighted mean difference in diastolic BP, −3.8 mm Hg [95% CI, −5.3 to −2.3], P < .001). A substantial heterogeneity was observed for both systolic (I2 = 75.5%) and diastolic BP (I2 = 85.3%).

TC and LDL-C

Of the 9 studies reporting TC level, 6 demonstrated a statistically significant benefit of pharmacist care (Figure 3A). Of the 7 studies reporting LDL-C level, 4 demonstrated a statistically significant benefit of pharmacist care (Figure 3B). For both outcomes no study demonstrated a statistically significant difference in favor of the usual care group. The pooled estimate showed a significant reduction in TC level (weighted mean difference, −17.4 mg/L [95% CI, −25.5 to −9.2], P < .001) and LDL-C (weighted mean difference, −13.4 mg/L [95% CI, −23.0 to −3.8], P = .006) for pharmacist care compared with usual care. A substantial heterogeneity was also observed for both TC (I2 = 78.5%) and LDL-C (I2 = 86.5%) levels.

Smoking

Two studies suggested that pharmacist care helped decrease smoking (Figure 4). The pooled estimate showed a statistically significant reduction in smoking for pharmacist care compared with the usual care (relative risk, 0.77 [95% CI, 0.67 to 0.89], P = .001). No significant heterogeneity was observed.

Subgroup Analyses

To explore the possible differences between studies and in view of the substantial heterogeneity, post hoc subgroup analyses were conducted according to the type of pharmacist care, the type and number of interventions, and the inclusion of uncontrolled or a mix of controlled and uncontrolled hypertensive patients (Table 3). These analyses were conducted for the outcome BP, for which a relatively large number of studies were available (n = 19). Pharmacist-directed care and pharmacist-collaborative care were both associated with statistical reductions in systolic and diastolic BP, but no major differences were demonstrated between the 2 types of pharmacist care (pharmacist-directed care: weighted mean difference in systolic BP, −9.1 mm Hg [95% CI, −11.7 to −6.4]; weighted mean difference in diastolic BP, −5.1 mm Hg [95% CI, −7.0 to −3.1]; and pharmacist-collaborative care: weighted mean difference in systolic BP, −6.8 mm Hg [95% CI, −9.7 to −3.9]; and weighted mean difference in diastolic BP, −2.2 mm Hg [95% CI, − 4.6 to −0.2]) (Table 3). Moreover, there were no major differences in BP reductions according to the type or the number of interventions or to the control of BP.

Publication Bias

We explored the possibility of publication bias for studies in which the outcome was BP (n = 19). For both systolic and diastolic BP, asymmetry in the funnel plots was observed and an Egger test result was statistically significant, indicating a potential publication bias.

Sensitivity Analyses

Because of potential publication bias, a first sensitivity analysis was performed to explore the influence of relatively small studies (with fewer than 50 participants per randomization group; n = 7).30,33,34,42,44,47,50 After exclusion of these studies from the meta-analysis, a similar reduction in BP for pharmacist care compared with usual care group was observed (systolic BP mean difference, −7.3 mm Hg [95% CI, −9.6 to −5.0], I2 = 78.5%; diastolic BP mean difference, −2.5 mm Hg [95% CI, −3.8 to −1.2], I2 = 80.3%).

The second sensitivity analysis was performed to assess the influence of the study by Hennessy et al,25 which was the only study in which the pharmacist had no direct contact with patients. After exclusion of this study from the meta-analysis, a similar reduction in BP for the pharmacist care group compared with the usual care group was observed (sys tolic BP mean difference, −8.3 mm Hg [95% CI, −10.1 to −6.5], I2 = 41.9%; diastolic BP mean difference, −4.0 mm Hg [95% CI, −5.5 to −2.6], I2 = 72.7%).

To explore the impact of study quality on the effect estimates, a third sensitivity analysis was conducted restricting analysis to studies of good quality. A study was of “good quality” if it had a low risk of bias on 3 items or more (of 6) using the Cochrane Risk of Bias Tool.23 Of 19 studies with the BP outcome, 818,31,35,43,44,46,48,49 (assessing 1955 participants) were of good quality and showed similar significant reductions in BP for the pharmacist care group compared with the usual care group (systolic BP mean difference, −7.8 mm Hg [95% CI, −9.6 to −6.0], I2 = 6.5%; diastolic BP mean difference, −3.8 mm Hg [95% CI, −5.3 to −2.3], I2 = 64.4%).

COMMENT

Our systematic review, identifying 30 RCTs that assessed 11 765 outpatients, supports the benefit of pharmacist care interventions in the management of major CVD risk factors among outpatients. Pharmacist interventions achieved greater reductions in systolic and diastolic BP, TC, and LDL-C, and in the risk of smoking compared with the usual care group. The most frequent interventions, exclusively provided by pharmacists or implemented in collaboration with physicians or nurses, were (1) educational interventions for patients (education and counseling about medications, lifestyle, or compliance); (2) feedback to physician (DRPs identification, recommendation to physician regarding medications), and (3) medication management (medication review from medical records and monitoring of drug therapy such as adjustment or change of medications).

Our results underscore the significant benefits of pharmacist interventions in CVD risk factors and are in line with those of a previous narrative review, which suggested that pharmacist-led interventions were associated with a better control of some CVD risk factors (hypertension and dyslipidemia) in outpatients.22 Furthermore, our findings are supported by a recent systematic review53 evaluating the effect of pharmacist as team members on patient care. In this review, Chisholm-Burns et al53 reported a mean difference between the pharmacist group and the comparison group of −6.3 mg/dL (95% CI, −6.5 to −6.0) in LDL-C, −7.8 mm Hg (95% CI, −9.7 to −5.8) in systolic BP, and −2.9 mm Hg (95% CI, −3.8 to −2.0) in diastolic BP. Nevertheless, this review was restricted to studies conducted in the United States and evaluated only interventions of pharmacist as a team member, ie, pharmacist-collaborative care interventions. Furthermore, no sensitivity analyses were conducted in this review.

Pharmacist interventions varied among the identified studies and possibly included several cointerventions. Therefore, it was difficult to clearly delineate the different types of interventions, making it difficult to precisely identify which intervention was more efficient to help the management of CVD risk factors among outpatients. Our analyses that were restricted to studies assessing BP, the most frequently reported outcome, did not allow us to identify which intervention was more efficient to decrease BP. A systematic review of pharmacist care among patients with heart failure suggested that pharmacist interventions implemented in collaboration with physicians or nurses were more efficient to reduce the rate of hospitalizations compared with interventions exclusively provided by pharmacists.21 Nevertheless, our review did not show better outcomes in favor of pharmacist interventions exclusively provided by pharmacists or in favor of pharmacist interventions implemented in collaboration with physicians or nurses. Therefore, further studies are needed to define and evaluate which pharmacist interventions are the most effective for the management of CVD risk factors in different health care system organizations or jurisdictions.

The traditional view of the pharmacist's role in primary care is medication distribution. Although this role remains an important part of the activity of a pharmacist, evidence documented in our systematic review and previous reviews21,53 demonstrates a transformation of pharmacy practice toward a more clinical, patient-centered role and a collaborative approach toward pharmacist-physician in patient care. The enhanced role of the pharmacist as member of CVD health care is more successfully implemented and accepted in North America health care system compared with the European health care system. Indeed, most studies9,18,25,2729,3136,4246,48,51,52 identified in our review were conducted in North America and only 2 studies30,50 were conducted in Europe.

Our review has some limitations. First, although we conducted a rigorous and systematic review, we did not search for unindexed and unpublished literature. Our analyses indicate a potential publication bias that suggests that studies reporting favorable results of pharmacist interventions were more likely published than those reporting negative results.23 Consequently, the average estimates of the effect of pharmacist interventions may be overestimated. However, our sensitivity analysis, which excluded relatively small studies, showed that the estimate of the effect of pharmacist interventions on BP was similar to the analysis including all studies. Second, while most studies favored pharmacist care compared with usual care, a substantial heterogeneity was observed in the effect of pharmacists' interventions on BP, TC, and LDL-C, which suggests a large variation in the effect of pharmacist interventions.53 As we expected heterogeneity, we used random effects analysis to allow for differences in the treatment effect from study to study.54 Differences in terms of interventions and setting, disease severity of patients or cointerventions may explain this heterogeneity. We explored the potential sources of heterogeneity by conducting subgroup analyses by the type of pharmacist care and the type of pharmacist interventions. We found no difference in effect on BP according to the type of pharmacist care and the type of interventions. Moreover, sensitivity analyses accounting for study quality and study size reported similar effects on BP. We also investigated whether differences were observed between studies including uncontrolled or a mix of controlled and uncontrolled hypertensive patients but found no major differences. Other potential causes of heterogeneity could be comorbidities, number of medications, or age of the patients but would have required individual level data to be identified.55

Despite these limitations, our review had unique strengths. Our review was conducted following the Cochrane Handbook for Systematic Reviews of Interventions23 and the PRISMA statement.24 Our review was systematic in its coverage; considered major modifiable CVD risk factors, such as hypertension, dyslipidemia, and smoking; and included studies assessing the effect of pharmacist-directed care as well as pharmacist-collaborative care.

In conclusion, our results support the beneficial role of pharmacist care in the management of CVD risk factors among outpatients. Given the difficulties in accessing primary care physicians, the integration of pharmacist in the care of outpatients should be considered as a valuable solution for improving the management of CVD risk factors. Further studies are needed to identify which type of pharmacist interventions are best suited to help manage CVD risk factors and how this type of pharmacist care could be enhanced in various health care systems.

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Article Information

Correspondence: Valérie Santschi, PharmD, PhD, Institute of Social and Preventive Medicine, Rue du Bugnon 17, 1005 Lausanne, Switzerland (valerie.santschi@gmail.com).

Accepted for Publication: May 16, 2011.

Author Contributions: Drs Santschi and Chiolero had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Santschi, Chiolero, Burnand, and Paradis. Acquisition of data: Santschi, Chiolero, and Colosimo. Analysis and interpretation of data: Santschi, Chiolero, Burnand, and Paradis. Drafting of the manuscript: Santschi and Chiolero. Critical revision of the manuscript for important intellectual content: Santschi, Chiolero, Burnand, Colosimo, and Paradis. Statistical analysis: Santschi, and Chiolero. Obtained funding: Paradis. Administrative, technical, and material support: Santschi, Chiolero, and Paradis. Study supervision: Burnand and Paradis.

Financial Disclosure: None reported.

Funding/Support: This study was supported in part by the Canadian Institutes of Health Research (CIHR) Applied Public Health Research Chair in Chronic Disease Prevention to Paradis.

Previous Presentation: This study was presented as a poster at the North American Congress of Epidemiology; June 22, 2011; Montreal, Quebec, Canada.

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