Tackling the Inverse Care Law with pharmacist-led cardio-renal-metabolic service in a socioeconomically deprived population: A prospective scoping intervention study

Tackling the Inverse Care Law with pharmacist-led cardio-renal-metabolic service in a socioeconomically deprived population: A prospective scoping intervention study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Tackling the Inverse Care Law with pharmacist-led cardio-renal-metabolic service in a socioeconomically deprived population: A prospective scoping intervention study Tania Ramos, Amit Verma, Iain Speirits, Ling Zhang, Janice McInally, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6209460/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Jun, 2025 Read the published version in International Journal of Clinical Pharmacy → Version 1 posted 6 You are reading this latest preprint version Abstract Background Chronic kidney disease (CKD) is a leading cause of premature mortality, often coexisting with cardiovascular disease and diabetes mellitus; disproportionately affecting socioeconomically deprived groups. CKD is projected to increase due to ageing, obesity and diabetes. General practice clinical pharmacists (GPCPs) have been shown to be effective in challenging chronic disease prescribing. GPCP services for CKD remains underexplored. Aim To scope the potential of a GPCP-led multidisciplinary intervention to optimise cardio-renal and metabolic risk factors in CKD stages 3–4. Method Adults with CKD stages 3a to 4 from two urban, socioeconomically deprived general practices in NHS Greater Glasgow and Clyde in UK, were identified via practice records and GP referrals. Eligible patients were invited to attend a GPCP-led clinic (Nov 2021 – Jan 2024), that included CKD monitoring (primary measure), patient education, life-style advice and medicines optimisation. Anonymised pre- and post-intervention data were analysed. Results In total, 253 participants (median age 77, range 26 to 99) met inclusion criteria; 62% lived in the most deprived areas of Scotland; 62% were female. Of the 163 (64%) attending. eGFR increased by a mean of 2.9 (95% CI 1.41 to 4.40, p < 0.001) ml/min/1.73m 2 over 12 months, with improvements in CKD staging, blood pressures, lipid profiles, and HbA1c. Medicines optimisation included lipid lowering (62%), antihypertensives (47%), sodium-glucose co-transporter-2 inhibitors (42%), adverse drug effect management (16%), including nephrotoxic cessation. Conclusion An integrated pharmacist-led, general practice-based cardio-renal and metabolic clinic, improved key CKD-related outcomes in deprived population. Further studies are needed to confirm long-term impact. Figures Figure 1 Impact of findings on practice statements To the author’s knowledge, this scoping study is the first to explore the potential of general practice clinical pharmacists optimising treatment for chronic kidney disease (CKD) within a general practice setting. Focused on a socioeconomically deprived population experiencing a significant disease burden, with known resource limitation and healthcare gaps. Explores integrated multidisciplinary working and capacity building within routine practice, showcasing real-world feasibility. Main limitations include small sample size and absence of a usual care comparator limiting direct comparison, although pre- to post-intervention improvements to CKD measures were observed. Introduction Chronic kidney disease (CKD) affects ~ 700 million people worldwide.[ 1 ] It is a leading cause of premature death, with socioeconomically deprived and vulnerable groups being disproportionately affected [ 1 ]. In the UK, > 10% of adults (> 7.2 million) are estimated to live with CKD [ 2 ]. It is an independent risk factor for cardiovascular disease (CVD) and is associated with diabetes mellitus, hypertension and CVD progression,[ 3 – 5 ] reducing individual’s quality of life and increasing financial challenges for healthcare providers and participants [ 2 ]. In 2023, it was estimated to cost the economy £7 billion annually; £6.4 billion direct costs to the National Health Service (NHS) and projected to increase due a growing prevalence of obesity, diabetes, hypertension, glomerular disease and an ageing population [ 1 , 6 ]. CKD is staged according to Modification of Diet in Renal Disease by estimated glomerular filtration rates (eGFR) from 1 to 5 (normal to end-stage kidney disease - ESKD).[ 7 ] Stage 3–4 being associated with 14% higher relative risk of cardiovascular mortality when compared to normal kidney function (40% vs. 26%), and an even greater risks with ESKD [ 8 , 9 ]. Likewise, CKD commonly affects 50% of patient with type 2 diabetes (T2DM), many of whom die from CVD [ 10 ]. Together, CKD, CVD and diabetes commonly co-exist and share common risk factors: obesity, hypertension, hypercholesterolaemia, smoking [ 11 , 12 ]. However, such multimorbidity generally occurs later in life, with a greater burden of disease in more socioeconomically deprived communities,[ 13 ] where resources and service provision can be lacking and/or limited resulting in the continuation of ‘the inverse care law’ [ 14 , 15 ]. These disparities may be further exacerbated by the general practice workforce crisis [ 16 – 18 ]. Similarly, single disease models of care may have limitations, and potential harms, for individuals experiencing multimorbidity and associated polypharmacy [ 19 , 20 ]. Therefore a person-centred holistic approach is necessary to address modifiable risk factors, improve survival and quality of life [ 11 ]. For more than 20 years, general practice clinical pharmacists (GPCPs) in the United Kingdom, North America, and Australasia have been shown to be effective at addressing challenging areas of prescribing as autonomous non-medical prescribers ( i.e. prescribers who are not doctors), optimising chronic disease management for single conditions, and freeing GP capacity [ 21 – 23 ]. In part, in Scotland this has led to greater integration of pharmacy teams within general practices to deliver the pharmacotherapy section of the General Medical Services Contract (Scotland) [ 23 , 24 ], with similar initiatives being developed in England and Wales [ 25 ]. GPCPs in Scotland are highly qualified and potentially well positioned within general practice teams to address challenging areas of care for people with CKD, who commonly experience multimorbidity and polypharmacy as part of complex interventions [ 20 ]. Therefore this study aimed to scope the potential of a GPCP-led multidisciplinary intervention optimising the management of cardio-renal-metabolic risk factors in participants with stage 3–4 CKD in general practices serving a highly socio-economically deprived community. Aim This prospective study aims to scope the feasibility of a pharmacist-led multidisciplinary clinical intervention to optimise cardio-renal and metabolic risk factors in participants CKD stages 3–4, in a general practice setting. Ethics approval Was sought from the NHS West of Scotland Research Ethics Service. It was determined that ethical approval was not required as the study was considered service evaluation and a development of routine care. NHSGGC Caldicott data advice was sought to analyse anonymised. Methods Study design and setting This prospective feasibility study assessing the development of an intervention service for individuals with CKD stages 3–4 was carried out from November 2021 to January 2024 and is reported in line with the Template for Intervention Description and Replication (TIDIeR) [ 26 ]. NHS Greater Glasgow and Clyde (NHSGGC) serves a population of 1.4 million people across six Health and Social Care Partnerships (HSCP) that integrates health and social care services. Glasgow is known to have one of the highest CVD mortality rates in the UK [ 18 ]. Two general practices in one HSCP serving a highly urbanised and socioeconomically deprived population were approached and agreed to participate. Participant identification and inclusion All participants aged ≥ 18 years old coded as CKD stage 3a, 3b or 4 (eGFR 15 to 59 ml/min/1.73m 2 ), registered with the participating practices, were assessed for inclusion. Practice electronic clinical records were searched to identify participants in November 2021. Additional non-coded participants were identified during routine GP reviews and referred to the GPCP clinic during the study period, and were included. Participants were excluded from the GPCP clinic if they had progressed to stage 5/ESKD, or had type 1 diabetes (T1DM), as insulin optimisation is managed by specialist diabetic nurses within the HSCP. Participants were also excluded if they were receiving optimal pharmacotherapy and/or achieving optimal measures in line with guidelines: eGFR > 60; blood pressure < 130/80 mmHg in reduced kidney function with diabetes or < 140/90 mmHg without diabetes; lipid profile (low density lipoprotein cholesterol (LDLc) < 1.8mmol/L in secondary CVD prevention or participants received a statin for primary CVD prevention); glycated haemoglobin (HbA1c) < 53mmol/mol, were excluded [ 27 – 35 ]. This was considered appropriate in order to allow greater capacity to review participants not meeting therapeutic goals who were receiving suboptimal pharmacological treatment. [Insert Fig. 1 here] Intervention This was delivered by two experienced GPCPs; 18 and 12 years respectively, one was a prescriber and the other was not. Both had completed additional postgraduate qualifications, clinical training, and were NHSGGC employees. Clinical support and mentoring were provided by practice GPs as part of the multidisciplinary team working. Initial GPCPs interventions were delivered during a regular weekly clinic – two sessions per week – March to December 2022. In year two, annual reviews were conducted by one GPCP and practice nurses, March to December 2023, (Fig. 1 ). All eligible participants were invited by letter for a face-to-face 20 minute appointment with the GPCPs at their general practice, and requested to bring a fresh urine sample to the appointment for albumin:creatinine ratio (ACR) testing. For those unable to attend the practice, a phone review appointment was offered and arranged. Participants not responding to the letter invite, were contacted by GPCP by phone and re-invited. Prior to reviews the GPCPs developed individual participant care plans. At the first appointment the GPCP discussed and contextualised the individual’s CKD risk and progression from their most recent tests, co-morbidities, medicines and lifestyle. Participants were provided with written CKD information from Kidney Care UK website [ 36 ]. Therapeutic targets for: blood pressure (< 130/80 mmHg)[ 27 – 29 ]; HbA1c (≤ 53 mmol/l)[ 28 – 30 ] for participant with T2DM diabetics; and lipid reduction and treatment in line with guidelines were discussed [ 31 , 32 ]. For example, for primary prevention of CVD this involved initiation/optimisation of atorvastatin to 20mg daily, and for secondary prevention of established CVD aiming for LDLc < 1.8 mmol/l, with high intensity statin treatment.[ 31 ] For frail participants, where appropriate, higher targets for blood pressure and HbA1c were accepted according to their tolerance [ 33 – 35 ]. Lifestyle advice focused on diet, alcohol intake, exercise and smoking cessation. Polypharmacy reviews were carried out to optimise co-morbidity treatment, minimise avoidable medicines-related harms e.g. nephrotoxic medicines deprescribing [ 37 ]. Where appropriate, follow-up reviews were conducted via telephone, unless an in-person appointment was required e.g. blood pressure measurement. Frequency of follow-up was informed by participant’s need and guidelines e.g. 2 weekly when antihypertensive initiated, stopped or changed,[ 38 ] 12 weeks for statin initiation/optimisation and diabetic treatment optimisation [ 31 , 35 ]. Data collection and analysis Pre-determined participant-level data were collected and collated in a specifically piloted and tested Excel format (November 2021), and participants were referred in by their GP. Participant-level data included: age; sex; postcode allowing mapping of Scottish Index of Multiple Deprivation (SIMD) codes [ 39 ]; eGFR; ACR; CKD stage; blood pressure, HbA1c; lipid profile (total cholesterol, non-high density lipoprotein cholesterol (non-HDLc) and LDLc); and co-morbidities (hypertension, coronary artery disease, type 2 diabetes, atrial fibrillation, stroke, peripheral vascular disease, heart failure (HF) – as defined in guidelines,[ 40 ] and a large national study of 314 general practices, Scotland [ 41 ]. These co-morbidities were included as they commonly co-exist in CKD participants [ 41 ]. Post-intervention data were collected January 2024 as listed above, and included the number of participant contacts; face-to-face and/or telephone reviews. This was assessed as being an appropriate time point to assess potential parameters changes, especially for eGFR as 12 months treatment is needed to assess for the effects of sodium-glucose co-transporter-2 inhibitors (SGLT2i) [ 42 ]. Anonymised data was considered through exploratory analysis for this prospective intervention feasibility scoping study of service development, in line with previous studies [ 43 , 44 ]. Twelve months pre- and post-intervention parameters were compared. Where post-intervention data was missing, last observation carried forward was applied. Parametric and non-parametric statistical tests were applied where appropriate as guided by data viability, using Minitab, LLC®. Whilst results of testing are included for information purposes, this study is a prospective intervention scoping study, and therefore, all analysis included are purely for hypothesis-generating purposes. Patient and Public Involvement Participants were not involved in the design, conduct or dissemination of this study. Results Participant characteristics Initial electronic record searches identified 255 participants ≥18 years old. However, some participants fulfilled the exclusion criteria. Three participants coded as CKD-4 had progressed to CKD-5, two participants had a diagnosis of T1DM and 19 participants received optimal pharmacological treatment and achieved treatment targets. An additional 22 participants were identified by practice GPs and referred to the GPCP, resulting in 253 participants meeting inclusion criteria with a median age of 77 (range 26 to 99) years, 62% were female and 62% lived in the most deprived SIMD quintile (Table 1). Hypertension, followed by coronary artery disease, T2DM, HF were the most common co-morbidities; multimorbidity was common (table 1). Of the 253 invited for face-to-face or phone review 163 (64%) attended and required a median of 1 (range 1 to 10) appointments. GPCP-led intervention and CKD monitoring Most prescribing interventions involved initiation and optimisation of lipid lowering medicines (62%), with initiation accounting for 37%. This was followed by antihypertensives (47%), SGLT2is (42%), Table 2. Adverse drug effect management and nephrotoxic medicines deprescribing accounted for 10% and 6%, respectively, of changes. At 12 months post-intervention improvements were observed in eGFR; mean increase 2.9 (95% CI 1.41 to 4.40, p<0.001) ml/min/1.73m 2 , that was associated with a potentially non-significant improvement in participants’ CKD stages (X 2 =5.762, d.f = 3, p=0.123), Table 3. Reductions were also observed in participants’ blood pressures, lipid profiles, and HbA1cs to varying degrees, however while participants were requested to provide urine samples for ACR testing a minority did, 40% (n=65/163). Four participants were referred to NHSGGC heart failure (HF) diagnostic pathway after presenting shortness of breath, pitting oedema, New York Heart Classification greater than II, and serum N-terminal pro-brain natriuretic peptide >400 ng/L. Diagnosis after echocardiogram identified one participant with mild mitral valve disease, aortic regurgitation and ejection fraction 60-65%, two participants as having HF with preserved ejection fraction (>55%), and one with a reduced ejection fraction of 23%. Discussion Statement of key findings This scoping feasibility service development study observed significant improvement in all cardio-renal-metabolic risk factors, in response to a complex GPCP-led intervention involving participant education, lifestyle advice, medicines initiation and optimisation. Accomplishing a mean 2.9 (95% CI 1.41 to 4.40, p < 0.001) ml/min/1.73m 2 increase in eGFR, with an 10% increase in participants categorised as having less severe CKD stage 1–2, and a general reduction in CKD severity. Medicines optimisation and deprescribing of nephrotoxic medicines contributed to reductions in blood pressure, lipid profiles and eGFR improvements. Strengths and Weaknesses The main strength of this study, to the authors’ knowledge, is that this is the first to scope the potential of GPCPs optimising treatment for participants with CKD in a general practice setting. Another strength was that this service development focused on addressing the healthcare needs of participants in a highly socioeconomically deprived population where it is known that the burden of disease is greatest, and resources are stretched [ 13 , 14 , 23 , 45 ]. Therefore, potentially indicating a way of further integrating multidisciplinary working to meet participants’ health care needs, creating greater healthcare system capacity, and expectations for policy makers; as part of a solution to the general practice workforce crisis [ 17 , 24 ]. In addition the general practice culture enabled integrated multidisciplinary working with GP clinical support and mentoring that allowed the GPCPs to work to their highest level of professional practice; drawing on the wider team where appropriate e.g. onward referrals to cardiology. As with all studies there are a number of limitations. The lack of usual care comparator, however this service development was constricted by a need to test a pragmatic change in multidisciplinary working within routine practice. This may also be considered as a study strength considering the observed changes achieved. Sample size, statistical power and randomisation. As already acknowledge this study scoped the potential feasibility of GPCP-led CKD initiatives and may help inform future integrated multidisciplinary working and appropriately statistically powered studies. Generalisability, although this study involved practices in a highly urbanised region, limiting applicability to rural areas where transport links and service access may be challenging, findings may be of interest to others working in similar urban settings. The availability of experienced GPCPs may not be typical of newer pharmacists recruited to general practice [ 46 ]. Observed improvements in clinical measures do not necessarily translate into better quality of life, although it is possible to speculate that optimisation of management in line with guidelines will have a positive effect on reducing cardiovascular risks and progression to ESKD [ 27 , 31 , 32 ]. We acknowledge that excluding patients diagnosed with type 1 diabetes from this initial scoping study is a potential weakness, however the numbers were low and we could include this group in future studies to help bridge potential primary-secondary care gaps in care. Interpretation This study’s population is comparable to a previous national study of 314 general practice across Scotland, with our population being marginally older at 77 versus 75 years old, and more males 37% rather than 36% [ 41 ]. Hypertension and diabetes are the most common causes of CKD [ 11 , 47 ], and our population reflected this with 72% of participants being hypertensive and 30% T2DM [ 48 ]. Yet, the incidence of co-morbidities recorded in our study was higher than that previously reported in a similar population [ 49 ]. However, this may be related to the practices serving a more deprived population [ 50 ]. Previous studies utilising pharmacists to optimise chronic disease management, challenging areas of prescribing and complex participant groups is not a new concept with GPCPs demonstrating their effectiveness for more than 20 years [ 21 – 23 , 51 , 52 ]. However, a previous pharmacist-led secondary care CKD US Veterans Affairs outpatients study demonstrated increases in antihypertensive prescribing but failed to show improvements in blood pressure control or report eGFR changes 12 months post-intervention [ 53 ]. CKD-focused initiatives within primary care have far-reaching implications to the public health such as delaying disease progression and helping participants avoid a reduced quality of life, end-stage kidney disease (ESKD), and, ultimately, premature death. Greater integration of multidisciplinary working with pharmacy teams can enhance general practice capacity, and reduce avoidable economic and personal costs. (22, 23, 43). A challenge for practices which may limit the reach of CKD, and other initiatives, is a lack of coding limiting participant identification and recall as shown by the opportunistic inclusion of participants in this study. While a lack of coding may be due to COVID-pandemic effects and changes to the general practice contract in Scotland [ 54 ], this is also an issue in other regions of the UK where up to 55% of CKD participants were not coded [ 55 ], nor T2DMs with CKD [ 56 ]. However, and unfortunately, the potential of GPCP-led CKD and other similar initiatives may be stifled by the expectations of policy makers and health service managers, despite the development of professional frameworks and enthusiasm of staff to develop their participant-facing roles within multidisciplinary teams. We argue that GPCPs are ideally placed to improve coding and optimise the management of cardio-renal and metabolic risk factors. [ 57 ] Further research Future research should engage the support of people with lived experience to co-design the development and evaluate such complex multimorbidity interventions, drawing on randomised controlled trials with embedded economic and qualitative evaluations. Research should also consider assessing the impact of CKD participant education initiatives on disease progression and outcomes. Conclusion Integrated general practice clinical pharmacists are well positioned to improve key cardio-renal and metabolic risk factors in a socioeconomically deprived population. Future studies are required to confirm benefits observed in this study. Declarations Acknowledgements Special thanks to the patients and practices staff for their support with this service development study. Nichola McAllister and Laura Marshall for their support with data capture. Chief Scientist Office for support through Dr Johnson’s NHS Research Scotland Career Research Fellowship. Funding This service development scoping study was primarily funded by NHSGGC North East Glasgow Health and Social Care Partnership. Additional support and funding for analysis and manuscript preparations were provided by NHSGGC Pharmacy Services Research Catalytic Funding. The funders were not involved in data collection, analysis or interpretation of findings. Conflicts of interest None declared. References Francis A, Harhay MN, Ong ACM et al. Chronic kidney disease and the global public health agenda: an international consensus. Nat Rev Nephrol, 2024. Farrimond B, Agathangelou G, Gofman L et al. Kidney Research UK. Kidney disease: A UK public health emergency. The health economics of kidney disease to 2033 2023. https://www.kidneyresearchuk.org/wp-content/uploads/2023/06/Economics-of-Kidney-Disease-full-report_accessible.pdf . Accessed 27.08.2024. 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Impact of the pharmacist-led intervention on the control of medical cardiovascular risk factors for the primary prevention of cardiovascular disease in general practice: A systematic review and meta‐analysis of randomised controlled trials. Br J Clin Pharmacol. 2020;86(1):29–38. George J, Pfleger D, McCaig D, et al. Independent prescribing by pharmacists: a study of the awareness, views and attitudes of Scottish community pharmacists. Pharm World Sci. 2006;28(2):45–53. Cooney D, Moon H, Liu Y, et al. A pharmacist based intervention to improve the care of patients with CKD: a pragmatic, randomized, controlled trial. BMC Nephrol. 2015;16:56. Morales DR, Minchin M, Kontopantelis E et al. Estimated impact from the withdrawal of primary care financial incentives on selected indicators of quality of care in Scotland: controlled interrupted time series analysis. BMJ, 2023:e072098. Molokhia M, Okoli GN, Redmond P, et al. Uncoded chronic kidney disease in primary care: a cross-sectional study of inequalities and cardiovascular disease risk management. Br J Gen Pract. 2020;70(700):e785–92. Sisk R, Cameron R, Tahir W, et al. Diagnosis codes underestimate chronic kidney disease incidence compared with eGFR-based evidence: a retrospective observational study of patients with type 2 diabetes in UK primary care. Br J Gen Pract Open. 2024;8(1):20230079. Forsyth P, Radley A, Rushworth GF, et al. The Collaborative Care Model: Realizing healthcare values and increasing responsiveness in the pharmacy workforce. Res Social Administrative Pharm. 2023;19(1):110–22. Tables Table 1 – Participant demographics by practice. CKD: chronic kidney disease. SIMD: Scottish Index of Multiple Deprivation. Practice A (n = 116) Practice B (n = 137) Total (n = 253) Age, median (range) 78 (26-99) 76 (32-95) 77 (26-99) Female, n (%) 69 (59) 89 (65) 158 (62) SIMD, n (%) SIMD 1 most deprived 69 (59) 88 (64) 157 (62) SIMD 2 18 (16) 25 (18) 43 (17) SIMD 3 21 (18) 15 (11) 36 (14) SIMD 4-5 least deprived 8 (7) 9 (7) 17 (7) Chronic kidney disease, n (%) Stage 1-2 (>60mL/min/1.73m 2 ) 14 (12) 27 (20) 41 (16) Stage 3a (45-59 mL/min/1.73m 2 ) 58 (50) 67 (49) 125 (49) Stage 3b (30-44 mL/min/1.73m 2 ) 32 (28) 27 (20) 59 (23) Stage 4 (15-29 mL/min/1.73m 2 ) 12 (10) 16 (12) 28 (11) Stage 5 (<15 mL/min/1.73m 2 ) 0 0 0 Co-morbidity, n (%) Hypertension, 87 (75) 93 (68) 182 (72) Coronary artery disease 39 (34) 54 (39) 93 (37) Type 2 diabetes mellitus 39 (34) 36 (26) 75 (30) Atrial fibrillation 20 (17) 17 (12) 38 (15) Cerebral vascular accident 21 (18) 18 (13) 30 (12) Peripheral vascular disease 10 (9) 8 (6) 18 (7) Heart Failure 26 (22) 28 (20) 54 (21) Reduced ejection fraction ( £40%) 6 (5) 7 (5) 13 (5) Mid-range ejection fraction (41-49%) 5 (4) 7 (5) 12 (5) Preserved ejection fraction (³50%)* 15 (13) 14 (10) 29 (12) Number of co-morbidities, excluding CKD, n (%) 0 8 (7) 13 (9) 21 (8) 1 38 (33) 39 (28) 77 (30) 2-3 58 (50) 70 (51) 128 (51) 4-7 12 (10) 15 (11) 27 (11) *With signs and symptoms [40]. Table 2 – Pharmacological interventions Medicines changes, n (%) Practice A (n = 74) Practice B (n = 89) Total (n = 163) Statins and/or ezetimibe 48 (65) 53 (60) 101 (62) Initiated 31 (42) 29 (33) 60 (37) Up-titrated 17 (23) 24 (27) 41 (25) Antihypertensives (total) 37 (50) 40 (45) 77 (47) Initiated 17 (23) 22 (25) 39 (24) Up-titrated 20 (27) 18 (20) 38 (23) Angiotensin-converting enzyme inhibitors Initiated 7 (10) 10 (11) 17 (10) Up-titrated 13 (18) 11 (12) 24 (15) Angiotensin reception blockers Initiated 1 (1) 4 (5) 5 (3) Up-titrated 5 (7) 2 (2) 7 (4) Angiotensin receptor-neprilysin inhibitor Initiated 0 2 (2) 2 (1) Up-titrated 0 1 (1) 1 (1) Beta-blockers Initiated 5 (7) 5 (6) 10 (6) Up-titrated 4 (5) 4 (5) 8 (5) Calcium channel blockers Initiated 9 (12) 5 (6%) 14 (9) Up-titrated 2 (3) 1 (1) 3 (2) Mineralocorticoid receptor antagonist Initiated 0 1 (1) 1 (1) Up-titrated 0 3 (3) 3 (2) Sodium-glucose co-transporter 2 inhibitors Initiated 36 (49) 33 (37) 69 (42) Glucagon-Like Peptide-1 Receptor Agonists Initiated 1 (1) 1 (1) 2 (1) Up-titrated 1 (1) 1 (1) 2 (1) Nephrotoxics Deprescribed a 6 (8) 4 (5) 10 (6) Adverse drug effects Deprescribed 4 (5%) c 1 (1%) e 4 (5%) c 3 (3%) d 3 (3%) e 1 (1%) f 16 (10%) a Naproxen, diclofenac, furosemide, metformin per eGFR <30 ml/min/1.73m 2 . b SGLT2i: Light-headedness, dizziness, sickness, nocturia, back pain. d ACEi: dry cough. e Statin: myalgia. f Edoxaban: dizziness. Table 3 – Change in chronic kidney disease stages pre- to 12 months post-GPCP intervention. eGFR: Estimated glomerular filtration rate. CKD stages (n, %) Practice A (n = 74) Practice B (n = 89) Total (n = 163) Pre-intervention Post-intervention Pre-intervention Post-intervention Pre-intervention Post-intervention Stage 1-2 (eGFR >60mL/min/1.73m 2 ) 9 (12) 13 (18) 14 (16) 26 (29) 23 (14) 39 (24) Stage 3a (eGFR 45-59 mL/min/1.73m 2 ) 35 (47) 34 (46) 45 (51) 42 (47) 80 (49) 76 (47) Stage 3b (eGFR 30-44 mL/min/1.73m 2 ) 25 (34) 22 (30) 21 (24) 13 (15) 46 (28) 35 (21) Stage 4-5 (eGFR <15-29 mL/min/1.73m 2 ) 5 (7) 5 (7) 9 (10) 8 (9) 14 (9) 13 (8) Table 4 – Changes in primary and secondary clinical measures pre- to 12 months post-GPCP intervention. eGFR: Estimated glomerular filtration rate; SBP: Systolic blood pressure; DBP: Diastolic blood pressure; HbA1c: Haemoglobin glycosylate A1c; TC: Total cholesterol; LDLc: non-HDLc: non-high density lipoprotein cholesterol; Low-density lipoprotein cholesterol. Practice A (n = 74) Mean [95%CI] P value Practice B (n = 89) Mean [95%CI] P value Total (n = 163 ) Mean [95%CI] P value Pre-intervention Post-intervention Pre-intervention Post-intervention Pre-intervention Post-intervention Primary clinical measures eGFR, mL/min/1.73m 2 ± SD (n) 48 ± 14 (74) 49 ± 14 (74) a 1.2 [-0.69, 3.00] P = 0.217 49 ± 15 (89) 54 ± 16 (89) f 4.4 [2.10, 6.62] P <0.001 49 ± 14 (163) 52 ± 16 (163) 2.9 [1.41, 4.40] P <0.001 Serum creatinine, mmol/L ± SD (n) 116 ± 35 (74) 114 ± 34 (74) a -2.6 [-5.98, 0.79] P = 0.131 114 ± 39 (89) 106 ± 32 (89) f -8.1 [-12.88, -3.30] P = 0.001 115 ± 37 (163) 110 ± 33 (163) -5.6 [-8.63, -2.56] P <0.001 Secondary clinical measures Blood pressure SBP, mmHg ± SD (n) 134 ± 18 (74) 125 ± 12 (74) b -8.9 [-12.63, -5.10] P <0.001 136 ± 17 (89) 125 ± 17 (89) g -10.2 [-13.85, -6.54] P <0.001 135 ± 17 (163) 125 ± 15 (163) -9.59 [-12.19, -6.99] P <0.001 DBP, mmHg ± SD (n) 74 ± 11 (74) 72 ± 10 (74) b -2.1 [-4.30, 0.14] P = 0.065 73 ± 13 (89) 70 ± 10 (89) g -2.9 [-5.27, -048] P = 0.019 71 ± 10 (163) 74 ± 12 (163) -2.52 [-4.15, -0.88] P = 0.003 HbA1c, mmol/mol ± SD (n) 51 ± 19 (59) c 48 ± 13 (59) d -3.1 [-6.45, 0.35] P = 0.077 48 ± 16 (75) h 47 ± 14 (75) i -1.7 [-3.65, 0.34] P = 0.103 49 ± 17 (135) 47 ± 14 (135) -2.25 [-4.08, 0.42] P = 0.016 Non-diabetics and IGT 39 ± 5 (34) 40 ± 5 (34) 1.2 [0.39, 1.96] P = 0.004 41 ± 6 (52) 41 ± 5 (52) 0.75 [-0.86, 2.36] P = 0.337 40 ± 5 (86) 41 ± 5 (86) 0.29 [-0.46, 1.04] P = 0.443 T2DM 67 ± 20 (25) 58 ± 13 (25) -8.8 [-16.45, -1.15] P = 0.026 65 ± 19 (23) 60 ± 19 (23) -4.7 [-10.88, 1.40] P = 0.124 66 ± 19 (48) 59 ± 16 (48) -6.85 [-11.66, -2.05] P = 0.006 TC, mmol/L ± SD (n) 4.4 ± 1.1 (74) 4.0 ± 1.0 (74) e -0.4 [-0.56, -0.15] P = 0.001 4.4 ± 1.4 (86) 3.9 ± 1.1 (86) j -0.5 [-0.70, -0.31] P <0.001 4.4 ± 1.2 (160) 3.9 ± 1.1 (160) -0.44[-0.58, -0.29] P <0.001 PP-CVD 4.4 ± 1.1 (27) 4.7 ± 1.1 (27) 0.3 [-0.05, 0.61] P = 0.094 4.9 ± 1.4 (40) 4.2 ± 1.2 (40) -0.7 [-1.08, -0.36] P <0.001 4.8 ± 1.3 (67) 4.3 ± 1.2 (67) -0.5 [-0.79, -0.29] P <0.001 SP-CVD 4.2 ± 1.1 (47) 3.8 ± 0.9 (47) -0.4 [-0.66, -0.13] P = 0.004 3.9 ± 1.1 (46) 3.5 ± 0.8 (46) -0.3 [-0.52, -0.12] P = 0.002 4.0 ± 1.1 (93) 3.7 ± 0.9 (93) -0.4 [-0.52, -0.20] P <0.001 Non-HDLc, mmol/L ± SD (n) 3.2 ± 1.0 (74) 2.9 ± 1.0 (74) e -0.3 [-0.51, -0.09] P = 0.005 3.1 ± 1.3 (86) 2.6 ± 1.0 (86) j -0.5 [-0.66, -0.28] P <0.001 3.1 ± 1.2 (160) 2.7 ± 1.0 (160) -0.4 [-0.53, -0.25] P <0.001 PP-CVD 3.4 ± 0.9 (27) 3.2 ± 1.1 (27) -0.2 [-0.48, 0.18] P = 0.356 3.5 ± 1.4 (40) 2.9 ± 1.1 (40) -0.6 [-0.98, -0.30] P = 0.001 3.5 ± 1.2 (67) 3.0 ± 1.1 (67) -0.4 [-0.69, -0.20] P = 0.001 SP-CVD 3.0 ± 1.1 (47) 2.6 ± 0.9 (47) -0.4 [-0.6, -0.11] P = 0.006 2.7 ± 1.1 (46) 2.4 ± 0.8 (46) -0.3 [-0.53, -0.13] P = 0.002 2.9 ± 1.1 (93) 2.5 ± 0.9 (93) -0.4 [-0.53, -0.19] P <0.001 LDLc, mmol/L ± SD (n) 2.3 ± 0.9 (74) 2.1 ± 0.9 (74) e -0.2 [-0.41, -0.08] P = 0.004 2.3 ± 1.2 (86) 1.9 ± 0.9 (86) j -0.4 [-0.59, -0.23] P <0.001 2.0 ± 0.9 (160) 2.3 ± 1.1 (160) -0.3 [-0.46, -0.21] P <0.001 PP-CVD 2.6 ± 1.0 (27) 2.4 ± 1.1 (27) -0.2 [-0.52, 0.09] P = 0.153 2.8 ± 1.3 (40) 2.2 ± 1.0 (40) -0.6 [-0.97, -0.29] P <0.001 2.7 ± 1.2 (67) 2.3 ± 1.0 (67) -0.5 [-0.70, -0.23] P <0.001 SP-CVD 2.2 ± 0.9 (47) 1.9 ± 0.8 (47) -0.3 [-0.46, 0.06] P = 0.010 1.9 ± 0.8 (46) 1.7 ± 0.8 (46) -0.2 [-0.39, -0.06] P = 0.007 2.0 ± 0.8 (93) 1.8 ± 0.8 (93) -0.2 [-0.37, -0.12] P <0.001 Cite Share Download PDF Status: Published Journal Publication published 04 Jun, 2025 Read the published version in International Journal of Clinical Pharmacy → Version 1 posted Editorial decision: Minor revisions 30 Apr, 2025 Reviewers agreed at journal 13 Mar, 2025 Reviewers invited by journal 13 Mar, 2025 Editor invited by journal 13 Mar, 2025 Editor assigned by journal 12 Mar, 2025 First submitted to journal 11 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6209460","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":428296746,"identity":"8d23f181-de45-4e0f-b59b-306e9246c9a0","order_by":0,"name":"Tania Ramos","email":"data:image/png;base64,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","orcid":"https://orcid.org/0009-0002-8055-6502","institution":"NHS Greater Glasgow and Clyde Primary Care Division: NHS Greater Glasgow and Clyde","correspondingAuthor":true,"prefix":"","firstName":"Tania","middleName":"","lastName":"Ramos","suffix":""},{"id":428296747,"identity":"380ba0bc-9ca1-42fa-b0d2-88ba242a57cb","order_by":1,"name":"Amit Verma","email":"","orcid":"","institution":"Parade Group Practice. NHS Greater Glasgow and Clyde Primary Care Division: NHS Greater Glasgow and Clyde","correspondingAuthor":false,"prefix":"","firstName":"Amit","middleName":"","lastName":"Verma","suffix":""},{"id":428296748,"identity":"3e3e1bf2-97f8-4ff5-86b7-225a9b91f640","order_by":2,"name":"Iain Speirits","email":"","orcid":"","institution":"NHS Greater Glasgow and Clyde Primary Care Division: NHS Greater Glasgow and Clyde","correspondingAuthor":false,"prefix":"","firstName":"Iain","middleName":"","lastName":"Speirits","suffix":""},{"id":428296749,"identity":"0a5658cb-ec3f-4d39-95ae-808e34ca4f5f","order_by":3,"name":"Ling Zhang","email":"","orcid":"","institution":"Townhead Medical Practice. NHS Greater Glasgow and Clyde Primary Care Division: NHS Greater Glasgow and Clyde","correspondingAuthor":false,"prefix":"","firstName":"Ling","middleName":"","lastName":"Zhang","suffix":""},{"id":428296750,"identity":"c476917e-e0b2-4c95-848b-c4d3edc98f3d","order_by":4,"name":"Janice McInally","email":"","orcid":"","institution":"Townhead Medical Practice. NHS Greater Glasgow and Clyde Primary Care Division: NHS Greater Glasgow and Clyde","correspondingAuthor":false,"prefix":"","firstName":"Janice","middleName":"","lastName":"McInally","suffix":""},{"id":428296751,"identity":"c4340f67-5e62-42f9-a9f8-2cdd32f156f6","order_by":5,"name":"Catherine McShane","email":"","orcid":"","institution":"Parade Group Practice. NHS Greater Glasgow and Clyde Primary Care Division: NHS Greater Glasgow and Clyde","correspondingAuthor":false,"prefix":"","firstName":"Catherine","middleName":"","lastName":"McShane","suffix":""},{"id":428296752,"identity":"024d75f2-4e8d-4225-a360-b405d345bd46","order_by":6,"name":"Brian Kennon","email":"","orcid":"","institution":"QEUH: Queen Elizabeth University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Brian","middleName":"","lastName":"Kennon","suffix":""},{"id":428296753,"identity":"3c91954d-20e7-4dec-968c-fabdc64224d5","order_by":7,"name":"Paul Forsyth","email":"","orcid":"","institution":"Golden Jubilee National Hospital","correspondingAuthor":false,"prefix":"","firstName":"Paul","middleName":"","lastName":"Forsyth","suffix":""},{"id":428296754,"identity":"655f3bb4-8f6a-4552-8ee7-5b3c4234cc26","order_by":8,"name":"Richard Lowrie","email":"","orcid":"","institution":"NHS Greater Glasgow and Clyde Primary Care Division: NHS Greater Glasgow and Clyde","correspondingAuthor":false,"prefix":"","firstName":"Richard","middleName":"","lastName":"Lowrie","suffix":""},{"id":428296755,"identity":"92915051-55a2-4afa-8aa5-38d5709d6786","order_by":9,"name":"Chris F Johnson","email":"","orcid":"","institution":"NHS Greater Glasgow and Clyde Primary Care Division: NHS Greater Glasgow and Clyde","correspondingAuthor":false,"prefix":"","firstName":"Chris","middleName":"F","lastName":"Johnson","suffix":""}],"badges":[],"createdAt":"2025-03-12 07:13:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6209460/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6209460/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11096-025-01938-8","type":"published","date":"2025-06-04T15:57:30+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":78869514,"identity":"00475bfd-ab6d-43ec-a568-2a838d470f11","added_by":"auto","created_at":"2025-03-20 05:33:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":62879,"visible":true,"origin":"","legend":"\u003cp\u003eService development intervention and evaluation timeline. GPCP: general practice clinical pharmacist.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6209460/v1/7973109fe7dd3e5038f1adf1.png"},{"id":84243157,"identity":"dcabe0c1-e7ad-4e72-8ea6-bb9014081168","added_by":"auto","created_at":"2025-06-09 16:12:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1142945,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6209460/v1/526b1404-4e51-4955-b0fb-1a9a0d49901b.pdf"}],"financialInterests":"","formattedTitle":"Tackling the Inverse Care Law with pharmacist-led cardio-renal-metabolic service in a socioeconomically deprived population: A prospective scoping intervention study","fulltext":[{"header":"Impact of findings on practice statements ","content":"\u003cul\u003e\n \u003cli\u003eTo the author\u0026rsquo;s knowledge, this scoping study is the first to explore the potential of general practice clinical pharmacists optimising treatment for chronic kidney disease (CKD) within a general practice setting.\u003c/li\u003e\n \u003cli\u003eFocused on a socioeconomically deprived population experiencing a significant disease burden, with known resource limitation and healthcare gaps.\u003c/li\u003e\n \u003cli\u003eExplores integrated multidisciplinary working and capacity building within routine practice, showcasing real-world feasibility.\u003c/li\u003e\n \u003cli\u003eMain limitations include small sample size and absence of a usual care comparator limiting direct comparison, although pre- to post-intervention improvements to CKD measures were observed.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eChronic kidney disease (CKD) affects\u0026thinsp;~\u0026thinsp;700\u0026nbsp;million people worldwide.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] It is a leading cause of premature death, with socioeconomically deprived and vulnerable groups being disproportionately affected [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the UK, \u0026gt;\u0026thinsp;10% of adults (\u0026gt;\u0026thinsp;7.2\u0026nbsp;million) are estimated to live with CKD [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It is an independent risk factor for cardiovascular disease (CVD) and is associated with diabetes mellitus, hypertension and CVD progression,[\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] reducing individual\u0026rsquo;s quality of life and increasing financial challenges for healthcare providers and participants [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In 2023, it was estimated to cost the economy \u0026pound;7\u0026nbsp;billion annually; \u0026pound;6.4\u0026nbsp;billion direct costs to the National Health Service (NHS) and projected to increase due a growing prevalence of obesity, diabetes, hypertension, glomerular disease and an ageing population [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCKD is staged according to Modification of Diet in Renal Disease by estimated glomerular filtration rates (eGFR) from 1 to 5 (normal to end-stage kidney disease - ESKD).[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] Stage 3\u0026ndash;4 being associated with 14% higher relative risk of cardiovascular mortality when compared to normal kidney function (40% \u003cem\u003evs.\u003c/em\u003e 26%), and an even greater risks with ESKD [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Likewise, CKD commonly affects 50% of patient with type 2 diabetes (T2DM), many of whom die from CVD [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Together, CKD, CVD and diabetes commonly co-exist and share common risk factors: obesity, hypertension, hypercholesterolaemia, smoking [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, such multimorbidity generally occurs later in life, with a greater burden of disease in more socioeconomically deprived communities,[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] where resources and service provision can be lacking and/or limited resulting in the continuation of \u0026lsquo;the inverse care law\u0026rsquo; [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. These disparities may be further exacerbated by the general practice workforce crisis [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Similarly, single disease models of care may have limitations, and potential harms, for individuals experiencing multimorbidity and associated polypharmacy [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Therefore a person-centred holistic approach is necessary to address modifiable risk factors, improve survival and quality of life [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor more than 20 years, general practice clinical pharmacists (GPCPs) in the United Kingdom, North America, and Australasia have been shown to be effective at addressing challenging areas of prescribing as autonomous non-medical prescribers (\u003cem\u003ei.e.\u003c/em\u003e prescribers who are not doctors), optimising chronic disease management for single conditions, and freeing GP capacity [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In part, in Scotland this has led to greater integration of pharmacy teams within general practices to deliver the pharmacotherapy section of the General Medical Services Contract (Scotland) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], with similar initiatives being developed in England and Wales [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. GPCPs in Scotland are highly qualified and potentially well positioned within general practice teams to address challenging areas of care for people with CKD, who commonly experience multimorbidity and polypharmacy as part of complex interventions [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Therefore this study aimed to scope the potential of a GPCP-led multidisciplinary intervention optimising the management of cardio-renal-metabolic risk factors in participants with stage 3\u0026ndash;4 CKD in general practices serving a highly socio-economically deprived community.\u003c/p\u003e \u003cp\u003eAim\u003c/p\u003e \u003cp\u003eThis prospective study aims to scope the feasibility of a pharmacist-led multidisciplinary clinical intervention to optimise cardio-renal and metabolic risk factors in participants CKD stages 3\u0026ndash;4, in a general practice setting.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthics approval\u003c/strong\u003e \u003cp\u003eWas sought from the NHS West of Scotland Research Ethics Service. It was determined that ethical approval was not required as the study was considered service evaluation and a development of routine care. NHSGGC Caldicott data advice was sought to analyse anonymised.\u003c/p\u003e \u003c/p\u003e "},{"header":"Methods","content":"\u003ch3\u003eStudy design and setting\u003c/h3\u003e\n\u003cp\u003eThis prospective feasibility study assessing the development of an intervention service for individuals with CKD stages 3\u0026ndash;4 was carried out from November 2021 to January 2024 and is reported in line with the Template for Intervention Description and Replication (TIDIeR) [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eNHS Greater Glasgow and Clyde (NHSGGC) serves a population of 1.4\u0026nbsp;million people across six Health and Social Care Partnerships (HSCP) that integrates health and social care services. Glasgow is known to have one of the highest CVD mortality rates in the UK [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]. Two general practices in one HSCP serving a highly urbanised and socioeconomically deprived population were approached and agreed to participate.\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eParticipant identification and inclusion\u003c/h2\u003e\n \u003cp\u003eAll participants aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years old coded as CKD stage 3a, 3b or 4 (eGFR 15 to 59 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e), registered with the participating practices, were assessed for inclusion. Practice electronic clinical records were searched to identify participants in November 2021. Additional non-coded participants were identified during routine GP reviews and referred to the GPCP clinic during the study period, and were included. Participants were excluded from the GPCP clinic if they had progressed to stage 5/ESKD, or had type 1 diabetes (T1DM), as insulin optimisation is managed by specialist diabetic nurses within the HSCP.\u003c/p\u003e\n \u003cp\u003eParticipants were also excluded if they were receiving optimal pharmacotherapy and/or achieving optimal measures in line with guidelines: eGFR\u0026thinsp;\u0026gt;\u0026thinsp;60; blood pressure\u0026thinsp;\u0026lt;\u0026thinsp;130/80 mmHg in reduced kidney function with diabetes or \u0026lt;\u0026thinsp;140/90 mmHg without diabetes; lipid profile (low density lipoprotein cholesterol (LDLc)\u0026thinsp;\u0026lt;\u0026thinsp;1.8mmol/L in secondary CVD prevention or participants received a statin for primary CVD prevention); glycated haemoglobin (HbA1c)\u0026thinsp;\u0026lt;\u0026thinsp;53mmol/mol, were excluded [\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e]. This was considered appropriate in order to allow greater capacity to review participants not meeting therapeutic goals who were receiving suboptimal pharmacological treatment.\u003c/p\u003e\n \u003cp\u003e[Insert Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e here]\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eIntervention\u003c/h3\u003e\n\u003cp\u003eThis was delivered by two experienced GPCPs; 18 and 12 years respectively, one was a prescriber and the other was not. Both had completed additional postgraduate qualifications, clinical training, and were NHSGGC employees. Clinical support and mentoring were provided by practice GPs as part of the multidisciplinary team working. Initial GPCPs interventions were delivered during a regular weekly clinic \u0026ndash; two sessions per week \u0026ndash; March to December 2022. In year two, annual reviews were conducted by one GPCP and practice nurses, March to December 2023, (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eAll eligible participants were invited by letter for a face-to-face 20 minute appointment with the GPCPs at their general practice, and requested to bring a fresh urine sample to the appointment for albumin:creatinine ratio (ACR) testing. For those unable to attend the practice, a phone review appointment was offered and arranged. Participants not responding to the letter invite, were contacted by GPCP by phone and re-invited.\u003c/p\u003e\n\u003cp\u003ePrior to reviews the GPCPs developed individual participant care plans. At the first appointment the GPCP discussed and contextualised the individual\u0026rsquo;s CKD risk and progression from their most recent tests, co-morbidities, medicines and lifestyle. Participants were provided with written CKD information from Kidney Care UK website [\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e]. Therapeutic targets for: blood pressure (\u0026lt;\u0026thinsp;130/80 mmHg)[\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]; HbA1c (\u0026le;\u0026thinsp;53 mmol/l)[\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e] for participant with T2DM diabetics; and lipid reduction and treatment in line with guidelines were discussed [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e]. For example, for primary prevention of CVD this involved initiation/optimisation of atorvastatin to 20mg daily, and for secondary prevention of established CVD aiming for LDLc\u0026thinsp;\u0026lt;\u0026thinsp;1.8 mmol/l, with high intensity statin treatment.[\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e] For frail participants, where appropriate, higher targets for blood pressure and HbA1c were accepted according to their tolerance [\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e]. Lifestyle advice focused on diet, alcohol intake, exercise and smoking cessation. Polypharmacy reviews were carried out to optimise co-morbidity treatment, minimise avoidable medicines-related harms e.g. nephrotoxic medicines deprescribing [\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eWhere appropriate, follow-up reviews were conducted via telephone, unless an in-person appointment was required e.g. blood pressure measurement. Frequency of follow-up was informed by participant\u0026rsquo;s need and guidelines e.g. 2 weekly when antihypertensive initiated, stopped or changed,[\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e] 12 weeks for statin initiation/optimisation and diabetic treatment optimisation [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eData collection and analysis\u003c/h3\u003e\n\u003cp\u003ePre-determined participant-level data were collected and collated in a specifically piloted and tested Excel format (November 2021), and participants were referred in by their GP. Participant-level data included: age; sex; postcode allowing mapping of Scottish Index of Multiple Deprivation (SIMD) codes [\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e]; eGFR; ACR; CKD stage; blood pressure, HbA1c; lipid profile (total cholesterol, non-high density lipoprotein cholesterol (non-HDLc) and LDLc); and co-morbidities (hypertension, coronary artery disease, type 2 diabetes, atrial fibrillation, stroke, peripheral vascular disease, heart failure (HF) \u0026ndash; as defined in guidelines,[\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e] and a large national study of 314 general practices, Scotland [\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e]. These co-morbidities were included as they commonly co-exist in CKD participants [\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003ePost-intervention data were collected January 2024 as listed above, and included the number of participant contacts; face-to-face and/or telephone reviews. This was assessed as being an appropriate time point to assess potential parameters changes, especially for eGFR as 12 months treatment is needed to assess for the effects of sodium-glucose co-transporter-2 inhibitors (SGLT2i) [\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eAnonymised data was considered through exploratory analysis for this prospective intervention feasibility scoping study of service development, in line with previous studies [\u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e]. Twelve months pre- and post-intervention parameters were compared. Where post-intervention data was missing, last observation carried forward was applied. Parametric and non-parametric statistical tests were applied where appropriate as guided by data viability, using Minitab, LLC\u0026reg;. Whilst results of testing are included for information purposes, this study is a prospective intervention scoping study, and therefore, all analysis included are purely for hypothesis-generating purposes.\u003c/p\u003e\n\u003ch3\u003ePatient and Public Involvement\u003c/h3\u003e\n\u003cp\u003eParticipants were not involved in the design, conduct or dissemination of this study.\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eParticipant characteristics\u003c/h2\u003e\n\u003cp\u003eInitial electronic record searches identified 255 participants \u0026ge;18 years old. However, some participants fulfilled the exclusion criteria. Three participants coded as CKD-4 had progressed to CKD-5, two participants had a diagnosis of T1DM \u0026nbsp;and 19 participants received optimal pharmacological treatment and achieved treatment targets. An additional 22 participants were identified by practice GPs and referred to the GPCP, resulting in 253 participants meeting inclusion criteria with a median age of 77 (range 26 to 99) years, 62% were female and 62% lived in the most deprived SIMD quintile (Table 1). Hypertension, followed by coronary artery disease, T2DM, HF were the most common co-morbidities; multimorbidity was common (table 1). Of the 253 invited for face-to-face or phone review 163 (64%) attended and required a median of 1 (range 1 to 10) appointments.\u003c/p\u003e\n\u003ch2\u003eGPCP-led intervention and CKD monitoring\u003c/h2\u003e\n\u003cp\u003eMost prescribing interventions involved initiation and optimisation of lipid lowering medicines (62%), with initiation accounting for 37%. This was followed by antihypertensives (47%), SGLT2is (42%), Table 2. \u0026nbsp;Adverse drug effect management and nephrotoxic medicines deprescribing accounted for 10% and 6%, respectively, of changes. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAt 12 months post-intervention improvements were observed in eGFR; mean increase\u0026nbsp;2.9 (95% CI 1.41 to 4.40, p\u0026lt;0.001) ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e, that was associated with a potentially non-significant improvement in participants\u0026rsquo; CKD stages (X\u003csup\u003e2\u003c/sup\u003e=5.762, d.f = 3, p=0.123), Table 3. Reductions were also observed in participants\u0026rsquo; blood pressures, lipid profiles, and HbA1cs to varying degrees, however while participants were requested to provide urine samples for ACR testing a minority did, 40% (n=65/163).\u003c/p\u003e\n\u003cp\u003eFour participants were referred to NHSGGC heart failure (HF) diagnostic pathway after presenting shortness of breath, pitting oedema, New York Heart Classification greater than II, and serum N-terminal pro-brain natriuretic peptide \u0026gt;400 ng/L. \u0026nbsp;Diagnosis after echocardiogram identified one participant with mild mitral valve disease, aortic regurgitation and ejection fraction 60-65%, two participants as having HF with preserved ejection fraction (\u0026gt;55%), and one with a reduced ejection fraction of 23%.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStatement of key findings\u003c/h2\u003e \u003cp\u003eThis scoping feasibility service development study observed significant improvement in all cardio-renal-metabolic risk factors, in response to a complex GPCP-led intervention involving participant education, lifestyle advice, medicines initiation and optimisation. Accomplishing a mean 2.9 (95% CI 1.41 to 4.40, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e increase in eGFR, with an 10% increase in participants categorised as having less severe CKD stage 1\u0026ndash;2, and a general reduction in CKD severity. Medicines optimisation and deprescribing of nephrotoxic medicines contributed to reductions in blood pressure, lipid profiles and eGFR improvements.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Weaknesses\u003c/h2\u003e \u003cp\u003eThe main strength of this study, to the authors\u0026rsquo; knowledge, is that this is the first to scope the potential of GPCPs optimising treatment for participants with CKD in a general practice setting. Another strength was that this service development focused on addressing the healthcare needs of participants in a highly socioeconomically deprived population where it is known that the burden of disease is greatest, and resources are stretched [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Therefore, potentially indicating a way of further integrating multidisciplinary working to meet participants\u0026rsquo; health care needs, creating greater healthcare system capacity, and expectations for policy makers; as part of a solution to the general practice workforce crisis [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In addition the general practice culture enabled integrated multidisciplinary working with GP clinical support and mentoring that allowed the GPCPs to work to their highest level of professional practice; drawing on the wider team where appropriate e.g. onward referrals to cardiology.\u003c/p\u003e \u003cp\u003eAs with all studies there are a number of limitations. The lack of usual care comparator, however this service development was constricted by a need to test a pragmatic change in multidisciplinary working within routine practice. This may also be considered as a study strength considering the observed changes achieved. Sample size, statistical power and randomisation. As already acknowledge this study scoped the potential feasibility of GPCP-led CKD initiatives and may help inform future integrated multidisciplinary working and appropriately statistically powered studies. Generalisability, although this study involved practices in a highly urbanised region, limiting applicability to rural areas where transport links and service access may be challenging, findings may be of interest to others working in similar urban settings. The availability of experienced GPCPs may not be typical of newer pharmacists recruited to general practice [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Observed improvements in clinical measures do not necessarily translate into better quality of life, although it is possible to speculate that optimisation of management in line with guidelines will have a positive effect on reducing cardiovascular risks and progression to ESKD [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. We acknowledge that excluding patients diagnosed with type 1 diabetes from this initial scoping study is a potential weakness, however the numbers were low and we could include this group in future studies to help bridge potential primary-secondary care gaps in care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eInterpretation\u003c/h2\u003e \u003cp\u003eThis study\u0026rsquo;s population is comparable to a previous national study of 314 general practice across Scotland, with our population being marginally older at 77 versus 75 years old, and more males 37% rather than 36% [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Hypertension and diabetes are the most common causes of CKD [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e], and our population reflected this with 72% of participants being hypertensive and 30% T2DM [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Yet, the incidence of co-morbidities recorded in our study was higher than that previously reported in a similar population [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. However, this may be related to the practices serving a more deprived population [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Previous studies utilising pharmacists to optimise chronic disease management, challenging areas of prescribing and complex participant groups is not a new concept with GPCPs demonstrating their effectiveness for more than 20 years [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. However, a previous pharmacist-led secondary care CKD US Veterans Affairs outpatients study demonstrated increases in antihypertensive prescribing but failed to show improvements in blood pressure control or report eGFR changes 12 months post-intervention [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCKD-focused initiatives within primary care have far-reaching implications to the public health such as delaying disease progression and helping participants avoid a reduced quality of life, end-stage kidney disease (ESKD), and, ultimately, premature death. Greater integration of multidisciplinary working with pharmacy teams can enhance general practice capacity, and reduce avoidable economic and personal costs. (22, 23, 43).\u003c/p\u003e \u003cp\u003eA challenge for practices which may limit the reach of CKD, and other initiatives, is a lack of coding limiting participant identification and recall as shown by the opportunistic inclusion of participants in this study. While a lack of coding may be due to COVID-pandemic effects and changes to the general practice contract in Scotland [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e], this is also an issue in other regions of the UK where up to 55% of CKD participants were not coded [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e], nor T2DMs with CKD [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. However, and unfortunately, the potential of GPCP-led CKD and other similar initiatives may be stifled by the expectations of policy makers and health service managers, despite the development of professional frameworks and enthusiasm of staff to develop their participant-facing roles within multidisciplinary teams. We argue that GPCPs are ideally placed to improve coding and optimise the management of cardio-renal and metabolic risk factors. [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eFurther research\u003c/h2\u003e \u003cp\u003eFuture research should engage the support of people with lived experience to co-design the development and evaluate such complex multimorbidity interventions, drawing on randomised controlled trials with embedded economic and qualitative evaluations. Research should also consider assessing the impact of CKD participant education initiatives on disease progression and outcomes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIntegrated general practice clinical pharmacists are well positioned to improve key cardio-renal and metabolic risk factors in a socioeconomically deprived population. Future studies are required to confirm benefits observed in this study.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSpecial thanks to the patients and practices staff for their support with this service development study. Nichola McAllister and Laura Marshall for their support with data capture. Chief Scientist Office for support through Dr Johnson\u0026rsquo;s NHS Research Scotland Career Research Fellowship.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis service development scoping study was primarily funded by NHSGGC North East Glasgow Health and Social Care Partnership. Additional support and funding for analysis and manuscript preparations were provided by NHSGGC Pharmacy Services Research Catalytic Funding. The funders were not involved in data collection, analysis or interpretation of findings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone declared.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFrancis A, Harhay MN, Ong ACM et al. Chronic kidney disease and the global public health agenda: an international consensus. Nat Rev Nephrol, 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarrimond B, Agathangelou G, Gofman L et al. Kidney Research UK. Kidney disease: A UK public health emergency. The health economics of kidney disease to 2033 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.kidneyresearchuk.org/wp-content/uploads/2023/06/Economics-of-Kidney-Disease-full-report_accessible.pdf\u003c/span\u003e\u003cspan address=\"https://www.kidneyresearchuk.org/wp-content/uploads/2023/06/Economics-of-Kidney-Disease-full-report_accessible.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 27.08.2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnders HJ, Huber TB, Isermann B, et al. CKD in diabetes: diabetic kidney disease versus nondiabetic kidney disease. 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Pharm World Sci. 2006;28(2):45\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCooney D, Moon H, Liu Y, et al. A pharmacist based intervention to improve the care of patients with CKD: a pragmatic, randomized, controlled trial. BMC Nephrol. 2015;16:56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorales DR, Minchin M, Kontopantelis E et al. Estimated impact from the withdrawal of primary care financial incentives on selected indicators of quality of care in Scotland: controlled interrupted time series analysis. BMJ, 2023:e072098.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMolokhia M, Okoli GN, Redmond P, et al. Uncoded chronic kidney disease in primary care: a cross-sectional study of inequalities and cardiovascular disease risk management. Br J Gen Pract. 2020;70(700):e785\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSisk R, Cameron R, Tahir W, et al. 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SIMD: Scottish Index of Multiple Deprivation.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003ePractice A (n = 116)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003ePractice B (n = 137)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003eTotal (n = 253)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 37px;\"\u003e\n \u003cp\u003eAge, median (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e78 (26-99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e76 (32-95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e77 (26-99)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 37px;\"\u003e\n \u003cp\u003eFemale, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e69 (59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e89 (65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e158 (62)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 37px;\"\u003e\n \u003cp\u003eSIMD, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35px;\"\u003e\n \u003cp\u003eSIMD 1 most deprived\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e69 (59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e88 (64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e157 (62)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35px;\"\u003e\n \u003cp\u003eSIMD 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e18 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e25 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e43 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35px;\"\u003e\n \u003cp\u003eSIMD 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e21 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e15 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e36 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35px;\"\u003e\n \u003cp\u003eSIMD 4-5 least deprived\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e8 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e9 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e17 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 58px;\"\u003e\n \u003cp\u003eChronic kidney disease, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35px;\"\u003e\n \u003cp\u003eStage 1-2 (\u0026gt;60mL/min/1.73m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e14 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e27 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e41 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35px;\"\u003e\n \u003cp\u003eStage 3a (45-59 mL/min/1.73m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e58 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e67 (49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e125 (49)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35px;\"\u003e\n \u003cp\u003eStage 3b (30-44 mL/min/1.73m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e32 (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e27 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e59 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35px;\"\u003e\n \u003cp\u003eStage 4 (15-29 mL/min/1.73m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e12 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e16 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e28 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35px;\"\u003e\n \u003cp\u003eStage 5 (\u0026lt;15 mL/min/1.73m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 37px;\"\u003e\n \u003cp\u003eCo-morbidity, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35px;\"\u003e\n \u003cp\u003eHypertension,\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e87 (75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e93 (68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e182 (72)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35px;\"\u003e\n \u003cp\u003eCoronary artery disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e39 (34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e54 (39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e93 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35px;\"\u003e\n \u003cp\u003eType 2 diabetes mellitus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e39 (34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e36 (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e75 (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35px;\"\u003e\n \u003cp\u003eAtrial fibrillation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e20 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e17 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e38 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35px;\"\u003e\n \u003cp\u003eCerebral vascular accident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e21 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e18 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e30 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35px;\"\u003e\n \u003cp\u003ePeripheral vascular disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e10 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e8 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e18 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35px;\"\u003e\n \u003cp\u003eHeart Failure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e26 (22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e28 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e54 (21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32px;\"\u003e\n \u003cp\u003eReduced ejection fraction (\u0026nbsp;\u0026pound;40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e6 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e7 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e13 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32px;\"\u003e\n \u003cp\u003eMid-range ejection fraction (41-49%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e5 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e7 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e12 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32px;\"\u003e\n \u003cp\u003ePreserved ejection fraction (\u0026sup3;50%)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e15 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e14 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e29 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 58px;\"\u003e\n \u003cp\u003eNumber of co-morbidities, excluding CKD, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e8 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e13 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e21 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e38 (33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e39 (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e77 (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35px;\"\u003e\n \u003cp\u003e2-3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e58 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e70 (51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e128 (51)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35px;\"\u003e\n \u003cp\u003e4-7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e12 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e15 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e27 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*With signs and symptoms [40].\u003c/p\u003e\n\u003cp\u003eTable 2\u0026nbsp;\u0026ndash; Pharmacological interventions\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"99%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedicines changes, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePractice A\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 74)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePractice B\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 89)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 163)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eStatins and/or ezetimibe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e48 (65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e53 (60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e101 (62)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eInitiated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e31 (42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e29 (33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e60 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eUp-titrated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e17 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e24 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e41 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 54px;\"\u003e\n \u003cp\u003eAntihypertensives (total)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e37 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e40 (45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e77 (47)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eInitiated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e17 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e22 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e39 (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eUp-titrated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e20 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e18 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e38 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eAngiotensin-converting enzyme inhibitors\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003eInitiated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e7 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e10 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e17 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003eUp-titrated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e13 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e11 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e24 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eAngiotensin reception blockers\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003eInitiated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e4 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e5 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003eUp-titrated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e5 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e2 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e7 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eAngiotensin receptor-neprilysin inhibitor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003eInitiated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e2 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e2 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003eUp-titrated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eBeta-blockers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003eInitiated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e5 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e5 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e10 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003eUp-titrated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e4 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e4 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e8 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eCalcium channel blockers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003eInitiated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e9 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e5 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e14 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003eUp-titrated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e2 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e3 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eMineralocorticoid receptor antagonist\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003eInitiated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003eUp-titrated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e3 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e3 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eSodium-glucose co-transporter 2 inhibitors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eInitiated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e36 (49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e33 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e69 (42)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eGlucagon-Like Peptide-1 Receptor Agonists\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eInitiated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e2 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eUp-titrated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e2 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eNephrotoxics\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eDeprescribed\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e6 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e4 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e10 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003eAdverse drug effects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eDeprescribed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e4 (5%)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e1 (1%)\u003csup\u003ee\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e4\u0026nbsp;(5%)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e3 (3%)\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e3 (3%)\u003csup\u003ee\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e1 (1%)\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e16 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/em\u003e\u003cem\u003eNaproxen, diclofenac, furosemide, metformin per eGFR \u0026lt;30 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e.\u003csup\u003e\u0026nbsp;\u003c/sup\u003e \u003csup\u003eb\u003c/sup\u003eSGLT2i: Light-headedness, dizziness, sickness, nocturia, back pain. \u003csup\u003ed\u003c/sup\u003eACEi: dry cough. \u003csup\u003ee\u003c/sup\u003eStatin: myalgia. \u003csup\u003ef\u003c/sup\u003eEdoxaban: dizziness.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTable 3 \u0026ndash; Change in chronic kidney disease stages pre- to 12 months post-GPCP intervention. \u003cem\u003eeGFR: Estimated glomerular filtration rate.\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"98%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCKD stages (n, %)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePractice A (n = 74)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePractice B (n = 89)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal (n = 163)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003ePre-intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003ePost-intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003ePre-intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003ePost-intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003ePre-intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003ePost-intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStage 1-2\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(eGFR \u0026gt;60mL/min/1.73m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e9 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e13 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e14 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e26 (29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e23 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e39 (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStage 3a\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(eGFR 45-59 mL/min/1.73m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e35 (47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e34 (46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e45 (51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e42 (47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e80 (49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e76 (47)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStage 3b\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(eGFR 30-44 mL/min/1.73m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e25 (34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e22 (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e21 (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e13 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e46 (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e35 (21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStage 4-5\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(eGFR \u0026lt;15-29 mL/min/1.73m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e5 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e5 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e9 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e8 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e14 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e13 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 4 \u0026ndash; Changes in primary and secondary clinical measures pre- to 12 months post-GPCP intervention. \u003cem\u003eeGFR: Estimated glomerular filtration rate; SBP: Systolic blood pressure; DBP: Diastolic blood pressure; HbA1c: Haemoglobin glycosylate A1c; TC: Total cholesterol; LDLc: non-HDLc: non-high density lipoprotein cholesterol; Low-density lipoprotein cholesterol.\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"97%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePractice A (n = 74)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 10px;\"\u003e\n \u003cp\u003eMean [95%CI]\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePractice B (n = 89)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003eMean [95%CI]\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal (n = 163\u003c/strong\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003eMean [95%CI]\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003ePre-intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003ePost-intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003ePre-intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003ePost-intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003ePre-intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003ePost-intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary clinical measures\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 16px;\"\u003e\n \u003cp\u003eeGFR,\u003c/p\u003e\n \u003cp\u003emL/min/1.73m\u003csup\u003e2\u0026nbsp;\u003c/sup\u003e\u0026plusmn; SD (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e48 \u0026plusmn; 14 (74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e49 \u0026plusmn; 14 (74)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e1.2 [-0.69, 3.00]\u003c/p\u003e\n \u003cp\u003eP = 0.217\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e49 \u0026plusmn; 15 (89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e54 \u0026plusmn; 16 (89)\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e4.4 [2.10, 6.62]\u003c/p\u003e\n \u003cp\u003eP \u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e49 \u0026plusmn; 14 (163)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e52 \u0026plusmn; 16 (163)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e2.9 [1.41, 4.40]\u003c/p\u003e\n \u003cp\u003eP \u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 16px;\"\u003e\n \u003cp\u003eSerum creatinine,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003emmol/L \u0026plusmn; SD (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e116\u0026nbsp;\u0026plusmn; 35 (74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e114\u0026nbsp;\u0026plusmn; 34 (74)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-2.6 [-5.98, 0.79]\u003c/p\u003e\n \u003cp\u003eP = 0.131\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e114 \u0026plusmn; 39 (89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e106 \u0026plusmn; 32 (89)\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-8.1 [-12.88, -3.30]\u003c/p\u003e\n \u003cp\u003eP = 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e115 \u0026plusmn; 37 (163)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e110 \u0026plusmn; 33 (163)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-5.6 [-8.63, -2.56]\u003c/p\u003e\n \u003cp\u003eP \u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSecondary clinical measures\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 16px;\"\u003e\n \u003cp\u003eBlood pressure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003eSBP, mmHg \u0026plusmn; SD (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e134 \u0026plusmn; 18 (74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e125 \u0026plusmn; 12 (74)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-8.9 [-12.63, -5.10]\u003c/p\u003e\n \u003cp\u003eP \u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e136 \u0026plusmn; 17 (89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e125 \u0026plusmn; 17 \u0026nbsp;(89)\u003csup\u003eg\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-10.2 [-13.85, -6.54]\u003c/p\u003e\n \u003cp\u003eP \u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e135 \u0026plusmn; 17 (163)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e125 \u0026plusmn; 15 (163)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-9.59 [-12.19, -6.99]\u003c/p\u003e\n \u003cp\u003eP \u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003eDBP, mmHg \u0026plusmn; SD (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e74 \u0026plusmn; 11 (74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e72 \u0026plusmn; 10 (74)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-2.1 [-4.30, 0.14]\u003c/p\u003e\n \u003cp\u003eP = 0.065\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e73 \u0026plusmn; 13 (89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e70 \u0026plusmn; 10 \u0026nbsp;(89)\u003csup\u003eg\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-2.9 [-5.27, -048]\u003c/p\u003e\n \u003cp\u003eP = 0.019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e71 \u0026plusmn; 10 (163)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e74 \u0026plusmn; 12 (163)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-2.52 [-4.15, -0.88]\u003c/p\u003e\n \u003cp\u003eP = 0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 16px;\"\u003e\n \u003cp\u003eHbA1c, mmol/mol \u0026plusmn; SD (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e51 \u0026plusmn; 19 (59)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e48 \u0026plusmn; 13 (59)\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-3.1 [-6.45, 0.35]\u003c/p\u003e\n \u003cp\u003eP = 0.077\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e48 \u0026plusmn; 16 (75)\u003csup\u003eh\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e47 \u0026plusmn; 14 (75)\u003csup\u003ei\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-1.7 [-3.65, 0.34]\u003c/p\u003e\n \u003cp\u003eP = 0.103\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e49 \u0026plusmn; 17 (135)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e47 \u0026plusmn; 14 (135)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-2.25 [-4.08, 0.42]\u003c/p\u003e\n \u003cp\u003eP = 0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003eNon-diabetics and IGT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e39 \u0026plusmn; 5 (34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e40 \u0026plusmn; 5 (34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e1.2 [0.39, 1.96]\u003c/p\u003e\n \u003cp\u003eP = 0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e41 \u0026plusmn; 6 (52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e41 \u0026plusmn; 5 (52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0.75 [-0.86, 2.36]\u003c/p\u003e\n \u003cp\u003eP = 0.337\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e40 \u0026plusmn; 5 (86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e41 \u0026plusmn; 5 (86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0.29 [-0.46, 1.04]\u003c/p\u003e\n \u003cp\u003eP = 0.443\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003eT2DM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e67 \u0026plusmn; 20 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e58 \u0026plusmn; 13 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-8.8 [-16.45, -1.15]\u003c/p\u003e\n \u003cp\u003eP = 0.026\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e65 \u0026plusmn; 19 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e60 \u0026plusmn; 19 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-4.7 [-10.88, 1.40]\u003c/p\u003e\n \u003cp\u003eP = 0.124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e66 \u0026plusmn; 19 (48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e59 \u0026plusmn; 16 (48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-6.85 [-11.66, -2.05]\u003c/p\u003e\n \u003cp\u003eP = 0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 16px;\"\u003e\n \u003cp\u003eTC, mmol/L \u0026plusmn; SD (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e4.4 \u0026plusmn; 1.1 (74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e4.0 \u0026plusmn; 1.0 (74)\u003csup\u003ee\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.4 [-0.56, -0.15]\u003c/p\u003e\n \u003cp\u003eP = 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e4.4 \u0026plusmn; 1.4 (86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e3.9 \u0026plusmn; 1.1 (86)\u003csup\u003ej\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-0.5 [-0.70, -0.31]\u003c/p\u003e\n \u003cp\u003eP \u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e4.4 \u0026plusmn; 1.2 (160)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e3.9 \u0026plusmn; 1.1 (160)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-0.44[-0.58, -0.29]\u003c/p\u003e\n \u003cp\u003eP \u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003ePP-CVD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e4.4 \u0026plusmn; 1.1 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e4.7 \u0026plusmn; 1.1 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e0.3 [-0.05, 0.61]\u003c/p\u003e\n \u003cp\u003eP = 0.094\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e4.9 \u0026plusmn; 1.4 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e4.2 \u0026plusmn; 1.2 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-0.7 [-1.08, -0.36]\u003c/p\u003e\n \u003cp\u003eP \u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e4.8 \u0026plusmn; 1.3 (67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e4.3 \u0026plusmn; 1.2 (67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-0.5 [-0.79, -0.29]\u003c/p\u003e\n \u003cp\u003eP \u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003eSP-CVD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e4.2 \u0026plusmn; 1.1 (47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e3.8 \u0026plusmn; 0.9 (47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.4 [-0.66, -0.13]\u003c/p\u003e\n \u003cp\u003eP = 0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e3.9 \u0026plusmn; 1.1 (46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e3.5 \u0026plusmn; 0.8 (46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-0.3 [-0.52, -0.12]\u003c/p\u003e\n \u003cp\u003eP = 0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e4.0 \u0026plusmn; 1.1 (93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e3.7 \u0026plusmn; 0.9 (93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-0.4 [-0.52, -0.20]\u003c/p\u003e\n \u003cp\u003eP \u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 16px;\"\u003e\n \u003cp\u003eNon-HDLc, mmol/L \u0026plusmn; SD (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e3.2 \u0026plusmn; 1.0 (74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e2.9 \u0026plusmn; 1.0 (74)\u003csup\u003ee\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.3 [-0.51, -0.09]\u003c/p\u003e\n \u003cp\u003eP = 0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e3.1 \u0026plusmn; 1.3 (86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e2.6 \u0026plusmn; 1.0 (86)\u003csup\u003e\u0026nbsp;j\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-0.5 [-0.66, -0.28]\u003c/p\u003e\n \u003cp\u003eP \u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e3.1 \u0026plusmn; 1.2 (160)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e2.7 \u0026plusmn; 1.0 (160)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-0.4 [-0.53, -0.25]\u003c/p\u003e\n \u003cp\u003eP \u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003ePP-CVD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e3.4 \u0026plusmn; 0.9 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e3.2 \u0026plusmn; 1.1 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.2 [-0.48, 0.18]\u003c/p\u003e\n \u003cp\u003eP = 0.356\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e3.5 \u0026plusmn; 1.4 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e2.9 \u0026plusmn; 1.1 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-0.6 [-0.98, -0.30]\u003c/p\u003e\n \u003cp\u003eP = 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e3.5 \u0026plusmn; 1.2 (67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e3.0 \u0026plusmn; 1.1 (67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-0.4 [-0.69, -0.20]\u003c/p\u003e\n \u003cp\u003eP = 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003eSP-CVD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e3.0 \u0026plusmn; 1.1 (47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e2.6 \u0026plusmn; 0.9 (47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.4 [-0.6, -0.11]\u003c/p\u003e\n \u003cp\u003eP = 0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e2.7 \u0026plusmn; 1.1 (46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e2.4 \u0026plusmn; 0.8 (46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-0.3 [-0.53, -0.13]\u003c/p\u003e\n \u003cp\u003eP = 0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e2.9 \u0026plusmn; 1.1 (93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e2.5 \u0026plusmn; 0.9 (93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-0.4 [-0.53, -0.19]\u003c/p\u003e\n \u003cp\u003eP \u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 16px;\"\u003e\n \u003cp\u003eLDLc, mmol/L \u0026plusmn; SD (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e2.3 \u0026plusmn; 0.9 (74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e2.1 \u0026plusmn; 0.9 (74)\u003csup\u003ee\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.2 [-0.41, -0.08]\u003c/p\u003e\n \u003cp\u003eP = 0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e2.3 \u0026plusmn; 1.2 (86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e1.9 \u0026plusmn; 0.9 (86)\u003csup\u003e\u0026nbsp;j\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-0.4 [-0.59, -0.23]\u003c/p\u003e\n \u003cp\u003eP \u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e2.0 \u0026plusmn; 0.9 (160)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e2.3 \u0026plusmn; 1.1 (160)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-0.3 [-0.46, -0.21]\u003c/p\u003e\n \u003cp\u003eP \u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003ePP-CVD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e2.6 \u0026plusmn; 1.0 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e2.4 \u0026plusmn; 1.1 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.2 [-0.52, 0.09]\u003c/p\u003e\n \u003cp\u003eP = 0.153\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e2.8 \u0026plusmn; 1.3 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e2.2 \u0026plusmn; 1.0 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-0.6 [-0.97, -0.29]\u003c/p\u003e\n \u003cp\u003eP \u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e2.7 \u0026plusmn; 1.2 (67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e2.3 \u0026plusmn; 1.0 (67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-0.5 [-0.70, -0.23]\u003c/p\u003e\n \u003cp\u003eP \u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003eSP-CVD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e2.2 \u0026plusmn; 0.9 (47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e1.9 \u0026plusmn; 0.8 (47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-0.3 [-0.46, 0.06]\u003c/p\u003e\n \u003cp\u003eP = 0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e1.9 \u0026plusmn; 0.8 (46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e1.7 \u0026plusmn; 0.8 (46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-0.2 [-0.39, -0.06]\u003c/p\u003e\n \u003cp\u003eP = 0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e2.0 \u0026plusmn; 0.8 (93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e1.8 \u0026plusmn; 0.8 (93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-0.2 [-0.37, -0.12]\u003c/p\u003e\n \u003cp\u003eP \u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-clinical-pharmacy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcp","sideBox":"Learn more about [International Journal of Clinical Pharmacy](https://www.springer.com/journal/11096)","snPcode":"11096","submissionUrl":"https://submission.nature.com/new-submission/11096/3","title":"International Journal of Clinical Pharmacy","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6209460/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6209460/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eChronic kidney disease (CKD) is a leading cause of premature mortality, often coexisting with cardiovascular disease and diabetes mellitus; disproportionately affecting socioeconomically deprived groups. CKD is projected to increase due to ageing, obesity and diabetes. General practice clinical pharmacists (GPCPs) have been shown to be effective in challenging chronic disease prescribing. GPCP services for CKD remains underexplored.\u003c/p\u003e\u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eTo scope the potential of a GPCP-led multidisciplinary intervention to optimise cardio-renal and metabolic risk factors in CKD stages 3\u0026ndash;4.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eAdults with CKD stages 3a to 4 from two urban, socioeconomically deprived general practices in NHS Greater Glasgow and Clyde in UK, were identified via practice records and GP referrals. Eligible patients were invited to attend a GPCP-led clinic (Nov 2021 \u0026ndash; Jan 2024), that included CKD monitoring (primary measure), patient education, life-style advice and medicines optimisation. Anonymised pre- and post-intervention data were analysed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn total, 253 participants (median age 77, range 26 to 99) met inclusion criteria; 62% lived in the most deprived areas of Scotland; 62% were female. Of the 163 (64%) attending. eGFR increased by a mean of 2.9 (95% CI 1.41 to 4.40, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e over 12 months, with improvements in CKD staging, blood pressures, lipid profiles, and HbA1c. Medicines optimisation included lipid lowering (62%), antihypertensives (47%), sodium-glucose co-transporter-2 inhibitors (42%), adverse drug effect management (16%), including nephrotoxic cessation.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eAn integrated pharmacist-led, general practice-based cardio-renal and metabolic clinic, improved key CKD-related outcomes in deprived population. Further studies are needed to confirm long-term impact.\u003c/p\u003e","manuscriptTitle":"Tackling the Inverse Care Law with pharmacist-led cardio-renal-metabolic service in a socioeconomically deprived population: A prospective scoping intervention study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-20 05:17:09","doi":"10.21203/rs.3.rs-6209460/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revisions","date":"2025-04-30T12:24:12+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2025-03-13T13:24:45+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-13T10:48:53+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"International Journal of Clinical Pharmacy","date":"2025-03-13T10:38:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-12T13:00:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Clinical Pharmacy","date":"2025-03-12T03:11:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-clinical-pharmacy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcp","sideBox":"Learn more about [International Journal of Clinical Pharmacy](https://www.springer.com/journal/11096)","snPcode":"11096","submissionUrl":"https://submission.nature.com/new-submission/11096/3","title":"International Journal of Clinical Pharmacy","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"72bd6a94-b60a-4582-b6c8-1ce0415c4a35","owner":[],"postedDate":"March 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-06-09T16:09:49+00:00","versionOfRecord":{"articleIdentity":"rs-6209460","link":"https://doi.org/10.1007/s11096-025-01938-8","journal":{"identity":"international-journal-of-clinical-pharmacy","isVorOnly":false,"title":"International Journal of Clinical Pharmacy"},"publishedOn":"2025-06-04 15:57:30","publishedOnDateReadable":"June 4th, 2025"},"versionCreatedAt":"2025-03-20 05:17:09","video":"","vorDoi":"10.1007/s11096-025-01938-8","vorDoiUrl":"https://doi.org/10.1007/s11096-025-01938-8","workflowStages":[]},"version":"v1","identity":"rs-6209460","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6209460","identity":"rs-6209460","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}