An economic evaluation of community pharmacy-dispensed naloxone in Canada

Aims

To determine the cost-effectiveness of pharmacy-based intranasal (IN) and intramuscular (IM) naloxone distribution in Canada.

Methods

We developed a state-transition model for pharmacy-based naloxone distribution, every 3 years, to illicit, prescription, opioid-agonist therapy and nonopioid use populations compared to no naloxone distribution. We used a monthly cycle length, lifetime horizon and a Canadian provincial Ministry of Health perspective. Transition probabilities, cost and utility data were retrieved from the literature. Costs (2020) and quality-adjusted life years (QALY) were discounted 1.5% annually. Microsimulation, 1-way and probabilistic sensitivity analyses were conducted.

Results

Distribution of naloxone to all Canadians compared to no distribution prevented 151 additional overdose deaths per 10,000 persons, with an incremental cost-effectiveness ratio (ICER) of $50,984 per QALY for IM naloxone and an ICER of $126,060 per QALY for IN naloxone. Distribution of any naloxone to only illicit opioid users was the most cost-effective. One-way sensitivity analysis showed that survival rates for illicit opioid users were most influenced by the availability of either emergency medical services or naloxone.

Conclusion

Distribution of IM and IN naloxone to all Canadians every 3 years is likely cost-effective at a willingness-to-pay threshold of $140,000 Canadian dollars/QALY (~3 × gross domestic product from the World Health Organization). Distribution to people who use illicit opioids was most cost-effective and prevented the most deaths. This is important, as more overdose deaths could be prevented through nationwide public funding of IN naloxone kits through pharmacies, since individuals report a preference for IN naloxone and these formulations are easier to use, save lives and are cost-effective. Can Pharm J (Ott) 2024;157:xx-xx.

Pharmacist Disciplinary Action: What Do Pharmacists Get in Trouble for?

Objective

This study aims to determine the reasons for disciplinary action and resultant consequences for Canadian pharmacists and any associations with demographic factors.

Methods

Regulatory body disciplinary action cases from 10 Canadian provinces were coded. Demographic information was coded.

Results

There were 665 pharmacist cases from nine provinces between January 2010 and December 2020. The rate of disciplinary action was low (1.37 cases/1,000 practitioners/year). Professional misconduct was the most common category of violation. Male pharmacists were overrepresented in disciplinary action cases. Most cases involved community pharmacists.

Conclusion

This study is the first, to our knowledge, in Canada to analyze the demographic factors of pharmacists subjected to disciplinary action. It updates a previous review of pharmacist disciplinary action (Foong et al. 2018).

Dentist Disciplinary Action: What Do Dentists Get in Trouble for?

Objective

This study aims to determine the reasons for disciplinary action, the consequences and any associations with demographic factors for Canadian dentists.

Methods

Publicly available regulatory body disciplinary action cases from 10 Canadian provinces were coded. Demographic factors were also coded.

Results

There were 344 dentist cases from five provinces between January 2010 and December 2020. The rate of disciplinary action was low (1.38 cases/1,000 practitioners/year). Clinical incompetence was the most common category of disciplinary action, followed by professional misconduct and dishonest business practices. Male dentists were overrepresented in the disciplinary action cases compared to the rest of the workforce.

Conclusion

This study is the first, to our knowledge, to describe the outcomes of regulatory body disciplinary action for Canadian dentists.

Reasons for Low Regulatory Body Discipline Rates for Canadian Hospital Pharmacists

Background: Past research on disciplinary action by pharmacist regulatory bodies has shown that most cases concern community pharmacists, with few occurring in a hospital setting.  Objective: To investigate how discipline-related issues involving pharmacists are dealt with by hospital pharmacy departments in Canada.  Methods: Hospital pharmacy directors and managers from small, medium, and large hospitals across Canada were invited to participate in semi-structured telephone interviews. The interview questions focused on the discipline process in participants’ organizations, the situations when reporting to the regulatory body is deemed to be warranted, possible penalties, and recommendations for improving the regulatory body or organizational discipline process.  Results: Ten participants, from British Columbia, Saskatchewan, Ontario, New Brunswick, Prince Edward Island, and Newfoundland and Labrador, agreed to be interviewed. Five key themes emerged as contributing to lower rates of hospital pharmacist discipline cases being escalated to the regulatory college level: robust organizational discipline processes independent from the regulatory college, a practice environment promoting competence, union representation, preference for a remedial approach to discipline, and lack of clarity about when to report to the regulatory authority.  Conclusions: This study identified a number of reasons why discipline of hospital pharmacists by a regulatory body may be less prevalent than discipline relating to community pharmacists. The main reasons may be lack of clarity about when to report a case to the regulator and a lack of transparency, given that many cases are handled internally within hospitals. Environmental supports for competence and employee protections (e.g., through a union) may also reduce discipline cases.  RÉSUMÉ  Contexte : Des recherches antérieures sur les mesures disciplinaires prises par les organismes de réglementation des pharmaciens ont montré que la plupart des cas concernaient des pharmaciens communautaires, et que peu se produisaient en milieu hospitalier.  Objectif : Examiner comment les questions disciplinaires impliquant des pharmaciens sont traitées par les départements de pharmacie hospitalière au Canada.  Méthodes : Les directeurs et gestionnaires de pharmacies de petits, moyens et grands hôpitaux au Canada ont été invités à participer à des entrevues téléphoniques semi-structurées. Les questions portaient sur le processus disciplinaire en place dans les organismes des participants; les situations où le signalement à l’organisme de réglementation était jugé justifié; les sanctions possibles; et les recommandations pour améliorer le processus disciplinaire de l’organisme de réglementation ou de l’organisme.  Résultats : Dix participants de la Colombie-Britannique, de la Saskatchewan, de l’Ontario, du Nouveau-Brunswick, de l’Île-du-Prince-Édouard et de Terre-Neuve-et-Labrador ont accepté d’être interrogés. Cinq thèmes clés ont été identifiés comme contribuant au taux plus faible de cas de discipline des pharmaciens hospitaliers remontés au niveau de l’organisme de réglementation : des processus disciplinaires organisationnels solides indépendants de l’organisme de réglementation; un environnement de pratique favorisant la compétence; la représentation syndicale; la préférence pour une approche corrective de la discipline; et le manque de clarté quant au moment où il faut signaler à l’autorité de réglementation.  Conclusions : Cette étude a identifié un certain nombre de raisons pour lesquelles les mesures disciplinaires relatives des pharmaciens hospitaliers par un organisme de réglementation peuvent être moins répandues que celles liées aux pharmaciens communautaires. Les principales raisons pourraient être le manque de clarté quant au moment de signaler un cas à l’autorité réglementaire et un manque de transparence, étant donné que de nombreux cas sont traités en interne dans les hôpitaux. Les soutiens environnementaux pour la compétence et la protection des employés (par exemple, par l’entremise d’un syndicat) peuvent également réduire les cas de discipline. 

Pharmacy students' perceived willingness and ability to negotiate for paid co-operative education positions

Background

Evidence of a gender wage gap has been identified across many professions, with some evidence in pharmacy. Negotiation is one potential strategy to address this gap and it is underutilized, especially among women. No studies to date have examined pharmacy student perceptions of negotiation when applying for co-operative education positions – a potential sign of willingness to negotiate for entry-level positions upon graduation.

Objectives

To examine pharmacy students' comfort with and ability to engage employers in negotiation over wage and other work-related considerations for mandatory and paid co-operative education work terms at the University of Waterloo (Waterloo, Ontario, Canada).

Methods

Two focus groups, one for female and one for male students, were performed with students who had completed at least one co-operative education placement. Focus groups aimed to elucidate students perceived ability to negotiate with potential employers, to identify strategies that educators can employ to better support students through the hiring and negotiation process, and to elicit student perceptions on the gender wage gap in pharmacy. Focus groups were audio recorded and transcribed verbatim, and data were coded inductively by two independent reviewers, employing thematic analysis.

Results

Three major and two minor themes were identified: Preservation of the relationship; Power differential and perceived ability to negotiate; Institutional support and training; Negative experience with negotiation and wage gaps; and the presence of a gendered approach to negotiation. Pharmacy students rarely engage in negotiation during co-operative hiring processes at the University of Waterloo, with some female students expressing hesitation to negotiate due to concerns about being perceived as “bossy”. Students of both genders felt poorly equipped to engage in negotiation with a potential employer, and lacked confidence in initiating such a conversation.

Conclusions

Students identified a number of factors which influence their ability and desire to negotiate wages during co-op placement, including the requirements and logistics of placements, the perceived power imbalance between students and potential employers, and a concern that any wage negotiation may overshadow the value placed by students on the opportunities to provide patient care. Educators can play a role in equipping students, especially female students, with tools to enter into conversations on wages with potential employers.

Evaluation of an Intergenerational and Technological Intervention for Loneliness: Protocol for a Feasibility Randomized Controlled Trial

BACKGROUND

Social integration and mental health are vital aspects of healthy aging. However, close to half of Canadians older than 80 years report feeling socially isolated. Research has shown that social isolation leads to increased mortality and morbidity, and various interventions have been studied to alleviate loneliness among older adults. This proposal presents an evaluation of an intervention that provides one-on-one coaching, is intergenerational, provides both educational and socialization experiences, and increases technology literacy of older adults to overcome loneliness.

OBJECTIVE

This paper describes the protocol of a randomized, mixed-methods study that will take place in Ontario, Canada. The purpose of this study is to evaluate if an intergenerational technology literacy program can reduce social isolation and depression in older adults via quantitative and qualitative outcome measures.

METHODS

This study is a randomized, mixed-methods, feasibility trial with 2 conditions. Older adults in the intervention condition will receive 1 hour of weekly technological assistance to send an email to a family member, for 8 weeks, with the assistance of a volunteer. Participants in the control condition will not receive any intervention. The primary outcomes are loneliness, measured using the University of California, Los Angeles Loneliness Scale, and depression, measured using the Center for Epidemiologic Studies Depression scale, both of which are measured weekly. Secondary outcomes are quality of life, as assessed using the Older People's Quality of Life-Brief version, and technological literacy, evaluated using the Computer Proficiency Questionnaire-12, both of which will be administered before and after the intervention. Semistructured interviews will be completed before and after the intervention to assess participants' social connectedness, familiarity with technology, and their experience with the intervention. The study will be completed in a long-term care facility in Southwestern Ontario, Canada. Significance was set at P<.05.

RESULTS

This study was funded in April 2019 and ethical approval was obtained in August 2019. Recruitment for the study started in November 2019. The intervention began in February 2020 but was halted due to the COVID-19 pandemic. The trial will be restarted when safe. As of March 2020, 8 participants were recruited.

CONCLUSIONS

Information and communication technology interventions have shown varying results in reducing loneliness and improving mental health among older adults. Few studies have examined the role of one-on-one coaching for older adults in addition to technology education in such interventions. Data from this study may have the potential to provide evidence for other groups to disseminate similar interventions in their respective communities.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/23767.

Remunerated patient care services and injections by pharmacists: An international update

Objectives

Recognizing pharmacists' increasing roles as primary care providers, programs offering remuneration for patient care services and the administration of injections by pharmacists continue to be implemented. The objective of this article is to provide an update on remuneration programs available to pharmacists internationally for nondispensing services.

Data sources

Systematic searches for relevant articles published from January 2013 to February 2018 across PubMed (MEDLINE), Embase, International Pharmaceutical Abstracts, Cochrane Library, Econlit, Scopus and Web of Science. Gray literature searches, including targeted searches of websites of payers and pharmacy associations, were also performed.

Study selection

Programs were included if they were newly introduced or had changes to patient eligibility criteria and fees since previously published reviews and if they were established programs offered by third-party payers for activities separate from dispensing.

Data extraction

Descriptive information on each program was extracted, including the program's jurisdiction (country and state, provincial or regional level, as applicable), payer, service description, patient eligibility criteria and fee structure.

Results

Over the 5-year period studied, 95 new programs for noninjection patient care services and 37 programs for pharmacist-administered injections were introduced. Large ranges in fees offered for similar programs were observed across programs, even within the same country or region, at an average of $US 71 for an initial medication review, $19 for follow-ups to these reviews, $18 for prescription adaptations and $13 for injection administration. Apart from some smoking cessation programs in England, which offered incentive payments for successful quits, all services were remunerated on a fee-for-service basis, often in the form of a flat fee regardless of the time spent providing the service.

Conclusion

Although funding for pharmacists' activities continues to show growth, concerns identified in previous reviews persist, including the great variability in remunerated activities, patient eligibility and fees. These issues may limit opportunities for multijurisdictional program and service outcome evaluation. Can Pharm J (Ott) 2019;152:xx-xx.

Demystifying serotonin syndrome (or serotonin toxicity)

OBJECTIVE

To review the symptoms of serotonin toxicity (commonly referred to as serotonin syndrome) and the causative drugs and their mechanisms of action, and to equip primary care providers with practical strategies to prevent and identify serotonin toxicity.

QUALITY OF EVIDENCE

PubMed and Google Scholar were searched for relevant articles on serotonin toxicity, the causes, and the differential diagnosis using search terms related to serotonin toxicity (serotonin syndrome, serotonin toxicity, serotonin overdose), causes (individual names of drug classes, individual drug names), and diagnosis (differential diagnosis, neuroleptic malignant syndrome, anticholinergic toxicity, discontinuation syndrome, malignant hyperthermia, serotonin symptoms). Experts in psychiatric medicine, psychiatric pharmacy, clinical pharmacology, and medical toxicology were consulted. Evidence is level II and III.

MAIN MESSAGE

Serotonin toxicity is a drug-induced condition caused by too much serotonin in synapses in the brain. Cases requiring hospitalization are rare, and mild cases caused by serotonin-mediated side effects are unlikely to be fatal. Patients present with a combination of neuromuscular, autonomic, and mental status symptoms. Serotonin-elevating drugs include monoamine oxidase inhibitors, serotonin reuptake inhibitors, and serotonin releasers. Most cases involve 2 drugs that increase serotonin in different ways; the most concerning combination is a monoamine oxidase inhibitor with a selective serotonin reuptake inhibitor or a serotonin-norepinephrine reuptake inhibitor.

CONCLUSION

Family physicians play a key role in identifying and preventing serotonin syndrome by teaching patients to recognize symptoms and monitoring patients throughout therapy.

[Not Available]

Objectif

Passer en revue les symptômes de la toxicité sérotoninergique (communément appelée le syndrome sérotoninergique), les médicaments causatifs et leurs mécanismes d’action, et proposer aux médecins de soins primaires des stratégies pratiques pour prévenir et dépister la toxicité sérotoninergique.

Qualité des données

Une recherche documentaire a été effectuée dans PubMed et Google Scholar pour trouver des articles pertinents sur la toxicité sérotoninergique, ses causes et les diagnostics différentiels, à l’aide d’expressions de recherche liées à la toxicité sérotoninergique (serotonin syndrome, serotonin toxicity, serotonin overdose), à ses causes (noms individuels de classes de médicaments, noms individuels de médicaments), et à son diagnostic (differential diagnosis, neuroleptic malignant syndrome, anticholinergic toxicity, discontinuation syndrome, malignant hyperthermia, serotonin symptoms). Des experts en médecine psychiatrique, en pharmacie psychiatrique, en pharmacologie clinique et en toxicologie médicale ont été consultés. Les données probantes sont de niveaux II et III.

Message principal

La toxicité sérotoninergique est un problème induit par des médicaments, qui est causé par la présence de trop de sérotonine dans les synapses du cerveau. Les cas qui exigent une hospitalisation sont rares, et il est peu probable que les cas bénins dus aux effets secondaires médiés par la sérotonine soient fatals. Les patients présentent une combinaison de symptômes neuromusculaires, du système nerveux autonome et de l’état mental. Parmi les médicaments qui augmentent la sérotonine se trouvent les inhibiteurs de la monoamine oxydase, les inhibiteurs de la recapture de la sérotonine et les libérateurs de sérotonine. Dans la plupart des cas, 2 médicaments qui augmentent la sérotonine de façons différentes sont en cause; la combinaison la plus inquiétante est un inhibiteur de la monoamine oxydase avec un inhibiteur sélectif de la recapture de la sérotonine ou un inhibiteur de la recapture de la sérotonine-noradrénaline.

Conclusion

Les médecins de famille jouent un rôle important dans la détection et la prévention du syndrome sérotoninergique en enseignant aux patients à reconnaître les symptômes et en surveillant les patients durant toute leur thérapie.

Physician and Pharmacist Medication Decision-Making in the Time of Electronic Health Records: Mixed-Methods Study

Background

Primary care needs to be patient-centered, integrated, and interprofessional to help patients with complex needs manage the burden of medication-related problems. Considering the growing problem of polypharmacy, increasing attention has been paid to how and when medication-related decisions should be coordinated across multidisciplinary care teams. Improved knowledge on how integrated electronic health records (EHRs) can support interprofessional shared decision-making for medication therapy management is necessary to continue improving patient care.

Objective

The objective of our study was to examine how physicians and pharmacists understand and communicate patient-focused medication information with each other and how this knowledge can influence the design of EHRs.

Methods

This study is part of a broader cross-Canada study between patients and health care providers around how medication-related decisions are made and communicated. We visited community pharmacies, team-based primary care clinics, and independent-practice family physician clinics throughout Ontario, Nova Scotia, Alberta, and Quebec. Research assistants conducted semistructured interviews with physicians and pharmacists. A modified version of the Multidisciplinary Framework Method was used to analyze the data.

Results

We collected data from 19 pharmacies and 9 medical clinics and identified 6 main themes from 34 health care professionals. First, Interprofessional Shared Decision-Making was not occurring and clinicians made decisions based on their understanding of the patient. Physicians and pharmacists reported indirect Communication, incomplete Information specifically missing insight into indication and adherence, and misaligned Processes of Care that were further compounded by EHRs that are not designed to facilitate collaboration. Scope of Practice examined professional and workplace boundaries for pharmacists and physicians that were internally and externally imposed. Physicians decided on the degree of the Physician-Pharmacist Relationship, often predicated by colocation.

Conclusions

We observed limited communication and collaboration between primary care providers and pharmacists when managing medications. Pharmacists were missing key information around reason for use, and physicians required accurate information around adherence. EHRs are a potential tool to help clinicians communicate information to resolve this issue. EHRs need to be designed to facilitate interprofessional medication management so that pharmacists and physicians can move beyond task-based work toward a collaborative approach.

Remunerated patient care services and injections by pharmacists: An international update

OBJECTIVES

Recognizing pharmacists' increasing roles as primary care providers, programs offering remuneration for patient care services, and the administration of injections by pharmacists continue to be implemented. The objective of this article is to provide an update on remuneration programs available to pharmacists internationally for nondispensing services.

DATA SOURCES

Systematic searches for relevant articles published from January 2013 to February 2018 across Pubmed (Medline), Embase, International Pharmaceutical Abstracts, Cochrane Library, Econlit, Scopus, and Web of Science. Gray literature searches, including targeted searches of websites of payers and pharmacy associations, were also performed.

STUDY SELECTION

Programs were included if they were newly introduced or had changes to patient eligibility criteria and fees since previously published reviews and if they were established programs offered by third-party payers for activities separate from dispensing.

DATA EXTRACTION

Descriptive information on each program was extracted, including the program's jurisdiction (country and state, provincial, or regional level, as applicable), payer, service description, patient eligibility criteria, and fee structure.

RESULTS

Over the 5-year period studied, 95 new programs for noninjection patient care services and 37 programs for pharmacist-administered injections were introduced. Large ranges in fees offered for similar programs were observed across programs, even within the same country or region, at an average of $US 71 for an initial medication review, $19 for follow-ups to these reviews, $18 for prescription adaptations, and $13 for injection administration. Apart from some smoking cessation programs in England, which offered incentive payments for successful quits, all services were remunerated on a fee-for-service basis, often in the form of a flat fee regardless of the time spent providing the service.

CONCLUSION

Although funding for pharmacists' activities continues to show growth, concerns identified in previous reviews persist, including the great variability in remunerated activities, patient eligibility, and fees. These issues may limit opportunities for multijurisdictional program and service outcome evaluation.

Will I lose my license for that? A closer look at Canadian disciplinary hearings and what it means for pharmacists' practice to full scope

Objective

Concerns about liability from clinical errors have been cited as a barrier preventing greater adoption of practice change. Our objective was to determine the most common actions or omissions that result in disciplinary action for pharmacists and the restrictive actions imposed.

Methods

Canadian disciplinary reports were reviewed. Cases were coded as charges of professional misconduct, unskilled practice or dishonest business practices.

Results

There were 558 disciplinary cases from 10 provinces that occurred between January 2010 and July 2017. Professional misconduct charges commonly involved stealing/diverting or inappropriately dispensing narcotic drugs, pharmacy supervision/premises charges and refusing to cooperate with the college. Charges of unskilled practice included dispensing the wrong drug, failing to assess the appropriateness of a drug order, providing the wrong dose and failing to counsel. Fraudulent billing practices and accepting rebates from generic drug companies were the most common dishonest business practices. Professional misconduct, unskilled practice and dishonest business practice charges were involved in 342 (61%), 169 (30%) and 191 (34%) cases, respectively. Most cases occurred in community pharmacies and were not caused by an isolated clinical error. Fines were the most common penalty, followed by temporary license suspensions, professional development and reprimands. License revocations were the least common (4%), often involving professional misconduct.

Conclusion

This review suggests that disciplinary action against a pharmacist for an isolated, unintentional clinical error is uncommon and that losing a license is rare. Fear of disciplinary action should not be a barrier to practice change or the provision of full-scope patient care services.

Ready or not? Pharmacist perceptions of a changing injection scope of practice before it happens

Background

Since 2012, Ontario pharmacists have been authorized to administer the influenza vaccine. In April 2016, the Ontario College of Pharmacists (OCP) proposed to expand the Pharmacy Act to allow pharmacists to vaccinate against 13 additional conditions. The OCP held an online public consultation and invited pharmacists, members of the public and organizations to weigh in on the proposed changes. Our objective was to explore the factors influencing how Ontario pharmacists may adopt or reject an expanding scope of practice, using data from the public consultation.

Methods

We coded the responses to the public consultation in 2 ways: 1) sentiment analysis and 2) an integrative approach to coding using Rogers's diffusion of innovations theory across 5 domains: relative advantage, compatibility, complexity, trialability and observability.

Results

Responses from pharmacists, the public and organizations were moderately positive on average. Pharmacists most commonly mentioned relative advantages, including benefits for patients, pharmacists, physicians and the health system. Positive responses focused on accessibility for patients, improved vaccine coverage, lower health care spending and freed physician time but cited lack of prescribing privileges as a barrier to the proposed changes. Negative responses focused on increased workload, patient safety concerns and the complexity of travel medicine.

Conclusions

The expanded immunization services are likely to be well received by most pharmacists. Convenience and accessibility for patients were commonly cited benefits, but the changes will be only a slight improvement over the current system unless pharmacists can prescribe these vaccines. Although employers responded positively, the question remains whether they will support pharmacists in a way that aligns with pharmacists' values and expectations. Decision makers must pay close attention to the pharmacy infrastructure and how this will affect uptake of these services. Recognition of this, combined with pharmacists' positive perceptions of the expanded scope, will facilitate smooth integration of this legislation into Ontario pharmacy practice.

How Appropriate Is All This Data Sharing? Building Consensus Around What We Need to Know About Shared Electronic Health Records in Extended Circles of Care

BACKGROUND

The bulk of healthcare spending is on individuals who have complex needs related to age, income, chronic disease and mental illness. Care involves many different professions, and interoperable electronic health records (EHRs) are increasingly essential.

OBJECTIVES

The objective of this paper is to describe the use of a nominal group technique (NGT) to develop a stakeholder-centred research agenda for clinical interoperability in extended circles of care that include social supports.

METHODS

We held a day-long meeting with 30 stakeholders, including primary care providers, social supports, patient representatives, health region managers, technology experts, health organizations and experts in privacy, law and ethics. Participants considered, "What research needs to be done to better understand how EHRs should be shared across large healthcare teams that include social supports?" Following sensitizing presentations from researchers and participants, we used an NGT to generate and rank research questions on a 9-point Likert scale. We retained research questions that had a mean score of at least 6.5/9 by at least 70% of the participants over two rounds of consensus-building.

RESULTS

Participants identified and ranked 57 research questions. Five items achieved consensus, related to 1) the impact of information sharing on care team outcomes, 2) data quality/accuracy, 3) cost/benefit, 4) what processes use what data and 5) regulation/legislation.

CONCLUSION

Healthcare reforms are increasingly focused on systems that integrate and coordinate multidisciplinary care, facilitated by EHRs. Research prioritization will ensure common concerns and barriers are addressed and resolved.

What Interventions Should Pharmacists Employ to Impact Health Practitioners’ Prescribing Practices?

Objective:

To determine which interventions are effective in influencing health practitioners’ prescribing practices and explore differences in intervention complexity, setting, sustainability, cost effectiveness, and impact on patient outcomes.

Methods:

A systematic search for English-language systematic reviews was performed in MEDLINE, Cumulative Index of Nursing and Allied Health Literature, EMBASE, and the Cochrane Library from the date of inception to July 2005 using search terms in accordance with Cochrane recommendations. Included reviews were required to clearly report a search strategy, inclusion/exclusion criteria, literature assessment criteria, and methods for synthesizing or summarizing information and references. Two reviewers independently identified studies for inclusion, assessed study quality, and extracted relevant information. Interventions were classified as consistently effective, inconsistently effective, and effectiveness uncertain.

Results:

Thirty-four of 4585 titles reviewed met the inclusion criteria. Quality scores ranged from 70% to 100%. Consistently effective interventions included reminders (manual and computerized), audit and feedback, educational outreach visits, organizational strategies, and patient-mediated interventions. Inconsistently effective interventions included computer decision support systems and educational meetings. Multi-faceted interventions were consistently shown to be more efficacious than single interventions. Limited data precluded exploration of the effects of interventions in different settings, sustainability of effect, cost effectiveness, and patient clinical outcomes.

Conclusions:

Interventions that are most effective for impacting prescribing practice include audit and feedback, reminders, educational outreach visits, and patient-mediated interventions. To maximize impact, pharmacists’ efforts to positively impact prescribing practices should focus on these intervention types rather than relying primarily on passive didactics or dissemination of guidelines.

Clinical effectiveness of trastuzumab: early experience

Objective. To assess the clinical effectiveness of trastuzumab among metastatic breast cancer (MBC) patients and compare the results to those reported in the two pivotal clinical trials and product monograph.

Design. Retrospective chart review of all patients who had initiated trastuzumab monotherapy or combination therapy for MBC within the Alberta Cancer Board (ACB) from August 1998 to May 2001.

Setting. Two public tertiary cancer centres in the Canadian province of Alberta.

Patients. Of 90 patients reviewed within the ACB, 72 women were eligible for the study.

Main outcome measures. The primary endpoints measured were time to treatment failure (TTF) and survival. Secondary end-points measured included adverse events and compliance with ACB guidelines for trastuzumab administration.

Results. Among all 72 patients, median TTF was 7.6 months and median survival was 14.4 months. Trastuzumab combination therapy was associated with a significantly longer median TTF compared to trastuzumab monotherapy (P= 0.011). With respect to survival, no significant advantage was seen with combination therapy over monotherapy (P= 0.438). Infusion-related reactions were reported in 11.1% of our patients, while cardiotoxicity was reported in12.5%.

Conclusions. Overall, we found that trastuzumab performs better in the clinical setting than it did in the pivotal trials with respect to TTF (2.5 vs. 2.4 months and 8.2 vs. 6.9 months), but not as well with respect to survival (10.0 vs. 13.0 months and 21.0 vs. 25.1 months). In comparison to the product monograph, we report a significantly lower incidence of infusion-related reactions and a slightly higher incidence of cardiotoxicity.

Effect of a mobile phone intervention on quitting smoking in a young adult population of smokers: randomized controlled trial study protocol

Background

Tobacco use remains the number one cause of preventable chronic disease and death in developed countries worldwide. In North America, smoking rates are highest among young adults. Despite that the majority of young adult smokers indicate wanting to quit, smoking rates among this age demographic have yet to decline. Helping young adults quit smoking continues to be a public health priority. Digital mobile technology presents a promising medium for reaching this population with smoking cessation interventions, especially because young adults are the heaviest users of this technology.

Objective

The primary aim of this trial is to determine the effectiveness of an evidence-informed mobile phone app for smoking cessation, Crush the Crave, on reducing smoking prevalence among young adult smokers.

Methods

A parallel randomized controlled trial (RCT) with two arms will be conducted in Canada to evaluate Crush the Crave. In total, 1354 young adult smokers (19 to 29 years old) will be randomized to receive the evidence-informed mobile phone app, Crush the Crave, or an evidence-based self-help guide known as “On the Road to Quitting” (control) for a period of 6 months. The primary outcome measure is a 30-day point prevalence of abstinence at the 6-month follow-up. Secondary outcomes include a 7-day point prevalence of abstinence, number of quit attempts, reduction in consumption of cigarettes, self-efficacy, satisfaction, app utilization metrics, and use of smoking cessation services. A cost-effectiveness analysis is included.

Results

This trial is currently open for recruitment. The anticipated completion date for the study is April 2016.

Conclusions

This randomized controlled trial will provide the evidence to move forward on decision making regarding the inclusion of technology-based mobile phone interventions as part of existing smoking cessation efforts made by health care providers. Evidence from the trial will also inform the development of future apps, provide a deeper understanding of the factors that drive change in smoking behavior using an app, and improve the design of cessation apps. This trial is among the first to assess the effect of a comprehensive and evidence-informed mHealth smoking cessation app on a large sample of young adult smokers. Strengths of the trial include the high-quality research design and in-depth assessment of the implementation of the intervention. If effective, the trial has the potential to demonstrate that including mHealth technology as a population-based intervention strategy can cost-effectively reach a greater proportion of the population and help young adult smokers to quit.

Trial Registration

ClinicalTrials.gov NCT01983150; http://clinicaltrials.gov/ct2/show/NCT01983150 (Archived by WebCite at http://www.webcitation.org/6VGyc0W0i).

Paying pharmacists for patient care: A systematic review of remunerated pharmacy clinical care services

BACKGROUND

Expansion of scope of practice and diminishing revenues from dispensing are requiring pharmacists to increasingly adopt clinical care services into their practices. Pharmacists must be able to receive payment in order for provision of clinical care to be sustainable. The objective of this study is to update a previous systematic review by identifying remunerated pharmacist clinical care programs worldwide and reporting on uptake and patient care outcomes observed as a result.

METHODS

Literature searches were performed in several databases, including MEDLINE, Embase and International Pharmaceutical Abstracts, for papers referencing remuneration, pharmacy and cognitive services. Searches of the grey literature and Internet were also conducted. Papers and programs were identified up to December 2012 and were included if they were not reported in our previous review. One author performed data abstraction, which was independently reviewed by a second author. All results are presented descriptively.

RESULTS

Sixty new remunerated programs were identified across Canada, the United States, Europe, Australia and New Zealand, ranging in complexity from emergency contraception counseling to minor ailments schemes and comprehensive medication management. In North America, the average fee provided for a medication review is $68.86 (all figures are given in Canadian dollars), with $23.37 offered for a follow-up visit and $15.16 for prescription adaptations. Time-dependent fees were reimbursed at $93.60 per hour on average. Few programs evaluated uptake and outcomes of these services but, when available, indicated slow uptake but improved chronic disease markers and cost savings.

DISCUSSION

Remuneration for pharmacists' clinical care services is highly variable, with few programs reporting program outcomes. Programs and pharmacists are encouraged to examine the time required to perform these activities and the outcomes achieved to ensure that fees are adequate to sustain these patient care activities.

Cost-utility analysis of a multidisciplinary strategy to manage osteoarthritis of the knee: economic evaluation of a cluster randomized controlled trial study

OBJECTIVE

To determine if a pharmacist-initiated multidisciplinary strategy provides value for money compared to usual care in participants with previously undiagnosed knee osteoarthritis.

METHODS

Pharmacies were randomly allocated to provide either 1) usual care and a pamphlet or 2) intervention care, which consisted of education, pain medication management by a pharmacist, physiotherapy-guided exercise, and communication with the primary care physician. Costs and quality-adjusted life-years (QALYs) were determined for patients assigned to each treatment and incremental cost-effectiveness ratios (ICERs) were determined.

RESULTS

From the Ministry of Health perspective, the average patient in the intervention group generated slightly higher costs compared with usual care. Similar findings were obtained when using the societal perspective. The intervention resulted in ICERs of $232 (95% confidence interval [95% CI] -1,530, 2,154) per QALY gained from the Ministry of Health perspective and $14,395 (95% CI 7,826, 23,132) per QALY gained from the societal perspective, compared with usual care.

CONCLUSION

A pharmacist-initiated, multidisciplinary program was good value for money from both the societal and Ministry of Health perspectives.

Publicly funded remuneration for the administration of injections by pharmacists: An international review

BACKGROUND

The administration of injections has become an increasingly common addition to pharmacists' scope of practice. Four Canadian provinces, all US states and a number of other countries have regulations allowing pharmacists to administer injections. However, the extent to which such services are remunerated is unknown.

METHODS

We contacted regulatory and advocacy organizations within those jurisdictions where pharmacists are authorized to administer injections to identify publicly funded programs that pay pharmacists for these services, as well as details of the eligible drugs/vaccines. Patient or private insurer payment programs were excluded.

RESULTS

Of the 281 organizations we contact-ed, 104 provided information on a total of 34 pharmacist vaccination programs throughout Canada, the United States, England, Wales and Ireland. Converted to 2013 Canadian dollars, remuneration averages $13.12 (SD $4.63) per injection (range, $4.14-$21.21). All regions allow pharmacists to bill for administration of the influenza vaccine, while some states allow for a number of other vaccines. Alberta has the broadest range of injections eligible for remuneration.

DISCUSSION

Despite evidence of increased vaccination rates in areas allowing pharmacist administration of injections, the availability of publicly funded remuneration programs and the fee offered vary by more than 5-fold across North America and the United Kingdom.

CONCLUSION

Pharmacist-administered injections have great public health potential. The range of injections eligible for remuneration should be expanded to include a wide range of vaccines and other injectable drugs, and remuneration should be sufficient to encourage more pharmacists to provide this service.

Pharmacist-initiated intervention trial in osteoarthritis: a multidisciplinary intervention for knee osteoarthritis

OBJECTIVE

Knee osteoarthritis (OA) is a commonly undiagnosed condition and care is often not provided. Pharmacists are uniquely placed for launching a multidisciplinary intervention for knee OA.

METHODS

We performed a cluster randomized controlled trial with pharmacies providing either intervention care or usual care (14 and 18 pharmacies, respectively). The intervention included a validated knee OA screening questionnaire, education, pain medication management, physiotherapy-guided exercise, and communication with the primary care physician. Usual care consisted of an educational pamphlet. The primary outcome was the pass rate on the Arthritis Foundation's quality indicators for OA. Secondary outcomes included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Lower Extremity Function Scale (LEFS), the Paper Adaptive Test-5D (PAT-5D), and the Health Utilities Index Mark 3 (HUI3).

RESULTS

One hundred thirty-nine patients were assigned to the control (n = 66) and intervention (n = 73) groups. There were no differences between the groups in baseline measures. The overall quality indicator pass rate was significantly higher in the intervention arm compared to the control arm (difference of 45.2%; 95% confidence interval 34.5, 55.9). Significant improvements were observed for the intervention care group as compared to the usual care group in the WOMAC global, pain, and function scores at 3 and 6 months (all P < 0.01); the PAT-5D daily activity scores at 3 and 6 months (both P < 0.05); the PAT-5D pain scores at 6 months (P = 0.05); the HUI3 single-attribute pain scores at 3 and 6 months (all P < 0.05); and the LEFS scores at 6 months (P < 0.05).

CONCLUSION

Pharmacists can launch a multidisciplinary intervention to identify knee OA cases, improve the utilization of treatments, and improve function, pain, and quality of life.

Evaluating the labour costs associated with pharmacy adaptation services in British Columbia

BACKGROUND

Pharmacists' scope of practice has been steadily expanding across Canada to encompass clinical activities. In January 2009, pharmacists in British Columbia (BC) were given the authority to adapt prescriptions for renewals; change in dose, formulation or regimen; and therapeutic substitutions. This study evaluated the labour costs associated with pharmacy adaptation services in BC. >

METHODS

Ten high-adapting pharmacies participated in the study. Through workflow observations, we measured the time incurred for adapted and nonadapted prescriptions.

RESULTS

We observed 91 adapted prescriptions and 1081 nonadapted prescriptions. The total average time to provide adapted prescriptions was 6:43 minutes (SD 3:50) longer than to provide nonadapted prescriptions. The total average cost of an adapted prescription was $6.10 greater than a nonadapted prescription. Renewals took the least amount of time to complete, and therapeutic substitutions took the most time to complete.

DISCUSSION

Through workflow observations, it was determined that 10 stages of activity occur when adapting a prescription, with the most time being expended during the documentation and processing phases. Labour costs associated with adapted prescriptions were higher than for nonadapted prescriptions.

Pharmacy Owner and Manager Perceptions of Pharmacy Adaptation Services in British Columbia

Introduction:

As of January 2009, pharmacists in British Columbia (BC) have been able to adapt prescriptions to provide renewals; change the dosage, formulation or regimen; and substitute therapeutically equivalent therapies for reasons of cost or continuity of care.

Objectives:

To describe and characterize pharmacy manager and owner perceptions of pharmacy adaptation services in BC.

Methods:

Over a 1-month period, pharmacy owners, dispensary managers and regional managers from “high-adapter” pharmacies (>60 adaptations/month) and “low-adapter” pharmacies (<10 adaptations/month) were interviewed. During the semi-structured interviews, participants were asked to comment on uptake, cost, revenue and general perceptions of adaptation services. All data were assessed using content analysis.

Results:

Very few capital costs were incurred. Those costs included additional human resource costs (training and staff), updating computer software to produce physician notification forms, fax machine upgrades, additional physical storage and paper. The other emerging themes from the interviews included sustainability, patient and physician knowledge of the program, perceived benefits of the program, suggested changes to the program, high-adapting pharmacies as being champions of pharmacy adaptation services and potential barriers to adoption within a pharmacy.

Discussion:

In general, few changes were made as a result of the adaptation program and minimal capital costs were incurred. The documentation stage was the most labour-intensive aspect of adapting prescriptions. Perceived benefits related to providing the patient with continuity of care. Most of the suggested changes involved reducing restrictions on the program and providing greater opportunities for pharmacists to exercise their clinical judgment.

Pharmacists' preferences for providing patient-centered services: a discrete choice experiment to guide health policy

BACKGROUND

In Canada, most pharmacists are not paid to provide patient-centered services. In other areas of the world these services have suffered from poor adoption by pharmacists.

OBJECTIVE

To determine pharmacists' preferences for providing patient-centered services.

METHODS

Senior pharmacy students and pharmacists in British Columbia and Alberta were recruited to complete a discrete choice experiment. In 18 different choice-sets, respondents were asked to choose 1 of 3 options that included 2 different hypothetical patient-centered services and a status quo option. For each hypothetical service, we described the following attributes: service type and setting, personal income and job satisfaction, professional fee, and educational requirements. Multinomial logit and latent class regression models determined respondents' relative preference weights for each attribute.

RESULTS

Of 539 respondents who completed the questionnaire, 49% were dispensary pharmacists or managers, 12% were dispensary owners or regional managers, 21% were clinical pharmacists, and 16% were students. When choosing new services, respondents were very averse to having their personal income or job satisfaction decrease. They also preferred a higher professional fee for the service (to be paid to the pharmacy) and preferred a weeklong course or a preceptorship over no education before embarking on new services. Respondents also preferred medication or disease management services, were not interested in screening, and were averse to typical pharmacy services. Finally, respondents preferred the clinic setting over the dispensary. Preferences differed according to several factors including respondents' employment and time in practice.

CONCLUSIONS

Pharmacists prefer to provide patient-centered services over typical pharmacy services. Most will need to be assured that their income and job satisfaction will be maintained or increased and that they will have access to suitable advanced education. Decision-makers should carefully consider these preferences to improve program success and sustainability.

After patients are diagnosed with knee osteoarthritis, what do they do?

OBJECTIVE

To learn more about the health services and products that patients use after receiving a diagnosis of knee osteoarthritis (OA), as well as the trajectory of their health-related quality of life (HRQOL).

METHODS

Using a simple screening survey, community pharmacists identified 194 participants with previously undiagnosed knee OA. Of these participants, 190 were confirmed to have OA on further investigation. At baseline and 1, 3, and 6 months after diagnosis, a survey was administered to assess health services, product use, and HRQOL, including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Medical Outcomes Study Short Form 36 (SF-36) health survey, the Paper Adaptive Test (PAT-5D-QOL), and the Health Utilities Index Mark 3.

RESULTS

With a mean age of 63 years, participants were mostly women, white, and overweight. By 6 months, more than 90% of the participants had visited their family physician to discuss their OA, and more than 50% of participants took either prescription or nonprescription analgesics. In addition, three-quarters of the participants started exercising, one-third initiated activity aids, and one-third had started natural medicine products. At 6 months compared with baseline, significant improvements were seen in the SF-36 physical component summary (P = 0.001) and bodily pain domain scores (P = 0.02), the PAT-5D-QOL overall, pain, and usual daily activities scores (P < 0.001 for all), and the WOMAC total, pain, and function scores (P < 0.001 for all).

CONCLUSION

Within 6 months of receiving a diagnosis of knee OA, participants made several lifestyle interventions, often without the advice of a health professional, and saw improvements in their pain and function.

Pharmacy 2.0

It's the not-so-distant future. A new patient tells you that he's been reading reviews of your pharmacy online. He suffers from a chronic disease and your pharmacy's specialty services were recommended in an article by a local blogger. Later that day, while you're talking with a new mom about the safety of routine immunizations for her children, she references Facebook, YouTube and something she calls “mommy blogs” when discussing concerns over autism and seizure disorders. After work, you're introduced to a local physician at the gym who has just opened a new practice. You ask for her business card, and she replies, “I'm on LinkedIn.” That night, the local news reports the results of a huge research trial. Anticipating phone calls and questions when you get to work tomorrow morning, you wonder where you can quickly find some of the experts' thoughts on this new data. Welcome to Pharmacy 2.0.

Pharmacists' Perspectives on Providing Chronic Disease Management Services in the Community — Part II: Development and Implementation of Services

Background:

The need for alternative methods of providing primary care and chronic disease management (CDM) is becoming more urgent. To understand pharmacists' role in this changing health care system, we must better understand their desire and capacity to provide these services.

Methods:

Key stakeholders from all facets of pharmacy practice were recruited to participate in focus groups held in Alberta and British Columbia. Qualitative methodologies involving a phenomenological approach with content analysis were used to gather and analyze information.

Results:

In total, 36 pharmacists participated in 8 focus groups to identify enablers and challenges to the provision of CDM (reported in Part I). The topic of how such services could be implemented in the community developed naturally from these discussions. Participants expressed a need for changes to both the physical layout of pharmacies (to incorporate private counselling spaces) and the documentation and information systems used (to improve communication and continuity of care). Furthermore, the intentions of both pharmacists and employers must be communicated effectively to all parties, including patients. Participants also identified an alternative remuneration model as being essential, to allow adequate time for provision of CDM services and to ensure that current high-quality dispensing practices can be continued.

Conclusion:

Pharmacists have a tremendous opportunity to change practice and to contribute more to patient care. To guide and implement such change will require that pharmacists restructure their physical and information environments, strengthen their relationships with key stakeholders and develop a sustainable model of practice that includes the needs of the business, the client (patient) and the pharmacist.

Pharmacists' Perspectives on Providing Chronic Disease Management Services in the Community — Part I: Current Practice Environment

Background:

Several practice models have been developed to support pharmacists in providing chronic disease management. However, most of these models have not been readily accepted by pharmacists, which has led to low uptake and short-term change.

Methods:

Pharmacists were recruited to participate in focus groups held in Alberta and British Columbia. Qualitative methodologies involving a phenomenological approach with content analysis were used to gather and analyze information.

Results:

In total, 36 pharmacists participated in 8 focus groups. Analysis of their discussions revealed 4 main themes: the current practice environment and the need for education about, remuneration for and a plan for the implementation of chronic disease management services. Participants cited several challenges to the provision of this type of care, as experienced in the current practice environment: time constraints; relationships with physicians, patients and employers; limited access to clinical information; and absence of a model for chronic disease management in pharmacy practice. However, these perceptions were not universal, and pharmacists with experience in this area described some of these commonly cited “challenges” (e.g., relationships with physicians) as enablers in their own practices. In addition, staff pharmacists, regional managers and owners often had differing opinions about the key challenges and the role of remuneration.

Conclusion:

Some of the perceived challenges to providing chronic disease management described by staff pharmacists were not consistently supported by employers or those with experience in this practice area. This observation suggests that the greatest challenge to developing a successful model of chronic disease management for pharmacists lies in pharmacists' own perceptions about their relationships with other health care providers and their own role as health care professionals. These issues must be addressed if the practice of pharmacy is to move forward.