Lalitha Raman-Wilms

Fetal genital effects of first-trimester sex hormone exposure: a meta-analysis.

Objective To determine if first-trimester exposure to ex hormones, and oral contraceptives (OCs) specifically, is associated with an increased risk of external fetal genital malformations. Data Sources MEDLINE and Science Citation Index data bases were searched for the years 1966–1992 for relevant English-language articles on first-trimester sex-hormone ex-posure and fetal genital changes. Methads of Study Selection One hundred eighty-six arti-cles were identified initially. Inclusion criteria were cohort or case-control studies, first-trimester sex-hormone exposure, and live infants or full-term stillborn infants with external genital malformations. Exclusion criteria were diethylstil-bestrol exposure, spontaneous abortions, and teratogen ex-posure. Data Extraction and Synthesis The Methods section of each study was reviewed independently by two authors and two outside reviewers, using the above criteria. Fourteen studies, seven cohort and seven case-control, involving 65,565 women, met the criteria for meta-analysis. Extracted data were entered into 2 × 2 tables. The overall summary odds ratio (OR) was 1.09 (95% confidence interval [CI] 0.90–1.32); subanalysis of OC exposure identified an OR of 0.98 (95% CI 0.24–3.94). Conclusion There was no association between first-trimester exposure to sex hormones generally (or to OCs specifically) and external genital malformations. Thus, women exposed to sex hormones after conception may be assured there is no increased risk of fetal sexual malformation.

An Interfaculty Pain Curriculum: Lessons learned from six years experience

Abstract Minimal pain content has been documented in pre‐licensure curricula and students lack important pain knowledge at graduation. To address this problem, we have implemented and evaluated a mandatory Interfaculty Pain Curriculum (IPC) yearly since 2002 for students (N = 817 in 2007) from six Health Science Faculties/Departments. The 20‐h pain curriculum continues to involve students from Dentistry, Medicine, Nursing, Pharmacy, Physical Therapy, and Occupational Therapy as part of their 2nd or 3rd year program. Evaluation methods based on Kirkpatrick’s model now include evaluation of a Comprehensive Pain Management Plan along with the previously used Pain Knowledge and Beliefs Questionnaire (PKPQ) and Daily Content and Process Questionnaires (DCPQ). Important lessons have been learned and subsequent changes made in this iterative curriculum design based on extensive evaluation over the 6‐year period. Modifications have included case development more relevant to the diverse student groups, learning contexts that are uni‐, inter‐, and multi‐professional, and facilitator development in working with interprofessional student groups. PKBQ scores have improved in all years with a statistically significant average change on correct responses from 14% to 17%. The DCPQ responses have also indicated consistently that most students (85–95%) rated highly the patient panel, expert‐lead clinically focused sessions, and small interprofessional groups. Relevancy and organization of the information presented have been generally rated highly from 80.3% to 91.2%. This curriculum continues to be a unique and valuable learning opportunity as we utilize lessons learned from extensive evaluation to move the pain agenda forward with pre‐licensure health science students.

What Are Priorities for Deprescribing for Elderly Patients? Capturing the Voice of Practitioners: A Modified Delphi Process

Polypharmacy and inappropriate medication use among older adults contribute to adverse drug reactions, falls, cognitive impairment, noncompliance, hospitalization and mortality. While deprescribing - tapering, reducing or stopping a medication - is feasible and relatively safe, clinicians find it difficult to carry out. Deprescribing guidelines would facilitate this process. The aim of this paper is to identify and prioritize medication classes where evidence-based deprescribing guidelines would be of benefit to clinicians. A modified Delphi approach included a literature review to identify potentially inappropriate medications for the elderly, an expert panel to develop survey content and three survey rounds to seek consensus on priorities. Panel participants included three pharmacists, two family physicians and one social scientist. Sixty-five Canadian geriatrics experts (36 pharmacists, 19 physicians and 10 nurse practitioners) participated in the survey. Twenty-nine drugs/drug classes were included in the first survey with 14 reaching the required (≥ 70%) level of consensus, and 2 new drug classes added from qualitative comments. Fifty-three participants completed round two, and 47 participants completed round three. The final five priorities were benzodiazepines, atypical antipsychotics, statins, tricyclic antidepressants, and proton pump inhibitors; nine other drug classes were also identified as being in need of evidence-based deprescribing guidelines. The Delphi consensus process identified five priority drug classes for which expert clinicians felt guidance is needed for deprescribing. The classes of drugs that emerged strongly from the rankings dealt with mental health, cardiovascular, gastroenterological, and neurological conditions. The results suggest that deprescribing and overtreatment occurs through the full spectrum of primary care, and that evidence-based deprescribing guidelines are a priority in the care of the elderly.

Developmental evaluation as a strategy to enhance the uptake and use of deprescribing guidelines: protocol for a multiple case study

BackgroundThe use of developmental evaluation is increasing as a method for conducting implementation research. This paper describes the use of developmental evaluation to enhance an ongoing study. The study develops and implements evidence-based clinical guidelines for deprescribing medications in primary care and long-term care settings. A unique feature of our approach is our use of a rapid analytical technique.Methods/DesignThe team will carry out two separate analytical processes: first, a rapid analytical process to provide timely feedback to the guideline development and implementation teams, followed by a meta-evaluation and second, a comprehensive qualitative analysis of data after the implementation of each guideline and a final cross-case analysis. Data will be gathered through interviews, through observational techniques leading to the creation of field notes and narrative reports, and through assembling team documents such as meeting minutes. Transcripts and documents will be anonymized and organized in NVIVO by case, by sector (primary care or long-term care), and by implementation site. A narrative case report, directed coding, and open coding steps will be followed. Clustering and theming will generate a model or action map reflecting the functioning of the participating social environments.DiscussionIn this study, we will develop three deprescribing guidelines and will implement them in six sites (three family health teams and three long-term care homes), in a sequential iterative manner encompassing 18 implementation efforts. The processes of 11 distinct teams within four conceptual categories will be examined: a guideline priority-setting group, a guideline development methods committee, 3 guideline development teams, and 6 guideline implementation teams. Our methods will reveal the processes used to develop and implement the guidelines, the role and contribution of developmental evaluation in strengthening these processes, and the experience of six sites in implementing new evidence-based clinical guidelines. This research will generate new knowledge about team processes and the uptake and use of deprescribing guidelines in family health teams and long-term care homes, with a goal of addressing polypharmacy in Canada. Clinicians and researchers creating clinical guidelines to introduce improvements into daily practice may benefit from our developmental evaluation approach.

The ethics of Canadian entry-to-practice pain competencies: How are we doing?

BACKGROUND Although unrelieved pain continues to represent a significant problem, prelicensure educational programs tend to include little content related to pain. Standards for professional competence strongly influence curricula and have the potential to ensure that health science students have the knowledge and skill to manage pain in a way that also allows them to meet professional ethical standards. OBJECTIVES To perform a systematic, comprehensive examination to determine the entry-to-practice competencies related to pain required for Canadian health science and veterinary students, and to examine how the presence and absence of pain competencies relate to key competencies of an ethical nature. METHODS Entry-to-practice competency requirements related to pain knowledge, skill and judgment were surveyed from national, provincial and territorial documents for dentistry, medicine, nursing, pharmacy, occupational therapy, physiotherapy, psychology and veterinary medicine. RESULTS Dentistry included two and nursing included nine specific pain competencies. No references to competencies related to pain were found in the remaining health science documents. In contrast, the national competency requirements for veterinary medicine, surveyed as a comparison, included nine pain competencies. All documents included competencies pertaining to ethics. CONCLUSIONS The lack of competencies related to pain has implications for advancing skillful and ethical practice. The lack of attention to pain competencies limits the capacity of health care professionals to alleviate suffering, foster autonomy and use resources justly. Influencing professional bodies to increase the number of required entry-to-practice pain competencies may ultimately have the greatest impact on education and practice.

Core Competencies in Natural Health Products for Canadian Pharmacy Students

Objective. To reach consensus on core competency statements for natural health products (NHPs) for Canadian pharmacy students. Methods. Four rounds of a modified Delphi method were used to achieve consensus on core competency statements for NHPs. Pharmacy educators from Canada and the United States, and representatives from Canadian pharmacy organizations ranked their agreement using a 5-point Likert scale. Results. Consensus was achieved on 3 NHP-related core competency statements: (1) to incorporate NHP knowledge when providing pharmaceutical care; (2) to access and critically appraise NHP-related information sources; and (3) to provide appropriate education to patients and other health care providers on the effectiveness, potential adverse effects, and drug interactions of NHPs. Conclusions. Consensus was reached among leaders in NHP education on 3 NHP-related core competency statements. Implementation of these competencies would ensure that graduating Canadian pharmacists would be able to fulfill their professional responsibilities related to NHPs.

Self-efficacy for deprescribing: A survey for health care professionals using evidence-based deprescribing guidelines

Background Although polypharmacy is associated with significant morbidity, deprescribing can be challenging. In particular, clinicians express difficulty with their ability to deprescribe (i.e. reduce or stop medications that are potentially inappropriate). Evidence‐based deprescribing guidelines are designed to help clinicians take action on reducing or stopping medications that may be causing more harm than benefit. Objectives Determine if implementation of evidence‐based guidelines increases self‐efficacy for deprescribing proton pump inhibitor (PPI), benzodiazepine receptor agonist (BZRA) and antipsychotic (AP) drug classes. Methods A deprescribing self‐efficacy survey was developed and administered to physicians, nurse practitioners and pharmacists at 3 long‐term care (LTC) and 3 Family Health Teams in Ottawa, Canada at baseline and approximately 6 months after sequential implementation of each guideline. For each drug class, overall and domain‐specific self‐efficacy mean scores were calculated. The effects of implementation of each guideline on self‐efficacy were tested by estimating the difference in scores using paired t‐test. A linear mixed‐effects model was used to investigate change over time and over practice sites. Results Of eligible clinicians, 25, 21, 18 and 13 completed the first, second, third and fourth survey respectively. Paired t‐tests compared 14 participants for PPI and BZRA, and 9 for AP. Overall self‐efficacy score increased for AP only (95% confidence intervals (CI) 0.32 to 19.79). Scores for domain 2 (develop a plan to deprescribe) increased for PPI (95% CI 0.52 to 24.12) and AP guidelines (95% CI 2.46 to 18.11); scores for domain 3 (implement the plan for deprescribing) increased for the PPI guideline (95% CI 0.55 to 14.24). Longitudinal analysis showed an increase in non‐class specific scores, with a more profound effect for clinicians in LTC where guidelines were routinely used. Conclusion Implementation of evidence‐based deprescribing guidelines appears to increase clinicians’ self‐efficacy in developing and implementing a deprescribing plan for specific drug classes. HighlightsPrescribers have identified many challenges in their ability to carry out deprescribing activities.Self‐efficacy reflects how long one will persevere when faced with challenges.Using evidence‐based deprescribing guidelines influences self‐efficacy for deprescribing.A self‐efficacy assessment tool provides a novel approach to evaluating usefulness of polypharmacy management initiatives.

The Pain Interprofessional Curriculum Design Model

Objective Although the University of Toronto Centre for the Study of Pain has successfully implemented an Interfaculty Pain Curriculum since 2002, we have never formalized the process in a design model. Therefore, our primary aim was to develop a model that provided an overview of dynamic, interrelated elements that have been important in our experience. A secondary purpose was to use the model to frame an interactive workshop for attendees interested in developing their own pain curricula. Methods The faculties from Dentistry, Medicine, Nursing, Occupational Therapy, Pharmacy, and Physical Therapy met to develop the model components. Discussion focused on patient-centered pain assessment and management in an interprofessional context, with pain content being based on the International Association for the Study of Pain-Interprofessional Pain Curriculum domains and related core pain competencies. Profession-specific requirements were also considered, including regulatory/course requirements, level of students involved, type of course delivery, and pedagogic strategies. Results The resulting Pain Interprofessional Curriculum Design Model includes components that are dynamic, competency-based, collaborative, and interrelated. Key questions important to developing curricular components guide the process. The Model framed two design workshops with very positive responses from international and national attendees. Conclusions The Pain Interprofessional Curriculum Design Model is based on established pain curricula and related competencies that are relevant to all health science students at the prelicensure (entry-to-practice) level. The model has been developed from our experience, and the components resonated with workshop attendees from other regions. This Model provides a basis for future interventions in curriculum design and evaluation.

A literature review of the impact of pharmacy students in immunization initiatives.

Background: Pharmacy students can help protect the public from vaccine-preventable diseases by participating in immunization initiatives, which currently exist in some Canadian and American jurisdictions. The objective of this article is to critically review evidence of student impact on public health through their participation in vaccination efforts. Methods: PubMed, CINAHL, Cochrane Database, EMBASE, International Pharmaceutical Abstracts, Scopus and Web of Science electronic databases were searched for peer-reviewed literature on pharmacy student involvement in vaccination programs and their impact on public health. Papers were included up to November 17, 2015. Two reviewers independently screened titles and abstracts and extracted data from eligible full-text articles. Results: Eighteen titles met all inclusion criteria. All studies were published between 2000 and 2015, with the majority conducted in the United States (n = 12). The number of vaccine doses administered by students in community-based clinics ranged from 109 to 15,000. Increases in vaccination rates in inpatient facilities ranged from 18.5% to 68%. Across studies, student-led educational interventions improved patient knowledge of vaccines and vaccine-preventable diseases. Patient satisfaction with student immunization services was consistently very high. Discussion: Methodology varied considerably across studies. The literature suggests that pharmacy students can improve public health by 1) increasing the number of vaccine doses administered, 2) increasing vaccination rates, 3) increasing capacity of existing vaccination efforts, 4) providing education about vaccines and vaccine-preventable diseases and 5) providing positive immunization experiences. Conclusion: Opportunities exist across Canada to increase pharmacy student involvement in immunization efforts and to assess the impact of their participation. Greater student involvement in immunization initiatives could boost immunization rates and help protect Canadians from vaccine-preventable diseases.

Knowledge, Perceptions and Attitudes toward Chronic Pain and Its Management: A Cross-Sectional Survey of Frontline Pharmacists in Ontario, Canada

The treatment of chronic pain consumes a significant share of primary care. Community and family health team pharmacists frequently see patients with chronic pain, thus have the opportunity to improve their care. To assess the knowledge, perceptions, and attitudes of Ontario pharmacists, we invited 5,324 Ontario pharmacists, to participate in an online survey we developed using Qualtrics. The 31-question survey gathered demographic information, assessed pharmacists’ knowledge of three chronic pain conditions; chronic lower back pain (CLBP, eight true/false statements); chronic headache disorder (CHD, eight true/false statements) and painful diabetic neuropathy (PDN, seven true/false statements), and their attitudes toward and perceptions of patients with these conditions, and knowledge, attitudes, and perceptions of opioids in pain management. We received 688 responses (12.9%) and 392 pharmacists completed the survey. The mean age of respondents was 48.5 years and 48.5% were male. More than 50% of respondents were in practice for more than 20 years and 58.7% worked 25–40 hours per week. The mean knowledge scores were 4.5/8, 5.5/8, and 5.3/8 for CBLP, CHD, and PDN respectively. While 95% of respondents were aware of the increasing death rates due to opioid use, only half were familiar with the Canadian guideline for safe opioid prescribing for non-cancer use. Responses were compared based on gender, time in practice and location of practice. Pharmacists with more than ten years of experience scored significantly higher than those with less experience. Fewer differences were found in comparisons of gender and location of practice. Safe and effective care of chronic pain patients, particularly with opioids, will require additional pharmacist education.