Lisa McCarthy

Case‐crossover study design in pharmacoepidemiology: systematic review and recommendations

The purpose of this study is to systematically identify and review articles that use the case‐crossover study design in the area of pharmacoepidemiology.

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.

Canadian "minor ailments" programs: Unanswered questions.

Six Canadian provinces allow pharmacists to prescribe for ambulatory conditions (also sometimes referred to as “minor ailments”; see below). In 2007, Alberta became the first province to lay the legislative groundwork for a pharmacist-led ambulatory condition program (PACP) through its “Additional Prescribing Authority.”1,2 In 2011, Nova Scotia and Saskatchewan introduced their PACPs. In 2014, Manitoba, New Brunswick and Prince Edward Island followed suit.2–4 Most recently, British Columbia and Newfoundland have submitted proposals for PACPs.5,6 In Ontario, despite advocacy efforts by the Ontario Pharmacists Association (OPA) and support from the Ontario College of Pharmacists (OCP), prescribing for ambulatory conditions was not part of the 2012 scope of practice changes.3,7 The Health Professions Regulatory Advisory Council (HPRAC), responsible for the scope of practice changes, reported that pharmacists had the necessary training, but suggested a working group be formed to discuss possible frameworks.7 To date, this group has not been convened. This commentary highlights 5 controversies regarding Canadian pharmacist-led ambulatory conditions programs, all of which are important considerations for other jurisdictions moving forward with such programs.

Initial Cholinesterase Inhibitor Therapy Dose and Serious Events in Older Women and Men: Serious Events with Cholinesterase Inhibitor Therapy

To examine dose‐related prescribing and short‐term serious events associated with initiation of cholinesterase inhibitor (ChEI) therapy.

Lack of Evidence to Guide Deprescribing of Antihyperglycemics: A Systematic Review

IntroductionIndividualizing glycemic targets to goals of care and time to benefit in persons with type 2 diabetes is good practice, particularly in populations at risk of hypoglycemia and adverse outcomes relating to the use of antihyperglycemics. Guidelines acknowledge the need for relaxed targets in frail older adults, but there is little guidance on how to safely deprescribe (i.e. stop, reduce or substitute) antihyperglycemics.MethodsThe purpose of this study was to synthesize evidence from all studies evaluating the effects of deprescribing versus continuing antihyperglycemics in older adults with type 2 diabetes. To this end, we searched MEDLINE, EMBASE, and Cochrane Library (July 2015) for controlled studies evaluating the effects of deprescribing antihyperglycemics in adults with type 2 diabetes. All such studies were eligible for inclusion in our study, and two independent reviewers screened titles, abstracts and full-text articles, extracted data, and evaluated risk of bias. Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment and a narrative summary were completed.ResultsWe identified two controlled before-and-after studies, both of very low quality. One study found that an educational intervention decreased glyburide use while not compromising glucose control. The other reported that cessation of antihyperglycemics in elderly nursing home patients resulted in a non-significant increase in glycated hemoglobin (HbA1C). No significant change in hypoglycemia rate was found in the only study with this outcome measure.ConclusionsThere is limited evidence available regarding deprescribing antihyperglycemic medications. Adequately powered, high-quality studies, particularly in the elderly and with clinically important outcomes, are required to support evidence-based decision-making.Protocol registration numberCRD42015017748.

Deprescribing: Future directions for research

A World Café workshop was held at the Bruyère Evidence-Based Deprescribing Guidelines Symposium in March 2018 with 30 participants (researchers, clinicians, policy makers, stakeholders). This workshop explored priorities for future work in the field of deprescribing and deprescribing guidelines through group discussion. The discussions were guided by the following questions: (1) What are deprescribing research priorities (to inform guideline development), (2) What outcome measures are important for developing deprescribing guidelines, and (3) How do we evaluate the implementation and effectiveness of deprescribing guidelines? Discussion from all 3 questions identified 6 main priority areas: (1) conducting high-quality and long-term clinical trials that measure patient-important outcomes, (2) focusing on patient involvement and perspectives, (3) investigating the pharmacoeconomics of deprescribing interventions, (4) understanding deprescribing interventions in different populations, (5) generating evidence on clinical management during deprescribing (e.g. managing adverse drug withdrawal effects, subsequent re-prescribing), and (6) implementing interventions in clinical practice. These topics represent what a group of experienced researchers, clinicians, and stakeholders in the field collectively felt was important to consider for design and implementation of future deprescribing studies. The aim is for these findings to stimulate future discussions and be considered by granting agencies, policy makers, deprescribing research networks, and individual researchers planning future deprescribing studies.

Comparison of prescribing practices for older adults treated by female versus male physicians: A retrospective cohort study

Importance Subtle but important differences have been described in the way that male and female physicians care for their patients, with some evidence suggesting women are more likely to adhere to best practice recommendations. Objective To determine if male and female physicians differ in their prescribing practices as measured by the initiation of lower-than-recommended dose cholinesterase inhibitor (ChEI) drug therapy for dementia management. Design, setting, and participants All community-dwelling Ontario residents aged 66 years and older with dementia and newly dispensed an oral ChEI drug (donepezil, galantamine, or rivastigmine) between April 1, 2010 and June 30, 2016 were included. Main outcome and measures The association between physician sex and the initiation of a lower than recommended-dose ChEI was examined using generalized linear mixed regression models, adjusting for patient and physician characteristics. Data were stratified by specialty. Secondary analyses explored the association between physician sex and cardiac screening as well as shorter duration of the initial prescription. Results The analysis included 3,443 female and 5,811 male physicians and the majority (83%) were family physicians, Female physicians were more likely to initiate ChEI therapy at a lower-than-recommended dose (Adjusted odds ratio = 1.43,95% confidence interval = 1.17 to 1.74). Compared to their male counterparts, female physicians were also more likely to follow other conservative prescribing practices including cardiac screening (55.1% vs. 49.2%, P-value<0.001) around the time of ChEI initiation, and dispensing a shorter duration of initial prescription (41.8% vs 35.5% P-value<0.001). Conclusions There is a statistically significant and important difference in ChEI prescribing patterns between female and male physicians, suggesting that female physicians may be more careful and conservative in their approaches. This will inform future research to determine if patients receiving lower-than-recommended initial doses also have better outcomes.

Integrating medication samples into the traditional community pharmacy supply chain: a feasibility study

To assess the feasibility of a medication sampling program involving community pharmacists.

Prioritizing intraprofessional collaboration for optimal patient care: A call to action

Introduction Patients benefit when pharmacists work together. Studies have shown that increased collaboration between pharmacists across the care continuum of hospital, primary care and community practice settings results in improved patient health outcomes, reduced wait times and costs, and increased patient satisfaction and trust in their health care team. Patients suffer the consequences of miscommunication or missed communication between health care professionals. Patients report getting “mixed messages” from different sources, leading to frustration and confusion that can compromise understanding, motivation and adherence to treatment. Patients are more receptive to medical advice when they know that their health care team, including pharmacists, is working together to optimize their pharmacotherapy outcomes. Patients are not the only ones who desire collaboration. Pharmacists want and need access to patient information and other members of the health care team so they can optimize their contributions to patient care. The National Association of Pharmacy Regulatory Authorities (NAPRA) highlights the importance of collaboration in pharmacist practice. Standard 2 in the Model Standards of Practice for Canadian Pharmacists describes in detail the expectations for pharmacists to work respectfully, ethically and in a timely manner with colleagues to develop and maintain relationships for the benefit of patients. This standard applies not only to pharmacist collaboration with other health care professionals but also to pharmacist collaboration with other pharmacists. A parallel may be drawn with our physician colleagues who are expected to uphold professional standards to ensure safe and effective care of patients across family, hospital and specialty practice settings. Explicit guidelines for conducting referrals and consults are provided jointly by the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada. Despite the regulatory standards that exist and the general consensus that intraprofessional collaboration is a “good thing to do,” in our experience, the application of effective pharmacist-pharmacist collaboration from theory into practice is challenging.

Interprovincial Variation of Psychotropic Prescriptions Dispensed to Older Canadian Adults

Background Utilization of psychotropic medications among the elderly has garnered attention due to concerns about safety and degree of efficacy, but may be used differently across regions. Methods We conducted a cross-sectional study of all antipsychotic, benzodiazepine, and trazodone prescriptions dispensed to seniors ( ≥ 65 years) leveraging IQVIA (Durham, NC) GPM data in 2013. We report the units dispensed (per 100 seniors) by province. Results Nationally, on average, 26,210 units of antipsychotics, 24,257 of benzodiazepines, and 7,519 of trazodone were dispensed in 2013 for every 100 seniors; reports varied across Canada. The rate of antipsychotic and benzodiazepine prescribing was highest in New Brunswick (AP: 35,375 units per 100, BZD: 43,989 units per 100), and lowest in Newfoundland & Labrador for antipsychotics (20,974 per 100) and Saskatchewan for benzodiazepines (12,692 per 100). Trazodone unit dispensation rates were highest in Nova Scotia (9,164 per 100) and lowest in Newfoundland & Labrador (2,968 per 100). Conclusions There is considerable geographic variation in the prescribing patterns of antipsychotics, benzodiazepine, and trazodone. This study serves as the first step in understanding these differences, while future work is needed to develop region-specific strategies to optimize the prescribing of psychotropic medications to older Canadian adults.