Self-care and minor ailments: The view from Canada

This manuscript offers a glimpse into the Canadian healthcare system, emphasizing the prevalence and management of minor ailments through self-care practices. The first section outlines the strengths and challenges of the healthcare system, including access issues and escalating costs. The second section explores self-care in Canada, outlines the Self-Care Readiness Index, and Canadians' proactive management of common conditions through self-care activities, including the use of over-the-counter (OTC) medicines. Consumer behaviors, preferences, and the thriving OTC market are discussed. It also discusses existing programs and initiatives encouraging self-care. While lacking a coordinated national strategy, various organizations, including Health Canada, have taken steps to regulate and promote self-care products. The role of pharmacies, industry groups, and public health campaigns in fostering self-care is explored, along with public access to OTC medicines, Rx-to-OTC switching, and consumer expectations related to such medicines. Factors influencing self-care and self-medication are explored, focusing on access to medical care, public perceptions of OTC medicines, and the public's ability to engage in appropriate actions. The crucial role of pharmacists in minor ailment care is examined. Insights are provided into Canada's healthcare landscape, emphasizing the significance of self-care in managing minor ailments. The public has access to many resources on how to engage in self-care and deal with minor ailments, but a formal system to promote them is lacking. The findings prompt considerations for future healthcare policies and public health campaigns, highlighting the evolving nature of healthcare practices in the nation.

Major Shifts in Acid Suppression Drug Utilization After the 2019 Ranitidine Recalls in Canada and United States

BACKGROUND

Drug shortages are a complex global challenge, and few studies have analyzed quantitative data on their impacts. In September 2019, detection of a nitrosamine impurity in ranitidine led to recalls and shortages.

AIMS

We investigated the extent of the ranitidine shortage and its impacts on acid suppression drug utilization in Canada and the United States (US).

METHODS

We conducted an interrupted time series analysis of acid suppression drug purchases in Canada and the US from 2016 through 2021 using IQVIA's MIDAS database. We used autoregressive integrated moving average models to determine the impact of the shortage on purchasing rates for ranitidine, other histamine-2 receptor antagonists (H2RAs), and proton pump inhibitors (PPIs).

RESULTS

Prior to the recalls, 20,439,915 ranitidine units were purchased monthly in Canada and 189,038,496 in the US on average. After the recalls started in September 2019, purchasing rates decreased for ranitidine (Canada p = 0.0048, US p < 0.0001) and increased for non-ranitidine H2RAs (Canada p = 0.0192, US p = 0.0534). One month into the recalls, purchasing rates dropped by 99% (Canada) and 53% (US) for ranitidine and increased by 128.3% (Canada) and 37.3% (US) for non-ranitidine H2RAs. PPI purchasing rates did not change significantly in either country.

CONCLUSIONS

The ranitidine shortage led to immediate and sustained shifts in H2RA utilization in both countries, potentially affecting hundreds of thousands of patients. Our results emphasize the need for future studies of the clinical and financial implications of the shortage, and the importance of ongoing work to mitigate and prevent drug shortages.

Peripartum mental health and the role of the pharmacist: A scoping review

BACKGROUND

The global prevalence of peripartum mental illness is 20%, though estimates have increased since the start of the COVID-19 pandemic. Chronic illnesses affect one in five pregnancies and may be associated with higher rates of peripartum mental illness. Though pharmacists are well-positioned to facilitate appropriate and timely care of co-occurring mental and physical health conditions during this period, little is understood regarding their potential roles.

OBJECTIVES

To understand the current evidence examining the role of pharmacists to improve the outcomes of women with peripartum mental illness, with and without chronic illness.

METHODS

A scoping review was performed with assistance from an interdisciplinary team following the Joanna Briggs Institute framework. MEDLINE, Embase, PsychNet and International Pharmaceutical Abstracts databases were searched. English-language articles (published up to May 30, 2022) were screened and assessed for eligibility, and data were charted to collate results, by dual independent reviewers.

RESULTS

The search strategy produced 922 articles. After screening, 12 articles were included (5 narrative reviews, 7 primary research). There was limited discussion or empirical data regarding specific interventions (screening, counseling), opportunities (accessibility, managing stigma, forming trusting relationships and building rapport with patients) or barriers (lack of privacy, time constraints, adequate remuneration, training) associated with an expanded role of pharmacists in peripartum mental health care. The clinical complexity arising from co-occurring mental health and chronic illnesses was not explored, other than a small pilot study involving pharmacists screening for depression among pregnant women with diabetes.

CONCLUSIONS

This review highlights the limited evidence available on the explicit role of pharmacists in supporting women with peripartum mental illness, including those with comorbidity. More research, including pharmacists as study participants, is required to fully understand the potential roles, barriers, and facilitators of integrating pharmacists into peripartum mental healthcare to improve the outcomes of women in the peripartum period.

Pharmacists' knowledge, perceptions and practices regarding frailty: A cross-sectional survey across practice settings in Canada

Background

Data on Canadian pharmacists' knowledge and perceptions about frailty in older adults and its assessment in pharmacy practice are scarce.

Methods

A cross-sectional survey of 349 Canadian pharmacists was conducted to evaluate pharmacists' knowledge, perceptions and practices regarding frailty. Descriptive analyses summarized responses by practice setting, and a multivariable logistic regression model examined associations between respondent characteristics and the likelihood of assessing frailty.

Results

Most respondents were female (70%), aged ≤34 years (47%), Canadian graduates (83%), from Ontario/Quebec (51%) and from urban centres (58%). Although a significant proportion agreed it is important for pharmacists to know (80%) and assess (56%) patient frailty status, only 36% reported assessing frailty in practice. Respondents exclusively practising in a community pharmacy were significantly less likely to agree that it is important for a pharmacist to know or assess frailty status and to report assessing it. Factors associated with a greater likelihood of assessment included positive beliefs about the importance of knowing a patient's frailty status and having a greater proportion of older patients with cognitive or functional impairment in practice.

Discussion

Findings suggest that pharmacists generally agree with the importance of understanding frailty as it relates to the appropriate use of medications, but most do not assess it. Further research is needed to identify the barriers to assessing frailty, while guidance is needed on which of the available screening tools can best be integrated into a clinical pharmacy practice.

Conclusion

There is an opportunity to improve pharmaceutical care for older adults by providing pharmacists the means and resources to assess frailty in practice.

Prevalence of prescription and non-prescription polypharmacy by frailty and sex among middle-aged and older Canadians

BACKGROUND

Estimates of polypharmacy have primarily been derived from prescription claims, and less is known about the use of non-prescription medications (alone or in combination with prescription medications) across the frailty spectrum or by sex. Our objectives were to estimate the prevalence of polypharmacy (total, prescription, non-prescription, and concurrent prescription and non-prescription) overall, and by frailty, sex and broad age group.

DATA

Canadian Health Measures Survey, Cycle 5, 2016 to 2017.

METHODS

Among Canadians aged 40 to 79 years, all prescription and non-prescription medications used in the month prior to the survey were documented. Polypharmacy was defined as using five or more medications total (prescription and non-prescription), prescription only and non-prescription only. Concurrent prescription and non-prescription use was defined as two or more and three or more of each. Frailty was defined using a 31-item frailty index (FI) and categorized as non-frail (FI ≤ 0.1) and pre-frail or frail (FI > 0.1). Survey-weighted descriptive statistics were calculated overall and age standardized.

RESULTS

We analyzed 2,039 respondents, representing 16,638,026 Canadians (mean age of 56.9 years; 51% women). Overall, 52.4% (95% confidence interval [CI] = 47.3 to 57.4) were defined as pre-frail or frail. Age-standardized estimates of total polypharmacy, prescription polypharmacy and concurrent prescription and non-prescription medication use were significantly higher among pre-frail or frail versus non-frail adults (e.g., total polypharmacy: 64.1% versus 31.8%, respectively). Polypharmacy with non-prescription medications was common overall (20.5% [95% CI = 16.1 to 25.8]) and greater among women, but did not differ significantly by frailty.

INTERPRETATION

Polypharmacy and concurrent prescription and non-prescription medication use were common among Canadian adults, especially those who were pre-frail or frail. Our findings highlight the importance of considering non-prescribed medications when measuring the exposure to medications and the potential risk for adverse outcomes.

'Fitting in the pharmacist' - a qualitative analysis of the perceived relationship between community pharmacists and older adults with complex care needs

OBJECTIVES

To explore the current perceived relationship between older adults with varying levels of frailty and healthcare needs and community pharmacists.

METHODS

This qualitative study conducted a thematic analysis of focus groups with older adults and older adult caregivers and community pharmacist participants. Participants were recruited following a maximum variation sampling technique. Verbatim transcripts were inductively coded using NVivo to develop key findings.

KEY FINDINGS

Four major themes emerged: (i) Pharmacy Landscape, (ii) Prescription and Non-Prescription Drug Safety, (iii) Patient-Pharmacist Relationship and (iv) Recommendations for Pharmacy Practice. Themes demonstrate three key findings: (1) older adults approach drug information with a key focus on safety and cost of both prescription and non-prescription drugs, (2) there is a demonstrated opportunity, recognized by older adults and practitioners, for community pharmacists to expand their role in the care of older adults, (3) community pharmacists are able, interested and/or have already incorporated frailty assessments into their practice to better support their care of the older adult population with varying levels of frailty.

CONCLUSIONS

The results demonstrate a reason for the community pharmacist role to shift. The unique knowledge and skills of community pharmacists, coupled with their accessibility and strong patient-clinician relationship, have the potential to better support older adults with varying levels of frailty.

Economic evaluation of pharmacists prescribing for minor ailments in Ontario, Canada: a cost-minimization analysis

OBJECTIVES

The objective of this study was to use a decision-analytic model to examine the potential economic impact of establishing a remunerated programme for pharmacists prescribing for minor ailments (PPMA) in Ontario, Canada.

METHODS

A novel decision tool was developed to assess the economic impact of pharmacists prescribing for upper respiratory tract infections (URTIs), contact dermatitis (CD) and conjunctivitis by performing a cost-minimization analysis from a public payer perspective. Two prescribing strategies were compared: (1) PPMA, where patients may seek care from pharmacists or physicians, and (2) the usual care model (UCM), where all patients receive care from physicians. Two remuneration models for the PPMA strategy were also compared: (1) a prescription-detached scenario (PDS), where pharmacists were remunerated CAD$18.00 for each consultation, and (2) a Prescription-Attached Scenario (PAS), where pharmacists were only remunerated if a decision to prescribe was made.

KEY FINDINGS

At a service uptake rate of 38% for the PDS, the PPMA model led to savings of $7.51, $4.08 and $5.15 per patient for URTIs, CD and conjunctivitis, respectively. Per 30 000 patients, the PPMA model for these minor ailments was projected to lead to cumulative reductions in visits to the emergency department, family physician and walk-in clinics by 799, 3677 and 5090, respectively.

CONCLUSIONS

The results of the study strongly suggest that enabling community pharmacists to assess and prescribe for minor ailments could potentially lead to large savings for the government in Ontario, Canada. In 100% of the PAS scenarios simulated, pharmacists as prescribers led to cost savings.

Self-care education across Canadian pharmacy schools: Curriculum survey findings

Background

Self-care instruction in pharmacy curricula is essential given the impact pharmacists have in caring for patients in the community and their evolving role in this area. The primary objective of this study was to strengthen our current understanding of self-care education across undergraduate Canadian pharmacy programs.

Methods

A national curriculum survey and follow-up phone interview was conducted in 2019 to assess the quantity and quality of self-care instruction across Canadian pharmacy schools. Representatives were selected based on theirparticipation in the Association of Faculties of Pharmacy of Canada Self-Care Therapeutics and Minor Ailments special interest group.

Results

Responses were received from all 10 pharmacy schools in Canada. Self-care education varies across Canadian pharmacy curricula, reflecting differences in scopes of practice across provinces, topics of interest and availability of space within curricula by the various faculties. Specifically, there was considerable variability in the number of hours devoted to self-care education, course content and methods for integration and teaching.

Conclusions

Results of this study may help inform and evolve self-care curricula across the country. We argue that strategies for enhancing current programs may include establishing a minimum number of core hours and topics, expanding natural health product content and curricular content oversight by a lead faculty member. Can Pharm J (Ott) 2021;154:xx-xx.

An Infographic Assignment to Translate Self-Care Therapeutics into Practical Application

Innovation

An infographic assignment was developed and integrated into an advanced self-care therapeutics elective course in a School of Pharmacy to facilitate practical communication of dynamic and innovative approaches to patient care while supporting diversity in assessment.

Description

The 'Spotlight on Self-Care' assignment required pharmacy students to develop three infographic deliverables detailing comprehensive care for one minor ailment. The three deliverables were: 1) a magazine insert for healthcare professionals, 2) a patient-friendly handout, and 3) a pharmacists' companion practice tool. All deliverables were assessed by rubrics using consistent criteria, including: clinical content, logical presentation, research quality, visual elements and formatting. The five highest-scoring magazine inserts were offered publication in the Pharmacy Practice and Business Magazine after peer review.

Critical Appraisal

The submitted infographics put clinical content from the course into action by leveraging recent trends in effective communication. As an assessment, the infographic assignment recognized a unique profile of skills in the students that was statistically different from the profile of skills that was evaluated by the multiple-choice examinations. The key issues to address include reducing grading time requirements and developing strategies to detect copyrighted materials. Future investigations into the nature of the skills gained by the students through the exercise, as well as their perceptions regarding the professional value of the exercise, are important for refining the administration of this assignment.

Succinate dehydrogenase mutations: paraganglioma imaging and at-risk population screening

Paragangliomas are rare vascular tumours of the autonomic nervous system. They can be classified as sympathetic or parasympathetic. Sympathetic paragangliomas, which include phaeochromocytomas, tend to be functional and symptomatic. Parasympathetic paragangliomas are usually non-functional and may present with mass effect. Forty percent of paragangliomas are linked to genetic syndromes, most commonly due to mutations of the succinate dehydrogenase (SDH) enzyme complex and are collectively known as paraganglioma syndromes, of which five are described. Genetic testing is recommended for all patients, and their first-degree relatives, diagnosed with paragangliomas. When SDH mutations are discovered, biochemical screening and imaging surveillance is indicated. There is currently no consensus on imaging surveillance protocols. Most advocate full-body imaging, but the choice of technique and frequency varies. If paragangliomas are demonstrated, functional imaging to look for synchronous tumours or metastases is indicated. 2-[¹⁸F]-fluoro-2-deoxy-d-glucose (¹⁸F-FDG) positron-emission tomography (PET)-computed tomography (CT) is the technique of choice for metastatic evaluation, but [¹²³I]-metaiodobenzylguanidine or [¹¹¹In]-DTPA-octreotide scintigraphy are also utilised. Current research into emerging positron-emitting radiolabelled somatostatin analogues have yielded promising results, which is likely to be reflected in future guidelines. As genetic testing becomes increasingly prevalent, the need to answer the remaining questions regarding surveillance imaging is paramount.

Non-prescription proton-pump inhibitors for self-treating frequent heartburn: the role of the Canadian pharmacist

Heartburn and acid regurgitation are the cardinal symptoms of gastroesophageal reflux and occur commonly in the Canadian population. Multiple non-prescription treatment options are available for managing these symptoms, including antacids, alginates, histamine-H2 receptor antagonists (H2RAs), and proton-pump inhibitors (PPIs). As a result, pharmacists are ideally positioned to recommend appropriate treatment options based upon an individual’s needs and presenting symptoms, prior treatment response, comorbid medical conditions, and other relevant factors. Individuals who experience mild heartburn and/or have symptoms that occur predictably in response to known precipitating factors can manage their symptoms by avoiding known triggers and using on-demand antacids and/or alginates or lower-dose non-prescription H2RAs (e.g. ranitidine 150 mg). For those with moderate symptoms, lifestyle changes, in conjunction with higher-dose non-prescription H2RAs, may be effective. However, for individuals with moderate-to-severe symptoms that occur frequently (i.e. ≥2 days/week), the non-prescription (Schedule II) PPI omeprazole 20 mg should be considered. The pharmacist can provide important support by inquiring about the frequency and severity of symptoms, identifying an appropriate treatment option, and recognizing other potential causes of symptoms, as well as alarm features and atypical symptoms that would necessitate referral to a physician. After recommending an appropriate treatment, the pharmacist can provide instructions for its correct use. Additionally, the pharmacist should inquire about recurrences, respond to questions about adverse events, provide monitoring parameters, and counsel on when referral to a physician is warranted. Pharmacists are an essential resource for individuals experiencing heartburn; they play a crucial role in helping individuals make informed self-care decisions and educating them to ensure that therapy is used in an optimal, safe, and effective manner.