Pharmacist Prescribing at Inpatient Discharge in Alberta

Background

Pharmacists in the province of Alberta may apply for additional prescribing authorization (APA), which allows them to independently prescribe medications. Currently, no literature exists about pharmacist prescribing for inpatients at the time of discharge.

Objectives

The primary objective was to report the proportion of patients for whom inpatient pharmacists with APA prescribed at discharge across Alberta, Canada. Secondary objectives were to describe discharge interventions other than prescribing that were provided, enablers of and barriers to discharge prescribing, and differences in discharge prescribing by facility or population type, clinical area, and health care charting system.

Methods

A descriptive, cross-sectional web-based survey of inpatient pharmacists with APA across Alberta was conducted over a 6-week period in early 2022.

Results

A total of 104 respondents met the inclusion criteria. Under half (45/102, 44.1%) of the participants reported prescribing at discharge. Those that reported prescribing at discharge did so for only a median 14.5% of their patients. The most common enabler of discharge prescribing was a supportive care team, and the most common barrier was the presence of other prescribers. Pharmacists who did not report prescribing at discharge selected "discomfort with being responsible for the prescription" and "fear of professional liability" as barriers more often than those who did report discharge prescribing (51.0% [26/51] vs 33.3% [13/39] and 43.1% [22/51] vs 25.6% [10/39], respectively). The proportion of pharmacists who reported prescribing at discharge was greater with increasing population/facility size (30% [6/20] of pharmacists in settings that served small populations vs 50% [29/58] of those in settings that served large populations).

Conclusions

Inpatient pharmacists who use APA at discharge reported prescribing for only a minority of patients, and discharge prescribing practices varied widely across the province. Future areas of research include how pharmacists can overcome barriers to prescribing at discharge.

Pharmacist intervention for glycaemic control in the community (the RxING study)

OBJECTIVE

To determine the effect of a community pharmacist prescribing intervention on glycaemic control in patients with poorly controlled type 2 diabetes.

DESIGN

Pragmatic, before-after design.

SETTING

12 community pharmacies in Alberta, Canada.

PARTICIPANTS

Type 2 diabetes receiving oral hypoglycaemic medications and with glycated haemoglobin (HbA1c) of 7.5-11%.

INTERVENTION

Pharmacists systematically identified potential candidates by inviting patients with type 2 diabetes to test their HbA1c using validated point-of-care technology. Pharmacists prescribed 10 units of insulin glargine at bedtime, adjusted by increments of 1 unit daily to achieve a morning fasting glucose of ≤5.5 mmol/L. The patients were followed up at 2, 4, 8, 14, 20 and 26 weeks.

PRIMARY OUTCOME

Change in HbA1c from baseline to week 26.

SECONDARY OUTCOMES

Proportion of patients achieving target HbA1c, changes in oral hypoglycaemic agents, quality of life and patient satisfaction, persistence on insulin glargine, number of insulin dosage adjustments per patient and number of hypoglycaemic episodes.

RESULTS

We screened 365 patients of whom 111 were eligible. Of those, 100 (90%) were enrolled in the study; all 11 patients who did not consent refused to use insulin. Average age was 64 years (SD 10.4), while average diabetes duration was 10.2 years (SD 7). HbA1c was reduced from 9.1% (SD 1) at baseline to 7.3% (SD 0.9); a change of 1.8% (95% CI 1.4 to 2, p<0.001). Fasting plasma glucose was reduced from 11 (SD 3.3) to 6.9 mmol/L (SD 1.8); a change of 4.1 mmol/L (95% CI of 3.3 to 5, p=0.007). Fifty-one per cent of the patients achieved the target HbA1c of ≤7% at the end of the study.

CONCLUSIONS

This is the first completed study of independent prescribing by pharmacists. Our results showed similar improvements in glycaemic control as previous physician-led studies. RxING provides further evidence for the benefit of pharmacist care in diabetes.

TRIAL REGISTRATION

clinicaltrials.gov; Identifier: NCT01335763.

Adverse events associated with paediatric use of complementary and alternative medicine: Results of a Canadian Paediatric Surveillance Program survey

BACKGROUND

Despite many studies confirming that the use of complementary and alternative medicine (CAM) by children is common, few have assessed related adverse events.

OBJECTIVE

To conduct a national survey to identify the frequency and severity of adverse events associated with paediatric CAM use.

METHODS

Survey questions were developed based on a review of relevant literature and consultation with content experts. In January 2006, the Canadian Paediatric Surveillance Program distributed the survey to all paediatricians and paediatric subspecialists in active practice in Canada.

RESULTS

Of the 2489 paediatricians who received the survey, 583 (23%) responded. Respondents reported that they asked patients about CAM use 38% of the time and that patients disclosed this information before being questioned only 22% of the time. Forty-two paediatricians (7%) reported seeing adverse events, most commonly involving natural health products, in the previous year. One hundred five paediatricians (18%) reported witnessing cases of delayed diagnosis or treatment (n=488) that they attributed to the use of CAM.

CONCLUSION

While serious adverse events associated with paediatric CAM appear to be rare, delays in diagnosis or treatment seem more common. Given the lack of paediatrician-patient discussion regarding CAM use, our findings may under-represent adverse events. A lack of reported adverse events should not be interpreted as a confirmation of safety. Active surveillance is required to accurately assess the incidence, nature and severity of paediatric CAM-related adverse events. Patient safety demands that paediatricians routinely inquire about the use of CAM.

Stories from the trenches: Experiences of Alberta pharmacists in obtaining additional prescribing authority

BACKGROUND

Pharmacists in Alberta can apply to the Alberta College of Pharmacists in order to obtain the designation of additional prescriber. This designation uniquely allows them to initiate therapy, in addition to other medication-related activities. Our objective was to examine specific experiences of pharmacists regarding the decision to apply and the application itself, and use this information to help inform other pharmacists who are considering additional prescribing.

METHODS

All pharmacists involved in a randomized, controlled trial being conducted in rural Alberta who had received their additional prescribing authorization (APA) were invited to participate. Pharmacists were contacted via e-mail and asked to respond to questions regarding their experiences in applying for APA. Responses were analyzed using content analysis and the identites of all respondents were kept anonymous.

RESULTS

Fourteen pharmacists were invited to participate. Review and examination of the responses revealed 3 main themes: motivation, hurdles and outcomes. Motivation can be understood as the reasons why they applied for their APA. Hurdles include any problems encountered of a personal, environmental or professional nature. Outcomes refer to how this designation has changed their practice.

DISCUSSION

Pharmacists had to address many factors that were unexpected during the application process; however, the eventual outcome of obtaining APA was deemed beneficial, both professionally and with regard to patient care.

CONCLUSION

The information shared from these pharmacists will help other pharmacists, regardless of jurisdiction, overcome some of the challenges associated with obtaining advanced prescribing privileges.

Improving asthma symptom control in rural communities: the design of the Better Respiratory Education and Asthma Treatment in Hinton and Edson study

METHODS

The prevalence of asthma in adults in the United States is approximately 7%, and 9% of asthma patients will require hospitalization each year. Many patients do not seek care, as they do not recognize overuse of beta-agonists as a risk factor for poorly controlled asthma. However, pharmacists are able to identify these patients through refill information on reliever medication prescriptions and potentially initiate community-management opportunities for these patients.

DESIGN

The study is a randomized, controlled trial. Patients are randomized to intervention or usual care.

STUDY POPULATION

Patients are high-risk asthma patients (defined as having an ER visit or hospitalization in the previous year, or using >2 canisters of short-acting beta-agonist in the previous 6 months). They are identified through community pharmacies.

OBJECTIVES

The primary objective is to determine the effect of an education and referral intervention program initiated by community pharmacists, working with high-risk asthma patients, family physicians and respiratory therapists, on asthma control, as measured by the Asthma Control Questionnaire (ACQ). Secondary objectives include determining the effect of this program on ER visits/hospitalizations, inhaled corticosteroid use, courses of oral steroids and FEV(1).

INTERVENTION

The intervention includes patient education, assessment and optimization of drug therapy, and physician referral as needed. Patients are referred to a respiratory therapist within 1 week of randomization for measurement of FEV(1) and reinforcement of education. Patients assigned to usual care receive written asthma information, referral to a respiratory therapist and usual pharmacy and physician care. UNIQUE ASPECTS: The design of the Better Respiratory Education and Asthma Treatment in Hinton and Edson (BREATHE) study is unique, given the multidisciplinary involvement, rural and community based, pharmacist initiated and targets specifically high risk patients. We believe that this study will show that management of asthma patients, involving the major role-players in their asthma care, will improve their asthma control.