Patient perspectives on the vital primary care role of community pharmacists in Nova Scotia, Canada: qualitative findings from the PUPPY Study

OBJECTIVES

Community pharmacists play an important role in primary care access and delivery for all patients, including patients with a family physician or nurse practitioner ("attached") and patients without a family physician or nurse practitioner ("unattached"). During the COVID-19 pandemic, community pharmacists were accessible care providers for unattached patients and patients who had difficulty accessing their usual primary care providers ("semi-attached"). Before and during the pandemic, pharmacist services expanded in several Canadian provinces. The aim of this qualitative study was to explore patient experiences receiving care from community pharmacists, and their perspectives on the scope of practice of community pharmacists.

METHODS

Fifteen patients in Nova Scotia, Canada, were interviewed. Participant narratives pertaining to pharmacist care were analyzed thematically.

KEY FINDINGS

Attached, "semi-attached," and unattached patients valued community pharmacists as a cornerstone of care and sought pharmacists for a variety of health services, including triaging and system navigation. Patients spoke positively about expanding the scope of practice for community pharmacists, and better optimization of pharmacists in primary care.

CONCLUSIONS

System decision-makers should consider the positive role community pharmacists can play in achieving primary care across the Quintuple Aim (population health, patient and provider experiences, reducing costs, and supporting equity in health).

mRNA COVID-19 vaccine safety among older adults from the Canadian National Vaccine Safety Network

This study examined short-to-medium term safety of COVID-19 vaccines among adults aged ≥65 years using the Canadian National Vaccine Safety Network active safety surveillance data. Both vaccinated and unvaccinated older adult participants recruited from seven provinces and territories were included in the analysis. Safety was assessed at 7 days after COVID-19 vaccination (dose 1, 2 and 3), and 7 months after dose 1. Multivariable logistic regression was used to examine the association between BNT162b2/mRNA-1273 COVID-19 vaccines and two short-term health events: 1) health event preventing daily activities and/or required medical consultation, 2) serious health events resulting in an emergency department visit and/or hospitalization within 7 days following each dose. We also assessed the rates of serious health events for the period between dose 1 and 2, and 7-months following dose 1. Between December 2020 and February 2022, a total of 173,038, 104,452, and 13,970 older adults completed dose 1, dose 2, and dose 3 surveys, respectively. The control survey was completed by 2,955 unvaccinated older adults. Health events occurred more frequently among recipients after dose 2 homologous mRNA-1273 (adjusted odds ratio [95 % confidence interval]: 2.91 [2.24-3.79]) and dose two heterologous (BNT162b2 followed by mRNA-1273): 1.50 [1.12-2.02] compared to unvaccinated counterparts. There was no difference in event rates after any dose of BNT162b2 and unvaccinated participants. The rates of serious health events following COVID-19 vaccination were very low (≤0.3 %) across all vaccine products and doses, and were not higher compared to unvaccinated controls, and were not associated with an emergency department visit or hospitalization within 7 days following vaccination. Reported symptoms were self-limited and rarely required medical assessment. Our findings further strengthen the current evidence that mRNA COVID-19 vaccines are safe and can be used to inform older adults about expected adverse events following COVID-19 vaccination.

Corrigendum to "Uptake of community pharmacist prescribing over a three-year period" [Exploratory Research in Clinical and Social Pharmacy, Volume 9, March 2023, 100221]

[This corrects the article DOI: 10.1016/j.rcsop.2023.100221.].

Making it happen: Development of an interprofessional deprescribing education programme

Deprescribing is the planned and supervised reduction or discontinuation of medications that may be causing harm or are no longer benefiting a patient. The need for deprescribing to be a routine part of patient care is essential with an aging population and the rising prevalence of polypharmacy, which has been associated with increased adverse outcomes such as falls, hospitalizations and mortality. Deprescribing is a complex intervention that requires collaboration between the patient, caregivers and healthcare providers to adequately support all involved, as well as to ensure medications are not restarted in error. The objective of this article is to describe the stepwise approach to planning and ongoing development of an online, interprofessional deprescribing education programme for healthcare providers and students with the goal of enhancing deprescribing practice. There were four main planning and development components: (1) a needs assessment to provide guidance on programme design, development and delivery; (2) a consultative programme planning process with an advisory group of stakeholders and patient partners to inform programme learning outcomes and content; (3) a core development team for the creation of programme content; and (4) planning for programme evaluation. Based on the stepwise and consultative process, programme outcomes were identified, and five modules were developed.

Pharmacy student contribution to direct patient care during inpatient hospital experiential rotations: a scoping review

OBJECTIVES

The aim of this scoping review was to identify and characterise pharmacy students' contributions to extend pharmacist's direct patient care during inpatient hospital experiential rotations.

METHODS

A search of PubMed, Embase and CINAHL databases from 2000 to July 2021 was conducted. Articles were included if they involved pharmacy students during experiential rotations, described student's contribution to direct patient care in the inpatient hospital setting, and reported outcomes. Included articles were categorised according to clinical pharmacy key performance indicators (cpKPIs) and non-cpKPI care activities. Students' contributions to reported outcomes were extracted and summarised.

KEY FINDINGS

Thirty-six of 1182 identified articles were included which were either descriptive or quasi-experimental design. Studies reported student involvement in the delivery of single or multiple cpKPIs: medication reconciliation on admission (n = 13), pharmaceutical care (n = 13), interprofessional care rounds (n = 4), patient education during hospital stay (n = 6), medication reconciliation at discharge (n = 7) and patient education at discharge (n = 10). Eight studies reported student involvement in non-cpKPI activities, including clinical interventions (n = 5), clinical services (n = 2) and postdischarge follow-up (n = 1). Reported outcomes included service measure counts, process and clinical outcome measures.

SUMMARY

This review identified the contributions of pharmacy students in the provision of a range of direct patient care services and associated outcomes during experiential rotations in the inpatient hospital setting. Students delivering care as part of the pharmacy team as 'care extenders' has the potential to expose more patients to key pharmacist activities that have been linked to demonstrated positive outcomes.

Categorization of deprescribing communication tools: A scoping review

BACKGROUND

Deprescribing can be beneficial to a wide variety of patients but is often not done due to barriers including lack of time and challenges starting conversations.

OBJECTIVES

This study aimed to identify and broadly categorize existing deprescribing communication tools for clinicians and patients.

METHODS

Our scoping review protocol was based on the Arksey and O'Malley methods and incorporated the Levac and Joanna Briggs Institute recommendations. EMBASE, CINAHL, PsycINFO, MEDLINE, and grey literature were searched, with two independent reviewers assessing eligibility. A backwards search of the texts chosen for full text screen was completed. Two reviewers independently completed data extraction using a pre-specified data collection form.

FINDINGS

Databases identified 1121 results, searching of grey literature identified 49 results, and backwards searching identified 1323 results. After screening, 32 resources were included which contained 40 unique tools. Most tools were Canadian and targeted adults over 65 years old living in the community. Most tools had not been tested in the intended patient audience or evaluated for effectiveness.

DISCUSSION

Deprescribing tools have been developed to facilitate conversations by providing structure, education, and decision-making approaches. More research is needed to test the effectiveness of existing tools.

Environmental scan of current strategies to decrease sedative-hypnotic drug use and promote sleep in hospital patients

BACKGROUND

Sedative-hypnotic drugs are often initiated in hospital to manage insomnia and anxiety. Guidelines discourage their use, particularly in older adults, due to risks of falls, fractures, and delirium.

AIM

To identify publicly available resources to decrease the use of sedative-hypnotic drugs and promote sleep in hospital.

METHOD

An advanced Google search with 6 search strategies was conducted. Key websites were also identified and searched. Hospital- or community-based resources using non-pharmacologic measures to reduce sedative-hypnotic drug use and/or to promote sleep were included if they were publicly available in English within the past 5 years. Full text screening and data extraction was performed independently by 2 reviewers; a third reviewer resolved disagreements by consensus.

RESULTS

A total of 79 resources met inclusion criteria, with 65 (82.3%) providing education and 31 (39.2%) describing sleep hygiene strategies. Other resources included deprescribing (17, 21.5%), relaxation training (13, 16.5%), cognitive behavioural therapy for insomnia (9, 11.4%), and policies (7, 8.9%). The resources primarily targeted patients (59, 74.7%) followed by healthcare providers (9, 11.4%). There were 9 resources (11.4%) that applied to both community and hospital settings, and another 2 (2.5%) designed specifically for hospital.

CONCLUSION

Many resources were available to patients and healthcare providers to reduce inappropriate or ineffective use of sedative-hypnotic drugs and promote better sleep. Specific resources for the hospital setting were infrequent and recommended that clinicians stop hospital-initiated sedatives when patients are discharged. Identified resources can be adapted by healthcare organizations to develop sedative-hypnotic prescribing programs and policies.

Target users' acceptance of a pharmacist-led prescribing service for pre-exposure prophylaxis (PrEP) for human immunodeficiency virus (HIV)

Background

Pre-exposure prophylaxis (PrEP) for human immunodeficiency virus (HIV) is a highly effective way to reduce virus transmission. There have been increasing calls to improve access to PrEP in Canada. One way to improve access is by having more prescribers available. The objective of this study was to determine target users' acceptance of a PrEP-prescribing service by pharmacists in Nova Scotia.

Methods

A triangulation, mixed-methods study was conducted consisting of an online survey and qualitative interviews underpinned by the Theoretical Framework of Acceptability (TFA) constructs (affective attitude, burden, ethicality, intervention coherence, opportunity cost, perceived effectiveness and self-efficacy). Participants were those eligible for PrEP in Nova Scotia (men who have sex with men or transgender women, persons who inject drugs and HIV-negative individuals in serodiscordant relationships). Descriptive statistics and ordinal logistic regression were used to analyze survey data. Interview data were deductively coded according to each TFA construct and then inductively coded to determine themes within each construct.

Results

A total of 148 responses were captured by the survey, and 15 participants were interviewed. Participants supported pharmacists' prescribing PrEP across all TFA constructs from both survey and interview data. Identified concerns related to pharmacists' abilities to order and view lab results, pharmacists' knowledge and skills for sexual health and the potential for experiencing stigma within pharmacy settings.

Conclusion

A pharmacist-led PrEP-prescribing service is acceptable to eligible populations in Nova Scotia. The feasibility of PrEP prescribing by pharmacists should be pursued as an intervention to increase access to PrEP.

Emergency department utilization and hospital admissions for ambulatory care sensitive conditions among people seeking a primary care provider during the COVID-19 pandemic

BACKGROUND

Primary care attachment improves health care access and health outcomes, but many Canadians are unattached, seeking a provider via provincial wait-lists. This Nova Scotia-wide cohort study compares emergency department utilization and hospital admission associated with insufficient primary care management among patients on and off a provincial primary care wait-list, before and during the first waves of the COVID-19 pandemic.

METHODS

We linked wait-list and Nova Scotian administrative health data to describe people on and off wait-list, by quarter, between Jan. 1, 2017, and Dec. 24, 2020. We quantified emergency department utilization and ambulatory care sensitive condition (ACSC) hospital admission rates by wait-list status from physician claims and hospital admission data. We compared relative differences during the COVID-19 first and second waves with the previous year.

RESULTS

During the study period, 100 867 people in Nova Scotia (10.1% of the provincial population) were on the wait-list. Those on the wait-list had higher emergency department utilization and ACSC hospital admission. Emergency department utilization was higher overall for individuals aged 65 years and older, and females; lowest during the first 2 COVID-19 waves; and differed more by wait-list status for those younger than 65 years. Emergency department contacts and ACSC hospital admissions decreased during the COVID-19 pandemic relative to the previous year, and for emergency department utilization, this difference was more pronounced for those on the wait-list.

INTERPRETATION

People in Nova Scotia seeking primary care attachment via the provincial wait-list use hospital-based services more frequently than those not on the wait-list. Although both groups have had lower utilization during COVID-19, existing challenges to primary care access for those actively seeking a provider were further exacerbated during the initial waves of the pandemic. The degree to which forgone services produces downstream health burden remains in question.

A Proposed Curricular Framework for an Interprofessional Approach to Deprescribing

Deprescribing involves reducing or stopping medications that are causing more harm than good or are no longer needed. It is an important approach to managing polypharmacy, yet healthcare professionals identify many barriers. We present a proposed pre-licensure competency framework that describes essential knowledge, teaching strategies, and assessment protocols to promote interprofessional deprescribing skills. The framework considers how to involve patients and care partners in deprescribing decisions. An action plan and example curriculum mapping exercise are included to help educators assess their curricula, and select and implement these concepts and strategies within their programs to ensure learners graduate with competencies to manage increasingly complex medication regimens as people age.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-022-01704-9.

Adverse Events Following Immunization With mRNA and Viral Vector Vaccines in Individuals With Previous Severe Acute Respiratory Syndrome Coronavirus 2 Infection From the Canadian National Vaccine Safety Network

BACKGROUND

Adults previously infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) develop short-term immunity and may have increased reactogenicity to coronavirus disease 2019 (COVID-19) vaccines. This prospective, multicenter, active-surveillance cohort study examined the short-term safety of COVID-19 vaccines in adults with a prior history of SARS-CoV-2.

METHODS

Canadian adults vaccinated between 22 December 2020 and 27 November 2021 were sent an electronic questionnaire 7 days post-dose 1, dose 2, and dose 3 vaccination. The main outcome was health events occurring in the first 7 days after each vaccination that prevented daily activities, resulted in work absenteeism, or required a medical consultation, including hospitalization.

RESULTS

Among 684 998 vaccinated individuals, 2.6% (18 127/684 998) reported a prior history of SARS-CoV-2 infection a median of 4 (interquartile range: 2-6) months previously. After dose 1, individuals with moderate (bedridden) to severe (hospitalized) COVID-19 who received BNT162b2, mRNA-1273, or ChAdox1-S vaccines had higher odds of a health event preventing daily activities, resulting in work absenteeism or requiring medical consultation (adjusted odds ratio [95% confidence interval]: 3.96 [3.67-4.28] for BNT162b2, 5.01 [4.57-5.50] for mRNA-1273, and 1.84 [1.54-2.20] for ChAdox1-S compared with no infection). Following dose 2 and 3, the greater risk associated with previous infection was also present but was attenuated compared with dose 1. For all doses, the association was lower or absent after mild or asymptomatic infection.

CONCLUSIONS

Adults with moderate or severe previous SARS-CoV-2 infection were more likely to have a health event sufficient to impact routine activities or require medical assessment in the week following each vaccine dose.

The impact of the COVID-19 pandemic on primary care physicians and nurses in Nova Scotia: a qualitative exploratory study

BACKGROUND

The COVID-19 pandemic has brought immense disruption worldwide, dramatically altering the ways we live, work and learn on a day-to-day basis; however, few studies have investigated this from the perspective of primary care providers. In this study, we sought to explore the experiences of primary care providers in the province of Nova Scotia, with the intention of understanding the impact of the COVID-19 pandemic on primary care providers' ability to provide care, their information pathways, and the personal and professional impact of the pandemic.

METHODS

We conducted an exploratory qualitative research study involving semistructured interviews conducted via Zoom videoconferencing or telephone with primary care providers (physicians, nurse practitioners and family practice nurses) who self-identified as working in primary health care in Nova Scotia from June 2020 to April 2021. We performed a thematic analysis involving coding and classifying data according to themes. Emergent themes were then interpreted by seeking commonalties, divergence, relationships and overarching patterns in the data.

RESULTS

Twenty-four primary care providers were interviewed. Subsequent analysis identified 4 interrelated themes within the data: disruption to work-life balance, disruptions to "non-COVID-19" patient care, impact of provincial and centralized policies, and filtering and processing an influx of information.

INTERPRETATION

Our findings showed that managing a crisis of this magnitude requires coordination and new ways of working, balancing professional and personal life, and adapting to already implemented changes (i.e., virtual care). A specific primary care pandemic response plan is essential to mitigate the impact of future health care crises.

Uptake of community pharmacist prescribing over a three-year period

Objectives

Pharmacists in Nova Scotia have had legislated authority to prescribe since 2011. This study aimed to describe the prescribing activities of pharmacists and the characteristics of patients who used pharmacist prescribing services.

Methods

Using provincial health administrative databases we identified all community pharmacists who prescribed during the study period (October 2016 to March 2020) and correspondingly patients who had medications prescribed by a pharmacist during this period. Differences in, and predictors of the quantity of pharmacist prescribing over three fiscal years (April 2017 to March 2020) were described. Pharmacist prescribing activity was compared across the fiscal years of the study period with One-way Analysis of Variance. Negative binomial regression examined patient factors associated with use of pharmacist prescribing services. Analysis was carried out using SAS ENTERPRISE GUIDE v.8.2 (SAS Institute Cary, NC, USA).

Key findings

A total of 1182 pharmacist prescribers were identified, who on average prescribed 24.6, 26.3, and 32.5 (p < 0.001) times per month in fiscal years 2018, 2019, 2020, respectively. The patient cohort contained 372,203 Nova Scotians over the 3-year period. For approved common and minor ailment prescribing in Nova Scotia, gastroesophageal reflux disease, vaccines (non-travel), contraceptive management, herpes zoster treatment, and allergic rhinitis had the highest number of prescriptions over the study period. Patient factors most strongly related to receiving more prescribing services by a pharmacist included receiving income assistance without copay (Incidence rate ratio (IRR) = 1.70), having >2 comorbidities (IRR = 1.51), male sex (IRR = 1.03), and greater age (IRR = 1.01). Those from an urban area (IRR = 0.92) or having a higher income (IRR = 0.95) received fewer pharmacist prescribing services (all p < 0.0001).

Conclusions

Pharmacist prescribing increased over the 3-year period. Patients who were older and those with multiple comorbidities used pharmacist prescribing services most often. Prescribing activities represent an increasingly utilized role for pharmacists in primary care.

Community pharmacists’ acceptance of prescribing for pre-exposure prophylaxis (PrEP) for human immunodeficiency virus (HIV)

Background:

Pre-exposure prophylaxis (PrEP) for human immunodeficiency virus (HIV) prevention is highly effective. Pharmacists can increase PrEP accessibility through pharmacist prescribing. This study aimed to determine pharmacists’ acceptance of a pharmacist PrEP prescribing service in Nova Scotia.

Methods:

A triangulation mixed methods study consisting of an online survey and qualitative interviews was conducted with Nova Scotia community pharmacists. The survey questionnaire and qualitative interview guide were underpinned by the 7 constructs of the Theoretical Framework of Acceptability (affective attitude, burden, ethicality, opportunity costs, intervention coherence, perceived effectiveness and self-efficacy). Survey data were analyzed descriptively and with ordinal logistic regression to determine associations between variables. Interview transcripts were deductively coded according to the same constructs and then inductively coded to identify themes within each construct.

Results:

A total of 214 community pharmacists completed the survey, and 19 completed the interview. Pharmacists were positive about PrEP prescribing in the constructs of affective attitude (improved access), ethicality (benefits communities), intervention coherence (practice alignment) and self-efficacy (role). Pharmacists expressed concerns about burden (increased workload), opportunity costs (time to provide the service) and perceived effectiveness (education/training, public awareness, laboratory test ordering and reimbursement).

Conclusion:

A PrEP prescribing service has mixed acceptability to Nova Scotia pharmacists yet represents a model of service delivery to increase PrEP access to underserved populations. Future service development must consider pharmacists’ workload, education and training as well as factors relating to laboratory test ordering and reimbursement.

Community pharmacists' expanding roles in supporting patients before and during COVID-19: An exploratory qualitative study

BACKGROUND

Timely access and attachment to a primary healthcare provider is associated with better population health outcomes. In Canada, community pharmacists are highly accessible and patients struggling to access a family physician or nurse practitioner (i.e., "unattached") may seek care from a community pharmacist. Community pharmacists took on additional roles during the COVID-19 pandemic; however, little is known about how community pharmacists managed the needs of attached and unattached patients before and during the COVID-19 pandemic.

AIM

To describe Nova Scotian community pharmacists' roles in caring for unattached patients before and during the COVID-19 pandemic and identifying barriers and facilitators to optimizing patient access.

METHOD

Semi-structured interviews with community pharmacists (n = 11) across the province of Nova Scotia (Canada) were conducted.

RESULTS

Five key themes were noted: (1) rising pressure on pharmacists to meet unique health needs of attached and unattached patients; (2) what pharmacists have to offer (e.g., accessibility, trustworthiness); (3) positioning pharmacists in the system (e.g., how pharmacists can address gaps in primary healthcare); (4) pharmacist wellbeing; and, (5) recommendations for practice post-pandemic (e.g., maintain some policy changes made during the COVID-19 pandemic).

CONCLUSION

Before and during the pandemic, community pharmacists played a significant and increasing role providing care to patients, especially unattached patients. With growing numbers of unattached patients, it is vital that community pharmacists are supported to provide services to care for the health needs of patients.

Healthcare provider awareness, attitudes, beliefs, and behaviors regarding the role of pharmacists as immunizers

We explored perceptions of healthcare providers in Nova Scotia and New Brunswick about pharmacists as immunizers. Pharmacists' scopes of practice are increasingly broadening to include immunization, and providers and policymakers may find meaning in the lessons we learned. Invitations to participate in our online survey were circulated by professional associations, health authorities, and in social media posts. A total of 204 healthcare providers completed our survey, of whom 59.3% were pharmacists, 17.6% were nurses, and 23.0% were physicians. Nurses (30.6%) and physicians (34.0%) experienced fewer logistical barriers to immunizing compared to pharmacists, 71.1% of whom identified practice logistics as a determinant in offering vaccines to patients (p  < .001). Pharmacists were most supportive of the expansion of their own scope of practice to include the provision of vaccines to adults (95.9%) and children as young as five years (92.6%) compared to nurses (72.2% and 69.4%) and physicians (61.7% and 40.4%) (p  < .001). Diversity of opinion was evident even among pharmacists about whether they should be permitted to vaccinate children younger than five years. Nurse and physician respondents had lower odds of thinking pharmacists have enough training to vaccinate (p  < .001), that vaccines should be given in a pharmacy (p  < .001), and of supporting the expansion of pharmacists' scope of practice (p  < .001) than pharmacists did in the multivariable analyses. Pharmacists are well-positioned and willing to vaccinate and generally have support from their nurse and physician peers, but logistical challenges and interprofessional complexities persist as barriers to optimizing immunization by pharmacists.

Supporting Interprofessional Collaboration in Deprescribing: Needs Assessment for an Education Program

INTRODUCTION

: Deprescribing is a complex process involving patients and healthcare providers. The aim of the project was to examine the learning needs and preferences of healthcare providers and students to inform the development of an interprofessional deprescribing education program.

METHODS

: An online survey of pharmacists, nurses, nurse practitioners, family physicians, and associated students practicing or studying in Nova Scotia was conducted. Respondents were recruited by purposive and snowball sampling to have at least five respondents within each professional/student group. Questions captured participant's self-reported comfort level and professional role for 12 deprescribing tasks and their learning preferences.

RESULTS

: Sixty-nine respondents (46 healthcare providers and 23 students) completed the questionnaire. Average comfort levels for all 12 deprescribing tasks ranged from 40.22 to 78.90 of 100. Respondents reported their preferred deprescribing learning activities as watching videos and working through case studies. Healthcare providers preferred to learn asynchronously online, while students preferred a mix of online and in-person delivery.

DISCUSSION

: Learning needs related to deprescribing tasks and roles were identified, as well as preferences for format and delivery of education. Development of an education program that can provide a shared understanding of collaborative deprescribing tailored to learner preferences may improve deprescribing in practice.

Increased self-reported pharmacist prescribing during the COVID-19 pandemic: Using the Theoretical Domains Framework to identify barriers and facilitators to prescribing

Background

Community pharmacists are positioned to improve access to medications through their ever-expanding role as prescribers, with this role becoming more pronounced during the COVID-19 pandemic.

Objectives

Our research aimed to determine the extent of self-reported pharmacist prescribing pre-COVID-19 and during the COVID-19 pandemic, to identify barriers and facilitators to pharmacist prescribing, and to explore the relationship between these factors and self-reported prescribing activity.

Methods

A questionnaire based on the Theoretical Domains Framework (TDFv2) assessing self-reported prescribing was electronically distributed to all direct patient care pharmacists in NS (N = 1338) in July 2020. Wilcoxon signed-rank tests were used to examine temporal differences in self-reported prescribing activity. TDFv2 responses were descriptively reported as positive (agree/strongly agree), neutral (uncertain), and negative (strongly disagree/disagree) based on the 5-point Likert scale assessing barriers and facilitators to prescribing from March 2020 onward (i.e., ‘during’ COVID-19). Simple logistic regression was used to measure the relationship between TDFv2 domain responses and self-reported prescribing activity.

Results

A total of 190 pharmacists (14.2%) completed the survey. Over 98% of respondents reported prescribing at least once per month in any of the approved prescribing categories, with renewals being the most common activity reported. Since the pandemic, activity in several categories of prescribing significantly increased, including diagnosis supported by protocol (29.0% vs. 58.9%, p < 0.01), minor and common ailments (25.3% vs 34.7%, p = 0.03), preventative medicine (22.1% vs. 33.2%, p < 0.01). Amongst the TDFv2 domains, Beliefs about Consequences domain had the largest influence on prescribing activity (OR = 3.13, 95% CI 1.41–6.97, p < 0.01), with Social Influences (OR = 2.85, 95% CI 1.42–5.70, p < 0.01) being the next most influential.

Conclusion

Self-reported prescribing by direct patient care community pharmacists in Nova Scotia increased during the COVID-19 pandemic, particularly for government-funded services. Key barriers to address, and facilitators to support pharmacist prescribing were identified and can be used to inform future interventions.

Implementation of pharmacist-led deprescribing in collaborative primary care settings

In many jurisdictions pharmacists share prescribing responsibilities with other members of the primary care team. Responsibility for deprescribing, the healthcare professional supervised withdrawal of medications that are no longer needed, has not been assumed by a specific member of the primary care team. In this commentary we describe implementation of pharmacist-led deprescribing in collaborative primary care settings using the seven components of knowledge translation. Patient and stakeholder engagement shaped the deprescribing intervention. The intervention was implemented in three collaborative primary care clinics in two Canadian provinces. The evaluation included measures of medication appropriateness, patient satisfaction, and healthcare professional satisfaction. Pharmacist-led deprescribing in primary care was acceptable to both patients and healthcare professionals and demonstrated a reduction of medications deemed to confer more risk than benefit. Our findings support successes in pharmacist-led deprescribing. Future work is needed to understand how to successfully implement and evaluate pharmacist-led deprescribing more widely.

Barriers and Facilitators Related to Delivery of Hospital Pharmacy Services to Women, Children, and Their Families during a Pandemic: A Qualitative Study

Background

When the COVID-19 pandemic was declared in March 2020, health care professionals were challenged to adapt quickly and efficiently to change their work practices. However, an evidence-informed approach has not yet been used to systematically gather data on barriers and facilitators related to delivery of hospital pharmacy services in Canada.

Objectives

The primary objective was to identify and describe barriers and facilitators related to the delivery of hospital pharmacy services to women, children, and their families during the COVID-19 pandemic. The secondary objective was to provide recommendations for improvement in delivery of pharmacy services to enhance patient care during pandemics.

Methods

This qualitative study involved semistructured virtual interviews with pharmacists who worked in direct or nondirect patient care throughout the pandemic (since March 2020) at women's and/or children's hospitals in Canada. Individual interviews were completed virtually using conferencing software. An interview guide mapped to the Theoretical Domains Framework version 2 (TDFV2) was used to facilitate the interviews. Interviews were audio-recorded and transcribed verbatim by the principal investigator. Transcribed interviews were coded, mapped to the TDFV2, and analyzed using thematic analysis.

Results

Interviews were completed with 21 pharmacists in 7 provinces across Canada. Barriers and facilitators coded to the TDFV2 were grouped into 4 main themes: communication and collaboration, adaptability, health and well-being, and preparedness.

Conclusions

Participants highlighted a significant number of barriers that they experienced during the COVID-19 pandemic; overall, however, participants reported that they felt prepared for subsequent waves of the COVID-19 pandemic and future pandemics.

COVID-19 - an opportunity to improve access to primary care through organizational innovations? A qualitative multiple case study in Quebec and Nova Scotia (Canada)

Background

COVID-19 catalyzed a rapid and substantial reorganization of primary care, accelerating the spread of existing strategies and fostering a proliferation of innovations. Access to primary care is an essential component of a healthcare system, particularly during a pandemic. We describe organizational innovations aiming to improve access to primary care and related contextual changes during the first 18 months of the COVID-19 pandemic in two Canadian provinces, Quebec and Nova Scotia.

Methods

We conducted a multiple case study based on 63 semi-structured interviews (n = 33 in Quebec, n = 30 in Nova Scotia) conducted between October 2020 and May 2021 and 71 documents from both jurisdictions. We recruited a diverse range of provincial and regional stakeholders (e.g., policy-makers, decision-makers, family physicians, nurses) involved in reorganizing primary care during the COVID-19 pandemic using purposeful sampling (e.g., based on role, region). Interviews were transcribed verbatim and thematic analysis was conducted in NVivo12. Emerging results were discussed by team members to identify salient themes and organized into logic models.

Results

We identified and analyzed six organizational innovations. Four of these – centralized public online booking systems, centralized access centers for unattached patients, interim primary care clinics for unattached patients, and a community connector to health and social services for older adults – pre-dated COVID-19 but were accelerated by the pandemic context. The remaining two innovations were created to specifically address pandemic-related needs: COVID-19 hotlines and COVID-dedicated primary healthcare clinics.

Innovation spread and proliferation was influenced by several factors, such as a strengthened sense of community amongst providers, decreased patient demand at the beginning of the first wave, renewed policy and provider interest in population-wide access (versus attachment of patients only), suspended performance targets (e.g., continuity ≥80%) in Quebec, modality of care delivery, modified fee codes, and greater regional flexibility to implement tailored innovations.

Conclusion

COVID-19 accelerated the uptake and creation of organizational innovations to potentially improve access to primary healthcare, removing, at least temporarily, certain longstanding barriers. Many stakeholders believed this reorganization would have positive impacts on access to primary care after the pandemic. Further studies should analyze the effectiveness and sustainability of innovations adapted, developed, and implemented during the COVID-19 pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08140-w.

The Canadian National Vaccine Safety Network: surveillance of adverse events following immunisation among individuals immunised with the COVID-19 vaccine, a cohort study in Canada

INTRODUCTION

COVID-19 vaccines require enhanced safety monitoring after emergency approval. The Canadian National Vaccine Safety Network monitors the safety of COVID-19 vaccines and provides enhanced monitoring for healthy, auto-immune, immunocompromised, pregnant and breastfeeding populations and allows for the detection of safety signals.

METHODS AND ANALYSIS

Online participant reporting of health events in vaccinated and unvaccinated individuals 12 years of age and older is captured in three surveys: 1 week after dose 1, 1 week after dose 2 and 7 months after dose 1. Medically attended events are followed up by telephone. The number, percentage, rate per 10 000 and incident rate ratios with 95% CIs are calculated by health event, vaccine type, sex and in 10-year age groups.

ETHICS AND DISSEMINATION

Each study site has Research Ethics Board approvals for the project (UBC Children's & Women's, CIUSSS de l'Estrie-CHUS, Health PEI, Conjoint Health Research Ethics Board, University of Calgary and Alberta Health Services, IWK Health, Unity Health Toronto and CHU de Québec-Université Laval Research Ethics Boards). Individuals are invited to participate in this active surveillance and electronic consent is given before proceeding to each survey. Weekly reports are shared with public health and posted on the study website. At least one peer-reviewed manuscript is produced.

Using the behavior change wheel to link published deprescribing strategies to identified local primary healthcare needs

BACKGROUND

Polypharmacy is a major global problem. Evidence in primary care shows deprescribing can be beneficial. Behaviour change theories such as the Theoretical Domains Framework (TDF) and the Behaviour Change Wheel (BCW) can help develop successful implementation of deprescribing initiatives.

OBJECTIVES

To link locally identified deprescribing influencers with components of successfully trialed deprescribing strategies, with the aim of informing the development of local deprescribing initiatives.

METHODS

Two background studies were completed. A qualitative study of interviews and focus groups identified influencers of deprescribing from local primary care physicians, nurse practitioners, and pharmacists. Transcripts were coded using the TDF and mapped to the Intervention Functions of the BCW. A scoping review identified studies that investigated primary care deprescribing strategies, which were mapped to the BCW Intervention Functions and the Behaviour Change Techniques (BCTs). For this analysis, six main TDF domains from the qualitative study were linked to the BCTs identified in the scoping review through the Intervention Functions of the BCW.

RESULTS

Within the BCW component Capability, one TDF domain identified in the qualitative study, Memory, Attention and Decision Process, was linked to strategies like academic detailing from the scoping review. For the Opportunity component, two TDF domains, Social Influences and Environmental Context and Resources, were linked to strategies such as pharmacist medication reviews, providing patient information leaflets, and evidence-based deprescribing tools. For the Motivation component, three TDF domains, Social/Professional Role and Identity, Intentions, and Beliefs about Consequences, were linked to strategies such as sending deprescribing information to prescribers, using tools to identify eligible patients, and having patients report adverse events of medications.

CONCLUSIONS

This analysis identified deprescribing strategies that can be used to address influencers related to behaviour change from the perspective of primary care providers, and to assist with future deprescribing initiative development and implementation in the local context.

Interventions to reduce benzodiazepine and sedative-hypnotic drug use in acute care hospitals: A scoping review

BACKGROUND

Benzodiazepines and sedative-hypnotic drugs (BZD/SHD) are commonly utilized in the acute care setting for insomnia and anxiety and are associated with cognitive impairment, falls, and fractures. Interventions to reduce use of BZD/SHD in hospitals are not well characterized.

OBJECTIVE

The objective was to conduct a scoping review to identify and characterize interventions to reduce the use of BZD/SHD by adults in the acute care setting.

METHODS

English language studies and abstracts that described an intervention to reduce BZD/SHD in adult hospital patients were included. Six databases (PubMed, EMBASE, CINAHL, PsycINFO, Scopus, and Web of Science) were searched up to July 2018 and updated to February 3, 2021. The grey literature (Opengrey, Grey Matters, Google Advanced) was searched up to July 2018. Titles and abstracts were screened and full-text articles were reviewed and charted by three independent reviewers. Stakeholders were consulted to inform the scoping review and collect perspectives on the findings.

RESULTS

There were 13,046 records identified and 43 studies included. The most common study designs were uncontrolled before and after (23/43, 53.5%) and randomized controlled trials (7/43, 16.3%). The majority of studies tested a single intervention (32/43, 74.4%) such as education, deprescribing, relaxation training and sleep protocols. Patients were frequently the target of relaxation training and behavior change interventions; while sleep protocols, multifaceted interventions, education and deprescribing were usually directed at healthcare providers, either alone or in combination with patients. Most studies reported positive results in decreasing BZD/SHD use (27/43, 62.8%).

CONCLUSIONS

The scoping review found a variety of interventions to decrease the utilization of BZD/SHD in hospitals. Multifaceted interventions aimed at patients and healthcare providers that include a combination of education, sleep protocols, and deprescribing may support reductions in BZD/SHD use. Stakeholders also recommended policy and system changes such as computer alerts due to feasibility and workload.

Deprescribing interventions in primary health care mapped to the Behaviour Change Wheel: A scoping review

BACKGROUND

Polypharmacy and inappropriate medication use are an increasing concern. Deprescribing may improve medication use through planned and supervised dose reduction or stopping of medications. As most medication management occurs in primary health care, which is generally described as the first point of access for day-to-day care, deprescribing in primary health care is the focus on this review.

OBJECTIVE

This scoping review aimed to identify and characterize strategies for deprescribing in primary health care and map the strategies to the Behaviour Change Wheel (BCW).

METHODS

A scoping review was conducted that involved searches of six databases (2002-2018) and reference lists of relevant systematic reviews and included studies. Studies that described and evaluated deprescribing strategies in primary health care were eligible. Two independent reviewers screened articles and completed data charting with charting verified by a third. Deprescribing strategies were mapped to the intervention functions of the BCW and linked to specific Behaviour Change Techniques (BCT).

RESULTS

Searches yielded 6871 citations of which 43 were included. Nineteen studies were randomized, 24 were non-randomized. Studies evaluated deprescribing in terms of medication changes, feasibility, and prescriber/patient perspectives. Deprescribing strategies involved various professionals (physicians, pharmacists, nurses), as well as patients and were generally multifaceted. A wide range of intervention functions were identified, with 41 BCTs mapped to Environmental restructuring, 38 BCTs mapped to Enablement, and 34 BCTs mapped to Persuasion.

CONCLUSIONS

Deprescribing strategies in primary health care have used a variety of BCTs to address individual professionals (e.g. education) as well as strategies that addressed the practice setting, including support from additional team members (e.g. pharmacists, nurses and patients). Further research is warranted to determine comparative effectiveness of different BCTs, which can help facilitate implementation of deprescribing strategies, thereby reducing polypharmacy, in primary health care.

Point Prevalence Survey of Benzodiazepine and Sedative-Hypnotic Drug Use in Hospitalized Adult Patients

 ABSTRACTBackground: Benzodiazepines and sedative-hypnotic drugs (BZD/ SHDs), such as zopiclone and the antidepressant trazodone, pose risks such as falls, fractures, and confusion, especially for older adults. Use of these drugs in the acute care setting is poorly understood.Objectives: To determine the point prevalence and characteristics of use of BZD/SHDs in hospitals in Nova Scotia, Canada.Methods: A point prevalence survey was conducted for adults admitted to all hospitals with at least 30 acute care beds between May and August 2016. Drugs administered intravenously, patients in long-term care, and patients receiving mental health services, addiction treatment, or critical care were excluded. The proportion of included patients who had received a BZD/SHD within the 24 h before the start of the survey was determined. A descriptive statistical analysis was performed.Results: Overall BZD/SHD prevalence was 34.6% (487/1409) across the 16 eligible hospitals. The average age was 70.3 years, and 150 (30.8%) of the patients were 80 years or older. Among the 585 prescriptions for these patients, commonly used drugs were zopiclone (32.0%), lorazepam (21.9%), and trazodone (21.9%). The most common indications for use were bedtime/daytime sedation (60.0%) and anxiety (12.5%). More than half of the prescriptions (55.7%) had been initiated at home, 37.6% were started in hospital, and the place of initiation was unknown for 6.7%. Benzodiazepines were prescribed more frequently to patients under 65 years than those 80 years or older (41.3% versus 22.2%, p < 0.001) whereas trazodone was more frequently prescribed to the older of these 2 age groups (52.7% versus 14.3%, p < 0.001).Conclusions: BZD/SHDs were frequently used by hospitalized adult patients in Nova Scotia. Trazodone appears to have been substituted for benzodiazepines in the oldest age group. Pharmacists should direct their efforts toward preventing inappropriate initiation of BZD/SHDs in hospital, particularly for elderly patients.RÉSUMÉContexte : Les benzodiazépines et les médicaments sédatifs-hypnotiques (BZD/MSH), comme la zopiclone et l’antidépresseur trazodone, comportent des risques de chute, de fracture et de confusion, particulièrement chez les personnes âgées. Il existe une mauvaise compréhension de l’utilisation de ces médicaments dans un contexte de soins intensifs.Objectifs : Déterminer la prévalence ponctuelle et les caractéristiques de l’utilisation des BZD/MSH dans des hôpitaux en Nouvelle-Écosse, au Canada.Méthodes : Une enquête sur la prévalence ponctuelle a été menée entre mai et août 2016 auprès d’adultes admis dans les hôpitaux comptant au moins 30 lits en soins intensifs. Les patients recevant ces medicaments par voie intraveineuse, ceux en établissement de soins de longue durée, ceux recevant des services en santé mentale ou un traitement pour la toxicomanie ou encore ceux des soins intensifs ont été exclus de l’enquête. La détermination de la proportion des patients inclus dans l’étude portait sur ceux qui avaient reçu des BZD/MSH au cours des 24 h précédant le début de l’enquête, et elle a été suivie d’une analyse statistique descriptive.Résultats :De manière générale, l’usage des BZD/MSH s’élevait à 34,6 % (487/1409) dans les 16 hôpitaux participants. L’âge moyen des patients était de 70,3 ans et 150 (30,8 %) étaient âgés d’au moins 80 ans. Parmi les 585 prescriptions pour ces patients, les médicaments communément utilisés étaient la zopiclone (32,0 %), le lorazepam (21,9 %) et le trazodone (21,9 %). Les indications d’utilisation les plus répandues concernaient la sédation au coucher et en cours de journée (60 %) et l’anxiété (12,5 %). Plus de la moitié des prescriptions (55,7 %) ont commencé à domicile, 37,6 % ont commencé à l’hôpital, et le lieu du début de la prise de ces médicaments était inconnu dans 6,7 % des cas. La prescription des benzodiazépines s’adressait plus souvent aux patients de moins de 65 ans qu’à ceux d’au moins 80 ans (41,3 % par rapport à 22,2 %, p < 0,001), tandis que la prescription de trazodone s’adressait plus souvent aux personnes de la tranche d’âge plus avancée (52,7 % par rapport à 14,3 %, p < 0,001).Conclusions : Les BZD/MSH étaient fréquemment utilisés par les patients adultes hospitalisés en Nouvelle-Écosse. La trazodone semble avoir remplacé les benzodiazépines dans le groupe plus âgé. Les pharmaciens devraient orienter leurs efforts sur la prévention de la prise inappropriée des BZD/MSH en hôpital, particulièrement par les patients plus âgés.

2017/18 and 2018/19 seasonal influenza vaccine safety surveillance, Canadian National Vaccine Safety (CANVAS) Network

Background

The Canadian National Vaccine Safety (CANVAS) network monitors the safety of seasonal influenza vaccines in Canada.

Aim

To provide enhanced surveillance for seasonal influenza and pandemic influenza vaccines.

Methods

In 2017/18 and 2018/19 influenza seasons, adults (≥ 15 years of age) and parents of children vaccinated with the seasonal influenza vaccine participated in an observational study using web-based active surveillance. Participants completed an online survey for health events occurring in the first 7 days after vaccination. Participants who received the influenza vaccine in the previous season, but had not yet been vaccinated for the current season, were unvaccinated controls.

Results

In 2017/18, 43,751 participants and in 2018/19, 47,798 completed the online safety survey. In total, 957 of 30,173 participants vaccinated in 2017/18 (3.2%; 95% confidence interval (CI): 3.0–3.4) and 857 of 25,799 participants vaccinated in 2018/19 (3.3%; 95% CI: 3.1–3.5) reported a health problem of sufficient intensity to prevent their normal daily activities and/or cause them to seek medical care (including hospitalisation). This compared to 323 of 13,578 (2.4%; 95% CI: 2.1–2.6) and 544 of 21,999 (2.5%; 95% CI: 2.3–2.7) controls in each respective season. The event rate in vaccinated adults and children was higher than the background rate and was associated with specific influenza vaccines. The higher rate of events was associated with systemic symptoms and migraines/headaches.

Conclusion

In 2017/18 and 2018/19, higher rates of events were reported following seasonal influenza vaccination than in the pre-vaccination period. This signal was associated with several seasonal influenza vaccine products.

Influencers on deprescribing practice of primary healthcare providers in Nova Scotia: An examination using behavior change frameworks

Background:

Deprescribing is a complex process requiring consideration of behavior change theory to improve implementation and uptake.

Aim:

The aim of this study was to describe the knowledge, attitudes, beliefs, and behaviors that influence deprescribing for primary healthcare providers (family physicians, nurse practitioners (NPs), and pharmacists) within Nova Scotia using the Theoretical Domains Framework version 2 (TDF(v2)) and the Behavior Change Wheel.

Methods:

Interviews and focus groups were completed with primary care providers (physicians, NPs, and pharmacists) in Nova Scotia, Canada. Coding was completed using the TDF(v2) to identify the key influencers. Subdomain themes were also identified for the main TDF(v2) domains and results were then linked to the Behavior Change Wheel—Capability, Opportunity, and Motivation components.

Results:

Participants identified key influencers for deprescribing including areas related to Opportunity, within TDF(v2) domain Social Influences, such as patients and other healthcare providers, as well as Physical barriers (TDF(v2) domain Environmental Context and Resources), such as lack of time and reimbursement.

Conclusion:

Our results suggest that a systematic approach to deprescribing in primary care should be supported by opportunities for patient and healthcare provider collaborations, as well as practice and system level enhancements to support sustainability of deprescribing practices.

Point Prevalence Survey of Benzodiazepine and Sedative-Hypnotic Drug Use in Hospitalized Adult Patients

BACKGROUND

Benzodiazepines and sedative-hypnotic drugs (BZD/SHDs), such as zopiclone and the antidepressant trazodone, pose risks such as falls, fractures, and confusion, especially for older adults. Use of these drugs in the acute care setting is poorly understood.

OBJECTIVES

To determine the point prevalence and characteristics of use of BZD/SHDs in hospitals in Nova Scotia, Canada.

METHODS

A point prevalence survey was conducted for adults admitted to all hospitals with at least 30 acute care beds between May and August 2016. Drugs administered intravenously, patients in long-term care, and patients receiving mental health services, addiction treatment, or critical care were excluded. The proportion of included patients who had received a BZD/SHD within the 24 h before the start of the survey was determined. A descriptive statistical analysis was performed.

RESULTS

Overall BZD/SHD prevalence was 34.6% (487/1409) across the 16 eligible hospitals. The average age was 70.3 years, and 150 (30.8%) of the patients were 80 years or older. Among the 585 prescriptions for these patients, commonly used drugs were zopiclone (32.0%), lorazepam (21.9%), and trazodone (21.9%). The most common indications for use were bedtime/daytime sedation (60.0%) and anxiety (12.5%). More than half of the prescriptions (55.7%) had been initiated at home, 37.6% were started in hospital, and the place of initiation was unknown for 6.7%. Benzodiazepines were prescribed more frequently to patients under 65 years than those 80 years or older (41.3% versus 22.2%, p < 0.001) whereas trazodone was more frequently prescribed to the older of these 2 age groups (52.7% versus 14.3%, p < 0.001).

CONCLUSIONS

BZD/SHDs were frequently used by hospitalized adult patients in Nova Scotia. Trazodone appears to have been substituted for benzodiazepines in the oldest age group. Pharmacists should direct their efforts toward preventing inappropriate initiation of BZD/SHDs in hospital, particularly for elderly patients.

Evaluation of the experiences and needs of users of a drug information resources website

Objective

This article describes the evaluation of the experiences and needs of users of the Drug Information Resources (DIR) website. The DIR website attracts traffic and use from around the world, with the highest number of users in Canada and the United States.

Methods

An online questionnaire was developed through use of a literature review and Google Analytics data. Face validity testing and test-retest reliability were completed prior to releasing the questionnaire.

Results

Although the Google Analytics data showed that the site is used internationally, most respondents were Canadian students. They used the site for academic and clinical purposes and reported it was easy to use, was well organized, and included required resources, and they would recommend it to others.

Conclusion

The DIR website was found to be a valuable resource for educational and clinical use. Future studies will aim to obtain input from international users.

Medication-related criteria in frailty assessment tools: A narrative review

OBJECTIVE

To review medication-related criteria within validated frailty tools.

METHODS

Narrative review of validated frailty assessment tools. Frailty tools were identified from recently published reviews; each tool was reviewed to determine whether any medication-related criteria were included and how these criteria contributed to the scoring/assessment of frailty.

RESULTS

Eight out of 16 validated frailty tools included medication-related criteria. The majority of criteria were a numerical cut-off of number of medications taken; however, the specific cut-off was not consistent.

CONCLUSION

Inclusion of medication-related criteria in frailty tools is highly variable. Future research is required to determine whether incorporation of medication use into frailty assessment can impact outcomes in terms of frailty prevention and treatment.

Pharmacists' immunization experiences, beliefs, and attitudes in New Brunswick, Canada

Background:

The expansion of pharmacist scope of practice to include provision of immunizations has occurred or is being considered in various countries. There are limited data evaluating the experiences of Canadian pharmacists in their role as immunizers.

Objective:

To describe the experiences of pharmacists in the Canadian province of New Brunswick as immunizers, including vaccines administered and perceived barriers and facilitators to providing immunizations.

Methods:

An anonymous, self-administered, web-based questionnaire was offered via email by the New Brunswick Pharmacists’ Association to all its members. The survey tool was adapted, with permission, from a tool previously used by the American Pharmacists Association and validated using content validity and test-retest reproducibility. Pharmacist reported immunization activities and perceived facilitators and barriers to providing immunization services were assessed.

Results:

Responses from 168 (response rate of 26%) were evaluable. Approximately 90% of respondents worked in community practice full time, 65% were female and 44% were practicing for 20 or more years. Greater than 75% reported administering: hepatitis A and B, influenza, and zoster vaccines. The majority of respondents felt fully accepted (agreed or strongly agreed) as immunization providers by patients, local physicians, and the provincial health department (97%, 70%, and 78%, respectively). Most commonly reported barriers were: lack of a universally funded influenza immunization program, insufficient staffing and space, and concerns around reimbursement for services.

Conclusions:

Pharmacists in New Brunswick, Canada are actively participating in the provision of a variety of immunizations and felt fully supported by patients and other healthcare providers. Barriers identified may provide insight to other jurisdictions considering expanding the role of pharmacists as immunizers.

Knowledge, attitudes, behaviours, and beliefs of healthcare provider students regarding mandatory influenza vaccination

Influenza infection poses the same risk to healthcare students as to practising clinicians. While there is substantial dialog about the benefits, risks, and ethics of mandatory influenza immunization policies in Canada, there has been little engagement of healthcare students. To explore the knowledge, attitudes, beliefs, and behaviours of healthcare students, we administered a web-based survey to students at Dalhousie University. Influenza vaccination status varied by program type, with 86.3% of medical students (n = 124) and 52.4% of nursing students (n = 96) self-reporting receipt of the influenza vaccine both in the previous and current seasons; pharmacy students' coverage fell between the two. Pharmacy students had higher mean knowledge scores (10.0 out of 13 questions) than medical (9.26) and nursing (8.88) students. Between 56.1% and 64.5% of students across disciplines were in support of a mandatory masking or vaccination policy, and between 72.6% and 82.3% of students would comply if such a policy were in place. A sense of duty to be immunized, desire to be taught more about influenza and influenza vaccine, belief that the hospital has a right to know vaccination status, support for declination policy, and willingness to accept consequences of noncompliance were all predictors of student support of mandatory policies. Medical and pharmacy students tended to hold more pro-influenza vaccination attitudes, had higher knowledge scores, and better vaccine coverage than nursing students. Based on the overall vaccination behaviour, knowledge, beliefs, and attitudes of students surveyed, this study demonstrates that mandatory influenza immunization policies are generally supported by the next generation of practitioners.

Evaluation of the impact of immunization policies, including the addition of pharmacists as immunizers, on influenza vaccination coverage in Nova Scotia, Canada: 2006 to 2016

Background

Influenza is a serious public health concern, resulting in morbidity, mortality and significant expense to healthcare systems worldwide. Annual vaccination is the most effective way to prevent influenza. The National Advisory Committee on Immunization in Canada recommends that everyone six months of age and older without contraindications should be vaccinated. The Canadian province of Nova Scotia implemented a publicly-funded universal influenza vaccination program in the 2010–2011 influenza season. In 2013, pharmacists in Nova Scotia gained the authority to provide a variety of vaccinations, including the publicly-funded influenza vaccine. This study aimed to investigate any changes in influenza vaccine coverage following the implementation of each policy change: 1) universal publicly-funded program and 2) universal publicly-funded program with the addition of pharmacists.

Methods

Influenza seasons evaluated were from 2006-2007 to 2015–2016. Coverage was estimated by examining Nova Scotia census data with aggregate immunization administration data, including the total number of vaccinations administered according to vaccine provider (physician, public health or pharmacist), geographic region, vaccine recipient age and year.

Results

The analysis showed an increase in influenza vaccine coverage immediately following the implementation of the two studied policy changes. Vaccine coverage increased from 36.4 to 38% following the implementation of the universally funded vaccine policy. Following the implementation of pharmacists as immunizers, coverage increased from 35.7 to 41.7%. Vaccine coverage was highest in those 65 years of age and older during all years evaluated. Physicians provided the highest proportion of vaccines during all study periods, however a decreasing trend through all periods was observed. Physicians proportionately provided more vaccines in urban areas; whereas pharmacist and public health immunization providers in rural areas provided proportionately more vaccinations than their urban counterparts.

Conclusions

The addition of a universally funded vaccination policy and the addition of pharmacists as providers of the influenza vaccine resulted in increases in vaccine coverage initially. Additional research is needed to determine the long-term impacts of the policy changes on vaccination coverage and to identify other important factors affecting vaccine uptake.

Patient experiences with influenza immunizations administered by pharmacists

Influenza vaccination is the most effective way to reduce influenza infection and related complications. Unfortunately, vaccination coverage remains suboptimal. The addition of pharmacists as immunizers may assist in improving vaccine coverage. The experiences of patients who have received influenza vaccines from pharmacists is an important consideration for jurisdictions considering the addition of pharmacists as immunizers. We describe the reported experiences of recipients of influenza vaccinations by pharmacists in the community pharmacy setting in Nova Scotia, Canada. During the 2013-2014 influenza season, a paper-based quality assurance questionnaire was provided to interested vaccine recipients to assess their previous vaccination experiences and current experience at the pharmacy. More than 6,500 vaccine recipients completed questionnaires. The majority of respondents cited convenience as a main reason for receiving the vaccine in the pharmacy, with 50% indicating the service was better in the pharmacy and another 40% that the service was as good as elsewhere. Respondents also reported a positive environment in the pharmacy (e.g., less stressful, less exposure to sick people) as well as professionalism and knowledge of the pharmacists. Areas for improvement identified included better communication around the paperwork required (e.g., consent forms) and the wait time post-vaccination. This evaluation demonstrated that people who chose to be vaccinated by community pharmacists reported positive experiences and convenience was the primary factor for selecting a pharmacy as the site for vaccination.

Impact of pharmacists as immunizers on influenza vaccination coverage in the community-setting in Nova Scotia, Canada: 2013-2015

BACKGROUND

Annual immunization is the most effective way to prevent influenza and its associated complications. However, optimal immunization rates are not being met in Nova Scotia, Canada. Additional providers, such as pharmacists, may improve access and convenience to receive vaccines. Pharmacists began immunizing patients 5 years of age and older within the publicly funded universal influenza vaccination program during the 2013-2014 influenza season. The objective of this study was to evaluate influenza immunization coverage rates before and after pharmacists in Nova Scotia gained authority to immunize as part of the publicly funded universal influenza vaccination program.

METHODS

Influenza immunization data was obtained from the Department of Health and Wellness from 2010 to 2015. Data included billing data from physicians and pharmacists, and local public health data. Vaccination coverage was calculated as proportion of vaccinations received in comparison to the total population.

RESULTS

Prior to pharmacists immunizing, overall vaccination coverage for Nova Scotia residents 6 months of age and older was 35.8 % in 2012-2013, increasing to 41.8 % coverage in 2013-2014 the year pharmacists began immunizing. A decrease of 1.9 to 39.9 % was observed in 2014-2015. In patients 65 years of age and older living in the community, coverage has increased from 61.8 % in 2012-2013 to 71.6 % in 2013-2014, and again to 73.3 % in 2014-2015 with the addition of pharmacists immunizing. Prior to pharmacists immunizing the highest coverage noted for this portion of the population was 61.8 %.

CONCLUSIONS

The addition of pharmacists as immunizers within a publicly funded universal influenza vaccination program was found to increase overall vaccination coverage in the first year and to maintain higher coverage rates in the second year than those observed before pharmacists began immunizing. Increases in coverage in both years were observed in the elderly. Future research will be required to determine the ongoing impact of the addition of pharmacists as immunizers and other strategies to improve vaccination coverage.

Impact of pharmacists as immunizers on vaccination rates: A systematic review and meta-analysis

BACKGROUND

Underutilization of vaccination programs remains a significant public health concern. Pharmacists serve as educators, facilitators, and in some jurisdictions, as administrators of vaccines. Though pharmacists have been involved with immunizations in various ways for many years, there has yet to be a systematic review assessing the impact of pharmacists as immunizers in these three roles.

OBJECTIVE

To complete a systematic review of the literature on the impact of pharmacists as educators, facilitators, and administrators of vaccines on immunization rates.

METHODS

We identified 2825 articles searching the following databases from inception until October 2015: PubMed, EMBASE, Cochrane Libraries, Cumulative Index to Nursing and Allied Health Literature, International Pharmaceutical Abstracts, Google Scholar. Grey literature was identified through use of the Canadian Agency for Drugs and Technology in Health "Grey Matters" search tool. Content from relevant journals and references of included studies were also searched. Inclusion criteria were clinical or epidemiologic studies in which pharmacists were involved in the immunization process. Studies were excluded if no comparator was reported. Two reviewers independently completed data extraction and bias assessments using standardized forms.

RESULTS

Thirty-six studies were included in the review, 22 assessed the role of pharmacists as educators and/or facilitators and 14 assessed their role as administrators of vaccines. All studies reviewed found an increase in vaccine coverage when pharmacists were involved in the immunization process, regardless of role (educator, facilitator, administrator) or vaccine administered (e.g., influenza, pneumococcal), when compared to vaccine provision by traditional providers without pharmacist involvement. Limitations of the results include the large number of non-randomized trials and the heterogeneity between study designs.

CONCLUSIONS

Pharmacist involvement in immunization, whether as educators, facilitators, or administrators of vaccines, resulted in increased uptake of immunizations. PROSPERO Registration: CRD42013005067.

Impact of pharmacists as immunizers on influenza vaccination coverage in Nova Scotia, Canada

Immunization coverage in Canada has continued to fall below national goals. The addition of pharmacists as immunizers may increase immunization coverage. This study aimed to compare estimated influenza vaccine coverage before and after pharmacists began administering publicly funded influenza immunizations in Nova Scotia, Canada. Vaccination coverage rates and recipient demographics for the influenza vaccination seasons 2010-2011 to 2012-2013 were compared with the 2013-2014 season, the first year pharmacists provided immunizations. In 2013-2014, the vaccination coverage rate for those ≥5 years of age increased 6%, from 36% in 2012-2013 to 42% (p<0.001). Pharmacists administered over 78,000 influenza vaccinations, nearly 9% of the province's population over the age of five. Influenza vaccine coverage rates for those ≥65 increased by 9.8% (p<0.001) in 2013-2014 compared to 2012-2013. Influenza vaccination coverage in Nova Scotia increased in 2013-2014 compared to previous years with a universal influenza program. Various factors may have contributed to the increased coverage, including the addition of pharmacists as immunizers and media coverage of influenza related fatalities. Future research will be necessary to fully determine the impact of pharmacists as immunizers.