Pilot randomized controlled trial of a program to enhance experience and adherence with adjuvant endocrine therapy among women with non-metastatic breast cancer: 12-month quantitative results

PURPOSE

Adjuvant endocrine therapy (AET) reduces recurrence risk after hormone receptor-positive breast cancer, but non-adherence is common. We pilot-tested SOIE, a program to enhance AET experience and adherence, to assess its acceptability, feasibility, and effects on psychosocial precursors of AET adherence.

METHODS

We conducted a 12-month pilot randomized controlled trial among women who had a first AET prescription. Intervention group received SOIE while control group received usual care. Psychosocial factors from the Theory of Planned Behavior (TPB) (intention - primary outcome -, attitude, subjective norm, behavioral control), additional constructs (AET knowledge, social support, coping planning), impact of AET services received, and adherence were measured by questionnaires at baseline, 3-month, and 12-month endpoints. Group patterns were compared using repeated measures analyses with generalized estimating equations.

RESULTS

A total of 106 women were randomized (participation = 54.9%; intervention n = 52; control n = 54; retention = 93.8%). Among SOIE women, ≥ 90% received the program components and were satisfied. Both groups scored high on adherence intentions and group patterns over time were not statistically different. In the intervention group, AET knowledge and coping planning with side effects increased (group-by-time p-value = .002 and .016), a higher proportion reported that AET services received helped them take their AET (p < .05) and have a consistent daily intake (p = .01).

CONCLUSION

SOIE is feasible and acceptable for survivors with an AET. SOIE did not significantly impact adherence intentions but was beneficial for other program outcomes and daily intake.

IMPLICATIONS FOR CANCER SURVIVORS

SOIE may represent an encouraging avenue to enhance supportive care and empower survivors with managing AET.

Pain relief and associated factors: a cross-sectional observational web-based study in a Quebec cohort of persons living with chronic pain

Objectives

Randomized clinical trials are used to evaluate the efficacy of various pain treatments individually, while a limited number of observational studies have portrayed the overall relief experienced by persons living with chronic pain. This study aimed to describe pain relief in real-world clinical settings and to identify associated factors.

Methods

This exploratory web-based cross-sectional study used data from 1,419 persons recruited in the community. Overall pain relief brought by treatments used by participants was assessed using a 0%-100% scale (10-unit increments).

Results

A total of 18.2% of participants reported minimal pain relief (0%-20%), 60.0% moderate to substantial pain relief (30%-60%), and 21.8% extensive pain relief (70%-100%). Multivariable multinomial regression analysis revealed factors significantly associated with greater pain relief, including reporting a stressful event as circumstances surrounding the onset of pain, living with pain for ≥10 years, milder pain intensity, less catastrophic thinking, use of prescribed pain medications, use of nonpharmacological pain treatments, access to a trusted healthcare professional, higher general health scores, and polypharmacy. Factors associated with lower pain relief included surgery as circumstances surrounding pain onset, use of over-the-counter pain medications, and severe psychological distress.

Discussion

In this community sample of persons living with chronic pain, 8 out of 10 persons reported experiencing at least moderate relief with their treatment. The analysis has enabled us to explore potential modifiable factors as opportunities for improving the well-being of persons living with chronic pain.

Changing society, changing research: integrating gender to better understand physical and psychological treatments use in chronic pain management

ABSTRACT

Treatment of chronic pain should be multimodal and include pharmacological, physical, and psychological treatments. However, because various barriers to physical and psychological treatments (PPTs) exist, a better understanding of biopsychosocial factors leading to their use is relevant. This study aimed to explore the association between gender identity, gender-stereotyped personality traits, and the use of PPTs in chronic pain management. The ChrOnic Pain trEatment cohort, a self-reported data infrastructure resulting from a web-based recruitment of 1935 people living with chronic pain (Quebec, Canada) was analyzed. Gender identity was operationalized as women, men, and nonbinary. Gender-stereotyped personality traits were measured using the Bem Sex-Role Inventory (feminine, masculine, androgynous, undifferentiated). A checklist of 31 types of PPTs that can be used for chronic pain management was presented to participants (yes/no). From the 1433 participants, 85.5% reported using at least one PPT. Hot-cold therapies (43.4%), exercise (41.9%), and meditation (35.2%) were the most frequently used PPTs, but most popular PPTs were not the same among women and men. Women reported a significantly higher use of PPTs in general (87.2% vs 77.2%; P < 0.001). Multivariable and interaction analyses showed that identifying as a man decreased the odds of reporting the use of PPTs (odds ratio: 0.32, 95% confidence interval: 0.11-0.92) but only among participants who scored high on both masculine and feminine personality traits (those classified as androgynous). The high prevalence of PPTs use found in our study is positive. Our results are relevant for a more personalized promotion of PPTs for chronic pain management.

Where we live matters: a comparison of chronic pain treatment between remote and non-remote regions of Quebec, Canada

Objective

Where a person lives is a recognized socioeconomic determinant of health and influences healthcare access. This study aimed to compare the pain treatment profile of persons with chronic pain (CP) living in remote regions to those living in non-remote regions (near or in major urban centers).

Methods

A cross-sectional study was performed among persons living with CP across Quebec. In a web-based questionnaire, participants were asked to report in which of the 17 administrative regions they were living (six considered "remote"). Pain treatment profile was drawn up using seven variables: use of prescribed pain medications, over-the-counter pain medications, non-pharmacological pain treatments, multimodal approach, access to a trusted healthcare professional for pain management, excessive polypharmacy (≥10 medications), and use of cannabis for pain.

Results

1,399 participants completed the questionnaire (women: 83.4%, mean age: 50 years, living in remote regions: 23.8%). As compared to persons living in remote regions, those living in non-remote regions were more likely to report using prescribed pain medications (83.8% vs. 67.4%), a multimodal approach (81.5% vs. 75.5%), experience excessive polypharmacy (28.1% vs. 19.1%), and report using cannabis for pain (33.1% vs. 20.7%) (bivariable p < 0.05). Only the use of prescribed medications as well as cannabis remained significantly associated with the region of residence in the multivariable models.

Discussion

There are differences in treatment profiles of persons with CP depending on the region they live. Our results highlight the importance of considering remoteness, and not only rurality, when it comes to better understanding the determinants of pain management.

The Medication Quantification Scale 4.0: An Updated Index Based on Prescribers' Perceptions of the Risk Associated With Chronic Pain Medications

To quantify risks associated with drug utilization in the real world for the treatment of chronic pain (CP), an index called the Medication Quantification Scale (MQS) was developed in 1992 in the United States and last updated in 2003. This study aimed to update, adapt to the contemporary Canadian context, and validate a revised version of the MQS (the MQS-4.0). Step 1: An expert committee adapted the MQS to the Canadian clinical practice context. Step 2: An update of risk weights given to medication subclasses was achieved using a prescriber survey (weights were derived from median 0-10 scores given to each subclass). Step 3: Construct validity of the MQS-4.0 was assessed after applying risk weights to the medication use profile of persons living with CP covered by public drug insurance plan. Thirty-six medication subclasses were included in the MQS-4.0. A total of 207 prescribers (physicians, pharmacists, and nurse practitioners) participated in the perception survey; 10.63% identified as pain specialists. When risk weights were applied to prescription claims (n = 9,122), the MQS-4.0 score was associated (P < .05) with the MQS-III score and variables associated with polypharmacy (eg, Charlson Comorbidity Index, number of prescribers or health care visits). This study provides an updated index intended for adult populations based on prescribers' perceptions of the risk associated with CP medications that can be useful for clinical practice and research among persons living with CP in Canada. It will, however, be relevant to verify whether similar risk weights are obtained in future pain specialist surveys. PERSPECTIVE: The MQS-4.0 is an update of the MQS used for quantifying the risk associated with the use of analgesics/coanalgesics. Adequate psychometrics properties were found.

Relationship Between Diet Quality and Glucose-Lowering Medication Intensity Among Adults With Type 2 Diabetes: Results From the CARTaGENE Cohort

Background

In real-world settings, whether diet and medication are used as complements for glycemic management in type 2 diabetes (T2D) remains unclear. This study assessed the relationship between diet quality and intensity of glucose-lowering medication among adults with T2D.

Methods

This cross-sectional study included 352 adults with T2D from the CARTaGENE Québec population-based cohort. Diet quality was assessed using the Healthful Plant-Based Diet Index (hPDI). Glucose-lowering medication intensity was graded according to self-reported information on the type and number of drugs: no medication; oral monotherapy; oral polytherapy; and insulin with and without oral medication. In the subsample of 239 individuals who reported the medication dosages, intensity was also graded using the Medication Effect Score (MES).

Results

In multivariable-adjusted models, we found no evidence of a relationship between the hPDI and medication intensity, assessed using the categorical approach (Pbetween-group = 0.25) or the MES (P = 0.43). However, the hPDI was inversely associated with the MES among men < 50 years of age and women < 60 years (β1-point MES = -2.24 [95% confidence interval, -4.46, -0.02] hPDI points), but not among older individuals (β = -0.03 [-1.28, 1.21] hPDI points). Evidence of a nonsignificant inverse relationship between the hPDI and HbA1c was observed (β10-point hPDI = -0.23% [-0.63, 0.17]), whereas a positive and significant association between the MES and hemoglobin (Hb)A1c was found (β1-point MES = 0.30% [0.10, 0.51]).

Conclusions

In this cohort of adults with T2D, there was an overall lack of complementarity between diet quality and intensity of glucose-lowering medication. The issue was particularly important among younger adults for whom diet quality was inversely associated with intensity of medication.

Health care system costs related to potentially inappropriate medication use involving opioids in older adults in Canada

BACKGROUND

Older adults are at risk of potentially inappropriate medication use given polypharmacy, multimorbidity, and age-related changes, which contribute to the growing burden associated with opioid use. The objective of this study was to estimate the costs of health service utilization attributable to opioid use and potentially inappropriate medication use involving opioids in older adults in a public health care system.

METHODS

The sample included 1201 older adults consulting in primary care, covered by the public drug plan, without a cancer diagnosis and opioid use in the year before interview. Secondary analyses were conducted using two data sources: health survey and provincial administrative data. Health system costs included inpatient and outpatient visits, physician billing, and medication costs. Unit costs were calculated using annual financial and activity reports from 2013-2014, adjusted to 2022 Canadian dollars. Opioid use and potentially inappropriate medication use involving opioids were identified over 3 years. Generalized linear models with gamma distribution were employed to model 3-year costs associated with opioid use and potentially inappropriate medication use involving opioids. A phase-based approach was implemented to provide descriptive results on the costs associated with each phase: i) no use, ii) opioid use, and iii) potentially inappropriate medication use involving opioids.

RESULTS

Opioid use and potentially inappropriate medication use involving opioids were associated with adjusted 3-year costs of $2,222 (95% CI: $1,179-$3,264) and $8,987 (95% CI: $7,370-$10,605), respectively, compared to no use. In phase-based analyses, costs were the highest during inappropriate use.

CONCLUSIONS

Potentially inappropriate medication use involving opioids is associated with higher costs compared to those observed with opioid use and no use. There is a need for more effective use of health care resources to reduce costs for the health care system.

Educational needs and preferences of adult patients with acute or chronic pain: a mixed methods systematic review protocol

OBJECTIVES

This review will aim to synthesize the available quantitative and qualitative evidence on the educational needs and preferences of adult patients with acute or chronic pain.

INTRODUCTION

Acute and chronic pain are prevalent problems and are associated with significant individual and societal consequences. Education is a critical component of pain management. However, the impact of educational interventions on pain outcomes remains limited. The lack of patient input--what patients want to know and how they want to be informed--is one of the main issues underlying intervention design.

INCLUSION CRITERIA

We will include qualitative, quantitative, and mixed methods studies describing the educational needs and preferences of adult patients with acute or chronic pain.

METHODS

This review will follow the JBI guidelines for mixed methods systematic reviews. We will search MEDLINE (PubMed), Embase (Ovid), PsycINFO (Ovid), CINAHL (EBSCO), the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and ProQuest Dissertations and Theses. The search strategy will commence from the year 1990 onward and there will be no language restrictions. The retrieved titles, abstracts, and full-text reports will be screened by pairs of independent reviewers. These pairs of reviewers will also independently extract data using the JBI tools for mixed methods systematic reviews. Methodological quality will be assessed using the mixed methods appraisal tool. A convergent integrated approach to synthesis and integration of the quantitative and qualitative data will be used.

REVIEW REGISTRATION

PROSPERO CRD42022303834.

Experiences and Perceptions of Medical Cannabis among People Living with Chronic Pain and Community Pharmacists: A Qualitative Study in Canada

Background

The use of cannabis to treat chronic pain is under debate despite high expectations from patients. Qualitative data obtained by exploring both patients' and health professionals' perspectives are scarce.

Aims

This study aimed to understand the experiences and perceptions of people living with chronic pain and community pharmacists regarding the role of cannabis in chronic pain treatment in the Canadian context where both medical and recreational cannabis are legal.

Methods

We conducted 12 online focus groups (July 2020-February 2021) with 26 patients and 19 community pharmacists using semistructured discussion guides. All discussions were audio recorded and transcribed verbatim were analyzed using a reflexive thematic approach.

Results

We developed three themes related to patients' perspectives and three themes related to pharmacists' perspectives. Patients' perspectives included (1) cannabis as an alternative to other pain medications, (2) a new treatment with potential health-related risks, and (3) a therapy rather than a recreational drug. Pharmacists' perspectives included (1) challenges in monitoring drug interactions with cannabis in the context of scarce research data, (2) informing and treating patients self-medicating with cannabis amid its growing popularity, and (3) financial costs and legal constraints for patients.

Conclusions

This study highlights patients' and pharmacists' urgent need for reliable information regarding the benefits and risks of cannabis. Training tailored to pharmacists' needs and evidence-based information for patients should be developed to support pharmacists' practice, improve patients' experiences, and promote safe cannabis use.

Polypharmacy and Excessive Polypharmacy Among Persons Living with Chronic Pain: A Cross-Sectional Study on the Prevalence and Associated Factors

Purpose

Polypharmacy can be defined as the concomitant use of ≥5 medications and excessive polypharmacy, as the use of ≥10 medications. Objectives were to (1) assess the prevalence of polypharmacy and excessive polypharmacy among persons living with chronic pain, and (2) identify sociodemographic and clinical factors associated with excessive polypharmacy.

Patients and Methods

This cross-sectional study used data from 1342 persons from the ChrOnic Pain trEatment (COPE) Cohort (Quebec, Canada). The self-reported number of medications currently used by participants (regardless of whether they were prescribed or taken over-the-counter, or were used for treating pain or other health issues) was categorized to assess polypharmacy and excessive polypharmacy.

Results

Participants reported using an average of 6 medications (median: 5). The prevalence of polypharmacy was 71.4% (95% CI: 69.0-73.8) and excessive polypharmacy was 25.9% (95% CI: 23.6-28.3). No significant differences were found across gender identity groups. Multivariable logistic regression revealed that factors associated with greater chances of reporting excessive polypharmacy (vs <10 medications) included being born in Canada, using prescribed pain medications, and reporting greater pain intensity (0-10) or pain relief from currently used pain treatments (0-100%). Factors associated with lower chances of excessive polypharmacy were using physical and psychological pain treatments, reporting better general health/physical functioning, considering pain to be terrible/feeling like it will never get better, and being employed.

Conclusion

Polypharmacy is the rule rather than the exception among persons living with chronic pain. Close monitoring and evaluation of the different medications used are important for all persons, especially those with limited access to care.

Pain Medications Used by Persons Living With Fibromyalgia: A Comparison Between the Profile of a Quebec Sample and Clinical Practice Guidelines

Background

Pharmacological management of fibromyalgia is complex. Chronic pain management is characterized by off-label prescribing and use, multimorbidity, and polypharmacy.

Aims

This study aimed to describe pain medications use and perceived risk among people living with fibromyalgia and compare this use to evidence-based recommendations.

Methods

Directive telephone interviews were conducted with 63 individuals self-reporting a diagnosis of fibromyalgia (Quebec, Canada). The questionnaire addressed specific questions about their pain and pharmacological treatments currently used for pain management (prescribed and over-the-counter). Collected data were compared to the Canadian Fibromyalgia Clinical Practice Guidelines and to evidence reports published by recognized organizations.

Results

Despite a lack of robust scientific evidence to support opioids use to manage pain in fibromyalgia, 33% of our sample reported using them. Nonsteroidal anti-inflammatory drugs were used by 54.0% of participants, although this medication is not recommended due to lack of efficacy. Tramadol, which is recommended, was used by 23.8% of participants. Among the medications strongly recommended, anticonvulsants were used by 36.5%, serotonin norepinephrine reuptake inhibitor antidepressants by 55.6%, and tricyclic antidepressants by 22.2%. Cannabinoids (17.5%) and medical cannabis (34.9%) use were also reported. For all of these medication subclasses, no differences were found between participants not reporting (n = 35) or reporting (n = 28) more than one pain diagnosis (P < 0.05). Medication subclasses considered most at risk of adverse effects by participants were the least used.

Conclusions

Results reveal discordance between evidence-based recommendations and medications use, which highlights the complexity of pharmacological treatment of fibromyalgia.

Trends in Prescription Chronic Pain Medication Use before and during the First Wave of the COVID-19 Pandemic in Québec, Canada: An Interrupted Time Series Analysis

BACKGROUND

In Canada, a state of health emergency was declared in May 2020 as a result of the COVID-19 pandemic. This study aimed to assess trends in the use of prescription medication for pain management by people living with chronic pain before and during the first wave of the pandemic.

METHODS

Participants (n = 177) were adults reporting chronic pain who had completed a web-based questionnaire in 2019 and for whom complete longitudinal private and public insurance prescription claims were available. The monthly prevalence of medication use for nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and prescribed cannabinoids was assessed. An interrupted time series analysis was then performed to evaluate if the COVID-19 pandemic had had an impact on trends in pain medication use.

RESULTS

The beginning of the first wave of the pandemic was associated with the onset of a downward trend in opioid use (p < 0.05); no such association was found regarding NSAIDs. However, point prevalence of opioid use at the beginning (Nov. 2019) and at the end (Mai 2020) of the study period remained somewhat stable (17.0% vs. 16.4%). Regarding prescribed cannabinoids, a gradual increase in use was observed over the entire study period independently from the impact of the first wave of the pandemic (15.3% vs. 22.6%, p < 0.05).

CONCLUSION

While the occurrence of the first wave did have an impact on opioid use among people living with chronic pain, access to and use of opioids appear to have returned to normal before the end of the first wave of COVID-19.

Are Lipid-Lowering and Antihypertensive Medications Used as Complements to Heart-Healthy Diets? A Scoping Review

In cardiovascular disease (CVD) prevention, whether antihypertensive and lipid-lowering medications are used as complements to heart-healthy diets has not been thoroughly assessed. This scoping review aimed to 1) analyze observational studies that assessed the relationship between diet and antihypertensive/lipid-lowering medication use and 2) evaluate whether medication was used as a complement to heart-healthy dietary intakes. We searched MEDLINE, Embase, Web of Science, and CINAHL through 14 January, 2023, for studies that assessed either 1) intraindividual changes in diet associated with lipid-lowering/antihypertensive medication initiation or use or 2) interindividual differences in diet between users and nonusers of these medications. A total of 17 studies were included. Of those, 3 prospectively assessed the intraindividual changes in diet associated with medication initiation or use, but none documented potential changes in diet prior to medication initiation. The 14 other studies compared dietary intakes of medication users and nonusers, most of which also relied on an incomplete assessment of the temporal dynamics between diet and medication use as they employed cross-sectional (n = 12) or repeated cross-sectional (n = 2) designs. Data from 8 studies, including 4 of the 5 studies from Europe, suggested that medication was used as a complement to heart-healthy diets, whereas data from the 9 other studies, including the 4 conducted in the United States, provided no such evidence, indicating potential between-country differences in this relationship. Finally, no studies investigated how the dynamics between diet and medication use influenced the long-term CVD risk. This scoping review suggests that the current literature on the relationship between lipid-lowering/antihypertensive medication use and diet provides an incomplete perspective on how medication may influence diet in CVD prevention. Prospective studies assessing intraindividual changes in diet associated with medication initiation and use and how these dynamics influence the CVD risk are thus needed.

Changes in self-rated physical and mental health and life satisfaction associated with opioid and potentially inappropriate opioid prescribing in primary care older adults

OBJECTIVE

To examine changes in life satisfaction and physical and mental health associated with opioid and potentially inappropriate opioid prescribing (PIOP) among older adults.

METHODS

Secondary data analysis from the Étude sur la Santé des Aînés (ESA)-Services study. The sample consisted of 945 older adults recruited in primary care with available health survey information linked to administrative medical record data. The exposure of interest was categorized as no prescription, opioid prescription, and PIOP, defined using the Beers criteria. Outcomes were self-rated physical health, mental health, and life satisfaction measured at baseline and at a 3-year follow-up. Generalized estimating equations were used to examine 3-year changes in outcomes as a function of opioid prescribing. Analyses were adjusted for covariates relating to health, psychosocial, and sociodemographic factors as well as duration/frequency of opioid prescribing. Analyses were conducted in the overall sample and in non-cancer patients.

RESULTS

The sample had an average age of 73.1 years; the majority was Canadian-born (96.3%) while females made up over half (55.4%) the sample. Compared to not receiving an opioid prescription, PIOP was associated with a deterioration in physical health (ORadjusted = 0.65; 95%CI = 0.49, 0.86), but not mental health and life satisfaction. In non-cancer patients, PIOP was associated with poorer physical health (ORadjusted = 0.59; 95%CI = 0.40, 0.87) and opioid prescribing was marginally associated with improved life satisfaction (ORadjusted = 1.58; 95%CI = 0.96, 2.60).

CONCLUSION

PIOP was associated with a deterioration in physical health. Patient-centred chronic pain management and the effect on health and well-being require further study in older adults.

Strategies to prevent long-term opioid use following trauma: a Canadian practice survey

PURPOSE

To evaluate how Canadian clinicians involved in trauma patient care and prescribing opioids perceive the use and effectiveness of strategies to prevent long-term opioid therapy following trauma. Barriers and facilitators to the implementation of these strategies were also assessed.

METHODS

We conducted a web-based cross-sectional survey. Potential participants were identified by trauma program managers and directors of the targeted departments in three Canadian provinces. We designed our questionnaire using standard health survey research methods. The questionnaire was administered between April 2021 and November 2021.

RESULTS

Our response rate was 47% (350/744), and 52% (181/350) of participants completed the entire survey. Most respondents (71%, 129/181) worked in teaching hospitals. Multimodal analgesia (93%, 240/257), nonsteroidal anti-inflammatory agents (77%, 198/257), and physical stimulation (75%, 193/257) were the strategies perceived to be the most frequently used. Several preventive strategies were perceived to be very effective by over 80% of respondents. Of these, some that were reported as not being frequently used were perceived to be among the most effective ones, including guidelines or protocols, assessing risk factors for opioid misuse, physical health follow-up by a professional, training for clinicians, patient education, and prescription monitoring systems. Staff shortages, time constraints, and organizational practices were identified as the main barriers to the implementation of the highest ranked preventive strategies.

CONCLUSIONS

Several strategies to prevent long-term opioid therapy following trauma are perceived as being effective by those prescribing opioids in this population. Some of these strategies appear to be commonly used in everyday practice and others less so. Future research should focus on which preventive strategies should be given higher priority for implementation before assessing their effectiveness.

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.

Interprofessional Collaboration and Team Effectiveness of Pharmacists in General Practice: A Cross-National Survey

As team-based care continues to evolve, pharmacists have been included in general practice teams in many countries, to varying extents, to improve medication use and patient safety. However, evidence on interprofessional collaboration and team effectiveness of pharmacists in general practice is sparse. This study aimed to compare the extent of interprofessional collaboration and team effectiveness of general practice pharmacists in Australia with international sites (Canada and the UK), and identify the factors associated with interprofessional collaboration and team effectiveness. General practice pharmacists from Australia, Canada, and the UK were identified through professional organisations and networks, and invited to participate in an online survey, adapted from existing validated tools. The survey explored interprofessional collaboration through four sub-domains (professional interactions, relationship initiation, trust and role clarity, and commitment to collaboration) and team effectiveness of general practice pharmacists. Of the 101 respondents (26 from Australia, 44 from Canada and 31 from the UK), 79% were female and 78% were aged below 50 years. Interprofessional collaboration and team effectiveness appeared to be high and similar between countries. Total scores for collaboration of pharmacists were 86.1 ± 7.4 in Australia, 88.5 ± 7.5 in the UK, and 89.1 ± 7.3 in Canada (mean ± SD, where higher scores represent more advanced collaboration), while the team effectiveness scores of the pharmacists were 88.6 ± 14.6 in Canada, 91.8 ± 14.6 in Australia and 97.5 ± 14.0 in the UK. Pharmacists who had worked in general practice for a longer time showed advanced interprofessional collaboration while those who worked exclusively in general practice had higher scores for team effectiveness. Overall, general practice pharmacists in the three countries were highly collaborative with general practitioners. Long-term employment and longer work hours could enhance interprofessional collaboration and team effectiveness in general practice pharmacists by improving trust and working relationships over time.

French-Canadian Translation and Cultural Adaptation of the Clinical Opiate Withdrawal Scale: The COWS-FC

OBJECTIVE

The main objective of the present study was to develop a French-Canadian translation and adaptation of the COWS (i.e., the COWS-FC) for the assessment of opioid withdrawal symptoms in clinical and research settings.

METHODS

The French-Canadian translation and cultural adaptation of the COWS was performed following guidelines for the translation and cross-cultural adaptation of self-report measures. The steps consisted of (1) initial translation from English to French, (2) synthesis of the translation, (3) back-translation from French to English, (4) expert committee meeting, (5) test of the prefinal version among healthcare professionals and (6) review of final version by the expert committee. The expert committee considered four major areas where the French-Canadian version should achieve equivalence with the original English-version of the COWS. These areas were (1) semantic equivalence; (2) idiomatic equivalence; (3) experiential equivalence and (4) conceptual equivalence.

RESULTS

Rigorous steps based on the guidelines for the translation and cultural adaptation of assessment tools were followed, which led to a semantically equivalent version of the COWS. After a pretest among healthcare professionals, members from the expert committee agreed upon slight modifications to the French-Canadian version of the COWS to yield a final COWS-FC version.

CONCLUSIONS

A French-Canadian translation and adaptation of the COWS (i.e., the COWS-FC) was developed. The COWS-FC could be used for the assessment of opioid withdrawal symptoms in clinical and research settings.

Factors associated with potentially inappropriate opioid use in community-living older adults consulting in primary care

OBJECTIVE

To study the factors associated with opioid use and potentially inappropriate opioid use (PIOU) in primary care older adults with non-cancer pain referring to the conceptual framework developed by the American Agency for Healthcare Research and Quality.

METHODS

This is a secondary analysis of health survey and medico-administrative data from Québec, Canada. Individuals aged ≥65 were recruited between 2011 and 2013 in primary care clinics to participate in face-to-face interviews. The sample included 945 older adults without a malignant tumor over the study period or any tumor in the 2 years surrounding opioid use. Opioid use within a 3 year follow-up period was identified from the public drug plan database. Potentially inappropriate opioid use (PIOU) was defined using the American Geriatrics Society Beers 2019 list. Multinomial regression analyses were performed to study the factors (patient, pain, substance use, provider, healthcare system) associated with opioid use and PIOU.

RESULTS

In this sample of older adults, 26.2% used an opioid and 18.4% were categorized as PIOU. Factors associated with PIOU compared to opioid use included female sex, higher psychological distress, number of emergency department visits, and recruitment type of healthcare practice. Factors associated with PIOU compared to no use included female sex, country of origin, presence of a trauma, physical/psychiatric multimorbidity, number of outpatient consultations, pain severity/type, and number of prescribers.

CONCLUSIONS

Mental health and health system factors were associated with PIOU. Results highlights the importance of a multidisciplinary approach for pain management, and the urgent need for implementing organizational efforts to optimize opioid use in primary care.

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.

Prevalence of cannabis use for pain management in Quebec: A post-legalization estimate among generations living with chronic pain

Background

Medical cannabis has been legal in Canada since 2001, and recreational cannabis was legalized in October 2018, which has led to a widespread increase in the accessibility of cannabis products.

Aims

This study aimed to estimate the prevalence of cannabis use among adults living with chronic pain (CP) and investigate the relationship between age and cannabis use for CP management.

Methods

A cross-sectional analysis of the COPE Cohort data set, a large Quebec sample of 1935 adults living with CP, was conducted. Participants completed a web-based questionnaire in 2019 that contained three yes/no questions about past-year use of cannabis (i.e., for pain management, management of other health-related conditions, recreational purposes).

Results

Among the 1344 participants who completed the cannabis use section of the questionnaire, the overall prevalence of cannabis use for pain management was 30.1% (95% confidence interval 27.7-32.7). Differences were found between age groups, with the highest prevalence among participants aged ≤26 years (36.5%) and lowest for those aged ≥74 years (8.8%). A multivariable logistic model revealed that age, region of residence, generalized pain, use of medications or nonpharmacological approaches for pain management, alcohol/drug consumption, and smoking were associated with the likelihood of using cannabis for pain management.

Conclusions

Cannabis is a common treatment for the management of CP, especially in younger generations. The high prevalence of use emphasizes the importance of better knowledge translation for people living with CP, rapidly generating evidence regarding the safety and efficacy of cannabis, and clinicians' involvement in supporting people who use cannabis for pain management.

What methods are used to study the association between medication adherence trajectories, estimated with the group-based trajectory modeling (GBTM) method, and health-related outcomes?-a protocol for a systematic review

BACKGROUND

The group-based trajectory modeling (GBTM) method is increasingly used in pharmacoepidemiologic studies to describe medication adherence trajectories over time. However, assessing the associations between these medication adherence trajectories and health-related outcomes remains challenging. The purpose of this review is to identify and systematically review the methods used to assess the association between medication adherence trajectories, estimated from the GBTM method, and health-related outcomes.

METHODS

We will conduct a systematic review according to the recommendations of the Cochrane handbook for systematic reviews of interventions 6.2. Results will be reported following PRISMA 2020 (Preferred Reporting Items for Systematic Reviews and Meta-analyses) recommendations. We will search in the following databases: PubMed, Embase, PsycINFO, Web of Science, CINAHL, and Cochrane Library. Two reviewers will independently select articles and extract data. Discrepancies at every step will be resolved through discussion, and consensus will be reached for all disagreed articles. A third reviewer will act as a referee if needed. We will produce tables to synthesize the modalities used to estimate medication adherence trajectories with GBTM. We will also synthesize the modalities used to assess the association between these medication adherence trajectories and health-related outcomes by identifying the types of health-related outcomes studied and how they are defined, the statistical models used, and how the medication adherence trajectories were used in these models, and the effect measure yield. We will also review the limitations and biases reported by the authors and their attempts to mitigate them. We will provide a narrative synthesis.

DISCUSSION

This review will provide a thorough exploration of the strategies and methods used in medication adherence research to estimate the associations between medication adherence trajectories, estimated with GBTM, and the different health-related outcomes. It will represent the first crucial steps toward optimizing these methods in adherence studies.

SYSTEMATIC REVIEW REGISTRATION

Prospero CRD42021213503 .

Gender Differences in Medication Adverse Effects Experienced by People Living With Chronic Pain

Objectives

Understanding gender differences in chronic pain (CP) outcome research is essential to optimal treatment delivery. This study explored the associations between gender identity, gender roles, and the number of non-life-threatening pain medication adverse effects reported as severe by people living with CP.

Methods

The analyses were conducted using the COPE Cohort, a dataset generated through a web-based recruitment of adults with CP. Participants were asked how they identified themselves (women, men, unknown, unspecified) and gender roles were measured using the Bem Sex-Role Inventory (subgroups were formed applying the median split method). Pain medication adverse effects were assessed using a standardized checklist (none/mild/moderate/severe). A zero-inflated Poisson model was used to assess gender identity, gender roles and their interaction as potential predictors of the number of pain medication adverse effects.

Results

A total of 1,343 participants reported using pain medications. Adjusting for potential confounders, both gender identity (men vs. women: ß = −0.32, p = 0.0024) and gender roles (androgynous vs. undifferentiated: ß = 0.26, p = 0.0030) were associated with the number of pain medication adverse effects reported as severe, and they interacted with each other. The stratified analysis by gender roles showed that women reported a greater number of severe adverse effects than men among those classified as masculine and androgynous.

Discussion

Although we are unable to confirm whether the associations can be explained by differences in the experience or in the reporting of effects, gender identity and gender roles should both be explored when studying pain medication adverse effects.

Depression and the risk of hospitalization in type 2 diabetes patients: A nested case-control study accounting for non-persistence to antidiabetic treatment

INTRODUCTION

Depression is one of the most common comorbidities of type 2 diabetes. The relationship between these two diseases seems to be bidirectional. Both conditions separately lead to significant morbidity and mortality, including hospitalization. Moreover, depression is associated with non-persistence with antidiabetic drugs.

OBJECTIVES

To measure the effect of depression on morbidity and particularly on all-cause, diabetes-related, cardiovascular-related and major cardiovascular events-related hospitalization, adjusting for non-persistence to antidiabetic drugs and other confounders.

METHODS

We performed a nested case-control study within a cohort of type 2 diabetic individuals initiating antidiabetic drugs. Using the health administrative data of the province of Quebec, Canada, we identified all-cause, diabetes-related, cardiovascular-related and major cardiovascular hospitalizations during a maximum follow-up of eight years after the initiation of antidiabetic drug treatment. A density sampling method matched all cases with up to 10 controls by age, sex, and the Elixhauser comorbidity index. The effect of depression on hospitalization was estimated using conditional logistic regressions adjusting for non-persistence to antidiabetic drug treatment and other variables.

RESULTS

We identified 41,550 all-cause hospitalized cases, of which 34,437 were related to cardiovascular (CV) diseases, 29,584 to diabetes, and 13,867 to major CV events. Depression was diagnosed in 2.51% of all-cause hospitalizations and 1.16% of matched controls. 69.11% of cases and 72.59% of controls were on metformin monotherapy. The majority (71.62% vs 75.02%, respectively) stayed on metformin monotherapy without adding or switching drugs during follow-up. Non-persistence was at similar rates (about 30%) in both groups. In the multivariable analyses, depression was associated with an increased risk for all-cause hospitalizations, with odds ratios (ORs) ranging from 2.21 (95% CI: 2.07-2.37) to 1.32 (95% CI: 1.22-1.44) according to the model adjustment (from the univariate to the fully adhjusted).

CONCLUSION

Depression increased the risk of all-cause hospitalizations among patients treated for diabetes, even after accounting for non-persistence and other potentially confounding factors. These results stress the impact of depression on diabetic patients' use of health care resources.

Pharmacists practising in family medicine groups: An evaluation 2 years after experiencing a virtual community of practice

Background:

In 2018, a virtual community of practice (CoP) for pharmacists working in family medicine groups (FMGs) in Quebec province was developed. The aim of this CoP—called Réseau Québécois des Pharmaciens GMF (RQP GMF)—was to foster best practices by supporting FMG pharmacists. This study assesses the processes and outcomes of this CoP 2 years after its creation.

Methods:

We performed a cross-sectional web-based study from March to May 2020. All FMG pharmacists who were registered as members of the RQP GMF (n = 326) were sent an invitation via a newsletter. The link to the questionnaire was also publicized in the CoP Facebook group. The questionnaire comprised a 38-item validated instrument assessing 8 dimensions of the CoP. A descriptive analysis was performed.

Results:

A total of 112 FMG pharmacists (34.4%) completed the questionnaire. Respondents agreed that the RQP GMF was a joint enterprise (mean score, 4.18/5), that members shared their knowledge (mean score, 3.94/5) and engaged mutually (mean score, 3.50/5) and that the RQP GMF provided support (mean score, 3.92/5) and capacity building (mean score, 4.01/5). In general, they were satisfied with the implementation process (mean score, 3.68/5) and with activities proposed (mean score, 3.79/5). A lower proportion of respondents agreed that their participation in the RQP GMF generated external impacts, which led to a smaller mean score (3.37/5) for this dimension.

Conclusion:

The RQP GMF, one of the first communities of practice for pharmacists practising in family medicine groups, attained most of the objectives initially intended by the CoP. These results will facilitate the adaptation of processes and activities to better fulfil members’ needs. Can Pharm J (Ott) 2021;154:xx-xx.

Swallowing the pill of adverse effects: A qualitative study of patients' and pharmacists' experiences and decision-making regarding the adverse effects of chronic pain medications

Introduction

Pharmacological treatments of chronic pain can lead to numerous and sometimes serious adverse effects. Drawing on a social science approach to chronic illness, this study aimed to understand the experiences of people living with chronic pain and community pharmacists regarding the definition, prevention and management of analgesic adverse effects.

Methods

This qualitative study proceeded through 12 online focus groups (FGs) with people living with chronic pain (n = 26) and community pharmacists (n = 19), conducted between July 2020 and February 2021 in the province of Quebec, Canada. The semistructured discussion guides covered participants' definitions of adverse effects and decision‐making regarding their prevention and management. Discussions were audio‐recorded, transcribed verbatim and analysed using grounded theory.

Results

Both people with chronic pain and pharmacists provided varying definitions of analgesic adverse effects depending on patients' social and clinical characteristics. Present quality of life and serious long‐term risks related to treatment were described as key dimensions influencing adverse effect appraisal. Dilemmas and discrepancies occurred between patients and pharmacists when choosing to prioritize pain relief or adverse effect prevention. Some patients lacked information about their medications and wanted to be more involved in decisions, while many pharmacists were concerned by patients' self‐management of adverse effects. Preventing opioid‐related overdoses often led pharmacists to policing practices. Despite most pharmacists wishing they could have a key role in the management of pain and adverse effects face organizational and financial barriers.

Conclusion

Defining, preventing and managing adverse effects in the treatment of chronic pain requires a person‐centred approach and shared decision‐making. Clinical training improvements and healthcare organization changes are needed to support pharmacists in providing patients with community‐based follow‐up and reliable information about the adverse effects of chronic pain treatments.

Patient or Public Contribution

A person with lived experience of chronic pain was involved as a coinvestigator in the study. He contributed to shaping the study design and objectives, including major methodological decisions such as the choice of pharmacists as the most appropriate professionals to investigate. In addition, 26 individuals with chronic pain shared their experiences extensively during the FGs.

Chronic pain patients' willingness to share personal identifiers on the web for the linkage of medico-administrative claims and patient-reported data: The chronic pain treatment cohort

PURPOSE

The linkage between patient-reported data and medico-administrative claims is of great interest for epidemiologic research. The goal of this study was to assess the willingness of people living with chronic pain to share personal identifiers on the web for the linkage of medico-administrative and patient-reported data.

METHODS

This methodological investigation was achieved in the context of the implementation of the chronic pain treatment (COPE) cohort. A web-based recruitment initiative targeting adults living with chronic pain was conducted in the province of Quebec (Canada).

RESULTS

A total of 1935 participants completed the questionnaire (mean age: 49.86 ± 13.27; females: 83.69%), 921 (47.60%) of which agreed to data linkage and shared their personal identifiers (name, date of birth, health insurance number online). The most common reasons for refusal were: (1) concerns regarding data security/privacy (25.71%) and (2) the belief that the requested data were too personal/intrusive (13.52%). Some participants did not understand the relevance of data linkage (11.81%). Participants from the COPE cohort and those from the subsample who agreed to data linkage were comparable to other random samples of chronic pain individuals in terms of age and pain characteristics.

CONCLUSIONS

Although approximately half of the participants refused data linkage, our approach allowed for the implementation of a data platform that contains a diverse and substantial sample. This investigation has also led to the formulation of recommendations for web-based data linkage, including placing items designed to assess willingness to share personal identifiers at the end of the questionnaire, adding explanatory videos, and using a mixed-mode questionnaire.

Experience and perspectives of users and non-users of the Ask your pharmacist teleconsultation platform

Background

There is a growing trend concerning the use of information and communication technologies (ICT) for seeking health-related information such as information on medications and side effects. However, people looking online for health information cannot always judge the credibility of the information.

Objective(s)

This study aimed to describe patients' and pharmacists' experience using an asynchronous teleconsultation platform entitled “Ask Your Pharmacist” (AYP) and gather their perspectives and those of various healthcare and social services professionals providing primary care.

Methods

We performed semi-structured individual interviews over the telephone with patients having used the platform, pharmacists providing teleconsultation services on the platform, and various professionals delivering healthcare and psychosocial services to ambulatory patients. The questions explored specific themes, such as the perceived utility and impacts of the platform. We transcribed the interviews and performed a content analysis.

Results

We interviewed eight patients, six AYP pharmacists, and 15 healthcare and social services professionals. Participants perceived that the platform was simple to use and accessible. They also perceived that AYP promoted the visibility and the value of pharmacists' services. Some constraints were also shared, notably regarding questions requiring immediate attention or about complex situations.

Conclusions

The experience and perspectives of users and non-users of the AYP platform are mostly positive, but concerns were also raised regarding patients' safety. Results suggest that AYP could be a complementary tool to offer to ambulatory patients for simple, general and non-urgent problems.

User experience with the Ask Your Pharmacist teleconsultation platform

Background:

An increasing number of pharmacists use technology and social media to connect with patients. However, such means may pose confidentiality issues and legal problems. To correct this situation, a platform of teleconsultation services provided by pharmacists, titled “Ask Your Pharmacist,” was created in Quebec, Canada.

Methods:

A web-based satisfaction survey was carried out among patients and pharmacists who have used the Ask Your Pharmacist platform to describe their experience and satisfaction with the platform and explore the perceived usefulness of this service in the province of Quebec.

Results:

A total of 53 patients and 27 pharmacists completed the survey. Most patients were satisfied or very satisfied with their experience with Ask Your Pharmacist (96.2%), said that it met their need (88.7%), and agreed they would not have to consult again about the matter discussed with the pharmacist (75.5%). The main motivation of pharmacists for volunteering on Ask Your Pharmacist was to meet the needs of patients (85.1%), promote their profession (55.6%), improve drug utilization in the population (55.6%) and increase accessibility to a pharmacist (51.9%). Most (81.5%) felt that providing written consultation (rather than oral) required more research on their part.

Discussion:

Most patients judged they would not have to have another consultation about the matter discussed with the pharmacist, suggesting that Ask Your Pharmacist may avoid the need for physician and emergency department visits.

Conclusion:

Most patients and pharmacists were satisfied with their experience with Ask Your Pharmacist and perceived this service as useful. Further studies should assess the impact of this platform on the utilization of other health care services. Can Pharm J (Ott) 2021;154:xx-xx.

Depression but not non-persistence to antidiabetic drugs is associated with mortality in type 2 diabetes: A nested case-control study

AIMS

To measure the effect of depression on mortality of individuals newly treated with antidiabetic drugs, accounting for non-persistence to treatment.

METHODS

We conducted a nested case-control study within a cohort of newly treated individuals with diabetes. Using Quebec administrative data, we identified all-cause, diabetes-related, cardiovascular-related and major cardiovascular event deaths during a maximum follow-up of eight years. Each case was matched with up to 10 controls by age, sex, follow-up, and comorbidity index. We used conditional logistic regressions to estimate the effect of depression on mortality, adjusting for non-persistence to antidiabetic drug treatment, and other variables.

RESULTS

We retrieved 13,558 deaths, of which 3,652 were related to cardiovascular diseases, 2,112 to major cardiovascular events, and 311 to diabetes. Depression was associated with an increased risk of all-cause and cardiovascular-related deaths, with adjusted odds ratios (ORs) ranging from 1.32 (95% CI: 1.21-1.45) to 1.72 (95% CI: 1.57-1.88) depending on the model, but not with diabetes-related mortality.

CONCLUSION

Depression is independently associated with all-cause and cardiovascular-related mortality in individuals with type 2 diabetes, even when adjusting for non-persistence to antidiabetic drug treatment. Identifying risk factors for depression and implementing a screening and proper treatment for depression may help reducing mortality.

Development of an electronic tool (e-AdPharm) to address unmet needs and barriers of community pharmacists to provide medication adherence support to patients

BACKGROUND

Community pharmacists are best placed to improve medication adherence because they frequently interact with patients and have been trained to manage medication-related problems. Therefore, it is essential to equip pharmacists adequately to detect non-adherent patients quickly and intervene to improve medication adherence.

OBJECTIVE

To design e-AdPharm, a tool that addresses unmet needs and barriers of community pharmacists to provide medication adherence support to patients with chronic diseases.

METHODS

A qualitative study using 4 focus group discussions with community pharmacists was conducted with a semi-structured interview guide and discussions lasting for 1-2 h. The discussions covered the barriers and needs of pharmacists related to medication adherence support provided to patients, their expectations of an electronic tool based on prescription refills to help them provide this support, and the design of the tool. Focus group data were coded and analyzed using an iterative process, with thematic and descriptive analyses.

RESULTS

Twenty-six community pharmacists participated. Lack of time and motivation from pharmacists and patients were common barriers to the provision of medication adherence support. Accordingly, community pharmacists wished to measure medication adherence quickly, provide easily interpretable data to patients on their medication use, and raise the patient's awareness of non-adherence. The pharmacists expressed their need to have an electronic tool to share medication adherence information with the treating physician. Regarding the design of e-AdPharm, the pharmacists wanted a table displaying medication adherence with a color code representing adherence level. They also stressed the importance of a structured section enabling them to continuously document the interventions made and the need for patient follow-ups.

CONCLUSIONS

e-AdPharm meet the needs and overcome the barriers of community pharmacists to provide medication adherence support to their patients. Future studies should examine the feasibility of implementing e-AdPharm in community pharmacies and test its efficacy for improving medication adherence.

Case Management in Primary Care for Frequent Users of Health Care Services: A Realist Synthesis

PURPOSE

Case management (CM) is a promising intervention for frequent users of health care services. Our research question was how and under what circumstances does CM in primary care work to improve outcomes among frequent users with chronic conditions?

METHODS

We conducted a realist synthesis, searching MEDLINE, CINAHL, Embase, and PsycINFO (1996 to September 2017) for articles meeting the following criteria: (1) population: adult frequent users with chronic disease, (2) intervention: CM in a primary care setting with a postintervention evaluation, and (3) primary outcomes: integration of services, health care system use, cost, and patient outcome measures. Academic and gray literature were evaluated for relevance and robustness. Independent reviewers extracted data to identify context, mechanism, and outcome (CMO) configurations. Analysis of CMO configurations allowed for the modification of an initial program theory toward a refined program theory.

RESULTS

Of the 9,295 records retrieved, 21 peer-reviewed articles and an additional 89 documents were retained. We evaluated 19 CM interventions and identified 11 CMO configurations. The development of a trusting relationship fostering patient and clinician engagement in the CM intervention was recurrent in many CMO configurations.

CONCLUSION

Our refined program theory proposes that in the context of easy access to an experienced and trusted case manager who provides comprehensive care while maintaining positive interactions with patients, the development of this relationship fosters the engagement of both individuals and yields positive outcomes when the following mechanisms are triggered: patients and clinicians feel supported, respected, accepted, engaged, and committed; and patients feel less anxious, more secure, and empowered to self-manage.

Public Health Outcomes May Differ After Switching from Brand-Name to Generic Angiotensin II Receptor Blockers

Background

It is unclear whether generics are as safe as brand-name drugs in cardiology. For public health surveillance purposes, we evaluated if switching from the brand-name losartan, valsartan, or candesartan impacted the occurrence of the following outcomes: emergency room (ER) consultations, hospitalizations, or death.

Study Design

This was a retrospective cohort study.

Methods

This study was conducted in the Quebec Integrated Chronic Disease Surveillance System, including healthcare administrative data of the population of Quebec, Canada. We included brand-name users of losartan, valsartan, or candesartan aged ≥ 66 years who had undergone ≥ 30 days of stable treatment on the brand-name drug prior to cohort entry (substitution time-distribution matching was used to prevent immortal time bias). Outcomes up to 1 year were compared between groups using multivariable Cox proportional hazards regression models (validity assumptions were verified).

Results

In our cohorts (losartan, n =15,783; valsartan, n =16,907; candesartan, n =26,178), mean age was 76–78 years, 59–66% were female, 90–92% had hypertension, and 13–15% had heart failure. Validity assumptions were violated for losartan only. For patients switched to generic valsartan, the hazard ratio (95% confidence interval) was 1.07 (0.99–1.14) for ER consultation, 1.26 (1.14–1.39) for hospitalization, and 1.01 (0.61–1.67) for death. The corresponding rates for candesartan were 1.00 (0.95–1.05), 0.96 (0.89–1.03), and 0.57 (0.37–0.88), respectively.

Conclusions

We observed an increased risk of hospitalizations for patients switched to generic valsartan, and a decreased risk of death for patients switched to generic candesartan, compared with those who continued taking the brand-name drug. The differences between generic and brand-name drugs may lead to some differences in public health outcomes, but this safety signal must be further studied using other cohorts and settings.

Electronic supplementary material

The online version of this article (10.1007/s40268-020-00307-2) contains supplementary material, which is available to authorized users.

Monitoring and managing medication adherence in community pharmacies in Quebec, Canada

Background

Community pharmacists have direct access to prescription refill information and regularly interact with their patients. Therefore, they are in a unique position to promote optimal medication use.

Objectives

To describe how community pharmacists in Quebec, Canada, identify nonadherent patients, monitor medication use and promote optimal medication adherence.

Methods

An invitation to complete a web-based survey was published online through different platforms, including a Facebook pharmacists' group, an electronic newsletter, a pharmacy network forum and e-mail. The survey included questions on participant characteristics, methods used by pharmacists to identify nonadherent patients and monitor medication use and interventions they used to promote medication adherence.

Results

In total, 342 community pharmacists completed the survey. The participants were mainly women (71.6%), staff pharmacists (56.7%) and aged 30 to 39 years (34.2%). The most common method to identify nonadherent patients was to check gaps between prescription refills (98.8%). The most common intervention to promote adherence was patient counselling (82.5%). The most common barriers to identifying nonadherent patients were lack of time (73.1%) and lack of prescription information (65.8%), whereas the most common barriers to intervening were anticipation of a negative reaction from their patients (91.2%) and lack of time (64%).

Conclusion

Lack of time and lack of prescription information are frequent challenges encountered by community pharmacists regarding effective monitoring and management of patients with poor medication adherence. Pharmacists could benefit from electronic tools based on prescription refills that would provide quick and easily interpretable information on their patients' medication adherence. Can Pharm J (Ott) 2020;153:xx-xx.

French-Canadian translation of a self-report questionnaire to monitor opioid therapy for chronic pain: The Opioid Compliance Checklist (OCC-FC)

Context: Chronic noncancer pain (CNCP) is a frequent condition among Canadians. The psychosocial and economic costs of CNCP for individuals, their families, and society are substantial. Though opioid therapy is often used to manage CNCP, it is also associated with risks of misuse. The Opioid Compliance Checklist (OCC) was developed to monitor opioid misuse in patients taking opioids for CNCP. The objective of the present study was to provide a French-Canadian translation of the eight-item OCC, the OCC-FC. Methods: The eight-item OCC was translated for use in Québec using published guidelines for the translation and adaptation of self-report measures, including an expert committee and a double forward-backward translation process. A pretest of the adapted eight-item OCC was also conducted among 30 patients with CNCP. Results: A French-Canadian version of the OCC was generated. When ambiguity in the items was detected during expert committee consultation or pretest administration, modifications made were kept to a strict minimum to facilitate future comparisons across studies using the original English and translated French-Canadian version. Discussion: This study provides a culturally adapted tool that will contribute to identifying French-Canadian patients with CNCP who misuse opioids over the course of opioid therapy. This translation of the OCC has the strong potential to be useful in research and clinical settings.

Exposure to guideline-recommended drugs after a first acute myocardial infarction in older adults: does deprivation matter?

BACKGROUND

Inequities between guideline-recommended drugs (GRD) exposure and socioeconomic status might exist. The objective was to assess the association between a material and a social deprivation index and GRD exposure following a first acute myocardial infarction (AMI) in older adults in the province of Quebec.

METHODS

We conducted a retrospective cohort study using the Quebec Integrated Chronic Disease Surveillance System. Elderly ≥66 years, hospitalized for a first AMI between January 1, 2006, and December 31, 2011 and covered by the public drug plan were identified. Exposure to GRD (i.e. simultaneous use of 1) antiplatelet, 2) beta-blocker, 3) lipid-lowering and 4) angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker drugs) was assessed 30 and 365 days following hospital discharge. Associations between deprivation index and GRD exposure were estimated with log-binomial regressions adjusting for potential confounders.

RESULTS

Exposure to GRD was 52.2% and 48.0%, 30 and 365 days after hospital discharge, respectively. No statistically significant association was observed in multivariate analysis for both time points. Thirty days post hospital discharge, adjusted prevalence ratio of non-exposure to GRD was 0.98 (95% confidence interval [CI]: 0.95-1.02) for most materially deprived vs. least deprived and 1.04 (95% CI: 0.99-1.08) for most socially deprived vs. least deprived. Similar results were observed for 365 days.

CONCLUSION

Exposure to GRD after a first urgent AMI among older adults insured by the public drug plan in the province of Quebec is relatively low. Reasons and risk groups for this low exposure should be studied to improve secondary prevention. However, results suggest equitable access to GRD, regardless of deprivation.

Impact of pharmacists' interventions on the pharmacotherapy of patients with complex needs monitored in multidisciplinary primary care teams

OBJECTIVES

Recently, pharmacists have joined multidisciplinary healthcare teams within family medicine groups (FMG) in Quebec Province, Canada. This study assessed the impact of their interventions on the pharmacotherapy of patients with complex needs monitored in FMGs.

METHODS

We performed a pre/post real-life intervention study among patients with complex needs referred to the FMG pharmacist in four FMGs in Quebec City. Pharmacists collected data at baseline, during follow-up and up to 6 months after the first encounter. They recorded all drug-related problems (DRPs) identified, interventions made and recommendations that were accepted by physicians. The researchers used the data collected to compare the medication regimen complexity index (MRCI) and medication adherence (using the proportion of days covered (PDC)) before and after the pharmacist's interventions. Descriptive statistics and paired sample t-tests were computed.

KEY FINDINGS

Sixty-four patients (median age: 74.5 years) were included; four patients were lost to follow-up. Pharmacists detected 300 DRPs (mean: 7.2 per patient) during the study period for which they made an intervention. The most common DRP was 'drug use without indication' (27%). The physicians accepted 263 (87.7%) of those interventions. The mean number of prescribed drugs per patient decreased from 13.8 (95% confidence interval (CI): 12.24 to 15.29) to 12.4 (95% CI: 10.92 to 13.90). The mean MRCI decreased from 47.18 to 41.74 (-5.44; 95% CI: 1.71 to 9.17), while the mean PDC increased from 84.4% to 90.0% (+5.6%; 95% CI: 2.7% to 8.4%).

CONCLUSION

Family medicine groups pharmacists can detect and resolve DRPs and can reduce medication regimen complexity and non-adherence to treatment in patients with complex needs monitored in FMGs.

Trends in Hospital Visits for Generic and Brand-Name Warfarin Users in Québec, Canada: A Population-Based Time Series Analysis

BACKGROUND

Federal standards authorize the commercialization of generic medicines after bioequivalence versus the brand-name originator has been demonstrated. For drugs with narrow therapeutic indexes, such as warfarin, the accepted difference in bioavailability is ≤ 10%. No systematic pharmacovigilance studies are conducted once generics become available.

OBJECTIVE

We aimed to assess the impact of the arrival of generic warfarin on hospital visit trends (hospital admissions or emergency room consultations) in warfarin users.

METHODS

This was an observational interrupted time series analysis (2 January 1996 to 1 January 2016). Using the Québec Integrated Chronic Disease Surveillance System, we included all patients who were aged ≥ 66 years, publicly covered and using brand-name or generic warfarin (N = 280,158). We estimated rates of hospital visits in 6-month periods, 5 years before and up to 15 years after the arrival of generic warfarin. Periods before and after were compared using segmented regression models for all users along with exploratory (generic vs. brand name)/subgroup analyses (cardiovascular comorbidities and socioeconomic status).

RESULTS

Generic warfarin arrived on the market on 2 January 2001. Over the 20-year period of the study, the mean rate of hospital visits was 113 for 100 brand-name or generic users per 6-month period and was similar before and after the arrival of the generics. Up to 15 years after the arrival of the generics, the rates of hospital visits were 10% higher for generic than for brand-name users, which was confirmed by subgroup analyses.

CONCLUSIONS

Overall, we observed no impact on hospital visits after the arrival of generic warfarin in all the population treated with any type of warfarin. However, a higher crude rate of hospital visits among generic users than brand-name users remains to be validated using a different methodology and specific outcomes.

Did Generic Clopidogrel Commercialization Affect Trends of ER Consultations and Hospitalizations in the Population Treated with Clopidogrel?

BACKGROUND

Clopidogrel has been widely used to prevent atherothrombotic events. Since 2011, pharmacists have offered their patients the opportunity to switch to generic clopidogrel, an economic alternative. Whether bioequivalence of generic cardiovascular drugs translates into clinical equivalence at a population level remains unclear and needs to be further documented.

OBJECTIVE

We aimed to evaluate the impact of generic clopidogrel commercialization on adverse events (AEs): hospitalizations or emergency room (ER) consultations.

METHODS

This is an interrupted time series analysis using the Quebec Integrated Chronic Disease Surveillance System. We included all patients ≥ 66 years old who were users of the brand-name clopidogrel or a generic version (n = 6) 24 months before and up to 12 months after generics commercialization. Rates of AEs were computed, and periods before and after generics commercialization were analyzed by segmented regression models along with exploratory analyses (generic vs. brand name). Sensitivity analyses were also performed using stratification of the time series by (1) sex, (2) the number of prevalent cardiovascular comorbidities, and (3) socioeconomic status.

RESULTS

Time series were constituted of 89,525 clopidogrel users (mean age 78 years, 45% women, 71% ischemic heart disease, 34% stroke). For all users, there was a mean rate of 157 AEs per 1000 user-months, stable trend before (-0.1% [95% confidence interval -0.3 to 0.1] and after (0.0% [- 0.5 to 0.6]) generics commercialization. In exploratory analyses, once generic clopidogrel versions were commercialized, rates of AEs were 19.2% (95% CI 11.7-26.7) higher for generic versus brand-name users. This difference persisted up to 1 year. Sensitivity analyses yielded similar results.

CONCLUSIONS

The population treated with clopidogrel had similar rates of hospitalizations or ER consultations before and after generics commercialization. However, differences in rates of hospitalizations or ER consultations between generic and brand-name clopidogrel users may represent a drug safety signal which remains to be validated. Using a different study design, permitting adjustment for potential confounders, could be useful in this regard.

Exploring the role of teams and technology in patients' medication decision making

OBJECTIVES

We know little about how electronic health records (EHRs) should be designed to help patients, pharmacists, and physicians participate in interprofessional shared decision making. We used a qualitative approach to understand better how patients make decisions with their health care team, how this information influences decision making about their medications, and finally, how this process can be improved through the use of EHRs.

DESIGN

Participants from 4 regions across Canada took part in a semistructured interview and completed a brief demographic survey. The interview transcripts were thematically analyzed by means of the multidisciplinary framework method.

SETTINGS AND PARTICIPANTS

Thirty participants, 18 years of age and older with at least one chronic illness, were recruited from across Canada. We interviewed participants in their homes, at the school of pharmacy, or another location of their choosing.

RESULTS

We identified 4 main themes: (1) complexity of patient decision making: who, where, what, when, why; (2) relationships with physicians and pharmacists: who do I trust for what?; (3) accessing health information for decision making: how much and from where?; and (4) patients' methods of managing information for health decision making. Across the themes, participants appreciated expert advice from professionals and wanted to be informed about all options, despite concerns about limited knowledge. EHRs were perceived as a potential solution to many of the barriers identified.

CONCLUSION

Patients make decisions with their health care providers as well as with family and friends. The pharmacist and physicians play different roles in helping patients in making decisions. We found that making EHRs accessible not only to health care providers but also to patients can provide a cohesive and clear context for making medication-related decisions. EHRs may facilitate clear communication, foster interprofessional understanding, and improve patient access to their health information. Future research should examine how to develop EHRs that are adaptive to user needs and desires.

Case management in primary care for frequent users of healthcare services with chronic diseases and complex care needs: an implementation and realist evaluation protocol

INTRODUCTION

Significant evidence in the literature supports case management (CM) as an effective intervention to improve care for patients with complex healthcare needs. However, there is still little evidence about the facilitators and barriers to CM implementation in primary care setting. The three specific objectives of this study are to: (1) identify the facilitators and barriers of CM implementation in primary care clinics across Canada; (2) explain and understand the relationships between the actors, contextual factors, mechanisms and outcomes of the CM intervention; (3) identify the next steps towards CM spread in primary care across Canada.

METHODS AND ANALYSIS

We will conduct a multiple-case embedded mixed methods study. CM will be implemented in 10 primary care clinics in five Canadian provinces. Three different units of analysis will be embedded to obtain an in-depth understanding of each case: the healthcare system (macro level), the CM intervention in the clinics (meso level) and the individual/patient (micro level). For each objective, the following strategy will be performed: (1) an implementation analysis, (2) a realist evaluation and (3) consensus building among stakeholders using the Technique for Research of Information by Animation of a Group of Experts method.

ETHICS AND DISSEMINATION

This study, which received ethics approval, will provide innovative knowledge about facilitators and barriers to implementation of CM in different primary care jurisdictions and will explain how and why different mechanisms operate in different contexts to generate different outcomes among frequent users. Consensual and prioritised statements about next steps for spread of CM in primary care from the perspectives of all stakeholders will be provided. Our results will offer context-sensitive explanations that can better inform local practices and policies and contribute to improve the health of patients with complex healthcare needs who frequently use healthcare services. Ultimately, this will increase the performance of healthcare systems and specifically mitigate ineffective use and costs.

Measuring adherence to oral antidiabetic multi-drug treatment: Comparative validity of prescription claims-based adherence measures against hospitalization

BACKGROUND

The use of prescription claims data to measure adherence to diabetes treatment is very common in research. However, there is no clear evidence regarding the accuracy of the methods used to assess adherence to multi-drug treatments for the many patients using multiple antidiabetic drugs.

PURPOSE

To assess the validity of prescription claims-based adherence measures in the context of multiple oral antidiabetic drug treatment.

METHODS

A cohort of patients who began their antidiabetic drug treatment with at least two oral antidiabetic drugs (new users) was created using Quebec medico-administrative data. Four different prescription claims-based adherence measures were assessed: proportion of days covered (PDC) by at least one class of drugs, mean PDC, PDC by all classes and daily polypharmacy possession ratio (DPPR). All-cause and diabetes-related hospitalizations were the validation criteria. To assess the validity of the measures, receiver operating characteristic (ROC) curves were plotted for each measure and each criterion.

RESULTS

A total of 5982 individuals were included. The areas under the ROC curves for the PDC by at least one class of drugs, the mean PDC, the PDC by all classes of drugs and the DPPR were respectively 0.54 (95% CI: 0.52-0.56), 0.51 (0.49-0.53), 0.50 (0.48-0.52) and 0.51 (0.49-0.53) with all-cause hospitalization as criterion and 0.55 (0.53-0.57), 0.53 (0.51-0.55), 0.51 (0.49-0.53) and 0.53 (0.51-0.55) using diabetes-related hospitalization as criterion.

CONCLUSIONS

The results suggest that all measures have poor validity in predicting hospitalizations thus raising concerns about their utility in the assessment of adherence to multi-drug treatment. Future research should assess the capacity of these measures to predict other outcomes more closely related to medication adherence.

Physician and Pharmacist Medication Decision-Making in the Time of Electronic Health Records: Mixed-Methods Study

Background

Primary care needs to be patient-centered, integrated, and interprofessional to help patients with complex needs manage the burden of medication-related problems. Considering the growing problem of polypharmacy, increasing attention has been paid to how and when medication-related decisions should be coordinated across multidisciplinary care teams. Improved knowledge on how integrated electronic health records (EHRs) can support interprofessional shared decision-making for medication therapy management is necessary to continue improving patient care.

Objective

The objective of our study was to examine how physicians and pharmacists understand and communicate patient-focused medication information with each other and how this knowledge can influence the design of EHRs.

Methods

This study is part of a broader cross-Canada study between patients and health care providers around how medication-related decisions are made and communicated. We visited community pharmacies, team-based primary care clinics, and independent-practice family physician clinics throughout Ontario, Nova Scotia, Alberta, and Quebec. Research assistants conducted semistructured interviews with physicians and pharmacists. A modified version of the Multidisciplinary Framework Method was used to analyze the data.

Results

We collected data from 19 pharmacies and 9 medical clinics and identified 6 main themes from 34 health care professionals. First, Interprofessional Shared Decision-Making was not occurring and clinicians made decisions based on their understanding of the patient. Physicians and pharmacists reported indirect Communication, incomplete Information specifically missing insight into indication and adherence, and misaligned Processes of Care that were further compounded by EHRs that are not designed to facilitate collaboration. Scope of Practice examined professional and workplace boundaries for pharmacists and physicians that were internally and externally imposed. Physicians decided on the degree of the Physician-Pharmacist Relationship, often predicated by colocation.

Conclusions

We observed limited communication and collaboration between primary care providers and pharmacists when managing medications. Pharmacists were missing key information around reason for use, and physicians required accurate information around adherence. EHRs are a potential tool to help clinicians communicate information to resolve this issue. EHRs need to be designed to facilitate interprofessional medication management so that pharmacists and physicians can move beyond task-based work toward a collaborative approach.

Anticoagulation management services in community pharmacy: Feasibility of implementing a quality improvement programme through a practice-based research network

WHAT IS KNOWN AND OBJECTIVE

The literature has reported suboptimal real-world use of oral anticoagulants in patients with atrial fibrillation (AF). Anticoagulation management services (AMSs) in community pharmacy have rarely been evaluated, and no formal process is available to enable pharmacists to evaluate and improve their clinical practices. Our objective was to assess the feasibility of implementing, through a practice-based research network (PBRN), a quality improvement programme on AMSs by community pharmacists for AF patients and explore its impact on the quality of clinical practices and pharmacists' knowledge.

METHODS

An uncontrolled pre/post-pilot study was conducted through a PBRN. Pharmacists identified 5-20 AF patients on oral anticoagulants per pharmacy and completed questionnaires at baseline (T0) and after 6 months (T6). Clinical practices were evaluated using a set of quality indicators (QIs). QI scores ranged from 0% (no QI achieved) to 100% (all QIs achieved). The programme included an audit and feedback based on QIs and a personalized training programme (including online videos). Participation rates and satisfaction were documented. Mean changes (T6-T0), with 95% confidence interval (CI), in QIs and knowledge scores were computed.

RESULTS AND DISCUSSION

A total of 37 pharmacies (50 pharmacists) identified 222 patients who had received either vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs), or both. All pharmacies received their baseline quality report (audit), and facilitators contacted by phone 97% of pharmacies (feedback). Each of the six online videos was completed by at least 48% of pharmacists. Baseline mean global QI scores for VKAs and DOACs were 39.1% (95% CI: 35.7%-42.4%) and 12.3% (7.8%-16.8%), respectively. Over a 6-month period, they increased by 12.5% points (7.5%-17.5%) and 9.9% points (3.8%-16.1%), respectively. Baseline mean global knowledge score was 68.7% (65.4%-72.0%) and increased by 4.3% points (1.2%-7.4%).

WHAT IS NEW AND CONCLUSION

Implementing a quality improvement programme for AMS in community pharmacy is relevant and feasible and may improve pharmacists' practices and knowledge.

Effectiveness of motivational interviewing interventions on medication adherence in adults with chronic diseases: a systematic review and meta-analysis

Background

Medication adherence is frequently suboptimal in adults with chronic diseases, resulting in negative consequences. Motivational interviewing (MI) is a collaborative conversational style for strengthening a person's motivation and commitment to change. We aimed to assess whether MI interventions are effective to enhance medication adherence in adults with chronic diseases and to explore the effect of individual MI intervention characteristics.

Methods

We searched electronic databases and reference lists of relevant articles to find randomized controlled trials (RCTs) that assessed MI intervention effectiveness on medication adherence in adults with chronic diseases. A random-effects model was used to estimate a pooled MI intervention effect size and its heterogeneity (I 2 ). We also explored the effects of individual MI characteristics on MI intervention effect size using a meta-regression with linear mixed model.

Results

: Nineteen RCTs were identified, and 16 were included in the meta-analysis. The pooled MI intervention effect size was 0.12 [95% confidence interval (CI) = (0.05, 0.20), I 2 = 1%]. Interventions that were based on MI only [β = 0.183, 95% CI = (0.004, 0.362)] or those in which interventionists were coached during intervention implementation [β = 0.465, 95% CI = (0.028, 0.902)] were the most effective. MI interventions that were delivered solely face to face were more effective than those that were delivered solely by phone [β = 0.270, 95% CI = (0.041, 0.498)].

Conclusions

This synthesis of RCTs suggests that MI interventions might be effective at enhancing of medication adherence in adults treated for chronic diseases. Further research is however warranted, as the observed intervention effect size was small.