46. Did the CME/CPD train leave with half the passengers? A needs assessment of Québec specialist associations' CPD units

This presentation reports on the results of a needs assessment conducted amongst the 34 Quebec specialist associations, which are accredited as CME/CPD providers by Quebec’s College of Physicians, in accordance with the Canadian Association of Continuing Medical Education’s criteria. In 2006, a mix of methods (survey, semi-structured interviews and program documentation review) were used to assess CPD units’ learning needs in the areas of CME and CPD, the extent to which they carried out a list of specific tasks associated to providers’ responsibilities, barriers encountered in meeting standards, and the kind of help needed to improve performance. Although CME/CPD fields have evolved considerably in the past 20 years, results indicate that few of the advances have made their way down to the associations. The majority still provides education in the form of traditional CME, where speakers talk about new developments in medicine. Whereas the systematic approach of CME is well integrated in most units, few go beyond perceptions in their needs assessments, use problem-based learning methods, enablers, reinforcement and outcome evaluations, or help specialists self-evaluate and reflect on their practice. These methods and approaches are believed to increase CME effectiveness. Most Canadian specialists get a large proportion of their CE from non academic medical organizations such as professional associations and learned societies. However, information available in the literature does not allow generalization of our observations to other organizations of this nature. Since non academic organizations are important CME/CPD providers, we propose that more attention be given on the way trainers are trained and innovations are shared in our CE system. What minimal knowledge and skills should be required of a CME/CPD professional today? Together with its affiliated associations and academic partners, the Federation of Medical Specialists of Quebec (FMSQ) has decided to tackle this important issue in the coming years. Olson CA, Tooman TR, Leist JC. Contents of a core library in continuing medical education: a delphi study. JCEHP 2005; 25:278-88. Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA 1995; 274:700-5. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients' care. Lancet 2003; 362:1225-30.

Adverse events associated with prescription drug cost-sharing among poor and elderly persons

CONTEXT

Rising costs of medications and inequities in access have sparked calls for drug policy reform in the United States and Canada. Control of drug expenditures by prescription cost-sharing for elderly persons and poor persons is a contentious issue because little is known about the health impact in these subgroups.

OBJECTIVES

To determine (1) the impact of introducing prescription drug cost-sharing on use of essential and less essential drugs among elderly persons and welfare recipients and (2) rates of emergency department (ED) visits and serious adverse events associated with reductions in drug use before and after policy implementation.

DESIGN AND SETTING

Interrupted time-series analysis of data from 32 months before and 17 months after introduction of a prescription coinsurance and deductible cost-sharing policy in Quebec in 1996. Separate 10-month prepolicy control and postpolicy cohort studies were conducted to estimate the impact of the drug reform on adverse events.

PARTICIPANTS

A random sample of 93 950 elderly persons and 55 333 adult welfare medication recipients.

MAIN OUTCOME MEASURES

Mean daily number of essential and less essential drugs used per month, ED visits, and serious adverse events (hospitalization, nursing home admission, and mortality) before and after policy introduction.

RESULTS

After cost-sharing was introduced, use of essential drugs decreased by 9.12% (95% confidence interval [CI], 8.7%-9.6%) in elderly persons and by 14.42% (95% CI, 13.3%-15.6%) in welfare recipients; use of less essential drugs decreased by 15.14% (95% CI, 14.4%-15.9%) and 22.39% (95% CI, 20.9%-23.9%), respectively. The rate (per 10 000 person-months) of serious adverse events associated with reductions in use of essential drugs increased from 5.8 in the prepolicy control cohort to 12.6 in the postpolicy cohort in elderly persons (a net increase of 6.8 [95% CI, 5.6-8.0]) and from 14.7 to 27.6 in welfare recipients (a net increase of 12.9 [95% CI, 10.2-15.5]). Emergency department visit rates related to reductions in the use of essential drugs also increased by 14.2 (95% CI, 8.5-19.9) per 10 000 person-months in elderly persons (prepolicy control cohort, 32.9; postpolicy cohort, 47.1) and by 54.2 (95% CI, 33.5-74.8) among welfare recipients (prepolicy control cohort, 69.6; postpolicy cohort, 123.8). These increases were primarily due to an increase in the proportion of recipients who reduced their use of essential drugs. Reductions in the use of less essential drugs were not associated with an increase in risk of adverse events or ED visits.

CONCLUSIONS

In our study, increased cost-sharing for prescription drugs in elderly persons and welfare recipients was followed by reductions in use of essential drugs and a higher rate of serious adverse events and ED visits associated with these reductions.

The longitudinal case study: from Schön's model to self-directed learning

BACKGROUND

Rapid changes observed in information technologies, medical practice, and learning methods encourage physicians to develop new updating strategies. To test its feasibility and to help physicians devise new learning and updating strategies, the knowing-in-action model developed by Schön was applied in planning and evaluating an interactive workshop. Acquisition of knowledge was tested.

METHODS

The office and hospital charts of a family physician were reviewed. They were used to prepare a longitudinal case study, based on the real-life story of a hypertensive patient followed by her doctor over a period of 15 years. The clinician's approach to solving clinical problems was triangulated for credibility with general practitioners, specialists, and the information available in the literature. This longitudinal case study was used to develop an interactive educational workshop. The workshop was presented to physicians who had registered in an accredited continuing medical education event. Changes in pre- and postevent knowledge among the participants were assessed using touch pad technology to evaluate the effectiveness of this approach on the acquisition of knowledge related to management of arterial hypertension and associated clinical problems.

RESULTS

A comparison of pre- and post-test data showed a significant improvement in knowledge for participants who answered all questions on both questionnaires (n = 8/37). The average score of these participants increased from 5.5 of 10 before the workshop to 8.3 of 10 after the workshop (p < .05). Participants reported a high satisfaction rate for the event.

FINDINGS

A workshop using the longitudinal case study enables physicians to perceive their daily practice through a continuing education activity in which they experience the processes of reflection in action and reflection on action described by Schön. It also increases awareness of the gap between current practice and experts' recommendations and provides an opportunity to evaluate the means for bridging or closing this gap. It sensitizes the physician to patients' changing needs and prompts the clinician to reflect on the who, what, when, where, and how of learning.

The Office of the Future Project: the integration of new technology into office practice. Academic detailing through the super highway. Quebec Research Group on Medication Use in the Elderly

Effective management of drug therapy in the elderly is a challenge for primary-care physicians. There are 20,400 drugs approved for marketing in Canada. Most elderly patients will fill 33 prescriptions per year and take 5 different medications. To be a safe prescriber in the 1990s, physicians need to be aware that 33,000 drug interactions, 6,500 drug-disease contraindications, and 3,500 drug-allergy contraindications have been documented. Inappropriate prescribing is a problem in the elderly. At least one inappropriate prescription is given to 12% to 46% of seniors, and 25% of drug-related hospital admissions are due to prescribing errors. Half of all physicians will write at least one inappropriate prescription for an elderly patient each year, and one quarter of inappropriate prescriptions will be created by the presence of multiple prescribing physicians. Academic detailing is the most effective approach to improve physician prescribing. However, it is an expensive intervention that must be limited to a small number of drugs and conditions, and it must be continued to retain its effectiveness. Furthermore, it fails to address the problems created by multiple prescribers. In this project, we developed a prototype of the future office practice. Physicians are equipped with personal computers and expert prescribing-system software. This electronic academic detailer reviews all current medications for a patient, identifies therapeutic duplications, generates alerts for 50 prescribing problems that have been identified as clinically relevant by a Canadian expert panel, suggests suitable alternatives, and reviews all new prescriptions for potential problems. Information on all prescriptions received by the physicians' elderly patients is downloaded weekly from the provincial prescription claims database, so that the primary physician is able to coordinate and manage all drugs prescribed to their patients by all physicians. The effectiveness of this intervention is being evaluated in a randomized controlled trial of 110 physicians and approximately 16,000 elderly patients in Montreal. We will test whether the intervention reduces the rate of inappropriate prescribing, as well as the rate of drug-related injuries and hospitalizations among patients treated by physicians in the experimental group.

[Characteristics of physicians prescribing more psychotropic drugs to women than to men]

In industrialized countries, gender differences observed in health condition and the use of medical services appear insufficient to explain a greater consumption of psychotropic drugs in women than men. The authors have tested the hypothesis that physician prescribing patterns largely explains this observation. They demonstrate, using data from the Régie de l'assurance maladie du Québec for people aged 65 and over, that physicians' sociodemographic and practice characteristics are significantly associated with the percentage of men and women who receive a psychotropic drug prescription in their practice.

Analysis of Centers for Disease Control and Prevention criteria for the eosinophilia-myalgia syndrome in a geographically defined population

OBJECTIVE

To test whether individuals can be identified in a geographically defined population who would meet criteria for the eosinophilia-myalgia syndrome (EMS) established by the US Centers for Disease Control and Prevention (CDC), i.e, (1) eosinophil count > 1 x 10(9)/l, (2) myalgia severe enough to limit usual activities of daily living, and (3) no evidence of infection or neoplasm that could explain the first 2 findings.

METHODS

To discover the number of individuals who would meet CDC criteria, the population was exhaustively searched using methods adapted from active pharmacoepidemiologic surveillance. Medical consultants and primary care practitioners were questioned as many as 5 times in a search for patients with severe myalgia. A predetermined protocol was used to screen those patients who appeared to meet CDC criteria for EMS using active surveillance methods. The study population was limited to Québec and Ontario (combined population 18,980,000) with special attention to the period July 1, 1992, to June 30, 1993.

RESULTS

The prevalence of severe incapacitating myalgia was 43 per 100,000 persons, including 19 individuals with eosinophilia > 1 x 10(9)/l, who met CDC criteria for EMS. None of these individuals were reported to have taken L-tryptophan (LT).

CONCLUSION

The CDC criteria for EMS are met by individuals in the general population who have never been exposed to LT.

Do too many cooks spoil the broth? Multiple physician involvement in medical management of elderly patients and potentially inappropriate drug combinations

OBJECTIVES

To determine (a) whether the risk of a potentially inappropriate drug combination (PIDC) increases with the number of physicians involved in the medical management of an elderly patient and (b) whether the risk of a PIDC is reduced if a patient has a single primary care physician or a single dispensing pharmacy, or both.

DESIGN

Cross-sectional retrospective provincial database study.

PARTICIPANTS

A regionally stratified random sample of 51,587 elderly medicare registrants in Quebec who (a) visited at least one physician in 1990, (b) were not living in a health care institution for the entire year and (c) had been dispensed at least one prescription for a cardiovascular drug, a psychotropic drug or a nonsteroidal anti-inflammatory drug (NSAID).

OUTCOME MEASURES

Information on all physician visits and drugs dispensed during 1990. Physician claims were used to identify the number of physicians involved in a patient's management and whether the patient had one primary care physician. Prescription claims were used to identify the number of PIDCs, prescribing physicians and dispensing pharmacies.

RESULTS

The prevalence of PIDCs ranged from 4.0% (among those in the NSAID group) to 20.3% (among those in the psychotropic drug group). Of the PIDCs identified, 17.6% to 25.8% resulted from contemporaneous prescribing by different physicians. The number of prescribing physicians was the most important risk factor for a PIDC in all drug groups (odds ratio [OR] 1.44 to 1.71). The presence of a single primary care physician lowered the risk for cardiovascular and psychotropic PIDCs (OR 0.70 and 0.79 respectively) but not for NSAID PIDCs (OR 0.94). The use of a single dispensing pharmacy lowered the risk of a PIDC in all drug groups (OR 0.68 to 0.79).

CONCLUSION

The greater the number of physicians prescribing medications for an elderly patient, the greater is the risk that the patient will receive a PIDC. A single primary care physician and a single dispensing pharmacy may be "protective" factors in preventing PIDCs.

Continuing occurrence of eosinophilia myalgia syndrome in Canada

Eosinophilia myalgia syndrome (EMS), was defined by the Centers for Disease Control (CDC) as eosinophilia > 1000 mm3 and incapacitating myalgia without infection or neoplasm. Studies suggested that use of L-tryptophan (L-T), was a risk factor. We conducted a pharmacoepidemiological survey in Canada where access to L-T is limited. Using the active surveillance method, a 100% sample of potentially involved specialists and a 15% sample of family physicians from Ontario and Quebec were surveyed regarding treatment of patients with severe myalgia within the past year. Follow-up amplified clinical and laboratory information. Overall response rates were 61.4%. Thirty-eight per cent of respondents reported at least one patient. Of 6423 patients assessed, 19 'definite' and 25 'possible' EMS cases were identified. Information from physicians did not suggest use of L-T in patients with definite or possible EMS. It was considered that the cases found an underestimate of the incidence of EMS. Its continuing occurrence in Canada brings causal interpretations of earlier studies into question.

Neurokinin receptors antagonists: old and new

Four neurokinin antagonists of different size have been used to counteract the myotropic effects of substance P, neurokinin A and neurokinin B in isolated organs containing a single receptor type (monoreceptor systems). These are: the dog carotid artery, the rabbit jugular and cava veins and the guinea pig ileum (NK-1), the rabbit pulmonary artery (NK-2) and the rat portal vein (NK-3). Undeca and octapeptides containing 2 D-Trp residues in their sequences were slightly more active on the NK-1, than on the NK-2 and NK-3 receptors and showed little selectivity. In contrast, compound AcThr-D.Trp(For)-Phe.NMe Bz was found to be as good an antagonist as the larger compounds and showed some selectivity for the NK-1 receptors. When tested against kinins or angiotensin, all compounds were found to be inactive, suggesting that they are specific for neurokinins. The present results show that NK-1 receptor antagonism can be obtained with compounds of different size, including tripeptides and nonpeptides.