Caractérisation d'un organogel à base d'un dérivé amphiphile de la L-alanine

Mémoire numérisé par la Direction des bibliothèques de l'Université de Montréal

Technologies de prescription informatisée et transformation du rôle des pharmaciens communautaires

L’amélioration de la qualité de l’utilisation des médicaments dans les soins primaires est devenue un enjeu crucial. Les pharmaciens communautaires se présentent comme des acteurs centraux dans l’atteinte de cet objectif, en réclamant une extension de leur rôle. L’objectif principal de cette thèse est de mieux comprendre comment les technologies de prescription informatisée (eRx) influencent la transformation du rôle des pharmaciens communautaires. Le premier article présente les résultats d’une étude de cas qui aborde la transformation du rôle des pharmaciens communautaires à partir du concept de professionnalisation. Elle propose un modèle logique des influences d’une technologie de eRx sur cette professionnalisation, élaboré à partir de la typologie de Davenport. Ce modèle logique a été validé en interviewant douze pharmaciens communautaires participant à un projet pilote typique de technologie de eRx. A partir des perceptions des pharmaciens communautaires, nous avons établi que la technologie était susceptible de soutenir la professionnalisation des pharmaciens en passant par cinq mécanismes : la capacité analytique, l’élimination des intermédiaires, l’intégration, l’automatisation et la diffusion des connaissances. Le deuxième article analyse les perturbations induites par les différentes fonctions des technologies de eRx sur la stabilité de la juridiction des pharmaciens communautaires, en se basant sur un cadre de référence adapté d’Abbott. À partir de trente-trois entrevues, avec des praticiens (médecins et pharmaciens) et des élites, cette étude de cas a permis de décrire en détail les influences des différentes fonctions sur les modalités d’action des professionnels, ainsi que les enjeux soulevés par ces possibilités. La perturbation principale est liée aux changements dans la distribution des informations, ce qui influence les activités de diagnostic et d’inférence des professionnels. La technologie peut redistribuer les informations relatives à la gestion des médicaments autant au bénéfice des médecins qu’au bénéfice des pharmaciens, ce qui suscite des tensions entre les médecins et les pharmaciens, mais aussi parmi les pharmaciens. Le troisième article présente une revue systématique visant à faire une synthèse des études ayant évalué les effets des technologies de eRx de deuxième génération sur la gestion des médicaments dans les soins primaires. Cette revue regroupe dix-neuf études menées avec des méthodes observationnelles. Les résultats rapportés révèlent que les technologies sont très hétérogènes, le plus souvent immatures, et que les effets ont été peu étudiés au-delà des perceptions des utilisateurs, qui sont mitigées. Le seul effet positif démontré est une amélioration de la qualité du profil pharmacologique accessible aux professionnels, alors que des effets négatifs ont été démontrés au niveau de l’exécution des prescriptions, tels que l’augmentation du nombre d’appels de clarification du pharmacien au prescripteur. Il semble donc que l’on en connaisse peu sur les effets des technologies de eRx de deuxième génération. Ces trois études permettent de constater que les nouvelles technologies de eRx peuvent effectivement influencer la transformation du rôle du pharmacien communautaire en perturbant les caractéristiques des prescriptions, et surtout, l’information et sa distribution. Ces perturbations génèrent des possibilités pour une extension du rôle des pharmaciens communautaires, tout en soulignant les défis intra et interprofessionnels associés à l’actualisation de ces possibilités. Dans l’ensemble, nos résultats soulignent que les perturbations associées aux technologies de eRx dépassent les éléments techniques du travail des utilisateurs, pour englober de multiples perturbations quant à la nature même du travail et du rôle des professionnels. Les décideurs et acteurs impliqués dans le déploiement des technologies de eRx auraient avantage à prendre en compte l’ensemble de ces considérations pour rapprocher les effets observés des bénéfices promis de ces technologies.The quality of medication use in primary care needs to improve: this has become a crucial issue. Community pharmacists want to play a key role in meeting this objective and are calling for an expanded role. The main objective of this thesis is to better understand how electronic prescription (eRx) technologies are influencing the transformation of the role played by community pharmacists. The first article presents results from a case study on the transformation of the community pharmacists’ role, based on the concept of professionalization. It proposes a logical model of how an eRx technology influences this professionalization, developed from the Davenport typology. The logical model was validated by interviewing twelve community pharmacists participating in a typical pilot project involving an eRx technology. Based on the perceptions of community pharmacists, we have determined that there are five mechanisms by which the technology is likely to support the professionalization of pharmacists: analytic capacity, the elimination of intermediaries, integration, automation and the dissemination of knowledge. The second article analyzes the disturbances produced by the various functions of eRx technologies on the jurisdiction of community pharmacists, based on an adaptation of Abbott’s model. Using data from 33 interviews with practitioners, physicians and pharmacists, as well as elite members of these two professions, this case study provides a detailed description of how different functions influence professionals’ modalities of action, as well as the issues raised by these possibilities. The primary disturbance is associated with changes in the distribution of information, which can influence the diagnostic and inference activities of professionals. The technology may redistribute information on the management of medication to the benefit of both physicians and pharmacists, and this creates tensions, not only between physicians and pharmacists but also among pharmacists. The third article presents a systematic review that synthesized studies assessing the impacts of second-generation eRx technologies on the management of medication in primary care. It examined 19 studies that applied observational methods. The findings reveal that the technologies are very heterogeneous and often far from mature, and that their effects received little attention beyond the perceptions of users, which were mixed. The only positive impact shown is an improvement to the quality of the pharmacological profile available to professionals. Negative impacts touched on the execution of prescriptions, such as a greater number of calls from pharmacists to prescribers to clarify information. It would therefore appear that little is known about the impacts of second-generation eRx technologies. These three studies allow us to conclude that new eRx technologies may well influence how the role of the community pharmacist is being transformed, specifically by disturbing the characteristics of prescriptions and, above all, information and its distribution. These disturbances generate opportunities for extending the role of community pharmacists, while underscoring the intra and interprofessional challenges associated with their realization. Overall, our results suggest that the disturbances associated with eRx technologies go beyond technical aspects of users’ work, to include multiple disturbances of the very nature of the professionals’ work and role. The decision makers and actors involved in deploying eRx technologies would be well advised to take all these considerations into account to bring the observed effects of these technologies more in line with their promised benefits

Tyrosine-based rivastigmine-loaded organogels in the treatmant of Alzheimer's disease

Faculté de PharmacieOrganogels can be prepared by immobilizing an organic phase into a threedimensional network coming from the self-assembly of a low molecular weight gelator molecule. In this work, an injectable subcutaneous organogel system based on safflower oil and a modified-tyrosine organogelator was evaluated in vivo for the delivery of rivastigmine, an acetylcholinesterase (AChE) inhibitor used in the treatment of Alzheimer’s disease. Different implant formulations were injected and the plasmatic drug concentration was assayed for up to 35 days. In parallel, the inhibition of AChE in different brain sections and the biocompatibility of the implants were monitored. The pharmacokinetic profiles were found to be influenced by the gel composition, injected dose and volume of the implant. The sustained delivery of rivastigmine was accompanied by a significant prolonged inhibition of AChE in the hippocampus, a brain structure involved in memory. The implant induced only a minimal to mild chronic inflammation and fibrosis, which was comparable to poly(D,L-lactide-co-glycolide) in situ-forming implants. These findings suggest that tyrosine-based organogels could represent an alternative approach to current formulations for the sustained delivery of cholinesterase inhibitors.IRS

Using linked administrative, clinical and primary data to explore the impact of and factors associated with non-adherence to in-hospital medication changes in 30-days post hospital discharge

Introduction Identifying strategies to prevent hospital readmissions remains elusive since the reasons for returning to hospital can include a number of interlinked patient, health provider and system level factors. The impact of patient medications are of significant interest since a large proportion of re-admissions are related to adverse drug events. Objectives and Approach The objective was to determine which factors are associated with non-adherence to in-hospital medications and the impact of non-adherence on re-hospitalization, emergency department visits and death in the 30-days post discharge for patients admitted at two tertiary care academic hospitals in Montreal, Quebec between October 2014 and May 2016. Non-adherence to in-hospital changes was measured by comparing patient discharge prescriptions (patient chart) to medications filled in community 30-days post-discharge (dispensing data) and included i) community medications stopped in-hospital and filled post-discharge, ii) community medications modified in-hospital but not filled at the modified daily-dose, and iii) new medications not filled post-discharge. Results Among 2,895 included patients, mean age was 70 (SD 15) and 58% were males. A median of 4 in-hospital medication changes were made (IQR:3-6) and 54% of patients were non-adherent to at least one change. Multivariable Poisson models suggested that the most important factor associated with the number of new medications not filled post discharge was out of pocket cost; for each additional $10 increase in costs there was a 20% increase in the number of new medications not filled. Multivariable time-varying Cox models suggested that in patients who filled medications post-discharge, selective non-adherence to new and discontinued medications reduced the risk adverse health outcomes in 30-days, while not filling any medications post discharge more than doubled the risk of an adverse event in 30-days. Conclusion/Implications Not only did the majority of patients not follow all medication changes that were made during hospitalization, the extent to which this occurred significantly impacted the risk of hospital re-admissions and ED visits. Policy and patient level interventions should be developed specifically targeting barriers for adherence to medication changes

Impacts of second-generation electronic prescriptions on the medication management process in primary care: A systematic review

International audienceOBJECTIVE:To describe second-generation electronic prescription (eRx) technologies and identify their impacts on the medication management process in primary care. Second-generation eRx technologies have focused on networking various stakeholders so that they can communicate electronically.METHOD:Using key words, a search was conducted of the relevant databases up to January 2011. A manual search was conducted of the bibliographies of the studies as well as the prior systematic reviews found. The tables of contents of the major periodicals in the field were also searched. This included studies of the impacts of eRx technologies that allow electronic circulation of information between prescription sites and dispensing sites, independent of the methodology used. A structured form was used to extract the data. The studies' impacts were classified by stage in the medication management process (prescription, transmission of the prescription, execution of the prescription and use of the medication).RESULTS:Nineteen observational studies were included in this review. Most of them (10/19) have evaluated users' perceptions using interviews, focus groups or questionnaires. Two technology models stand out: the push model, under which the prescriber directs the prescription toward a specific pharmacy, and the pull model, under which any authorized pharmacy can download a given prescription into its system. The push model is the most widely used, particularly in the United States. Communication between prescribers and dispensers is usually unidirectional, and communications standards have to be refined. The only demonstrated impacts of second-generation eRx technologies were found at two levels: positive impacts on the quality of the pharmacological profile available to professionals, and negative impacts on the execution of prescriptions in pharmacies. Stakeholders' perceptions were mixed and reflected considerable differences according to context, the type of technology used, the intensity of its use and its maturity. Electronic transmission of prescriptions provides a new way to monitor patient compliance.CONCLUSION:There is little empirical data demonstrating benefits to second-generation eRx technologies, even if it is a highly promoted model for improving primary care quality. More research is required, with studies that measure the impacts of second-generation technologies using empirical data and conducted in the context of actual use. Future studies should also employ the same terminology and provide full descriptions of context, type of technology and intensity of us

Respect de l'autonomie et de la vie privée lors de l'accès et l'utilisation secondaire des données personnelles de santé au Québec: perspectives croisées et solutions émergentes

Conférence présentée lors du 89e Congrès de l'ACFAS du 9 au 13 mai 2022

Formulaire d'information et de consentement - Projet TRAP

Formulaire d'information et de consentement utilisé dans le cadre du Projet TRA

Plan de gestion des données de recherche - Extrait

Extrait du plan de gestion des données de recherche pour le Projet TRAP. Ce plan a été légèrement modifié de sa version originale afin d'assurer la sécurité des données, tout en favorisant les principes de science ouverte

Projet TRAP

Le projet TRAP vise à mieux comprendre les points de vue et expériences de diverses parties prenantes concernées par les processus d'accès et d'utilisation secondaire des données personnelles de santé au Québec ainsi qu'à acquérir de nouvelles connaissances quant aux enjeux éthiques, juridiques et organisationnels y étant associés