Experiences of Health System Preceptors and Faculty Advisors with Community Service-Learning Initiatives: Learning from the Dalhousie University Drug Use Management and Policy Residency Program

From 2001 to 2011, an innovative approach to pharmaceutical policy and drug use management graduate education—the Drug Use Management and Policy Residency Program—was developed and implemented by the College of Pharmacy at Dalhousie University in Halifax, Nova Scotia, Canada. This in-depth qualitative assessment of the experience of faculty members and site preceptors who guided residents in their 17-week placements identifies components, characteristics, strategies, and principles associated with successful service-learning initiatives and provides guidance around the development of programs in other jurisdictions.

Trends and uptake of new formulations of controlled-release oxycodone in Canada

Purpose: This study investigated the impact of changing availability of tamper‐deterrent and non‐tamper‐deterrent oxycodone on prescribing patterns of controlled‐release oxycodone across Canada. Methods: We conducted a population‐based, serial cross‐sectional study of controlled‐release oxycodone dispensing from community pharmacies across Canada between October 2007 and April 2016. We calculated rates of dispensing (tablets per 100 population) and reported the relative market share of generic non‐tamper‐deterrent controlled‐release oxycodone. All analyses were reported nationally and stratified by province. Results: After the introduction of a tamper‐deterrent formulation, the national rate of controlled‐release oxycodone dispensing fell by 44.6% (from 26.4 to 14.6 tablets per 100 population from February 2012 to April 2016). Between December 2012 and July 2013, there was moderate uptake of generic non‐tamper‐deterrent controlled‐release oxycodone (968 452 tablets; 16.0% in July 2013), which appeared to have little impact on the overall rate of controlled‐release oxycodone dispensing in Canada. However, the uptake of generic non‐tamper‐deterrent oxycodone varied considerably by province. By April 2016, 55.0% of all controlled‐release oxycodone tablets dispensed in Quebec were for the generic formulation. […

Hypertension control: results from the Diabetes Care Program of Nova Scotia registry and impact of changing clinical practice guidelines

BACKGROUND: The objective of this study was to determine the rate of blood pressure control according to 4 sets of Canadian guidelines published over a decade in patients with diabetes mellitus attending Diabetes Centres in the province of Nova Scotia. METHODS: One hundred randomly selected charts from each of 13 Diabetes Centres audited between 1997 and 2001 were extracted from the Diabetes Care Program of Nova Scotia Registry. Multivariate logistic regression analyses examined the relationship between individual characteristics and self-reported antihypertensive use. Included were 1132 adults, mean age 63 years (48% male), with 9 years mean time since diagnosis of diabetes. RESULTS: According to the 1992 guidelines, 63% of the patients and according to the 2003 guidelines, 84% of patients were above target blood pressure or receiving antihypertensive medications. Forty-seven percent of patients are considered to be hypertensive and not on treatment according to 2003 guidelines. The results of the multivariate analyses showed that the only factors independently associated with anti-hypertensive use was oral anti-hyperglycemic use. CONCLUSION: Hypertension is an additional risk factor in those with diabetes mellitus for macrovascular and microvascular complications. The health and budgetary impacts of addressing the treatment gap need to be further explored

Expanding the Scope of Community Pharmacy Practice in Nova Scotia: Impacts on Provincial COVID-19 Response

Nova Scotia has expanded the scope of practice for community pharmacists by allowing, among other changes, pharmacist prescribing under specific circumstances (2011) and administration of drugs by injection (2013), thereby alleviating stress on the health system. Due to these progressive expansions in community pharmacy scope of practice, Nova Scotia community pharmacy personnel (about 1,500 pharmacists and 246 technicians working in 315 pharmacies) were rapidly able to play key roles in the province’s response to the COVID-19 pandemic. Community pharmacies provided medicines, medical devices, personal protective equipment, hand hygiene solutions, thermometers, and pulse oximeters to patients and the public. In addition, they have responded to patients’ COVID-19-related needs by treating symptoms; providing referrals; discussing the benefits and risks of COVID-19 vaccines and administering them; making nirmatrelvir/ritonavir assessments; and addressing vaccine hesitancy and the spread of misinformation about COVID-19. Moreover, as in some other provinces, community pharmacists in Nova Scotia have played a leading role in delivering COVID-19 vaccines from almost the start of the vaccination campaign in December 2020. Their role expanded further in May 2022, when pharmacists were granted prescribing authority for inhaled budesonide in accordance with the provincial protocol to treat mild SARS-CoV-2 respiratory symptoms. La Nouvelle-Écosse a élargi le champ d’exercice des pharmaciens communautaires en autorisant, entre autres, la prescription par un pharmacien dans des circonstances spécifiques (2011) et l’administration de médicaments par injection (2013), soulageant ainsi le système de santé. Grâce à ces élargissements progressifs du champ d’exercice des pharmacies communautaires, le personnel des pharmacies communautaires de Nouvelle-Écosse (environ 1 500 pharmaciens et 246 techniciens travaillant dans 315 pharmacies) a pu contribuer de manière cruciale et rapide à la réponse de la province à la pandémie de COVID-19. Les pharmacies communautaires ont fourni des médicaments, des dispositifs médicaux, des équipements de protection individuelle, des solutions pour l’hygiène des mains, des thermomètres et des oxymètres de pouls aux patients et au public. En outre, elles ont répondu aux besoins des patients liés à la COVID-19 en traitant les symptômes, en orientant les patients, en discutant des avantages et des risques des vaccins contre la COVID-19 et de leur administration, en évaluant la pertinence de traiter certains patients au nirmatrelvir/ritonavir et en répondant à l’hésitation vaccinale et à la diffusion d’informations erronées sur la COVID-19. De plus, les pharmaciens communautaires de Nouvelle-Écosse, comme ceux d’autres provinces, ont joué un rôle de premier plan dans l’administration des vaccins contre la COVID-19 dès le début de la campagne de vaccination en décembre 2020. Leur rôle s’est encore élargi en mai 2022, lorsque les pharmaciens ont été autorisés à prescrire du budésonide inhalé, conformément au protocole provincial, pour traiter les symptômes respiratoires légers du SRAS-CoV-2

Adherence to guidelines and the Screening Tool of Older Persons' potentially inappropriate Prescriptions criteria for colchicine dosing for gout treatment in beneficiaries of the Nova Scotia Seniors' Pharmacare Program Clinical Therapeutics

Purpose: Colchicine is commonly used in the management of gout; however, older persons have higher risks of toxicity. Accordingly, the Screening Tool of Older Person’s potentially inappropriate Prescriptions (STOPP) criteria for colchicine consider 43 months of treatment as potentially inappropriate in older persons. Recent evidence also suggests lower dosing of colchicine is as effective and results in fewer toxicities than high-dose colchicine. The objectives of this study were to determine the dose, duration, and prescribers of colchicine and to evaluate adherence to the STOPP criteria and international guidelines for colchicine in older persons. Methods: A retrospective, observational study was conducted from April 1, 2006 to March 31, 2011 to evaluate colchicine use. Nova Scotia Seniors’ Pharmacare Program beneficiaries who met inclusion criteria for an incident case of gout and who filled at least 1prescription for colchicine during the study period were included. Colchicine dose and duration were reported descriptively. Multivariate logistic regression was used to identify predictors of the study population in making a claim for colchicine 490 and 4180 days. Findings: A total of 518 persons were dispensed 1327 courses of colchicine during the study period. The mean daily dose of colchicine ranged from 1.39 to 1.50 mg. Colchicine doses 41.2 mg were prescribed in approximately one-third of the study population. Colchicine was prescribed for 490 days in 14.2% of treatment courses and for 4180 days in 8.1% of treatment courses. Female sex was the only predictor of treatment duration 490 days. Implications: This study is the first to report on colchicine dose and duration using STOPP criteria in a specific cohort of older persons with incident gout. Strategies to improve colchicine prescribing in older persons are needed

Influence of drug safety advisories on drug utilisation: an international interrupted time series and meta-analysis

OBJECTIVE: To evaluate the association between regulatory drug safety advisories and changes in drug utilisation. DESIGN: We conducted controlled, interrupted times series analyses with administrative prescription claims data to estimate changes in drug utilisation following advisories. We used random-effects meta-analysis with inverse-variance weighting to estimate the average postadvisory change in drug utilisation across advisories. STUDY POPULATION: We included advisories issued in Canada, Denmark, the UK and the USA during 2009-2015, mainly concerning drugs in common use in primary care. We excluded advisories related to over-the-counter drugs, drug-drug interactions, vaccines, drugs used primarily in hospital and advisories with co-interventions within ±6 months. MAIN OUTCOME MEASURES: Change in drug utilisation, defined as actual versus predicted percentage change in the number of prescriptions (for advisories without dose-related advice), or in the number of defined daily doses (for dose-related advisories), per 100 000 population. RESULTS: Among advisories without dose-related advice (n=20), the average change in drug utilisation was -5.83% (95% CI -10.93 to -0.73; p=0.03). Advisories with dose-related advice (n=4) were not associated with a statistically significant change in drug utilisation (-1.93%; 95% CI -17.10 to 13.23; p=0.80). In a post hoc subgroup analysis of advisories without dose-related advice, we observed no statistically significant difference between the change in drug utilisation following advisories with explicit prescribing advice, such as a recommendation to consider the risk of a drug when prescribing, and the change in drug utilisation following advisories without such advice. CONCLUSIONS: Among safety advisories issued on a wide range of drugs during 2009-2015 in 4 countries (Canada, Denmark, the UK and the USA), the association of advisories with changes in drug utilisation was variable, and the average association was modest

Evidence-based cardiovascular care in the community: A population-based cross-sectional study

BACKGROUND: Ischaemic heart disease and congestive heart failure are common and important conditions in family practice. Effective treatments may be underutilized, particularly in women and the elderly. The objective of the study was to determine the rate of prescribing of evidence-based cardiovascular medications and determine if these differed by patient age or sex. METHODS: We conducted a two-year cross-sectional study involving all hospitals in the province of Nova Scotia, Canada. Subjects were all patients admitted with ischaemic heart disease with or without congestive heart failure between 15 October 1997 and 14 October 1999. The main measure was the previous outpatient use of recommended medications. Chi-square analyses followed by multivariate logistic regression analyses were used to examine age-sex differences. RESULTS: Usage of recommended medications varied from approximately 60% for beta-blockers and angiotensin converting enzyme (ACE) inhibitors to 90% for antihypertensive agents. Patients aged 75 and over were significantly less likely than younger patients to be taking any of the medication classes. Following adjustment for age, there were no significant differences in medication use by sex except among women aged 75 and older who were more likely to be taking beta-blockers than men in the same age group. CONCLUSIONS: The use of evidence-based cardiovascular medications is rising and perhaps approaching reasonable levels for some drug classes. Family physicians should ensure that all eligible patients (prior myocardial infarction, congestive failure) are offered beta-blockers or ACE inhibitors

Medication Persistence Rates and Factors Associated with Persistence in Patients Following Stroke: A Cohort Study

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Hydroxyzine Initiation Following Drug Safety Advisories on Cardiac Arrhythmias in the UK and Canada: A Longitudinal Cohort Study

INTRODUCTION: Regulatory advisories on hydroxyzine and risk of QT prolongation and Torsade de pointes (TdP) were issued in the UK in April 2015 and Canada in June 2016. We hypothesized patients with risk factors for QT prolongation and TdP, compared with those without risk factors, would be less likely to initiate hydroxyzine in the UK and in British Columbia (BC), Canada, following advisories. METHODS: We conducted a longitudinal study with repeated measures, and evaluated hydroxyzine initiation in a UK cohort and a concurrent BC control cohort (April 2013-March 2016) as well as in a BC advisory cohort (June 2014-May 2017). RESULTS: This study included 247,665 patients in the UK cohort, 297,147 patients in the BC control cohort, and 303,653 patients in the BC advisory cohort. Over a 12-month post-advisory period, hydroxyzine initiation decreased by 21% in the UK (rate ratio 0.79, 95% confidence interval 0.66-0.96) relative to the expected level of initiation based on the pre-advisory trend. Hydroxyzine initiation did not change in the BC control cohort or following the Canadian advisory in the BC advisory cohort. The decrease in hydroxyzine initiation in the UK in the 12 months after the advisories was not significantly different for patients with risk factors compared with those without risk factors. CONCLUSION: Hydroxyzine initiation decreased in the UK, but not in BC, in the 12 months following safety advisories. The decrease in hydroxyzine initiation in the UK was not significantly different for patients with versus without risk factors for QT prolongation and TdP

Hypertension and type 2 diabetes: What family physicians can do to improve control of blood pressure - an observational study

Background: The prevalence of type 2 diabetes is rising, and most of these patients also have hypertension, substantially increasing the risk of cardiovascular morbidity and mortality. The majority of these patients do not reach target blood pressure levels for a wide variety of reasons. When a literature review provided no clear focus for action when patients are not at target, we initiated a study to identify characteristics of patients and providers associated with achieving target BP levels in community-based practice. Methods: We conducted a practice- based, cross-sectional observational and mailed survey study. The setting was the practices of 27 family physicians and nurse practitioners in 3 eastern provinces in Canada. The participants were all patients with type 2 diabetes who could understand English, were able to give consent, and would be available for follow-up for more than one year. Data were collected from each patient’s medical record and from each patient and physician/nurse practitioner by mailed survey. Our main outcome measures were overall blood pressure at target (< 130/80), systolic blood pressure at target, and diastolic blood pressure at target. Analysis included initial descriptive statistics, logistic regression models, and multivariate regression using hierarchical nonlinear modeling (HNLM). Results: Fifty-four percent were at target for both systolic and diastolic pressures. Sixty-two percent were at systolic target, and 79% were at diastolic target. Patients who reported eating food low in salt had higher odds of reaching target blood pressure. Similarly, patients reporting low adherence to their medication regimen had lower odds of reaching target blood pressure. Conclusions: When primary care health professionals are dealing with blood pressures above target in a patient with type 2 diabetes, they should pay particular attention to two factors. They should inquire about dietary salt intake, strongly emphasize the importance of reduction, and refer for detailed counseling if necessary. Similarly, they should inquire about adherence to the medication regimen, and employ a variety of patient-oriented strategies to improve adherence