2016 OPEN summit

Poster presentation abstracts

Session A: Practice Models

1. Results of the evaluation framework scoping review

Ava Nainifard, Teegan Ignacy, Lucas Di Nardo, Sarah Rietkoetter, Lisa Dolovich

A scoping literature review was conducted to identify and assess existing pharmacy and allied healthcare evaluation frameworks, measures, and outcomes to be used to develop a pharmacy services evaluation framework in the Canadian context. Published literature was searched from 1990 to 2014 using Medline, Embase and CINAHL. Grey literature was searched using OpenGrey, Health Care Management Information Consortium, National Technical Information Services, Google Scholar, and governmental and organizational websites. In total, 26 published articles and 18 evaluation frameworks from the grey literature were identified. No comprehensive evaluation frameworks related to pharmacy services were found in the literature.

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2. Jurisdictional and evidence review of pharmacist-led minor ailments programs: Toward an Ontario framework

Rebekah Lee, Lisa McCarthy

Six provinces have authorized pharmacist prescribing for minor ailments (PPMA). We undertook a jurisdictional and evidence review related to PPMA. Medline, Embase, IPA and Google were searched (from inception to November 2014) to identify relevant materials. Available evidence suggests PPMA results in moderate to high symptom resolution rates, high patient satisfaction and potential cost savings. In Canada, prescribing is restricted to a list of ailments and drug formulary; however, training requirements vary. Saskatchewan has developed prescribing guidelines and reimburses pharmacies for this service. Preliminary evaluations of PPMA are promising. Understanding existing systems informs the dialogue about future frameworks in other provinces, including Ontario.

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3. Pharmacists’ expanded immunization authority: A regulatory review

Nancy Waite, Dana Church, Sarah Johnson, Lalitha Raman-Wilms, Nedzad Pojskic, Jane Pearson-Sharpe, Eric Schneider, Sherilyn Houle

This review summarizes pharmacist immunization authority across several jurisdictions. Two independent reviewers searched legislation and contacted key informants and found that 6 out of 10 provinces allow pharmacists to administer vaccines. Ontario, Newfoundland/Labrador, Saskatchewan, New Zealand, and several Australian jurisdictions limit authority to the influenza vaccine. All US states allow pharmacists to immunize, with 78% authorizing any vaccine. Training requirements are similar across jurisdictions, and pharmacy student legislation is similar although not identical to pharmacist authority. Pharmacists’ immunization authority is expanding across Canada. All reviewed jurisdictions require similar training; however, some differences exist regarding eligible vaccines and requirements for physician orders.

Session B: Patient Care

1. Pharmacist prescribing: A scoping review about the views and experiences of patients and the public

Ida-Maisie Famiyeh, Lisa McCarthy

This scoping review describes the views and experiences of patients and the public about pharmacist prescribing. Sources included Medline, Embase and IPA (searched from inception to November 2015) and emerging themes were narratively synthesized. Of 2,377 citations, 22 articles met the inclusion criteria with most originating from the United Kingdom. Patients were satisfied with pharmacists’ interpersonal communication and the services provided. Patients and the public were concerned about the lack of accessibility of their medical records by pharmacists and privacy during the consultation. Identified themes are being used to develop questions about pharmacist prescribing for an Ontario study of patients.

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2. Should I continue taking my acid reflux medication? Development and pilot testing of a patient decision aid

Wade Thompson, Barbara Farrell, Vivian Welch, Lise Bjerre, Peter Tugwell

Proton pump inhibitors (PPIs) effectively treat gastroesophageal reflux disease. Many patients with mild or moderate symptoms require PPIs for 4–8 weeks but take them long term unnecessarily. Patients may face the decision to continue their PPI, use a lower dose or stop and use only when symptoms return (on-demand). Decisions should be informed, consistent with values and made in collaboration with a clinician. Patient decision aids educate patients and help them clarify values. We developed a decision aid to empower patients to make an informed, shared decision surrounding continued PPI treatment, and will pilot test the decision aid in two primary care clinics.

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3. Factors affecting the delivery of a pharmacist-led medication review: Evidence from the MedsCheck annual service

Petros Pechlivanoglou, Lusine Abrahamyan, Linda MacKeigan, Lisa Dolovich, Giulia Consiglio, Valeria Rac, Jonghyun Shin, Suzanne Cadarette, Murray Krahn

We identified factors affecting the likelihood of eligible Ontario seniors receiving the MedsCheck Annual (MCA) service. We designed a cohort study using pharmacy claims from linked health administrative databases collected between April 2012 and March 2013 for a 20% random sample of Ontario seniors. We identified pharmacy “claim-dates” for individuals receiving three or more chronic prescription medications who had not had an MCA within the last year. We developed a conceptual framework that identified potential individual, pharmacy and community-level predictors of MCA utilization. A generalized-estimating-equations model was constructed to estimate the effect of each factor on the likelihood of receiving an MCA. Of the 2,878,958 eligible claim-dates, 65,605 included an MCA. Compared with eligible individuals who did not receive an MCA, recipients were more likely to have had a prior MCA (OR:3.05), receive a new medication on the claim-date (OR:1.78), be receiving a high-risk medication (OR:1.1) or have recently been discharged from hospital (OR:1.07). In contrast, MCA recipients had fewer medications (baseline: 3–4 medications; ORs: 7–8 medications:0.80, 9–11 medications:0.64, 12+ medications:0.44) and fewer comorbidities (OR:0.98) were less likely to receive an MCA in a rural (baseline: urban. ORs: small urban:0.75, rural:0.74) or high-volume pharmacy (OR:0.65) or if prescribed an inappropriate medication (OR:0.9). Those prescribed a new or high-risk medication or those who had been recently hospitalized were more likely to receive an MCA. In contrast, older seniors with multiple comorbidities and multiple medications were less likely to receive an MCA. Policy regarding MCA funding may need to evolve to ensure that those at greatest need receive timely and comprehensive medication reviews.

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4. Opioid management in chronic pain by pharmacists providing care in the community setting in Ontario

Beth Sproule, Feng Chang, Tejal Patel, Jane Jurcic, Lalitha Raman-Wilms

The objectives of this study were to develop and evaluate a pharmacist-training program in opioid management, and to evaluate the feasibility of a pharmacist-led clinical service for opioid management in chronic pain. The training program consisted of an online course, five seminars, and a mentoring program. Self-assessments of ability and test scores improved post training (n=27, p=0.01). In the ongoing clinical phase, pharmacists are using the pharmaceutical care model to implement an opioid management service into their practice in patients initiating opioids or prescribed high-dose opioids. This project is one strategy to promote pharmacist engagement in opioid management as part of the healthcare team in primary care.

Session C: Pharmacist Services

1. The Ontario MedsCheck Diabetes pharmacist medication review service: A descriptive analysis of service recipients between 2010–2014 using administrative claims data

Lisa Dolovich, Lori MacCallum, Giulia Consiglio, Linda MacKeigan, Elizabeth Bojarski, Nedzad Pojskic, Suzanne Cadarette

A MedsCheck Diabetes (MCD) consultation is a pharmacist-led medication review service funded by the Ontario government for people with diabetes. Pharmacists are remunerated $75 for an annual review and $25 for follow-up assessments. This cohort study leverages linked administrative claims data from September 13, 2010 (inception) to March 31, 2014, including the Ontario Drug Benefit program data where MCD services are recorded. The MCD service was provided to 406,694 Ontarians (45% seniors, 54% male) since inception. Over 95% of MCD services delivered were annual reviews. 2011– 12 was the highest service delivery year (126,538 recipients), with a very slight decline overall in subsequent years, more prominent amongst those 66 years and older. 19% of recipients were immigrants; 7% of recipients had experienced a hospitalization or emergency department visit 30 days before MCD. In the year before MCD, recipients 66 years and older received an average of 10 prescription drugs and 9% had high medication costs ($4,000+). In under 4 years, approximately 25% of Ontarians with diabetes have received an MCD. Few recipients received a follow-up assessment. Initial uptake of MCD service was rapid; however, the number receiving the service over time is decreasing, especially among older Ontarians.

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2. Estimating uptake of community pharmacists independently renewing and adapting prescriptions: A preliminary investigation

Rebecca Babaei-Rad, Elizabeth Bojarski, Linda Perfetto, Michael Nashat, Lisa McCarthy

We evaluated the feasibility of analyzing data gathered through proprietary electronic documentation modules to explore Ontario pharmacists’ uptake of renewals and adaptations authority. Over one year (Mar 2014 to Feb 2015), 555 records were created: 550 (99%) were renewal, with emergency supply being the most frequent reason (460/550, 83.5%). Several limitations of the data include the following: small sample size, few encounters documented, days’ supply and prescriber credentials were not included, and the module lacked capacity for reporting on multiple renewals performed in one encounter. Changes to the modules and their enhanced usage are required before province-wide hypotheses can be generated.

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3. Pharmaceutical opinions in Ontario: A descriptive analysis using administrative claims data

Lisa Dolovich, Giulia Consiglio, Andrew Calzavara, Elizabeth Bojarski, Linda MacKeigan, Nedzad Pojskic, Lori MacCallum, Suzanne Cadarette

A Pharmaceutical Opinion (PO) is a community pharmacy service reimbursed since 2011 by the Ontario Drug Benefit (ODB) plan. It consists of a pharmacist’s drug therapy recommendation to the prescriber with an outcome of the prescription being dispensed as prescribed, not dispensed, or adjusted. This cohort study leveraged linked administrative claims data from April 1, 2011 to March 31, 2013. The PO service was provided to 226,971 Ontarians from April 1, 2011 to March 31, 2013. Provision of POs more than doubled over these two years of the program. The majority resulted in a recommendation to change a prescription (73%; similar across sexes). Over the two years of the program, 58% of recipients were women and 30% of recipients were social assistance beneficiaries. In the 30 days before a PO claim, 15% of all recipients had experienced a hospitalization or emergency department visit. In the year before a PO claim of those over 66 years of age, 12% had high medication costs ($4,000+) and received an average of 11 prescription drugs. Only 27% of POs claims had a prescription filled on the same day. The majority of PO recipients were seniors and women, similar to what we see for prescription volume. Most POs involved a recommendation to change the prescription. Most POs were not billed on the same day as the claimant’s dispensed prescriptions, limiting ability to identify the medication associated with each PO.

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4. Best practices in the provision of MedsCheck services: A multi-case study

Amanda Day, Linda MacKeigan, Lisa Dolovich, Sara Guilcher

In 2007, Ontario’s MedsCheck was the first community pharmacy-based medication review program to be publicly funded in Canada. Because best practices for medication reviews have not been described in the literature, objectives of this multi-case study are to: (1) characterize best practices for adherence-focused medication reviews such as MedsCheck, (2) identify facilitators, and (3) make recommendations for achieving best practice. Golden’s Star Model for the design of healthcare organizations will provide the study framework. Using best practices criteria adapted from the nursing literature, 4–6 community pharmacy cases will be selected. Data sources will include non-participatory observations of MedsCheck consultations, MedsCheck documentation, and semi-structured interviews with pharmacy staff.

Session D: Interprofessional Care

1. Development of an evidence-based clinical practice guideline for deprescribing of antihyperglycemics in the elderly

Cody Black, Wade Thompson, Manon Bouchard, Heather Lochnan, Lori MacCallum, Lisa McCarthy, Carlos Rojas-Fernandez, Salima Shamji, Ross Upshur, Vivian Welch, Barbara Farrell

Diabetes management in the frail elderly can be challenging. Canadian diabetes guidelines have recently relaxed A1C targets for this population, considering risk of hypoglycemia and unknown benefit of overly intense control. This deprescribing guideline is being developed using GRADE (Grading of Recommendations Assessment, Development, and Evaluation) informed by systematic review and expert consensus, as per methods developed by the Deprescribing team. The poster features findings, quality of evidence ratings and a draft recommendation. Suggestions for clinical considerations are included. This research aims to develop an evidence-based deprescribing guideline that allows prescribers to effectively manage antihyperglycemics in the frail elderly.

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2. Effect of a proton pump inhibitor (PPI) deprescribing guideline on PPI drug costs in long-term care

Wade Thompson, Matthew Hogel, Denis O’Donnell, Yan Li, Kednapa Thavorn, Lisa Dolovich, Lisa McCarthy, Cody Black, Barbara Farrell, Michael Elten

PPIs treat upper gastrointestinal diseases, but should be used only for a short duration in many patients. Canadian public drug programs spent $247 million on PPIs in 2012. Between 50–80% of PPI use may be inappropriate. Our group developed a PPI deprescribing guideline to reduce unnecessary PPI use and implemented it in three long-term care (LTC) homes. We evaluated the effect of the guideline in one LTC home by measuring PPI use and drug costs nine months before guideline implementation and 12 months after. We found a reduction in PPI use and drug costs after guideline implementation.

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3. The Opioid Education Partnership: Pharmacists as collaborators in reducing prescription opioid misuse

Feng Chang, Tejal Patel, Agnes Kluz, Rosemary Killeen

Canada has the second highest use of opioids in the world, with opioid misuse occurring in as many as one in five patients. Overuse is on the rise, putting patients at risk for hospitalizations and overdose deaths. Physicians and pharmacists frequently encounter opioid-related adverse events but gaps exist in clinician knowledge, attitudes and beliefs regarding prescription opioids. There is also a lack of resources promoting meaningful collaborations between physicians and pharmacists. The Opioid Education Partnership is an initiative that targets primary care providers, students and trainees in medicine and pharmacy to support and facilitate collaborative care for patients receiving prescription opioids. The partnership uses a three-pronged approach: (1) an online education program drawing upon evidence-based guidelines and best practices; (2) an accompanying toolkit of resources and practice tools readily accessible for practitioners at the point of care; and (3) an online platform for participants to provide peer support, share knowledge and practice experiences. Ultimately, this initiative aims to promote pharmacists working collaboratively with physicians in reducing prescription opioid misuse.

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4. Engaging pharmacists, clinicians, and the public in determining the components and processes needed to use the knowledge and the practice of “deprescribing”

Barbara Farrell, James Conklin, Susan Conklin, Hannah Irving

The Deprescribing project aims to assist clinicians, pharmacists, and patients in coordinating the reduction or discontinuation of medications that may no longer be indicated or may be causing side effects. Our applied health research question process uses a community-engagement approach in two communities to involve pharmacists, clinicians, and the public in conversations to introduce the benefit of deprescribing and the process of appropriately, effectively and safely using the evidence-based tools available to assist them. This poster provides an initial overview of community profiles, as well as perspectives on the components and processes needed to use the knowledge and the practice of “deprescribing.”

Session E: Building Capacity in Health

1. The impact of a PPI deprescribing guideline on clinician self-efficacy for deprescribing tasks

Barbara Farrell, Lisa Sunstrum, James Conklin, Lalitha Raman-Wilms, Hannah Irving, David de Launay, Wasem Alsabbagh

Clinicians express a lack of confidence or ability in carrying out tasks related to deprescribing medications. Evidence-based deprescribing guidelines are intended to provide support to facilitate deprescribing. Currently, no instruments exist to measure self-efficacy to deprescribe medications. We developed a survey, using Bandura’s methods, to measure self-efficacy in carrying out nine deprescribing tasks. Pre- and post-implementation surveys were administered to physicians, pharmacists and nurse practitioners in our six sites for each of the three deprescribing guidelines. This poster highlights the survey development process and quantitative findings related to proton pump inhibitor deprescribing self-efficacy before and after guideline implementation.

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2. Expanding pharmacy practice research capacity in Canada: The making of a stakeholder-engaged, multi-institutional, multi-disciplinary collaboration

Lisa Dolovich, Linda MacKeigan, Sara Marshall, Nancy Waite

OPEN’s structure was developed to provide central support for the multi-institutional, multidisciplinary research collaborative, and to support stakeholder input. Activities have included forming research teams; providing central financial, operational, capacity building and knowledge translation support; and building strong relationships with stakeholders. In 2015, 31 investigators, 24 staff and over 60 students from multiple disciplines at 10 institutions are working on 22 studies using quantitative and qualitative methods using primary data collection or administrative data. An executive group directs OPEN and works closely with three committees representing research leads, and scientific and stakeholder advisors. Ongoing interaction with government, policy and professional associations, health organizations, practitioners and patients provide valuable research input. The 2014 OPEN Summit succeeded in engaging key stakeholders to discuss research results and direct ongoing research. In addition, evidence is regularly presented to policy makers to inform healthcare transformation.

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3. Deprescribing guidelines for the elderly: How developmental evaluation is strengthening our process

James Conklin, Barbara Farrell, Hannah Irving, Lalitha Raman-Wilms, Lisa McCarthy, Carlos Rojas-Fernandez, Kevin Pottie, Lise Bjerre

Optimal approaches to developing and implementing deprescribing guidelines have yet to be identified. Using AGREE-II (Appraisal of Guidelines for Research and Evaluation), and GRADE (Grading of Recommendations Assessment, Development, and Evaluation), quality of evidence and strength of recommendations were rated, and developmental evaluation was performed using ethnographic methods. Three deprescribing guidelines were developed and implemented in six practice sites. Factors that appear to consistently facilitate successful development include team members’ expertise in content/methods, access to additional expertise/resources through professional networks, and staff support. Developmental evaluation contributes to the improvement of processes used to develop and implement an optimized deprescribing guideline.

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4. Understanding the value of collaboration in health services research

Nancy Waite, Lisa Wenger, Martin Cooke, Kelly Grindrod, Brad Jennings, Linda MacKeigan, Sara Marshall, Beth Sproule, Lisa Dolovich, Emily Milne

OPEN is a multi-institutional, multidisciplinary research program established in 2013 to enhance pharmacist-led medication management services. An online survey examining team performance and central support was completed by 34 members (response rate: 61%). Interviews were conducted with 23 members to examine perceptions of collaboration. Results were shared internally for reflection and to identify strategies for maintaining and improving the collaboration. Most respondents (n=28, 85%) were satisfied with how members work together and 91% (n=30) agreed that the benefits of collaboration exceeded drawbacks. Respondents valued building relationships with those with a diversity of expertise, expanding their impact and achieving research objectives through collaboration. While 94% (n=31) rated central communications as good, just over half (61%, n=20) felt left out of decision-making. Respondents stressed the importance of focused research plans, timely guidance, manageable workload, shared resources and committed partners. OPEN participants appreciated drawing on diverse perspectives and expertise to attain a shared goal of enhanced pharmacy practice. Members identified opportunities to sustain and enhance the collaboration.