2016 OPEN research showcase

Oral presentation abstracts

Research presentations • Session 1

1. Community pharmacists’ perspectives on shared decision making within diabetes management

Zahava R.S. Rosenberg-Yunger, Lee Verweel, Michael R. Gionfriddo, Lori McCallum, Lisa Dolovich

Purpose: To describe Ontario community pharmacists’ perceptions of shared decision making within the context of diabetes management; and to describe the potential challenges of implementing this approach within a community pharmacy setting.

Method: This qualitative study used semi-structured interviews with a convenience sample of community pharmacists. Data was analyzed using descriptive statistics and thematic analysis.

Results: We conducted 16 interviews with pharmacists, of which nine were certified diabetes educators (CDE), and six were male. Overall, participants incorporated a person-centered approach, which focused on education when conducting a MedChecks for Diabetes©. There was variation in participants’ description and application of shared decision making, as well as in their perceived level of training in shared decision making. Some challenges were also highlighted by participants surrounding the implementation of a shared decision making approach in their practice.

Conclusion: Pharmacists, in our study, lacked consensus about the definition of shared decision making, as well as methods of incorporating it within their practice. Further education of pharmacists in shared decision making and its integration into community pharmacy is needed.

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2. The public’s willingness to use pharmacist prescribing services

Ida-Maisie Famiyeh, Linda MacKeigan, Alison Thompson, Kerry Kuluski, Lisa McCarthy

Background: In 2012, legislative changes expanded Ontario pharmacists’ roles to include prescribing. Studies have looked at the public’s views about pharmacist prescribing but less is known about the influence of these views on decisions to use the services.

Purpose: To describe how the views of the public about current pharmacist prescribing services shape their willingness to use these services.

Method: Qualitative research with one-on-one semi-structured interviews. Nineteen adults who had used pharmacy services (filled/refilled a prescription, received medication advice) within the past 3-months were interviewed. Data were analyzed for latent themes using thematic analysis and from a constructivist perspective.

Results: Participants viewed pharmacist prescribing services as having potential medication-related (e.g. inaccurate dose changes), communication (e.g. pharmacist not updating physician about prescribing decisions) and relationship (e.g. physician not agreeing with patient’s use of service) risks. These risks were weighed against potential benefits (efficiency, timely access) to decide whether they would (or not) use the services. Participants’ risk-benefit perceptions were influenced by their subjective experiences with medications and medication-related services.

Conclusion: Participants’ experiences shaped their views about the potential risks and benefits of pharmacist prescribing services, which influenced their willingness to (or not) use these services.

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3. Patient goals influenced by medications: An analysis from a trial of the Health TAPESTRY program

Vivian Bui, Larkin Lamarche, Lisa Dolovich on behalf of the Health TAPESTRY team

Background: Person-centred care involves an interprofessional team-based approach to address all patient needs. Pharmacists take responsibility for addressing the medication safety and management aspects of health so that people can gain the most benefit from medications.

Purpose: The objectives of this study are to explore whether priority health goals set by older adults can be influenced by medication use and what type of medication related goals are set by older adults.

Method: This descriptive analysis reviewed priority health goals set by patients participating in a randomized controlled trial of the effectiveness of the Health TAPESTRY program in older adults (aged 70 years of age and older).

Results: Fourteen percent of goals were clearly related to medications and almost one third of the participants made at least one goal that could be influenced by medications. Pain management was a common area of concern for participants.

Implications: During assessment pharmacists need to consider how priority goals unrelated to medication can affect care provided.

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4. Perceived barriers and facilitators to providing methadone maintenance treatment among rural community pharmacists in southwestern Ontario

Joseph Fonseca, Andrew Chan, Feng Chang

Purpose: Rural patients have limited access to methadone maintenance treatment (MMT), an opioid addiction-treatment service that could be offered by community pharmacists. The aim of this study was to identify rural community pharmacists’ perceived barriers, motivations, and solutions to offering MMT to their patients.

Method: One-on-one, semi-structured interviews conducted with community pharmacists who practice in rural southwestern Ontario. Interview transcripts were analyzed using inductive qualitative content analysis.

Findings: Increased workload, extended operating hours, and concerns about safety, theft, community resistance, and availability of methadone training courses were identified as pharmacist-related barriers to providing MMT services. Professional satisfaction was the strongest motivation. Limited pharmacy staff availability exacerbated concerns about increased workload and security. Rural emergency-response times were cited among safety concerns. Participating pharmacists felt that rural regions had fewer MMT prescribers and that community members in rural regions had greater apprehension about addiction-treatment services than those in urban regions. Pharmacists proposed that a coordinated, multi-center approach to providing MMT could improve access to treatment among rural patients.

Conclusion: Rural community pharmacy practice has unique barriers to implementing and providing MMT services. A coordinated, multi-pharmacy approach may be an option to provide and expand MMT services in rural regions.

Research presentations • Session 2

5. Pilot study of nurse and pharmacist-led OTN (Ontario Telemedicine Network) based clinic for management of prostate cancer patients on oral therapy

Tom McFarlane, Stacey Hubay

Background: Given the aging population and increasing prevalence of cancer in Ontario, more and more resources will need to be allocated to the management of oncology patients. Many of these patients will be located in rural areas which can make traveling to a tertiary cancer centre to receive care difficult. In addition, the number of emergent therapies in the oncology milieu which are oral is increasing; this puts particular onus on the patient to administer therapy properly and may reduce opportunities for follow up. Remote technologies, such as internet based teleconferencing platforms, have been successfully used in the past to manage and monitor patients in an attempt to obviate the need to physically travel to treatment locations.

Purpose: This randomized, open label study will evaluate a nurse and pharmacist led clinic conducted remotely from Grand River Regional Cancer Centre at Grand River Hospital (GRRCC/GRH) using OTN teleconferencing as a platform for patients with metastatic prostate cancer receiving oral chemotherapy agents.

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6. MyMEDS: A systematic review of the effectiveness of patient side-effect and symptom self-reporting via eHealth tools

Karla Lancaster, April Chan, Vivian Bui, Annie Lok, Lisa Dolovich

Introduction: EHealth tools (e.g., PHRs) are becoming increasingly popular for helping patients self-manage medications and chronic conditions. Little research has examined the effectiveness of eHealth tools for patient self-reporting of symptoms, side effects and drug-related problems.

Purpose: This review aims to determine whether eHealth tools featuring patient self-reporting functions are effective at prompting appropriate medication changes and improving patient outcomes.

Method: MEDLINE, EMBASE and CINAHL were searched from 2000 through to Jan 4, 2016. References were also searched. Title, abstract and full text review, as well as data abstraction and risk of bias assessment were performed in duplicate.

Results: 18 studies were included, from which 15 unique eHealth tools were identified. Limited evidence shows that eHealth tools may be successfully used to make recommendations and changes to medication regimes based on patient self-reports. EHealth tools may also be successful in helping improve symptoms.

Discussion: There is not enough evidence to draw conclusions as to the effectiveness of eHealth tools on self-management, self-efficacy, medication self-monitoring, and overall patient health. Online self-management may be as effective as face-to-face interventions. Patients generally found eHealth tools useful in improving communication with health care providers.

Conclusion: Although eHealth tools show promise for helping patients self-manage medications and chronic conditions, uptake remains low. Research should focus on making eHealth tools user-friendly. More high-quality research focusing on patient-important outcomes is necessary.

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7. Distribution of influenza vaccine to community pharmacies in Ontario

Richard Violette, Nancy Waite, John Papastergiou, Sherilyn Houle, Jane Pearson Sharpe, Emily Milne

Background: Prior to the 2016–17 flu season, Ontario distributed influenza vaccine to health care providers (HCPs), including community pharmacies, via two mechanisms. Inside the GTA, the Ontario Government Pharmaceutical and Medical Supply Service (OGPMSS) organized scheduled door-to-door delivery of vaccine to HCPs. Outside the GTA, the vaccine was distributed by OGPMSS to local public health units (PHUs), which then distributed the vaccine to HCPs in their regions using various distribution practices.

Purpose: Issues related to the acquisition of influenza vaccine have been cited by pharmacists as a barrier to providing immunization to patients. The purpose of this study is to better understand the experience of community pharmacies in acquiring the vaccine under the former distribution system. More specifically, we aim to identify barriers, challenges and benefits of these distribution practices and assess their impact on patients, pharmacists and pharmacies.

Method: An online survey was developed and distributed to 400 community pharmacies in Ontario. Proportional representation from PHUs across the province was achieved by first identifying pharmacies participating in the Universal Influenza Immunization Program within each PHU, and then randomly selecting pharmacies to participate from within each region.

Results: The survey was completed by 193 respondents. Analysis of survey data is currently underway.

Conclusion: Results to date suggest that under the former distribution system, many community pharmacies experienced issues acquiring influenza vaccine, especially early in the flu season. With the recently implemented wholesaler distribution system for pharmacies outside the GTA in the 2016–17 flu season, our data provides a necessary snapshot of past practices through which the new distribution system can be more readily assessed to ensure that previous inefficiencies are not repeated; and that the influenza immunization needs of Ontarians are now being met by an improved, timely and consistent access to the vaccine for community pharmacists.

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8. Economic analysis of community pharmacists providing influenza vaccination in Ontario

Daria O’Reilly, Gord Blackhouse, Sheri Burns, James Bowen, Natasha Burke, Jeff Mehltretter, Nancy Waite, Sherilyn Houle

Background: In 2012, Ontario pharmacists were authorized to administer influenza vaccines to those 5 years of age and older. Little is known on the economic impact of this program.

Purpose: To conduct a pre–post comparison of the healthcare resource use and indirect costs associated with this legislative change, from 2011/12 to 2013/14, from Ministry of Health and societal perspectives.

Method: Changes in vaccination rates were determined from administrative data. Efficacy of the vaccine, rates of complications, hospitalizations, and lost productivity due to illness or obtaining the vaccine in different settings were obtained from the literature. Program costs considered both vaccine costs and professional fees for administration.

Results: The net increase of 448,000 vaccinations realized after pharmacies participated in influenza immunization, particularly among individuals of lower age and healthier status than individuals vaccinated in physicians’ offices, resulted in a savings of $763,000 in direct health care costs. Additionally, $4.5 million in lost productivity was saved due to the accessibility of pharmacy vaccinations outside of typical work hours, and $3.4 million was saved from reduced absenteeism due to influenza illness.

Conclusion: The convenience of pharmacy-based vaccination rates among younger and healthier patients is estimated to result in significant savings from both direct and indirect/productivity costs.

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9. Cost effectiveness analysis of drugs for chronic hepatitis C infection: Informing listing decisions for interferon-free direct-acting antiviral regimens in Canada

William Wong, Karen M Lee, Sumeet Singh and Murray Krahn

Background: Prior to 2011, pegylated interferon plus ribavirin (PR) was the standard therapy for chronic hepatitis C (CHC). Since 2014, a number of interferon-free direct-acting antiviral agents (DAAs) have been approved. While these treatments appear to be more effective at achieving sustained virologic response in CHC patients, they are significantly more expensive than PR.

Purpose: In anticipation of the need for information regarding the comparative cost-effectiveness of new regimens, we updated a previous cost-effectiveness analysis used to inform listing decisions in Canada by including recently approved and emerging regimens for the treatment of CHC infection (genotypes 1 through 4).

Method: A state-transition model was developed in the form of a cost-utility analysis. Regimens included in the analysis were approved in Canada, recommended by major guidelines, or considered to have a high likelihood of approval in Canada as of February 2015. The cohort under consideration had a mean age of 50 years and was defined by treatment status (naive versus experienced), and cirrhosis status (non-cirrhotic versus cirrhotic). Treatment effect estimates for sustained virologic response (SVR) and relative risk of adverse events were obtained from a concurrent network meta-analysis. Other inputs for the economic model were derived from published sources and validated by clinical experts. Drug costs were obtained from the Canadian provincial formularies, or directly from manufacturers.

Results: For each genotype 1 population at least one of the interferon-free therapies appeared to be economically attractive compared with PR alone, at a willingness-to-pay of $50,000 per Quality-adjusted-life-year (QALY). The regimen that was the most cost-effective varied by population. For each genotype 2-4 treatment naive population, the interferon-free or the PR-based DAA therapies appeared not to be economically attractive compared with PR alone, at a willingness-to-pay of $50,000 per QALY. For each genotype 2-4 treatment-experienced population, there were interferon-free or the PR-based DAA therapies that appeared to be attractive at a willingness to pay of $50,000 per QALY when compared with no treatment.

Conclusion: Public health policy should be informed by consideration of health benefit, social and ethical values, feasibility, and cost-effectiveness. Our analysis assists the development of HCV reimbursement recommendations by informing the latter criterion. Considering the rapid pace of development of treatments for CHC, updated and expanded reviews will be necessary in the future.

Research presentations • Session 3

10. Mapping pharmacists’ services availability and utilization in Ontario in relation to vulnerable populations distribution

Wasem Alsabbagh, Suzanne Cadarette, Giulia Consiglio, Katie Cook, Martin Cooke, Susan Elliott, Peter Johnson, Marina Simeonova, Lindsay Wong, Nancy Waite

Background: With expanded scope, community pharmacists deliver a variety of significant clinical services. However, how the availability and utilization of these services is aligned with the residential concentrations of vulnerable populations, such as people with low income, is unknown.

Purpose: We aimed to examine: (1) the availability of pharmacists’ immunization service in relation to residential areas of people who are deprived in Ontario, (2) the feasibility of describing the utilization of various pharmacy services (including immunization, MedsCheck annual, MedsCheck Diabetes, MedsCheck at home, MedsCheck long-term care, Pharmaceutical Opinion or smoking cessation) in Ontario by geographical units, and (3) the utility of the Open source program R to map pharmacy services in Ontario.

Method: For objective 1, we obtained publicly available data about pharmacies and pharmacists in Ontario from the Ontario College of Pharmacists; and from Statistics Canada for overall, social, and material deprivation index quintile at dissemination areas (DAs) level depending on the 2006 population census. Each accredited pharmacy in Ontario was matched with the pharmacy location’s DA deprivation index. Then, for each accredited pharmacy in Ontario, the number and proportion of community pharmacist(s) who practice in this pharmacy and who is (are) authorized to administer the flu vaccine was calculated. Data were analyzed using one-way ANOVA and significance level was set at alpha=0.05. For objective 2, we accessed six linked administrative databases. Descriptive analyses were performed where numbers and proportions were calculated to identify the proportion of pharmacy services recipients who have missing geographical data (missing postal code), and the level of geographic analysis with the lowest proportion of non-reportable cells (i.e., cell size <6). For objective 3, we assessed the feasibility of using R to map pharmacy services in Ontario at Local Health Integration Network (LHIN) level by plotting current LHIN boundaries in Ontario and assessing the counts of persons who are 65 years or more in each LHIN and the proportion of them that received influenza vaccination through pharmacies.

Results: From all pharmacies in Ontario (N=3,984) matching to deprivation index was possible for 82.2% (n=3,274). Of them, 2,858 (87.3%) had at least one pharmacist who is authorized to administer the flu vaccine. This proportion did not differ significantly between pharmacies located in most deprived DAs (88.4%) and least deprived DAs (89.4%). Similarly, the number of pharmacist(s) who is/are authorized to administer the flu vaccine did not differ significantly between pharmacies regardless of the deprivation index of their DAs. Similar results were obtained for overall, social and material deprivation index.

In the fiscal year of April 2013-March 2014, the number of all pharmacy services available in the data base was 461,107. Of them, postal codes of recipients of these services were overwhelmingly available (99.8%). This availability was similar among recipients of all individual pharmacy services. The preliminary results identified, in general, LHIN as a feasible geographic unit for mapping with the minimum non-reportable data. However, some pharmacy services (immunization, MedsCheck annual, MedsCheck Diabetes, and pharmaceutical opinion) could be analyzed at a more detailed level (i.e. at the first three characters of the postal code or the forward sortation area FSA). The same feasibility was noticed when analyses was stratified by age group (<65, ≥65) and sex. R was feasible to create Choropleth maps of pharmacy services based on LHIN boundaries.

Conclusion: The preliminary results of this study indicate that the availability of community pharmacists’ immunization services does not differ according to the residential concentrations of deprived populations; and the analyses of the utilization of community pharmacist services may be feasible at LHIN level in general. The results of this research will help in identifying areas that potentially have unmet needs and informing the development of pharmacy services in ways that may be promising for reducing health disparities in Ontario.

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11. Assessment of pharmacists’ explicit and implicit bias toward visible minority individuals

Fahad Alzahrani, Nancy Waite, Martin Cooke, Michael Beazely, Jonathan Blay

Background: Canada’s population of visible minorities is growing and within them disparities continue to exist, including in the quality and delivery of healthcare. In recent years, considerable attention has been paid to the possibility that provider bias toward racial and ethnic groups, even unknowingly, plays a significant role in creating and perpetuating healthcare disparities. Some recent studies have found that implicit and explicit bias toward visible minority exists among physicians, but it is unknown whether pharmacists are similarly biased and whether their biases are associated with their patient’s perceptions of pharmaceutical care services.

Purpose: The purpose of this study is to examine of explicit and implicit biases among pharmacists toward Black and Arab patients.

Method: A quantitative approach will be used to determine whether pharmacists are implicitly and explicitly biased toward black and Arab patients. Ontario Community pharmacists will be invited by e-mail to participate in the Implicit Association Test (IAT) via a secure website.

Implications: As Canada becomes a more diverse nation it is important that healthcare providers strive to eliminate healthcare disparities stemming from racial and ethnic bias by developing interventions and specific strategies to reduce them and their effects on pharmacy care. To our knowledge, this is the first study to use the Implicit Association Test in pharmacy practice research, so it will also provide data and a methodological cornerstone for future studies on pharmacist bias.

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12. Assessment of knowledge, attitude and behaviour of practicing community pharmacists towards influenza vaccine hesitancy in Ontario

Gokul Pullagura, Nancy Waite, Richard Violette

Background: Influenza vaccine is available free-of-cost to all residents of Ontario through multiple providers, including pharmacists. Yet, coverage remains sub-optimal. Vaccine hesitancy, defined as voluntary refusal or delay in vaccination despite availability, is a growing concern across all health care providers that may contribute to an increased risk of vaccine-preventable disease outbreaks and lapses in herd-immunity.

Purpose: Limited research exists around the experience of vaccine hesitancy (VH) from the perspective of the community pharmacist. The purpose of this study is to assess the knowledge, attitude and behavior of community pharmacists towards influenza vaccine hesitancy in Ontario within the context of pharmacy. More specifically, we aim to explore the specificity of VH in pharmacy including the identification of the pharmacy-specific barriers and challenges to engaging with patients in productive vaccine conversations within community pharmacy.

Method: A cross sectional survey was developed, validated and distributed electronically to 5,610 practicing community pharmacists identified through the Ontario College of Pharmacists member database. This mixed-methods study also includes an additional interview component; however interviews are still in progress.

Results: The survey was completed by 734 respondents. Ongoing analyses of the collected survey data are currently underway.

Implications: Preliminary results suggest that while community pharmacists do encounter vaccine hesitancy within their practice, a number of pharmacy specific barriers and operational challenges exist which prevents them from fully engaging with patients in this space. Solutions to overcoming the challenges of vaccine hesitancy in the community pharmacy must be explored to support pharmacists’ engagement with vaccine-hesitant individuals, to ensure continued uptake of pharmacy-based influenza vaccination services and to ultimately improve overall influenza vaccination coverage.

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13. Determining the clinical effectiveness and patient satisfaction of a pharmacist-managed travel medicine clinic under an expanded scope of practice: Study methods and status

Sherilyn Houle, Christina Bascom, Meagen Rosenthal

Background: As part of their expanding scope, pharmacists nationwide are expressing interest in becoming more involved with travel medicine, and Ontario pharmacists will soon be able to also administer a select list of travel vaccines. However, little evidence on the effectiveness of pharmacist-provided travel medicine services, including prescribing and administering vaccinations, exists.

Purpose: This study aims to determine the clinical effectiveness and patient satisfaction of a pharmacist-managed travel medicine clinic under an expanded scope.

Method: 100 patients seeking pre-travel consultations at the pharmacist-led Travel Health Network clinic in St. Albert, Alberta, are being enrolled. The pharmacist has certification in travel medicine, and authorization to prescribe Schedule I drugs and administer any vaccine by injection. The clinic provides pre-travel consultations, prescriptions for oral drugs, and stocks and administers all necessary travel vaccines. Data will be collected on patient demographics, health status, travel itinerary, recommended oral and injectable therapies, and the proportion of recommendations adhered to by patients. Following completion of travel, patients are surveyed to determine their satisfaction with the service and any health concerns faced during travel.

Results: Enrollment of patients is ongoing, with data collection expected to be complete in early 2017.

Implications: The results of this study will help inform policy decisions related to the pharmacist’s role in travel health, and can be utilized to develop toolkits and clinical support services for pharmacists wishing to introduce travel medicine consultations into their practices.