The Canadian Chronic Disease Surveillance System: A model for collaborative surveillance.

Chronic diseases have a major impact on populations and healthcare systems worldwide. Administrative health data are an ideal resource for chronic disease surveillance because they are population-based and routinely collected. For multi-jurisdictional surveillance, a distributed model is advantageous because it does not require individual-level data to be shared across jurisdictional boundaries. Our objective is to describe the process, structure, benefits, and challenges of a distributed model for chronic disease surveillance across all Canadian provinces and territories (P/Ts) using linked administrative data. The Public Health Agency of Canada (PHAC) established the Canadian Chronic Disease Surveillance System (CCDSS) in 2009 to facilitate standardized, national estimates of chronic disease prevalence, incidence, and outcomes. The CCDSS primarily relies on linked health insurance registration files, physician billing claims, and hospital discharge abstracts. Standardized case definitions and common analytic protocols are applied to the data for each P/T; aggregate data are shared with PHAC and summarized for reports and open access data initiatives. Advantages of this distributed model include: it uses the rich data resources available in all P/Ts; it supports chronic disease surveillance capacity building in all P/Ts; and changes in surveillance methodology can be easily developed by PHAC and implemented by the P/Ts. However, there are challenges: heterogeneity in administrative databases across jurisdictions and changes in data quality over time threaten the production of standardized disease estimates; a limited set of databases are common to all P/Ts, which hinders potential CCDSS expansion; and there is a need to balance comprehensive reporting with P/T disclosure requirements to protect privacy. The CCDSS distributed model for chronic disease surveillance has been successfully implemented and sustained by PHAC and its P/T partners. Many lessons have been learned about national surveillance involving jurisdictions that are heterogeneous with respect to healthcare databases, expertise and analytical capacity, population characteristics, and priorities.

Adoption of the Nova Scotia (Canada) Community Pharmacy Medication Management Program, 1-Year Post-Initiation.

BACKGROUND: Pharmacists conduct medication reviews to optimize drug therapy. Each jurisdiction implements and funds these programs differently. OBJECTIVE: To describe the uptake of the first year of a community pharmacy medication review program reimbursed by the publically insured seniors' drug benefit program in Nova Scotia, Canada. METHODS: This retrospective analysis included 294 pharmacies and 105,000 beneficiaries enrolled in the Nova Scotia Seniors' Pharmacare Program. Prescription and service claims data from this program were analyzed to determine type and number of beneficiaries receiving a medication review, number and predictors of pharmacies completing reviews, and number of prescribed medications 6-months before and 6-months after the review. RESULTS: 428 medication reviews were conducted and billed by 33% of Nova Scotia pharmacies (1-50 reviews per pharmacy per year). The mean number and range of medications before the review were 10.8 (4-28) and following the review 10.4 (0-24), with an average decrease of 0.4 medications (95% CI 0.1-0.6), p=.0043). Patients receiving a review had a mean age of 75.2 years; 64.9% were female. Most pharmacies conducted reviews when patients reached their annual copayment (93%). CONCLUSIONS: Approximately 33% of pharmacies billed at least one medication review in the first year of the program. In spite of a $150 reimbursement per community pharmacy medication review, only 428 reviews were conducted over a 13-month period for a population of over 100,000 seniors. Results suggest financial reimbursement alone is not sufficient to implement a medication management program; health systems need to determine patient, pharmacist, pharmacy and health system level strategies to implement medication reviews more broadly.

System struggles and substitutes: A qualitative study of general practitioner and psychiatrist experiences of prescribing antipsychotics to children and adolescents.

There are significant controversies regarding rising antipsychotic prescription trends in children and adolescents. Many pharmacoepidemiology trend studies have been published, and interpretations of these data are helpful in explaining what is happening in prescribing practices, but not why these patterns exist. There is a lack of qualitative data in this area, and the experience of prescribing antipsychotics to children and adolescents has not been adequately researched. We conducted a qualitative study using an interpretive phenomenological analysis of physicians' experiences of antipsychotic prescribing to children and adolescents. Prescribers participated in individual interviews and a focus group. We used a staged approach for data analysis of transcriptions. In all, 11 physicians including psychiatrists and general practitioners participated in our study. We identified themes related to context, role and identity, and decision-making and filtering Struggles with health system gaps were significant leading to the use of antipsychotics as substitutes for other treatments. Physicians prescribed antipsychotics to youth for a range of indications and had significant concerns regarding adverse effects. Our results provide knowledge regarding the prescribers' experience of antipsychotics for children and adolescents. Important gaps exist within the health system that are creating opportunities for the initiation and continued use of these agents.

The impact of statins on health services utilization and mortality in older adults discharged from hospital with ischemic heart disease: a cohort study.

BACKGROUND: Cardiovascular disease (CVD) carries a high burden of morbidity and mortality and is associated with significant utilization of health care resources, especially in the elderly. Numerous randomized trials have established the efficacy of cholesterol reduction with statin medications in decreasing mortality in high-risk populations. However, it is not known what the effect of the utilization of these medications in complex older adults has had on mortality and on the utilization of health services, such as physician visits, hospitalizations or cardiovascular procedures. METHODS: This project linked clinical and hospital data from the Improving Cardiovascular Outcomes in Nova Scotia (ICONS) database with administrative data from the Population Health Research Unit to identify all older adults hospitalized with ischemic heart disease between October 15, 1997 and March 31, 2001. All patients were followed for at least one year or until death. Multiple regression techniques, including Cox proportional hazards models and generalized linear models were employed to compare health services utilization and mortality for statin users and non-statin users. RESULTS: Of 4232 older adults discharged alive from the hospital, 1629 (38%) received a statin after discharge. In multivariate models after adjustment for demographic and clinical characteristics, and propensity score, statins were associated with a 26% reduction in all- cause mortality (hazard ratio (HR) 0.74, 95% confidence interval (CI) 0.63-0.88). However, statin use was not associated with subsequent reductions in health service utilization, including re-hospitalizations (HR, 0.98, 95% CI 0.91-1.06), physician visits (relative risk (RR) 0.97, 95% CI 0.92-1.02) or coronary revascularization procedures (HR 1.15, 95% CI 0.97-1.36). CONCLUSION: As the utilization of statins continues to grow, their impact on the health care system will continue to be important. Future studies are needed to continue to ensure that those who would realize significant benefit from the medication receive it.

Impact of a criteria-based reimbursement policy on the use of respiratory drugs delivered by nebulizer and health care services utilization in Nova Scotia, Canada.

BACKGROUND: In February 2000, the Nova Scotia Seniors' Pharmacare Program announced a change in the reimbursement of respiratory drugs that added specific reimbursement criteria for wet nebulization therapy. Policy implementation coincided with multifaceted interventions to assist patients and providers with the change. OBJECTIVE: To assess the impact of the new policy and associated interventions on the use of wet nebulization and portable inhaler delivery systems of respiratory drugs and on the utilization of health services. METHODS: The administrative claims database identified all beneficiaries (age > or = 65 yrs) who received at least one respiratory drug prescription in the 12 months before the study. These patients were then grouped into the wet nebulization cohort or the control cohort receiving a metered-dose or a dry-powder inhaler. The study period was from April 1998-February 2002. Use of respiratory drugs, physician visits, and hospitalizations were compared between study cohorts using an interrupted time-series design. RESULTS: A sharp decrease was noted in use of wet nebulization after the policy announcement, along with an increase in use of short-acting beta2-agonists and anticholinergic agents delivered by metered-dose or drypowder inhaler. From December 1999 to December 2001, in the heavy wet nebulization cohort (a subset of the wet nebulization cohort), wet nebulization use dropped from 100% to 35%; in the wet nebulization cohort, wet nebulization use decreased from 67% to 20%. Rates of spacer device use were 42%, 31%, and 17% in the heavy wet nebulization, wet nebulization, and control cohorts, respectively, in December 2001. Rates of general practitioner visits and hospitalizations for respiratory conditions did not increase in the intervention cohorts after the policy announcement. In fact, relative to the control cohort, health services use in response to the policy and interventions in the wet nebulization cohort decreased. CONCLUSION: The reimbursement policy resulted in decreased use of respiratory drugs delivered by wet nebulization without a negative impact on general practitioner visits and hospitalizations for respiratory conditions.

Use of physician profiles to influence prescribing of topical corticosteroids.

BACKGROUND: Physician profiling is a tool used to attempt to affect changes in prescribing. The Drug Evaluation Alliance of Nova Scotia (DEANS) decided to implement a physician profiling project to determine if prescribing of topical corticosteroids could be altered. OBJECTIVES: To evaluate a DEANS initiative utilizing physician prescribing profiles to shift prescribing of topical corticosteroids from higher to lower potency agents in beneficiaries of the Nova Scotia Seniors' Pharmacare Program. METHODS: Administrative claims from the Nova Scotia Seniors' Pharmacare program were used to identify prescriptions for topical corticosteroids. Prescriptions were summarized at the individual physician level, and aggregated by Anatomical Therapeutic Classification into weak, moderately potent, potent and very potent products. The number of prescriptions for topical corticosteroids was compared for the twelve-month period before and after mailing of the profiles. Overall results were aggregated by utilization and expenditures. RESULTS: The number of prescriptions for topical corticosteroids per physician profiled was 44.0 in 2000/2001 and 42.8 in 2001/2002 (p = NS) and the expenditures per physician profiled were 838.94 dollars in 2000/2001 and 826.81 dollars in 2001/2002 (p = NS). There was a small decrease in prescriptions dispensed for potent topical products over the profiling period (52.4% of prescriptions in 2000/2001 versus 51.5% of prescriptions in 2001/2002, p=0.03). Otherwise, changes in utilization or expenditures for topical corticosteroids were not statistically different between the profiling periods. CONCLUSIONS: This project showed that mailing unsolicited individual-level profiles did not alter prescribing or expenditures for topical corticosteroids over a two-year period. Further work is needed to determine physician attitudes towards such projects.

Topical corticosteroid prescribing patterns following changes in drug benefit status.

OBJECTIVE: To examine changes in prescribing patterns for topical corticosteroid products dispensed to elderly patients in Nova Scotia, Canada, after all but 2 combination topical corticosteroid products were removed from the Nova Scotia Seniors' Pharmacare Program benefit list. METHODS: Administrative prescription claims from the Nova Scotia Seniors' Pharmacare Program were used to identify the number and costs of topical corticosteroid, antifungal, antibiotic, and combination corticosteroid products dispensed. Time-series analysis was used to compare the periods before (April 1, 1999-March 31, 2000) and after (April 1, 2000-March 31, 2001) the delisting. RESULTS: In 1999-2000, 26,031 of 103 400 eligible elderly patients (25%) and in 2000-2001, 22,837 of 95,550 eligible elderly (24%) received a prescription for a defined topical product. Nova Scotia Seniors' Pharmacare Program expenditures for all topical products decreased from 11.88 to 10.60 Canadian dollars per beneficiary per year (11%) after the policy revision. Topical combination products decreased from 18% of all topical products dispensed to 14%, while the percentage of potent corticosteroid products dispensed increased from 24% to 27% over the study period. Pre- and post-policy time-trend analysis showed statistically significant increasing trends in cost per beneficiary for all topical products and potent corticosteroid products. Combination corticosteroid products showed no change in trends for costs per beneficiary before, and a slight increasing trend after, the policy revision. CONCLUSIONS: Prescribing of topical corticosteroid combination products in Nova Scotia decreased following the formulary revision. There was an increase in potent topical corticosteroid prescribing. Future study involving evaluation of patient outcomes would be useful.