Societal preferences in the treatment of pediatric medulloblastoma: Balancing risk of death and quality of life.

PURPOSE: Medulloblastoma is the most prevalent childhood brain cancer. Children with medulloblastoma typically receive a combination of surgery, radiation, and chemotherapy. The survival rate is high but survivors often have sequelae from radiotherapy of the entire developing brain and spinal cord. Ongoing genetic studies have suggested that decreasing the dose of radiation might be possible among children with favorable molecular variants; however, this may result in an increased disease recurrence. As such, there is a need to investigate the nature of trade-offs that individuals are willing to make regarding the treatment of medulloblastoma. METHOD: We used best-worst scaling to estimate the importance of attributes affecting the general public's decision making around the treatment of medulloblastoma. After conducting focus groups, we selected three relevant attributes: (1) the accuracy of the genetic test; (2) the probability of serious adverse effects of the treatment(s); and (3) the survival rate. Using the paired method, we applied a conditional logit model to estimate preferences. RESULTS: In total, 3,006 respondents (51.3% female) with an average age of 43 years answered the questionnaires. All coefficients were statistically significantly different from zero and the attribute levels of adverse effects and the survival rate had the most impact on individuals' stated decision making. CONCLUSION: Overall, respondents showed high sensitivity to children experiencing disability particularly in the setting of a good prognosis. However, among children with poor prognostic molecular variants, participants showed tolerance about having a child with mild and partial disability compared to a low rate of survival.

Opinions and preferences of British Columbia pharmacists and physicians on medication management services.

BACKGROUND: Medication management (MM) services are being provided by pharmacists across Canada in various forms, but pharmacist-physician collaboration is still not a routine practice in most jurisdictions. This survey aimed to gather pharmacists' and physicians' opinions and preferences for MM provision. METHODS: Two parallel, cross-sectional online surveys, including best-worst scaling tasks, were designed for pharmacists and physicians in British Columbia to capture and compare their preferences for a number of attributes of MM. RESULTS: Surveys were completed by 119 pharmacists and 146 physicians. Results indicate that pharmacists and physicians had similar opinions on many aspects of MM. Ninety-five percent of pharmacists and 69% of physicians believed that additional health services are needed to help patients optimize the use of their medications. However, the majority of each group felt that they were the most important health care professional in providing this service. Most pharmacists (79%) and some physicians (25%) thought that optimizing use of medications would result in both decreased costs and utilization to the health care system. Both pharmacists and physicians felt that the best attribute of an MM service would be if the services resulted in improved health and medication use for patients. Both groups were motivated by increased remuneration for MM; however, the relative strength of preference for this was higher among physicians. Interestingly, physicians valued improved medication adherence as a result of MM more highly than pharmacists did. DISCUSSION AND CONCLUSION: Most pharmacists and physicians agreed that improving patients' health and medication use would be the best attribute of MM and that there is a need for such services. However, physicians also had strong preferences for being remunerated for participating in MM provision.

Factors associated with pharmacists' perceptions of their working conditions and safety and effectiveness of patient care.

BACKGROUND: In recent years, the role of pharmacists has changed, as have various provincial legislations, which now allow pharmacists to provide additional health services to patients. With these changes comes growing concern about how well the current pharmacy working environment is adapting and whether it may also be creating work-related stress that may contribute to potentially unsafe practices of patient care. METHODS: To characterize the current working conditions of pharmacists in British Columbia, an online survey was developed and distributed to all College of Pharmacists of BC (CPBC) registrants by email. The survey consisted of questions on pharmacists' demographics, practice setting and perceptions of workplace conditions. Responses were collected from October 1 to November 10, 2013. All data were summarized using descriptive statistics, and regression models were constructed to assess the association between various factors and pharmacists' self-reported working conditions. RESULTS: Twenty-three percent (1241/5300) of pharmacists registered with the CPBC responded, with 78% working in the community pharmacy setting (58% chain, 19% independent). Pharmacists mostly disagreed with the statements that they had enough time for breaks or lunches or to do their jobs, as well as enough staffing support. Pharmacists' perceptions of their workplace environment were negatively associated with workplace-imposed advanced service quotas (for medication reviews, immunizations and prescription adaptations); being employed at chain store pharmacies, compared to independent pharmacies or hospitals/long-term care settings; and higher prescription volume. DISCUSSION: Pharmacists working in chain community pharmacies who are required to meet monthly quotas for expanded services reported a substantial negative impact on their working conditions and perceived safety of patient care. Can Pharm J (Ott) 2016;149:xx-xx.

BC Medication Management Project: Perspectives of pharmacists, patients and physicians.

BACKGROUND: The BC Medication Management Project (BCMMP) was developed by the BC Ministry of Health and the BC Pharmacy Association. This pilot project ran from September 2010 to January 2012. Pharmacists reviewed patients' medication histories, discussed best use of medications, provided education and monitored for adverse effects, developed a plan to deal with medication issues and created a best possible medication history. METHODS: To evaluate the experience of participating in the BCMMP, challenges and strengths of the project and the alignment of these experiences with the overarching goals, focus groups and interviews were conducted with 6 stakeholder groups. Themes were compared within and across stakeholder type and descriptively analyzed. RESULTS: A total of 88 people participated in the focus groups/interviews. Pharmacists stated that providing BCMMP services was professionally satisfying and concurred with patients that the service did benefit them. However, participating in the BCMMP was not seen as financially sustainable by pharmacy owners, and there were concerns about patient selection. Physicians expressed concerns about increased workload associated with the BCMMP, for which they were not compensated. The computer system and burden of documentation were identified as the greatest problems. CONCLUSIONS: The BCMMP pilot project was enthusiastically received by pharmacists and patients who felt that it benefited patients and moved the pharmacy profession in a positive direction. It was widely felt that the BCMMP could be successful and sustainable if the identified challenges are addressed.

Perceptions of British Columbia residents and their willingness to pay for medication management services provided by pharmacists.

BACKGROUND: Across Canada, pharmacists have expanded their scope of practice by performing medication management (MM) services. However, little is currently known about the opinions and attitudes of patients and the general population toward MM services. METHODS: A cross-sectional online survey, including a best-worst scaling task, was designed to understand the general public's opinions, preferences and willingness-to-pay with respect to MM services in British Columbia. RESULTS: Of 977 individuals contacted, 819 responded to the questionnaire (84% response rate). The mean age was 45 years (standard deviation [SD] 16 years), and 37% were male. Overall, 93% of respondents felt that the medication advice from their pharmacist resulted in improvement in patient outcomes and/or medication use. This was also selected as the "best" attribute of MM, while other preferred attributes of MM included being able to obtain an appointment with the pharmacist on the same day or via walk-in, improved patient-physician relationships and MM sessions able to be completed in 15 minutes with the pharmacist. The average willingness to pay for MM was $24.55 (SD $21.44). Younger males with higher household income and those who had had MM in the past were willing to pay more for MM services out of pocket. DISCUSSION AND CONCLUSION: The accessibility of pharmacists was valued highly by respondents who, overall, were supportive of MM services and recognized the potential of pharmacists' involvement in drug therapy management to improve patient outcomes and medication use. Alternative models of funding are worth considering for the sustainability of MM service provision.

De-escalation of therapy for pediatric medulloblastoma: trade-offs between quality of life and survival.

BACKGROUND: Treatment intensity for pediatric medulloblastoma may vary depending on the type of medulloblastoma. In some cases, the dose of radiation may be reduced or eliminated. Correspondingly, there may be trade-offs between quality of life and survival. In this study, focus groups were conducted with parents and clinicians to explore their opinions about these trade-offs as well as the alignment/misalignment between parents and clinicians regarding the trade-offs. METHODS: One hour semi-structured focus groups were conducted with parents of children with medulloblastoma and health care providers who were involved in the care of these children. RESULTS: Parents and providers showed differences in which factors they believe have the greatest impact on quality of life for children with medulloblastoma and their families. For parents, the most important factor is social functioning and their child's ability to make friends and have a social life. In contrast, providers thought that parents cared most about their child's cognitive functioning and ability to attend and perform in school. CONCLUSION: Understanding parents' perspectives on quality of life is important in terms of providing support services that target the areas that the parents prioritize. The types of functioning that are most strongly correlated with quality of life from the parents' perspective may be the ones that should be targeted to protect during treatment. Pediatr Blood Cancer 2014;61:1300-1304. © 2014 Wiley Periodicals, Inc.

Pharmacy-based Immunization in Rural Communities Strategy (PhICS): A community cluster-randomized trial.

BACKGROUND: Influenza is a major cause of morbidity and mortality in Canada, with up to 7000 influenza-related deaths occurring every year. The elderly and individuals with chronic diseases are at increased risk for influenza-related morbidity and mortality. METHODS: We conducted a 2-year, community cluster-randomized trial targeting elderly people and at-risk groups to assess the effectiveness of pharmacy-based influenza vaccination clinics on influenza vaccination rates. Small rural communities in interior and northern British Columbia were randomly allocated to the intervention or control. In the intervention communities, pharmacy-based influenza vaccination clinics were held and were promoted to eligible patients using personalized invitations from the pharmacists, invitations distributed opportunistically by a pharmacist to eligible patients presenting to pharmacies during the flu season and community-wide promotion using posters and the local media. The main outcome measure was a difference in the mean influenza vaccination rates. The immunization rates were calculated using the number of immunizations given in each community divided by the population size estimated from the census data. RESULTS: Baseline influenza immunization rates in the population ≥65 years of age were the same in the control (n = 10, mean 85.6% [SD 16.6]) and intervention (n = 14, mean 83.8% [SD 16.3]) communities in 2009 (p = 0.79). In 2010, the mean influenza immunization rate was 56.9% (SD 28.0) in the control communities (n = 15) and 80.1% (SD 18.4) in the intervention communities (n = 14) (p = 0.01) for those ≥65 years of age. However, in 2010, for those 2 to 64 years with chronic medical conditions, the immunization rates were lower in the intervention communities (mean 16.3% [SD 7.1]) compared with the control communities (mean 21.2% [SD 5.8]) (p = 0.04). CONCLUSION: Clinics were feasible and well attended and they resulted in increased vaccination rates for elderly residents. In contrast, vaccination rates in the younger population with comorbidities remained low and unchanged.

Impact of Loneliness and Social Isolation on Mental Health Outcomes Among Individuals With Rheumatic Diseases During the COVID-19 Pandemic.

OBJECTIVE: The study objective was to assess mental and social health outcomes for individuals with rheumatic disease during the COVID-19 pandemic and evaluate the relationship of loneliness and social isolation with depression and anxiety. METHODS: We administered an international cross-sectional online survey to individuals with rheumatic disease(s) (≥18 years) between April 2020 and September 2020, with a follow-up survey from December 2020 to February 2021. We used questionnaires to evaluate loneliness (3-item UCLA Loneliness Scale [UCLA-3]), social isolation (Lubben Social Network Scale [LSNS-6]), depression (Patient Health Questionnaire [PHQ-9]), and anxiety (Generalized Anxiety Disorder 7-item [GAD-7] Scale). We used multivariable linear regression models to evaluate the cross-sectional associations of loneliness and social isolation with depression and anxiety at baseline. RESULTS: Seven hundred eighteen individuals (91.4% women, mean age: 45.4 ± 14.2 years) participated in the baseline survey, and 344 completed the follow-up survey. Overall, 51.1% of participants experienced loneliness (UCLA-3 score ≥6) and 30.3% experienced social isolation (LSNS-6 score <12) at baseline. Depression (PHQ-9 score ≥10) and anxiety (GAD-7 score ≥10) were experienced by 42.8% and 34.0% of participants at baseline, respectively. Multivariable models showed that experiencing both loneliness and social isolation, in comparison to experiencing neither, was significantly associated with an average 7.27 higher depression score (ß = 7.27; 95% confidence interval [CI]: 6.08-8.47) and 5.14 higher anxiety score (ß = 5.14; 95% CI: 4.00-6.28). CONCLUSION: Aside from showing substantial experience of loneliness and social isolation during the COVID-19 pandemic, our survey showed significant associations with depression and anxiety. Patient supports to address social health have potential implications for also supporting mental health.

How do individuals with colorectal cancer perceive the term "cancer survivor": a cross-sectional survey.

BACKGROUND: There are growing discussions regarding the term "cancer survivor," particularly how patients with cancer relate to it. OBJECTIVE: To assess how individuals diagnosed with colorectal cancer (CRC) perceive the term "cancer survivor." METHODS: We conducted an international cross-sectional study and, using social media, invited individuals who were ≥18 years; received a diagnosis for CRC; and can communicate in English. We administered an online survey comprising both quantitative (e.g., multiple choice) and qualitative (e.g., open-ended) questions. We used logistic regression to assess determinants of participants' perspectives towards the term "cancer survivor." Qualitative responses were analyzed using content analysis. RESULTS: In all, 539 participants with CRC completed the survey, including 122 (22.6%) undergoing treatment and 417 (77.4%) who completed treatment. Participants who had completed treatment were four times more likely to relate with term "cancer survivor" compared to those undergoing treatment (adjusted odds ratio (aOR), 4.0; 95% confidence interval (CI) 2.4 to 6.7). Participants diagnosed with CRC ≥50 years were also more likely to relate with the term compared to those diagnosed < 50 years (aOR, 1.88; 95% (CI) 1.2 to 3.0). Analysis of open-ended survey responses revealed aversion, discomfort, indifference, reluctance, and acceptance as themes which capture the spectrum of feelings towards the term "cancer survivor." CONCLUSION: Perspectives of individuals with CRC towards the term "cancer survivor" differ according to treatment status and age of diagnosis. IMPLICATION OF CANCER SURVIVORS: Our study amplifies voices of the CRC community towards reconsideration of the term "cancer survivor", considering the implications of treatment status and age in highlighting the importance of language.

Virtual Oncology Appointments during the Initial Wave of the COVID-19 Pandemic: An International Survey of Patient Perspectives.

There has been rapid implementation of virtual oncology appointments in response to the COVID-19 pandemic, particularly in its first wave. Our objective was to assess patterns and perspectives towards virtual oncology appointments during the pandemic among patients with cancer undergoing active treatment. We conducted an international Internet-based cross-sectional survey. Participants were eligible if they (1) were ≥18 years of age; (2) had been diagnosed with cancer (3) were currently undergoing cancer treatment, and (4) spoke English or French. Between 23 April 2020 and 9 June 2020, 381 individuals accessed the survey, with 212 actively undergoing treatment for cancer, including 27% with colorectal, 21% with breast, 7% with prostate and 7% with lung cancer. A total of 52% of respondents were from Canada and 35% were from the United States. Many participants (129, 62%) indicated having had a virtual oncology appointment during the COVID-19 pandemic and most were satisfied with their experience (83%). We found older participants (≥50 years; adjusted OR 0.22, 95% CI 0.06 to 0.85 compared to <50 years) and those with shortest duration of treatment (≤3 months; adjusted OR 0.06; 95% CI 0 to 0.69 compared to >12 months) were less likely to be satisfied with virtual oncology appointments. Virtual health platforms used differed across countries with higher telephone use in Canada (87%) and other countries (86%) as compared to the United States (54%; p-value < 0.05), where there was higher use of video conferencing. Altogether, our findings demonstrate favorable patient perspectives towards virtual oncology appointments experienced during the first wave of the COVID-19 pandemic.

How do parents and providers trade-off between disability and survival? Preferences in the treatment of pediatric medulloblastoma.

OBJECTIVE: The aim of this study was to determine the preferences of parents with children with medulloblastoma and clinicians who manage this condition and their trade-offs between survival and disability using a best-worst scaling (BWS) choice experiment. METHODS: Mixed methods were used to develop a BWS tool. Health professionals involved in the care of medulloblastoma patients were contacted through oncology networks in Canada. Parents of children diagnosed with brain tumors were recruited via two clinics in Vancouver and Toronto. The profile case BWS was used with each participant completing 12 choice profiles with the respondent indicating the best and worst features of each profile. Surveys were stratified into good, moderate, and poor prognosis based on the probability of survival presented. Paired model conditional logit analysis was used to generate quantitative preferences. RESULTS: Fifty-four parents (80% female) and 176 providers (36% female, 79% oncologists) participated in this study. There were many similarities in the parents' and providers' preferences for treatment although the parents tended to value survival higher than disability while providers seemed to value the opposite. Specifically, providers were willing to take more risk of recurrence in a child with good prognosis compared to intermediate and poor prognosis. Also, parents were less willing to take more survival risks than providers when they had to trade-off between mild disability and survival rate. CONCLUSION: This study provides useful insights into the preferences of parents and health care providers, the stakeholders of a collaborative decision for the treatment of pediatric medullo-blastoma, and compares their values and trade-offs between different levels of survival and disability.

Cost-utility analysis of a multidisciplinary strategy to manage osteoarthritis of the knee: economic evaluation of a cluster randomized controlled trial study.

OBJECTIVE: To determine if a pharmacist-initiated multidisciplinary strategy provides value for money compared to usual care in participants with previously undiagnosed knee osteoarthritis. METHODS: Pharmacies were randomly allocated to provide either 1) usual care and a pamphlet or 2) intervention care, which consisted of education, pain medication management by a pharmacist, physiotherapy-guided exercise, and communication with the primary care physician. Costs and quality-adjusted life-years (QALYs) were determined for patients assigned to each treatment and incremental cost-effectiveness ratios (ICERs) were determined. RESULTS: From the Ministry of Health perspective, the average patient in the intervention group generated slightly higher costs compared with usual care. Similar findings were obtained when using the societal perspective. The intervention resulted in ICERs of $232 (95% confidence interval [95% CI] -1,530, 2,154) per QALY gained from the Ministry of Health perspective and $14,395 (95% CI 7,826, 23,132) per QALY gained from the societal perspective, compared with usual care. CONCLUSION: A pharmacist-initiated, multidisciplinary program was good value for money from both the societal and Ministry of Health perspectives.

Empowering pharmacists in asthma management through interactive SMS (EmPhAsIS): study protocol for a randomized controlled trial.

BACKGROUND: Medication regimens for asthma are particularly vulnerable to adherence problems because of the requirement for long-term use and periods of symptom remission experienced by patients. Pharmacists are suited to impact medication adherence given their training, skills, and frequent contact with patients. The Empowering pharmacists in asthma management through interactive SMS (EmPhAsIS) trial involves an intervention leveraging mobile health (mHealth) technology to support community pharmacy practice with the hypothesis of improved medication adherence in asthma. METHODS/DESIGN: This study is a pragmatic pharmacy-based, cluster, randomized controlled trial with 12 months of intervention delivery and follow-up. Pharmacies (the clusters) will be randomized at a 1:1 ratio to provide intervention or usual care. The EmPhAsIS intervention consists of patient asthma education, short message service (SMS)-based monthly assessment of adherence, and follow-up of non-adherent individuals by community pharmacists. There are no inclusion or exclusion criteria for pharmacies. Patients are eligible if they: are 14 years of age or older, fill a prescription for inhaled corticosteroid (either monotherapy or in a combination inhaler with long-acting beta-agonists), have been diagnosed with asthma, possess a mobile phone with SMS capabilities, and have no communication difficulties such as inability to communicate in English, or significant impairment in vision, hearing, or speech. The primary outcome is adherence to inhaled corticosteroids ascertained by the medication possession ratio, the ratio of the days of medication supplied to days in a given time interval. This study will also evaluate secondary outcomes including: asthma control, asthma-related quality of life, asthma-related hospital admissions, and use of reliever medications during the follow-up period. A nested economic evaluation using a probabilistic decision-analytic model will be used to perform a cost-effectiveness analysis from the societal perspective of the intervention compared with usual care over a 10-year time horizon. DISCUSSION: Considering the prevalence of asthma, the extent of the non-adherence problem in this disease, and the availability of effective treatments, there is a tremendous potential to reduce the burden of asthma through improving adherence. This is the first study of an intervention based on mobile communication technology involving community pharmacists in asthma management. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02170883; date of registration: 19 June 2014.

Pharmacist-initiated intervention trial in osteoarthritis: a multidisciplinary intervention for knee osteoarthritis.

OBJECTIVE: Knee osteoarthritis (OA) is a commonly undiagnosed condition and care is often not provided. Pharmacists are uniquely placed for launching a multidisciplinary intervention for knee OA. METHODS: We performed a cluster randomized controlled trial with pharmacies providing either intervention care or usual care (14 and 18 pharmacies, respectively). The intervention included a validated knee OA screening questionnaire, education, pain medication management, physiotherapy-guided exercise, and communication with the primary care physician. Usual care consisted of an educational pamphlet. The primary outcome was the pass rate on the Arthritis Foundation's quality indicators for OA. Secondary outcomes included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Lower Extremity Function Scale (LEFS), the Paper Adaptive Test-5D (PAT-5D), and the Health Utilities Index Mark 3 (HUI3). RESULTS: One hundred thirty-nine patients were assigned to the control (n = 66) and intervention (n = 73) groups. There were no differences between the groups in baseline measures. The overall quality indicator pass rate was significantly higher in the intervention arm compared to the control arm (difference of 45.2%; 95% confidence interval 34.5, 55.9). Significant improvements were observed for the intervention care group as compared to the usual care group in the WOMAC global, pain, and function scores at 3 and 6 months (all P < 0.01); the PAT-5D daily activity scores at 3 and 6 months (both P < 0.05); the PAT-5D pain scores at 6 months (P = 0.05); the HUI3 single-attribute pain scores at 3 and 6 months (all P < 0.05); and the LEFS scores at 6 months (P < 0.05). CONCLUSION: Pharmacists can launch a multidisciplinary intervention to identify knee OA cases, improve the utilization of treatments, and improve function, pain, and quality of life.

After patients are diagnosed with knee osteoarthritis, what do they do?

OBJECTIVE: To learn more about the health services and products that patients use after receiving a diagnosis of knee osteoarthritis (OA), as well as the trajectory of their health-related quality of life (HRQOL). METHODS: Using a simple screening survey, community pharmacists identified 194 participants with previously undiagnosed knee OA. Of these participants, 190 were confirmed to have OA on further investigation. At baseline and 1, 3, and 6 months after diagnosis, a survey was administered to assess health services, product use, and HRQOL, including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Medical Outcomes Study Short Form 36 (SF-36) health survey, the Paper Adaptive Test (PAT-5D-QOL), and the Health Utilities Index Mark 3. RESULTS: With a mean age of 63 years, participants were mostly women, white, and overweight. By 6 months, more than 90% of the participants had visited their family physician to discuss their OA, and more than 50% of participants took either prescription or nonprescription analgesics. In addition, three-quarters of the participants started exercising, one-third initiated activity aids, and one-third had started natural medicine products. At 6 months compared with baseline, significant improvements were seen in the SF-36 physical component summary (P = 0.001) and bodily pain domain scores (P = 0.02), the PAT-5D-QOL overall, pain, and usual daily activities scores (P < 0.001 for all), and the WOMAC total, pain, and function scores (P < 0.001 for all). CONCLUSION: Within 6 months of receiving a diagnosis of knee OA, participants made several lifestyle interventions, often without the advice of a health professional, and saw improvements in their pain and function.

Improving osteoarthritis detection in the community: pharmacist identification of new, diagnostically confirmed osteoarthritis.

OBJECTIVE: Osteoarthritis (OA) is the most common arthritis and a leading cause of disability. Many persons with knee OA are not diagnosed and not referred for treatment. Therefore, identification of patients with knee pain who have undiagnosed OA needs to be improved. Our objective was to determine if pharmacists, using a simple screening questionnaire, can identify individuals with previously undiagnosed knee OA. METHODS: Patients with knee pain and no previous diagnosis of knee OA were recruited by community pharmacists who used a simple questionnaire (<10 minutes to complete) to determine likelihood of knee OA. Patients who were likely to have knee OA were referred for a standardized knee examination and radiograph. RESULTS: Of the 411 patients screened by pharmacists, 274 were eligible. Of these, 44 declined, 35 were ineligible (18 had a previous OA diagnosis,16 had other inflammatory conditions, and 1 was excluded for other reasons), and 1 died. The remaining 194 were mostly female (62%) with a mean age of 62 years and were mostly white (86%). Body mass index (BMI) was classified as normal (18.5-24.9 kg/m(2)) in 29%, overweight (25.0-29.9 kg/m(2)) in 45%, and obese (>30.0 kg/m(2)) in 26%. Of those examined, 190 (98%) of 194 met the American College of Rheumatology clinical criteria for knee OA. The radiographic results revealed that most participants likely had mild OA. CONCLUSION: Pharmacists administering a simple screening questionnaire can identify >80% of patients with knee pain who have undiagnosed knee OA. Based on radiographs and BMI, much of this OA is early and may be amenable to intervention.