A Systematic Review of Antimicrobial Stewardship Interventions to Improve Management of Bacteriuria in Hospitalized Adults.

OBJECTIVE: To determine whether implementation of antimicrobial stewardship (AMS) interventions improve management of bacteriuria in hospitalized adults. DATA SOURCES: EMBASE, MEDLINE, CINAHL, and Clinical Trials Registries via Cochrane CENTRAL were searched from inception through May 2021. Reference lists of included studies were searched, and Scopus was used to retrieve articles that cited included references. STUDY SELECTION AND DATA EXTRACTION: Randomized and nonrandomized trials, controlled before-after studies, interrupted time-series studies, and repeated measures studies evaluating AMS interventions for hospitalized adult inpatients with bacteriuria were included. Risk of bias was assessed independently by 3 team members and compared. Results were summarized descriptively. DATA SYNTHESIS: The search yielded 5509 articles, of which 13 met inclusion criteria. Most common interventions included education (N = 8) and audit and feedback (N = 5) alone or in combination with other interventions. Where assessed, resource and antimicrobial use primarily decreased and appropriateness of antimicrobial use improved; however, impact on guideline adherence was variable. All studies were rated as having unclear or serious risk of bias. This review summarizes and assesses the quality of evidence for AMS interventions to improve the management of bacteriuria. Results provide guidance to both AMS teams and researchers aiming to develop and/or evaluate AMS interventions for management of bacteriuria. CONCLUSIONS: This review demonstrated benefit of AMS interventions on management of bacteriuria. However, most studies had some risk of bias, and an overall effect across studies is unclear due to heterogeneity in outcome measures.

Exploring parity in female authorship of pharmacoepidemiology articles: A case study of the Canadian Network for Observational Drug Effect Studies and its citing articles.

PURPOSE: The Canadian Network for Observational Drug Effect Studies (CNODES) studies the benefits and risks of post-market drugs and evaluates its research mobilization efforts for accountability, demonstrating value, and learning. As part of these evaluation efforts, and acknowledging gender disparity in authorship across many academic disciplines, CNODES examined the relationship between gender and authorship in its own journal articles and the literature citing them. METHODS: CNODES articles (published 2012-2017) and all citing articles were identified and extracted using Scopus. Scopus author IDs were used to extract full names and a web service (www.genderapi.com) was used to estimate gender, converting all probabilities <80% to "indeterminate." T-tests and visualizations were used to compare the proportion of females between CNODES and the citing literature. RESULTS: Twenty-eight CNODES articles and 463 citing articles were identified. The mean number of authors per article was 9.5 in CNODES articles and 5.7 in the citing literature. CNODES articles had a female authorship rate of 36%, compared to 29% in the citing literature (7% difference, 95% CI: [1%, 13%]). There were no female authors in 14% of CNODES articles versus 36% of the citing literature. Women were first authors in 25% and corresponding authors in 14% of CNODES articles. CONCLUSIONS: This analysis provides a benchmark and method to monitor progress in female parity in pharmacoepidemiology authorship. Further work is needed to determine and address barriers and facilitators to women's recruitment and advancement in the field of pharmacoepidemiology.

Regional variation in the potentially inappropriate first-line use of fluoroquinolones in Canada as a key to antibiotic stewardship? A drug utilization review study.

BACKGROUND: Serious adverse effects of fluoroquinolone antibiotics have been described for more than decade. Recently, several drug regulatory agencies have advised restricting their use in milder infections for which other treatments are available, given the potential for disabling and possibly persistent side effects. We aimed to describe variations in fluoroquinolone use for initial treatment of urinary tract infection (UTI), acute bacterial sinusitis (ABS), and acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in the outpatient setting across Canada. METHODS: Using administrative health data from six provinces, we identified ambulatory visits with a diagnosis of uncomplicated UTI, uncomplicated AECOPD or ABS. Antibiotic exposure was determined by the first antibiotic dispensed within 5 days of the visit. RESULTS: We identified 4,303,144 uncomplicated UTI events among 2,170,027 women; the proportion of events treated with fluoroquinolones, mostly ciprofloxacin, varied across provinces, ranging from 18.6% (Saskatchewan) to 51.6% (Alberta). Among 3,467,678 ABS events (2,087,934 patients), between 2.2% (Nova Scotia) and 11.2% (Ontario) were dispensed a fluoroquinolone. For 1,319,128 AECOPD events among 598,347 patients, fluoroquinolones, mostly levofloxacin and moxifloxacin, ranged from 5.8% (Nova Scotia) to 35.6% (Ontario). The proportion of uncomplicated UTI and ABS events treated with fluoroquinolones declined over time, whereas it remained relatively stable for AECOPD. CONCLUSIONS: Fluoroquinolones were commonly used as first-line therapies for uncomplicated UTI and AECOPD. However, their use varied widely across provinces. Drug insurance formulary criteria and enforcement may be a key to facilitating better antibiotic stewardship and limiting potentially inappropriate first-line use of fluoroquinolones.

Building a framework for the evaluation of knowledge translation for the Canadian Network for Observational Drug Effect Studies.

PURPOSE: The Canadian Network for Observational Drug Effect Studies (CNODES), a network of pharmacoepidemiologists and other researchers from seven provincial sites, provides evidence on the benefits and risks of drugs used by Canadians. The Knowledge Translation Team, one of CNODES' four main teams, evaluates the impact of its efforts using an iterative and emergent approach. This article shares key lessons from early evaluation phases, including identifying stakeholders and their evaluation needs, choosing evaluation theories and approaches, and developing evaluation questions, designs, and methods appropriate for the CNODES context. METHODS: Stakeholder analysis was conducted using documentary analysis to determine key contextual factors and research evidence needs of decision maker partners and other stakeholders. Selected theories and frameworks from the evaluation and knowledge translation literature informed decisions about evaluation design and implementation. A developmental approach to evaluation was deemed appropriate due to the innovative, complex, and ever-changing context. RESULTS: A theory of change, logic model, and potential evaluation questions were developed, informed by the stakeholder analysis. Early indicators of program impact (citation metrics, alternative metrics) have been documented; efforts to collect data on additional indicators are ongoing. CONCLUSION: A flexible, iterative, and emergent evaluation approach allows the Knowledge Translation Team to apply lessons learned from completed projects to ongoing research projects, adapt its approaches based on stakeholder needs, document successes, and be accountable to funders/stakeholders. This evaluation approach may be useful for other international pharmacoepidemiology research networks planning and implementing evaluations of similarly complex, multistakeholder initiatives that are subject to constant change.

Measuring the impact of pharmacoepidemiologic research using altmetrics: A case study of a CNODES drug-safety article.

PURPOSE: To provide an overview of altmetrics, including their potential benefits and limitations, how they may be obtained, and their role in assessing pharmacoepidemiologic research impact. METHODS: Our review was informed by compiling relevant literature identified through searching multiple health research databases (PubMed, Embase, and CIHNAHL) and grey literature sources (websites, blogs, and reports). We demonstrate how pharmacoepidemiologists, in particular, may use altmetrics to understand scholarly impact and knowledge translation by providing a case study of a drug-safety study conducted by the Canadian Network of Observational Drug Effect Studies. RESULTS: A common approach to measuring research impact is the use of citation-based metrics, such as an article's citation count or a journal's impact factor. "Alternative" metrics, or altmetrics, are increasingly supported as a complementary measure of research uptake in the age of social media. Altmetrics are nontraditional indicators that capture a diverse set of traceable, online research-related artifacts including peer-reviewed publications and other research outputs (software, datasets, blogs, videos, posters, policy documents, presentations, social media posts, wiki entries, etc). CONCLUSION: Compared with traditional citation-based metrics, altmetrics take a more holistic view of research impact, attempting to capture the activity and engagement of both scholarly and nonscholarly communities. Despite the limited theoretical underpinnings, possible commercial influence, potential for gaming and manipulation, and numerous data quality-related issues, altmetrics are promising as a supplement to more traditional citation-based metrics because they can ingest and process a larger set of data points related to the flow and reach of scholarly communication from an expanded pool of stakeholders. Unlike citation-based metrics, altmetrics are not inherently rooted in the research publication process, which includes peer review; it is unclear to what extent they should be used for research evaluation.

Deprescribing cholinesterase inhibitors and memantine in dementia: guideline summary.

INTRODUCTION: Cholinesterase inhibitors (ChEIs) and memantine are medications used to treat the symptoms of specific types of dementia. Their benefits and harms can change over time, particularly during long term use. Therefore, appropriate use of ChEIs and memantine involves both prescribing these medications to individuals who are likely to benefit, and deprescribing (withdrawing) them from individuals when the risks outweigh the benefits. We recently developed an evidence-based clinical practice guideline for deprescribing ChEIs and memantine, using robust international guideline development processes. MAIN RECOMMENDATIONS: Our recommendations aim to assist clinicians to: identify individuals who may be suitable for a trial of deprescribing ChEIs and memantine (such as those who do not have an appropriate indication, those who have never experienced a benefit, those who appear to be no longer benefitting, and those who have severe or end-stage dementia); and taper treatment and monitor individuals during the deprescribing process. CHANGES IN MANAGEMENT AS A RESULT OF THE GUIDELINE: Deprescribing ChEIs and memantine through shared decision making with individuals and their caregivers by: ▶determining their treatment goals; ▶discussing benefits and harms of continuing and ceasing medication, from the start of therapy and throughout; and ▶engaging them in monitoring after discontinuation, while informing carers that the individual will continue to decline after discontinuation. This approach may reduce adverse drug reactions and medication burden, leading to improved quality of life in people with dementia.

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

PURPOSE: This study investigated the impact of changing availability of tamper-deterrent and non-tamper-deterrent oxycodone on prescribing patterns of controlled-release oxycodone across Canada. METHODS: We conducted a population-based, serial cross-sectional study of controlled-release oxycodone dispensing from community pharmacies across Canada between October 2007 and April 2016. We calculated rates of dispensing (tablets per 100 population) and reported the relative market share of generic non-tamper-deterrent controlled-release oxycodone. All analyses were reported nationally and stratified by province. RESULTS: After the introduction of a tamper-deterrent formulation, the national rate of controlled-release oxycodone dispensing fell by 44.6% (from 26.4 to 14.6 tablets per 100 population from February 2012 to April 2016). Between December 2012 and July 2013, there was moderate uptake of generic non-tamper-deterrent controlled-release oxycodone (968 452 tablets; 16.0% in July 2013), which appeared to have little impact on the overall rate of controlled-release oxycodone dispensing in Canada. However, the uptake of generic non-tamper-deterrent oxycodone varied considerably by province. By April 2016, 55.0% of all controlled-release oxycodone tablets dispensed in Quebec were for the generic formulation. Elsewhere in Canada, this prevalence was less than 30%, ranging between 1.6% (Prince Edward Island) and 26.9% (British Columbia) at the end of our study period. CONCLUSIONS: The changing availability of tamper-deterrent and non-tamper-deterrent formulations of controlled-release oxycodone in Canada has had variable influence on the rate of use of these products across Canada. Future research should explore whether the availability of generic controlled-release oxycodone has led to measurable changes in the safety of oxycodone use in Canada.

Antipsychotic Drug Dispensations in Older Adults, Including Continuation After a Fall-Related Hospitalization: Identifying Adherence to Screening Tool of Older Persons' Potentially Inappropriate Prescriptions Criteria Using the Nova Scotia Seniors' Pharmacare Program and Canadian Institute for Health's Discharge Databases.

PURPOSE: Despite well-established concerns regarding adverse drug effects, antipsychotics are frequently prescribed for older adults. Our first objective was to identify trends in antipsychotic dispensations to older Nova Scotians. STOPP (Screening Tool of Older Persons' Potentially Inappropriate Prescriptions) criteria identify antipsychotic use in those with a history of falls as potentially inappropriate. Our second objective was to identify trends, predictors, and adherence with this STOPP criteria by identifying continued antipsychotic dispensations following a fall-related hospitalization. METHODS: A descriptive cross-sectional cohort study of Nova Scotia Seniors' Pharmacare Program (NSSPP) beneficiaries ≥ 66 years with at least one antipsychotic dispensation annually from April 1, 2009 to March 31, 2014 was completed. As well, unique beneficiaries with at least one antipsychotic dispensation in the four-year period between April 1, 2009 and March 31, 2013 were linked to fall-related hospitalizations recorded in the Canadian Institute for Health Information Discharge Abstract Database. The relationship of age, sex, fiscal year, days supply and length-of-stay were studied to identify predictors of continued antipsychotic dispensation post-discharge. Descriptive statistics and multivariate logistic analysis were performed. Odds ratios for the association of risk factors and adherence to STOPP criteria were calculated. FINDINGS: We identified that in each year observed, there were 6% of eligible NSSPP beneficiaries that received at least one antipsychotic dispensation. Approximately 70% of antipsychotic dispensations were for second generation agents, primarily quetiapine and risperidone. Of the unique beneficiaries with at least one antipsychotic dispensation in the four-year period between April 1, 2009 and March 31, 2013 who survived a fall-related hospitalization over 75% were dispensed an antipsychotic in the 100 days following hospital discharge. Logistic regression showed no statistically significant association between potentially inappropriate therapy and potential predictors in multivariate analysis. IMPLICATIONS: In each year from 2009 to 2014, 6% of Nova Scotia Seniors' Pharmacare beneficiaries were dispensed at least one antipsychotic prescription. Over 75% of the older adults who received an antipsychotic dispensation in the 100 days prior to a fall-related hospitalization, continued the drug class after discharge. This demonstrates that despite the recommendations of quality indicators such as the STOPP criteria, antipsychotics are continued in individuals at a high risk of falling. Future investigations are needed to inform health team, system, and policy interventions to improve concordance with this antipsychotic specific STOPP criterion when appropriate.

Antipsychotic Prescribing Practices in Those with Parkinsonism: Adherence to Guidelines.

Several evidence-informed treatment guidelines recommend against the use of typical antipsychotics in patients with Parkinson's disease; of the atypical antipsychotics, clozapine and quetiapine are preferred. The purpose of this study is to determine the frequency with which potentially inappropriate antipsychotics are dispensed to older adults in Nova Scotia who are on levodopa-containing medications. In this cohort, 59.9% were dispensed a preferred atypical antipsychotic and 12.6% a potentially harmful typical antipsychotic. Our results suggest that potentially inappropriate prescribing practices are common in the neuropsychiatric management of patients with parkinsonism and that there is an opportunity for education and improvement in prescribing practices.

Cost-effectiveness of a nurse practitioner-family physician model of care in a nursing home: controlled before and after study.

AIMS: To examine the cost-effectiveness of a nurse practitioner-family physician model of care compared with family physician-only care in a Canadian nursing home. BACKGROUND: As demand for long-term care increases, alternative care models including nurse practitioners are being explored. DESIGN: Cost-effectiveness analysis using a controlled before-after design. METHODS: The study included an 18-month 'before' period (2005-2006) and a 21-month 'after' time period (2007-2009). Data were abstracted from charts from 2008-2010. We calculated incremental cost-effectiveness ratios comparing the intervention (nurse practitioner-family physician model; n = 45) to internal (n = 65), external (n = 70) and combined internal/external family physician-only control groups, measured as the change in healthcare costs divided by the change in emergency department transfers/person-month. We assessed joint uncertainty around costs and effects using non-parametric bootstrapping and cost-effectiveness acceptability curves. RESULTS: Point estimates of the incremental cost-effectiveness ratio demonstrated the nurse practitioner-family physician model dominated the internal and combined control groups (i.e. was associated with smaller increases in costs and emergency department transfers/person-month). Compared with the external control, the intervention resulted in a smaller increase in costs and larger increase in emergency department transfers. Using a willingness-to-pay threshold of $1000 CAD/emergency department transfer, the probability the intervention was cost-effective compared with the internal, external and combined control groups was 26%, 21% and 25%. CONCLUSION: Due to uncertainty around the distribution of costs and effects, we were unable to make a definitive conclusion regarding the cost-effectiveness of the nurse practitioner-family physician model; however, these results suggest benefits that could be confirmed in a larger study.

Corrigendum to "Uptake of community pharmacist prescribing over a three-year period" [Exploratory Research in Clinical and Social Pharmacy, Volume 9, March 2023, 100221].

[This corrects the article DOI: 10.1016/j.rcsop.2023.100221.].

A qualitative study evaluating barriers and enablers to improving antimicrobial use for the management of bacteriuria in hospitalized adults.

Objective: The objective of this study was to explore barriers and enablers to improving the management of bacteriuria in hospitalized adults. Design: Qualitative study. Setting: Nova Scotia, Canada. Participants: Nurses, physicians, and pharmacists involved in the assessment, diagnosis, and treatment of bacteriuria in hospitalized patients. Methods: Focus groups (FGs) were completed between May and July 2019. FG discussions were facilitated using an interview guide that consisted of open-ended questions coded to the theoretical domains framework (TDF) v2. Discussions were transcribed verbatim then independently coded to the TDFv2 by two members of the research team and compared. Thematic analysis was used to identify themes. Results: Thirty-three healthcare providers from five hospitals participated (15 pharmacists, 11 nurses, and 7 physicians). The use of antibiotics for the treatment of asymptomatic bacteriuria (ASB) was the main issue identified. Subthemes that related to management of ASB included: "diagnostic uncertainty," difficulty "ignoring positive urine cultures," "organizational challenges," and "how people learn." Barriers and/or enablers to improving the management of bacteriuria were mapped to 12 theoretical domains within these subthemes. Barriers and enablers identified by participants that were most extensively discussed related to the domains of environmental context and resources, belief about capabilities, social/professional role and identity, and social influences. Conclusions: Healthcare providers highlighted barriers and recognized enablers that may improve delivery of care to patients with bacteriuria. A wide range of barriers at the individual and organization level to address diagnostic challenges and improve workload should be considered to improve management of bacteriuria.

Differences in utilisation of gastroprotective drugs between 2001 and 2005 in Australia and Nova Scotia, Canada.

PURPOSE: This study aimed to compare use of histamine H2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs), 2001-2005, in the elderly and social security beneficiaries in Australia (AUS) and Nova Scotia, Canada (NS). METHODS: Prescription dispensing data were collected for all subsidised H2RAs and PPIs. In AUS, dispensing data for concession beneficiaries were obtained from the Pharmaceutical Benefits Scheme database. In NS, data were sourced from the Pharmacare database. Relevant population data were used to convert to World Health Organisation Anatomic Therapeutic Chemical defined daily doses (2005) per 1000 beneficiaries per day (DDD/1000/day). RESULTS: Overall use of gastroprotective agents was similar and rising in NS and AUS (100-160 DDD/1000/day) over this 5-year time window. However, the proportion of this use accounted for by PPIs was far higher in AUS (over 85% by 2005) than in NS (23% rising to 35% over the 5 years). In AUS, PPI use rose from 50 to about 140 DDD/1000/day over the 5 years, whereas PPI use in NS rose slowly to less than 60 DDD/1000/day by 2005. H2RA use in NS was always high (over 100 DDD/1000/day), whereas in AUS, H2RA use fell from 54 to around 24 DDD/1000/day over this period. CONCLUSIONS: AUS had much higher use of PPIs than NS over 2001-2005. The proportion of PPIs in all gastroprotective agents rose in AUS to be nearly 90%. The differences in utilisation during this time window could lead to differences in health outcomes from either lower gastro-intestinal bleeding risk or higher long-term adverse effects of PPIs.

The geographic accessibility of pharmacies in Nova Scotia.

INTRODUCTION: Geographic proximity is an important component of access to primary care and the pharmaceutical services of community pharmacies. Variations in access to primary care have been found between rural and urban areas in Canadian and international jurisdictions. We studied access to community pharmacies in the province of Nova Scotia. METHODS: We used information on the locations of 297 community pharmacies operating in Nova Scotia in June 2011. Population estimates at the census block level and network analysis were used to study the number of Nova Scotia residents living within 800 m (walking) and 2 km and 5 km (driving) distances of a pharmacy. We then simulated the impact of pharmacy closures on geographic access in urban and rural areas. RESULTS: We found that 40.3% of Nova Scotia residents lived within walking distance of a pharmacy; 62.6% and 78.8% lived within 2 km and 5 km, respectively. Differences between urban and rural areas were pronounced: 99.2% of urban residents lived within 5 km of a pharmacy compared with 53.3% of rural residents. Simulated pharmacy closures had a greater impact on geographic access to community pharmacies in rural areas than urban areas. CONCLUSION: The majority of Nova Scotia residents lived within walking or short driving distance of at least 1 community pharmacy. While overall geographic access appears to be lower than in the province of Ontario, the difference appears to be largely driven by the higher proportion of rural dwellers in Nova Scotia. Further studies should examine how geographic proximity to pharmacies influences patients' access to traditional and specialized pharmacy services, as well as health outcomes and adherence to therapy. Can Pharm J 2013;146:39-46.

Patterns of Antipsychotic Dispensation to Long-Term Care Residents.

OBJECTIVES: To describe dispensing patterns of antipsychotic medications to long-term care (LTC) residents and assess factors associated with continuation of an antipsychotic after a fall-related hospitalization. DESIGN: A retrospective cohort study. SETTING AND PARTICIPANTS: Nova Scotia Seniors Pharmacare Program (NSSPP) beneficiaries age 66 years and older who resided in LTC and received at least 1 dispensation of an antipsychotic within the study period of April 1, 2009, to March 31, 2017. METHODS: Linkage of administrative claims data from the NSSPP and the Canadian Institute of Health Information Discharge Abstract Database identified LTC residents with an antipsychotic dispensation and from the subgroup of those dispensed antipsychotic medications who experienced a fall-related hospitalization. Antipsychotic dispensing patterns were reported with counts and means. Predictors of continuation of an antipsychotic after a fall-related hospitalization (sex, length of stay, days supplied, age, year of admission, rural/urban) were reported and analyzed with multiple logistic regression. RESULTS: There were 19,164 unique NSSPP beneficiaries who were dispensed at least 1 prescription for an antipsychotic medication. Of those who received at least 1 antipsychotic dispensation 90% (n = 17,201) resided in LTC. A mean of 40% (n = 2637) of LTC residents received at least 1 antipsychotic dispensation in each year. Risperidone and quetiapine were dispensed most frequently. Of the 544 beneficiaries residing in LTC who survived a fall-related hospitalization, 439 (80.7%) continued an antipsychotic after hospital discharge. Female sex [OR 1.7, 95% CI (1.013‒2.943)], age 66‒69 [OR 4.587, 95% CI (1.4‒20.8)], 75-79 [OR 2.8, 95% CI (1.3‒6.3)], and 80‒84 years [OR 3.1, 95% CI (1.6‒6.4)] (compared with age 90+ years) were associated with increased risk of antipsychotic continuation. CONCLUSIONS AND IMPLICATIONS: With 90% of antipsychotic dispensations in Nova Scotia being to LTC residents and 40% of LTC residents being dispensed antipsychotics in any year there is a need to address this level of antipsychotic dispensation to older adults.

Uptake of community pharmacist prescribing over a three-year period.

Objectives: Pharmacists in Nova Scotia have had legislated authority to prescribe since 2011. This study aimed to describe the prescribing activities of pharmacists and the characteristics of patients who used pharmacist prescribing services. Methods: Using provincial health administrative databases we identified all community pharmacists who prescribed during the study period (October 2016 to March 2020) and correspondingly patients who had medications prescribed by a pharmacist during this period. Differences in, and predictors of the quantity of pharmacist prescribing over three fiscal years (April 2017 to March 2020) were described. Pharmacist prescribing activity was compared across the fiscal years of the study period with One-way Analysis of Variance. Negative binomial regression examined patient factors associated with use of pharmacist prescribing services. Analysis was carried out using SAS ENTERPRISE GUIDE v.8.2 (SAS Institute Cary, NC, USA). Key findings: A total of 1182 pharmacist prescribers were identified, who on average prescribed 24.6, 26.3, and 32.5 (p < 0.001) times per month in fiscal years 2018, 2019, 2020, respectively. The patient cohort contained 372,203 Nova Scotians over the 3-year period. For approved common and minor ailment prescribing in Nova Scotia, gastroesophageal reflux disease, vaccines (non-travel), contraceptive management, herpes zoster treatment, and allergic rhinitis had the highest number of prescriptions over the study period. Patient factors most strongly related to receiving more prescribing services by a pharmacist included receiving income assistance without copay (Incidence rate ratio (IRR) = 1.70), having >2 comorbidities (IRR = 1.51), male sex (IRR = 1.03), and greater age (IRR = 1.01). Those from an urban area (IRR = 0.92) or having a higher income (IRR = 0.95) received fewer pharmacist prescribing services (all p < 0.0001). Conclusions: Pharmacist prescribing increased over the 3-year period. Patients who were older and those with multiple comorbidities used pharmacist prescribing services most often. Prescribing activities represent an increasingly utilized role for pharmacists in primary care.

Increased self-reported pharmacist prescribing during the COVID-19 pandemic: Using the Theoretical Domains Framework to identify barriers and facilitators to prescribing.

BACKGROUND: Community pharmacists are positioned to improve access to medications through their ever-expanding role as prescribers, with this role becoming more pronounced during the COVID-19 pandemic. OBJECTIVES: Our research aimed to determine the extent of self-reported pharmacist prescribing pre-COVID-19 and during the COVID-19 pandemic, to identify barriers and facilitators to pharmacist prescribing, and to explore the relationship between these factors and self-reported prescribing activity. METHODS: A questionnaire based on the Theoretical Domains Framework (TDFv2) assessing self-reported prescribing was electronically distributed to all direct patient care pharmacists in NS (N = 1338) in July 2020. Wilcoxon signed-rank tests were used to examine temporal differences in self-reported prescribing activity. TDFv2 responses were descriptively reported as positive (agree/strongly agree), neutral (uncertain), and negative (strongly disagree/disagree) based on the 5-point Likert scale assessing barriers and facilitators to prescribing from March 2020 onward (i.e., 'during' COVID-19). Simple logistic regression was used to measure the relationship between TDFv2 domain responses and self-reported prescribing activity. RESULTS: A total of 190 pharmacists (14.2%) completed the survey. Over 98% of respondents reported prescribing at least once per month in any of the approved prescribing categories, with renewals being the most common activity reported. Since the pandemic, activity in several categories of prescribing significantly increased, including diagnosis supported by protocol (29.0% vs. 58.9%, p < 0.01), minor and common ailments (25.3% vs 34.7%, p = 0.03), preventative medicine (22.1% vs. 33.2%, p < 0.01). Amongst the TDFv2 domains, Beliefs about Consequences domain had the largest influence on prescribing activity (OR = 3.13, 95% CI 1.41-6.97, p < 0.01), with Social Influences (OR = 2.85, 95% CI 1.42-5.70, p < 0.01) being the next most influential. CONCLUSION: Self-reported prescribing by direct patient care community pharmacists in Nova Scotia increased during the COVID-19 pandemic, particularly for government-funded services. Key barriers to address, and facilitators to support pharmacist prescribing were identified and can be used to inform future interventions.

The effect of an educational intervention on meperidine use in Nova Scotia, Canada: a time series analysis.

PURPOSE: To evaluate the impact of a prescriber focused individual educational and audit-feedback intervention undertaken by the Nova Scotia Prescription Monitoring Program (NSPMP) in March/April 2007 to reduce meperidine use. METHOD: The NSPMP records all prescriptions for controlled substances dispensed in community pharmacies in Nova Scotia, Canada. Oral meperidine use from 1 July 2005 to 31 December 2009 was examined using NSPMP data. Monthly totals for the following were obtained: number of individual patients who filled at least one meperidine prescription, number of prescriptions, and number of tablets dispensed. Data were analyzed graphically to observe overall trends. The intervention effect was estimated on the logarithmic scale with autocorrelations over time modeled by an integrated autoregressive moving average model for each outcome measure. RESULTS: An overall trend toward decreasing use from July 2005 to December 2009 was apparent for all three outcome measures. The intervention was associated with a statistically significant reduction in meperidine use, after adjusting for the overall long-term trend. Compared with the pre-intervention period, the monthly number of patients declined by 12% (p < 0.001; 95% confidence interval [CI] = 5%-18%), prescriptions by 10% (p < 0.001; 95%CI = 3%-17%), and tablets by 13.5% (p < 0.001, 95%CI = 6%-29%) in the post-intervention period. CONCLUSION: Given the risks associated with meperidine, determining that this intervention successfully reduced meperidine use is encouraging. This study highlights the potential for using population data such as the NSPMP to evaluate the effectiveness of population-level interventions to improve medication use, including professional, organizational, financial, and regulatory initiatives.

Population prevalence of high dose paracetamol in dispensed paracetamol/opioid prescription combinations: an observational study.

BACKGROUND: Paracetamol (acetaminophen) is generally considered a safe medication, but is associated with hepatotoxicity at doses above doses of 4.0 g/day, and even below this daily dose in certain populations. METHODS: The Nova Scotia Prescription Monitoring Program (NSPMP) in the Canadian province of Nova Scotia is a legislated organization that collects dispensing information on all out-of-hospital prescription controlled drugs dispensed for all Nova Scotia residents. The NSPMP provided data to track all paracetamol/opioids redeemed by adults in Nova Scotia, from July 1, 2005 to June 30, 2010. Trends in the number of adults dispensed these prescriptions and the numbers of prescriptions and tablets dispensed over this period were determined. The numbers and proportions of adults who filled prescriptions exceeding 4.0 g/day and 3.25 g/day were determined for the one-year period July 1, 2009 to June 30, 2010. Data were stratified by sex and age (<65 versus 65+). RESULTS: Both the number of prescriptions filled and the number of tablets dispensed increased over the study period, although the proportion of the adult population who filled at least one paracetamol/opioid prescription was lower in each successive one-year period. From July 2009 to June 2010, one in 12 adults (n = 59,197) filled prescriptions for over 13 million paracetamol/opioid tablets. Six percent (n = 3,786) filled prescriptions that exceeded 4.0 g/day and 18.6% (n = 11,008) exceeded 3.25 g/day of paracetamol at least once. These findings exclude non-prescription paracetamol and paracetamol-only prescribed medications. CONCLUSIONS: A substantial number of individuals who redeem prescriptions for paracetamol/opioid combinations may be at risk of paracetamol-related hepatotoxicity. Healthcare professionals must be vigilant when prescribing and dispensing these medications in order to reduce the associated risks.