Factors associated with early nonpersistence among patients experiencing side effects from a new medication.

BACKGROUND: Drug discontinuation (i.e., nonpersistence) is often attributed to the emergence of adverse effects. However, it is not known whether other factors increase the risk of nonpersistence when adverse effects occur. OBJECTIVES: To identify factors associated with early nonpersistence among patients experiencing adverse effects from newly prescribed medications. METHODS: A questionnaire was mailed to new users of antihypertensive, antihyperglycemic, and lipid-lowering medications in Saskatchewan, Canada, between 2019 and 2020. Only respondents experiencing adverse effects were included. Responses were compared between the nonpersistent group (i.e., people who had discontinued their medication) and the persistent group (i.e., those who were taking their medication at the time of the survey). Statistically significant factors were tested in multivariable logistic regression models. Odds ratios (ORs) and 95% CIs were reported. RESULTS: Of the 3973 returned questionnaires, 813 respondents experienced adverse -effects from their new medication and were included in the study. Of these, 143 respondents (17.5%) had stopped their medication at the time of survey completion; most discontinuations (72.1%) occurred within 1 month of the first dose. Nonpersistent patients were older, had lower income, and were less likely to be taking an antihyperglycemic medication. After covariate adjustment, 6 factors were independently associated with nonpersistence: age less than 65 years (OR 1.56 [95% CI 1.01-2.41]), female sex (1.67 [1.08-2.59]), health condition not considered dangerous (2.09 [1.25-3.51]), medication not considered important for health (6.90 [4.40-10.84]), failure to expect adverse effects before starting medication (2.67 [1.74-4.10]), and taking 2 or more medications (0.45 [0.27-0.73]). CONCLUSION: Despite the strong link between the emergence of adverse effects and early nonpersistence, our findings confirm that this association is highly influenced by several factors external to the physical experiences caused by the new medication.

Impact of the SIMPL-SYNC Refill Synchronization Program on medication adherence: A pragmatic randomized controlled trial.

OBJECTIVE: To determine the impact of the SIMPL-SYNC refill synchronization (SSRS) service compared with that of usual care (UC) on medication adherence when applied as an opt-out strategy among patients receiving chronic medications. DESIGN: This was a pragmatic randomized controlled trial. SETTING AND PARTICIPANTS: The study was conducted in 2 community pharmacies located in Saskatchewan, Canada. Eligible patients were chronic medication users visiting the study pharmacies. OUTCOME MEASURES: The primary outcome was the percentage of individuals achieving optimal adherence to all eligible study medications. Eligible study medications included 22 commonly used medication classes used to treat diverse conditions. Adherence was assessed for each medication class after 300 days using the proportion of days covered (PDC). Optimal adherence was defined as PDC ≥ 80%. RESULTS: A total of 488 patients were screened for eligibility, and 190 patients were included in the intention-to-treat analysis (95 in SSRS, 95 in UC). The mean age of participants was 59 years, and 34% (65/190) were older than 65 years. A total of 574 individual adherence observations representing the 22 eligible study medication classes were generated from the 190 study participants. The percentage of individuals achieving optimal adherence to all their eligible study medications was 50.5% (48/95) in the SSRS group versus 44.2% (42/95) in the UC group (P = 0.383). Similarly, no statistically significant difference was observed in a per-protocol analysis assessing people who participated fully in the service; the percentage of individuals achieving optimal adherence to all their eligible study medications was 55.1% (38/69) in SSRS versus 40.7% (33/81) in UC (P = 0.080). Patient refusal of the refill synchronization services was common among randomized patients. CONCLUSION: SSRS service failed to detect a robust improvement in medication adherence when delivered using an opt-out strategy. However, small improvements in adherence or benefits to specific subgroups of patients could not be ruled out.

Establishing the Incidence and Prevalence of Multiple Sclerosis in Saskatchewan.

OBJECTIVE: To validate a case definition of multiple sclerosis (MS) using health administrative data and to provide the first province-wide estimates of MS incidence and prevalence for Saskatchewan, Canada. METHODS: We used population-based health administrative data between January 1, 1996 and December 31, 2015 to identify individuals with MS using two potential case definitions: (1) ≥3 hospital, physician, or prescription claims (Marrie definition); (2) ≥1 hospitalization or ≥5 physician claims within 2 years (Canadian Chronic Disease Surveillance System [CCDSS] definition). We validated the case definitions using diagnoses from medical records (n=400) as the gold standard. RESULTS: The Marrie definition had a sensitivity of 99.5% (95% confidence interval [CI] 92.3-99.2), specificity of 98.5% (95% CI 97.3-100.0), positive predictive value (PPV) of 99.5% (95% CI 97.2-100.0), and negative predictive value (NPV) of 97.5% (95% CI 94.4-99.2). The CCDSS definition had a sensitivity of 91.0% (95% CI 81.2-94.6), specificity of 99.0% (95% CI 96.4-99.9), PPV of 98.9% (95% CI 96.1-99.9), and NPV of 91.7% (95% CI 87.2-95.0). Using the more sensitive Marrie definition, the average annual adjusted incidence per 100,000 between 2001 and 2013 was 16.5 (95% CI 15.8-17.2), and the age- and sex-standardized prevalence of MS in Saskatchewan in 2013 was 313.6 per 100,000 (95% CI 303.0-324.3). Over the study period, incidence remained stable while prevalence increased slightly. CONCLUSION: We confirm Saskatchewan has one of the highest rates of MS in the world. Similar to other regions in Canada, incidence has remained stable while prevalence has gradually increased.

Does the association between adherence to statin medications and mortality depend on measurement approach? A retrospective cohort study.

BACKGROUND: The aim of this study was to examine the relationship between mortality and statin adherence using two different approaches to adherence measurement (summary versus repeated-measures). METHODS: A retrospective cohort study was conducted using administrative data from Saskatchewan, Canada between 1994 and 2008. Eligible individuals received a prescription for a statin following hospitalization for acute coronary syndrome (ACS). Adherence was measured using proportion of days covered (PDC) expressed either as: 1) a fixed summary measure, or 2) as a repeatedly measured covariate. Multivariable Cox-proportional hazards models were used to estimate the association between adherence and mortality. RESULTS: Among 9,051 individuals, optimal adherence (≥80%) modeled with a fixed summary measure was not associated with mortality benefits (adjusted HR 0.97, 95% CI 0.86 to 1.09, p = 0.60). In contrast, repeated-measures approach resulted in a significant 25% reduction in the risk of death (adjusted HR 0.75, 95% CI 0.67 to 0.85, p < 0.01). CONCLUSIONS: Unlike the summary measure, the repeated measures approach produces a significant reduction of all-cause mortality with optimal adherence. This effect may be a result of the repeated measures approach being more sensitive, or more prone to survival bias. Our findings clearly demonstrate the need to undertake (and report) multiple approaches when assessing the benefits of medication adherence.

Multiple-domain Versus Single-domain Measurements of Socioeconomic Status (SES) for Predicting Nonadherence to Statin Medications: An Observational Population-based Cohort Study.

INTRODUCTION: Low socioeconomic status (SES) should be a robust predictor of medication nonadherence because it shares key features with the theoretical origins of this phenomenon. However, population-based studies have demonstrated weak associations overall, possibly because SES is inadequately represented. We compared the performance of multiple versus single-domain measures of SES as predictors of statin adherence. METHODS: This retrospective cohort study used population-based administrative data mapped to area-level census information of individuals who received a statin medication following a hospitalization for coronary heart disease. One-year adherence was calculated by dividing the sum of all tablets dispensed by the total number of days in the observation period (365 d following the first statin dispensation). Logistic regression models were constructed and the relative impact of each SES measure was assessed by its adjusted odds ratio (OR) and improvement over the predictive accuracy of a reference model that included non-SES factors only. RESULTS: More than two thirds (ie, 68.8%; 6517/9478) of eligible individuals exhibited optimal adherence (ie, ≥80%). The estimated impact of SES on optimal adherence differed depending on the SES measure tested. The highest performing single-domain measure, household income (OR=0.75; 95% confidence interval, 0.63-0.90; model c-statistic improvement 0.5%, P=0.04) generated a similar result to the multiple-domain measure (adjusted OR=0.74; 95% confidence interval, 0.62-0.88; model c-statistic improvement 0.7%, P=0.01). CONCLUSION: Multidomain measurements of SES using administrative databases mapped to census data are not associated with better performance in predicting statin medication adherence compared with single-domain measures such as household income.

Evaluation of a refill synchronization program in two community pharmacies.

OBJECTIVES: To describe medication adherence by the proportion of days covered before and after enrollment in a refill synchronization program. METHODS: We conducted a retrospective analysis of medication adherence in 2 pharmacies offering a refill synchronization program. The study population consisted of individuals who received 2 or more medications from any of 15 predefined medication classes within 6 months of enrollment in the synchronization program. Medication adherence and refill consolidation were measured over 6 months before and after enrollment. Optimal adherence was defined as proportion of days covered ≥80%. RESULTS: Among 109 patients who enrolled in the program between 2009 and 2014, 68 were included in a pre-post analysis of medication adherence. In the preenrollment period, optimal adherence was observed in 85% (217/254) of the medications taken by the 68 patients, increasing to 93% (237/254) in the postenrollment period (P <0.01). In addition, the percentage maintaining optimal adherence to all of their medications increased significantly from 60% (n = 41) to 83% (n = 57; P <0.01). CONCLUSION: Among a small group of patients who voluntarily participated in refill synchronization programs, high levels of medication adherence were observed in the preenrollment period. These results combined with previous studies suggest that voluntary participants of these programs are at a low risk for nonadherence; therefore, current estimates of benefit from refill synchronization programs may be overestimated.

Adherence to imatinib among patients attending Saskatchewan Cancer Agency Pharmacies.

RATIONALE: Chronic use of imatinib confers an important survival benefit for individuals with chronic myeloid leukemia. In Saskatchewan, the provincial cancer agency addresses important barriers to adherence by providing imatinib at no cost through specialized cancer centers. OBJECTIVE: To describe adherence to imatinib dispensed through the Saskatchewan Cancer Agency. STUDY DESIGN AND METHODS: We conducted a retrospective analysis of electronic pharmacy dispensation records from the Saskatchewan Cancer Agency. All dispensations for imatinib classified for hematologic malignancies were electronically abstracted by cancer center personnel and securely forwarded to investigators with all meaningful patient identifiers removed. All subjects receiving a new dispensation (i.e. using a 6-month washout period) for imatinib between 1 June 2004 and 31 December 2011 were included. The primary endpoint was optimal adherence to imatinib during the first year of therapy, defined as a medication possession ratio ≥ 80%. RESULTS: Ninety-one subjects were started on imatinib during the observation period. During the first year of therapy, 82.4% (75/91) maintained a medication possession ratio ≥ 80%. The percentage of individuals maintaining optimal adherence decreased only slightly when the observation period was extended to 2 (78.4%) or 3 years (78.8%). CONCLUSIONS: Non-adherence to imatinib is relatively infrequent when provided by the Saskatchewan Cancer Agency.

Socioeconomic status and nonadherence to antihypertensive drugs: a systematic review and meta-analysis.

BACKGROUND: Although conventional wisdom suggests that low socioeconomic status (SES) is a robust predictor of medication nonadherence, the strength of this association remains unclear. OBJECTIVES: 1) To estimate the proportion of studies that identified SES as a potential risk indicator of nonadherence, 2) to describe the type of SES measurements, and 3) to quantify the association between SES and nonadherence to antihypertensive pharmacotherapy. METHODS: A systematic review and meta-analysis research design was used. We searched multiple electronic databases for studies in English or French examining nonadherence to antihypertensive medications measured by electronic prescription databases where explanatory factors were considered. Two authors independently assessed quality, described the SES measure(s), and recorded its association with nonadherence to antihypertensives. A random-effects model meta-analysis was performed, and heterogeneity was examined by using the I(2) statistic. RESULTS: Fifty-six studies with 4,780,293 subjects met the inclusion criteria. Twenty-four of these studies (43%) did not report any SES measures. When it was reported (n = 32), only seven (13%) examined more than one component but none performed a multidimensional assessment. Most of the studies relied on income or income-related measures (such as prescription-drug benefits or co-payments) (27 of 32 [84%]). Meta-analysis could be quantified in 40 cohorts reported in 30 studies. Overall, the pooled adjusted risk estimate for nonadherence according to SES (high vs. low) was 0.89 (95% confidence interval 0.87-0.92; I(2) = 95%; P < 0.001). Similar patterns were observed in all subgroups examined. CONCLUSIONS: Published studies have not found a strong association between low SES and nonadherence to antihypertensive medications. However, important limitations in the assessment of SES can be identified in virtually all studies. Future studies are required to ascertain whether a stronger association is observed when SES is determined by comprehensive measures.

Measuring the Influence of Side Effect Expectations, Beliefs, and Incident Side Effects on the Risk for Drug Discontinuation Among Individuals Starting New Medications, a Cross-sectional Study.

Purpose: To measure the impact of beliefs, expectations, side effects, and their combined effects on the risk for medication nonpersistence. Patients and methods: Using a cross-sectional design, individuals from Saskatchewan, Canada who started a new antihypertensive, cholesterol-lowering, or antihyperglycemic medication were surveyed about risk factors for nonpersistence including: (a) beliefs measured by a composite score of three questions asking about the threat of the condition, importance of the drug, and harm of the drug; (b) incident side effects attributed to treatment; and (c) expectations for side effects before starting treatment. Descriptive statistics and logistic regression models were used to quantify the influence of these risk factors on the outcome of nonpersistence. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated. Results: Among 3,029 respondents, 5.8% (n=177) reported nonpersistence within four months after starting the new drug. After adjustment for numerous covariates representing sociodemographics, health-care providers, medication experiences and beliefs, both negative beliefs (OR: 7.26, 95%CI: 4.98-10.59) and incident side effects (OR: 8.00, 95%CI: 5.49-11.68) were associated with the highest odds of nonpersistence with no evidence of interaction. In contrast, expectations for side effects before starting treatment exhibited an important interaction with incident side effects following treatment initiation. Among respondents with incident side effects (n=741, 24.5%), the risk for early nonpersistence was 11.5% if they indicated an expectation for side effects before starting the medication compared to 23.6% if they did not (adjusted OR: 0.38, 95%CI: 0.25-0.60). Conclusion: Expectations for side effects may be a previously unrecognized but important marker of the probability to persist with treatment. A high percentage of new medication users appeared unprepared for the possibility of side effects from their new medication making them less resilient if side effects occur.

Collaborative Cardiovascular Risk Reduction in Primary Care II (CCARP II): Implementation of a systematic case-finding process for patients with uncontrolled risk factors.

BACKGROUND: Previous pharmacist interventions to reduce cardiovascular (CV) risk have been limited by low patient enrolment. The primary aim of this study was to implement a collaborative pharmacist intervention that used a systematic case-finding procedure to identify and manage patients with uncontrolled CV risk factors. METHODS: This was an uncontrolled, program implementation study. We implemented a collaborative pharmacist intervention in a primary care clinic. All adults presenting for an appointment with a participating physician were systematically screened and assessed for CV risk factor control by the pharmacist. Recommendations for risk factor management were communicated on a standardized form, and the level of pharmacist follow-up was determined on a case-by-case basis. We recorded the proportion of adults exhibiting a moderate to high Framingham risk score and at least 1 uncontrolled risk factor. In addition, we assessed before-after changes in CV risk factors. RESULTS: Of the 566 patients who were screened prior to visiting a participating physician, 186 (32.9%) exhibited moderate or high CV risk along with at least 1 uncontrolled risk factor. Physicians requested pharmacist follow-up for 60.8% (113/186) of these patients. Of the patients receiving the pharmacist intervention, 65.5% (74/113) were at least 50% closer to 1 or more of their risk factor targets by the end of the study period. Significant risk factor improvements from baseline were also observed. DISCUSSION: Through implementation of a systematic case-finding approach that was carried out by the pharmacist on behalf of the clinic team, a large number of patients with uncontrolled risk factors were identified, assessed and managed with a collaborative intervention. CONCLUSION: Systematic case finding appears to be an important part of a successful intervention to identify and manage individuals exhibiting uncontrolled CV risk factors in a primary care setting.

Proposing a redefinition of pharmaceutical care.

In many clinical practice settings, individual pharmaceutical care practitioners have thousands of patients who may receive their service. However, the pharmaceutical care approach provides virtually no guidance regarding how patients should be identified or prioritized by practicing pharmacists. We believe that pharmacists need to be "officially" accountable to specific patient groups at high risk for drug- or disease-induced morbidity within their practice. Consequently, the current definition of pharmaceutical care and its associated care processes need to be modified to ensure the activities of pharmacists are being focused on high-priority patients on a consistent basis.

Physician influence on medication adherence, evidence from a population-based cohort.

BACKGROUND: The overall impact of physician prescribers on population-level adherence rates are unknown. We aimed to quantify the influence of general practitioner (GP) physician prescribers on the outcome of optimal statin medication adherence. METHODS: We conducted a retrospective cohort study using health administrative databases from Saskatchewan, Canada. Participants included physician prescribers and their patients beginning a new statin medication between January 1, 2012 and December 31, 2017. We grouped prescribers based on the prevalence of optimal adherence (i.e., proportion of days covered ≥ 80%) within their patient group. Also, we constructed multivariable logistic regression analyses on optimal statin adherence using two-level non-linear mixed-effects models containing patient and prescriber-level characteristics. An intraclass correlation coefficient was used to estimate the physician effect. RESULTS: We identified 1,562 GPs prescribing to 51,874 new statin users. The median percentage of optimal statin adherence across GPs was 52.4% (inter-quartile range: 35.7% to 65.5%). GP prescribers with the highest patient adherence (versus the lowest) had patients who were older (median age 61.0 vs 55.0, p<0.0001) and sicker (prior hospitalization 39.4% vs 16.4%, p<0.001). After accounting for patient-level factors, only 6.4% of the observed variance in optimal adherence between patients could be attributed to GP prescribers (p<0.001). The majority of GP prescriber influence (5.2% out of 6.4%) was attributed to the variance unexplained by patient and prescriber variables. INTERPRETATION: The overall impact of GP prescribers on statin adherence appears to be very limited. Even "high-performing" physicians face significant levels of sub-optimal adherence among their patients.

An Advanced Pharmacy Practice Experience for Community Pharmacies Based on a Clinical Intervention Targeting Patients With Inflammatory Bowel Disease.

Experiential education is a critical component of any pharmacy undergraduate curriculum. Establishing new, high-quality practice sites can be challenging. We designed a new advanced pharmacy practice experiential rotation suitable for implementation in most community pharmacy settings. The aim of this article is to describe the design of this rotation entitled the Targeted Pharmacy Intervention in Inflammatory Bowel Disease (TPI-IBD) and to determine its impact on student knowledge and confidence using a before-after survey design. The TPI-IBD utilizes a student-delivered intervention as a platform for experiential learning in community pharmacy practice. The TPI was focused on patients with IBD, and implementation was guided by a co-preceptor from the university in collaboration with onsite-preceptors at each pharmacy. The TPI-IBD rotation was delivered from 6 community pharmacies during 5 weeks in 2018. Students conducted standardized monitoring on patients with IBD and met weekly with the university preceptor for case presentations and therapeutic discussions. Electronic charts were maintained by students who were responsible for ensuring detailed documentation on each patient. Knowledge, confidence, and overall satisfaction were assessed by a survey given to students before and after the rotation. Students were highly satisfied with the learning experience and improvements in knowledge and confidence were clearly demonstrated. The TPI strategy was an effective way to expand rotation options in community pharmacy sites with minimal burden on local preceptors.

A Randomized Controlled Trial of a Pretransplant Educational Intervention in Kidney Patients.

Poor patient knowledge about transplantation is a significant problem following kidney transplant. A video-based educational intervention was developed to supplement standard education provided by transplant teams. METHODS: A multicenter randomized controlled trial tested the intervention delivered to patients undergoing assessment or waitlisted for kidney transplant. Adult participants were randomized to the control (standard education) or the intervention group, consisting of electronic access to the videos (or digital video disks if no internet) plus standard education. Differences between groups in changes in transplant knowledge (measured by the Kidney Transplant Understanding Tool), education satisfaction, self-efficacy, and quality of life (secondary outcomes) were evaluated by a preintervention and postintervention survey. Video viewing habits were tracked and described for patients in the intervention group. RESULTS: One hundred sixty-two patients were enrolled, with 132 completing both questionnaires (n = 64 intervention and n = 68 control), with similar enrollment from 3 Canadian sites. Video viewing statistics in the complete cases indicated that 78% (50/64) watched the videos, with 70% (45/64) viewing them electronically, while 8% (5/64) received digital video disks and self-reported participation. Baseline knowledge scores in the intent-to-treat population were 55.4 ± 6.5 and 55.7 ± 7.1 in the intervention and control, respectively. The mean knowledge change in the intervention (2.1 ± 3.6) was significantly higher than in the control group (0.8 ± 3.4, P < 0.02). In the per-protocol analysis (patients with objective evidence of watching at least 80% of the videos), the knowledge improvements were 3.4 ± 3.8. Video group participants reported higher satisfaction with education (P < 0.02) and expressed positive comments in open-ended feedback. CONCLUSIONS: Electronic video education in the pretransplant setting improved knowledge and satisfaction.

The Saskatchewan Medication Assessment Program for Patients With Renal Failure: A Qualitative Study to Understand Health Care Provider Perspectives.

BACKGROUND: The Saskatchewan Medication Assessment Program (SMAP) compensates community pharmacists for medication reviews on eligible residents with the goal of optimizing patient care. Although medication reviews are meant to reduce risks associated with complex medication regimens, some patients may already be receiving specialized care from interdisciplinary health care teams from the renal programs in Saskatchewan. OBJECTIVE: A qualitative analysis was undertaken to examine the perceptions of health care providers about the SMAP process for patients receiving renal care in Saskatchewan. The goal was to explore potential benefits, facilitators, challenges, and/or barriers of the program in this population. DESIGN: Qualitative descriptive study. SETTING: The semi-structured interviews took place in the province of Saskatchewan. PARTICIPANTS: Community pharmacists, renal pharmacist, and nephrologists. METHODS: All nephrologists, renal pharmacists, and community pharmacies in Saskatoon and Regina were sent an invitation to participate in the study. Semi-structured interviews were completed with participants and were audio-recorded and transcribed verbatim. Coding was performed using NVIVO qualitative software, and meaning units and codes were consolidated into categories and subcategories using qualitative content analysis. RESULTS: A total of 9 community pharmacists, 10 renal pharmacists, and 8 nephrologists were interviewed. Community pharmacists had mixed levels of comfort providing SMAP assessments for renal patients, but expressed the desire to provide the best care possible and described patient benefits. Some categories (eg, barriers and improvements) and subcategories (eg, "collaboration/communication", "other challenges," and "suggestions for improvement") were consistent among all participant groups, while others (eg, "renal patients have complex care needs" and "duplication of service") were common among both renal pharmacists and nephrologists. The nephrologists had little knowledge of the program and of the role of the community pharmacist, indicating the need for improved education and communication. LIMITATIONS: The lack of renal patient perceptions on the SMAP process should be acknowledged and studied in future. A further limitation is the small sample size per subsample group. CONCLUSION: Despite some negative experiences, all of the participants believed the program can be beneficial. However, several recommendations were suggested to improve the SMAP process in renal patients and other complex patient populations.

CONTEXTE: Dans le but d'optimiser les soins aux patients, le Saskatchewan Medication Assessment Program (SMAP) rémunère les pharmaciens communautaires pour procéder à l'examen des médicaments prescrits aux résidents admissibles. Bien que ces examens visent à réduire les risques associés aux schémas posologiques complexes, certains patients reçoivent déjà des soins spécialisés par les équipes interdisciplinaires des programmes de santé rénale de la Saskatchewan. OBJECTIFS: Une analyse qualitative a été menée pour examiner la perception des fournisseurs de soins en regard du processus SMAP pour les patients recevant des soins de santé rénale en Saskatchewan. L'objectif était d'explorer les potentiels bienfaits, facilitateurs, défis et/ou obstacles du programme pour cette population. TYPE D'ÉTUDE: Étude qualitative et descriptive. CADRE: Entretiens semi-structurés s'étant tenus dans la province de la Saskatchewan. PARTICIPANTS: Des pharmaciens communautaires, des pharmaciens spécialisés en néphrologie et des néphrologues. MÉTHODOLOGIE: Tous les néphrologues, pharmaciens spécialisés en néphrologie et pharmaciens communautaires de Régina et de Saskatoon ont été invités à participer à l'étude. Des entretiens semi-structurés ont été menés auprès des participants. Les entretiens ont été enregistrés puis transcrits verbatim. Le logiciel d'analyse qualitative NVIVO a servi au codage; les unités et codes de signification ont été regroupés en catégories et sous-catégories à l'aide de l'analyse qualitative de contenu. RÉSULTATS: Neuf pharmaciens communautaires, dix pharmaciens spécialisés en néphrologie et huit néphrologues ont été interviewés. Les pharmaciens communautaires étaient plus ou moins confortables à l'idée de faire les évaluations du SMAP pour les patients atteints de néphropathies, mais ont exprimé le souhait d'en décrire les avantages aux patients et de fournir les meilleurs soins que possible. Certaines catégories (obstacles et améliorations) et sous-catégories (collaboration/communication, « autres défis ¼ et « suggestions d'améliorations ¼) étaient cohérentes entre les groupes, alors que d'autres (« les patients atteints de néphropathies ont des besoins complexes ¼ ou « dédoublement des services ¼) étaient fréquentes pour les néphrologues et les pharmaciens spécialisés en néphrologie. Les néphrologues en savaient très peu sur le programme et sur le rôle des pharmaciens communautaires, ce qui souligne la nécessité d'améliorer la sensibilisation et la communication. LIMITES: La perception des patients en regard du SMAP devrait être reconnue et étudiée dans de futurs essais. Aussi, le faible échantillon de chacun des sous-groupes de participants limite les résultats. CONCLUSION: Malgré quelques expériences négatives, tous les participants ont jugé que le programme peut être bénéfique. Plusieurs recommandations ont été avancées pour améliorer le processus du SMAP pour les patients atteints de néphropathies et pour d'autres populations de cas complexes. ENREGISTREMENT DE L'ESSAI: Sans objet.

Predictors of hospitalization in a Canadian MS population: A matched cohort study.

OBJECTIVE: Hospitalizations are the most costly component of healthcare in Canada, and hospitalization rates are higher in the multiple sclerosis (MS) population compared to the general population. This study aimed to examine predictors of hospitalizations in the MS population in Saskatchewan, Canada. METHODS: This retrospective cohort study used population-based health administrative data from Saskatchewan, Canada from 1996 to 2016. Subjects with MS were identified using a validated definition (≥3 hospital, physician, or drug claims for MS). Up to five general population controls were identified for each MS case and matched on sex, age, and geographical location. The rate of hospitalizations and reason for admission were determined for each case and control. Negative binomial (hospitalization rate) and binary logistic (reason for admission) regression models fitted with generalized estimating equations were used to test the following potential predictors: sex, age, median household income, calendar year, prior hospitalizations, and comorbidity status. RESULTS: We identified 4,878 MS cases (11,744 hospitalizations), and 23,662 matched controls (32,541 hospitalizations). Higher comorbidity burden, older age, and prior hospital admissions were associated with an increased rate of all-cause hospitalizations for both cohorts. Males were more likely to be hospitalized than females for all-cause (adjusted rate ratio: 1.20; 95% CI: 1.07 - 1.34) and MS-specific (adjusted odds ratio: 1.34; 95% CI 1.15 - 1.55) hospitalizations. The rate of MS-specific hospitalizations decreased with age, and there was no association with comorbidity or prior hospitalizations. A diagnosis of MS was associated with decreased odds of hospitalization due to neoplasms, diseases of the circulatory system, and mental health and behavioural disorders. CONCLUSION: Increased age, comorbidity, and prior hospital admissions are predictors of all-cause hospitalizations. Conversely, MS-related hospitalizations decreased as subjects aged, and there was no association with comorbidity. Our results highlight that reasons for hospitalizations can differ by age, and clinicians should consider this when managing patients, as they make efforts to reduce hospitalizations in the MS population.

A Canadian Survey on Adverse Symptoms Experienced by Solid Organ Transplant Recipients.

INTRODUCTION: Adverse symptoms experienced by solid organ transplant recipients remain largely unexplored despite their purported frequency. OBJECTIVE: To characterize patient perspectives on adverse symptoms, identifying the most problematic symptoms and the perceived cause and treatability, and to evaluate their impact on quality of life (QoL) and medication adherence. METHODS: An electronic survey was distributed to members of the Canadian Transplant Association, to characterize perceptions on symptom experience (Modified Transplant Symptom Occurrence and Distress Scale), and QoL (Short Form-12), medication adherence (Basel Assessment of Adherence to Immunosuppressive Medications Scale), demographics, and clinical situation. RESULTS: The questionnaire was distributed to 249 solid organ transplant recipients and achieved a 51% response rate (N = 127). Respondents reported a mean of 25 (standard deviation 10) adverse symptoms each. In women, the most prevalent and distressing symptoms were tiredness, lack of energy, sleep difficulties, difficulty concentrating or memory problems, diarrhea, joint pain, and depression. In men, they were tiredness, flatulence, lack of energy, sleep difficulties, and erectile problems. With the exception of flatulence, these symptoms were more often perceived to be caused by medical conditions rather than by immunosuppressants or other medications. Quality of life was similar to the general public, with mean physical and mental component scores of 47.4 (9.9) and 52.1 (8.2), respectively (relative to a US average of 50 [10]). However, QoL scores inversely correlated to the number of symptoms reported and were higher in patients who perceived all symptoms to be treatable. CONCLUSION: Adverse symptoms may impact patient well-being. Perceived cause and treatability should be further explored.

Self-Monitoring of Blood Glucose and Hypoglycemia-Related Hospitalization in a Population-Based Cohort of Canadian Patients With Type 1 or Type 2 Diabetes.

OBJECTIVES: The aim of this work was to determine whether: 1) blood glucose test strip use in the population is associated with hypoglycemia hospitalization rates, and 2) blood glucose test strip use among individuals is associated with a reduced risk of hypoglycemia hospitalization. METHODS: Administrative databases from Saskatchewan, Canada, were used to ascertain population-level hypoglycemia hospitalizations and test strip utilization over the period from 1996 to 2014. For objective 1, a generalized linear model with generalized estimating equations was fit to provincial data stratified by age group, sex and year. For objective 2, a nested case-control study was conducted for a cohort of insulin users with diagnosed diabetes. Multivariable conditional logistic regression was used to test the association of test strip use with hospitalization, after adjusting for clinical and demographic factors and health services use. Odds ratios (ORs) and 95% confidence intervals (95% CIs) are reported. RESULTS: A total of 5,166 hospitalizations for hypoglycemia were identified in the observation period. Annual glucose test strip use increased by over 350%; however, no association was found with provincial hypoglycemia hospitalization rate during the same period, even after controlling for all-cause hospitalizations and population demographics. In the case-control analysis, test strip use was not associated with hospitalization for hypoglycemia among insulin users (n=10,617; adjusted OR, 1.08; 95% CI, 0.88 to 1.31). A sensitivity analysis in an independent cohort of noninsulin users produced a similar finding (n=47,501; adjusted OR, 1.04; 95% CI, 0.55 to 1.94). CONCLUSION: Our findings add to the body of evidence against a protective effect of blood glucose test strip use for serious hypoglycemia.

Risk of heart failure in patients with recent-onset type 2 diabetes: population-based cohort study.

BACKGROUND: Although thiazolidinediones precipitate fluid retention in clinical trials, current guidelines advocate their use for patients with diabetes who are felt to be at low risk for heart failure (HF). METHODS AND RESULTS: An inception cohort study was conducted using Saskatchewan Health databases spanning the years 1991 to 1999 (before use of thiazolidinediones) to compare incidence rates of new HF in patients with recent-onset diabetes vs. the general population. Of 12,272 patients with new-onset type 2 diabetes (mean age 63 years), 718 (6%) developed HF over 5.2 years; median time until development of HF was 2.8 years. The adjusted rate of incident HF for the diabetes cohort was 794 cases per 100,000 person years compared with 275 per 100,000 person-years in the general population. Patients with recent-onset diabetes were more likely to develop HF than the general population (adjusted rate ratio 2.9; 95% CI 2.6 to 3.2) and the relative risk was most pronounced in those younger than 60 years (adjusted rate ratio 12.8; 95% CI 8.2 to 20.0). CONCLUSIONS: The incidence of HF is relatively high within 5 years of diabetes onset, calling into question the ease with which individuals with diabetes "at low risk of HF" can be identified.