A comparison of opioid use between WCB recipients and other Manitobans for knee, shoulder, back and carpal tunnel release procedures.

BACKGROUND: This study's objectives were to evaluate whether WCB claimants with conditions requiring certain surgical procedures are more likely to be prescribed outpatient opioids than other Manitobans and whether those prescribed opioids are more likely to still be on opioid medications 6 months post procedure. METHODS: We compared 7,246 WCB claims for a number of surgical procedures to 65,032 similar procedures performed in other Manitobans. Logistic regression was used to explore the association between being a WCB claimant and being prescribed opioids, while controlling for type of surgical procedure and other potential confounders. RESULTS: WCB claimants were more likely than other Manitobans to be prescribed opioids (adjusted OR 1.38; 95%CI 1.30-1.47). Amongst those prescribed opioids, the odds of being still on opioids 6 months post-procedure were not significantly elevated for WCB claimants (adjusted OR 1.09 95%CI 0.97-1.23). CONCLUSIONS: WCB claimants are prescribed opioids more often than non-claimants for similar procedures.

Proportion of opioid use due to compensated workers' compensation claims in Manitoba, Canada.

BACKGROUND: This study identifies the percentage of opioids prescribed for compensated workplace conditions in Manitoba, Canada and whether Workers Compensation Board (WCB) status is associated with higher prescription opioid doses. METHODS: Opioid prescriptions for WCB recipients were linked with databases housed at the Manitoba Center for Health Policy. Duration of continuous opioid prescription and morphine equivalents (ME) per day (ME/D) were calculated for individuals age 18-65. RESULTS: Over the period from 1998 to 2010, 3.8% of the total opioid dosage of medication prescribed in the study population were prescribed to WCB recipients. WCB recipients accounted for 2.1% of the individuals prescribed opioids. In adjusted analyses WCB recipients were more likely to be prescribed over 120 ME/D (OR 2.06 95% CI, 1.58-2.69). CONCLUSIONS: WCB recipients account for a small, but significant amount of the total opioid prescribed in Manitoba. Manitoba's WCB population is a group at increased risk of being prescribed over 120 ME/day.

Cost analysis of an intravenous to subcutaneous epoetin α conversion.

BACKGROUND/AIMS: A cost analysis of a conversion from intravenous (IV) to subcutaneous (SC) epoetin α in patients receiving chronic in-center hemodialysis (HD). METHODS: This retrospective analysis compared epoetin α drug costs during a 6-month period of IV usage (July to December 2010, period 1) to a 6-month period of SC usage (July to December 2011, period 2) in four large in-center HD units. Data were collected from quarterly counts of HD patients receiving epoetin α and monthly inventory billing records. RESULTS: 622 HD patients who received IV epoetin α (period 1) were compared to 609 HD patients who received SC epoetin α (period 2). A 12.6% decrease in dose was observed. The average weekly cost of epoetin α was USD 173.02 per patient during the IV period versus USD 151.20 per patient during the SC period. This equated to a yearly cost savings of USD 1,135 per patient with SC epoetin α. CONCLUSION: The switch from IV to SC epoetin α was successfully implemented in all four centers and realized significant cost savings.

Evaluation of a medication order writing standards policy in a regional health authority.

BACKGROUND: The Winnipeg Regional Health Authority (WRHA) implemented a medication order writing standards (MOWS) policy (including banned abbreviations) to improve patient safety. Widespread educational campaigns and direct prescriber feedback were implemented. METHODS: We audited orders within the WRHA from 2005 to 2009 and surveyed all WRHA staff in 2011 about the policy and suggestions for improving education and compliance. RESULTS: Overall, orders containing banned abbreviations, acronyms or symbols numbered 2261/8565 (26.4%) preimplementation. After WRHA-wide didactic education, the proportion declined to 1358/5461 (24.9%) (p = 0.043) and then, with targeted prescriber feedback, to 1186/6198 (19.1%) (p < 0.0001). A survey of 723 employees showed frequent violations of the MOWS, despite widespread knowledge of the policy. Respondents supported ongoing efforts to enforce the policy within the WRHA. Nonprescribers were significantly more likely than prescribers to agree with statements regarding enhancing compliance by defining prescriber/transcriber responsibilities and placing sanctions on noncompliant prescribers. DISCUSSION: Education, raising general awareness and targeted feedback to prescribers alone are insufficient to ensure compliance with MOWS policies. WRHA staff supported ongoing communication, improved tools such as compliant preprinted orders and reporting and feedback about medication incidents. A surprising number of respondents supported placing sanctions on noncompliant prescribers. CONCLUSION: Serial audits and targeted interventions such as direct prescriber feedback improve prescription quality in inpatient hospital settings. Education plus direct prescriber feedback had a greater impact than education alone on improving compliance with a MOWS policy. Future efforts at the WRHA to improve compliance will require an expanded focus on incentives, resources and development of action plans that involve all affected staff, not just prescribers. Plans include continued advertising, MOWS summaries in all charts, all-staff education, reminders and exploration of sustainable interventions for targeted feedback for prescribers.

Development and evaluation of a workplace-based preceptor training course for pharmacy practitioners.

BACKGROUND: There has been limited research about preceptor training programs that include coaching, experiential practice or development of preceptor coaching capacity. We describe the development and evaluation of a workplace preceptor training course for pharmacists and pharmacy technicians within a large regional health authority. METHODS: The instructional format was self-study readings and interactive seminars followed by structured practical experience plus feedback from a preceptor coach. During the structured practical experience, each participant served as a preceptor for a student or new staff member. Course evaluations and qualitative interviews were used to evaluate utility and perceived value among participants. Interview transcripts were analyzed using qualitative description and themes were aggregated; illustrative quotes are presented. RESULTS: Since 2006, a total of 40 pharmacists and technicians have participated in the course and interviews were conducted with 14 of these participants. Aspects of the course that interview participants found to be particularly useful included receiving feedback from a coach, implementing a lesson plan and identifying and using different learning and teaching styles. Some participants described changes in attitudes or behaviours toward new employees or students, the use of new learning styles and changes in focus and approach to being a preceptor. DISCUSSION: This unique course could be applied in other workplaces where pharmacy staff members help to deliver experiential education programs. The delivery format was appropriate for a mixed group of pharmacist and technician participants. CONCLUSION: A preceptor training course of readings, seminars and structured practical experience with feedback from a coach resulted in satisfaction with learning experiences and evidence of attitudinal and behavioural change up to 3 years after the course.

Patterns of antiemetic medication use during pregnancy: A multi-country retrospective cohort study.

OBJECTIVE: To compare patterns in use of different antiemetics during pregnancy in Canada, the United Kingdom, and the United States, between 2002 and 2014. METHODS: We constructed population-based cohorts of pregnant women using administrative healthcare data from five Canadian provinces (Alberta, British Columbia, Manitoba, Ontario, and Saskatchewan), the Clinical Practice Research Datalink from the United Kingdom, and the IBM MarketScan Research Databases from the United States. We included pregnancies ending in live births, stillbirth, spontaneous abortion, or induced abortion. We determined maternal use of antiemetics from pharmacy claims in Canada and the United States and from prescriptions in the United Kingdom. RESULTS: The most common outcome of 3 848 734 included pregnancies (started 2002-2014) was live birth (66.7% of all pregnancies) followed by spontaneous abortion (20.2%). Use of antiemetics during pregnancy increased over time in all three countries. Canada had the highest prevalence of use of prescription antiemetics during pregnancy (17.7% of pregnancies overall, 13.2% of pregnancies in 2002, and 18.9% in 2014), followed by the United States (14.0% overall, 8.9% in 2007, and 18.1% in 2014), and the United Kingdom (5.0% overall, 4.2% in 2002, and 6.5% in 2014). Besides use of antiemetic drugs being considerably lower in the United Kingdom, the increase in its use over time was more modest. The most commonly used antiemetic was combination doxylamine/pyridoxine in Canada (95.2% of pregnancies treated with antiemetics), ondansetron in the United States (72.2%), and prochlorperazine in the United Kingdom (63.5%). CONCLUSIONS: In this large cohort study, we observed an overall increase in antiemetic use during pregnancy, and patterns of use varied across jurisdictions. Continued monitoring of antiemetic use and further research are warranted to better understand the reasons for differences in use of these medications and to assess their benefit-risk profile in this population.

Iron replacement and supplementation in patients with chronic kidney disease.

Interest in optimizing iron management in the treatment of anemia of CKD is growing due to concerns that high doses of ESAs may have deleterious effects and the high cost of ESAs in comparison to iron therapy. International guidelines have defined iron targets for this patient population, but there are some unanswered questions with respect to long-term use of iron, such as the maximum TSAT or ferritin concentration and concerns with oxidative stress. Large head-to-head safety studies of the different i.v. iron preparations have not been performed to date and current safety data rely on small studies and spontaneous adverse event reporting. Interprofessional management of anemia, including iron therapy, has shown beneficial effects and should be encouraged.

Attitudes and behaviours of hospital pharmacy staff toward near misses.

Near misses may be early warning signals for errors. The purpose of this study was to examine the attitudes and behaviours of Manitoba hospital pharmacists and technicians toward near misses and reporting. A web-based survey of pharmacy staff at hospitals (all have non-punitive paper-based incident reporting systems) was conducted in 2009. Survey respondents were asked via a validated survey about experience with and attitudes and behaviours toward near misses. Factor analysis and Cronbach's α were used to determine internal consistency reliability. Differences between pharmacists and technicians were compared using Fisher's exact test for categorical data and t tests for survey scales. Of 37 hospitals, one large tertiary care hospital declined to participate. Of approximately 500 pharmacy staff, 122 (24%) responded. The majority (54.1%) were pharmacists, and most worked in Winnipeg (73.8%). The majority of respondents (62% overall--48% of technicians and 73% of pharmacists (p=.008)--had experienced at least one near miss within the previous three months. However, only 27% had reported a near miss with occurrence-reporting forms. There was no difference in the reporting behaviours scale (eight items, Cronbach's α=.824) between pharmacists and technicians (pharmacist score 30.9 ± 4.8, technician score 29.6 ± 6.0; p=.215). There was no difference in the attitudes scale (23 items, Cronbach's α=.873) between pharmacists and technicians (pharmacist score 81.9 ± 9.4, technician score 80.2 ± 10.6; p=.388). We observed similar behaviours and attitudes between hospital pharmacists and technicians, although reporting of near misses was low. Education of pharmacy staff and managers about near misses may help to encourage reporting.

Comparison of Pregnancy Outcomes of Patients Treated With Ondansetron vs Alternative Antiemetic Medications in a Multinational, Population-Based Cohort.

Importance: Ondansetron is frequently used to treat nausea and vomiting during pregnancy. Although some studies reported important safety signals, few studies have been sufficiently large to assess rare pregnancy outcomes. Objective: To study the association between ondansetron exposure during pregnancy and the risks of spontaneous abortion, stillbirth, and major congenital malformations. Design, Setting, and Participants: This is a cohort study conducted in 3 countries, with a meta-analysis. Participants included women and girls aged 12 to 55 years who experienced spontaneous abortion, induced abortion, stillbirth, or live birth between April 2002 and March 2016, as recorded in administrative data from 5 Canadian provinces (British Columbia, Alberta, Saskatchewan, Manitoba, and Ontario), the US IBM MarketScan Research Databases, and the UK Clinical Practice Research Datalink. The statistical analysis was completed in October 2020. Exposures: Exposure to ondansetron during pregnancy was compared with exposure to other commonly used antiemetics to minimize confounding by indication. Main Outcomes and Measures: The primary outcome was fetal death, defined as either spontaneous abortion or stillbirth. Secondary outcomes were the 2 components of the primary outcome and major congenital malformations identified during the year after a live birth. Adjusted hazard ratios were estimated using Cox proportional hazards models with time-dependent drug exposures and were adjusted using high-dimensional propensity scores. For major congenital malformations, adjusted odds ratios were estimated from logistic models. Site-level results were pooled using random-effects meta-analysis. Sensitivity analyses considered second-line antiemetic exposure and exposure specifically during 4 to 10 weeks of gestation. Results: Data from 456 963 pregnancies were included in this study of fetal death (249 787 [54.7%] in Canada, 197 913 [43.3%] in the US, and 9263 [2.0%] in the UK; maternal age, ≤24 years, 93 201 patients [20.4%]; 25-29 years, 149 117 patients [32.6%]; 30-34 years, 142 442 patients [31.2%]; and ≥35 years, 72 203 patients [15.8%]). Fetal death occurred in 12 907 (7.9%) of 163 810 pregnancies exposed to ondansetron, and 17 476 (5.7%) of 306 766 pregnancies exposed to other antiemetics. The adjusted hazard ratios were 0.91 (95% CI, 0.67-1.23) for fetal death with time-dependent ondansetron exposure during pregnancy, 0.82 (95% CI, 0.64-1.04) for spontaneous abortion, and 0.97 (95% CI, 0.79-1.20) for stillbirth. For major congenital malformations, the estimated odds ratio was 1.06 (95% CI, 0.91-1.22). Results of sensitivity analyses were generally consistent with those of the primary analyses. Conclusions and Relevance: In this large, multicenter cohort study, there was no association between ondansetron exposure during pregnancy and increased risk of fetal death, spontaneous abortion, stillbirth, or major congenital malformations compared with exposure to other antiemetic drugs.

Reliability and validity of a survey to evaluate attitudes and behaviours of pharmacy staff toward near misses.

The purpose of this study was to describe attitudes and behaviours of pharmacy staff toward near misses through a survey and interviews. Themes of an acknowledgment of pharmacy process changes resulting from near miss reporting, feelings of personal responsibility, minimizing the importance of reporting near misses, and a need for further education were evident in both the survey and qualitative discussions. This survey is useful to inform educational efforts and to encourage near miss reporting.

Reduced drug costs from switching hemodialysis patients from epoetin alfa in multidose vials to pre-filled syringes.

OBJECTIVE: We sought to evaluate epoetin alfa drug costs in hemodialysis (HD) patients after a province-wide switch from multidose vials (MDV) to prefilled syringes (PFS). METHODS: A retrospective study of epoetin alfa drug costs and estimated doses based on these costs during a six-month period of MDV usage (2007) were compared to a PFS usage period (2008). Data were collected from quarterly counts of HD patients receiving epoetin alfa in the Manitoba Renal Program (MRP) and monthly inventory billing records. RESULTS: 756 patients who received epoetin alfa MDV were compared to 799 patients who received epoetin alfa PFS. Average weekly dose calculated from drug costs was 13,282 units (MDV) versus 11,689 units (PFS). Average weekly costs were $195.71 (MDV) versus $183.23 (PFS). This translated to an estimated $12.48 per patient per week in savings ($518,519 annual savings across the Manitoba Renal Program). CONCLUSION: The switch from epoetin alfa MDV to epoetin alfa PFS realized cost savings, likely as a result of reduced drug wastage.

Pharmacotherapeutic options for the treatment of depression in patients with chronic kidney disease.

Depressive disorders occur in up to one-third of patients with chronic kidney disease CKD). First-line pharmacologic treatments include selective serotonin reuptake inhibitors and second generation agents, such as bupropion, mirtazapine, and venlafaxine. Although very little research has been conducted on the use of antidepressants in CKD, health care providers should be aware of renal dose adjustments for these agents, drug interactions, and potential adverse effects. This article reviews the epidemiology and significance of depression in patients with CKD and discusses drug therapy options for treatment of depression in this patient population.

Are CSN and NKF-K/DOQI mineral metabolism guidelines for hemodialysis patients achievable? Results from a provincial renal program.

BACKGROUND: The calcium, phosphorus, and parathyroid hormone targets recommended by the Canadian Society of Nephrology (CSN) encompass a wider range of values as compared to the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) guidelines. We sought to compare mineral metabolism parameters within the Manitoba Renal Program (MRP) to the CSN and NKF-K/DOQI guidelines. Medication use was also examined. METHODS: All hemodialysis patients in Manitoba were evaluated. Values for serum albumin, phosphorus, calcium, intact parathyroid hormone (PTH) and pertinent medications were collected. RESULTS: Five hundred and forty-six patients were included in the analysis. Fifty-three per cent to 81% of MRP patients met individual CSN targets. However, only 26% of patients achieved all targets, despite high usage of phosphate (85.5% calcium carbonate, 16.1% sevelamer, 1.3% aluminum) and PTH-lowering drug therapies (30.2% calcitriol, 2.7% cinacalcet). CONCLUSION: Only a small proportion of patients were able to achieve all three CSN mineral metabolism targets simultaneously. The majority of outliers presented with hyperphosphatemia or hypoparathyroidism.

Conversion from epoetin alfa to darbepoetin alfa within the Manitoba Renal Program: evaluation of dose ratios.

We sought to describe dose conversion ratios between epoetin alfa and darbepoetin alfa for patients with anemia of chronic kidney disease (CKD) in a large provincial renal program. Hemodialysis (HD), peritoneal dialysis (PD) and pre-dialysis patients with CKD were included. Laboratory parameters and darbepoetin alfa doses were compared to epoetin alfa doses (same route). In 2005, 857 patients received darbepoetin alfa and were compared to 746 patients who received epoetin alfa in 2003-2004. Mean dose conversion ratios were 12,939 IU, 53.1 microg, 244:1 for HD; 9,273 IU, 41.8 microg, 222:1 for PD; and 5,516 IU, 25.2 microg and 219:1 for CKD patients. The mean hemoglobin and iron parameters were within K/DOQI targets on both drugs. Conversion ratios in HD, PD and CKD patients using erythropoietic therapies was greater than 200:1 with both intravenous and subcutaneous dosing. Renal programs across Canada should consider dosage conversion ratios in addition to drug acquisition costs when considering a formulary decision about erythropoiesis stimulating agents.

A population-based analysis of statin utilization in British Columbia.

OBJECTIVE: The purpose of this research was to measure prevalent and incident statin use in the population of British Columbia from 1996 to 2004 across specific patient characteristics (sociodemographic and clinical). METHODS: Statin utilization and demographic data were assessed with the use of prescription drug claims. Medical and hospital claims for statin users were examined for evidence of ischemic heart disease (IHD), diabetes mellitus (DM), atherosclerosis, cerebrovascular disease, peripheral vascular disease (PVD), and disorders of lipid metabolism during the 3 years before the first statin prescription. RESULTS: Statin prevalence increased from 1996 to 2004 (1.28 %-6.59%). The greatest use was among those aged 65 to 84 years. Prevalent use of atorvastatin, simvastatin, and rosuvastatin increased over time. There were 211,964 new statin users between 1999 and 2004. Quarterly incident statin use increased over time from 1999 to 2004 (0.29%-0.49%). A socioeconomic gradient, whereby use was greater in those with low socioeconomic status, was observed for incident statin use. Incident atorvastatin use increased over time; simvastatin, cerivastatin, and rosuvastatin peaked and then declined; and new use of other statins decreased. Among 211,964 incident statin users, 74,542 (35.17%) had evidence of IHD only; 43,257 (20.41%) had DM but no IHD; 9781 (4.61%) had no DM or IHD but had atherosclerosis, cerebrovascular disease, or PVD; 47,634 (22.47%) had disorders of lipid metabolism only; and 36,750 (17.34%) had none of the medical conditions evaluated. CONCLUSIONS: Prevalent use (1996-2004) and incident use (1999-2004) of statins in an entire population have increased dramatically. Although many statin users (60.19%) had evidence of medical conditions that indicate appropriate statin use, 39.91% of users were at low risk for cardiovascular disease, and therefore the benefit of statins in this group remains small.

Antidepressant utilization in British Columbia from 1996 to 2004: increasing prevalence but not incidence.

OBJECTIVES: Expenditures on antidepressants in Canada are rapidly increasing; yet few studies have analyzed the characteristics of antidepressant users. This study investigated the prevalence and incidence of antidepressant use in British Columbia over eight years. METHODS: Antidepressant utilization and demographic data were assessed for the population of British Columbia from 1996 to 2004. Prescription claims were identified within the PharmaNet database for serotonin reuptake inhibitors (SSRI), tricyclics, monoamine oxidase inhibitors, bupropion (categorized separately for smoking cessation), and "novel" antidepressants, such as venlafaxine. Incident utilization (dispensed "first" antidepressant after two years without an antidepressant claim) and prevalent utilization were analyzed. All cohort members were required to have continuous registration with British Columbia medical services for at least two years before the first antidepressant claim. RESULTS: Prevalence of antidepressant use doubled, from 34 to 72 users per 1,000 population, between 1996 and 2004. The prevalence of particular classes of antidepressants also changed over time. Prevalence of novel antidepressants and SSRIs increased, although incidence of SSRIs decreased. Prevalent and incident use of bupropion for smoking cessation peaked in 1999 but then declined. Quarterly incident antidepressant use increased in 1998 and 1999 (6.5 and 11.3 users per 1,000) but decreased through 2004 (4.2 users per 1,000). Those aged 20 to 44 years and those aged 45 to 64 years showed the greatest peak in incident antidepressant use. A socioeconomic gradient in prescribing was observed. CONCLUSIONS: Prevalent antidepressant use has increased dramatically since 1996. By contrast, incident use increased from 1998 to 1999 but then decreased through 2004. Many complex factors likely contribute to antidepressant prescribing patterns.

Opioid use during pregnancy: a population-based cohort study.

BACKGROUND: Opioid use has increased dramatically in North America. The safety of opioids in pregnancy is uncertain, but they are associated with several fetal abnormalities and contribute to rising rates of neonatal abstinence syndrome. We examined opioid use before and during pregnancy in a complete population-based cohort. METHODS: We examined opioid use in a cohort of all pregnant women in Manitoba, Canada, from 2001 to 2013. Opioid use was defined by prescriptions for opioids, converted to oral morphine equivalents (MEQ), during the 3 months before pregnancy and for each trimester. Given that the exposure per person may vary (because not all women complete all time periods), we determined a weighted number of pregnancies in each period. RESULTS: During the study period, 174 848 completed pregnancies were eligible for analysis (173 680 live births and 1168 stillbirths and intrauterine deaths), which represented a weighted value of 175 174 pregnancies. Among these pregnancies, 6.7% of the women filled opioid prescriptions in the 3 months before pregnancy. Use declined to 4.2% during the first trimester and further declined to 3.0% and 2.9% in the second and third trimesters, respectively. Over the study period, there was a modest increase in opioid use overall (from 7.3% to 7.7%). MEQ did not decline during pregnancy, and the mean MEQ increased significantly over the study period (from 284 mg to 1218 mg). Prescriptions for codeine were filled by 96.9% of the users, accounting for 66.2% of MEQ. INTERPRETATION: Although many of the women using opioids before pregnancy discontinued or reduced use of these drugs during pregnancy, the volume of opioids consumed by those who continued opioid use did not decline during pregnancy. The increasing dosage and increased use of higher-potency opioids by pregnant women highlights the need for continued evaluation of and education about the benefits and risks of this practice.