Care-seeking experiences of unattached patients in the Canadian health care system: Qualitative study.

OBJECTIVE: To understand how lack of attachment to a regular primary care provider influences patients' outlooks on primary care, ability to address their health care needs, and confidence in the health care system. DESIGN: Qualitative descriptive study using semistructured interviews. SETTING: Canadian provinces of Nova Scotia, Ontario, and Quebec. PARTICIPANTS: Patients aged 18 years or older who were unattached or had become attached within 1 year of being interviewed and who resided in the province in which they were interviewed. METHODS: Forty-one semistructured interviews were conducted, during which participants were asked to describe how they had become unattached, their searches to find new primary care providers, their perceptions of and experiences with the centralized waiting list in their province, their experiences seeking care while unattached, and the impact of being unattached on their health and on their perceptions of the health care system. Interviews were transcribed and analyzed using a thematic approach. MAIN FINDINGS: Two main themes were identified in interviews with unattached or recently attached patients: unmet needs of unattached patients and the impact of being unattached. Patients' perceived benefits of attachment included access to care, longitudinal relationships with health care providers, health history familiarity, and follow-up monitoring and care coordination. Being unattached was associated with negative effects on mental health, poor health outcomes, decreased confidence in the health care system, and greater pre-existing health inequities. CONCLUSION: Having a regular primary care provider is essential to having access to high-quality care and other health care services. Attachment also promotes health equity and confidence in the public health care system and has broader system-level, social, and policy implications.

Patient perspectives on the vital primary care role of community pharmacists in Nova Scotia, Canada: qualitative findings from the PUPPY Study.

OBJECTIVES: Community pharmacists play an important role in primary care access and delivery for all patients, including patients with a family physician or nurse practitioner ("attached") and patients without a family physician or nurse practitioner ("unattached"). During the COVID-19 pandemic, community pharmacists were accessible care providers for unattached patients and patients who had difficulty accessing their usual primary care providers ("semi-attached"). Before and during the pandemic, pharmacist services expanded in several Canadian provinces. The aim of this qualitative study was to explore patient experiences receiving care from community pharmacists, and their perspectives on the scope of practice of community pharmacists. METHODS: Fifteen patients in Nova Scotia, Canada, were interviewed. Participant narratives pertaining to pharmacist care were analyzed thematically. KEY FINDINGS: Attached, "semi-attached," and unattached patients valued community pharmacists as a cornerstone of care and sought pharmacists for a variety of health services, including triaging and system navigation. Patients spoke positively about expanding the scope of practice for community pharmacists, and better optimization of pharmacists in primary care. CONCLUSIONS: System decision-makers should consider the positive role community pharmacists can play in achieving primary care across the Quintuple Aim (population health, patient and provider experiences, reducing costs, and supporting equity in health).

Understanding the experiences of Black Nova Scotians with community pharmacists.

Background: A history of medical abuse and social inequality confounded by persistent racial discrimination in health care has triggered mistrust between Black patients and health care providers. Although the consequences of systemic racism on health outcomes are well understood, little is known about how they manifest in pharmacy practice. The objective of this study was to explore the experiences of Black Nova Scotians with community pharmacists. Methods: This was a qualitative study that used focus groups and one-on-one interviews. Black Nova Scotians 18 years of age and older who have had interactions with community pharmacists were invited to participate. Focus groups and interviews were audio-recorded, transcribed and analyzed thematically. Results: Two focus groups (n = 10) and 6 one-on-one interviews were held between May and June 2021. Three major themes were identified: 1) difficulties navigating a pharmacy as a Black person, 2) lack of inclusivity and cultural competence in the pharmacy and 3) transactional relationships with pharmacists. Discussion: Most participants felt their race negatively affected the quality of care they received from the pharmacist and that pharmacists were not culturally competent. Most participants did not consider pharmacists to be part of their health care team and described feeling unsafe or uncomfortable in the pharmacy. Conclusions: Pharmacists have an important role in closing the health equity gap. This research highlights the need for pharmacy education to include cultural competence and will be used to guide strategies to improve access to culturally safe pharmacy services for Black Nova Scotians.

Medication-related criteria in frailty assessment tools: A narrative review.

OBJECTIVE: To review medication-related criteria within validated frailty tools. METHODS: Narrative review of validated frailty assessment tools. Frailty tools were identified from recently published reviews; each tool was reviewed to determine whether any medication-related criteria were included and how these criteria contributed to the scoring/assessment of frailty. RESULTS: Eight out of 16 validated frailty tools included medication-related criteria. The majority of criteria were a numerical cut-off of number of medications taken; however, the specific cut-off was not consistent. CONCLUSION: Inclusion of medication-related criteria in frailty tools is highly variable. Future research is required to determine whether incorporation of medication use into frailty assessment can impact outcomes in terms of frailty prevention and treatment.

Influenza Vaccination in Older Adults: Recent Innovations and Practical Applications.

Influenza can lead to serious illness, particularly for older adults. In addition to short-term morbidity and mortality during the acute infection, recovery can be prolonged and often incomplete. This may lead to persistent declines in health and function, including catastrophic disability, which has dramatic implications for the well-being and support needs of older adults and their caregivers. All of this means that prevention of infection and effective treatment when illness has occurred are of paramount importance. In this narrative review, we discuss the effectiveness of influenza vaccines for the prevention of influenza illness and serious outcomes in older adults. We review evidence of vaccine effectiveness for older adults in comparison with younger age groups, and also highlight the importance of frailty as a determinant of vaccine effectiveness. We then turn our attention to the question of why older and frailer individuals have poorer vaccine responses, and consider changes in immune function and inflammatory responses. This sets the stage for a discussion of newer influenza vaccine products that have been developed with the aim of enhancing vaccine effectiveness in older adults. We review the available evidence on vaccine efficacy, effectiveness and cost benefits, consider the potential place of these innovations in clinical geriatric practice, and discuss international advisory committee recommendations on influenza vaccination in older adults. Finally, we highlight the importance of influenza prevention to support healthy aging, along with the need to improve vaccine coverage rates using available vaccine products, and to spur development of better influenza vaccines for older adults in the near future.

Evaluation of the impact of immunization policies, including the addition of pharmacists as immunizers, on influenza vaccination coverage in Nova Scotia, Canada: 2006 to 2016.

BACKGROUND: Influenza is a serious public health concern, resulting in morbidity, mortality and significant expense to healthcare systems worldwide. Annual vaccination is the most effective way to prevent influenza. The National Advisory Committee on Immunization in Canada recommends that everyone six months of age and older without contraindications should be vaccinated. The Canadian province of Nova Scotia implemented a publicly-funded universal influenza vaccination program in the 2010-2011 influenza season. In 2013, pharmacists in Nova Scotia gained the authority to provide a variety of vaccinations, including the publicly-funded influenza vaccine. This study aimed to investigate any changes in influenza vaccine coverage following the implementation of each policy change: 1) universal publicly-funded program and 2) universal publicly-funded program with the addition of pharmacists. METHODS: Influenza seasons evaluated were from 2006-2007 to 2015-2016. Coverage was estimated by examining Nova Scotia census data with aggregate immunization administration data, including the total number of vaccinations administered according to vaccine provider (physician, public health or pharmacist), geographic region, vaccine recipient age and year. RESULTS: The analysis showed an increase in influenza vaccine coverage immediately following the implementation of the two studied policy changes. Vaccine coverage increased from 36.4 to 38% following the implementation of the universally funded vaccine policy. Following the implementation of pharmacists as immunizers, coverage increased from 35.7 to 41.7%. Vaccine coverage was highest in those 65 years of age and older during all years evaluated. Physicians provided the highest proportion of vaccines during all study periods, however a decreasing trend through all periods was observed. Physicians proportionately provided more vaccines in urban areas; whereas pharmacist and public health immunization providers in rural areas provided proportionately more vaccinations than their urban counterparts. CONCLUSIONS: The addition of a universally funded vaccination policy and the addition of pharmacists as providers of the influenza vaccine resulted in increases in vaccine coverage initially. Additional research is needed to determine the long-term impacts of the policy changes on vaccination coverage and to identify other important factors affecting vaccine uptake.

Assessment of Mesenteric Tissue Saturation, Oxygen Saturation, and Heart Rate Pre- and Post-Blood Transfusion in Very Low-Birth-Weight Infants Using Abdominal Site Near-Infrared Spectroscopy.

BACKGROUND: Preterm infants often receive blood transfusions during hospitalization. Although transfusions are intended to enhance oxygen delivery, previous studies found decreases in tissue and mesenteric oxygen saturation during and after blood transfusions without changes in vital signs and hemoglobin oxygen saturation. PURPOSE: To study the effect of blood transfusions on regional mesenteric tissue oxygen saturation (rSO2), hemoglobin saturation of oxygen (SpO2), and heart rate (HR) in premature infants. METHOD: A prospective, observational, nonrandomized study using a repeated-measures design was done to evaluate changes in physiologic variables (HR, SpO2, rSO2) before, during, and after a blood transfusion in premature infants. RESULTS: A convenience sample of 30 infants with a mean gestational age of 25.5 (2.1) weeks was recruited. Repeated-measures analysis of variance found no significant differences in HR (P = .06) and SpO2 (P = .55) over time. However, significant differences occurred in rSO2 over the 3 time periods (P < .001). The rSO2 increased during the transfusion from 40.3% to 41.5%, but decreased to 34.9% in the posttransfusion period. Pairwise comparisons revealed statistically significant mean rSO2 differences between pretransfusion and posttransfusion (P < .001), and during transfusion to posttransfusion (P < .001) periods. IMPLICATIONS FOR RESEARCH: This study supports previous findings of perfusion changes during blood transfusions in preterm infants. IMPLICATIONS FOR PRACTICE: Measuring mesenteric tissue oxygenation during blood transfusion in very low-birth-weight infants can potentially add another physiologic parameter to guide further clinical assessment and interventions during transfusions.

Multimodal Pain Management in Older Elective Arthroplasty Patients.

BACKGROUND: Pain management after elective arthroplasty in older adults is complicated due to the risk of undertreatment of postoperative pain and potential adverse effects from analgesics, notably opioids. Using combinations of analgesics has been proposed as potentially beneficial to achieve pain control with lower opioid doses. OBJECTIVE: We compared a multimodal pain protocol with a traditional one, in older elective arthroplasty patients, measuring self-rated pain, incidence of postoperative delirium, quantity and cost of opioid analgesics consumed. METHODS: One hundred fifty-eight patients, 70 years and older, admitted to tertiary care for elective arthroplasty were prospectively assessed postoperative days 1-3. Patients received either traditional postoperative analgesia (acetaminophen plus opioids) or a multimodal pain protocol (acetaminophen, opioids, gabapentin, celecoxib), depending on surgeon preference. Self-rated pain, postoperative delirium, and time to achieve standby-assist ambulation were compared, as were total opioid doses and analgesic costs. RESULTS: Despite receiving significantly more opioid analgesics (traditional: 166.4 mg morphine-equivalents; multimodal: 442 mg morphine equivalents; t = 10.64, P < .0001), there was no difference in self-rated pain, delirium, or mobility on postoperative days 1-3. Costs were significantly higher in the multimodal group (t = 9.15, P < .0001). Knee arthroplasty was associated with higher pain scores than hip arthroplasty, with no significant difference in opioid usage. CONCLUSION: A multimodal approach to pain control demonstrated no benefit over traditional postoperative analgesia in elective arthroplasty patients, but with significantly higher amounts of opioid consumed. This poses a potential risk regarding tolerability in frail older adults and results in increased drug costs.

THE VAXED PROJECT: an assessment of immunization education in Canadian health professional programs.

BACKGROUND: Knowledge & attitudes of healthcare providers (HCP) have significant impact on frequency with which vaccines are offered & accepted but many HCP are ill equipped to make informed recommendations about vaccine merits & risks. We performed an assessment of the educational needs of trainees regarding immunization and used the information thus ascertained to develop multi-faceted, evaluable, educational tools which can be integrated into formal education curricula. METHODS: (i) A questionnaire was sent to all Canadian nursing, medical & pharmacy schools to assess immunization-related curriculum content (ii) A 77-item web-based, validated questionnaire was emailed to final-year students in medicine, nursing, & pharmacy at two universities in Nova Scotia, Canada to assess knowledge, attitudes, & behaviors reflecting current immunization curriculum. RESULTS: The curriculum review yielded responses from 18%, 48%, & 56% of medical, nursing, & pharmacy schools, respectively. Time spent on immunization content varied substantially between & within disciplines from <1 to >50 hrs. Most schools reported some content regarding vaccine preventable diseases, immunization practice & clinical skills but there was considerable variability and fewer schools had learning objectives or formal evaluation in these areas. 74% of respondents didn't feel comfortable discussing vaccine side effects with parents/patients & only 21% felt they received adequate teaching regarding immunization during training. CONCLUSIONS: Important gaps were identified in the knowledge of graduating nursing, medical, & pharmacy trainees regarding vaccine indications/contraindications, adverse events & safety. The national curriculum review revealed wide variability in immunization curriculum content & evaluation. There is clearly a need for educators to assess current curricula and adapt existing educational resources such as the Immunization Competencies for Health Professionals in Canada.

Use of wet nebulized inhaled respiratory medications under criteria-based reimbursement guidelines in a publicly funded Seniors' Pharmacare Program in Nova Scotia, Canada.

BACKGROUND: During the 1999/2000 fiscal year, approximately 19% of beneficiaries in the Nova Scotia Seniors' Pharmacare Program (NSSPP), a publicly funded drug insurance program in Nova Scotia, Canada, received inhaled respiratory medications by wet nebulization. The cost was estimated at more than Can $2 million annually. On August 1, 2000, the NSSPP initiated new criteria-based reimbursement guidelines for wet nebulized respiratory medications, requiring prior authorization. OBJECTIVE: Within the NSSPP, we examined approved reimbursement requests to determine demographic characteristics of those who accessed wet nebulized therapy through exception criteria, compare these factors between those who accessed wet nebulized therapy within the exception criteria and those who fell outside the criteria, identify indications for use of wet nebulization, and determine patterns of wet nebulization use. METHODS: Two hundred approved requests, received between August 1, 2000, and April 30, 2001, were randomly selected and reviewed for indications and patterns of use. RESULTS: Of 200 requests reviewed, 28 were excluded due to coverage in another Pharmacare program (Community Services). Of the 172 requests reviewed, 27% were for nursing home or other residential care facility residents. Indications and patterns of use differed only by place of residence (P<0.001). The majority of indications (72%) fell within outlined reimbursement criteria, with the most frequently cited indication (56%) being inability to use portable inhalers due to cognitive or physical disability. Almost one third (28%) of exception requests were approved for other reasons (31% of these were for short-term use [ie, <3 months] secondary to an acute respiratory infection or for palliative care; 69% continued to access wet nebulization because of a preference or a perception of greater effectiveness). Examination of patterns of use demonstrated that 36% of beneficiaries, primarily community dwelling (P < 0.001), were using wet nebulized therapy and portable inhalers concurrently. CONCLUSIONS: The majority of approved requests for wet nebulization criteria fell within the established reimbursement guidelines. Many approvals outside of guidelines were clinically valid. Approval of requests outside the criteria highlights the need for flexibility in the claims administrative and adjudication system to respond to unique circumstances not covered by established criteria. However, concurrent use of wet nebulization and portable inhalers by some beneficiaries suggests suboptimal use of portable inhalers, the need for portable inhalers for patients using wet nebulization when they leave their residence, and the need for more patient education.

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

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

Economic evaluation of oseltamivir phosphate for postexposure prophylaxis of influenza in long-term care facilities.

OBJECTIVES: To compare the cost-effectiveness of oseltamivir postexposure prophylaxis during influenza A outbreaks with that of amantadine postexposure prophylaxis or no postexposure prophylaxis in long-term care facilities (LTCFs). DESIGN: Cost-effectiveness analysis based on decision analytic model from a government-payer perspective. SETTING: A Canadian LTCF, with high staff vaccination, at the beginning of influenza season. PARTICIPANTS: Elderly, influenza-vaccinated patients living in a Canadian LTCF. MEASUREMENTS: Incremental costs (or savings) per influenza-like illness case avoided compared with usual care. RESULTS: From a government-payer perspective, this analysis showed that oseltamivir was a dominant strategy because it was associated with the fewest influenza-like illness cases, with cost savings of $1,249 per 100 patients in 2001 Canadian dollars compared with amantadine and $3,357 per 100 patients compared with no prophylaxis. Costs for amantadine dose calculation and hospitalization for adverse events contributed to amantadine being a more-expensive prophylaxis strategy than oseltamivir. Both prophylaxis strategies were more cost-effective than no prophylaxis. CONCLUSION: Despite high influenza vaccination rates, influenza outbreaks continue to emerge in LTCFs, necessitating cost-effective measures to further limit the spread of influenza and related complications. Although amantadine has a lower acquisition cost than oseltamivir, it is associated with more adverse events, lower efficacy, and individualized dosing requirements, leading to higher overall costs and more influenza-like illness cases than oseltamivir. Therefore the use of oseltamivir postexposure prophylaxis is more cost-effective than the current standard of care with amantadine prophylaxis or no prophylaxis.

Pharmacists' participation in an inhaled respiratory medication program: reimbursement of professional fees.

BACKGROUND: An intervention (termed Initiative) was initiated to facilitate converting beneficiaries of a public drug insurance program in the province of Nova Scotia from respiratory nebulization medications to inhalers. Community pharmacists provided patient education and billed professional fees for conversions or optimizing inhaled respiratory medication technique. OBJECTIVE: To determine community pharmacists' self-reported participation rate and identify facilitators and barriers to billing for professional fees. METHODS: A survey was developed and mailed to Nova Scotia pharmacists. Information on demographics, work environment, professional experience, financial aspects, billing experiences, and the billing process was collected. Quantitative and qualitative data were evaluated using bivariate and multivariate analyses, and a thematic process, respectively. RESULTS: Two hundred ninety-seven pharmacists responded. Self-reported billing rates for fees were 34% (switching delivery devices), 58% (optimizing AeroChamber use), and 37% (follow-up when replacing Aerochambers). Awareness of fees and the perception of consistent claim reimbursement were associated with billing for each fee (p < 0.05). Predisposing billing factors included awareness of fees, identifying situations requiring education, owner/manager position, male gender, perception that billing for education for optimizing technique is a minimum standard of practice, and prescription volume. Themes identified as barriers included inefficient billing process, inadequate fees, and lack of Initiative awareness. CONCLUSIONS: Predisposing factors were the most important facilitators of community pharmacists' participation in this program, while a cumbersome and time-consuming billing process was the primary barrier. Further research should determine the impact of the professional fee on patient health outcomes.