An economic evaluation of community pharmacy-dispensed naloxone in Canada.

Aims: To determine the cost-effectiveness of pharmacy-based intranasal (IN) and intramuscular (IM) naloxone distribution in Canada. Methods: We developed a state-transition model for pharmacy-based naloxone distribution, every 3 years, to illicit, prescription, opioid-agonist therapy and nonopioid use populations compared to no naloxone distribution. We used a monthly cycle length, lifetime horizon and a Canadian provincial Ministry of Health perspective. Transition probabilities, cost and utility data were retrieved from the literature. Costs (2020) and quality-adjusted life years (QALY) were discounted 1.5% annually. Microsimulation, 1-way and probabilistic sensitivity analyses were conducted. Results: Distribution of naloxone to all Canadians compared to no distribution prevented 151 additional overdose deaths per 10,000 persons, with an incremental cost-effectiveness ratio (ICER) of $50,984 per QALY for IM naloxone and an ICER of $126,060 per QALY for IN naloxone. Distribution of any naloxone to only illicit opioid users was the most cost-effective. One-way sensitivity analysis showed that survival rates for illicit opioid users were most influenced by the availability of either emergency medical services or naloxone. Conclusion: Distribution of IM and IN naloxone to all Canadians every 3 years is likely cost-effective at a willingness-to-pay threshold of $140,000 Canadian dollars/QALY (~3 × gross domestic product from the World Health Organization). Distribution to people who use illicit opioids was most cost-effective and prevented the most deaths. This is important, as more overdose deaths could be prevented through nationwide public funding of IN naloxone kits through pharmacies, since individuals report a preference for IN naloxone and these formulations are easier to use, save lives and are cost-effective. Can Pharm J (Ott) 2024;157:xx-xx.

Unintended consequences of communicating rapid COVID-19 vaccine policy changes- a qualitative study of health policy communication in Ontario, Canada.

BACKGROUND: The success of the COVID-19 vaccination roll-out depended on clear policy communication and guidance to promote and facilitate vaccine uptake. The rapidly evolving pandemic circumstances led to many vaccine policy amendments. The impact of changing policy on effective vaccine communication and its influence in terms of societal response to vaccine promotion are underexplored; this qualitative research addresses that gap within the extant literature. METHODS: Policy communicators and community leaders from urban and rural Ontario participated in semi-structured interviews (N = 29) to explore their experiences of COVID-19 vaccine policy communication. Thematic analysis was used to produce representative themes. RESULTS: Analysis showed rapidly changing policy was a barrier to smooth communication and COVID-19 vaccine roll-out. Continual amendments had unintended consequences, stimulating confusion, disrupting community outreach efforts and interrupting vaccine implementation. Policy changes were most disruptive to logistical planning and community engagement work, including community outreach, communicating eligibility criteria, and providing translated vaccine information to diverse communities. CONCLUSIONS: Vaccine policy changes that allow for prioritized access can have the unintended consequence of limiting communities' access to information that supports decision making. Rapidly evolving circumstances require a balance between adjusting policy and maintaining simple, consistent public health messages that can readily be translated into action. Information access is a factor in health inequality that needs addressing alongside access to vaccines.

Understanding the COVID-19 Vaccine Policy Terrain in Ontario Canada: A Policy Analysis of the Actors, Content, Processes, and Context.

(1) Background: Canada had a unique approach to COVID-19 vaccine policy making. The objective of this study was to understand the evolution of COVID-19 vaccination policies in Ontario, Canada, using the policy triangle framework. (2) Methods: We searched government websites and social media to identify COVID-19 vaccination policies in Ontario, Canada, which were posted between 1 October 2020, and 1 December 2021. We used the policy triangle framework to explore the policy actors, content, processes, and context. (3) Results: We reviewed 117 Canadian COVID-19 vaccine policy documents. Our review found that federal actors provided guidance, provincial actors made actionable policy, and community actors adapted policy to local contexts. The policy processes aimed to approve and distribute vaccines while continuously updating policies. The policy content focused on group prioritization and vaccine scarcity issues such as the delayed second dose and the mixed vaccine schedules. Finally, the policies were made in the context of changing vaccine science, global and national vaccine scarcity, and a growing awareness of the inequitable impacts of pandemics on specific communities. (4) Conclusions: We found that the triad of vaccine scarcity, evolving efficacy and safety data, and social inequities all contributed to the creation of vaccine policies that were difficult to efficiently communicate to the public. A lesson learned is that the need for dynamic policies must be balanced with the complexity of effective communication and on-the-ground delivery of care.

Understanding racialised older adults' experiences of the Canadian healthcare system, and codesigning solutions: protocol for a qualitative study in nine languages.

INTRODUCTION: Racialised immigrant older adults (RIOAs) in Canada have poorer self-rated health and are more likely to report chronic conditions, while they concurrently experience well-documented challenges in navigating and accessing the healthcare system. There is strong evidence that patient and caregiver engagement in their healthcare leads to improved management of chronic disease and better health outcomes. International research suggests that engagement has the potential to reduce health disparities and improve quality of care. We aim to (1) describe what role(s) RIOAs are/are not taking in their own healthcare, from the perspectives of participant groups (RIOAs, caregivers and healthcare providers (HCPs)); and (2) develop a codesign process with these participants, creating linguistically aligned and culturally aligned tools, resources or solutions to support patient engagement with RIOAs. METHODS AND ANALYSIS: Using a cross-cultural participatory action research approach, our work will consist of three phases: phase 1, strengthen existing partnerships with RIOAs and appropriate agencies and cultural associations; phase 2, on receipt of informed consent, in-depth interviews with RIOAs and caregivers (n=~45) and HCPs (n=~10), professionally interpreted as needed. Phase 3, work with participants, in multiple interpreted sessions, to codesign culturally sensitive and linguistically sensitive/aligned patient engagement tools. We will conduct this research in the Waterloo-Wellington region of Ontario, in Arabic, Bangla, Cantonese, Hindi, Mandarin, Punjabi, Tamil and Urdu, plus English. Data will be transcribed, cleaned and entered into NVivo V.12, the software that will support team-based analysis. Analysis will include coding, theming and interpreting the data, and, preparing narrative descriptions that summarise each language group and each participant group (older adults, caregivers and HCPs), and illustrate themes. ETHICS AND DISSEMINATION: Ethics clearance was obtained through the University of Waterloo Office of Research Ethics (ORE #43297). Findings will be disseminated through peer-reviewed publications, presentations and translated summary reports for our partners and participants.

In-home medication management by older adults: a modified ethnography study using digital photography walkabouts.

BACKGROUND: Medication mismanagement can lead to non-optimal management of chronic diseases and poor health outcomes. OBJECTIVE: The purpose of this study was to better understand meanings associated with in-home medication management and storage practices of older adults with chronic diseases. METHODS: A modified ethnographic approach using digital photography walkabouts, observation protocols and field notes were used to document in-home medication organisation and storage locations. Thematic analysis was used to generate themes and sub-themes. RESULTS: Data from multiple home visits of 10 participants (mean age = 76 years; 80% females) including 30 photographs, 10 observation protocols and field notes were analysed. The average number of medications used was reported to be 11.1 (range: 5-20). Themes and sub-themes include choice of storage location (sub-themes: impact on medication behaviour, visibility of medications and storage with other items), knowledge regarding appropriate medication storage conditions (sub-themes: impact on safety of patient and impact on stability of medications) and systems to manage in-home medication intake. DISCUSSION: In-home medication management reflects older adults perspectives regarding privacy, medication taking routine, knowledge about safe and effective storage and organisation systems. The lack of knowledge causing inappropriate medication storage not only impacts the stability of medications, but also increases risk of medication errors and safety, ultimately affecting medication intake behaviours.

Transforming primary care for older Canadians living with frailty: mixed methods study protocol for a complex primary care intervention.

INTRODUCTION: Older Canadians living with frailty are high users of healthcare services; however, the healthcare system is not well designed to meet the complex needs of many older adults. Older persons look to their primary care practitioners to assess their needs and coordinate their care. They may need care from a variety of providers and services, but often this care is not well coordinated. Older adults and their family caregivers are the experts in their own needs and preferences, but often do not have a chance to participate fully in treatment decisions or care planning. As a result, older adults may have health problems that are not properly assessed, managed or treated, resulting in poorer health outcomes and higher economic and social costs. We will be implementing enhanced primary healthcare approaches for older patients, including risk screening, patient engagement and shared decision making and care coordination. These interventions will be tailored to the needs and circumstances of the primary care study sites. In this article, we describe our study protocol for implementing and testing these approaches. METHODS AND ANALYSIS: Nine primary care sites in three Canadian provinces will participate in a multi-phase mixed methods study. In phase 1, baseline information will be collected through questionnaires and interviews with patients and healthcare providers (HCPs). In phase 2, HCPs and patients will be consulted to tailor the evidence-based interventions to site-specific needs and circumstances. In phase 3, sites will implement the tailored care model. Evaluation of the care model will include measures of patient and provider experience, a quality of life measure, qualitative interviews and economic evaluation. ETHICS AND DISSEMINATION: This study has received ethics clearance from the host academic institutions: University of Calgary (REB17-0617), University of Waterloo (ORE#22446) and Université Laval (#MP-13-2019-1500 and 2017-2018-12-MP). Results will be disseminated through traditional means, including peer-reviewed publications and conferences and through an extensive network of knowledge user partners. TRIAL REGISTRATION NUMBER: NCT03442426;Pre-results.

The Impact of Prescription Medication Cost Coverage on Oral Medication Use for Hypertension and Type 2 Diabetes Mellitus.

BACKGROUND: No previous study, to the best of our knowledge, has examined both the time trend and impact of not having insurance or prescription medication cost coverage (PMCC) on the usage of type 2 diabetes and hypertension oral medications in Ontario and New Brunswick, Canada. METHODS: We used data from the Canadian Community Health Survey (CCHS) from 2007 to 2014 to examine the time trend and impact of PMCC. A multivariable-adjusted logistic regression model was fitted. RESULTS: The pseudo-cohort included 23,215 individuals representing a population of approximately 8.7 million people. Overall, 20.0% of respondents reported absence of PMCC. This proportion increased slightly from 19.6% (95% confidence interval [CI] 95% CI [17.5, 22.5]) to 20.7% (95% CI [16.9, 23.1]). Adjusted odds ratios (OR) showed that uninsured individuals were 23% less likely to use their medications (OR = 0.77, 95% CI [0.657, 0.911]). CONCLUSION: There was a slight decline in PMCC over time and this decline was associated with reduced use of medications for type 2 diabetes and hypertension.

Remunerated patient care services and injections by pharmacists: An international update.

OBJECTIVES: Recognizing pharmacists' increasing roles as primary care providers, programs offering remuneration for patient care services, and the administration of injections by pharmacists continue to be implemented. The objective of this article is to provide an update on remuneration programs available to pharmacists internationally for nondispensing services. DATA SOURCES: Systematic searches for relevant articles published from January 2013 to February 2018 across Pubmed (Medline), Embase, International Pharmaceutical Abstracts, Cochrane Library, Econlit, Scopus, and Web of Science. Gray literature searches, including targeted searches of websites of payers and pharmacy associations, were also performed. STUDY SELECTION: Programs were included if they were newly introduced or had changes to patient eligibility criteria and fees since previously published reviews and if they were established programs offered by third-party payers for activities separate from dispensing. DATA EXTRACTION: Descriptive information on each program was extracted, including the program's jurisdiction (country and state, provincial, or regional level, as applicable), payer, service description, patient eligibility criteria, and fee structure. RESULTS: Over the 5-year period studied, 95 new programs for noninjection patient care services and 37 programs for pharmacist-administered injections were introduced. Large ranges in fees offered for similar programs were observed across programs, even within the same country or region, at an average of $US 71 for an initial medication review, $19 for follow-ups to these reviews, $18 for prescription adaptations, and $13 for injection administration. Apart from some smoking cessation programs in England, which offered incentive payments for successful quits, all services were remunerated on a fee-for-service basis, often in the form of a flat fee regardless of the time spent providing the service. CONCLUSION: Although funding for pharmacists' activities continues to show growth, concerns identified in previous reviews persist, including the great variability in remunerated activities, patient eligibility, and fees. These issues may limit opportunities for multijurisdictional program and service outcome evaluation.

How Appropriate Is All This Data Sharing? Building Consensus Around What We Need to Know About Shared Electronic Health Records in Extended Circles of Care.

BACKGROUND: The bulk of healthcare spending is on individuals who have complex needs related to age, income, chronic disease and mental illness. Care involves many different professions, and interoperable electronic health records (EHRs) are increasingly essential. OBJECTIVES: The objective of this paper is to describe the use of a nominal group technique (NGT) to develop a stakeholder-centred research agenda for clinical interoperability in extended circles of care that include social supports. METHODS: We held a day-long meeting with 30 stakeholders, including primary care providers, social supports, patient representatives, health region managers, technology experts, health organizations and experts in privacy, law and ethics. Participants considered, "What research needs to be done to better understand how EHRs should be shared across large healthcare teams that include social supports?" Following sensitizing presentations from researchers and participants, we used an NGT to generate and rank research questions on a 9-point Likert scale. We retained research questions that had a mean score of at least 6.5/9 by at least 70% of the participants over two rounds of consensus-building. RESULTS: Participants identified and ranked 57 research questions. Five items achieved consensus, related to 1) the impact of information sharing on care team outcomes, 2) data quality/accuracy, 3) cost/benefit, 4) what processes use what data and 5) regulation/legislation. CONCLUSION: Healthcare reforms are increasingly focused on systems that integrate and coordinate multidisciplinary care, facilitated by EHRs. Research prioritization will ensure common concerns and barriers are addressed and resolved.

A systematic review of interventions to improve medication information for low health literate populations.

BACKGROUND: Health literacy is a barrier to accurately understanding medication information. Current medication information is too difficult to understand for low health literate populations, which imposes a higher risk of misinterpreting prescription label instructions, dosage, duration, frequency, warning labels, written information and verbal pharmacist counseling. OBJECTIVES: The primary objective of this paper was to systematically review the evidence on interventions for improving medication knowledge and adherence for low health literate populations. METHODS: A database search of PubMed, Embase, International Pharmaceutical Abstracts, Web of Science, Cochrane Library, CINAHL, PsycINFO, and Scopus databases from the start of each database to studies published prior to March 30, 2015. Studies were included if they explicitly stated they included low health literate populations, included outcome measures for knowledge and/or adherence, focused on medication information, were written in English and were available in full text. Full text papers were excluded if there was no clear mention of an intervention being studied, if the intervention had no focus on any of the domains of health literacy, and if the authors did not specify the inclusion of patients with low health literacy. RESULTS: The review identified 1553 titles, 1009 abstracts, and 168 full text articles and included 47 articles in the final review. Of the 47 included studies, 70.2% (33/47) were published in the United States and 87.2 (41/47) were published between 2005 and 2014. Studies were grouped into six different types of interventions 1) written information 2) visual information 3) verbal information 4) label/medication bottle 5) reminder systems and 6) educational programs and services. Results demonstrate significant improvement of knowledge in 27 of 37 interventions and a significant improvement of adherence in 19 of 26 interventions. CONCLUSIONS: Interventions designed to support low health literate populations can improve patients' medication knowledge and adherence. The most effective interventions include additional aids that enforce written information, information that is personalized, information that is easy to navigate and tools that can be accessed when needed.

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

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

Evaluating the labour costs associated with pharmacy adaptation services in British Columbia.

BACKGROUND: Pharmacists' scope of practice has been steadily expanding across Canada to encompass clinical activities. In January 2009, pharmacists in British Columbia (BC) were given the authority to adapt prescriptions for renewals; change in dose, formulation or regimen; and therapeutic substitutions. This study evaluated the labour costs associated with pharmacy adaptation services in BC. > METHODS: Ten high-adapting pharmacies participated in the study. Through workflow observations, we measured the time incurred for adapted and nonadapted prescriptions. RESULTS: We observed 91 adapted prescriptions and 1081 nonadapted prescriptions. The total average time to provide adapted prescriptions was 6:43 minutes (SD 3:50) longer than to provide nonadapted prescriptions. The total average cost of an adapted prescription was $6.10 greater than a nonadapted prescription. Renewals took the least amount of time to complete, and therapeutic substitutions took the most time to complete. DISCUSSION: Through workflow observations, it was determined that 10 stages of activity occur when adapting a prescription, with the most time being expended during the documentation and processing phases. Labour costs associated with adapted prescriptions were higher than for nonadapted prescriptions.

Pharmacists' preferences for providing patient-centered services: a discrete choice experiment to guide health policy.

BACKGROUND: In Canada, most pharmacists are not paid to provide patient-centered services. In other areas of the world these services have suffered from poor adoption by pharmacists. OBJECTIVE: To determine pharmacists' preferences for providing patient-centered services. METHODS: Senior pharmacy students and pharmacists in British Columbia and Alberta were recruited to complete a discrete choice experiment. In 18 different choice-sets, respondents were asked to choose 1 of 3 options that included 2 different hypothetical patient-centered services and a status quo option. For each hypothetical service, we described the following attributes: service type and setting, personal income and job satisfaction, professional fee, and educational requirements. Multinomial logit and latent class regression models determined respondents' relative preference weights for each attribute. RESULTS: Of 539 respondents who completed the questionnaire, 49% were dispensary pharmacists or managers, 12% were dispensary owners or regional managers, 21% were clinical pharmacists, and 16% were students. When choosing new services, respondents were very averse to having their personal income or job satisfaction decrease. They also preferred a higher professional fee for the service (to be paid to the pharmacy) and preferred a weeklong course or a preceptorship over no education before embarking on new services. Respondents also preferred medication or disease management services, were not interested in screening, and were averse to typical pharmacy services. Finally, respondents preferred the clinic setting over the dispensary. Preferences differed according to several factors including respondents' employment and time in practice. CONCLUSIONS: Pharmacists prefer to provide patient-centered services over typical pharmacy services. Most will need to be assured that their income and job satisfaction will be maintained or increased and that they will have access to suitable advanced education. Decision-makers should carefully consider these preferences to improve program success and sustainability.