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).

Effectiveness and cost analysis of methods used to recruit older adult sedative users to a deprescribing randomized controlled trial during the COVID-19 pandemic.

Background: Recruitment to clinical trials is a challenge for researchers that became more pronounced because of COVID-19 public health protective measures, especially with respect to studies enrolling older adults. We completed an effectiveness and cost analysis of the recruitment methods used in The Your Answers When Needing Sleep in New Brunswick (YAWNS NB) study, a randomized controlled trial of a deprescribing intervention that recruited older adults with chronic use of sedatives during the pandemic. Methods: Study recruitment began during the COVID-19 pandemic. Strategies included random digit dialing (RDD), a targeted mail campaign and advertising through newspapers, online platforms (Google and Facebook), and television. Other awareness raising and recruitment strategies involved seniors' organizations, pharmacies, television news stories, and referrals. Recruitment effectiveness and cost analysis involved enrollment rate (ER), cost per randomized participant (CPRP), fractional cost (FC), fractional enrollment (FE), fractional enrollment-cost ratio (FEC), and efficacy index (EI) calculations. Results: There were 1295 interested older adults with 594 randomized into the study for an enrollment rate of 46%. The efficacy index (EI) was highest for Facebook ads (EI = 0.683) followed by television (EI = 0.426), and newsprint ads (EI = 0.298). The cost of RDD was highest per randomized participant at $1117.90 and produced the lowest EI (0.013). Conclusion: Facebook ads had the best efficacy index for recruiting older adults to the YAWNS NB study during the COVID-19 pandemic and television ads produced the most enrollments. RDD was expensive and yielded few recruits. Recruitment costs can be significant for recruiting community-dwelling older adults. This experience can inform recruitment strategy and budget development for future community studies enrolling older adults, especially in the context of the COVID-19 pandemic.

Migraine diagnosis and treatment: A knowledge and needs assessment of women's healthcare providers.

BACKGROUND: Studies suggest that migraine is often underdiagnosed and inadequately treated in the primary care setting, despite many patients relying on their primary care provider (PCP) to manage their migraine. Many women consider their women's healthcare provider to be their PCP, yet very little is known about migraine knowledge and practice patterns in the women's healthcare setting. OBJECTIVE: The objective of this study was to assess women's healthcare providers' knowledge and needs regarding migraine diagnosis and treatment. METHODS: The comprehensive survey assessing migraine knowledge originally developed for PCPs was used in this study, with the addition of a section regarding the use of hormonal medications in patients impacted by migraine. Surveys were distributed online, and primarily descriptive analyses were performed. RESULTS: The online survey was completed by 115 women's healthcare providers (response rate 28.6%; 115/402), who estimated that they serve as PCPs for approximately one-third of their patients. Results suggest that women's healthcare providers generally recognize the prevalence of migraine, but experience some knowledge gaps regarding migraine management. Despite 82.6% (95/115) of survey respondents feeling very comfortable or somewhat comfortable with diagnosing migraine, only 57.9% (66/114) reported routinely asking patients about headaches during annual visits. Very few were familiar with the American Academy of Neurology guidelines on preventative treatment (6.3%; 7/111) and the Choosing Wisely Campaign recommendations on migraine treatment (17.3%; 19/110), and many prescribed medications known to contribute to medication overuse headache. In addition, only 24.3% (28/115) would order imaging for a new type of headache, 35.7% (41/115) for worsening headache, and 47.8% (55/115) for headache with neurologic symptoms; respondents cited greater tendency with sending patients to an emergency department for the same symptoms. Respondents had limited knowledge of evidence-based, non-pharmacological treatments for migraine (i.e., biofeedback or cognitive behavioral therapy), with nearly none placing referrals for these services. Most providers were comfortable prescribing hormonal contraception (mainly progesterone only) to women with migraine without aura (80.9%; 89/110) and with aura (72.5%; 79/109), and followed American College of Obstetricians and Gynecologists (ACOG) guidelines to limit combination hormonal contraception for patients with aura. When queried, 6.3% or less (5/79) of providers would prescribe estrogen-containing contraception for women with migraine with aura. Only 37.3% (41/110) of respondents reported having headache/migraine education. Providers indicated interest in education pertaining to migraine prevention and treatment (96.3%; 105/109), migraine-associated disability (74.3%; 81/109), and diagnostic testing (59.6%; 65/109). CONCLUSION: Women's healthcare providers appear to have several knowledge gaps regarding the management of migraine in their patients. These providers would likely benefit from access to a headache-specific educational curriculum to improve provider performance and patient outcomes.

Policies for Deprescribing: An International Scan of Intended and Unintended Outcomes of Limiting Sedative-Hypnotic Use in Community-Dwelling Older Adults.

Policies have been put in place internationally to reduce the overuse of certain medications that have a high risk of harm, such as sedative-hypnotic drugs for insomnia or opioids for chronic non-cancer pain. We explore and compare the outcomes of policies aimed at deprescribing sedative-hypnotic medication in community-dwelling older adults. Prescription monitoring policies led to the highest rate of discontinuation but triggered inappropriate substitutions. Financial deterrents through insurance scheme delistings increased patient out-of-pocket spending and had minimal impact. Pay-for-performance incentives to prescribers proved ineffective. Rescheduling alprazolam to a controlled substance raised the street drug price of the drug and shifted use to other benzodiazepines, causing similar rates of overdose deaths. Driving safety policies and jurisdiction-wide educational campaigns promoting non-drug alternatives appear most promising for achieving intended outcomes and avoiding unintended harms. Sustainable change should be supported with direct-to-patient education and improved access to non-drug therapy, with an emphasis on evaluating both intended and unintended consequences of any deprescribing-oriented policy.

Patient care activities by community pharmacists in a capitation funding model mental health and addictions program.

BACKGROUND: Community pharmacists are autonomous, regulated health care professionals located in urban and rural communities in Canada. The accessibility, knowledge, and skills of community pharmacists can be leveraged to increase mental illness and addictions care in communities. METHODS: The Bloom Program was designed, developed, and implemented based on the Behaviour Change Wheel and a program of research in community pharmacy mental healthcare capacity building. We evaluated the Bloom Program as a demonstration project using mixed methods. A retrospective chart audit was conducted to examine outcomes and these are reported in this paper. RESULTS: We collected 201 patient charts from 23 pharmacies in Nova Scotia with 182 patients having at least one or more follow-up visits. Anxiety (n = 126, 69%), depression (n = 112, 62%), and sleep disorders (n = 64, 35%) were the most frequent mental health problems. Comorbid physical health problems were documented in 57% (n = 104). The average number of prescribed medications was 5.5 (range 0 to 24). Sixty seven percent (n = 122) were taking multiple psychotropics and 71% (n = 130) reported taking more than one medication for physical health problems. Treatment optimization was the leading reason for enrollment with more than 80% seeking improvements in symptom management and daily functioning. There were a total of 1233 patient-care meetings documented, of which the duration was recorded in 1098. The median time for enrolling, assessing, and providing follow-up care by pharmacists was 142 min (mean 176, SD 128) per patient. The median follow-up encounter duration was 15 min. A total of 146 patient care encounters were 60 min or longer, representing 13.3% of all timed encounters. CONCLUSIONS: Pharmacists work with patients with lived experience of mental illness and addictions to improve medication related outcomes including those related to treatment optimization, reducing polytherapy, and facilitating withdrawal from medications. Pharmacists can offer their services frequently and routinely without the need for an appointment while affording patient confidentiality and privacy. Important roles for pharmacists around the deprescribing of various medications (e.g., benzodiazepines) have previously been supported and should be optimized and more broadly implemented. Further research on the best mechanisms to incentivize pharmacists in mental illness and addiction's care should be explored.

A scoping review of weight bias by community pharmacists towards people with obesity and mental illness.

BACKGROUND: Community pharmacists are accessible health care professionals who are increasingly offering weight management programs. People living with serious mental illness have markedly higher rates of obesity and associated illness outcomes than the general population, providing pharmacists who are interested in offering weight management services with an identifiable patient subgroup with increased health needs. Issues with stigma within obesity and mental illness care are prevalent and can lead to inequities and reduced quality of care. METHODS: We conducted a scoping review to map and characterize the available information from published and grey literature sources regarding community pharmacists and weight bias towards obese people with lived experience of mental illness. A staged approach to the scoping review was used. RESULTS: Six articles and 6 websites were abstracted after we removed duplicates and applied our inclusion and exclusion criteria. The published studies that we found indicated that pharmacists and pharmacy students do demonstrate implicit and explicit weight bias. CONCLUSIONS: Very limited research is available regarding weight bias in pharmacists and stigma towards people with obesity, and we found no information on these phenomena relating to people with lived experience of mental illness. Investigations are needed to characterize the extent and nature of anti-fat bias and attitudes by pharmacists and the consequences of these attitudes for patient care.

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

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

Bridging the gap: knowledge seeking and sharing in a virtual community of emergency practice.

Disparities exist between rural and urban emergency departments with respect to knowledge resources such as online journals and clinical specialists. As knowledge is a critical element in the delivery of quality care, a web-based learning project was proposed to address the knowledge needs of emergency clinicians. One objective of this project was to evaluate the effectiveness of the online environment for knowledge exchange among rural and urban emergency clinicians. Descriptive and content analysis of the online discussion board revealed 202 postings with rural participants contributing the largest number of postings (75%; 152/202). Postings were used to establish a clinical presence (87/202), seek clinical information (52/202), and share clinical information (63/202). Postintervention survey results indicate that this modality introduced participants to new clinical experts and resources. The results provide direction for design of a virtual community of practice, which may reduce current knowledge resource disparities.

Administrative claims data analysis of nurse practitioner prescribing for older adults.

AIM: This paper is a report of a study to identify the patterns of prescribing by primary health care nurse practitioners for a cohort of older adults. BACKGROUND: The older adult population is known to receive complex pharmacotherapy. Monitoring prescribing to older adults can inform quality improvement initiatives. In comparison to other countries, research examining nurse practitioner prescribing in Canada is limited. Nurse practitioner prescribing for older adults is relatively unexplored in the international literature. Although commonly used to study physician prescribing, few studies have used claims data from drug insurance programmes to investigate nurse practitioner prescribing. METHOD: Drug claims for prescriptions written by nurse practitioners from fiscal years 2004/05 to 2006/07 for beneficiaries of the Nova Scotia Seniors' Pharmacare programme were analysed. Data were retrieved and analysed in May 2008. Prescribing was described for each drug using the World Health Organization Anatomical Therapeutic Chemical code classification system by usage and costs for each fiscal year. RESULTS: Antimicrobials and non-steroidal anti-inflammatory drugs consistently represented the top ranked groups for prescription volume and cost. Over the three fiscal years, antimicrobial prescription rates declined relative to rates of other groups of medications. Prescription volume per nurse doubled and cost per prescription increased by approximately 20%. CONCLUSION: Prescription claims data can be used to characterize the prescribing trends of nurse practitioners. Research linking patient characteristics, including diagnoses, to prescriptions is needed to assess prescribing quality. Some potential areas of improvement were identified with antimicrobial and non-steroidal antiinflammatory selection.

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.

Policy choices for pharmacare; the need to examine benefit design, medication management strategies and evaluation.

Outside hospitals, drug therapy is not universally insured by the Canadian public health care system. Coverage depends on choices made by the provincial and territorial governments in designing their pharmacare programs. A priority within the programs is ensuring that all Canadians have reasonable access to catastrophic drug coverage. However, the best way to provide this coverage is by no means clear. This commentary reviews evidence and experience from other countries in order to assess the options for a few key dimensions of expanding pharmacare coverage. These are: eligibility rules for individual coverage; drug assessment in terms of approval for coverage; medication management strategies; and finally ongoing program evaluation. Catastrophic drug coverage needs to be flexible to adapt to existing pharmacare programs and responsive to the competing demands for limited resources within the health care sector.