Team-based primary care reforms and older adults: a descriptive assessment of sociodemographic trends and prescribing endpoints in two Canadian provinces.

BACKGROUND: Team-based primary care reforms aim to improve care coordination by involving multiple interdisciplinary health professionals in patient care. Team-based primary care may support improved medication management for older adults with polypharmacy and multiple points of contact with the healthcare system. However, little is known about this association. This study compares sociodemographic and prescribing trends among older adults in team-based vs. traditional primary care models in Ontario and Quebec. METHODS: We constructed two provincial cohorts using population-level health administrative data from 2006-2018. Our primary exposure was enrollment in a team-based model of care. Key endpoints included adverse drug events (ADEs), potentially inappropriate prescriptions (PIPs), and polypharmacy. We plotted prescribing trends across the observation period (stratified by model of care) in each province. We used standardized mean differences to compare characteristics of older adults and providers, as well as prescribing endpoints. RESULTS: Formal patient/physician enrollment increased in both provinces since the time of policy implementation; team-based enrollment among older adults was higher in Quebec (47%) than Ontario (33%) by the end of our observation period. The distribution of sociodemographic characteristics was reasonably comparable between team-based and non-team-based patients in both provinces, aside from a persistently higher share of rural patients in team-based care. Most PIPs assessed either declined or remained relatively steady over time, regardless of model of care and province. Several PIPs were more common among team-based patients than non-team-based patients, particularly in Quebec. We did not detect notable trends in ADEs or polypharmacy in either province. CONCLUSIONS: Our findings offer encouraging evidence that many PIPs are declining over time in this population, regardless of patients' enrollment in team-based care. Rates of decline appear similar across models of care, suggesting these models may not meaningfully influence prescribing endpoints. Additional efforts are needed to understand the impact of team-based care among older adults and improve primary care prescribing practices.

Interventions to address potentially inappropriate prescriptions and over-the-counter medication use among adults 65 years and older in primary care settings: protocol for a systematic review.

PURPOSE: To inform recommendations by the Canadian Task Force on Preventive Health Care on potentially inappropriate prescribing and over-the-counter (OTC) medication use among adults aged 65 years and older in primary care settings. This protocol outlines the planned scope and methods for a systematic review of the benefits and harms and acceptability of interventions to reduce potentially inappropriate prescriptions and OTC medication use. METHODS: De novo systematic reviews will be conducted to synthesize the available evidence on (a) the benefits and harms of interventions to reduce potentially inappropriate prescriptions and OTC medications compared to no intervention, usual care, or non- or minimally active intervention among adults aged 65 years and older and (b) the acceptability of these interventions or attributes among patients. Outcomes of interest for the benefits and harms review are all-cause mortality, hospitalization, non-serious adverse drug reactions, quality of life, emergency department visits, injurious falls, medical visits, and the number of medications (and number of pills). Outcomes for the acceptability review are the preference for and relative importance of different interventions or their attributes. For the benefits and harms review, we will search MEDLINE, Embase, and Cochrane Central Register of Controlled Trials for randomized controlled trials. For the acceptability review, we will search MEDLINE, Embase, PsycInfo, Cochrane Central Register of Controlled Trials, and the NHS Economic Evaluation Database for experimental and observational studies with a comparator. Websites of relevant organizations, other grey literature sources, and reference lists of included studies and reviews will be searched. Title and abstract screening will be completed by two independent reviewers using the liberal accelerated approach. Full-text review, data extraction, risk of bias assessments, and GRADE (Grading of Recommendations Assessment, Development and Evaluation) will be completed independently by two reviewers, with any disagreements resolved by consensus or by consulting with a third reviewer. The GRADE approach will be used to assess the certainty of the evidence for outcomes. DISCUSSION: The results of this systematic review will be used by the Canadian Task Force on Preventive Health Care to inform their recommendation on potentially inappropriate prescribing and OTC medication use among adults aged 65 years and older. SYSTEMATIC REVIEW REGISTRATION: PROSPERO (KQ1: CRD42022302313; KQ2: CRD42022302324); Open Science Framework ( https://osf.io/urj4b/ ).

Economic Evaluations of Interventions to Optimize Medication Use in Older Adults with Polypharmacy and Multimorbidity: A Systematic Review.

PURPOSE: To conduct a systematic review of the economic impact of interventions intended at optimizing medication use in older adults with multimorbidity and polypharmacy. METHODS: We searched Ovid-Medline, Embase, CINAHL, Ageline, Cochrane, and Web of Science, for articles published between 2004 and 2020 that studied older adults with multimorbidity and polypharmacy. The intervention studied had to be aimed at optimizing medication use and present results on costs. RESULTS: Out of 3,871 studies identified by the search strategy, eleven studies were included. The interventions involved different provider types, with a majority described as a multidisciplinary team involving a pharmacist and a general practitioner, in the decision-making process. Interventions were generally associated with a reduction in medication expenditure. The benefits of the intervention in terms of clinical outcomes remain limited. Five studies were cost-benefit analyses, which had a net benefit that was either null or positive. Cost-utility and cost-effectiveness analyses resulted in incremental cost-effectiveness ratios that were generally within the willingness-to-pay thresholds of the countries in which the studies were conducted. However, the quality of the studies was generally low. Omission of key cost elements of economic evaluations, including intervention cost and payer perspective, limited interpretability. CONCLUSION: Interventions to optimize medication use may provide benefits that outweigh their implementation costs, but the evidence remains limited. There is a need to identify and address barriers to the scaling-up of such interventions, starting with the current incentive structures for pharmacists, physicians, and patients.

Does socio-economic status influence the effect of multimorbidity on the frequent use of ambulatory care services in a universal healthcare system? A population-based cohort study.

BACKGROUND: Frequent healthcare users place a significant burden on health systems. Factors such as multimorbidity and low socioeconomic status have been associated with high use of ambulatory care services (emergency rooms, general practitioners and specialist physicians). However, the combined effect of these two factors remains poorly understood. Our goal was to determine whether the risk of being a frequent user of ambulatory care is influenced by an interaction between multimorbidity and socioeconomic status, in an entire population covered by a universal health system. METHODS: Using a linkage of administrative databases, we conducted a population-based cohort study of all adults in Quebec, Canada. Multimorbidity (defined as the number of different diseases) was assessed over a two-year period from April 1st 2012 to March 31st 2014 and socioeconomic status was estimated using a validated material deprivation index. Frequents users for a particular category of ambulatory services had a number of visits among the highest 5% in the total population during the 2014-15 fiscal year. We used ajusted logistic regressions to model the association between frequent use of health services and multimorbidity, depending on socioeconomic status. RESULTS: Frequent users (5.1% of the population) were responsible for 25.2% of all ambulatory care visits. The lower the socioeconomic status, the higher the burden of chronic diseases, and the more frequent the visits to emergency departments and general practitioners. Socioeconomic status modified the association between multimorbidity and frequent visits to specialist physicians: those with low socioeconomic status visited specialist physicians less often. The difference in adjusted proportions of frequent use between the most deprived and the least deprived individuals varied from 0.1% for those without any chronic disease to 5.1% for those with four or more chronic diseases. No such differences in proportions were observed for frequent visits to an emergency room or frequent visits to a general practitioner. CONCLUSION: Even in a universal healthcare system, the gap between socioeconomic groups widens as a function of multimorbidity with regard to visits to the specialist physicians. Further studies are needed to better understand the differential use of specialized care by the most deprived individuals.

Persistence patterns with oral antidiabetes drug treatment in newly treated patients--a population-based study.

OBJECTIVE: We assessed persistence patterns with oral antidiabetes drug (OAD) in patients newly dispensed with different OAD classes. METHODS: We conducted a population-based cohort study using Quebec Health Insurance Board data. Patients aged 18 years or more newly dispensed an OAD between January 1, 1998 and December 31, 2003 were included in the study (n=98,940). Persistence was defined as consistently refilling a prescription for the initial OAD within three times the days' supply of the preceding claim. For nonpersistent patients, a second course of therapy was defined as treatment initiation with any OAD after a first discontinuation. Patients were followed from treatment initiation up to December 31, 2004, ineligibility for the drug plan or death, whichever came first, and treatment discontinuation or second course of treatment. Cox regression models were used to compute adjusted hazards ratios (AHR) of persistence and initiation of second courses of therapy. RESULTS: The probability of persisting with the initial OAD over a 12-month period was 65% and 56% for patients initiated on metformin and sylfonylurea, respectively. Compared to metformin, the likelihood of discontinuing the initial OAD over the study period was significantly higher for patients on sulphonylureas (AHR: 1.32; 95% CI 1.29-1.34). Patients started on sulphonylureas were also less likely to start a second course of therapy after a first treatment discontinuation (AHR: 0.91; 95% CI 0.89-0.93). CONCLUSIONS: Compared to diabetic patients initiated on metformin, those initiated on sulphonylureas displayed poorer persistence patterns.