The development of a Cannabis Knowledge Assessment Tool (CKAT).

BACKGROUND: Misconceptions about the health risks of cannabis remain prevalent, indicating the need to improve public health messaging and determine the effectiveness of educational programming. Our objective was to develop a standardized questionnaire to measure knowledge about cannabis in the context of cannabis legalization. METHODS: A Cannabis Knowledge Assessment Tool (CKAT) was created using the Delphi method. A purposive sample of healthcare professionals, policymakers, academics, patients, and students served as the content and development experts. Principal component analysis from the codes identified from open-ended feedback guided the item development. Upon completion, the CKAT was administered as a pre- and post-test in four schools (7th and 9th Grade) in Canada. The data were analysed to determine whether knowledge scores changed after participating in a cannabis education program. RESULTS: Twenty-four experts initially participated in the Delphi process and 18 (75% retention) continued throughout. Principal component analysis identified 3 domains: 1) effects of cannabis on the individual, 2) general information about cannabis, and 3) cannabis harm reduction. The final questionnaire consisted of 16 multiple-true-false questions (64 items) and received a Flesch-Kincaid Grade Level of 6.3, and a SMOG index score of 7.6. The CKAT was completed by 132 students; seventy-three 7th grade and fifty-nine 9th grade students. The baseline mean CKAT score was 46.2 (SD:5.5), which increased to 50.7 (SD:4.6) after the cannabis educational program (p<0.05). CONCLUSIONS: A novel tool to measure knowledge of cannabis was developed and piloted in 7th grade and 9th grade students. Future studies are required to test usability and validity of the CKAT in other contexts.

Current cancer therapies and their influence on glucose control.

This review focuses on the development of hyperglycemia arising from widely used cancer therapies spanning four drug classes. These groups of medications were selected due to their significant association with new onset hyperglycemia, or of potentially severe clinical consequences when present. These classes include glucocorticoids that are frequently used in addition to chemotherapy treatments, and the antimetabolite class of 5-fluorouracil-related drugs. Both of these classes have been in use in cancer therapy since the 1950s. Also considered are the phosphatidyl inositol-3-kinase (PI3K)/AKT/mammalian target of rapamycin (mTOR)-inhibitors that provide cancer response advantages by disrupting cell growth, proliferation and survival signaling pathways, and have been in clinical use as early as 2007. The final class to be reviewed are the monoclonal antibodies selected to function as immune checkpoint inhibitors (ICIs). These were first used in 2011 for advanced melanoma and are rapidly becoming widely utilized in many solid tumors. For each drug class, the literature has been reviewed to answer relevant questions about these medications related specifically to the characteristics of the hyperglycemia that develops with use. The incidence of new glucose elevations in euglycemic individuals, as well as glycemic changes in those with established diabetes has been considered, as has the expected onset of hyperglycemia from their first use. This comparison emphasizes that some classes exhibit very immediate impacts on glucose levels, whereas other classes can have lengthy delays of up to 1 year. A comparison of the spectrum of severity of hyperglycemic consequences stresses that the appearance of diabetic ketoacidosis is rare for all classes except for the ICIs. There are distinct differences in the reversibility of glucose elevations after treatment is stopped, as the mTOR inhibitors and ICI classes have persistent hyperglycemia long term. These four highlighted drug categories differ in their underlying mechanisms driving hyperglycemia, with clinical presentations ranging from potent yet transient insulin resistant states [type 2 diabetes mellitus (T2DM) -like] to rare permanent insulin-deficient causes of hyperglycemia. Knowledge of the relative incidence of new onset hyperglycemia and the underlying causes are critical to appreciate how and when to best screen and treat patients taking any of these cancer drug therapies.

An Advanced Pharmacy Practice Experience for Community Pharmacies Based on a Clinical Intervention Targeting Patients With Inflammatory Bowel Disease.

Experiential education is a critical component of any pharmacy undergraduate curriculum. Establishing new, high-quality practice sites can be challenging. We designed a new advanced pharmacy practice experiential rotation suitable for implementation in most community pharmacy settings. The aim of this article is to describe the design of this rotation entitled the Targeted Pharmacy Intervention in Inflammatory Bowel Disease (TPI-IBD) and to determine its impact on student knowledge and confidence using a before-after survey design. The TPI-IBD utilizes a student-delivered intervention as a platform for experiential learning in community pharmacy practice. The TPI was focused on patients with IBD, and implementation was guided by a co-preceptor from the university in collaboration with onsite-preceptors at each pharmacy. The TPI-IBD rotation was delivered from 6 community pharmacies during 5 weeks in 2018. Students conducted standardized monitoring on patients with IBD and met weekly with the university preceptor for case presentations and therapeutic discussions. Electronic charts were maintained by students who were responsible for ensuring detailed documentation on each patient. Knowledge, confidence, and overall satisfaction were assessed by a survey given to students before and after the rotation. Students were highly satisfied with the learning experience and improvements in knowledge and confidence were clearly demonstrated. The TPI strategy was an effective way to expand rotation options in community pharmacy sites with minimal burden on local preceptors.

Development of the REACH (Real Education About Cannabis and Health) Program for Canadian Youth.

BACKGROUND: Because cannabis use in children can have negative consequences, the recent legalization of recreational cannabis for adults in Canada creates an urgent need for youth education. METHOD: A multidisciplinary clinical rotation was developed wherein nursing and pharmacy students collaborated with youth (grades 7 through 10) to construct an educational program about cannabis. Four schools participated, representing a variety of socioeconomic demographics. Feedback was solicited from students and stakeholders. The purpose of this project was to create REACH (Real Education About Cannabis and Health), a toolkit and curriculum resource that includes lesson plans for teachers covering the science of cannabis, social science implications, peer pressure, decision making and harm reduction, videos featuring youth testimonials, and supplemental resources. RESULTS: Preliminary feedback suggests the materials are engaging and informative. CONCLUSION: A collaboration of health science students with youth in schools resulted in an authentic and relatable educational program about cannabis. Future studies will evaluate REACH's effectiveness in seventh- and ninth-grade students. [J Nurs Educ. 2020;59(8):465-469.].

Self-Monitoring of Blood Glucose and Hypoglycemia-Related Hospitalization in a Population-Based Cohort of Canadian Patients With Type 1 or Type 2 Diabetes.

OBJECTIVES: The aim of this work was to determine whether: 1) blood glucose test strip use in the population is associated with hypoglycemia hospitalization rates, and 2) blood glucose test strip use among individuals is associated with a reduced risk of hypoglycemia hospitalization. METHODS: Administrative databases from Saskatchewan, Canada, were used to ascertain population-level hypoglycemia hospitalizations and test strip utilization over the period from 1996 to 2014. For objective 1, a generalized linear model with generalized estimating equations was fit to provincial data stratified by age group, sex and year. For objective 2, a nested case-control study was conducted for a cohort of insulin users with diagnosed diabetes. Multivariable conditional logistic regression was used to test the association of test strip use with hospitalization, after adjusting for clinical and demographic factors and health services use. Odds ratios (ORs) and 95% confidence intervals (95% CIs) are reported. RESULTS: A total of 5,166 hospitalizations for hypoglycemia were identified in the observation period. Annual glucose test strip use increased by over 350%; however, no association was found with provincial hypoglycemia hospitalization rate during the same period, even after controlling for all-cause hospitalizations and population demographics. In the case-control analysis, test strip use was not associated with hospitalization for hypoglycemia among insulin users (n=10,617; adjusted OR, 1.08; 95% CI, 0.88 to 1.31). A sensitivity analysis in an independent cohort of noninsulin users produced a similar finding (n=47,501; adjusted OR, 1.04; 95% CI, 0.55 to 1.94). CONCLUSION: Our findings add to the body of evidence against a protective effect of blood glucose test strip use for serious hypoglycemia.

Prevalence of Type 1 and Type 2 Diabetes-Related Complications and Their Association With Determinants Identified in Canada's Survey on Living With Chronic Diseases-Diabetes Component.

OBJECTIVES: In this study, we estimated the prevalence of diabetes-related complications and the factors associated with them in Canadian patients with diabetes. METHODS: Data from the 2011 Survey on Living with Chronic Diseases in Canada---Diabetes Component (SLCDC-DM-2011) were used to calculate the weighted prevalence of 16 diabetes-related complications. A multivariable, sex-stratified logistic regression model was used to examine the association between each diabetes-related complication and select determinants. RESULTS: Among Canadian patients who self-reported having diabetes, 80.26% reported having at least 1 type of diabetes-related complication. The most frequently reported complications were high blood pressure (54.65%), cataracts (29.52%) and poor circulation (21.68%). Male patients were more associated to have at least 1 complication if they had an inappropriate body mass index (odds ratio [OR], 2.94; 95% confidence interval [CI], 1.39 to 6.23) and had a high level of glycated hemoglobin (OR, 2.32; 95% CI, 1.05 to 5.13), were older (OR, 6.92; 95% CI, 1.82 to 24.74) and had diabetes for a longer period of time (OR, 3.42; 95% CI, 1.71 to 6.85). Among the female patients, a longer duration diabetes was found to have a significant association with complications (OR, 2.00; 95% CI, 1.05 to 3.81). CONCLUSIONS: Our findings suggest that socioeconomic factors, including marital status, income and education, have a significant association with most types of complications. Our findings also confirm that low levels of physical activity and high levels of glycated hemoglobin were major determinants in many diabetes-related complications.

Impact of the SIMPL-SYNC Refill Synchronization Program on medication adherence: A pragmatic randomized controlled trial.

OBJECTIVE: To determine the impact of the SIMPL-SYNC refill synchronization (SSRS) service compared with that of usual care (UC) on medication adherence when applied as an opt-out strategy among patients receiving chronic medications. DESIGN: This was a pragmatic randomized controlled trial. SETTING AND PARTICIPANTS: The study was conducted in 2 community pharmacies located in Saskatchewan, Canada. Eligible patients were chronic medication users visiting the study pharmacies. OUTCOME MEASURES: The primary outcome was the percentage of individuals achieving optimal adherence to all eligible study medications. Eligible study medications included 22 commonly used medication classes used to treat diverse conditions. Adherence was assessed for each medication class after 300 days using the proportion of days covered (PDC). Optimal adherence was defined as PDC ≥ 80%. RESULTS: A total of 488 patients were screened for eligibility, and 190 patients were included in the intention-to-treat analysis (95 in SSRS, 95 in UC). The mean age of participants was 59 years, and 34% (65/190) were older than 65 years. A total of 574 individual adherence observations representing the 22 eligible study medication classes were generated from the 190 study participants. The percentage of individuals achieving optimal adherence to all their eligible study medications was 50.5% (48/95) in the SSRS group versus 44.2% (42/95) in the UC group (P = 0.383). Similarly, no statistically significant difference was observed in a per-protocol analysis assessing people who participated fully in the service; the percentage of individuals achieving optimal adherence to all their eligible study medications was 55.1% (38/69) in SSRS versus 40.7% (33/81) in UC (P = 0.080). Patient refusal of the refill synchronization services was common among randomized patients. CONCLUSION: SSRS service failed to detect a robust improvement in medication adherence when delivered using an opt-out strategy. However, small improvements in adherence or benefits to specific subgroups of patients could not be ruled out.

Correction to: Potential cost-savings from the use of the biosimilars filgrastim, infliximab and insulin glargine in Canada: a retrospective analysis.

In the original publication of this article [1], there is a mistake in the Fig. 2a, 2b, and 2c.

Potential cost-savings from the use of the biosimilars filgrastim, infliximab and insulin glargine in Canada: a retrospective analysis.

BACKGROUND: In 2014 and 2015, biosimilars for the drugs filgrastim, infliximab, and insulin glargine were approved for use in Canada. The introduction of biosimilars in Canada could provide significant cost savings for the Canadian healthcare system over originator biologic drugs, however it is known that the use of biosimilars varies widely across the world. The aim of this study was to estimate the use of biosimilars in Canada and potential cost-savings from their use. METHODS: We performed a retrospective analysis of Canadian drug purchases for filgrastim, infliximab, and insulin glargine from July 2016 to June 2018. This was a cross-sectional study and the time horizon was limited to the study period. As a result, no discounting of effects over time was included. Canadian drugstore and hospital purchases data, obtained from IQVIA™, were used to estimate the costs per unit and unit volume for biosimilars and originator biologic drugs within each province. Potential cost-savings were calculated as a product of the units of reference originator product purchased and the cost difference between the originator biologic and its corresponding biosimilar. RESULTS: The purchase of biosimilars varied by each province in Canada, ranging from a low of 0.1% to a high of 81.6% of purchases. In total, $1,048,663,876 Canadian dollars in savings could have been realized with 100% use of biosimilars over the originator products during this 2 year time period. The potential savings are highest in the province of Ontario ($349 million); however, even in smaller markets (PEI and Newfoundland), $28 million could have potentially been saved. Infliximab accounted for the vast majority of the potential cost-savings, whereas the purchases of the biosimilar filgrastim outpaced that of the originator drug in some provinces. In sensitivity analyses assuming only 80% of originator units would be eligible for use as a biosimilar, $838 million dollars in cost savings over this two-year time period would still have been realized. CONCLUSIONS: The overall use of biosimilar drugs in Canada is low. Policy makers, healthcare providers, and patients need to be informed of potential savings by increased use of biosimilars, particularly in an increasingly costly healthcare system.

Community pharmacists' experiences with the Saskatchewan Medication Assessment Program.

BACKGROUND: The Saskatchewan Medication Assessment Program (SMAP) is a publicly funded community pharmacy-based medication assessment service with limited previous evaluation. The purpose of this study was to explore community pharmacists' experiences with the SMAP. METHODS: Online, self-administered questionnaire that consisted of a combination of 53 Likert scale and free-text questions. All licensed pharmacists who were practising in a community pharmacy setting in Saskatchewan were eligible to participate. RESULTS: Response rate was 20.3% (n = 228/1124). Most respondents agreed that the SMAP is achieving all of its intended purposes. For example, 89.7% agreed that the SMAP improved medication safety for patients who receive the service. Most pharmacists enjoyed performing the assessments (84.6%) and were confident in their ability to identify drug-related problems (88.3%). Pharmacists reported lack of time, patients having difficulty coming to the pharmacy and restrictive eligibility criteria as the top barriers to the SMAP. Good teamwork, employer support and personal professional commitment were the top recognized facilitators. Respondents made several suggestions to improve the SMAP in the free-text areas of the questionnaire. CONCLUSIONS: Community pharmacists in Saskatchewan were positive and confident about performing medication assessments, and most agreed that the SMAP is achieving all of the intended purposes. Respondents also identified several barriers to providing SMAP services, which have resulted in specific recommendations that should be addressed to improve the program.

Effects of Pharmacy-Based Interventions on the Control and Management of Diabetes in Adults: A Systematic Review and Meta-Analysis.

OBJECTIVES: The aim of this systematic review and meta-analysis was to evaluate the effects of pharmacy-based interventions on clinical outcomes associated with diabetes-related complications as well as on nonclinical outcomes in people with diabetes. METHODS: We searched 4 main databases (MEDLINE, EMBASE, CINAHL and Cochrane Central Register of Controlled Trials) for studies that considered clinical and nonclinical outcomes of pharmacy-based interventions among people with diabetes. Clinical outcomes included patients' mean reductions of glycated hemoglobin (A1C) levels and body mass indexes (BMIs). Nonclinical outcomes included patients' healthcare utilization and quality of life. A meta-analysis was conducted to estimate the pooled net mean difference in clinical outcomes between the pharmacy-intervention and the control groups. RESULTS: Of the 44 studies included in the systematic review, 32 studies reported results from randomized controlled trials measuring reductions of A1C levels in 4,132 patients. Meta-analysis revealed that the standardized absolute mean difference in reduction of A1C levels from baseline to the time of the last follow up significantly favoured the pharmacy intervention versus the control group (0.96%; 95% CI 0.71 to 1.22; p<0.001). Of the studies, 13 reported BMI kg/m2 in 1,827 patients. The estimation of standardized absolute mean difference in reduction of BMI unit calculated through meta-analysis was 0.61 (95% CI 0.20 to 1.03; p=0.000) in favour of the pharmacy-intervention group. CONCLUSIONS: Pharmacy-based interventions have significant positive effects on controlling 2 major risks factors associated with diabetes-related complications: A1C levels and BMI. However, there is a dearth of evidence about the effects of pharmacy-based intervention on nonclinical outcomes, including healthcare utilization and quality of life.