Pharmacists practising in family medicine groups: An evaluation 2 years after experiencing a virtual community of practice.

BACKGROUND: In 2018, a virtual community of practice (CoP) for pharmacists working in family medicine groups (FMGs) in Quebec province was developed. The aim of this CoP-called Réseau Québécois des Pharmaciens GMF (RQP GMF)-was to foster best practices by supporting FMG pharmacists. This study assesses the processes and outcomes of this CoP 2 years after its creation. METHODS: We performed a cross-sectional web-based study from March to May 2020. All FMG pharmacists who were registered as members of the RQP GMF (n = 326) were sent an invitation via a newsletter. The link to the questionnaire was also publicized in the CoP Facebook group. The questionnaire comprised a 38-item validated instrument assessing 8 dimensions of the CoP. A descriptive analysis was performed. RESULTS: A total of 112 FMG pharmacists (34.4%) completed the questionnaire. Respondents agreed that the RQP GMF was a joint enterprise (mean score, 4.18/5), that members shared their knowledge (mean score, 3.94/5) and engaged mutually (mean score, 3.50/5) and that the RQP GMF provided support (mean score, 3.92/5) and capacity building (mean score, 4.01/5). In general, they were satisfied with the implementation process (mean score, 3.68/5) and with activities proposed (mean score, 3.79/5). A lower proportion of respondents agreed that their participation in the RQP GMF generated external impacts, which led to a smaller mean score (3.37/5) for this dimension. CONCLUSION: The RQP GMF, one of the first communities of practice for pharmacists practising in family medicine groups, attained most of the objectives initially intended by the CoP. These results will facilitate the adaptation of processes and activities to better fulfil members' needs. Can Pharm J (Ott) 2021;154:xx-xx.

Pharmacists practising in family medicine groups: What are their activities and needs?

WHAT IS KNOWN AND OBJECTIVE: Pharmacists' responsibilities and practices have expanded over the years to be more clinical. Working in other settings and collaborating with other healthcare professionals can lead to new needs that are unmet by actual training. This study was performed to describe the characteristics and practices of pharmacists working in family medicine groups (FMGs) and to assess their needs to develop a practice-based network fostering best practices. METHODS: A Quebec province-wide cross-sectional study was performed from May to August 2018. Pharmacists practising in FMGs were identified through phone calls to all listed FMGs and via direct emails. All identified pharmacists were emailed an invitation to complete an online questionnaire comprising questions to assess their sociodemographic characteristics, to describe their FMG and to assess their needs to reach an optimal practice. The link to the questionnaire was also publicized in a Facebook group of FMG pharmacists and by several professional organizations. A descriptive analysis was performed and discussed with two committees: a working group of FMG pharmacists and an advisory committee comprising key stakeholders. RESULTS AND DISCUSSION: A total of 299 FMG pharmacists were identified, and 178 (59.5%) completed the online questionnaire. Most were women (71.9%), were less than 40 years old (71.9%) and also practised as community pharmacists (76.4%). Reviewing medication to optimize pharmacotherapy and answering questions related to specific issues were the most frequent activities, with 86.0% and 90.4% of pharmacists, respectively, reporting that they performed these often or very often. The most frequently mentioned needs were training and mentorship adapted to the FMG practice and improvement in the understanding that other healthcare professionals have about the role of the FMG pharmacist. Performing comprehensive medication assessments and developing thorough pharmaceutical care plans were among the clinical competencies that pharmacists wanted to develop. Scientific and interprofessional communication was also among the abilities they wished to optimize. WHAT IS NEW AND CONCLUSION: This study provided unique information about pharmacists practising in FMGs and elicited several needs. The results will inform the development of a practice-based network aimed at fulfilling these needs.

Concordance of care processes between medical records and patient self-administered questionnaires.

BACKGROUND: Despite the increasing use of medical records to measure quality of care, studies have shown that their validity is suboptimal. The objective of this study is to assess the concordance of cardiovascular care processes evaluated through medical record review and patient self-administered questionnaires (SAQs) using ten quality indicators (TRANSIT indicators). These indicators were developed as part of a participatory research program (TRANSIT study) dedicated to TRANSforming InTerprofessional clinical practices to improve cardiovascular disease (CVD) prevention in primary care. METHODS: For every patient participating in the TRANSIT study, the compliance to each indicator (individual scores) as well as the mean compliance to all indicators of a category (subscale scores) and to the complete set of ten indicators (overall scale score) were established. Concordance between results obtained using medical records and patient SAQs was assessed by prevalence-adjusted bias-adjusted kappa (PABAK) coefficients as well as intraclass correlation coefficients (ICCs) and 95% confidence intervals (95% CI). Generalized linear mixed models (GLMM) were used to identify patients' sociodemographic and clinical characteristics associated with agreement between the two data sources. RESULTS: The TRANSIT study was conducted in a primary care setting among patients (n = 759) with multimorbidity, at moderate (16%) and high risk (83%) of cardiovascular diseases. Quality of care, as measured by the TRANSIT indicators, varied substantially between medical records and patient SAQ. Concordance between the two data sources, as measured by ICCs (95% CI), was poor for the subscale (0.18 [0.08-0.27] to 0.46 [0.40-0.52]) and overall (0.46 [0.40-0.53]) compliance scale scores. GLMM showed that agreement was not affected by patients' characteristics. CONCLUSIONS: In quality improvement strategies, researchers must acknowledge that care processes may not be consistently recorded in medical records. They must also be aware that the evaluation of the quality of care may vary depending on the source of information, the clinician responsible of documenting the interventions, and the domain of care.

Development and validation of PART (Pharmacotherapy Assessment in Renal Transplant Patients) criteria to assess drug-related problems in an outpatient renal transplant population: A cross-sectional study.

Kidney transplant recipients are at risk of pharmacological interactions and adverse drug reactions. Community pharmacists are uniquely poised to detect and intervene in cases of drug-related problems. The aims of this study were to develop and validate a list of explicit criteria to be used by community pharmacists to assess drug-related problems in kidney transplant patients, and to assess their frequency and their determinants. First, we used a modified RAND method where a panel of experts established the PART (Pharmacotherapy Assessment in Renal Transplant Patient) criteria. Then, we performed a cross-sectional study in which we applied the PART criteria to 97 prevalent kidney transplant recipients followed at a single university-affiliated center. The final list of PART criteria included 70 drug-related problems and was reliable (kappa: 0.88). An average of 1.2 drug-related problems per patient was detected when the PART criteria were applied, with 68% of patients having at least 1 problem. This figure was 1.4 per patient using the expert judgment of renal transplant pharmacists who had no access to the PART list. The total number of medications taken was the only factor associated with the number of drug-related problems (ß: 0.27 for an increase of five medications, 95% CI 0.005, 0.547). The PART criteria provide a novel tool for community pharmacists to systematically detect drug-related problems in kidney transplant recipients.

Beliefs influencing community pharmacists' interventions with chronic kidney disease patients: A theory-based qualitative study.

BACKGROUND: Drug-related problems (DRPs) are highly prevalent in chronic kidney disease (CKD) patients. Community pharmacists are ideally positioned to manage these DRPs. However, little is known about the factors influencing their interventions with CKD patients. OBJECTIVES: Using the theory of planned behavior (TPB), this qualitative study sought to: (1) explore the behavioral beliefs (perceived advantages and disadvantages), normative beliefs (perceived expectations of significant others) and control beliefs (perceived barriers and facilitators) influencing community pharmacists' interventions related to identifying and managing DRPs in CKD; and (2) compare these beliefs among three DRPs prevalent in CKD patients. METHODS: Community pharmacists in Quebec, Canada participated in face-to-face individual semi-structured interviews. The topic guide was based on the TPB. Three vignettes were presented to stimulate community pharmacists' thoughts about their interventions regarding: (1) the use of an inappropriate over-the-counter laxative; (2) prescriptions of anti-inflammatory medications; and (3) non-adherence to antihypertensive medication. Integral transcripts of audio recordings were analyzed using thematic analysis. The findings on each of the three DRPs were systematically compared. RESULTS: Fifteen community pharmacists participated in the study. All expressed a positive attitude toward DRP management, mentioning advantages such as gaining the patient's loyalty as a client and avoiding CKD complications. Participants mentioned that patients and physicians generally approve their interventions, but the dynamics of these relationships may vary depending on the DRP. Common barriers in the management of the three DRPs were the pharmacists' limited time and heavy workloads. The pharmacists felt that the main disadvantage is that these interventions interrupt the workflow in the pharmacy. CONCLUSION: Community pharmacists hold positive views of their interventions in CKD. However, enhancing community pharmacists' involvement in CKD care may require measures to facilitate pharmacists' proactivity, inter-professional collaboration and a work organization adapted to clinical activities.

Lasso Regression for the Prediction of Intermediate Outcomes Related to Cardiovascular Disease Prevention Using the TRANSIT Quality Indicators.

BACKGROUND: Cardiovascular disease morbidity and mortality are largely influenced by poor control of hypertension, dyslipidemia, and diabetes. Process indicators are essential to monitor the effectiveness of quality improvement strategies. However, process indicators should be validated by demonstrating their ability to predict desirable outcomes. The objective of this study is to identify an effective method for building prediction models and to assess the predictive validity of the TRANSIT indicators. METHODS: On the basis of blood pressure readings and laboratory test results at baseline, the TRANSIT study population was divided into 3 overlapping subpopulations: uncontrolled hypertension, uncontrolled dyslipidemia, and uncontrolled diabetes. A classic statistical method, a sparse machine learning technique, and a hybrid method combining both were used to build prediction models for whether a patient reached therapeutic targets for hypertension, dyslipidemia, and diabetes. The final models' performance for predicting these intermediate outcomes was established using cross-validated area under the curves (cvAUC). RESULTS: At baseline, 320, 247, and 303 patients were uncontrolled for hypertension, dyslipidemia, and diabetes, respectively. Among the 3 techniques used to predict reaching therapeutic targets, the hybrid method had a better discriminative capacity (cvAUCs=0.73 for hypertension, 0.64 for dyslipidemia, and 0.79 for diabetes) and succeeded in identifying indicators with a better capacity for predicting intermediate outcomes related to cardiovascular disease prevention. CONCLUSIONS: Even though this study was conducted in a complex population of patients, a set of 5 process indicators were found to have good predictive validity based on the hybrid method.

Anticoagulation management services in community pharmacy: Feasibility of implementing a quality improvement programme through a practice-based research network.

WHAT IS KNOWN AND OBJECTIVE: The literature has reported suboptimal real-world use of oral anticoagulants in patients with atrial fibrillation (AF). Anticoagulation management services (AMSs) in community pharmacy have rarely been evaluated, and no formal process is available to enable pharmacists to evaluate and improve their clinical practices. Our objective was to assess the feasibility of implementing, through a practice-based research network (PBRN), a quality improvement programme on AMSs by community pharmacists for AF patients and explore its impact on the quality of clinical practices and pharmacists' knowledge. METHODS: An uncontrolled pre/post-pilot study was conducted through a PBRN. Pharmacists identified 5-20 AF patients on oral anticoagulants per pharmacy and completed questionnaires at baseline (T0) and after 6 months (T6). Clinical practices were evaluated using a set of quality indicators (QIs). QI scores ranged from 0% (no QI achieved) to 100% (all QIs achieved). The programme included an audit and feedback based on QIs and a personalized training programme (including online videos). Participation rates and satisfaction were documented. Mean changes (T6-T0), with 95% confidence interval (CI), in QIs and knowledge scores were computed. RESULTS AND DISCUSSION: A total of 37 pharmacies (50 pharmacists) identified 222 patients who had received either vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs), or both. All pharmacies received their baseline quality report (audit), and facilitators contacted by phone 97% of pharmacies (feedback). Each of the six online videos was completed by at least 48% of pharmacists. Baseline mean global QI scores for VKAs and DOACs were 39.1% (95% CI: 35.7%-42.4%) and 12.3% (7.8%-16.8%), respectively. Over a 6-month period, they increased by 12.5% points (7.5%-17.5%) and 9.9% points (3.8%-16.1%), respectively. Baseline mean global knowledge score was 68.7% (65.4%-72.0%) and increased by 4.3% points (1.2%-7.4%). WHAT IS NEW AND CONCLUSION: Implementing a quality improvement programme for AMS in community pharmacy is relevant and feasible and may improve pharmacists' practices and knowledge.

Rationale, design, and preliminary results of the Quebec Warfarin Cohort Study.

Over- and undercoagulation with warfarin are associated with hemorrhagic and thromboembolic events, respectively. Genetic and clinical factors affect warfarin response, and the causes of this variability remain unclear. We present descriptive statistics and test for predictors of poor anticoagulation control. The Quebec Warfarin Cohort (QWC) comprises 1059 new warfarin users, with prospective follow-up using telephone questionnaires every 3 months for 1 year, and using healthcare administrative databases (RAMQ and Med-Echo) for 5 years prior to cohort entry and up to 10 years following active patient participation. Genetic material was collected, and genotyping of CYP2C9 and VKORC1 genes was conducted. Measured outcomes included the percentage of time patients spent within therapeutic range, anticoagulation control, warfarin dose, bleeding, and thromboembolic events. We report baseline characteristics and outcomes after 1 year of follow-up. Poor anticoagulation control was defined as time in therapeutic range <60% in the 3- to 12-month interval. Participants had a mean age of 71 years, and 62% were men. The most common indication for warfarin was atrial fibrillation (87%). Mean time in therapeutic range was 56% (±25%) in the 3 months following warfarin initiation, and 70% (±21%) in the 3- to 12-month interval. During follow-up, the rate of stroke or systemic embolism was 1.8 events per 100 person-years; for major bleeding events, 3.3 events per 100 person-years. Independent predictors of poor anticoagulation control were chronic kidney disease, heart failure, dyslipidemia, and age. The QWC represents a good research cohort to investigate clinical and genetic factors in a warfarin-anticoagulated population.

Development of Quality Indicators to Assess Oral Anticoagulant Management in Community Pharmacies for Patients with Atrial Fibrillation.

BACKGROUND: Few studies have evaluated the quality of oral anticoagulant management by community pharmacists. There is no complete set of quality indicators available for this purpose. OBJECTIVE: To develop a set of specific quality indicators to assess oral anticoagulant management by community pharmacists for patients with atrial fibrillation (AF). METHODS: Quality indicators were developed in 3 phases. In phase 1, potential quality indicators were generated based on clinical guidelines and a literature review. In phase 2, a modified RAND appropriateness method involving 2 rounds was implemented with 9 experts, who judged the appropriateness of quality indicators generated in phase 1 based on the extent to which they were accurate, based on evidence, relevant, representative of best practices, and measurable in community pharmacies. Phase 3 consisted of a feasibility assessment in 5 community pharmacies on 2 patients each. RESULTS: The final set included 38 quality indicators grouped into 6 categories: documentation (n = 29), risk assessment (n = 3), clinical control (n = 1), clinical follow-up (n = 15), choice of therapy (n = 11), and interaction management (n = 8). The quality indicators referred to process of care (n = 34), clinical outcomes (n = 2), or structure of care (n = 2). There were 24 quality indicators related to vitamin K antagonists (VKAs), and 17 were related to direct oral anticoagulants (DOACs). To assess quality indicators, a questionnaire was developed for completion by community pharmacists for each patient, which included 17 questions about VKA patients and 12 questions about DOAC patients. CONCLUSIONS: A first set of quality indicators is now available to assess the quality of oral anticoagulant management by community pharmacists for patients with AF. DISCLOSURES: This research was supported by the Réseau Québécois de recherche sur le médicament (RQRM); the Blueprint for Pharmacy in collaboration with Pfizer Canada; and the Cercle du Doyen of the Faculty of Pharmacy, University of Montreal. The study sponsors were not involved in the study design, data collection, data interpretation, the writing of the article, or the decision to submit the report for publication. Chartrand received a scholarship from the Fonds de Recherche du Québec en Santé (FRQ-S), the Réseau Québécois de recherche sur l'usage des médicaments with Pfizer, and the Faculty of Pharmacy, University of Montreal. Guénette holds a Junior-1 Clinician Researcher Award from the FRQ-S in partnership with the Société québécoise d'hypertension artérielle. Williamson holds a Junior-1 Career Award from the FRQ-S. Côté reported being a medical speaker for Bayer, Boehringer Ingelheim Canada, and Pfizer Canada. The other authors reported no conflicts of interest. Study concept and design were contributed by Lalonde, Chartrand, and Martin. Chartrand, Martin, and Lalonde collected the data, along with Brouillette, Côté, Huot, Landry, Martineau, Perreault, Williamson, and White-Guay. Data interpretation was performed by Chartrand, Gagnon, and Lalonde, along with Guénette and Martin. The manuscript was primarily written by Chartrand, along with Guénette and Lalonde, and revised by Chartrand, Guénette, and Lalonde, along with the other authors. A portion of this study's results was presented at the 4th RQRM Annual Meeting on September 22-23, 2014, in Orford, Quebec, Canada, in the form of an abstract, which was published in the Journal of Population Therapeutics and Clinical Pharmacology, 2014;21(2):e312.

Prevalence and Management of Drug-Related Problems in Chronic Kidney Disease Patients by Severity Level: A Subanalysis of a Cluster Randomized Controlled Trial in Community Pharmacies.

BACKGROUND: Drug-related problems (DRPs) are prevalent among chronic kidney disease (CKD) patients. However, little is known about their severity and management by community pharmacists. OBJECTIVES: To (a) describe the prevalence of DRPs by severity level in CKD patients and (b) assess the effect of a training-and-communication network program in nephrology (ProFiL) on these DRPs. METHODS: This is a secondary analysis of a cluster randomized controlled trial evaluating the effect of the ProFiL-program. In 6 CKD clinics, patients at CKD stage 3 or 4 and their community pharmacists were recruited and assigned to the ProFiL group or a usual care (UC) group. Using validated criteria, 2 pharmacists identified DRPs and assessed their severity at baseline and after 12 months. The mean annual change in the number of DRPs per patient by severity level was assessed using a 2-level multivariable linear mixed-effects model. RESULTS: A total of 494 pharmacists and 442 patients participated. At baseline, the prevalence (mean number of DRPs per patient [SD]) of mild DRPs (e.g., requiring dosage adjustment) and moderate DRPs (e.g., drug adherence requiring a monitoring plan) were 0.55 (0.98) and 1.04 (1.51), respectively. After 12 months, an unadjusted incremental annual reduction of 0.34 moderate DRPs (95% CI = -0.66 to -0.01) was observed in the ProFiL group compared with the UC group. After adjustment, no between-group differences were observed. CONCLUSIONS: Among patients followed in CKD clinics, most DRPs have a moderate severity requiring specific monitoring by pharmacists. The benefit of continuing education programs, such as ProFiL, to reduce moderate DRPs remains to be determined. DISCLOSURES: This study was supported by the Canadian Institutes of Health Research (grant number: MOP-230207). Part of the study was also funded by Pfizer Canada, Leo Pharma, and Amgen. The authors declare that they have no relevant financial interests. Study concept and design were contributed by Quintana-Bárcena, Lord, and Lalonde. Quintana-Bárcena, Lord, and Lizotte were responsible for the data analysis, and Quintana-Bárcena and Berbiche performed the statistical analysis. The manuscript was written by Quintana-Bárcena and Lalonde and revised by Quintana-Bárcena and Lalonde, along with the other authors.

Psychometric analysis of the TRANSIT quality indicators for cardiovascular disease prevention in primary care.

OBJECTIVE: To assess a selection of psychometric properties of the TRANSIT indicators. DESIGN: Using medical records, indicators were documented retrospectively during the 14 months preceding the end of the TRANSIT study. SETTING: Primary care in Quebec, Canada. PARTICIPANTS: Indicators were documented in a random subsample (n = 123 patients) of the TRANSIT study population (n = 759). INTERVENTIONS: For every patient, the mean compliance to all indicators of a category (subscale score) and to the complete set of indicators (overall scale score) were established. To evaluate test-retest and inter-rater reliabilities, indicators were applied twice, two months apart, by the same evaluator and independently by different evaluators, respectively. To evaluate convergent validity, correlations between TRANSIT indicators, Burge et al. indicators and Institut national d'excellence en santé et en services sociaux (INESSS) indicators were examined. MAIN OUTCOME MEASURES: Test-retest reliability, inter-rater reliability, and convergent validity. RESULTS: Test-retest reliability, as measured by intraclass correlation coefficients (ICCs) was equal to 0.99 (0.99-0.99) for the overall scale score while inter-rater reliability was equal to 0.95 (0.93-0.97) for the overall scale score. Convergent validity, as measured by Pearson's correlation coefficients, was equal to 0.77 (P < 0.001) for the overall scale score when the TRANSIT indicators were compared to Burge et al. indicators and to 0.82 (P < 0.001) for the overall scale score when the TRANSIT indicators were compared to INESSS indicators. CONCLUSIONS: Reliability was excellent except for eleven indicators while convergent validity was strong except for domains related to the management of CVD risk factors.

Community Pharmacist Training-and-Communication Network and Drug-Related Problems in Patients With CKD: A Multicenter, Cluster-Randomized, Controlled Trial.

BACKGROUND: Appropriate training for community pharmacists may improve the quality of medication use. Few studies have reported the impact of such programs on medication management for patients with chronic kidney disease (CKD). STUDY DESIGN: Multicenter, cluster-randomized, controlled trial. SETTING & PARTICIPANTS: Patients with CKD stage 3a, 3b, or 4 from 6 CKD clinics (Quebec, Canada) and their community pharmacies. INTERVENTION: Each cluster (a pharmacy and its patients) was randomly assigned to either ProFiL, a training-and-communication network program, or the control group. ProFiL pharmacists completed a 90-minute interactive web-based training program on use of medications in CKD and received a clinical guide, patients' clinical summaries, and facilitated access to the CKD clinic. OUTCOMES: Drug-related problems (primary outcome), pharmacists' knowledge and clinical skills, and patients' clinical attributes (eg, blood pressure and glycated hemoglobin concentration). MEASUREMENTS: Drug-related problems were evaluated the year before and after the recruitment of patients using a validated set of significant drug-related problems, the Pharmacotherapy Assessment in Chronic Renal Disease (PAIR) criteria. Pharmacists' questionnaires were completed at baseline and after 1 year. Clinical attributes were documented at baseline and after 1 year using available information in medical charts. RESULTS: 207 community pharmacies, 494 pharmacists, and 442 patients with CKD participated. After 1 year, the mean number of drug-related problems per patient decreased from 2.16 to 1.60 and from 1.70 to 1.62 in the ProFiL and control groups, respectively. The difference in reduction of drug-related problems per patient between the ProFiL and control groups was -0.32 (95% CI, -0.63 to -0.01). Improvements in knowledge (difference, 4.5%; 95% CI, 1.6%-7.4%) and clinical competencies (difference, 7.4%; 95% CI, 3.5%-11.3%) were observed among ProFiL pharmacists. No significant differences in clinical attributes were observed across the groups. LIMITATIONS: High proportion of missing data on knowledge and clinical skills questionnaire (34.6%) and clinical attributes (11.1%). CONCLUSIONS: Providing community pharmacists with essential clinical data, appropriate training, and support from hospital pharmacists with expertise in nephrology increases pharmacists' knowledge and reduces drug-related problems in patients with CKD who are followed up in clinics incorporating a multidisciplinary health care team.

Kidney Transplant Recipients' Perspectives on Cardiovascular Disease and Related Risk Factors After Transplantation: A Qualitative Study.

BACKGROUND: Cardiovascular disease (CVD) is a major cause of mortality among kidney transplant recipients (KTRs). These patients have a high prevalence of risk factors, such as hypertension, diabetes, and dyslipidemia. Despite regular medical care, few of them reach the recommended therapeutic targets. The objective of this study is to describe KTRs' perspectives on CVD and related risk factors, as well as their priorities for posttransplant care. METHODS: Twenty-six KTRs participated in a semistructured interview about their personal experience and offered their perspectives on CVD risk factors posttransplant. The interview was digitally recorded and the transcripts were analyzed using a thematic and content methodology. RESULTS: CVD and related risk factors appear to be underestimated and trivialized. Only 2 of 26 patients identified CVD prevention and treatment as a priority. The most important posttransplant priorities identified by patients were related to immunosuppressive drugs (13 of 26), posttransplant follow-up (10) and graft survival (9). However, 21 of 26 patients stated they wanted to be better informed about posttransplant CVD risk factors. CONCLUSIONS: CVD and related risk factors are not a priority for KTRs, and the importance of CVD is underestimated and trivialized. KTRs did recommend that tailored information be provided by various professionals and at several points in the transplantation process. This knowledge will help us develop a new approach to increase awareness of posttransplant CVD and related risk factors.

Identifying heavy health care users among primary care patients with chronic non-cancer pain.

Objective: The objective of this study was to identify biopsychosocial factors predicting primary care chronic non-cancer pain (CNCP) patients' risk of being heavy health care users. Methods: Patients reporting moderate to severe CNCP for at least 6 months with an active analgesic prescription from a primary care physician were recruited in community pharmacies. Recruited patients completed questionnaires documenting biopsychosocial characteristics. Using administrative databases, direct costs were estimated for health care services used by each patient in the year preceding and following the recruitment. Heavy health care users were defined as patients in the highest annual direct health care costs quartile. Logistic multivariate regression models using the Akaike information criterion were developed to identify predictors of heavy health care use. Results: The median annual direct health care cost incurred by heavy health care users (n = 63) was CAD (Canadian dollars) 7627, versus CAD 1554 for standard health care users (n = 188). The final predictive model of the risks of being a heavy health care user included pain located in the lower body (odds ratio [OR] = 3.03; 95% confidence interval [CI], 1.20-7.65), pain-related disability (OR = 1.24; 95% CI, 1.03-1.48), and health care costs incurred in the year prior to recruitment (OR = 17.67; 95% CI, 7.90-39.48). Variables in the model also included sex, comorbidity, patients' depression level, and attitudes toward medical pain cure. Conclusion: Patients suffering from CNCP in the lower body and showing greater disability were more likely to be heavy health care users, even after adjusting for previous-year direct health care costs. Improving pain management for these patients could have positive impacts on health care use and costs.

Objectif: Déterminer les facteurs biopsychosociaux prédictifs du risque d'être un grand utilisateur de services de santé chez les patients souffrant de douleur chronique non cancéreuse (DCNC) suivis en soins de première ligne.Méthodologie: Des patients souffrant d'une DCNC modérée à sévère depuis au moins six mois et bénéficiant d'une ordonnance d'analgésique valide donnée par un médecin de famille ont été recrutés dans des pharmacies communautaires. Les patients recrutés ont ensuite complété des questionnaires documentant leurs caractéristiques biopsychosociales. À l'aide de bases de données administratives, les coûts directs des services de santé utilisés par chaque patient au cours de l'année précédant et suivant son recrutement ont été estimés. Les grands utilisateurs de soins de santé ont été définis comme les patients faisant partie du quartile le plus élevé de coûts directs annuels en soins de santé. Des modèles de régression logistique multivariée utilisant le critère d'information Akaike ont été élaborés afin de déterminer les facteurs prédictifs de grande utilisation des soins de santé.Résultats: Le coût direct annuel médian en soins de santé chez les grands utilisateurs de soins de santé (n = 63) était de 7 627 CAD comparativement à 1 554 CAD pour les utilisateurs de soins de santé réguliers (n = 188). Le modèle prédictif final du risque d'être un grand utilisateur de soins de santé comprenait la douleur au niveau des membres inférieurs (rapport de cotes (RC) = 3,03; intervalle de confiance (IC) à 95 %: 1,20 ­ 7,65), la réduction de la capacité fonctionnelle liée à la douleur (RC = 1,24; IC à 95 %: 1,03 ­ 1,48) et les coûts directs en soins de santé au cours de l'année précédant le recrutement (RC = 17,67; IC à 95 %: 7,90 ­ 39,48). Les variables « sexe ¼, « comorbidité ¼, « dépression ¼ et « attitudes envers la guérison médicale ¼ étaient également retenues dans le modèle.Conclusion: Les patients souffrant de DCNC au niveau des membres inférieurs et présentant une détérioration de la capacité fonctionnelle liée à la douleur étaient plus susceptibles d'être de grands utilisateurs des soins de santé, même après ajustement pour le coût direct en soins de santé pendant l'année précédente. L'amélioration de la prise en charge de la douleur chez ces patients pourrait avoir des répercussions positives sur l'utilisation et le coût des soins de santé.

Evaluation of a continuous quality improvement program in anticoagulant therapy: Feasibility, satisfaction and perception.

BACKGROUND: The ACO Program (Programme ACO), a continuous quality improvement program (CQIP) in anticoagulation therapy, was offered in community pharmacies as a pilot project. OBJECTIVE: To evaluate the participants' appreciation for the various activities of the program. METHODS: Participants had access to training activities, including an audit with feedback, online training activities (OTA), clinical tools and support from facilitators. Cognitive behavioural learning determinants were evaluated before and 5 months after the beginning of the program. Participants' satisfaction and perception were documented via online questionnaires and a semistructured interview. RESULTS: Of the 52 pharmacists in the ACO Program, 47 participated in this evaluation. Seventy-seven percent of the participants completed at least 1 OTA and 6% published on the forum. The feeling of personal effectiveness rose from 8.01 (7.67-8.35) to 8.62 (8.24-8.99). The audit and feedback, as well as the high-quality OTA and their lecturers, were the most appreciated elements. DISCUSSION: There was a high OTA participation rate. The facilitators seemed to play a key role in the CQIP. The low level of participation in the forum reflects the known phenomenon of social loafing. Technical difficulties affecting the platform and data collection for the audit with feedback constituted limitations. CONCLUSION: The CQIP in anticoagulation therapy is appreciated by community pharmacists and is associated with an improved feeling of personal effectiveness.

External facilitators and interprofessional facilitation teams: a qualitative study of their roles in supporting practice change.

BACKGROUND: Facilitation is a powerful approach to support practice change. The purpose of this study is to better understand the facilitation roles exercised by both external facilitators and interprofessional facilitation teams to foster the implementation of change. Building on Dogherty et al.'s taxonomy of facilitation activities, this study uses an organizational development lens to identify and analyze facilitation roles. It includes a concise definition of what interprofessional facilitation teams actually do, thus expanding our limited knowledge of teams that act as change agents. We also investigate the facilitation dynamics between change actors. METHODS: We carried out a qualitative analysis of a 1-year process of practice change implementation. We studied four family medicine groups, in which we constituted interprofessional facilitation teams. Each team was supported by one external facilitator and included at least one family physician, one case manager nurse, and health professionals located on or off the family medicine group's site (one pharmacist, plus at least one nutritionist, kinesiologist, or psychologist). We collected our data through focus group interviews with the four teams, individual interviews with the two external facilitators, and case audit documentation. We analyzed both predetermined (as per Dogherty et al., 2012) and emerging facilitation roles, as well as facilitation dynamics. RESULTS: A non-linear framework of facilitation roles emerged from our data, based on four fields of expertise: change management, project management, meeting management, and group/interpersonal dynamics. We identified 72 facilitation roles, grouped into two categories: "implementation-oriented" and "support-oriented." Each category was subdivided into themes (n = 6; n = 5) for clearer understanding (e.g., legitimation of change/project, management of effective meetings). Finally, an examination of facilitation dynamics revealed eight relational ties occurring within and/or between groups of actors. CONCLUSIONS: Facilitation is an approach used by appointed individuals, which teams can also foster, to build capacity and support practice change. Increased understanding of facilitation roles constitutes an asset in training practitioners such as organizational development experts, consultants, facilitators, and facilitation teams. It also helps decision makers become aware of the multiple roles and dynamics involved and the key competencies needed to recruit facilitators and members of interprofessional facilitation teams.

Development and validation of criteria for classifying severity of drug-related problems in chronic kidney disease: A community pharmacy perspective.

PURPOSE: The development and validation of criteria for classifying severity of drug-related problems (DRPs) in chronic kidney disease (CKD) in the community pharmacy setting are described. METHODS: The Severity Categorization for Pharmaceutical Evaluation (SCOPE) criteria were adapted from an existing tool based on the interventions required to manage DRPs in community pharmacy. Ten community pharmacists reviewed the criteria. An expert panel involving community pharmacists, hospital pharmacists, family physicians, and nephrologists scored the relevance of each criterion. The severity of 487 DRPs identified among 168 patients was rated independently by two evaluators and by one evaluator on two occasions. Kappa reliability coefficients were computed. Severity as assessed by implicit judgment and the SCOPE criteria was compared. RESULTS: Three severity categories were defined (mild, moderate, and severe), each including two levels (for a total of six levels). At each level, specific interventions required to manage DRPs in community pharmacy were listed. The test-retest reliability coefficient by level was 0.85 (95% confidence interval [CI], 0.79-0.90), and the interrater reliability coefficient was 0.77 (95% CI, 0.72-0.82). The test-retest coefficient by category was 0.89 (95% CI, 0.84-0.95), and the interrater coefficient was 0.90 (95% CI, 0.86-0.94). A higher level of SCOPE was associated with more severe DRPs as rated by implicit judgment (p < 0.05). CONCLUSION: A set of criteria developed for use in the community pharmacy setting for evaluating the severity of DRPs in CKD proved to be reliable and correlated with clinical implicit judgment.

The prevention and management of chronic disease in primary care: recommendations from a knowledge translation meeting.

BACKGROUND: Seven chronic disease prevention and management programs were implemented across Quebec with funding support from a provincial-private industry funding initiative. Given the complexity of implementing integrated primary care chronic disease management programs, a knowledge transfer meeting was held to share experiences across programs and synthesize common challenges and success factors for implementation. METHODS: The knowledge translation meeting was held in February 2014 in Montreal, Canada. Seventy-five participants consisting of 15 clinicians, 14 researchers, 31 knowledge users, and 15 representatives from the funding agencies were broken up into groups of 10 or 11 and conducted a strengths, weaknesses, opportunities, and threats analysis on either the implementation or the evaluation of these chronic disease management programs. Results were reported back to the larger group during a plenary and recorded. Audiotapes were transcribed and summarized using pragmatic thematic analysis. RESULTS AND DISCUSSION: Strengths to leverage for the implementation of the seven programs include: (1) synergy between clinical and research teams; (2) stakeholders working together; (3) motivation of clinicians; and (4) the fact that the programs are evidence-based. Weaknesses to address include: (1) insufficient resources; (2) organizational change within the clinical sites; (3) lack of referrals from primary care physicians; and (4) lack of access to programs. Strengths to leverage for the evaluation of these programs include: (1) engagement of stakeholders and (2) sharing of knowledge between clinical sites. Weaknesses to address include: (1) lack of referrals; (2) difficulties with data collection; and (3) difficulties in identifying indicators and control groups. Opportunities for both themes include: (1) fostering new and existing partnerships and stakeholder relations; (2) seizing funding opportunities; (3) knowledge transfer; (4) supporting the transformation of professional roles; (5) expand the use of health information technology; and (6) conduct cost evaluations. Fifteen recommendations related to mobilisation of primary care physicians, support for the transformation of professional roles, and strategies aimed at facilitating the implementation and evaluation of chronic disease management programs were formulated based on the discussions at this knowledge translation event. CONCLUSION: The results from this knowledge translation day will help inform the sustainability of these seven chronic disease management programs in Quebec and the implementation and evaluation of similar programs elsewhere.

Efficacy of treatments and pain management for trapeziometacarpal (thumb base) osteoarthritis: protocol for a systematic review.

INTRODUCTION: The thumb is essential for daily activities. Unfortunately, this digit is commonly affected by trapeziometacarpal osteoarthritis (TMO), handicapping a large number of individuals. TMO constitutes an increasing human and economic burden for our society whose population is ageing. Limited access to adequate treatment is among the most important obstacles to optimal TMO management. Poor understanding of TMO characteristics, lack of knowledge about evidence-based treatments, simplistic pain management plans based solely on the patient's physical condition, absence of interprofessional communication and lack of multidisciplinary treatment guidelines contribute to inadequate TMO management. On the long term, our research project aims at improving the quality of care and services offered to patients with TMO by developing a patient-centred, evidence-based multidisciplinary management clinical pathway coordinated across the healthcare system. This proposed systematic review is a prerequisite to ensuring evidence-based practices and aims to document the efficacy of all the existing modalities for TMO management. METHODS AND ANALYSIS: The protocol of the systematic review is registered with PROSPERO and will be conducted using the guidelines Cochrane Handbook for Systematic Reviews of Interventions. We will identify studies in English and French concerning TMO treatments through searches in Cochrane Central, EMBASE, MEDLINE, PsychINFO, CINHAL, PubMed, OT Seekers, PEDRO and the grey literature. 2 reviewers will independently screen study eligibility, extract data and appraise studies using published assessment tools. Meta-analyses will be undertaken where feasible; otherwise, narrative syntheses will be carried out. The robustness of evidence will be assessed using the GRADE system. ETHICS AND DISSEMINATION: Ethics approval is not required for this study. A comprehensive knowledge exchange and transfer plan incorporating effective strategies will be used to disseminate the findings of this review and utilise them to optimise TMO management. TRIAL REGISTRATION NUMBER: PROSPERO CRD42015015623.

Facilitating Implementation of Interprofessional Collaborative Practices Into Primary Care: A Trilogy of Driving Forces.

Implementing interprofessional collaborative practices in primary care is challenging, and research about its facilitating factors remains scarce. The goal of this participatory action research study was to better understand the driving forces during the early stage of the implementation process of a community-driven and patient-focused program in primary care titled "TRANSforming InTerprofessional cardiovascular disease prevention in primary care" (TRANSIT). Eight primary care clinics in Quebec, Canada, agreed to participate by creating and implementing an interprofessional facilitation team (IFT). Sixty-three participants volunteered to be part of an IFT, and 759 patients agreed to participate. We randomized six clinics into a supported facilitation ("supported") group, with an external facilitator (EF) and financial incentives for participants. We assigned two clinics to an unsupported facilitation ("unsupported") group, with no EF or financial incentives. After 3 months, we held one interview for the two EFs. After 6 months, we held eight focus groups with IFT members and another interview with each EF. The analyses revealed three key forces: (1) opportunity for dialogue through the IFT, (2) active role of the EF, and (3) change implementation budgets. Decision-makers designing implementation plans for interprofessional programs should ensure that these driving forces are activated. Further research should examine how these forces affect interprofessional practices and patient outcomes.