Pharmacogenomics guided versus standard antidepressant treatment in a community pharmacy setting: A randomized controlled trial.

The literature on pharmacogenomics as a tool to support antidepressant precision is burgeoning. Recently, a more active role has been argued for pharmacists in pharmacogenomic testing, with both pharmacists and family physicians perceiving pharmacist-led testing as a valuable method by which to scale this innovation for depression treatment. In this prospective, single-blind randomized controlled design, we evaluated the impact of pharmacogenomics guided versus standard antidepressant treatment of depression and anxiety, implemented in three large community pharmacies. Participants were 213 outpatients diagnosed with major depressive disorder and/or generalized anxiety disorder, randomized to receive pharmacogenomics guided (n = 105) or standard antidepressant treatment (n = 108); participants were blinded to the study. Patient reported outcomes of depression, anxiety, disability, and treatment satisfaction were assessed at months 0, 1, 3, and 6. Hypotheses were investigated using mixed effect models on the full data. All clinical outcomes improved significantly. The primary outcome (depression) and two secondary outcomes (generalized anxiety and disability) exhibited significant time by group interactions indicating that they improved for participants who received pharmacogenomics guided treatment more so than they did for participants who received standard treatment. Treatment satisfaction improved similarly for both groups. Results contribute to a growing body of work evaluating the impact of pharmacogenomics testing to inform antidepressant medication treatment for depression and anxiety, and provides important initial evidence for the role of pharmacists in care delivery. Pharmacogenomic testing may be a valuable tool to allow pharmacists to more effectively collaborate in facilitating clinical treatment decisions. ClinicalTrials.gov registration: (NCT03591224).

Audit of community pharmacists' prescribing interventions: Quality assessment of a newly reimbursed service.

OBJECTIVES: To evaluate community pharmacists' reimbursed prescribing interventions (called pharmaceutical opinions/POs in Canada) by determining the types of drug-related problems (DRPs) identified; the type, quality, and clinical impact of recommendations made; and variation in recommendation quality across regions, pharmacy ownership type, and pharmacy size. DESIGN: Retrospective audit of randomly sampled service documentation records. SETTING: Community pharmacies in Ontario, Canada, 3 years after implementation of a government program that reimburses pharmacies for providing DRP-based POs to physicians. PARTICIPANTS: Thirty-six community pharmacies in 4 regions of Ontario. MAIN OUTCOME MEASURES: For each PO, 2 experienced clinical pharmacists independently, and then by consensus, determined the primary drug implicated and its therapeutic category, the type of DRP, and the type of prescriber recommendation. Each PO recommendation was assessed for clinical impact, evidence base, and overall quality. Chi-square analyses assessed the relationship between PO quality and pharmacy characteristics. RESULTS: Of 563 POs, 261 (46%) met reimbursement criteria for stating a DRP and prescriber recommendation. Among these eligible POs, systemic antiinfective (22%), alimentary tract and metabolism (19%), nervous system (15%), and cardiovascular (15%) drugs were most commonly identified in the DRP. Adverse drug reactions (which included drug interactions) were the most common type of DRP (42.5%), followed by "dose too high" (16%) and "needs additional therapy" (14%). Top recommendations were to change the drug (41%) and to decrease the dose (20%). The quality of the pharmacist's recommendation was judged to be good to excellent in 70% of the 261 eligible POs; quality was associated with region and ownership type. CONCLUSION: PO quality was suboptimal: the primary issue was failure to state a prescriber recommendation. Collaborative efforts are needed from community pharmacy stakeholders (schools of pharmacy, regulatory colleges, and continuing education providers) to help pharmacists enhance the quality of their POs, beginning with their clinical documentation skills.

Uptake of the MedsCheck annual medication review service in Ontario community pharmacies between 2007 and 2013.

BACKGROUND: MedsCheck Annual (MCA) is an Ontario government-funded medication review service for individuals taking 3 or more prescription medications for chronic conditions. METHODS: This cohort study analyzed linked administrative claims data from April 1, 2007, to March 31, 2013. Trends in MCA claims and recipient characteristics were examined. RESULTS: A total of 1,498,440 Ontarians (55% seniors, 55% female) received an MCA. One-third (36%) had 2 or more MCAs within 6 years. Service provision increased over time, with a sharper increase from 2010 onward. Almost half of Ontario pharmacies made at least 1 MCA claim in the first month of the program. Hypertension, respiratory disease, diabetes, psychiatric conditions and arthritis were common comorbidities. Recipients older than 65 years were most commonly dispensed an antihypertensive and/or antihyperlipidemic drug in the prior year and received an average of 11 unique prescription medications. Thirty-eight percent of recipients visited an emergency department or were hospitalized in the year prior to their first MCA. DISCUSSION: Over the first 6 years of the program, approximately 1 in 9 Ontarians received an MCA. There was rapid and widespread uptake of the service. Common chronic conditions were well represented among MCA recipients. Older MCA recipients had less emergency department use compared with population-based estimates. CONCLUSIONS: Medication reviews increased over time; however, the number of persons receiving the service more than once was low. Service delivery was generally consistent with program eligibility; however, there are some findings possibly consistent with delivery to less complex patients.

Initial uptake of the Ontario Pharmacy Smoking Cessation Program: Descriptive analysis over 2 years.

BACKGROUND: Smoking is a significant public health concern. The Ontario Pharmacy Smoking Cessation Program was launched in September 2011 to leverage community pharmacists and expand access to smoking cessation services for public drug plan beneficiaries. METHODS: We examined health care utilization data in Ontario to describe public drug plan beneficiaries receiving, and pharmacies providing, smoking cessation services between September 2011 and September 2013. Patient characteristics were summarized, stratified by drug plan group: seniors (age ≥65 years) or social assistance. Trends over time were examined by plotting the number of services, unique patients and unique pharmacies by month. We then examined use of follow-up services and prescription smoking cessation medications. RESULTS: We identified 7767 residents receiving pharmacy smoking cessation services: 28% seniors (mean age = 69.9, SD = 4.8; 53% male) and 72% social assistance (mean age = 44.4 years, SD = 11.8; 48% male). Cumulative patient enrollment increased over time with an average of 311 (SD = 61) new patients per month, and one-third (n = 1253) of pharmacies participated by the end of September 2013. Regions with the highest number of patients were Erie St. Clair (n = 1328) and Hamilton Niagara Haldimand Brant (n = 1312). Sixteen percent of all patients received another pharmacy service (e.g., MedsCheck) on the same day as smoking cessation program enrollment. Among patients with follow-up data, 56% received follow-up smoking cessation services (60% seniors, 55% social assistance) and 74% received a prescription smoking cessation medication. One-year quit status was reported for 12%, with a 29% success rate. CONCLUSIONS: Program enrollment has increased steadily since its launch, yet only a third of pharmacies participated and 56% of patients received follow-up services.

Initial perceptions of key stakeholders in Ontario regarding independent prescriptive authority for pharmacists.

BACKGROUND: A number of jurisdictions, both in Canada and internationally, have recently expanded pharmacists' scope of practice to allow prescriptive authority. OBJECTIVE: To ascertain the initial perceptions of the Ontario government and health professional stakeholder groups regarding the prospect of prescriptive authority for pharmacists. METHODS: Qualitative research methods were used; data sources were policy documents and semi-structured interviews with key informants from the Ontario government and pharmacy and medical professional organizations. Purposive and snowball sampling strategies were used to identify 17 key informants. Fifty-one relevant policy documents were retrieved through searches of organizational websites and interviewee suggestions. Interview transcripts and documents were content analyzed independently by 2 researchers; and once consensus was achieved on key themes, the primary investigator analyzed the remainder. RESULTS: Pharmacy organizations and Ontario government representatives both expressed support for pharmacist prescriptive authority, suggesting that it would enhance patient access to primary care. Medical organizations were opposed to this expanded pharmacist role, arguing that pharmacists' lack of training and experience in diagnosis and prescribing would endanger patient safety. Other concerns were fragmentation of care and pharmacists' lack of access to patient clinical information. Some government and pharmacy informants felt that pharmacist prescribing would decrease health system costs through substitution of cheaper health professionals for physicians, while others felt that costs would increase due to increased utilization of services. Medical organizations preferred delegated medical authority as the policy alternative to pharmacist prescribing. CONCLUSIONS: Widely different views were expressed by the Ontario government and pharmacy organizations on the one hand and medical professional organizations on the other hand, regarding the potential impact of pharmacist prescribing on patient safety and access to primary care. This is likely due, at least in part, to the lack of evidence on the expected impact of this expanded pharmacist role. More research is needed to help inform discussions regarding this issue.

Ontario family physician readiness to collaborate with community pharmacists on drug therapy management.

BACKGROUND: Empirical evidence suggests that pharmacist-physician collaboration can improve patients' clinical outcomes; however, such collaboration occurs relatively infrequently in the community setting. There has been little research on physicians' perspectives of such collaboration. OBJECTIVE: To ascertain Ontario family physician readiness to collaborate with community pharmacists on drug therapy management. METHODS: The survey instrument was based on the transtheoretical model of behavior change. It enquired about 3 physician behaviors that represented low-, mid-, and high-level collaboration with pharmacists. The survey was distributed by fax or mail to a random sample of 848 Ontario family physicians and general practitioners, stratified by practice location (urban/rural). RESULTS: The response rate was 36%. Most respondents reported conversing with community pharmacists about a patient's drug therapy management 5 or fewer times per week. Eighty-four percent reported that they regularly took community pharmacists' phone calls, whereas 78% reported that they sometimes sought pharmacists' recommendations regarding their patients' drug therapy. Twenty-eight percent reported that they sometimes referred their patients to community pharmacists for medication reviews, with 44% unaware of such a service. There were no differences in physician readiness to engage in any of the 3 collaborative behaviors in urban versus rural settings. More accurate patient medication lists were perceived as the main advantage (pro) of collaborating with community pharmacists and pharmacists' lack of patient information as the main disadvantage (con). Collectively, perceived pros of collaboration were positive predictors of physician readiness to collaborate on all 3 behaviors, whereas perceived cons were negative predictors for the low- and mid-level behaviors. Female physicians were more likely than males to seek pharmacists' recommendations, whereas more experienced physicians were more likely to refer patients to pharmacists for medication reviews. CONCLUSIONS: Overall, Ontario physicians were more engaged in the low- and mid-level collaboration with community pharmacists with respect to drug therapy management. The strongest predictor of physician readiness to collaborate was perceived advantages of collaboration.