Prescription Trends of Thiazide Diuretics in a Canadian Primary Care Population From 2015 to 2021.

Background: Hypertension Canada 2017 guidelines favoured the use of thiazide (TZ)-like diuretics, such as CLTD (chlorthalidone) and indapamide (IND) over hydrochlorothiazide (HCTZ). Health Canada warned in 2019 that HCTZ may be associated with increased risk of skin cancer. Our study looked at the changes in TZ prescriptions from 2015 to 2021 in Ontario, Canada. Methods: A retrospective cohort study was conducted of adults with hypertension, using electronic medical record data from the University of Toronto Practice-Based Research Network database covering mostly the Greater Toronto area. Outcomes included the proportion of patients who received a prescription of HCTZ, CLTD, or IND each month. Interrupted time-series analysis was used to evaluate the change in outcomes after publication of the 2017 guidelines and 2019 safety warning. Prescription trends were stratified by prescribing physicians' sex and year of medical school graduation. Results: A total of 100,428 patients with hypertension were included in the cohort, with 31,700 patients who received at least one TZ prescription from 343 family physicians. We found a declining trend in HCTZ prescriptions over time, accompanied by an increase in IND and CLTD prescriptions, with statistically significant but transient changes in prescription rates after publication of the 2017 guidelines and the 2019 safety warning for all 3 medications. Female physician and early-career physician prescription rates changed faster than that of their counterparts immediately after the Health Canada safety warning was issued. Conclusions: TZ diuretic prescription patterns have changed in recent years, but Hypertension Canada's 2017 guidelines and the 2019 Health Canada safety warning did not have a sustained significant impact on the change in prescription rates of HCTZ, IND, and CLTD.

Contexte: Les lignes directrices 2017 d'Hypertension Canada accordaient la priorité à l'utilisation de diurétiques apparentés aux thiazidiques (TZ), comme la chlorthalidone (CLTD) et l'indapamide (IND), plutôt que l'hydrochlorothiazide (HCTZ). En 2019, Santé Canada a émis une mise en garde indiquant que le HCTZ pourrait être associé à un risque accru de cancer de la peau. Notre étude s'intéressait à l'évolution des taux de prescriptions des différents diurétiques TZ entre 2015 et 2021 en Ontario, au Canada. Méthodologie: Une étude de cohorte rétrospective a été menée auprès d'adultes atteints d'hypertension à l'aide des données des dossiers médicaux électroniques du réseau de recherche fondé sur la pratique de l'Université de Toronto, qui couvre principalement la région du Grand Toronto. Les issues évaluées comprenaient la proportion de patients se faisant prescrire HCTZ, CLTD ou IND chaque mois. Une analyse de série chronologique interrompue a été réalisée pour évaluer l'évolution des issues après la publication des lignes directrices de 2017 et la mise en garde de 2019. Les tendances observées dans les prescriptions ont été stratifiées selon le sexe et l'année d'obtention du diplôme de médecine du médecin prescripteur. Résultats: Au total, 100 428 patients atteints d'hypertension ont été inclus dans la cohorte; 31 700 d'entre eux se sont fait prescrire un TZ au moins une fois par l'un des 343 médecins de famille prescripteurs. Nous avons observé une tendance à la baisse quant aux prescriptions de HCTZ, laquelle s'accompagnait d'une augmentation du nombre de prescriptions d'IND et de CLTD. La variation des taux de prescriptions pour les trois médicaments était statistiquement significative, mais transitoire après la publication des lignes directrices de 2017 et de la mise en garde de 2019. Les taux de prescriptions immédiatement après la publication de la mise en garde de Santé Canada ont changé plus vite pour les femmes médecins et les médecins en début de carrière que pour les autres médecins. Conclusions: Les habitudes de prescription des diurétiques thiazidiques ont changé dans les dernières années, mais les lignes directrices 2017 d'Hypertension Canada et la mise en garde émise en 2019 par Santé Canada n'ont pas eu un effet significatif durable sur la variation des taux de prescriptions de HCTZ, d'IND et de CLTD.

Global impacts of COVID-19 pandemic on sexual and reproductive health services: An international comparative study on primary care from the INTRePID Consortium.

OBJECTIVE: To understand how the COVID-19 pandemic has impacted sexual and reproductive health (SRH) visits. DESIGN: An ecological study comparing SRH services volume in different countries before and after the onset of the COVID-19 pandemic. SETTING: Seven countries from the INTernational ConsoRtium of Primary Care BIg Data Researchers (INTRePID) across four continents. POPULATION: Over 3.8 million SRH visits to primary care physicians in Australia, China, Canada, Norway, Singapore, Sweden and the USA. METHODS: Difference in average SRH monthly visits before and during the pandemic, with negative binomial regression modelling to compare predicted and observed number of visits during the pandemic for SRH visits. MAIN OUTCOME MEASURES: Monthly number of visits to primary care physicians from 2018 to 2021. RESULTS: During the pandemic, the average volume of monthly SRH visits increased in Canada (15.6%, 99% CI 8.1-23.0%) where virtual care was pronounced. China, Singapore, Sweden and the USA experienced a decline (-56.5%, 99% CI -74.5 to -38.5%; -22.7%, 99% CI -38.8 to -6.5%; -19.4%, 99% CI -28.3 to -10.6%; and -22.7%, 99% CI -38.8 to -6.5%, respectively); while Australia and Norway showed insignificant changes (6.5%, 99% CI -0.7 to -13.8% and 1.7%, 99% CI -6.4 to -9.8%). The countries that maintained (Australia, Norway) or surpassed (Canada) pre-pandemic visit rates had the greatest use of virtual care. CONCLUSIONS: In-person SRH visits to primary care decreased during the pandemic. Virtual care seemed to counterbalance that decline. Although cervical cancer screening appeared insensitive to virtual care, strategies such as incorporating self-collected samples for HPV testing may provide a solution in a future pandemic.

Reducing opioid use for chronic non-cancer pain in primary care using an evidence-based, theory-informed, multistrategic, multistakeholder approach: a single-arm time series with segmented regression.

BACKGROUND: Many countries have high opioid use among people with chronic non-cancer pain. Knowledge about effective interventions that could be implemented at scale is limited. We designed a national intervention that included audit and feedback, deprescribing guidance, information on catastrophising assessment, pain neuroscience education and a cognitive tool for use by patients with their healthcare providers. METHOD: We used a single-arm time series with segmented regression to assess rates of people using opioids before (January 2015 to September 2017), at the time of (October 2017) and after the intervention (November 2017 to August 2019). We used a cohort with historical comparison group and log binomial regression to examine the rate of psychologist claims in opioid users not using psychologist services prior to the intervention. RESULTS: 13 968 patients using opioids, 8568 general practitioners, 8370 pharmacies and accredited pharmacists and 689 psychologists were targeted. The estimated difference in opioid use was -0.51 persons per 1000 persons per month (95% CI -0.69, -0.34; p<0.001) as a result of the intervention, equating to 25 387 (95% CI 24 676, 26 131) patient-months of opioid use avoided during the 22-month follow-up. The targeted group had a significantly higher rate of incident patient psychologist claims compared with the historical comparison group (rate ratio: 1.37, 95% CI 1.16, 1.63; p<0.001), equating to an additional 690 (95% CI 289, 1167) patient-months of psychologist treatment during the 22-month follow-up. CONCLUSIONS: Our intervention addressed the cognitive, affective and sensory factors that contribute to pain and consequent opioid use, demonstrating it could be implemented at scale and was associated with a reduction in opioid use and increasing utilisation of psychologist services.

Impact of the COVID-19 pandemic on routine immunization coverage in children under 2 years old in Ontario, Canada: A retrospective cohort study.

BACKGROUND: The COVID-19 pandemic has caused a disruption in childhood immunization coverage around the world. This study aimed to determine the change in immunization coverage for children under 2 years old in Ontario, Canada, comparing time periods pre-pandemic to during the first year of the pandemic. METHODS: Observational retrospective open cohort study, using primary care electronic medical record data from the University of Toronto Practice-Based Research Network (UTOPIAN) database, from January 2019 to December 2020. Children under 2 years old who had at least 2 visits recorded in UTOPIAN were included. We measured up-to-date (UTD) immunization coverage rates, overall and by type of vaccine (DTaP-IPV-Hib, PCV13, Rota, Men-C-C, MMR, Var), and on-time immunization coverage rates by age milestone (2, 4, 6, 12, 15, 18 months). We compared average coverage rates over 3 periods of time: January 2019-March 2020 (T1); March-July 2020 (T2); and August-December 2020 (T3). RESULTS: 12,313 children were included. Overall UTD coverage for all children was 71.0% in T1, dropped by 5.7% (95% CI: -6.2, -5.1) in T2, slightly increased in T3 but remained lower than in T1. MMR vaccine UTD coverage slightly decreased in T2 and T3 by approximately 2%. The largest decreases were seen at ages 15-month and 18-month old, with drops in on-time coverage of 14.7% (95% CI: -18.7, -10.6) and 16.4% (95% CI: -20.0, -12.8) respectively during T2. When stratified by sociodemographic characteristics, no specific subgroup of children was found to have been differentially impacted by the pandemic. CONCLUSION: Childhood immunization coverage rates for children under 2 years in Ontario decreased significantly during the early period of the COVID-19 pandemic and only partially recovered during the rest of 2020. Public health and educational interventions for providers and parents are needed to ensure adequate catch-up of delayed/missed immunizations to prevent potential outbreaks of vaccine-preventable diseases.

Impact of a patient-specific national programme aimed at increasing the use of emollient moisturisers to reduce the risk of skin tears: a longitudinal cohort study.

OBJECTIVES: To evaluate the impact of a patient-specific national programme targeting older Australians and health professionals that aimed to increase use of emollient moisturisers to reduce to the risk of skin tears. DESIGN: A prospective cohort intervention. PARTICIPANTS: The intervention targeted 52 778 Australian Government's Department of Veterans' Affairs patients aged over 64 years who had risk factors for wound development, and their general practitioners (GPs) (n=14 178). OUTCOME MEASURES: An interrupted time series model compared the rate of dispensing of emollients in the targeted cohort before and up to 23 months after the intervention. Commitment questions were included in self-report forms. RESULTS: In the first month after the intervention, the rate of claims increased 6.3-fold (95% CI: 5.2 to 7.6, p<0.001) to 10 emollient dispensings per 1000 patients in the first month after the intervention. Overall, the intervention resulted in 10 905 additional patient-months of treatment. The increased rate of dispensing among patients who committed to talking to their GP about using an emollient was six times higher (rate ratio: 6.2, 95% CI: 4.4 to 8.7) than comparison groups. CONCLUSIONS: The intervention had a sustained effect over 23 months. Veterans who responded positively to commitment questions had higher uptake of emollients than those who did not.

Reduction in Use of Risperidone for Dementia in Australia Following Changed Guidelines.

Background: Risperidone is the only antipsychotic approved in Australia for the management of the behavioural and psychological symptoms of dementia (BPSD). In June 2015, the Australian Government Therapeutic Goods Administration (TGA) amended the indication to restrict use in BPSD to patients with Alzheimer's dementia for a maximum twelve-week duration. We aimed to determine whether the rate and duration of risperidone use for BPSD decreased following the regulatory changes. Methods: we conducted a study using the Australian Government Department of Veterans' Affairs administrative claims data and Pharmaceutical Benefits Scheme (PBS) 10% sample data. We included people aged 65 years or older and compared the rate and duration of risperidone use before and after the TGA labelling changes. Results: There was a sustained decrease in the trend of risperidone use for BPSD following the TGA labelling changes, with a monthly decrease of 1.7% in the aged care population, 0.5% in the community living population and 1.5% in the general older Australian population. Overall, in the 24 months post the TGA changes the reduction in the rate of use of risperidone ranged from 20% to 28% lower than compared to what the rate would have been without the TGA changes. The median duration of use of risperidone in aged-care residents decreased from 338 days in the year prior to the TGA labelling changes, to 240 days per person in the year after the changes. Conclusion: The TGA labelling changes were associated with a significant reduction in the rate of use of risperidone for BPSD in veterans living in both the aged care and community settings, and in the general older Australian population. The labelling changes were also associated with a reduced duration of risperidone use in aged care residents, although for most people the duration of use still exceeded the recommended 12-week maximum duration.

Initiation and continuation of antipsychotic medicines in older people following non-psychiatric hospital admission.

Background Internationally, antipsychotics are frequently initiated during hospital admission for older patients and use often continues post-discharge without indication. We located no Australian studies on this topic. Objective to identify the hospital admissions (excluding psychosis) associated with antipsychotic initiation and continuation in older Australians. Setting Australian Government Department of Veterans' Affairs. Method Retrospective analysis of administrative claims data for people admitted to hospital from 1 January 2014 to 31 December 2014, aged ≥ 65 years, who were antipsychotic naïve. Main outcome measure number of admissions associated with antipsychotic initiation, and the major diagnosis groups for these admissions. Where antipsychotics were initiated, we determined the time to cessation of antipsychotics after discharge. Results There were 142,009 hospital admissions for 66,415 people with a median age of 86 years. 921 (0.65%) admissions were associated with antipsychotic initiation, most commonly where the primary diagnoses were for mental and behavioural disorders excluding psychosis (17.8%) and injuries (16%). Fourteen percent of antipsychotic initiations were for primary diagnoses of delirium or dementia. When secondary diagnoses were considered, 55% of antipsychotic initiations were associated with delirium, dementia or both. The median duration of use among people who used antipsychotics was 132 days, and 40% continued use until death or one year follow-up. Conclusion Initiation of antipsychotics during hospital admissions was not frequent in this Australian population. Amongst those who did initiate antipsychotics, for almost half no diagnosis corresponding with an approved indication for use was recorded and long-term use of up to one year was common.