Setting Goals to Reduce Cardiovascular Risk: A Retrospective Chart Review of a Pharmacist-Led Initiative in the Workplace.

Background: Cardiovascular diseases (CVD) are the second leading cause of death in Canada with many modifiable risk factors. Pharmacists at a Canadian university delivered a novel CVD risk management program, which included goal-setting and medication management. Aim: This study aimed to describe what CVD prevention goals are composed of in a workplace CVD risk reduction program, and how might these goals change over time. Methods: A longitudinal, descriptive qualitative study using a retrospective chart review of clinical care plans for 15 patients enrolled in a CVD prevention program. Data across 6 visits were extracted from charts (n = 5413 words) recorded from May 2019-November 2020 and analyzed using quantitative content analysis and descriptive statistics. Results: Behavioural goals were most popular among patients and were more likely to change over the 12-month follow-up period, compared to health measure goals. Behavioural goals included goals around diet, physical activity (PA), smoking, medication, sleep and alcohol; health measure goals centered on weight measures, blood pressure (BP) and blood lipid levels. The most common behavioural goals set by patients were for diet (n = 11) and PA (n = 9). Over time, goals around PA, medication, alcohol and weight were adapted while others were added (e.g. diet) and some only continued. Patients experienced a number of barriers to their goal(s) which informed how they adapted their goal(s). These included environmental limitations (including COVID-19) and work-related time constraints. Conclusions: This study found CVD goal-setting in the pharmacist-led workplace wellness program was complex and evolved over time, with goals added and/or adapted. More detailed qualitative research could provide further insights into the patient-provider goal-setting experience in workplace CVD prevention.

Barriers to adult vaccination in Canada: A qualitative systematic review.

Background: In recent years, Canadian health care professionals have observed an increase in vaccine refusal. The objective of this study is to review published literature and identify the main themes related to vaccine hesitancy and barriers to vaccination in Canadian adults and recent immigrants. Methods: A qualitative systematic review was performed. A comprehensive search of MEDLINE (1946 to January 2021) and EMBASE (1974 to January 2021) was conducted to identify existing literature that addressed the primary research question. Studies were eligible for inclusion if the study population involved 1) the general population, 2) Indigenous populations, 3) recent immigrants to Canada or 4) Canadian health care professionals. Results: Thirty-four studies were included with a focus on the general population (n = 22), health care professionals (n = 10) and recent immigrant populations (n = 2). The most frequently reported barriers were lack of vaccine information (41%), lack of access to vaccination (38%), fear of adverse reactions (38%), financial reasons (29%), lack of awareness of vaccine existence (29%), antivaccine sentiments (24%), notion that older adults do not need vaccination (18%), misconceptions on vaccine effectiveness (12%), potential sexual health promotion stigma (6%) and fear of needles (3%). Interpretation: Barriers to vaccination among Canadians and recent immigrants continue to be a challenge in the health care system. Conclusions: The greatest yield in improving vaccination rates is likely to come from supporting vaccine-hesitant individuals in shifting their thinking to greater vaccine acceptance. Pharmacists are well positioned to address vaccine hesitancy and involvement through education, facilitation and administration of vaccines. Can Pharm J (Ott) 2022;155:xx-xx.

Perspectives and experiences with telepharmacy among pharmacists in Canada: A cross-sectional survey.

Objective: This study aims to understand Canadian pharmacists' use, experiences, and perspectives of telepharmacy. Methods: We conducted a cross-sectional online survey. Individuals were eligible to participate if they were currently a registered, licensed pharmacist practicing in Canada. We collected perspectives of both telepharmacy users and non-users by creating a survey logic that asked specific and shared questions between the two groups. Data was analyzed using descriptive statistics including means and standard deviations (SD) for continuous variables and proportions for categorical variables. Results: Between October and December 2020, 136 pharmacists completed the survey, including 61 (52.6%) telepharmacy users and 55 (47.4%) non-users. Among those who use telepharmacy, the majority of participants (39, 72.2%) expressed that telepharmacy augmented their clinical practice and feel comfortable managing minor ailments using telepharmacy (41, 80.4%). Among non-users, 45 (84.9%) indicated that telepharmacy will augment their clinical practice and 48 (90.6%) would feel comfortable managing minor ailments using telepharmacy. Important considerations for successful implementation of telepharmacy for those who use telepharmacy included easier system implementation (29, 19.3%), better privacy & data protection (28, 18.7%) and simple to learn technology (23, 15.3%). Conclusion: Despite the growing recognition of benefits of telepharmacy, our findings suggest that utilization among pharmacists in Canada is still quite low. Nonetheless, our study identified areas of consideration for better integration of telepharmacy in pharmacy practice including optimizing workflow, addressing barriers, and providing training to pharmacy students.

Perspectives and experiences with telepharmacy among pharmacists in Canada: A cross-sectional survey

Objective: This study aims to understand Canadian pharmacists’ use, experiences, and perspectives of telepharmacy. Methods: We conducted a crosssectional online survey. Individuals were eligible to participate if they were currently a registered, licensed pharmacist practicing in Canada. We collected perspectives of both telepharmacy users and non-users by creating a survey logic that asked specific and shared questions between the two groups. Data was analyzed using descriptive statistics including means and standard deviations (SD) for continuous variables and proportions for categorical variables. Results: Between October and December 2020, 136 pharmacists completed the survey, including 61 (52.6%) telepharmacy users and 55 (47.4%) nonusers. Among those who use telepharmacy, the majority of participants (39, 72.2%) expressed that telepharmacy augmented their clinical practice and feel comfortable managing minor ailments using telepharmacy (41, 80.4%). Among non-users, 45 (84.9%) indicated that telepharmacy will augment their clinical practice and 48 (90.6%) would feel comfortable managing minor ailments using telepharmacy. Important considerations for successful implementation of telepharmacy for those who use telepharmacy included easier system implementation (29, 19.3%), better privacy & data protection (28, 18.7%) and simple to learn technology (23, 15.3%). Conclusion: Despite the growing recognition of benefits of telepharmacy, our findings suggest that utilization among pharmacists in Canada is still quite low. Nonetheless, our study identified areas of consideration for better integration of telepharmacy in pharmacy practice including optimizing workflow, addressing barriers, and providing training to pharmacy students. (AU)

Medications and risk of motor vehicle collision responsibility in British Columbia, Canada: a population-based case-control study.

BACKGROUND: Many medications impair driving skills yet their influence on collision risk remains uncertain. We aimed to systematically investigate the risk of collision responsibility associated with common classes of prescription medications. METHODS: In this population-based case-control study we analysed linked driving and health records in British Columbia, Canada from Jan 1, 1997, to Dec 31, 2016. The study cohort included all drivers involved in an incident collision (defined as first collision after 3 collision-free years) that resulted in a police report. We scored police collision reports and classified drivers as responsible for the collision (cases) or not responsible (controls); drivers with indeterminate scores were excluded. We used logistic regression to determine odds of collision responsibility in drivers with current prescriptions for medications of interest versus drivers without prescriptions. To explore whether risk of collision responsibility was related to medication effect or driver factors, we compared risk in current medication users versus past users. To study whether drivers developed tolerance to medication effects, we compared risk in new (first 30 days of a prescription) versus established users. FINDINGS: During the study period, 4 906 925 drivers had their driving licence linked to health records; of these drivers, 747 662 unique drivers were involved in 837 919 incident collisions between Jan 1, 2000, and Dec 31, 2016. 382 685 drivers responsible for the collision (cases) and 332 259 drivers not responsible (controls) were included in the final analysis; 122 975 drivers with indeterminate responsibility were excluded. We found increased risk of collision responsibility in drivers prescribed sedating antipsychotics (adjusted odds ratio [aOR] 1·35 [98·75% CI 1·25-1·46]), long-acting benzodiazepines (aOR 1·30 [1·22-1·38]), short-acting benzodiazepines (aOR 1·25 [1·20-1·31]), and high-potency opioids (aOR 1·24 [1·17-1·30]). Among medications used for medical indications, the highest risk was seen in drivers prescribed neurological medications: cholinergic drugs (aOR 1·83 [1·39-2·40]), anticholinergic agents for Parkinson's disease (aOR 1·45 [1·08-1·96]), dopaminergic agents (aOR 1·20 [1·04-1·38]), and anticonvulsants (aOR 1·20 [1·14-1·26]). People currently taking benzodiazepines, non-sedating antidepressants, high-potency opioids, and anticonvulsants had increased risk compared with past users, and we did not find increased risk in new compared with established users of these drugs. INTERPRETATION: Drivers prescribed benzodiazepines or high-potency opioids are at increased risk of being responsible for collisions and this risk does not decrease over time. Several other classes of medications are associated with increased risk, but this association might be independent of medication effect. These findings can guide medication warnings and prescription choices and inform public education campaigns targeting impaired driving. FUNDING: Canadian Institutes of Health Research.

Pharmacist-led cardiovascular risk prevention in Western Canada: a qualitative study.

OBJECTIVES: Preventing cardiovascular diseases (CVD) is a public health and policy priority, including for employers. A novel CVD risk management programme that included medication management was delivered by pharmacists to employees of a Canadian university. This qualitative study describes the experiences and perceptions of participants who received individual health consultations in this programme. METHODS: A qualitative study design using free-text responses was adopted. Data (5658 words) came from evaluation surveys completed by 119 programme participants were iteratively coded and thematically analysed. KEY FINDINGS: We identified four themes characterising participant experiences of pharmacist-led CVD prevention. Theme one was labelled self-efficacy because personalised health information and advice on CVD risk factor management empowered participants to make improvements for their health. Participants expressed a range of positive responses about the longer consultations, supportive communication and safe setting of their pharmacist-led encounters; hence, Theme two is labelled pharmacists' interpersonal skills. The wider context of the programme included a number of enabling factors (Theme three) that either supported or limited participant engagement in the programme. A number of changes to behaviour and health measures were identified and participant suggestions to expand and continue the programme further contributed to perceptions of positive programme impact (Theme four). CONCLUSIONS: This study raises questions about how external resources and broader determinants might enable, or hinder, future programme success and sustainability. It also highlights the need for greater understanding and communication of the importance of primary prevention and the role of pharmacists in CVD risk reduction and workplace health promotion.

Work Productivity Losses and Associated Risk Factors Among University Employees in the CAMMPUS Wellness Program.

OBJECTIVE: The aim of this study was to comprehensively measure work productivity losses of employees enrolled in a pharmacist-led wellness program and assess associated risk factors. METHODS: The study sample was employees at least 18 years old with a Framingham Risk Score (FRS) at least 10% or 1+ medication-modifiable cardiovascular risk factor (196 participants at baseline and 166 at 12-month endpoint). Total work hour losses (WHL) were measured using the Valuation of Lost Productivity questionnaire. The factors anticipated to be associated with WHL included work habits, FRS, body mass index (BMI), physical activity, and health-related quality of life (HRQoL). RESULTS: Sedentary work habits, higher BMI, and lower HRQoL were significantly associated with more WHL for males. Among females, only a lower HRQoL was significantly associated with more WHL. CONCLUSIONS: Our findings help identify employees at greater risk for WHL and provide insights on how workplace wellness programs can be modified.

Prehospital Analgesia With Intranasal Ketamine (PAIN-K): A Randomized Double-Blind Trial in Adults.

STUDY OBJECTIVE: We compare intranasal ketamine with intranasal placebo in providing pain reduction at 30 minutes when added to usual paramedic care with nitrous oxide. METHODS: This was a randomized double-blind study of out-of-hospital patients with acute pain who reported a verbal numeric rating scale (VNRS) pain score greater than or equal to 5. Exclusion criteria were younger than 18 years, known ketamine intolerance, nontraumatic chest pain, altered mental status, pregnancy, and nasal occlusion. Patients received usual paramedic care and were randomized to receive either intranasal ketamine or intranasal saline solution at 0.75 mg/kg. The primary outcome was the proportion of patients with VNRS score reduction greater than or equal to 2 at 30 minutes. Secondary outcomes were pain reduction at 15 minutes, patient-reported comfort, satisfaction scores, nitrous oxide consumption, and incidence of adverse events. RESULTS: One hundred twenty subjects were enrolled. Seventy-six percent of intranasal ketamine patients versus 41% of placebo patients reported a greater than or equal to 2-point VNRS reduction at 30 minutes (difference 35%; 95% confidence interval 17% to 51%). Median VNRS reduction at 15 minutes was 2.0 and 1.0 and at 30 minutes was 3.0 and 1.0 for ketamine and placebo, respectively. Improved comfort at 15 and 30 minutes was reported for 75% versus 57% and 61% versus 46% of ketamine and placebo patients, respectively. Sixty-two percent of patients (95% confidence interval 49% to 73%) versus 20% (95% confidence interval 12% to 32%) reported adverse events with ketamine and placebo, respectively. Adverse events were minor, with no patients requiring physical or medical intervention. CONCLUSION: Added to nitrous oxide, intranasal ketamine provides clinically significant pain reduction and improved comfort compared with intranasal placebo, with more minor adverse events.

Cardiovascular Risk Reduction in the Workplace With CAMMPUS (Cardiovascular Assessment and Medication Management by Pharmacists at the UBC Site).

BACKGROUND: Cardiovascular (CV) disease is a leading cause of death despite being largely preventable. Employers increasingly offer preventive health programs in the workplace, and pharmacists are well suited to provide these programs. OBJECTIVE: To evaluate the impact of a pharmacist-led service on CV risk in University of British Columbia (UBC) employees. METHODS: This was a prospective observational pre-and-post design study, with participants as their own controls. Employees >18 years of age in the UBC health plan with a Framingham Risk Score (FRS) ≥10% or ≥1 medication-modifiable CV risk factor were included. Participants received a baseline assessment, individualized consultation for 12 months, and a final assessment by a pharmacist at the UBC Pharmacists Clinic. The primary end point was FRS reduction. RESULTS: Baseline assessment of 512 participants between September 2015 and October 2016 yielded 207 (40%) participants, of whom 178 (86%) completed the 12-month intervention. Participants were 54% female and 55% Caucasian, with an average age of 51 (SD = 9.1) years. FRS at baseline was <10 in 45.8%, 10 to 19.9 in 37.9%, and ≥20 in 16.4% of participants. Over 12 months, significant reductions in average FRS (from 11.7 [SD = 7.7] to 10.7 [SD = 7.3]; P = 0.0017) and other parameters were observed. Significant improvements in quality of life (EQ5D change of 0.031 [95% CI = 0.001, 0.062] P = 0.023) and medication adherence (MMAS-8 change of 0.42 [ P = 0.019]) were also noted. CONCLUSIONS AND RELEVANCE: UBC employees had improvements in health markers, self-reported quality of life, and medication adherence after receiving a 12-month pharmacist-led intervention. Pharmacists are encouraged to provide CV risk reduction services in workplaces.

Intranasal Lidocaine for Acute Management of Primary Headaches: A Systematic Review.

Intranasal lidocaine has been studied and recommended as an alternative in the management of acute headache. The objective of this systematic review was to evaluate the efficacy and safety of intranasal lidocaine in the acute management of primary headaches. The MEDLINE (1946 to May 2018), EMBASE (1974 to May 2018), Cochrane Central Register of Controlled Trials (2008 to May 2018), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to May 2018), and ClincialTrials.gov online databases were searched. Studies conducted in patients with acute primary headache were included if lidocaine was compared with placebo or alternative treatments, lidocaine dosing was specified, and patients' pain before and after treatment were clearly reported. Six studies met the inclusion criteria. Intranasal lidocaine demonstrated potential benefit over placebo in acute pain reduction and need for rescue medication only in the four studies deemed to be of poor quality, not in the two fair-quality studies. No study reported benefit in preventing headache recurrence or repeat visits to the emergency department. Lidocaine was associated with significantly higher rates of adverse events compared with placebo and may result in lower rates of patient satisfaction. There is insufficient evidence to support the use of intranasal lidocaine in acute management of primary headaches. Further research is warranted to better elucidate whether intranasal lidocaine has a role in the management of specific primary headache subtypes and whether there is an optimal regimen.

Intravenous cefazolin plus oral probenecid versus oral cephalexin for the treatment of skin and soft tissue infections: a double-blind, non-inferiority, randomised controlled trial.

OBJECTIVE: The purpose of our study was to determine if cephalexin 500 mg orally four times daily was non-inferior to cefazolin 2 g intravenously daily plus probenecid 1 g orally daily in the management of patients with uncomplicated mild-moderate skin and soft tissue infection (SSTI) presenting to the ED. METHODS: This was a prospective, multicentre, double dummy-blind, randomised controlled non-inferiority trial conducted at two tertiary care teaching hospitals in Canada. Patients were enrolled if they presented to the ED with an uncomplicated SSTI, and randomly assigned in a 1:1 fashion to oral cephalexin or intravenous cefazolin plus oral probenecid for up to 7 days. The primary outcome was failure of therapy at 72 hours. Clinical cure at 7 days, intravenous to oral medication transition admission to hospital and adverse events were also evaluated. RESULTS: 206 patients were randomised with 104 patients in the cephalexin group and 102 in the cefazolin and probenecid group. The proportion of patients failing therapy at 72 hours was similar between the treatment groups (4.2% and 6.1%, risk difference 1.9%, 95% CI -3.7% to 7.6%). Clinical cure at 7 days was not significantly different (100% and 97.7%, risk difference -2.3%, 95% CI -6.7% to 0.8%). CONCLUSION: Cephalexin at appropriate doses appears to be a safe and effective alternative to outpatient parenteral cefazolin in the treatment of uncomplicated mild-moderate SSTIs who present to the ED. TRIAL REGISTRATION NUMBER: NCT01029782; Results.

Capnography versus standard monitoring for emergency department procedural sedation and analgesia.

BACKGROUND: Procedural sedation and analgesia (PSA) is used frequently in the emergency department (ED) to facilitate painful procedures and interventions. Capnography, a monitoring modality widely used in operating room and endoscopy suite settings, is being used more frequently in the ED setting with the goal of reducing cardiopulmonary adverse events. As opposed to settings outside the ED, there is currently no consensus on whether the addition of capnography to standard monitoring modalities reduces adverse events in the ED setting. OBJECTIVES: To assess whether capnography in addition to standard monitoring (pulse oximetry, blood pressure and cardiac monitoring) is more effective than standard monitoring alone to prevent cardiorespiratory adverse events (e.g. oxygen desaturation, hypotension, emesis, and pulmonary aspiration) in ED patients undergoing PSA. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (2016, Issue 8), and MEDLINE, Embase, and CINAHL to 9 August 2016 for randomized controlled trials (RCTs) and quasi-randomized trials of ED patients requiring PSA with no language restrictions. We searched meta-registries (www.controlled-trials.com, www.clinicalstudyresults.org, and clinicaltrials.gov) for ongoing trials (February 2016). We contacted the primary authors of included studies as well as scientific advisors of capnography device manufacturers to identify unpublished studies (February 2016). We handsearched conference abstracts of four organizations from 2010 to 2015. SELECTION CRITERIA: We included any RCT or quasi-randomized trial comparing capnography and standard monitoring to standard monitoring alone for ED patients requiring PSA. DATA COLLECTION AND ANALYSIS: Two authors independently performed study selection, data extraction, and assessment of methodological quality for the 'Risk of bias' tables. An independent researcher extracted data for any included studies that our authors were involved in. We contacted authors of included studies for incomplete data when applicable. We used Review Manager 5 to combine data and calculate risk ratios (RR) and 95% confidence intervals (CI) using both random-effects and fixed-effect models. MAIN RESULTS: We identified three trials (κ = 1.00) involving 1272 participants. Comparing the capnography group to the standard monitoring group, there were no differences in the rates of oxygen desaturation (RR 0.89, 95% CI 0.48 to 1.63; n = 1272, 3 trials; moderate quality evidence) and hypotension (RR 2.36, 95% CI 0.98 to 5.69; n = 986, 1 trial; moderate quality evidence). There was only one episode of emesis recorded without significant difference between the groups (RR 3.10, 95% CI 0.13 to 75.88, n = 986, 1 trial; moderate quality evidence). The quality of evidence for the primary outcomes was moderate with downgrades primarily due to heterogeneity and reporting bias.There were no differences in the rate of airway interventions performed (RR 1.26, 95% CI 0.94 to 1.69; n = 1272, 3 trials; moderate quality evidence). In the subgroup analysis, we found a higher rate of airway interventions for adults in the capnography group (RR 1.44, 95% CI 1.16 to 1.79; n = 1118, 2 trials; moderate quality evidence) with a number needed to treat for an additional harmful outcome of 12. Although statistical heterogeneity was reduced, there was moderate quality of evidence due to outcome definition heterogeneity and limited reporting bias. None of the studies reported recovery time. AUTHORS' CONCLUSIONS: There is a lack of convincing evidence that the addition of capnography to standard monitoring in ED PSA reduces the rate of clinically significant adverse events. Evidence was deemed to be of moderate quality due to population and outcome definition heterogeneity and limited reporting bias. Our review was limited by the small number of clinical trials in this setting.