Influenza vaccination in community pharmacy: A cross-sectional survey of Canadian adults' knowledge, attitude and beliefs.

Background: In Canada, influenza vaccination rates are below recommended targets, with pharmacies the leading setting for vaccine administration. This work aimed to determine the Canadian public's current knowledge, attitudes and practices related to pharmacy-based influenza vaccination services. Methods: We surveyed 3000 Canadian residents aged ≥18 years using a cross-sectional, self-reported, online structured questionnaire between December 5 and 21, 2022. A representative survey population was recruited from the Léger Opinion (LEO) consumer panel. Data were weighted by age, region and gender, based on 2021 census data. Results: During the 2022-2023 season, 56.6% (95% confidence interval [CI], 54%-59.2%) of respondents reported receiving an influenza vaccine at a pharmacy, including 57.5% (95% CI, 54.2%-60.8%) of respondents considered to be at high risk of complications from influenza. Among respondents previously vaccinated at a pharmacy, 94.1% (95% CI, 91%-97.2%) were satisfied with the experience, citing convenience, accessibility and availability as factors influencing their decision. Among all respondents, 29.3% (95% CI, 27.5%-31.1%) reported that a pharmacist's recommendation for the influenza vaccine would affect their decision to be vaccinated, yet only 10.4% (95% CI, 5.9%-15%) who had discussions with a pharmacist specifically discussed the importance of influenza vaccination. Conclusion: Canadians are satisfied with pharmacy-based influenza vaccinations and value pharmacist recommendations. Pharmacists have an opportunity to boost influenza vaccination coverage in Canada by providing counselling on the importance of influenza vaccination to those seeking their advice on other health care needs, including younger adults and those with risk factors for serious illness from influenza.

Co-Administration of Influenza and COVID-19 Vaccines: A Cross-Sectional Survey of Canadian Adults' Knowledge, Attitudes, and Beliefs.

Vaccination rates against both influenza and COVID-19 fall short of targets, especially among persons at risk of influenza complications. To gain insights into strategies to boost influenza vaccine coverage, we surveyed 3000 Canadian residents aged ≥ 18 years and examined their knowledge and receipt of co-administered influenza and COVID-19 vaccines. During the 2022-2023 influenza season, 70% of respondents reported being aware the influenza and COVID-19 vaccines could be co-administered, but only 26.2% (95% CI, 23.6% to 28.8%) of respondents received them together. The most common reason for not getting the vaccines together was receipt of the COVID-19 vaccine before the annual influenza vaccine was available (reported by 34.5% [31.2% to 37.7%]). Lack of interest in co-administration was reported by 22.6% (20.8% to 24.3%); of this group, 20.8% (17.1% to 24.5%) reported seeing no benefit in receiving the two vaccines together and 17.2% (13.5% to 20.9%) were concerned about compounded adverse effects from the two vaccines. These results support the willingness of most Canadians to receive COVID-19 and influenza vaccines at the same time. Co-administration is a viable strategy to improve uptake of influenza vaccines, especially if health professionals proactively offer education and co-administration of influenza and COVID-19 (or other) vaccines as appropriate to clinical need.

Willingness of Canadian community pharmacists to adopt a proactive life-course approach to vaccination services.

BACKGROUND: Most Canadian jurisdictions authorize pharmacists to administer vaccines, with differences in vaccine and patient age eligibility. Vaccination rates could be further optimized if pharmacists took a more proactive role in life-course vaccine screening and administration. Health professional vaccine fatigue following the COVID-19 pandemic may negatively impact service delivery. OBJECTIVES: To assess vaccine fatigue among Canadian pharmacists, understand their willingness to provide proactive life-course vaccination services and identify associated vaccine practice facilitators. METHODS: One-on-one interviews were conducted with pharmacists recruited through a national community pharmacist Facebook group. Purposive sampling was used to select a diverse sample considering gender, province, and years of practice. Online interviews were conducted using a semi-structured guide with questions about vaccination experiences, perceptions of assuming a more proactive vaccinator role for adults and children, and current level of fatigue related to offering vaccination services. Interviews were audio-recorded, transcribed, and coded independently by 2 researchers; content analysis was used to identify themes. RESULTS: In spring 2023, interviews were conducted with 24 pharmacists from 5 Canadian provinces. Participants were receptive to a more proactive vaccinator role, feeling that vaccine fatigue had lessened, but strongly advocated for system and practice modifications to facilitate successful implementation. They emphasized the need for patient vaccination history access, the ability to administer all publicly funded vaccines, and fair compensation. Participants requested the development of electronic tools that connected to pharmacy systems that helped them navigate complex vaccine guidelines and clinical decision making, and the required documentation/billing. They also spoke of logistical concerns related to the incorporation of vaccination into their workflow and adequate staffing. Most participants were willing to vaccinate younger children if legislated age limits were lowered, provided they were trained and compensated appropriately. CONCLUSION: Pharmacists are interested in furthering their vaccination services offerings, including proactive screening and vaccination of young children.

Development and evaluation of virtual simulation games to increase the confidence and self-efficacy of healthcare learners in vaccine communication, advocacy, and promotion.

BACKGROUND: Although healthcare providers (HCPs) are the most trusted source of vaccine information, there is a paucity of easily accessible, multidisciplinary educational tools on vaccine communication for them. Virtual simulation games (VSGs) are innovative yet accessible and effective tools in healthcare education. The objectives of our study were to develop VSGs to increase HCP confidence and self-efficacy in vaccine communication, advocacy, and promotion, and evaluate the VSGs' effectiveness using a pre-post self-assessment pilot study. METHODS: A multidisciplinary team of experts in medicine, nursing, pharmacy, and simulation development created three VSGs for HCP learners focused on addressing conversations with vaccine hesitant individuals. We evaluated the VSGs with 24 nursing students, 30 pharmacy students, and 18 medical residents who completed surveys and 6-point Likert scale pre-post self-assessments to measure changes in their confidence and self-efficacy. RESULTS: There were no significant differences in baseline confidence and self-efficacy across the three HCP disciplines, despite varied levels of education. Post-VSG confidence and self-efficacy (median: 5) were significantly higher than pre-VSG (median: 4-5) for all three HCP disciplines (P ≤ 0.0005), highlighting the effectiveness of the VSGs. Medical residents reported significantly lower post-VSG confidence and self-efficacy than nursing and pharmacy learners despite completing the most significant amount of education. CONCLUSIONS: Following the completion of the VSGs, learners in medicine, nursing, and pharmacy showed significant improvement in their self-assessed confidence and self-efficacy in holding vaccine conversations. The VSGs as an educational tool, in combination with existing clinical immunization training, can be used to increase HCP confidence and engagement in vaccine discussions with patients, which may ultimately lead to increased vaccine confidence among patients.

RSV vaccination in older adults: Addressing vaccine hesitancy using the 3C model.

The first vaccine against respiratory syncytial virus (RSV) targeting older adults was approved for use in Canada in August 2023. As a frequent first point of contact for Canadians seeking advice on vaccination and the most common setting for the administration of influenza vaccines, community pharmacies will also play a role in RSV vaccination efforts. To address vaccine hesitancy confidently and effectively, pharmacists must be equipped with knowledge of the factors that affect a person's decision on whether to be vaccinated or not. The 3C Model of Vaccine Hesitancy summarizes these as complacency, confidence and convenience. This article introduces the model and describes the often-underrecognized relevance of RSV to older adults, including risk factors and burden of disease. It also reviews the history and status of vaccine development and approval and presents clinical trial data to equip pharmacists to discuss RSV vaccination with older adults who express vaccine hesitancy.

Knowledge, Perceptions, and Self-Reported Rates of Influenza Immunization among Canadians at High Risk from Influenza: A Cross-Sectional Survey.

The Public Health Agency of Canada recommends that 80% of high-risk persons, including adults aged ≥65 years and 18-64 years with certain comorbidities, be vaccinated against influenza. During the 2022-2023 influenza season, we conducted an online survey of 3000 Canadian residents aged ≥18 years randomly recruited from the Léger Opinion (LEO) consumer panel to assess knowledge and perceptions about influenza vaccination as well as survey self-reported vaccination rates. Overall, 47.3% received an influenza vaccination during the 2022-2023 season. Vaccination rates among persons aged 18-64 years with high-risk medical conditions (n = 686) and among adults aged ≥65 years (n = 708) were 46.4% and 77.4%, respectively; 77.8% and 88.5%, respectively, believed influenza vaccination was important for people at high risk from influenza. Only 35.8% of adults aged 18-64 years with comorbidities were aware of being at high risk; 66.0% of this group was vaccinated against influenza, compared with 37.0% of those unaware of being at high-risk. During 2022-2023, 51.3% of people aged ≥65 years and 43.0% of people aged 18-64 years with comorbidities discussed influenza vaccination with healthcare providers. These findings suggest gaps in education regarding the importance of influenza vaccination among people at risk of influenza complications.

A longitudinal qualitative study examining the impact of Check-In, a novel learning activity on burnout for pharmacy students.

INTRODUCTION: Burnout is a phenomenon that can occur in any occupation, but pharmacists may be more prone to its effects. Because of its relevance to the pharmacy profession, the University of Waterloo School of Pharmacy incorporated an active learning activity to teach pharmacy students about healthcare provider burnout. This activity, named Check-In, was launched in March 2020 and consisted of one-on-one check-ins between pharmacy students and staff. As the first learning activity of its kind, the researchers wished to investigate the ongoing impact of Check-In. METHODS: This qualitative, descriptive study was composed of telephone interviews with 13 students that partook in Check-In. These interviews were held at two different timepoints: six and 18 months post-activity. Participants were recruited until data saturation, and transcripts underwent thematic analysis. RESULTS: Four themes were identified from the interviews: (1) Check-In was a valuable learning activity; (2) students performed some form of checking in post-activity; (3) burnout could be recognized and defined by students; (4) Check-In's place in the pharmacy curriculum still needs to be determined. CONCLUSIONS: Check-In is an innovative learning activity to teach pharmacy learners about healthcare provider burnout. It can be utilized by pharmacy institutions to incorporate wellness and student mental health into curriculum.

Addressing maternal medication use during breastfeeding using clinical resources and a novel physiologically based pharmacokinetic model-derived metric: A qualitative study.

Introduction: Breastfeeding has major benefits to the maternal-infant dyad and yet healthcare providers have expressed uncertainty about advocating breastfeeding when mothers are taking medications. The tendency for some providers to be more cautious in their advising approach is likely a consequence of limited, unfamiliar, and unreliable existing information on medication use during lactation. A novel risk metric termed the Upper Area Under the Curve Ratio (UAR) was developed to overcome existing resource shortcomings. However, the perception and use of the UAR in practice by providers is not known. The aim of this study was to understand existing resource use and potential UAR use in practice, their advantages and disadvantages, and areas of improvement for the UAR. Methods: Healthcare providers mainly practicing in California with experience advising on medication use during lactation were recruited. One-on-one semi-structured interviews that included questions on current practices when advising medication use during breastfeeding, and approaches to a given a scenario with and without information about the UAR were conducted. The Framework Method was applied for data analysis to construct themes and codes. Results: Twenty-eight providers representing multiple professions and disciplines were interviewed. Six main themes emerged: (1) Current Practice Approaches, (2) Advantages of Existing Resources, (3) Disadvantages of Existing Resources, (4) Advantages of the UAR, (5) Disadvantages of the UAR, and (6) Strategies to Improve the UAR. Overall, 108 codes were identified that illustrated theme topics ranging from a general lack of metric use to the realities of advising. A workflow describing current practice approaches connected all other themes. Almost all disadvantages of existing resources could be overcome by advantages of other resources and the UAR. Several improvements to the UAR were identified to address its shortcomings. Conclusion: Through interviews with providers who use resources to advise on medication use during breastfeeding, an improved understanding of current practice approaches and accessed resources was ascertained. Ultimately, it was found that the UAR would confer multiple benefits over existing resources, and improvements of the UAR were identified. Future work should focus on implementing the suggested recommendations to ensure optimal uptake of the UAR to improve advising practices.

Pharmacist Disciplinary Action: What Do Pharmacists Get in Trouble for?

Objective: This study aims to determine the reasons for disciplinary action and resultant consequences for Canadian pharmacists and any associations with demographic factors. Methods: Regulatory body disciplinary action cases from 10 Canadian provinces were coded. Demographic information was coded. Results: There were 665 pharmacist cases from nine provinces between January 2010 and December 2020. The rate of disciplinary action was low (1.37 cases/1,000 practitioners/year). Professional misconduct was the most common category of violation. Male pharmacists were overrepresented in disciplinary action cases. Most cases involved community pharmacists. Conclusion: This study is the first, to our knowledge, in Canada to analyze the demographic factors of pharmacists subjected to disciplinary action. It updates a previous review of pharmacist disciplinary action (Foong et al. 2018).

Dentist Disciplinary Action: What Do Dentists Get in Trouble for?

Objective: This study aims to determine the reasons for disciplinary action, the consequences and any associations with demographic factors for Canadian dentists. Methods: Publicly available regulatory body disciplinary action cases from 10 Canadian provinces were coded. Demographic factors were also coded. Results: There were 344 dentist cases from five provinces between January 2010 and December 2020. The rate of disciplinary action was low (1.38 cases/1,000 practitioners/year). Clinical incompetence was the most common category of disciplinary action, followed by professional misconduct and dishonest business practices. Male dentists were overrepresented in the disciplinary action cases compared to the rest of the workforce. Conclusion: This study is the first, to our knowledge, to describe the outcomes of regulatory body disciplinary action for Canadian dentists.

Do entry year pharmacy students have similar personal characteristics? Comparing personalities, professional goals, and role perceptions.

BACKGROUND: Schools and faculties of pharmacy are responsible for selecting students to admit into the profession. Despite many similarities, admission processes, pharmacists' training, and scope of practice are different across jurisdictions. Students that are selected for admission may then differ in a number of ways, including by personality traits and other individual difference measures. OBJECTIVE: To compare the trait characteristics between students entering a New Zealand (NZ-University of Otago) and Canadian ((University of Waterloo) pharmacy programme and to compare their professional goals and role perceptions. METHODS: Incoming first year students at each university were invited to take an online questionnaire that included personality characteristics and potential predictors of involvement in pharmacists' roles: (1) the Big Five Inventory (openness, conscientiousness, extraversion, agreeableness, neuroticism); (2) the Achievement Goals Questionnaire-Revised; (3) the Rational Experiential Inventory; and (4) Counsellor Role Orientation. Statistical tests were conducted to determine if there were differences between entry level pharmacy students from NZ and Canada. RESULTS: 184 students (97/150 Otago, 87/118 Waterloo) completed the survey. On average, Waterloo students scored higher on agreeableness (M = 80 vs. 76, p = 0.06), conscientiousness (M = 70 vs. 68, p = 0.30), mastery-approach (M = 93 vs.90, p = 0.06), and faith-in-intuition (M = 67 vs. 61, p = 0.03) compared to Otago pharmacy students who were higher for openness M = 70 vs. 66, p = 0.09). An item measuring reliance on physicians for medicine advice was endorsed more by Otago pharmacy students (M = 35 vs. M = 15, p < 0.001). Items on time pressure (e.g., "It takes too much time to for a pharmacist to talk with a patient about the medication they receive") were higher for Otago students (M = 41 vs. M = 38, p = 0.26). Higher scores for pharmacist restriction ("There should be legal restrictions on what pharmacists can tell patients") were also seen among Otago students (M = 26 vs. M = 12, p < 0.001). There were important differences between entry level pharmacy students and practicing pharmacists in both jurisdictions. DISCUSSION: While entry-level pharmacy students had similar personality profiles, differences were observed in role expectations and in experiential learning orientation. This highlights differing societal views on the role of pharmacists in each respective country. Pharmacy schools should study their student bodies when designing their curricula and electives, helping ensure graduates feel like they have the training to do what they need to do. Future work will determine if these personality and learning goals influence students' preparation for practice.

Herpes zoster and human papillomavirus vaccination opportunities identified using electronic prompts at the time of scheduling influenza or COVID-19 vaccines.

Background: Due to workload and competing priorities, vaccination-related interactions in community pharmacies tend to be more reactive than proactive. The aim of this study is to determine the proportion of users of a web-based scheduling system for influenza and COVID-19 vaccines who may be eligible for herpes zoster or human papillomavirus (HPV) vaccination and interested in discussing these vaccines with a pharmacist. Methods: Individuals scheduling an influenza or COVID-19 vaccine at a pharmacy using the MedEssist platform between October 2021 and March 2022 were asked about their vaccination status against HPV (if aged 9-45) or herpes zoster (if aged ≥50). Those who were unvaccinated or unsure were asked to indicate their willingness to discuss this with a pharmacist. Logistic regression was performed to identify patient characteristics associated with responses to these screening questions. Results: Among 36,659 bookings by those aged 9 to 45 and 55,728 by those aged ≥50 that included responses to screening questions, 70.1% and 55.5% were potentially unvaccinated against HPV and herpes zoster, respectively, with approximately 1 in 5 also indicating willingness to have a discussion with the pharmacist. Those scheduling appointments for COVID-19 vaccines were significantly less likely to be vaccinated against HPV or herpes zoster and less willing to discuss this with a pharmacist than those seeking influenza vaccination. Discussion: Automated prompts while booking influenza or COVID-19 vaccinations have the potential to identify vaccine-willing individuals who may benefit from further discussion on their vaccination needs. Conclusion: Community pharmacies can leverage available technology to support the efficient and effective identification of individuals eligible for vaccination.

The impact of influenza on the ability to work, volunteer and provide care: results from an online survey of Canadian adults 50 years and older.

BACKGROUND: Influenza is associated with a decline in functional abilities among Canadian older adults, although specific impacts on daily life have not been fully explored. METHODS: In August 2019 and May 2020, we conducted surveys of Canadian adults 50-64 years and 65 years and older through an online market research platform. The survey included questions about the impact of diagnosed influenza or self-reported influenza-like-illness (ILI) on working, volunteering and caregiving. RESULTS: We surveyed 1006 adults in the 50-64 year age group about the 2018/19 season and 1001 about the 2019/20 season. In the 65 years and older age group, we surveyed 3548 and 3500 individuals about the 2018/19 and 2019/20 influenza seasons, respectively. In each season, nearly two-thirds of individuals 50-64 years with influenza/ILI were employed; 51.7% reported absenteeism in 2018/19 and 53.6% in 2019/20. Of the 20% of individuals 65 years and older who were employed, 47.0% of those with influenza/ILI were absent while ill in 2018/19 (39.8% in 2019/20). In 2018/2019, 29.6% of respondents 50-64 years old with influenza/ILI identified as volunteers (29.3% in 2019/2020). In both seasons, nearly half were unable to do so while ill. Of the 164 (32.7%) individuals 65 years and older who volunteered during the 2018/19 season, 80 (48.8%) did not while ill; 224 (37.3%) respondents volunteered in the 2019/20 season, and half were absent while ill. Of those 50-64 years with influenza/ILI, 97 (42.2%) and 57 (22.2%) were caregivers in 2018/19 and 2019/20, respectively. In 2018/19 and 2019/20, 40 (41.2%) and 28 (49.1%) caregivers were unable to provide care when ill, respectively. Of those with influenza/ILI in the 65 years and older age group, 123 (24.6%) and 162 (27.0%) were caregivers in 2018/19 and 2019/20, respectively. In 2018/19, 18 (14.6%) caregivers with influenza/ILI did not provide care while ill (42 [25.9%] in 2019/20). DISCUSSION: In Canadian older adults, influenza and ILI had notable impacts on ability to volunteer and provide care across two recent seasons. Optimization of influenza prevention in this population may yield important societal benefits.

Geographic distribution of Ontario pharmacists: A focus on rural and northern communities.

Introduction: Canadians living in rural and northern communities face particular health needs and challenges in accessing primary care services. Ontario pharmacists are increasingly able to optimize patient care with a broadening scope of practice; this was highlighted during the COVID-19 pandemic. This study explores the geographic distribution of pharmacists to evaluate their potential to deliver health care in rural and northern Ontario communities. Methods: A secondary analysis of the Ontario College of Pharmacists' registry data was undertaken, with all Part A pharmacists who had at least 1 patient care practice site included in the analysis. Full-time equivalent (FTE) hours worked at each practice site were calculated and compared with the population distribution. Ratios of FTEs per 1000 residents by census subdivision (which represents communities) were calculated and compared by geography, north vs south and urban vs rural (further subdivided by metropolitan-influenced zones). Results: The greatest availability of pharmacist FTEs was found in urban communities (with slightly better availability in the north), whereas the lowest availability was found in the most rural communities. A more granular observation revealed that northern communities were more likely to have no local pharmacist access (72%) compared with southern communities (24%). Discussion: Rural and northern communities are underserved. Novel approaches to overcoming the rural pharmacist care gap include rural practice incentives, targeted enrollment of rural students, increased rural exposure in pharmacy schools and the utilization of new technologies such as telepharmacy and drone medication deliveries.

Identifying vaccination deserts: The availability and distribution of pharmacists with authorization to administer injections in Ontario.

Introduction: Pharmacist-administered immunizations have been associated with improved vaccination rates; however, little is known about whether areas with little to no access to this service ("vaccination deserts") exist. The objective of this work is to determine the geographic availability of pharmacists with authorization to administer injections in the province of Ontario. Methods: Ontario College of Pharmacists registry data were used to identify patient care-providing pharmacists in community pharmacies and their ability to administer injections. Their number of hours worked was converted into full-time equivalents (FTEs), assuming 40 hours per week represents 1 FTE. Practice site(s) were mapped by postal code and presented by Public Health Unit (PHU) area. Communities within PHUs were further categorized as urban or rural and northern or southern, with ratios of FTEs per 1000 population calculated for both injection-trained and non-injection-trained pharmacists. Results: In total, 74.6% of Ontario's practising community pharmacists are authorized to provide injections. Northern PHUs had slightly better access to pharmacist injectors (0.61 FTEs/1000 overall vs 0.56/1000 in the south), while rural communities had lower availability (0.41 FTEs/1000) than urban communities (0.58 FTEs/1000). PHUs with greater population size and density had greater availability of pharmacist immunizers, while PHUs with greater land area were more likely to not have any immunizing pharmacists present (p < 0.001 for all). Discussion: As pharmacists increasingly become preferred vaccination providers, awareness of disparities related to access to pharmacy-based immunizations and collaboration with public health and primary care providers to address them (e.g., through mobile vaccination clinics) will be required to ensure equitable access. Can Pharm J (Ott) 2022;155:xx-xx.

Understanding predictors of pneumococcal vaccine uptake in older adults aged 65 years and older in high-income countries across the globe: A scoping review.

BACKGROUND: Pneumococcal disease causes substantial morbidity and mortality in older adults. Pneumococcal polysaccharide vaccine (PPV23) is routinely recommended to reduce the disease burden in this population. However, the vaccination coverage in older adults remains suboptimal in high-income countries. OBJECTIVES: We sought to understand the current landscape of published literature on the predictors of pneumococcal vaccine uptake in older adults aged 65 years and older in high-income countries, and to identify the gaps in literature to inform future research. METHODS: We conducted a scoping review employing the Arksey and O'Malley framework and Joanna Briggs Methods. We searched Medline, EMBASE, CINAHL, PsycInfo and Cochrane databases. We included quantitative and qualitative studies on predictors of pneumococcal vaccination in older adults that reported older adult- and pneumococcal vaccine-specific results, conducted in high-income settings, and published in English between January 2015 and April 2020. We excluded studies assessing interventions to improve vaccine uptake. We followed the Strategic Advisory Group of Experts on Immunization Working Group Vaccine Hesitancy Determinants Matrix to map the predictors within contextual, individual and social group, and vaccine and vaccination-specific influence determinants. Studies on providers and institutions were also included and results summarized separately. RESULTS: We included 52 publications in our review. Most of the predictors in 39 quantitative studies belonged to the individual and social group influences (n = 12), followed by contextual influences (n = 11) and vaccine and vaccination-specific issues (n = 3). Few qualitative studies explored the barriers to pneumococcal vaccination. Only five studies examined predictors from the healthcare providers' perspective. Three studies examined the institutional characteristics as the predictors of pneumococcal vaccination in older adults. CONCLUSIONS: We identified enablers and barriers of pneumococcal vaccination among older adults in high-income settings. We also identified gaps in the literature and provide recommendations for future research to address the gaps.

Reasons for Low Regulatory Body Discipline Rates for Canadian Hospital Pharmacists.

Background: Past research on disciplinary action by pharmacist regulatory bodies has shown that most cases concern community pharmacists, with few occurring in a hospital setting. Objective: To investigate how discipline-related issues involving pharmacists are dealt with by hospital pharmacy departments in Canada. Methods: Hospital pharmacy directors and managers from small, medium, and large hospitals across Canada were invited to participate in semi-structured telephone interviews. The interview questions focused on the discipline process in participants' organizations, the situations when reporting to the regulatory body is deemed to be warranted, possible penalties, and recommendations for improving the regulatory body or organizational discipline process. Results: Ten participants, from British Columbia, Saskatchewan, Ontario, New Brunswick, Prince Edward Island, and Newfoundland and Labrador, agreed to be interviewed. Five key themes emerged as contributing to lower rates of hospital pharmacist discipline cases being escalated to the regulatory college level: robust organizational discipline processes independent from the regulatory college, a practice environment promoting competence, union representation, preference for a remedial approach to discipline, and lack of clarity about when to report to the regulatory authority. Conclusions: This study identified a number of reasons why discipline of hospital pharmacists by a regulatory body may be less prevalent than discipline relating to community pharmacists. The main reasons may be lack of clarity about when to report a case to the regulator and a lack of transparency, given that many cases are handled internally within hospitals. Environmental supports for competence and employee protections (e.g., through a union) may also reduce discipline cases.

Contexte: Des recherches antérieures sur les mesures disciplinaires prises par les organismes de réglementation des pharmaciens ont montré que la plupart des cas concernaient des pharmaciens communautaires, et que peu se produisaient en milieu hospitalier. Objectif: Examiner comment les questions disciplinaires impliquant des pharmaciens sont traitées par les départements de pharmacie hospitalière au Canada. Méthodes: Les directeurs et gestionnaires de pharmacies de petits, moyens et grands hôpitaux au Canada ont été invités à participer à des entrevues téléphoniques semi-structurées. Les questions portaient sur le processus disciplinaire en place dans les organismes des participants; les situations où le signalement à l'organisme de réglementation était jugé justifié; les sanctions possibles; et les recommandations pour améliorer le processus disciplinaire de l'organisme de réglementation ou de l'organisme. Résultats: Dix participants de la Colombie-Britannique, de la Saskatchewan, de l'Ontario, du Nouveau-Brunswick, de l'Île-du-Prince-Édouard et de Terre-Neuve-et-Labrador ont accepté d'être interrogés. Cinq thèmes clés ont été identifiés comme contribuant au taux plus faible de cas de discipline des pharmaciens hospitaliers remontés au niveau de l'organisme de réglementation: des processus disciplinaires organisationnels solides indépendants de l'organisme de réglementation; un environnement de pratique favorisant la compétence; la représentation syndicale; la préférence pour une approche corrective de la discipline; et le manque de clarté quant au moment où il faut signaler à l'autorité de réglementation. Conclusions: Cette étude a identifié un certain nombre de raisons pour lesquelles les mesures disciplinaires relatives des pharmaciens hospitaliers par un organisme de réglementation peuvent être moins répandues que celles liées aux pharmaciens communautaires. Les principales raisons pourraient être le manque de clarté quant au moment de signaler un cas à l'autorité réglementaire et un manque de transparence, étant donné que de nombreux cas sont traités en interne dans les hôpitaux. Les soutiens environnementaux pour la compétence et la protection des employés (par exemple, par l'entremise d'un syndicat) peuvent également réduire les cas de discipline.

The effect of renin-angiotensin-aldosterone system inhibitors on continuous and binary kidney outcomes in subgroups of patients with diabetes: a meta-analysis of randomized clinical trials.

INTRODUCTION: Diabetic nephropathy is the leading cause of kidney failure. Clinical practice guidelines recommend prescribing renin-angiotensin aldosterone system inhibitors (RAASi) to prevent diabetic nephropathy at any stage. We conducted this systematic review and meta-analysis to compare the effects of RAASi with placebo and other antihypertensive agents in adults with diabetes on continuous and binary kidney outcomes to provide a comprehensive review of the class effect of RAASi on several subgroups. METHODS: A systematic electronic search to identify randomized clinical trials of a duration of ≥ 12 months that recruited ≥ 50 adult participants with type 1 or 2 diabetes with any stage of chronic kidney disease and proteinuria was conducted in MEDLINE, CINAHL, EMBASE, and Cochrane library with no language restriction. Studies were screened against the inclusion and exclusion criteria by two reviewers independently. RESULTS: In this meta-analysis, evidence was drawn from 26,551 patients with diabetes from 46 studies. Our analysis shows that RAASi were better than placebo in reducing SrCr (the raw mean difference [RMD] = -13.4 µmol/L; 95%CI: -16.78; -10.01) and albuminuria levels (standardized mean difference [SMD] = -1; 95%CI: -1.57, -0.44, I2 = 96%). When compared to other active treatments, RAASi did not reduce SrCr (RMD = 0.03 µmol/L; 95%CI: -6.4, 6.10, I2 = 76%), caused a non-significant reduction of GFR levels (RMD = -1.21 mL/min; 95%CI: -4.52, 2.09, I2 = 86%), and resulted in modest reduction of albuminuria levels (SMD = -0.55; 95%CI: -0.95, -0.16, I2 = 90%). RAASi were superior to placebo in reducing the risks of kidney failure (OR = 0.74; 95%CI: 0.56, 0.97) and doubling of serum creatinine levels (SrCr; OR = 0.71; 95%CI: 0.55, 0.91), but not in promoting the regression of albuminuria (OR = 3.00; 95%CI: 0.96, 9.37). RAASi, however, were not superior to other antihypertensives in reducing the risks of these outcomes. Patients with type 2 diabetes, macroalbuminuria and longer duration of diabetes had less risk of developing kidney failure in placebo-controlled trials, while longer duration of diabetes, normal kidney function, and hypertension increased the probability of achieving regression of albuminuria in active-controlled trials. CONCLUSION: While our findings revealed the non-superiority of RAASi over other antihypertensives and portrayed a class effect on several subgroups of study participants, it raised a challenging question on whether RAASi deserve their place as first-line therapy in managing diabetic nephropathy.