Projected health and economic outcomes of extending public funding of pharmacy services to include administration of Pneu23 and Td/Tdap immunizations by pharmacy practitioners in New Brunswick.

Background: Although legislation permits New Brunswick pharmacy professionals to administer a wide range of immunizations, public funding for these services is currently limited to immunizations against influenza and COVID-19 and was recently extended to include pneumococcal immunization (Pneu23) in individuals aged 65 years or older. We used administrative data to project health and economic outcomes associated with the current Pneu23 program and with extension of public funding to include: 1) younger adults aged 19 years or older in the Pneu23 program, and 2) tetanus boosters (Td/Tdap). Methods: Two model scenarios were compared: a Physician-Only model in which physicians remain the only practitioners to administer publicly funded Pneu23 and Td/Tdap, and a Blended model in which this service is also provided by pharmacy professionals. Immunization rates by practitioner type were projected based on physician billing data accessed via the New Brunswick Institute for Research, Data and Training in conjunction with trends observed with influenza immunization by pharmacists. These projections were used along with published data to estimate health and economic outcomes under each model. Results: Public funding of Pneu23 (65+), Pneu23 (19+) and Td/Tdap (19+) administration by pharmacy professionals is projected to yield increased immunization rates and physician time savings compared with the Physician-Only model. Public funding of Pneu23 and Td/Tdap administration by pharmacy professionals in those aged ≥19 years would result in cost savings, owing primarily to productivity losses avoided in the working age population. Discussion: Increased immunization rates, physician time savings and cost savings may be realized if public funding were extended to include administration of Pneu23 in younger adults and Td/Tdap, by pharmacy practitioners.

Prevalence of Frailty Among Hospitalized Older Adults in New Brunswick, Canada: an Administrative Data Population-Based Study.

Background: Characterizing the prevalence and distribution of frailty within a population can help guide decision-making and policy development by identifying health service resource needs. Here we describe the prevalence of frailty among hospitalized older adults in New Brunswick (NB), Canada. Methods: NB administrative hospital claims data were used to identify hospitalized older adults aged 65 or older between April 1, 2017 and March 31, 2019. Frailty was quantified using the Hospital Frailty Risk Score (HFRS), a validated frailty tool derived from claims data. Individuals with a HFRS ranked as intermediate or high were categorized as frail. The distribution of frailty across sex and age are described. Crude prevalence estimates and corresponding 95% confidence intervals are presented. Results: A total of 55,675 older adults (52% females) were hospitalized. The overall prevalence of frailty was 21.2% (95%CI: 20.9-21.6). Prevalence increased with age: 12.7% (95%CI: 12.3-13.1) in the 65-74 age group, 24.7% (95%CI: 24.1-25.3) in the 75-84 age group and 41.6% (95%CI: 40.6-42.7) for those aged 85 and over (p<.001). Discussion/Conclusion: The distribution of frailty is in line with that reported in other jurisdictions. We demonstrate the feasibility of the HFRS to identify and characterize frailty in a large sample of older adults who were hospitalized, using administrative data.

Mapping Canadian Data Assets to Generate Real-World Evidence: Lessons Learned from Canadian Real-World Evidence for Value of Cancer Drugs (CanREValue) Collaboration's RWE Data Working Group.

Canadian provinces routinely collect patient-level data for administrative purposes. These real-world data (RWD) can be used to generate real-world evidence (RWE) to inform clinical care and healthcare policy. The CanREValue Collaboration is developing a framework for the use of RWE in cancer drug funding decisions. A Data Working Group (WG) was established to identify data assets across Canada for generating RWE of oncology drugs. The mapping exercise was conducted using an iterative scan with informant surveys and teleconference. Data experts from ten provinces convened for a total of three teleconferences and two in-person meetings from March 2018 to September 2019. Following each meeting, surveys were developed and shared with the data experts which focused on identifying databases and data elements, as well as a feasibility assessment of conducting RWE studies using existing data elements and resources. Survey responses were compiled into an interim data report, which was used for public stakeholder consultation. The feedback from the public consultation was used to update the interim data report. We found that databases required to conduct real-world studies are often held by multiple different data custodians. Ninety-seven databases were identified across Canada. Provinces held on average 9 distinct databases (range: 8-11). An Essential RWD Table was compiled that contains data elements that are necessary, at a minimal, to conduct an RWE study. An Expanded RWD Table that contains a more comprehensive list of potentially relevant data elements was also compiled and the availabilities of these data elements were mapped. While most provinces have data on patient demographics (e.g., age, sex) and cancer-related variables (e.g., morphology, topography), the availability and linkability of data on cancer treatment, clinical characteristics (e.g., morphology and topography), and drug costs vary among provinces. Based on current resources, data availability, and access processes, data experts in most provinces noted that more than 12 months would be required to complete an RWE study. The CanREValue Collaboration's Data WG identified key data holdings, access considerations, as well as gaps in oncology treatment-specific data. This data catalogue can be used to facilitate future oncology-specific RWE analyses across Canada.

Community pharmacy rapid influenza A and B screening: A novel approach to expedite patient access to care and improve clinical outcomes.

OBJECTIVE: To investigate the impact and feasibility of community pharmacist-directed influenza screening and to evaluate the proportion of influenza-positive cases that resulted in the initiation of antiviral therapy by pharmacists. METHODS: Patients aged 5 and older with symptoms suggestive of influenza were recruited at 2 Shoppers Drug Mart locations in Toronto, Ontario, from December 12, 2014, to February 4, 2015. Nasal swabs were collected by pharmacists and screened using the BD Veritor system for Rapid Detection of Flu A+B. Positive tests for influenza were reported to patients' physicians and recommendations for antiviral therapy were made when indicated. Supportive care recommendations and telephone follow-up within 48 hours of assessment were provided to all patients. RESULTS: A total of 59 patients participated in the influenza screening program. Sixty-one percent of patients were at high risk for influenza-related complications, while 15% had more than one risk factor. Thirty-four percent of patients screened positive for influenza, of which 100% were influenza A. Of the patients who screened positive, a prescription for oseltamivir was obtained in 40% of cases. The majority of prescriptions were provided directly to the pharmacy (63%), while the balance was provided after the patients underwent medical examination at the request of their physicians (37%). The pharmacy team offered supportive care to all patients for symptom management. Over-the-counter pharmacotherapy was provided to 85% of patients. CONCLUSION: These results highlight the readiness of community pharmacists to participate in the management of patients with influenza and their ability to implement screening into pharmacy workflow. Community pharmacy-based influenza screening may facilitate prompt access to pharmacologic treatment for patients with influenza, as well as decrease burden on the health care system by redirecting influenza-negative patients from physicians' offices and hospitals. Timely physician communication remains a barrier to access to treatment, suggesting a potential key role for advanced pharmacist prescribing. Can Pharm J (Ott) 2016;149:83-89.

Community pharmacy-based A1c screening: a Canadian model for diabetes care.

OBJECTIVES: Point-of-care HbA1c screening devices are a valuable tool that community pharmacists can use to monitor patients with diabetes and improve their overall management. We previously reported our experiences using these devices to assess glycaemic control in diabetic patients at three community pharmacy locations in Toronto, Ontario. Here, we report data from screening of over 1000 patients at clinics held across Canada. METHODS: Community pharmacies across Canada offering A1c screening as part of their professional programmes were invited to upload screening data to a central database. A1c analysis was performed using the Bayer A1c Now. Patient recruitment and approach to A1c screening were at the discretion of the participating pharmacies and were not standardized. Data collection took place over a period of 8 months. KEY FINDINGS: The majority of patients screened (59.1%) had A1c values above target, indicating inadequate glycaemic control. Glycaemic control was generally poorer among patients on more intensive treatment regimens. A total of 1711 clinical interventions were performed by pharmacists. An average of two interventions were performed per patient, and we observed a trend towards increased numbers of interventions in patients with poorer glycaemic control. The prevalence of specific types of interventions showed an apparent shift from predominantly pharmacist-directed interventions in patients with better glycaemic control towards an increased prevalence of physician-directed interventions in patients with poorer glycaemic control. CONCLUSIONS: These results illustrate the prevalence of suboptimal glycaemic control among diabetic patients in the community, which represents a significant opportunity for pharmacists to use point-of-care screening to detect hyperglycaemia and intervene to improve disease management when warranted.

Community pharmacist-administered influenza immunization improves patient access to vaccination.

OBJECTIVES: To describe the demographic characteristics and risk factors of patients receiving influenza vaccination in community pharmacies and to understand patient experiences and perceptions surrounding being vaccinated by a pharmacist. METHODS: Survey data were collected by research pharmacists at 4 different community pharmacy locations in Toronto throughout a period of 8 weeks during October and November 2013. Participation in the survey was voluntary, and all patients vaccinated by pharmacists were invited to complete a survey following immunization. RESULTS: During the course of the study, 2498 vaccine doses were administered among all study sites, and 1502 surveys were completed. Our data showed a high degree of patient satisfaction, with 92% of patients indicating they were very satisfied with the pharmacist's injection technique and the services they received. Furthermore, 86% of patients were very comfortable with being vaccinated by a pharmacist, and 99% of patients reported they would recommend that friends and family be vaccinated by a pharmacist. Convenience and accessibility were major determinants of patient satisfaction, as shown by 46% of all written comments specifically addressing these factors. Of the patients surveyed, 25% were not regular annual vaccine recipients, and 47% were classified as being at high risk for influenza complications according to Public Health Agency of Canada criteria. Notably, 28% of total patients and 21% of high-risk patients reported that they would not have been immunized this year if pharmacy-based vaccination were not available. CONCLUSIONS: Our findings suggest that pharmacists provide a highly convenient and accessible option for seasonal flu vaccination that is viewed favourably by patients. Administration of the flu vaccine by pharmacists has the potential to positively affect public health by improving vaccination rates among high-risk patients, first-time or occasional vaccine recipients, and patients who may not otherwise have an opportunity to be vaccinated. It is hoped that expanding pharmacist vaccination services to include administration of other common vaccines would receive similar positive reception by patients and improve overall access to vaccination.

Glioma tumor stem-like cells promote tumor angiogenesis and vasculogenesis via vascular endothelial growth factor and stromal-derived factor 1.

Cancer stem cells (CSC) are predicted to be critical drivers of tumor progression due to their self-renewal capacity and limitless proliferative potential. An emerging area of research suggests that CSC may also support tumor progression by promoting tumor angiogenesis. To investigate how CSC contribute to tumor vascular development, we used an approach comparing tumor xenografts of the C6 glioma cell line containing either a low or a high fraction of CSC. Compared with CSC-low tumors, CSC-high tumors exhibited increased microvessel density and blood perfusion and induced increased mobilization and tumor recruitment of bone marrow-derived endothelial progenitor cells (EPC). CSC-high C6 cell cultures also induced higher levels of endothelial cell proliferation and tubule organization in vitro compared with CSC-low cultures. CSC-high cultures and tumors expressed increased levels of the proangiogenic factors vascular endothelial growth factor and stromal-derived factor 1, and when signaling by either factor was blocked, all aspects of angiogenesis observed in CSC-high cultures and tumors, including microvessel density, perfusion, EPC mobilization/recruitment, and stimulation of endothelial cell activity, were reduced to levels comparable with those observed in CSC-low cultures/tumors. These results suggest that CSC contribute to tumor angiogenesis by promoting both local endothelial cell activity and systemic angiogenic processes involving bone marrow-derived EPC in a vascular endothelial growth factor-dependent and stromal-derived factor 1-dependent manner.

Anticancer therapies combining antiangiogenic and tumor cell cytotoxic effects reduce the tumor stem-like cell fraction in glioma xenograft tumors.

Vascular endothelial cells have been identified as a critical component of the neural stem cell niche, raising the possibility that brain tumor stem-like cells (TSLC) may also rely on signaling interactions with nearby tumor vasculature to maintain their stem-like state. The disruption of such a TSLC vascular niche by an antiangiogenic therapy could result in loss of stemness characteristics associated with intrinsic drug resistance and, thus, preferentially sensitize TSLC to the effects of chemotherapy. Considering these possibilities, we investigated the impact of antiangiogenic anticancer therapy on the TSLC fraction of glioma tumors. Athymic nude mice bearing s.c. tumor xenografts of the C6 rat glioma cell line were treated with either a targeted antiangiogenic agent, antiangiogenic schedules of low-dose metronomic chemotherapy, combination therapies of antiangiogenic agents and chemotherapy, or, for the purpose of comparison, a conventional cytotoxic schedule of maximum tolerated dose chemotherapy using cyclophosphamide. Targeted antiangiogenic therapy or cytotoxic chemotherapy did not reduce the fraction of tumor sphere-forming units (SFU) in the tumor, whereas all treatment groups that combined both antiangiogenic and cytotoxic drug effects caused a significant reduction in SFU. This work highlights the possibility that selective eradication of TSLC may be achieved by targeting the tumor microenvironment (and potentially a supportive TSLC niche) rather than the TSLC directly. Furthermore, this work suggests a possible novel effect of antiangiogenic therapy, namely, as a chemosensitizer of TSLC, and thus represents a possible new mechanism to explain the ability of antiangiogenic therapy to enhance the efficacy of chemotherapy.