Design for a Canadian Digital Health Policy & Practices Observatory.

Canada has struggled to make digital health a reality. We identified 6 key issues that appear to impede progress: 1) an inability to coordinate the actions of a rapidly evolving set of stakeholders, 2) patients who lack the ability and resources to play a meaningful role in health system decision-making, 3) world-class innovation that doesn't reach the market, 4) an inability to kick-start interoperability projects that can catalyze system transformation, 5) an inability to procure early-stage innovative technologies at scale, and 6) an inability to share data seamlessly across organizational silos for patient coordination and care, health system management and research. We propose a set of policies and practices that can help Canada assess, monitor and provide feedback to stakeholders and citizens on how well they are progressing toward seamless digital health.

Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site: Quality Improvement Project.

BACKGROUND: Increased prescribing of proton pump inhibitors (PPIs) in the past few decades can be attributed mainly to long-term use of this type of therapy. Recent evidence indicates signals of harm associated with long-term use of PPIs, such as increased risk of Clostridium difficile infection, recurrence of C. difficile infection, and fracture. A few studies have assessed the effectiveness of step-down management of patients receiving long-term PPI therapy in ambulatory care settings. However, it is unknown whether PPIs can be discontinued in older people without return of gastrointestinal symptoms. OBJECTIVES: To determine the proportion of residents receiving long-term PPI therapy who were able to discontinue the drug without experiencing gastrointestinal symptoms warranting recommencement of the PPI or initiation of a histamine-2 receptor antagonist. METHODS: The records of residents who had been taking a PPI for longer than 6 months at a single residential care site were audited by one pharmacist to determine the PPI indication. For residents who fit the criteria for discontinuation (no indication for long-term PPI therapy, not currently experiencing gastrointestinal symptoms, no previous trial of PPI discontinuation without success, and no anxiety when medications are discontinued), the pharmacist faxed a recommendation to discontinue PPI therapy without tapering to the physicians' offices. For cases in which the recommendation was accepted, 3 pharmacists followed the residents weekly for 8 weeks to assess whether gastrointestinal symptoms returned. RESULTS: The pharmacist identified 28 residents who fit the criteria, and the recommendation to discontinue therapy was accepted for 27. At 8 weeks after the intervention, 19 (70%) of these residents were still asymptomatic and did not require re-initiation of medications to manage their gastrointestinal symptoms. CONCLUSIONS: These results support discontinuation of long-term PPI therapy for older people who fit the criteria for discontinuation. The study provided limited evidence to support the use of tapering. However, tapering can be used to identify the lowest effective dose and may increase patient comfort with deprescribing. Further research is needed to determine the effects of and best approaches to PPI discontinuation in older populations.

CONTEXTE: L'augmentation des prescriptions d'inhibiteurs de la pompe à protons (IPP) au cours des dernières décennies peut être attribuée principalement à l'utilisation à long terme de ce type de traitement. Des données récentes indiquent que l'utilisation à long terme des IPP comporte des dangers potentiels, notamment une augmentation du risque d'infection par Clostridium difficile, de récurrence de cette infection et de fracture. Quelques études ont évalué l'efficacité de la déprescription des IPP chez des patients recevant un traitement prolongé en milieu ambulatoire. Cependant, on ne sait pas s'il est possible de cesser l'utilisation d'IPP chez le patient âgé tout en évitant la réapparition de symptômes gastro-intestinaux. OBJECTIF: Déterminer la proportion de résidents pour qui l'on a été en mesure de cesser le traitement à long terme par IPP sans qu'apparaissent des symptômes gastro-intestinaux nécessitant la reprise du traitement par IPP ou l'amorce d'un traitement par antagoniste des récepteurs H2 de l'histamine. MÉTHODES: L'étude a eu lieu dans un seul centre d'hébergement et de soins de longue durée. Un pharmacien y a analysé les dossiers médicaux des résidents qui prenaient des IPP depuis plus de six mois afin de déterminer l'indication du médicament. Pour les résidents répondant aux critères de déprescription (aucune indication pour un traitement d'entretien, aucun symptôme gastro-intestinal à l'heure actuelle, aucune tentative antérieure de déprescrire un IPP en vain et aucune réaction anxieuse à l'arrêt de traitements), le pharmacien a envoyé par télécopieur aux bureaux des médecins un document recommandant l'interruption du traitement par IPP sans posologie dégressive. Dans les cas où la recommandation a été acceptée, trois pharmaciens ont suivi hebdomadairement les résidents pendant huit semaines afin de vérifier si des symptômes gastro-intestinaux réapparaissaient. RÉSULTATS: Le pharmacien a repéré 28 résidents répondant aux critères et la recommandation d'interruption de traitement a été acceptée pour 27 d'entre eux. Huit semaines après l'intervention, 19 (70 %) de ces résidents étaient toujours asymptomatiques et n'ont pas eu besoin qu'on leur prescrive de nouveau des médicaments pour traiter des symptômes gastro-intestinaux. CONCLUSIONS: Ces résultats viennent appuyer l'interruption du traitement à long terme d'IPP chez le patient âgé qui répond aux critères d'interruption. Cette étude n'a founi que peu de preuves qui appuient le recours à la posologie dégressive. Cependant, celle-ci peut servir à déterminer quelle est la plus faible dose efficace et elle peut aider les patients à être plus à l'aise avec l'interruption du traitement. Des recherches plus approfondies sont nécessaires pour préciser les conséquences de l'arrêt des IPP chez les personnes âgées et la meilleure approche à cette fin.

Treatment and outcome of Pseudomonas aeruginosa bacteraemia: an antibiotic pharmacodynamic analysis.

OBJECTIVES: To conduct a retrospective study of antibiotic pharmacodynamics in the treatment of Pseudomonas aeruginosa bacteraemia, and to identify pharmacodynamic indices associated with clinical cure. METHODS: Cases of P. aeruginosa bacteraemia were identified, and information related to patient demographics, clinical status, antibiotic treatment and clinical outcome were documented. Anti-pseudomonal therapy was assessed, and concentration versus time profiles were constructed using measured levels for aminoglycosides, or population pharmacokinetic models for other antibiotics. P. aeruginosa isolates from all patients were retrieved and MICs for the anti-pseudomonal agents used to treat the episode of bacteraemia were determined. Patient- and treatment-related factors were tested for associations with clinical outcome using univariate and multivariate analyses. RESULTS: Fifty cases of P. aeruginosa bacteraemia were identified and 38 cases were included in the pharmacodynamic analysis. Eighty-seven percent of patients received an aminoglycoside or ciprofloxacin and 79% received piperacillin or ceftazidime. A majority of patients, 71%, were administered a combination of antibiotics. Treatment outcomes were documented as persistent infection in 21%, death within 2-30 days in 21% and clinical cure in 58% of cases. Peak/MIC (P=0.001) and AUC24/MIC (P=0.002) for aminoglycosides and ciprofloxacin were significant factors in univariate tests. Only peak/MIC was associated independently with treatment outcome (P=0.017) in logistic regression analysis. The predicted probability of cure was > or =90% when peak/MIC was at least 8. CONCLUSION: Pharmacodynamic considerations including aggressive dosing with targeted peak/MICs for aminoglycosides and ciprofloxacin are strongly associated with clinical outcome and essential to the appropriate management of P. aeruginosa bacteraemia.