Understanding how emergency medicine physicians survive and thrive in rural practice: a theoretical model.

INTRODUCTION: The challenges facing emergency medicine (EM) services in Canada reflect the limitations of the entire healthcare system. The emergency department (ED) is uniquely situated in the healthcare system such that shortcomings in hospital- and community-based services are often first revealed there. This is especially true in rural settings, where there are additional site-specific barriers to the provision of EM care. Existing studies look at the factors that influence rural EM physicians in isolation. This study uses a qualitative approach and generates a theoretical model that describes the complex interplay between major factors that influence the experience of rural EM physicians. METHODS: Eight focus groups were conducted with 39 physicians from rural British Columbia, Canada. Semi-structured focus group protocols were designed to leverage the diversity of the focus groups, which included rural generalists, full-time EM practitioners, physicians from very small and remote communities, locums, international medical graduates, physicians new to practice, and physicians who no longer practice rural EM. Following the principles of grounded theory, interview probes were adjusted iteratively to reflect emerging findings. Transcripts were analysed to identify codes and major themes, which served as the basis for the theoretical model. RESULTS: The theoretical model reveals how the causal conditions (a lack of medical and human resources, and the isolation of rural communities due to topography, distance, and inclement weather) contribute to physicians' common experience of feeling fearful and under-supported at work. Two core phenomena emerge as important needs: supportive professional relationships, and healthcare system adaptability. Contextual factors such as remuneration and continuing medical education funding, and the intervening conditions of physicians' rural exposure during formative years, also have an effect. Physicians create innovative solutions to address the challenges that arise in the practice of rural EM. Ultimately, the ability to manage the pressures of rural EM leads physicians to either thrive in or leave rural EM practice. CONCLUSIONS: The theoretical model provides a more complex view of the realities of rural EM care than has been previously described. It identifies factors that enable and hinder rural EM physicians in their practice, and provides an understanding of the strategies they employ to navigate challenges. Some elements of the theoretical model have been previously identified. For example, existing work has found that many rural physicians experience fear and anxiety in their practice. The challenges posed by the variation in rural practice environments have also been previously identified as an important influence. Other elements of the theoretical model, and the common need for practitioners to creatively respond to barriers arising from the healthcare system's inability to respond to local needs, have not been previously identified. This work finds these factors to be a common experience for participants, and as such, more widespread recognition of the importance of these factors could lead to system improvements. Future research is needed to test the hypotheses proposed in this study and explore the generalizability of the findings.

The impact of medication reviews by community pharmacists.

OBJECTIVES: Many Canadians use prescription medicines that are unnecessary or that can lead to adverse events. In response, many provinces have introduced programs in which pharmacists are paid to perform medication reviews with patients. As the evidence on such programs is equivocal, we investigated the impact of British Columbia's program. DESIGN: Interrupted time series. SETTING: British Columbia, Canada. PARTICIPANTS: All residents of British Columbia who received a medication review between May 1, 2012, and June 30, 2013 (163,776 individuals). INTERVENTION: Using British Columbia's population-based PharmaNet drug utilization system, we collected data on community pharmacist-led medication reviews. The PharmaNet database contains a record of all medication reviews conducted in an ambulatory setting. MAIN OUTCOME MEASURES: We studied the impact of first medication reviews conducted between May 2012 and June 2013. We used interrupted time series analysis to assess longitudinal changes in patients receiving a standard review (n = 147,770) and a more intensive pharmacist consultation (n = 16,006). Our outcomes included drug utilization, costs, potentially inappropriate prescriptions, and medication persistence measured through the proportion of commonly used chronic medications that were eventually refilled. RESULTS: Overall, we observed few changes in the level or trend of any of the outcomes we studied. Both review types were followed by significant increases in both the number of prescriptions per month and expenditures. The continuation of long-term medications did not change for 3 of 4 classes, and increased very slightly for the final class. We found no evidence of deprescribing, either for classes that are potentially problematic for long-term use (benzodiazepines and proton pump inhibitors) or for potentially inappropriate prescriptions in seniors. CONCLUSIONS: Our results suggest that medication reviews did not significantly modify prescription drug use by recipients. Future iterations of such programs might be modified to be better targeted and to encourage closer collaboration between pharmacists and prescribing health care professionals.

Cost-related nonadherence to medicines in people with multiple chronic conditions.

BACKGROUND: Multimorbidity is common and frequently associated with medicine nonadherence. Although cost is a common reason for nonadherence, very little research has quantified cost-related nonadherence (CRNA) to medicines specifically in people with multimorbidity, the prevalence of CRNA for different conditions nor the impact of cost when prioritising treatment between conditions. OBJECTIVE: To determine the extent of CRNA in people with multimorbidity and the patient characteristics associated with these behaviours. DESIGN AND SETTING: People reporting two or more chronic conditions responding to a rapid response module regarding prescription drug affordability fielded between January 1 and June 30 2016 in the Canadian Community Health Survey, a cross-sectional household survey. METHODS: Ordinal logistic regression, adjusted for key sociodemographic, clinical and treatment related variables, of weighted population estimates of self-reported CRNA within one group of conditions, across multiple groups of conditions, or no CRNA. RESULTS: 10.2% of 8420 Canadians with multimorbidity reported CRNA. The majority (61%) reported CRNA within one group of conditions, especially respiratory (16%) and mental health disorders (17%). CRNA was more common in younger adults, people without employer or association drug insurance plans, poorer health status, more chronic conditions, and increased out-of-pocket prescription costs. Having no prescription insurance was associated with a higher probability of CRNA across multiple groups of conditions. CONCLUSIONS: People with multimorbidity primarily forego medicines because of cost within one group of conditions. However, those without drug insurance extended these behaviours to multiple condition groups. Further work is needed to determine how people prioritise the conditions and treatments that are foregone because of cost, and how to best incorporate this information into treatment plans.

Patterns of borrowing to finance out-of-pocket prescription drug costs in Canada: a descriptive analysis.

BACKGROUND: Out-of-pocket drug costs lead many Canadians to engage in cost-related nonadherence to prescription medications, but our understanding of other consequences such as borrowing money remains incomplete. In this descriptive study, we sought to quantify the frequency of borrowing to pay for prescription drugs in Canada and characteristics of Canadians who borrowed money for this purpose. METHODS: In partnership with Statistics Canada, we designed and administered a cross-sectional rapid-response module in the Canadian Community Health Survey administered by telephone to Canadians aged 12 years or more between January and June 2016. We restricted our analyses to participants who responded to the question regarding borrowing money to pay for prescription drugs and used logistic regression to identify characteristics associated with borrowing. RESULTS: A total of 28 091 Canadians responded to the survey (overall response rate 61.8%). The weighted proportion of respondents who reported having borrowed money to pay for prescription drugs in the previous year was 2.5% (95% confidence interval 2.2%-2.8%), an estimated 731 000 Canadians. The odds of borrowing were higher among younger adults, people in poor health and people lacking prescription drug insurance. Other factors associated with increased adjusted odds of borrowing were having 2 or more chronic conditions, low household income and higher out-of-pocket prescription drug costs. INTERPRETATION: Many Canadians reported borrowing money to pay for out-of-pocket prescription drug costs, and borrowing was more prevalent among already vulnerable groups that also report other compensatory behaviours to address challenges in paying for prescription drugs. Future research should investigate policy responses intended to increase equity in access to prescription drugs.

The consequences of patient charges for prescription drugs in Canada: a cross-sectional survey.

BACKGROUND: Many Canadians face substantial out-of-pocket charges for prescription drugs. Prior work suggests that this causes some patients to not take their medications as prescribed; however, we have little understanding of whether charges for prescription medicines lead patients to forego basic needs or to use more health care services. Our study aimed to quantify the consequences of patient charges for medicines in Canada. METHODS: As part of the 2016 Canadian Community Health Survey, we designed and fielded cross-sectional questions to 28 091 Canadians regarding prescription drug affordability, consequent use of health care services and trade-offs with other expenditures. We calculated weighted population estimates and proportions, and used logistic regression to determine which patient characteristics were associated with these behaviours. RESULTS: Overall, 5.5% (95% confidence interval 5.1%-6.0%) of Canadians reported being unable to afford 1 or more drugs in the prior year, representing 8.2% of those with at least 1 prescription. Drugs for mental health conditions were the most commonly reported drug class for cost-related nonadherence. About 303 000 Canadians had additional doctor visits, about 93 000 sought care in the emergency department, and about 26 000 were admitted to hospital at the population level. Many Canadians forewent basic needs such as food (about 730 000 people), heat (about 238 000) and other health care expenses (about 239 000) because of drug costs. These outcomes were more common among females, younger adults, Aboriginal peoples, those with poorer health status, those lacking drug insurance and those with lower income. INTERPRETATION: Out-of-pocket charges for medicines for Canadians are associated with foregoing prescription drugs and other necessities as well as use of additional health care services. Changes to protect vulnerable populations from drug costs might reduce these negative outcomes.

Understanding the patient experience of cost-related non-adherence to prescription medications through typology development and application.

Many patients report skipping doses, splitting pills, or not filling prescriptions due to out-of-pocket costs-a phenomenon known as cost-related non-adherence (CRNA). This study investigated CRNA from the patient's perspective, and, to our knowledge, is the first study to undertake a qualitative investigation of CRNA specifically. We report the results from 35 semi-structured interviews conducted in 2014-15 with adults in four Canadian cities across two provinces. We used framework analysis to develop a CRNA typology to characterize major factors in patients' CRNA decisions. Our typology identifies four major components: (1) the insurance reason driving the drug cost, (2) the individual's overall financial flexibility, (3) the burden of drug cost on the individual's budget, and (4) the importance of the drug from the individual's perspective. The first two components set the context for CRNA and the final two components are the drivers for the CRNA decision. We also found four major patterns in CRNA experiences: (1) CRNA in individuals with low financial flexibility occurred for all levels of drug importance and all but the lowest level of cost burden; (2) CRNA for high importance drugs only occurred when the drug cost had a high burden on an individual's budget; (3) CRNA in individuals with more financial flexibility primarily occurred in drugs with medium importance but high or very high cost burdens; and (4) CRNA for low importance drugs occurred at almost all levels of drug cost burden. Our study furthers the understanding of how numerous factors such as income, insurance, and individual preferences combine and interact to influence CRNA and suggests that policy interventions must be multi-faceted or encourage significant insurance redesign to reduce CRNA.

Coordination of chemical (trimethylamine oxide) and molecular (heat shock protein 70) chaperone responses to heat stress in elasmobranch red blood cells.

Chemical and molecular chaperones are organic compounds that protect and stabilize proteins from damage and aggregation as a result of cellular stress. Using the dogfish (Squalus acanthias) red blood cell (RBC) as a model, we examined whether elasmobranch cells with naturally high concentrations of the chemical chaperone trimethylamine oxide (TMAO) would induce the molecular chaperone heat shock protein 70 (HSP70) when exposed to an acute thermal stress. Our hypothesis was that TMAO is itself capable of preventing damage and preserving cellular function during thermal stress and thus that the heat shock response would be inhibited/diminished. We incubated RBCs in vitro with and without physiologically relevant concentrations of TMAO at 13°C and then exposed cells to a 1-h acute heat shock at 24°C. HSP70 protein expression was elevated in dogfish RBCs after the acute heat stress, but this induction was inhibited by extracellular TMAO. Regardless of the presence of TMAO and/or HSP70, we did not observe any cell damage, as indicated by changes in caspase 3/7 activity, protein carbonyls, membrane viability, or levels of ubiquitin. We also saw no change in RBC cell function, as determined by hemoglobin oxygen affinity or carrying capacity, in cells lacking the heat shock response but protected by TMAO. This study demonstrates that there is cellular coordination between chemical and molecular chaperones in response to an acute thermal stress in dogfish RBCs and suggests that TMAO has a thermoprotective role in these cells, thus eliminating the need for a heat shock response.