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1.  The effect of an educational intervention on meperidine use in Nova Scotia, Canada: a time series analysis 
Purpose
To evaluate the impact of a prescriber focused individual educational and audit–feedback intervention undertaken by the Nova Scotia Prescription Monitoring Program (NSPMP) in March/April 2007 to reduce meperidine use.
Method
The NSPMP records all prescriptions for controlled substances dispensed in community pharmacies in Nova Scotia, Canada. Oral meperidine use from 1 July 2005 to 31 December 2009 was examined using NSPMP data. Monthly totals for the following were obtained: number of individual patients who filled at least one meperidine prescription, number of prescriptions, and number of tablets dispensed. Data were analyzed graphically to observe overall trends. The intervention effect was estimated on the logarithmic scale with autocorrelations over time modeled by an integrated autoregressive moving average model for each outcome measure.
Results
An overall trend toward decreasing use from July 2005 to December 2009 was apparent for all three outcome measures. The intervention was associated with a statistically significant reduction in meperidine use, after adjusting for the overall long-term trend. Compared with the pre-intervention period, the monthly number of patients declined by 12% (p <0.001; 95% confidence interval [CI] = 5%–18%), prescriptions by 10% (p <0.001; 95%CI = 3%–17%), and tablets by 13.5% (p <0.001, 95%CI = 6%–29%) in the post-intervention period.
Conclusion
Given the risks associated with meperidine, determining that this intervention successfully reduced meperidine use is encouraging. This study highlights the potential for using population data such as the NSPMP to evaluate the effectiveness of population-level interventions to improve medication use, including professional, organizational, financial, and regulatory initiatives.
doi:10.1002/pds.2259
PMCID: PMC3747098  PMID: 22081471 CAMSID: cams3253
educational intervention; meperidine; pethidine; time series analysis
2.  Participants’ Perceptions of a Multidisciplinary Training Program for Graduate and Postgraduate Students in Drug Use Management and Policy 
Objective. To determine graduate and postgraduate students’ perceptions of a drug use management and policy program that applied wide-ranging policy research skills to inform pharmaceutical decision-making.
Design. Nine cohorts of graduate and postgraduate students from diverse academic and professional backgrounds were paired with health-system preceptors for 4 months, and supported by faculty advisors and administrators, to complete research projects that generated evidence to inform policy decisions.
Assessment. A self-administered survey instrument was sent to all alumni of the program over the previous 10 years. The majority of respondents indicated: their prior academic coursework could be applied to everyday life; service-learning projects complemented university programs; participation led to greater awareness of decision-makers’ needs and appreciation of their tacit knowledge; and communication abilities were enhanced with decision-makers, and academics. Many also reported personal desire to fulfill healthcare-system research needs; personal belief in their ability to make a difference; and increased postgraduation marketability.
Conclusion. A drug use management and policy program allowed graduate students from various disciplines to develop new skills and collaborate with experts to produce research evidence that was relevant to drug policy that addressed real-world problems.
doi:10.5688/ajpe775102
PMCID: PMC3687113  PMID: 23788813
pharmaceutical policy; service-learning; assessment; engaged scholarship; residency; knowledge co-production
3.  Medication Records in the Emergency Department: Agreement Between Paper-Based Charts and Automated Dispensing Device 
Background:
Research exploring the agreement between traditional medication records and electronic records generated by an automated dispensing device has been limited.
Objective:
To evaluate the extent of agreement between medication administration records written in paper-based emergency department charts and records generated by an automated dispensing device with regard to the presence or absence of a single, prespecified medication.
Methods:
Medication administration records in paper-based emergency department charts and medication dispensation records generated by an automated dispensing device were evaluated for concordance. The primary outcome measure was agreement between the 2 sources with regard to the presence or absence of a record for salbutamol by metered-dose inhaler (MDI) for randomly selected patients who presented to a pediatric emergency department with wheeze-related illness from January 1, 2008, to December 31, 2009.
Results:
In total, 1172 patient visits met the inclusion criteria. Of these, records for 1013 visits showed agreement between the paper-based emergency department chart and the dispensation record of the automated dispensing device (kappa = 0.71, 95% confidence interval 0.67–0.75). This value did not meet the target kappa of 0.80. Stratification by time of day, day of week, month, season, or year of presentation at triage or by triage level or disposition (whether or not the patient was admitted to the hospital ward) did not significantly affect the level of agreement between the 2 sources.
Conclusions:
Agreement between records of salbutamol MDI administration in paper-based charts and dispensation records from an automated dispensing device was substantial, but discrepancies were present. There are significant quality management, legal, clinical, and research reasons to strive for concordance between multiple records with respect to medication use in the emergency department. Data generated by automated dispensing devices have potential value for research, but their strengths and limitations need to be understood.
PMCID: PMC3420848  PMID: 22919103
data source; chart review; medical records; automated dispensing device; source de données; analyse de dossiers médicaux; dossiers médicaux; armoire de distribution automatisée
4.  The geographic accessibility of pharmacies in Nova Scotia 
Introduction:
Geographic proximity is an important component of access to primary care and the pharmaceutical services of community pharmacies. Variations in access to primary care have been found between rural and urban areas in Canadian and international jurisdictions. We studied access to community pharmacies in the province of Nova Scotia.
Methods:
We used information on the locations of 297 community pharmacies operating in Nova Scotia in June 2011. Population estimates at the census block level and network analysis were used to study the number of Nova Scotia residents living within 800 m (walking) and 2 km and 5 km (driving) distances of a pharmacy. We then simulated the impact of pharmacy closures on geographic access in urban and rural areas.
Results:
We found that 40.3% of Nova Scotia residents lived within walking distance of a pharmacy; 62.6% and 78.8% lived within 2 km and 5 km, respectively. Differences between urban and rural areas were pronounced: 99.2% of urban residents lived within 5 km of a pharmacy compared with 53.3% of rural residents. Simulated pharmacy closures had a greater impact on geographic access to community pharmacies in rural areas than urban areas.
Conclusion:
The majority of Nova Scotia residents lived within walking or short driving distance of at least 1 community pharmacy. While overall geographic access appears to be lower than in the province of Ontario, the difference appears to be largely driven by the higher proportion of rural dwellers in Nova Scotia. Further studies should examine how geographic proximity to pharmacies influences patients’ access to traditional and specialized pharmacy services, as well as health outcomes and adherence to therapy. Can Pharm J 2013;146:39-46.
doi:10.1177/1715163512473062
PMCID: PMC3676246  PMID: 23795168
5.  CNODES: the Canadian Network for Observational Drug Effect Studies 
Open Medicine  2012;6(4):e134-e140.
Abstract
Although administrative health care databases have long been used to evaluate adverse drug effects, responses to drug safety signals have been slow and uncoordinated. We describe the establishment of the Canadian Network for Observational Drug Effect Studies (CNODES), a collaborating centre of the Drug Safety and Effectiveness Network (DSEN). CNODES is a distributed network of investigators and linked databases in British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Quebec and Nova Scotia. Principles of operation are as follows: (1) research questions are prioritized by the coordinating office of DSEN; (2) the linked data stay within the provinces; (3) for each question, a study team formulates a detailed protocol enabling consistent analyses in each province; (4) analyses are “blind” to results obtained elsewhere; (5) protocol deviations are permitted for technical reasons only; (6) analyses using multivariable methods are lodged centrally with a methods team, which is responsible for combining the results to provide a summary estimate of effect. These procedures are designed to achieve high internal validity of risk estimates and to eliminate the possibility of selective reporting of analyses or outcomes. The value of a coordinated multi-provincial approach is illustrated by projects studying acute renal injury with high-potency statins, community-acquired pneumonia with proton pump inhibitors, and hyperglycemic emergencies with antipsychotic drugs. CNODES is an academically based distributed network of Canadian researchers and data centres with a commitment to rapid and sophisticated analysis of emerging drug safety signals in study populations totalling over 40 million.
PMCID: PMC3654509  PMID: 23687528
6.  Achieving optimal prescribing 
Canadian Family Physician  2012;58(8):820-821.
PMCID: PMC3418972  PMID: 22893327
8.  Population prevalence of high dose paracetamol in dispensed paracetamol/opioid prescription combinations: an observational study 
Background
Paracetamol (acetaminophen) is generally considered a safe medication, but is associated with hepatotoxicity at doses above doses of 4.0 g/day, and even below this daily dose in certain populations.
Methods
The Nova Scotia Prescription Monitoring Program (NSPMP) in the Canadian province of Nova Scotia is a legislated organization that collects dispensing information on all out-of-hospital prescription controlled drugs dispensed for all Nova Scotia residents. The NSPMP provided data to track all paracetamol/opioids redeemed by adults in Nova Scotia, from July 1, 2005 to June 30, 2010. Trends in the number of adults dispensed these prescriptions and the numbers of prescriptions and tablets dispensed over this period were determined. The numbers and proportions of adults who filled prescriptions exceeding 4.0 g/day and 3.25 g/day were determined for the one-year period July 1, 2009 to June 30, 2010. Data were stratified by sex and age (<65 versus 65+).
Results
Both the number of prescriptions filled and the number of tablets dispensed increased over the study period, although the proportion of the adult population who filled at least one paracetamol/opioid prescription was lower in each successive one-year period. From July 2009 to June 2010, one in 12 adults (n = 59,197) filled prescriptions for over 13 million paracetamol/opioid tablets. Six percent (n = 3,786) filled prescriptions that exceeded 4.0 g/day and 18.6% (n = 11,008) exceeded 3.25 g/day of paracetamol at least once. These findings exclude non-prescription paracetamol and paracetamol–only prescribed medications.
Conclusions
A substantial number of individuals who redeem prescriptions for paracetamol/opioid combinations may be at risk of paracetamol-related hepatotoxicity. Healthcare professionals must be vigilant when prescribing and dispensing these medications in order to reduce the associated risks.
doi:10.1186/1472-6904-12-11
PMCID: PMC3416683  PMID: 22709372
9.  Independent pharmacist prescribing in Canada 
Canadian Pharmacists Journal : CPJ  2012;145(1):17-23.e1.
Background: While pharmacists are trained in the selection and management of prescription medicines, traditionally their role in prescribing has been limited. In the past 5 years, many provinces have expanded the pharmacy scope of practice. However, there has been no previous systematic investigation and comparison of these policies.
Methods: We performed a comprehensive policy review and comparison of pharmacist prescribing policies in Canadian provinces in August 2010. Our review focused on documents, regulations and interviews with officials from the relevant government and professional bodies. We focused on policies that allowed community pharmacists to independently continue, adapt (modify) and initiate prescriptions.
Results: Pharmacists could independently prescribe in 7 of 10 provinces, including continuing existing prescriptions (7 provinces), adapting existing prescriptions (4 provinces) and initiating new prescriptions (3 provinces). However, there was significant heterogeneity between provinces in the rules governing each function.
Conclusions: The legislated ability of pharmacists to independently prescribe in a community setting has substantially increased in Canada over the past 5 years and looks poised to expand further in the near future. Moving forward, these programs must be evaluated and compared on issues such as patient outcomes and safety, professional development, human resources and reimbursement.
doi:10.3821/1913-701X-145.1.17
PMCID: PMC3567533  PMID: 23509483
10.  Coping Strategies Used by Patients Infected with Hepatitis C Virus Who Are Facing Medication Costs 
Background:
The prevalence of infection with hepatitis C virus (HCV) is increasing worldwide. Antiviral therapy, prescription and nonprescription medications, and nondrug therapies to treat HCV infection and to manage associated adverse effects are costly.
Objective:
To determine whether individuals infected with HCV attending a hepatology clinic were negatively affected by the costs of prescription medications, and if so, to determine coping strategies they adopted.
Methods:
Patients infected with HCV attending Hepatology Services, a clinic within the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia, were interviewed as part of an exploratory study (April 2 to July 8, 2008). The interview was based on a validated survey adapted for Nova Scotia. Information collected included demographic characteristics; types of prescription, nonprescription, and complementary medications used by patients; and strategies patients adopted to pay their medication costs.
Results:
Fifty patients (age 33–64 years) participated in the interviewer-administered survey, including 35 (70%) men and 19 people (38%) with household income less than $30 000. Frequently used medications were antidepressants (19 patients [38%]), antihypertensive agents (12 [24%]), anxiolytics (10 [20%]), and nonsteroidal anti-inflammatory drugs (10 [20%]). More than half (29 [58%]) were concerned about having sufficient money to pay for their medications. Coping strategies adopted in response to costs of prescription medications were either self-initiated or undertaken in consultation with physicians and/or other health care professionals. Sixteen (32%) of the respondents expressed the belief that physicians usually do not consider patients’ concerns about affordability when prescribing medications. Seven (14%) indicated they would seek help from a pharmacist to buy low-cost substitutes for their medications.
Conclusion:
This study highlighted a range of coping strategies adopted by patients infected with HCV in response to medication costs. It underscores that cost may limit access to essential medications within this patient population, even in a publicly funded health care system. Some of the coping strategies adopted might reduce patients’ persistence and adherence with medication therapy, which could lead to adverse health outcomes. Hospital and community pharmacists need to be aware of the challenges faced by patients in terms of paying for medications and should consider possible proactive responses to address potentially detrimental coping strategies.
PMCID: PMC3093420  PMID: 22479042
hepatitis C virus; treatment; cost of medications; chronic disease; coping strategies; pharmacists; virus de l’hépatite C; traitement; coût des médicaments; maladie chronique; stratégies d’adaptation; pharmaciens
11.  Hypertension and type 2 diabetes: What family physicians can do to improve control of blood pressure - an observational study 
BMC Family Practice  2011;12:86.
Background
The prevalence of type 2 diabetes is rising, and most of these patients also have hypertension, substantially increasing the risk of cardiovascular morbidity and mortality. The majority of these patients do not reach target blood pressure levels for a wide variety of reasons. When a literature review provided no clear focus for action when patients are not at target, we initiated a study to identify characteristics of patients and providers associated with achieving target BP levels in community-based practice.
Methods
We conducted a practice- based, cross-sectional observational and mailed survey study. The setting was the practices of 27 family physicians and nurse practitioners in 3 eastern provinces in Canada. The participants were all patients with type 2 diabetes who could understand English, were able to give consent, and would be available for follow-up for more than one year. Data were collected from each patient's medical record and from each patient and physician/nurse practitioner by mailed survey. Our main outcome measures were overall blood pressure at target (< 130/80), systolic blood pressure at target, and diastolic blood pressure at target. Analysis included initial descriptive statistics, logistic regression models, and multivariate regression using hierarchical nonlinear modeling (HNLM).
Results
Fifty-four percent were at target for both systolic and diastolic pressures. Sixty-two percent were at systolic target, and 79% were at diastolic target. Patients who reported eating food low in salt had higher odds of reaching target blood pressure. Similarly, patients reporting low adherence to their medication regimen had lower odds of reaching target blood pressure.
Conclusions
When primary care health professionals are dealing with blood pressures above target in a patient with type 2 diabetes, they should pay particular attention to two factors. They should inquire about dietary salt intake, strongly emphasize the importance of reduction, and refer for detailed counseling if necessary. Similarly, they should inquire about adherence to the medication regimen, and employ a variety of patient-oriented strategies to improve adherence.
doi:10.1186/1471-2296-12-86
PMCID: PMC3163533  PMID: 21834976
12.  The rate of prescribing gastrointestinal prophylaxis with either a proton pump inhibitor or an H2-receptor antagonist in Nova Scotia seniors starting nonsteroidal anti-inflammatory drug therapy 
BACKGROUND:
Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used agents that can cause serious gastrointestinal (GI) side effects. For patients at increased risk of NSAID-related GI complications, prophylaxis with either a nonselective NSAID plus gastroprotective agent (GPA) or, alternatively, therapy with a cyclooxygenase-2 selective inhibitor with or without a GPA such as a proton pump inhibitor (PPI), is recommended.
AIM:
To describe the rate, timing and duration of GI prophylaxis in Nova Scotia seniors receiving nonselective NSAIDs.
METHODS:
The Nova Scotia Seniors’ Pharmacare Program beneficiaries for the years 1998 to 2002 were studied. A cohort of incident NSAID and GPA users was selected from all nonselective NSAID users (no prescribed NSAID dispensed 12 months before the index month and no GPA dispensed two months before the index prescription). Monthly coprescribing rates were calculated by dividing the number of patients in the cohort using GPAs by the number of NSAID users. GI prophylactic coprescribing was defined as the coprescribing rate present at the first month (index month) of prescribing an NSAID.
RESULTS:
The cohort consisted of 12,906 patients. Seventy-five per cent of the nonselective NSAID prescriptions dispensed were for up to two months duration, with only 2.3% longer than one year. GI prophylaxis was given to only 3.8% of patients starting NSAIDs who were not on a GPA in the two months before starting NSAIDs. Of this 3.8%, 92.7% of the patients received H2-receptor antagonists (H2RAs), and 7% received PPIs. The rate of H2RA coprescribing increased with the number of consecutive months on an NSAID from 3.5% in the first month to 24.1% at 48 months. For PPIs, the coprescribing rate increased from 0.3% to 1.9% of all NSAID users in the cohort. The rate of gastroprophylaxis coprescribing for patients receiving NSAIDs did not rise with increasing age.
CONCLUSION:
In Nova Scotian seniors using nonselective NSAIDs, the rate of GI prophylaxis was low. Most patients received H2RAs as GPAs despite evidence that they offer insufficient protection.
PMCID: PMC2947001  PMID: 20711527
Cohort study; Cyclooxygenase-2 selective inhibitor; Drug utilization; Gastrointestinal prophylaxis; Histamine-2 receptor antagonist; Misoprostol; Nonsteroidal anti-inflammatory drugs; NSAIDs; Proton pump inhibitor; Prescribing; Seniors
13.  Potentially Inappropriate Prescribing of Benzodiazepines for Older Adults and Risk of Falls During a Hospital Stay: A Descriptive Study 
Background:
Falls have been identified as a potential adverse event associated with the administration of psychotropic medications to older patients.
Objective:
The objective of this exploratory study was to examine the association between potentially inappropriate prescribing of benzodiazepines, as defined by the Beers criteria, by older adults (at least 65 years of age) and the risk of having a fall during acute inpatient care.
Methods:
This 1-year retrospective cross-sectional study of discharges from a tertiary care hospital in Halifax, Nova Scotia, used pharmacy data to identify the prescription of benzodiazepines listed in the updated Beers criteria as being associated with an increased risk of falls. These data were linked with information on in-hospital falls from occurrence report forms.
Results:
For 5831 (58.1%) of the 10 044 discharges, the patient had received a prescription for at least one benzodiazepine during the hospital stay. A total of 574 falls were reported (for 374 patients), and 226 (39.4%) of the falls resulted in an injury. According to the Beers criteria, for 936 (9.3%) of the discharges, the patient had received a prescription for at least one potentially inappropriate benzodiazepine. However, there was no statistically significant difference between patients with a prescription for a potentially inappropriate benzodiazepine and those receiving an appropriate or no benzodiazepine in terms of occurrence of falls (4.5% versus 3.8%, p = 0.30) or fall-related injuries (2.6% versus 1.8%, p = 0.08). The median length of stay was about 3 days longer for the former group (9 versus 6 days, p < 0.001).
Conclusions:
The findings from the current study do not support use of the Beers criteria related to benzodiazepines alone for identifying patients at risk of falls or injuries.
PMCID: PMC2826959  PMID: 22478905
potentially inappropriate medications; benzodiazepines; fall-related injuries; older adults; acute care; Beers criteria; médicaments potentiellement inappropriés; benzodiazépines; blessures par chute; personnes âgées; soins de courte durée; critères de Beers
14.  The impact of statins on health services utilization and mortality in older adults discharged from hospital with ischemic heart disease: a cohort study 
Background
Cardiovascular disease (CVD) carries a high burden of morbidity and mortality and is associated with significant utilization of health care resources, especially in the elderly. Numerous randomized trials have established the efficacy of cholesterol reduction with statin medications in decreasing mortality in high-risk populations. However, it is not known what the effect of the utilization of these medications in complex older adults has had on mortality and on the utilization of health services, such as physician visits, hospitalizations or cardiovascular procedures.
Methods
This project linked clinical and hospital data from the Improving Cardiovascular Outcomes in Nova Scotia (ICONS) database with administrative data from the Population Health Research Unit to identify all older adults hospitalized with ischemic heart disease between October 15, 1997 and March 31, 2001. All patients were followed for at least one year or until death. Multiple regression techniques, including Cox proportional hazards models and generalized linear models were employed to compare health services utilization and mortality for statin users and non-statin users.
Results
Of 4232 older adults discharged alive from the hospital, 1629 (38%) received a statin after discharge. In multivariate models after adjustment for demographic and clinical characteristics, and propensity score, statins were associated with a 26% reduction in all- cause mortality (hazard ratio (HR) 0.74, 95% confidence interval (CI) 0.63-0.88). However, statin use was not associated with subsequent reductions in health service utilization, including re-hospitalizations (HR, 0.98, 95% CI 0.91-1.06), physician visits (relative risk (RR) 0.97, 95% CI 0.92-1.02) or coronary revascularization procedures (HR 1.15, 95% CI 0.97-1.36).
Conclusion
As the utilization of statins continues to grow, their impact on the health care system will continue to be important. Future studies are needed to continue to ensure that those who would realize significant benefit from the medication receive it.
doi:10.1186/1472-6963-9-198
PMCID: PMC2781001  PMID: 19889220
15.  Effect of Utilization Policies for Fluoroquinolones: A Pilot Study in Nova Scotia Hospitals 
Background:
Antimicrobial resistance results in increased morbidity, mortality, and costs to the health care system. Evidence suggests an association between the use of antimicrobials in hospitals and the development of antimicrobial resistance. Fluoroquinolones constitute one group of antimicrobials that are effective against a variety of bacterial infections, yet they may be subject to misuse. Many hospitals in Nova Scotia have implemented policies to improve antimicrobial prescribing, but the impact of these policies on utilization is unknown.
Objectives:
To evaluate the use of fluoroquinolones in Nova Scotia hospitals using the World Health Organization’s Anatomical Therapeutic Chemical classification system with defined daily doses (ATC/DDD) and to examine the influence of hospital policies for utilization of fluoroquinolones in community-acquired pneumonia.
Methods:
During the study period (April 1, 1997, to March 31, 2003), fluoroquinolones were administered at 31 of the 37 hospitals in Nova Scotia’s 9 district health authorities. Hospital administrative data, hospital characteristics, and pharmaceutical purchasing data related to use of these drugs were aggregated using the ATC/DDD methodology for the fiscal years 1997/1998 to 2002/2003. District pharmacy directors were surveyed to obtain information about district and individual hospital antibiotic policies. Descriptive statistics were calculated, and univariable regression and multilevel analyses were performed.
Results:
Mean overall fluoroquinolone use increased over the study period, from 47.2 DDD/1000 bed-days per year in fiscal year 1997/1998 to 163.8 DDD/1000 bed-days per year in fiscal year 2002/2003 (p < 0.001). Multilevel analysis showed that utilization policies aimed at appropriate prescribing did not affect the use of fluoroquinolones.
Conclusion:
This study revealed that drug purchasing, hospital administrative, and diagnostic data could be combined to compare the utilization of fluoroquinolones among different hospitals and district health authorities. Utilization policies had little effect on the amount, type, or route of fluoroquinolone use.
PMCID: PMC2826907  PMID: 22478860
drug utilization; antimicrobials; fluoroquinolones; policies; utilisation des médicaments; antimicrobiens; fluoroquinolones; politiques
16.  Medication Persistence Rates and Factors Associated with Persistence in Patients Following Stroke: A Cohort Study 
BMC Neurology  2008;8:25.
Background
Medication nonadherence can be as high as 50% and results in suboptimal patient outcomes. Stroke patients in particular can benefit from pharmacotherapy for thrombosis, hypertension, and dyslipidemia but are at high risk for medication nonpersistence.
Methods
Patients who were admitted to the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia, with stroke between January 1, 2001 and December 31, 2002 were analyzed. Data collected were pre-stroke function, stroke subtype, stroke severity, patient outcomes, and medication use at discharge, and six and 12 months post discharge. Medication persistence at six and 12 months and the factors associated with nonpersistence at six months were examined using multivariable stepwise logistic regression.
Results
At discharge, 420 patients (mean age 68.2 years, 55.7% male) were prescribed an average of 6.4 medications and mean prescription drug cost was $167 monthly. Antihypertensive (91%) and antithrombotic (96%) drug use at discharge were frequent, antilipidemic (73%) and antihyperglycemic (25%) drug use were less common. Self-reported persistence at six and 12 months after stroke was high (> 90%) for all categories.
In the multivariable model of medication nonpersistence at six months, people aged 65 to 79 years were less likely to be nonpersistent with antihypertensive medications than people aged 80 years or more (Odds ratio (OR) 0.11, 95% Confidence Interval (CI) 0.03–0.39). Monthly drug costs of < $90 or $90–199.99 were associated with greater nonpersistence, compared to monthly drug costs ≥$200 (OR 6.74, 95% CI 1.32–34.46 for < $90; OR 5.25, 95% CI 1.14–24.25 for $90–199.99). For the antithrombotic drug category, people aged 65 to 79 years were less likely to be nonpersistent than people aged 80 years or more (OR 0.23, 95% CI 0.06–0.81), and people who were disabled before admission were more likely to be nonpersistent than those not disabled (OR 7.01, 95% CI 1.66–29.58).
Conclusion
Patients reported high medication persistence rates six and 12 months after stroke. Identification of factors associated with nonpersistence (such as older age and prior disability) will help predict which patients are at higher risk for discontinuing their medications.
doi:10.1186/1471-2377-8-25
PMCID: PMC2474854  PMID: 18616796
17.  The relationship between type of drug therapy and blood glucose self-monitoring test strips claimed by beneficiaries of the Seniors' Pharmacare Program in Nova Scotia, Canada 
Background
The healthcare expenditure on self-monitoring of blood glucose (SMBG) test strips under the Nova Scotia Seniors' Pharmacare Program (NSSPP) has increased significantly in recent years. The objective of this study was to identify the frequency and cost of claims for blood glucose monitoring test strips by NSSPP beneficiaries in the fiscal year 2005/06 and to explore the variation in the use of test strips by type of treatment, age and sex.
Methods
Retrospective analysis was conducted using pharmacy administrative claims data for NSSPP beneficiaries. Study subjects were aged ≥ 65 years on October 1, 2004, received SMBG test strips in the 110 days prior to April 1, 2005, and were alive throughout the twelve month study period. Subjects were categorized into four groups: insulin only, oral antihyperglycemic agents (OAA) only, both OAA and insulin; and no reimbursed diabetes medications. Statistical analysis was performed to identify differences in expenditure by medication group and in frequency of SMBG test strips claimed by medication group, age, and sex.
Results
Of 13,564 included beneficiaries, 13.2% were categorized as insulin only, 53.5% OAA only, 7.2% both OAA and insulin, and 26.0% no reimbursed diabetes medications. Over half (58.7%) were femle. The insulin only category had the highest mean (± SD) number of SMBG test strips claimed per day (2.0 ± 1.5) with a mean annual total cost of $615 ± $441/beneficiary. Beneficiaries aged 80 years and above claimed fewer test strips than beneficiaries below 80 years.
Conclusion
This population based study shows that in Nova Scotia the SMBG test strips claimed by the majority of seniors were within Canadian guidelines. However, a small proportion of beneficiaries claimed for SMBG test strips infrequently or too frequently, which suggests areas for improvement. The provincial drug plan covers the majority of the costs of test strip utilization, suggesting that the majority of test strips claimed did not exceed the maximum allowable cost (MAC) established in the program's MAC policy. Drug insurance programs need to work with healthcare providers to determine if patients are using test strips optimally; and to determine their impact on patient outcomes. In addition, they need to determine the cost-effectiveness of their SMBG test strip reimbursement policies.
doi:10.1186/1472-6963-8-111
PMCID: PMC2426696  PMID: 18501012
18.  Drug information resources used by nurse practitioners and collaborating physicians at the point of care in Nova Scotia, Canada: a survey and review of the literature 
BMC Nursing  2006;5:5.
Background
Keeping current with drug therapy information is challenging for health care practitioners. Technologies are often implemented to facilitate access to current and credible drug information sources. In the Canadian province of Nova Scotia, legislation was passed in 2002 to allow nurse practitioners (NPs) to practice collaboratively with physician partners. The purpose of this study was to determine the current utilization patterns of information technologies by these groups of practitioners.
Methods
Nurse practitioners and their collaborating physician partners in Nova Scotia were sent a survey in February 2005 to determine the frequency of use, usefulness, accessibility, credibility, and current/timeliness of personal digital assistant (PDA), computer, and print drug information resources. Two surveys were developed (one for PDA users and one for computer users) and revised based on a literature search, stakeholder consultation, and pilot-testing results. A second distribution to nonresponders occurred two weeks following the first. Data were entered and analysed with SPSS.
Results
Twenty-seven (14 NPs and 13 physicians) of 36 (75%) recipients responded. 22% (6) returned personal digital assistant (PDA) surveys. Respondents reported print, health professionals, and online/electronic resources as the most to least preferred means to access drug information, respectively. 37% and 35% of respondents reported using "both print and electronic but print more than electronic" and "print only", respectively, to search monograph-related drug information queries whereas 4% reported using "PDA only". Analysis of respondent ratings for all resources in the categories print, health professionals and other, and online/electronic resources, indicated that the Compendium of Pharmaceuticals and Specialties and pharmacists ranked highly for frequency of use, usefulness, accessibility, credibility, and current/timeliness by both groups of practitioners. Respondents' preferences and resource ratings were consistent with self-reported methods for conducting drug information queries. Few differences existed between NP and physician rankings of resources.
Conclusion
The use of computers and PDAs remains limited, which is also consistent with preferred and frequent use of print resources. Education for these practitioners regarding available electronic drug information resources may facilitate future computer and PDA use. Further research is needed to determine methods to increase computer and PDA use and whether these technologies affect prescribing and patient outcomes.
doi:10.1186/1472-6955-5-5
PMCID: PMC1590010  PMID: 16822323
19.  Hypertension control: results from the Diabetes Care Program of Nova Scotia registry and impact of changing clinical practice guidelines 
Background
The objective of this study was to determine the rate of blood pressure control according to 4 sets of Canadian guidelines published over a decade in patients with diabetes mellitus attending Diabetes Centres in the province of Nova Scotia.
Methods
One hundred randomly selected charts from each of 13 Diabetes Centres audited between 1997 and 2001 were extracted from the Diabetes Care Program of Nova Scotia Registry. Multivariate logistic regression analyses examined the relationship between individual characteristics and self-reported antihypertensive use. Included were 1132 adults, mean age 63 years (48% male), with 9 years mean time since diagnosis of diabetes.
Results
According to the 1992 guidelines, 63% of the patients and according to the 2003 guidelines, 84% of patients were above target blood pressure or receiving antihypertensive medications. Forty-seven percent of patients are considered to be hypertensive and not on treatment according to 2003 guidelines. The results of the multivariate analyses showed that the only factors independently associated with anti-hypertensive use was oral anti-hyperglycemic use.
Conclusion
Hypertension is an additional risk factor in those with diabetes mellitus for macrovascular and microvascular complications. The health and budgetary impacts of addressing the treatment gap need to be further explored.
doi:10.1186/1475-2840-4-11
PMCID: PMC1215496  PMID: 16033647
20.  Evidence-based cardiovascular care in the community: A population-based cross-sectional study 
Background
Ischaemic heart disease and congestive heart failure are common and important conditions in family practice. Effective treatments may be underutilized, particularly in women and the elderly. The objective of the study was to determine the rate of prescribing of evidence-based cardiovascular medications and determine if these differed by patient age or sex.
Methods
We conducted a two-year cross-sectional study involving all hospitals in the province of Nova Scotia, Canada. Subjects were all patients admitted with ischaemic heart disease with or without congestive heart failure between 15 October 1997 and 14 October 1999. The main measure was the previous outpatient use of recommended medications. Chi-square analyses followed by multivariate logistic regression analyses were used to examine age-sex differences.
Results
Usage of recommended medications varied from approximately 60% for beta-blockers and angiotensin converting enzyme (ACE) inhibitors to 90% for antihypertensive agents. Patients aged 75 and over were significantly less likely than younger patients to be taking any of the medication classes. Following adjustment for age, there were no significant differences in medication use by sex except among women aged 75 and older who were more likely to be taking beta-blockers than men in the same age group.
Conclusions
The use of evidence-based cardiovascular medications is rising and perhaps approaching reasonable levels for some drug classes. Family physicians should ensure that all eligible patients (prior myocardial infarction, congestive failure) are offered beta-blockers or ACE inhibitors.
doi:10.1186/1471-2296-5-6
PMCID: PMC416476  PMID: 15059290
22.  Is There A Problem With Benzodiazepine Prescribing In Maritime Canada? 
Canadian Family Physician  1985;31:1591-1596.
The benzodiazepine prescribing habits of 64 maritime doctors were studied through collection and examination of carbon copies of all prescriptions over a 22 week period. Diazepam was the most frequently prescribed anxiolytic benzodiazepine, followed by chlordiazepoxide, then oxazepam. These three drugs accounted for almost 60% of all benzodiazepine prescriptions. Triazolam and flurazepam were prescribed eight times more frequently than the other hypnotics, nitrazepam and temazepam. The number of prescriptions judged to be inappropriately excessive was small (3.3% of 7,066). Efforts by drug manufacturers, pharmaceutical sales representatives and CME providers are needed to make the practicing physician aware of the phamacokinetics of the different benzodiazepines, so that an appropriate choice of drug and frequency of daily doses can be made.
PMCID: PMC2327851  PMID: 21274169
Benzodiazepines; therapeutics; prescribing habits
23.  Proton pump inhibitors and the risk of hospitalisation for community-acquired pneumonia: replicated cohort studies with meta-analysis 
Gut  2013;63(4):552-558.
Objective
Previous observational studies suggest that the use of proton pump inhibitors (PPIs) may increase the risk of hospitalisation for community-acquired pneumonia (HCAP). However, the potential presence of confounding and protopathic biases limits the conclusions that can be drawn from these studies. Our objective was, therefore, to examine the risk of HCAP with PPIs prescribed prophylactically in new users of non-steroidal anti-inflammatory drugs (NSAIDs).
Design
We formed eight restricted cohorts of new users of NSAIDs, aged ≥40 years, using a common protocol in eight databases (Alberta, Saskatchewan, Manitoba, Ontario, Quebec, Nova Scotia, US MarketScan and the UK's General Practice Research Database (GPRD)). This specific patient population was studied to minimise bias due to unmeasured confounders. High-dimensional propensity scores were used to estimate site-specific adjusted ORs (aORs) for HCAP at 6 months in PPI patients compared with unexposed patients. Fixed-effects meta-analytic models were used to estimate overall effects across databases.
Results
Of the 4 238 504 new users of NSAIDs, 2.3% also started a PPI. The cumulative 6-month incidence of HCAP was 0.17% among patients prescribed PPIs and 0.12% in unexposed patients. After adjustment, PPIs were not associated with an increased risk of HCAP (aOR=1.05; 95% CI 0.89 to 1.25). Histamine-2 receptor antagonists yielded similar results (aOR=0.95, 95% CI  0.75 to 1.21).
Conclusions
Our study does not support the proposition of a pharmacological effect of gastric acid suppressors on the risk of HCAP.
doi:10.1136/gutjnl-2013-304738
PMCID: PMC3963530  PMID: 23856153
Proton Pump Inhibition; Gastroesophageal Reflux Disease; Epidemiology; Meta-Analysis

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