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Objectives: Electronic medical record (EMR) prescription data may identify high antibiotic prescribers in primary care. However, practitioners doubt that population differences between providers and delayed antibiotic prescriptions are adequately accounted for in EMR-derived prescription rates. This study assessed the validity of using EMR prescription data to produce antibiotic prescription rates, accounting for these factors. Methods: The study was a secondary analysis of antimicrobial prescriptions collected from 4 primary care clinics from 2015 to 2017. For adults with selected respiratory and urinary infections, EMR diagnostic codes, prescription data, clinical diagnoses and demographics were abstracted. Overall and delayed prescription rates were produced for EMR diagnostic codes, clinical diagnoses, by clinic, and types of infection. Direct standardization was used to adjust for case mix differences by clinic. High antibiotic prescribers, above the 75th percentile for prescriptions, were compared with low antibiotic prescribers. Results: Of 3108 EMR visits, there were 2577 (85.4%) eligible visits with a clinical diagnosis and prescription information. Overall antibiotic prescription rates were similar utilizing EMR records (31.6%) or clinical diagnoses (32.6%, P =.40). When delayed prescriptions were removed, prescribing rates were lower (22.4%, P <.01). EMR data overestimated prescribing rates for conditions where antibiotics are usually not indicated (17.7% EMR vs 7.6% clinical diagnoses, P <.001). High antibiotic prescribers saw more cases where antibiotics are usually indicated (23.4%) compared to low prescribers (16.8%; P =.001). Conclusions: Electronic medical record prescribing rates are similar to those using clinical diagnoses overall, but overestimate prescribing by clinicians for conditions usually not needing antibiotics. EMR prescription rates do not account for delayed antibiotic prescriptions or differences in infection case-mix. [ABSTRACT FROM AUTHOR]

Agitation is a common presenting symptom of delirium for older adults in the emergency department (ED). No medications have been found to reduce delirium severity, symptoms, or mortality, yet they may cause harm. Guidelines suggest using medications only when patients are posing a risk of harm, situations which may arise frequently in the ED. We sought to characterize prescribing patterns of medications for agitation by ED physicians in Canadian hospitals. In this multicenter study, we surveyed physicians in Vancouver, Toronto, and Sherbrooke. Descriptive statistics were used to summarize group characteristics and starting doses were compared to order sets. Fisher exact tests were used for demographic comparison. Ordinal linear regression models were run to identify a relationship between starting dose of medications and location. Of the 137 physicians invited, 77 (56%) completed the survey. Use of order sets was greatest in Sherbrooke and least in Vancouver. The most common medications used across sites were haloperidol, lorazepam, and quetiapine. Benzodiazepines were used across all sites but were used significantly more frequently in Vancouver than the other sites. Practice location was a significant predictor of starting dose of haloperidol, with Sherbrooke and Toronto having a lower starting dose than Vancouver. Higher use of order sets correlated with lower and more consistent starting doses. Benzodiazepines are used across EDs in Canada despite little evidence for efficacy in delirium and risk of harm. Implementation of order sets may be a useful way to standardize ED management of older adults experiencing hyperactive delirium. [ABSTRACT FROM AUTHOR]

Living with rheumatoid arthritis (RA) for almost 40 years has not been an easy journey. My disease has been severe and difficult to manage; from the beginning there were challenges getting a diagnosis and in finding medications that were effective long term. Thirty years ago, unable to cope with the extreme pain and with 3 children aged 8, 11, and 13 who needed a functioning mother, my doctor prescribed an opioid. This medication gave me back some quality of life but taking opioids is not without significant risks. No one discussed the challenges I would face if and when the time came to stop taking them. With the opioid crisis there has been more pressure from government and medical licensing bodies to implement policies to restrict access for patients prescribed opioids and to encourage tapering. With the change in policy additional funding and resources are needed to help patients through the process but those supports do not exist across Canada. [ABSTRACT FROM AUTHOR]

Background: Canadians seeking medical cannabis (MC) may encounter difficulties in finding a healthcare provider (HCP) who authorizes their access to it. Barriers that HCPs face in authorizing MC are unclear. The objectives of this study were to evaluate HCP opinions, knowledge, comfort, and practice in MC prescribing and counseling on recreational cannabis use, and whether the COVID-19 pandemic affected MC prescribing practices. Methods: Eligible participants included HCPs (e.g., attending physicians, nurses, pharmacists) in Canada. A questionnaire evaluating their knowledge, comfort, and practice in medical and recreational cannabis was designed based on instruments developed in previous studies. Between April 13th-December 13th 2021, ninety-one healthcare associations were asked to distribute the survey to their members, and an advertisement was placed in the online Canadian Medical Association Journal. Descriptive statistics were used to analyze the results. Results: Twenty-four organizations agreed to disseminate the survey and 70 individuals completed it. Of respondents, 71% were attending physicians or medical residents, while the remainder were nurses, pharmacists or other HCPs. Almost none (6%) received training in MC in professional school but 60% did receive other training (e.g., workshops, conferences). Over half (57%) received more questions regarding MC since recreational cannabis was legalized, and 82% reported having patients who use MC. However, 56% felt uncomfortable or ambivalent regarding their knowledge of MC, and 27% were unfamiliar with the requirements for obtaining MC in Canada. The most common symptoms for recommending MC were pain and nausea, whereas the most common conditions for recommending it were cancer and intractable pain. The strongest barrier to authorizing MC was uncertainty in safe and effective dosage and routes of administration. The strongest barrier to recommending or authorizing MC was the lack of research evidence demonstrating its safety and efficacy. During the pandemic, many respondents reported that a greater number of their patients used cannabis to relieve anxiety and depression. Conclusions: Our results suggest that HCPs across Canada who responded to our survey are unfamiliar with topics related to MC. The strongest barriers appear to be lack of clinical research, and uncertainty in safe and effective MC administration. Increasing research, training, and knowledge may help HCPs feel more equipped to make informed treatment/prescribing decisions, which may help to improve access to MC. [ABSTRACT FROM AUTHOR]

BACKGROUND: Cognitive dysfunction is prevalent in multiple sclerosis (MS) and can have a negative effect on several aspects of the daily lives of individuals with MS. In 2010, members of the Consortium of Multiple Sclerosis Centers (CMSC) were surveyed to understand MS clinicians' screening, assessment, and treatment practices for cognitive problems. Given the advancements made in the field in the past decade, it was deemed time to reevaluate how cognitive dysfunction is managed in the clinical setting. METHODS: An online questionnaire was completed by 56 CMSC members. They were asked to describe their clinical practices, procedures for screening and further evaluation, and treatment recommendations for cognitive dysfunction. Participants were also asked whether their practice had changed in terms of the number of cognitive screenings, prescriptions for cognitive problems, and referrals for neuropsychological assessment and cognitive remediation in the past 5 years to allow for clinicians who had not been in practice for 10 years. RESULTS: Participants reported an increase in the number of cognitive screenings and referrals for neuropsychological assessments and cognitive remediation during the past 5 years. Compared with 2010, participants endorsed greater use of person-administered screening measures, such as the Symbol Digit Modalities Test, and fewer prescriptions for medications to improve cognitive functioning. CONCLUSIONS: Clinical practices are becoming more in line with the literature, with increased use of cognitive screening and remediation. Continued attention to cognitive problems will be an ongoing important component of MS-related care. [ABSTRACT FROM AUTHOR]

Background We evaluated the prescribing practices of anticonvulsant (AC) adjuncts to benzodiazepines in managing Alcohol Withdrawal Syndrome (AWS). We also examined the prescription of relapse prevention agents for Alcohol Use Disorder (AUD), and adverse events related to AWS treatment. Methods Records were reviewed retrospectively pertaining to medically ill adults aged 60 and above with AWS and admitted to a medicine or hospitalist unit of a Canadian centre between June 2013 and June 2018. Duration and dosing of benzodiazepine, dosing and type of AC and AUD agent, and adverse events were collected. A multivariable regression model was employed. Results 83 encounters were included in the study and 28 were prescribed an AC. The amount and duration of benzodiazepine administered were not statistically different between the benzodiazepine only and the AC adjunct groups, once severe AWS complications were accounted for. Five new prescriptions of traditional AUD agents were provided on discharge. No AC-associated adverse events occurred. Conclusions AC adjuncts for AWS did not decrease the amount of benzodiazepine administered nor shorten the duration of treatment. Their routine use is not supported by our findings. Our study highlights a missed opportunity for AUD agents to be prescribed during hospitalization. [ABSTRACT FROM AUTHOR]

Introduction: During the COVID-19 pandemic, with the implementation of social distancing regulations, there is increased concern around the mental health of the general population, including depression and anxiety. Mental health prescribing trends in Canada during COVID-19, at the time of writing, have not been investigated. Methods: This pilot study collected refill information of 365 patients from an independent community pharmacy in North York, Ontario to compare (1) initiation, (2) dose change, (3) dispensing frequency, and (4) defined daily dose of first-line antidepressants as defined by the Canadian Network for Mood and Anxiety Treatments and other select medications, including Z-drugs and benzodiazepines. Data from January 1 to May 31, 2019 were compared with data from January 1 to May 31, 2020. Results: The number of newly initiated antidepressant and antianxiety medications during the COVID-19 pandemic was not significantly affected compared to the same months in the prior year (Z=-1.149, p=0.251). Upon investigation of logistic regression, age was significantly correlated to antidepressant initiation in the year prior (p=0.038) whereas it was not during COVID-19, which may represent an increase in antidepressants in the younger population. There was a significant difference in the number of dose changes, which occurred between the two years, showing significantly more increases and switches of therapy (p=0.008) during COVID-19. There was significantly more frequent dispensing of benzodiazepine tablets (Z=2.402, p=0.016) in the first five months of 2020 compared to those of 2019. There were no statistically significant changes in the number of defined daily doses. Discussion: There are shifting trends in mental health prescribing. This result is concerning during a time when accessing appropriate mental health care is significantly impacted. This study emphasizes the need for benzodiazepine deprescribing due to the increase in benzodiazepines dispensed and the risk of misuse, tolerance, and dependence with long-term benzodiazepines. [ABSTRACT FROM AUTHOR]

Introduction: Fluoroquinolones (FQs) are a commonly prescribed class of antibiotics in Canada. Evidence of a constellation of possible adverse events is developing. Central and peripheral nervous system abnormalities and collagen-related events (including aortic aneurysm/dissection, tendinopathy/rupture and retinal detachment) are associated with FQ exposure in large population-based aftermarket studies. In 2017, Health Canada warned about rare FQ-related persistent or disabling side effects. This study explores FQ use in a rural community. Methods: Antibiotic prescriptions (including FQs) in the over 18 adult population (5416) were measured in the town of Sioux Lookout for 5 years, January 2013 to 31 December 2017. Results: FQ prescriptions accounted for 16.0% of adult antibiotics, superseded by penicillins (21.1%) and macrolides (18.2%). Ciprofloxacin accounted for one half of FQ use (51.2%), followed by levofloxacin (36.7%) and norfloxacin (13.3%). FQs were commonly used for respiratory (33%) and urinary tract infections (18%). Conclusion: Aftermarket evidence reports increased risk of 'disabling and persistent serious adverse events'(Health Canada) in patients using FQs. Appropriate clinical caution should be exercised in the prescribing of FQs. Common overuse seems to occur in the treatment of uncomplicated community-acquired pneumonia and cystitis, despite recommendations to use other antimicrobial agents as first-line treatments. [ABSTRACT FROM AUTHOR]

Background Benzodiazepine receptor agonist (BZRA) use disorder among older adults is a relatively common and challenging clinical condition. Method The Canadian Coalition for Seniors' Mental Health, with financial support from Health Canada, has produced evidencebased guidelines on the prevention, identification, assessment, and management of this form of substance use disorder. Results Inappropriate use of BZRAs should be avoided by considering non-pharmacological approaches to the management of late life insomnia, anxiety, and other common indications for the use of BZRA. Older persons should only be prescribed BZRAs after they are fully informed of alternatives, benefits, and risks associated with their use. Clinicians should have a high index of suspicion for the presence of BZRA use disorders. The full version of these guidelines can be accessed at www.ccsmh.ca Conclusions A person-centred, stepped care approach utilizing gradual dose reductions should be used in the management of BZRA use disorder. [ABSTRACT FROM AUTHOR]

Background: The International Duration Evaluation of Adjuvant Chemotherapy (IDEA) collaboration aimed to evaluate whether 3 months of adjuvant chemotherapy are noninferior to 6 months. Our study objectives were to characterize medical oncologists' perspectives toward the results of the IDEA collaboration and to evaluate how IDEA impacted prescribing patterns of adjuvant FOLFOX and CAPOX in colon cancer. Materials and Methods: A list of questions developed by four medical oncologists regarding IDEA results were formulated and distributed online to gastrointestinal medical oncologists globally. Descriptive statistics and chi‐square tests were used to summarize information. Results: Of 174 responses, 145 were complete and analyzed. Responses were obtained globally from South America (53%); the U.S. and Canada (28%); Europe, Australia, and New Zealand (12%); and Asia (7%). Most clinicians (98%) were aware of the IDEA study. Prior to IDEA, clinicians preferred FOLFOX over CAPOX (81% vs. 19%). Subsequent to IDEA, 55% of clinicians preferred CAPOX over FOLFOX (odds ratio, 5.0; 95% confidence interval, 3.0–8.5; p <.01 compared with pre‐IDEA). Two thirds (68%) of responders tailored duration of adjuvant therapy based on risk stratification. Most oncologists (76%) were more willing to discontinue oxaliplatin early if toxicities develop after the results of IDEA. Half of responders (50%) found that IDEA increased their confidence in decision making for adjuvant treatment; 36% were unchanged, and 15% indicated decreased confidence. Less than half (48%) were comfortable communicating the study results and the concept of a noninferiority trial with patients. Conclusion: IDEA appears to have shifted clinician preference from FOLFOX to CAPOX for adjuvant therapy, and most clinicians now use a risk‐stratified approach in determining duration of adjuvant therapy. Patient education resources may facilitate better communication of IDEA results to patients. Implications for Practice: This global survey illustrates that most gastrointestinal medical oncologists now use a risk‐stratified approach for determining the duration of adjuvant chemotherapy for stage III colon cancer. Clinicians are five times more likely to choose CAPOX over FOLFOX after the International Duration Evaluation of Adjuvant Chemotherapy (IDEA) collaboration results. This article reports medical oncologists' perspectives on the results of the IDEA Collaboration and assesses the real‐world update of this data. [ABSTRACT FROM AUTHOR]

The article discusses a study on the incidence of opioid use three months after an initial prescription and the reasons for consumption. Topics include exclusion of patients who did not speak French or English, the number of patients who were included at three-month follow-up, and percentage of an opioid naive population that chronically uses opioids at three months.

Background Utilization of psychotropic medications among the elderly has garnered attention due to concerns about safety and degree of efficacy, but may be used differently across regions. Methods We conducted a cross-sectional study of all antipsychotic, benzodiazepine, and trazodone prescriptions dispensed to seniors (≥ 65 years) leveraging IQVIA (Durham, NC) GPM data in 2013. We report the units dispensed (per 100 seniors) by province. Results Nationally, on average, 26,210 units of antipsychotics, 24,257 of benzodiazepines, and 7,519 of trazodone were dispensed in 2013 for every 100 seniors; reports varied across Canada. The rate of antipsychotic and benzodiazepine prescribing was highest in New Brunswick (AP: 35,375 units per 100, BZD: 43,989 units per 100), and lowest in Newfoundland & Labrador for antipsychotics (20,974 per 100) and Saskatchewan for benzodiazepines (12,692 per 100). Trazodone unit dispensation rates were highest in Nova Scotia (9,164 per 100) and lowest in Newfoundland & Labrador (2,968 per 100). Conclusions There is considerable geographic variation in the prescribing patterns of antipsychotics, benzodiazepine, and trazodone. This study serves as the first step in understanding these differences, while future work is needed to develop regionspecific strategies to optimize the prescribing of psychotropic medications to older Canadian adults. [ABSTRACT FROM AUTHOR]

Sexual and reproductive health is an important component of comprehensive health care for youth. This statement provides guidance for selecting and prescribing contraceptives for youth, including commonly prescribed hormonal contraceptives—the pill, patch, ring and injectable progestin—and long-acting reversible contraceptives (LARCs). LARCs, including subdermal implants (which are not available in Canada) and intrauterine contraceptives (IUCs), are substantially more effective during typical use than hormonal contraceptives. This statement endorses LARCs as the first-line option for contraception for Canadian youth, while emphasizing that providers must collaborate with youth to select a contraceptive method that is acceptable, safe, effective and practical for them. Strategies that eliminate obstacles to initiating and continuing contraception are provided. [ABSTRACT FROM AUTHOR]

Background: Empirical prescribing of antibiotics to women with symptoms of acute cystitis prior to culture results is common, but subsequent culture results are often negative. A clinical decision aid for prescribing decisions in acute cystitis was previously developed that could reduce these unnecessary antibiotic prescriptions but has not been validated. This study sought to validate this decision aid for empirical antibiotic prescribing decisions in a new cohort of women with suspected acute cystitis. Methods: External validation study of a clinical decision aid in 397 women with symptoms of acute cystitis, involving 230 Canadian family practitioners across Canada between 2009 and 2011. The sensitivity and specificity of the decision aid compared to a gold standard positive urine culture (defined as ≥10² cfu/ml (≥105 CFU/L)) was determined, and compared with physician management, and the earlier development cohort study estimates. Other outcomes assessed were total antibiotic prescriptions, unnecessary antibiotics for negative urine cultures, and recommendations for urine culture testing. Chi-square tests were used for unpaired comparisons, adjusted for physician clustering. McNemar's test was used for paired comparisons. Results: There were 245/397 (61.7%) positive urine cultures. The cystitis aid sensitivity was 202/245 (82.5%, 95% Confidence Interval (CI)) = 77.1%, 86.8%), compared to 167/208 (80.3%) in the previous development cohort (p = 0.54), and 239/245 (97.6%) by family physicians in the current study (p < 0.001). Specificity was low for physicians (10/152, 6.6%) compared to the decision aid (54/152, 35.5%; p < 0.001, resulting in more antibiotic prescriptions by physicians (381/397, 96.0%) than would occur with decision aid recommendations (300/397, 75.6%, p < 0.001). Unnecessary antibiotic prescriptions where urine cultures were negative would be reduced an absolute 11.1% with cystitis aid recommendations (98/397, 24.7%) compared to usual physician care (142/397, 35.8%; p = 0.001). Urine cultures would also be reduced (97/397, 24.4% decision aid vs 351/397, 88.4% physicians; p < 0.001). Conclusions: A 3-item clinical decision aid demonstrated reproducible accuracy in two cohorts of women with acute cystitis symptoms. Clinically important reductions in total and unnecessary antibiotic use, as well as urine culture testing, could result with routine clinical use compared to current empirical physician management practices. [ABSTRACT FROM AUTHOR]

Objective. Access to pregabalin via Ontario's public drug insurance program was expanded to an unrestricted model on April 1, 2013, from a prior authorization model. This study aims to identify the effect of expanded access on the rate of pregabalin use by publicly insured persons and to assess the characteristics of new patients initiating pregabalin following this expanded access. Methods. We conducted a cross-sectional time series analysis using the linked health administrative records of residents of Ontario, Canada, with public drug coverage who were dispensed a prescription for pregabalin between April 1, 2006, and December 31, 2014. Results. A total of 108,047 publicly insured persons were dispensed pregabalin over the study period. The overall rate of pregabalin use increased from 1.0 per 1,000 individuals in Q1 of 2013 to 22.0 per 1,000 individuals in Q4 of 2014. Musculoskeletal (81.6%) and neurological (68.1%) conditions were the most prevalent diagnoses in patients who initiated pregabalin following the expansion of access. Past and concomitant use of opioids, nonsteroidal anti-inflammatory drugs, and antidepressants was also common in this population. Conclusions. Formulary changes in Ontario have led to expanded access to pregabalin, which may have led to an increase in off-label use of these products and potential patient risk associated with concomitant use of pregabalin with central nervous system-depressing drugs. [ABSTRACT FROM AUTHOR]

The article offers information on the efforts for improving paediatric medications for Canadian children and youth. It discusses the policies governing the development, approval and reimbursement of medicines for adult populations; discussions on the need for process redesign for regulatory and reimbursement systems; and the information on the need to expand commercial access for child-friendly formulations.

Background: Dyslipidemia is an important risk factor for cardiovascular disease but is suboptimally managed. Pharmacists are accessible primary care professionals and with expanded scopes of practice (including prescribing), could identify and manage patients with dyslipidemia. We sought to evaluate the effect of pharmacist prescribing of dyslipidemia medications on the proportion of participants achieving target LDL-cholesterol (LDL-c) levels. Methods: We conducted a randomized controlled trial in 14 community pharmacies in Alberta, Canada. We enrolled adults with uncontrolled dyslipidemia as defined by the 2009 Canadian Dyslipidemia Guidelines. Intervention was pharmacist-directed dyslipidemia care, including assessment of cardiovascular risk, review of LDL-c, prescribing of medications, health behaviour interventions and follow-up every 6 weeks for 6 months. Usual care patients received their lipid results and a pamphlet on cardiovascular disease and usual care from their physician and pharmacist. Primary outcome was the proportion of participants achieving their target LDL-c (<2 mmol/L or ≥50% reduction) at 6 months between groups. Results: We enrolled 99 patients with a mean (SD) age of 63 (13) years, 49% male and baseline LDL-c of 3.37 mmol/L (0.98). Proportion of patients achieving LDL-c target was 43% intervention versus 18% control (p = 0.007). Adjusted odds of achieving target LDL-c were 3.3 times higher for the intervention group (p = 0.031), who also achieved greater reduction in LDL-c (1.12 mmol/L, SE = 0.112) versus control (0.42 mmol/L, SE = 0.109), for an adjusted mean difference of 0.546 mmol/L (SE = 0.157), p < 0.001. Conclusion: Pharmacist prescribing resulted in >3-fold more patients achieving target LDL-c levels. This could have major public health implications. [ABSTRACT FROM AUTHOR]

The article offers pharmacists with a practice overview to assess appropriateness of inhalation devices for the treatment of chronic obstructive pulmonary disease (COPD) and provide accurate patient education on the available inhalers.

Background: Proton pump inhibitors (PPIs) are often used inappropriately, without an indication, or for longer durations than recommended. Few tools exist to guide reassessment of their continued use and deprescribing if required. We aimed to reduce inappropriate drug use by developing and implementing a PPI deprescribing tool and process in a family medicine unit. Assessment of Problem: Primary care providers of adults taking a PPI for 8 weeks with an upcoming periodic health examination were reminded to reassess therapy via electronic medical record (EMR) messaging. A PPI Deprescribing Tool was uploaded into the EMR as a second reminder and to guide reassessment and deprescribing where indicated. Ten weeks after the examination a chart review assessed changes to PPI use. A follow up survey of providers assessed the utility and barriers to implementing the Deprescribing Tool. Results: Forty-three of 46 patients on PPIs (93%) had their PPI reassessed, resulting in 11 patients (26%) having their PPI deprescribed. Strategies for Improvement: Routine reassessment of long-term medications is often overlooked because of extensive demands on primary care providers' time. Deprescribing likely improved because potentially eligible patients were identified to the provider and a tool was provided at the time of the encounter to guide the deprescribing process. Lessons: Reassessment and deprescribing of PPIs can be supported by implementing a standardised process and use of guidance tools for clinicians. Providers found the timely and selective reminder message to deprescribe the most useful component of the intervention. [ABSTRACT FROM AUTHOR]

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These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program. Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported directly to ISMP through the ISMP Web site (www.ismp.org), by calling 800-FAIL-SAFE, or via e-mail at ismpinfo@ismp.org. ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications. [ABSTRACT FROM AUTHOR]

Background: Several published surveys have shown that chiropractors are generally split in their opinions regarding the right to prescribe drugs in chiropractic practice. Many of these studies have been limited by low response rates, leaving the generalizability of their findings open to question. The aim of the current study was to ascertain the general attitudes of chiropractors in Ontario, Canada toward the inclusion of drug prescription rights in their scope of practice. Relationships between these attitudes and the number of years in practice including differences in philosophical orientation were also explored. Methods: A 14-item questionnaire was developed and invitations sent via e-mail to all eligible 2,677 chiropractors in active practice registered electronically with the College of Chiropractors of Ontario in February 2015. Data were collected and analyzed using descriptive and inferential statistics. Results: 960 questionnaires were completed for a 36 % response rate. The majority of respondents agreed that chiropractors should be permitted to prescribe musculoskeletal medications such as over-the-counter and prescription-based analgesics, anti-inflammatories, and muscle relaxants. Over two-thirds also felt that with limited prescriptive authority chiropractors could help reduce patients' reliance on these types of drugs. Over three-quarters were opposed however to chiropractors having full prescribing rights. The majority indicated they recommend over-the-counter medications to acute and chronic patients to some extent in clinical practice. Nearly two-thirds perceived their knowledge of musculoskeletal medications as high or very high, while a similar proportion perceived their knowledge of drugs for non-musculoskeletal conditions to be low or very low. A majority of respondents felt that further education in pharmacology would be necessary for those in the profession wishing to prescribe medications. More recent graduates and those who espoused a broad scope of chiropractic practice were most in favour of limited prescribing rights for the profession. Conclusions: A majority of responding Ontario chiropractors expressed interest in expanding their scopes of practice to include limited drug prescription. These results together with those of other recent surveys could indicate a shift in chiropractors' attitudes toward drug prescription rights within the profession. Further surveys and/or qualitative studies of chiropractors in other jurisdictions are still needed. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) is a common cardiac arrhythmia, and leading cause of ischemic stroke. Despite proven effectiveness, warfarin remains an under-used treatment in atrial fibrillation patients. We sought to study, across three physician specialties, a range of factors that have been argued to have a disproportionate effect on treatment decisions. Methods: Cross-sectional survey of Canadian Family Doctors (FD: n = 500), Geriatricians (G: n = 149), and Internal Medicine specialists (IMS: n = 500). Of these, 1032 physicians were contactable, and 335 completed and usable responses were received. Survey questions and clinical vignettes asked about the frequency with which they see patients with atrial fibrillation, treatment practices, and barriers to the prescription of anticoagulants. Results: Stated prescribing practices did not significantly differ between physician groups. Falls risk, bleeding risk and poor patient adherence were all highly cited barriers to prescribing warfarin. Fewer geriatricians indicated that history of patient falls would be a reason for not treating with warfarin (G: 47%; FD: 71%; IMS: 72%), and significantly fewer changed reported practice in the presence of falls risk (χ2 (6) = 45.446, p < 0.01). Experience of a patient having a stroke whilst not on warfarin had a significant impact on vignette decisions; physicians who had had patients who experienced a stroke were more likely to prescribe warfarin (χ2 (3) =10.7, p = 0.013). Conclusions: Barriers to treatment of atrial fibrillation with warfarin affect physician specialties to different extents. Prior experience of a patient suffering a stroke when not prescribed warfarin is positively associated with intention to prescribe warfarin prescription, even in the presence of falls risk. [ABSTRACT FROM AUTHOR]

Objective: The primary objective of this study was to quantify the impact of a clinical practice intervention to promote the delivery of salbutamol by metered-dose inhaler (MDI) in a pediatric emergency department (PED). A secondary objective was to retrospectively document the components of the intervention. Methods: PED inventory data for salbutamol inhalation solution (nebules), MDIs, and holding chambers were obtained from the pharmacy department. Patient data were obtained from the hospital's decision support unit. Interrupted time series analysis was used to evaluate trends in salbutamol inventory data, patient triage acuity, and hospital admissions from January 1, 2003, to May 31, 2010. Interviews and administrative documents were used to identify components of the intervention, which began in 2006. Results: There was a 1,215% increase in the proportion of salbutamol delivered as MDIs compared to total inhaled salbutamol (MDI plus nebulization solution) following the intervention (95% CI 1,032% to 1,396%, p < 0.001). Increases in salbutamol MDI use were associated with the implementation of an institution-specific asthma care map. A relative decrease of 32% in the hospital admission rate (absolute -7.25%: 95% CI -8.31 to -6.19, p < 0.001) was associated with the change in salbutamol MDI use and the use of the asthma care map. Conclusions: A multifaceted intervention, designed and implemented by local PED clinical leaders, resulted in a pronounced change in salbutamol inhalation practice, with an associated decrease in admission rates. This intervention demonstrated many of the criteria for successful health system change. Findings from this research may be con-textualized to inform change elsewhere. [ABSTRACT FROM AUTHOR]

Purpose. Significant advances in the systemic management of metastatic non-small cell lung cancer (NSCLC) have occurred over the past decade, with options now including multiple lines of chemotherapy, epidermal growth factor receptor inhibitors, and antiangiogenic agents. Improvements in overall survival have been demonstrated in randomized controlled trials comparing these newer agents with best supportive care or standard therapy. This study examined uptake of these therapies in general practice and their impact on survival. Methods. This retrospective cohort study compared demographic, treatment, and survival data among 987 patients diagnosed with stage IV NSCLC at two institutions in 1998, 2003, and 2008. Cohorts were selected based on intervals when doublet chemotherapy, second-line chemotherapy, and targeted agents were incorporated into the standard treatment regimen. Results. The proportion of patients receiving systemic therapy increased over time (20% in 1998, 42% in 2008). Overall survival improved significantly across cohorts (p<.001), with 2-year survival rates of 0.3% in 1998, 4% in 2003, and 15% in 2008. In amultivariate survival analysis, the 2003 and 2008 cohorts were independently associated with longer survival, as was the use of one or more lines of systemic therapy. Elderly patients (aged ≥70 years) were also more likely to receive systemic therapy over time, with longer overall survival (p < .001). Conclusion. Over the past decade, there has been an increasing use of systemic therapy in stage IV NSCLC patients, including the elderly. This has been associated with significantly longer overall survival. [ABSTRACT FROM AUTHOR]

Background: Acceptance to a family practice is key to access and continuity of care. While Canadian patients increasingly report not being able to acquire acceptance to a family practice, little is known about the association between requiring opioids and acceptance. We aim to determine the proportion of family physicians who would accept new patients who require opioids and describe physician and practice characteristics associated with willingness to accept these patients. Methods: Census telephone survey of family physicians' practices in Nova Scotia, Canada. Measures: physician (i.e., age, sex, years in practice) and practice (i.e., number/type of provider in the practice, care hours/week) characteristics and practice-reported willingness to accept new patients who require opioids. Results: The survey was completed for 587 family physicians (83.7% response rate). 354 (60.3%) were taking new patients unconditionally or with conditions; 326 provided a response to whether they would accept new patients who require opioids; 91 (27.9%) reported they would not accept a new patient who requires opioids. Compared to family physicians who would not accept patients who require opioids, in bivariate analysis, those who would, tended to work in larger practices; had fewer years in practice; are female; and provided more patient care. The relationship to number of providers in the practice, having a nurse, and experience persisted in multivariate analysis. Conclusions: The strongest predictors of willingness to accept patients who require opioids are fewer years in practice (OR = 0.96 [95% CI 0.93, 0.99]) and variables indicating a family physician has support of a larger (OR = 1.19 [95% CI 1.00, 1.42]), interdisciplinary team (e.g., nurses, mental health professionals) (OR = 1.15 [95% CI 1.11, 5.05]). Almost three-quarters (72.1%) of surveyed family physicians would accept patients requiring opioids. [ABSTRACT FROM AUTHOR]

The article details recommendations of the Canadian Pharmacists Associatin (CPhA) on national issues for Canadian political candidates on the October 19, 2015 federal election. Topics covered include commitment of political parties to the development of a Pan-Canadian Pharmacare Program for access of people to low-cost medications and working with health care professionals on the National electronic (e)-Prescribing Plan. Also cited is the call to strengthen the National Immunization Strategy.