Past winners: Patient care

 



Heart Failure Medication Optimization Clinic   

Dr. Sheri Koshman
Mazankowski Alberta Heart Institute - Edmonton, Alberta

Background: Heart failure with reduced ejection fraction significantly affects many Canadians, leading to increased morbidity and mortality, as well as increased healthcare spending. As such, optimizing guideline-directed medical therapy (GDMT) is crucial for improving the health of HFrEF patients. The guidelines for this quadruple therapy for most of these patients with optimization being reached within 3 to 6 months. However, real-world data suggests that achieving timely optimization is challenging with the addition of multiple medications to standard care amongst other reasons. In turn, multidisciplinary strategies have been implemented to address low GDMT optimization rates and have shown effectiveness in improving GDMT utilization.  

Objectives: We sought to evaluate a focused medication optimization strategy led by a prescribing pharmacist and registered nurse team embedded within a specialty multidisciplinary heart failure clinic, compared to usual care in the same clinic.

Methods: The study compared patients with heart failure and reduced ejection fraction (HFrEF) receiving care in a pharmacist and nurse-led Medication Optimization Stream (Med-OpS) to those receiving usual care at the Mazankowski Alberta Heart Institute Heart Function Clinic (MAHI-HFC). Med-OpS, conducted from January 2022 to March 2023, involved a pharmacist and nurse team embedded within MAHI-HFC, focusing on medication optimization for HFrEF patients according to Canadian Cardiovascular Society guidelines. Patients were referred by clinic providers for quadruple guideline-directed medical therapy (GDMT) optimization, with the pharmacist prescribing and uptitrating medications, via telephone. MAHI-HFC, a tertiary care clinic for various heart failure types, typically handles medication optimization by providers or clinic nurses in-person or via telephone. The study inclusion criteria (March 2020 – September 2022) comprised patients aged over 18 with EF <40%, still alive six months post-first appointment, and excluded those receiving palliative care, with documented life expectancy <6 months, or already optimized GDMT. 

Results: Compared to MAHI-HFC, the Medication Optimization Stream (Med-OpS showed improvement in several areas. This includes an increase in the proportion of patients on optimal guideline-directed medical therapy (GDMT) and quadruple therapy, with approximately one-third of patients reaching full target doses, the overall utilization of most classes of GDMT improved, and including a notable change in the HFC-Score – though these improvements required more time and encounters. In addition, MAHI-HFC might still have been in the process of up-titration, given fewer encounters per patient and lower reported rates of physiologic barriers. The study's findings align with existing literature on the benefits of multidisciplinary care involving pharmacists and nurses in improving GDMT utilization. The Med-OpS strategy leveraged the expanded scope of pharmacy practice, including independent prescribing in Alberta. The study provided contemporary data on the utilization of quadruple therapy, including the use of mineralocorticoid receptor antagonists (MRAs), angiotensin receptor neprilysin inhibitors (ARNIs), and sodium-glucose cotransporter 2 inhibitors (SGLT2is), which is currently limited in the literature. Limitations of the study included its retrospective nature, which could introduce confounding factors and documentation biases. Referral to Med-OpS relied on physician or nurse practitioner discretion without a standardized protocol in place, potentially biasing the types of patients seen by Med-OpS. There were also significant baseline differences between the two groups, such as a larger proportion of patients with NYHA III symptoms and a lower proportion of hypertension in the HFC arm, although baseline physiologic parameters like B-type natriuretic peptide and systolic blood pressure were similar between groups. 

Conclusions: Utilizing a prescribing pharmacist and a registered nurse team embedded in a specialty heart failure clinic to perform focused medication optimization and titration can improve GDMT and help achieve guideline recommended timelines within 6 months when compared to usual specialty care. Future research should focus on determining the clinical and pharmacoeconomic outcomes of this strategy. 


The Sunnybrook Odette Cancer Centre Oral Anticancer Medication (OAM) Program

Christine Peragine and Victoria Bugaj
Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario 

Background: Increased availability of oral anticancer medications (OAMs) created a paradigm shift in oncology that introduced new challenges to treatment access, placed additional burden on the patient and prescriber to coordinate care, and increased risk for medication non-adherence and severe toxicity. Recognizing the emergent issues associated with OAM therapies, the Sunnybrook Odette Cancer Centre Pharmacy created an innovative program to optimize the clinical, and technical, medication-related support needed by OAM patients and prescribers

Objectives: OAM Program goals include: (1) coordinating timely and continuous OAM access; (2) improving OAM safety and effectiveness; (3) providing OAM information and education to patients, staff, and trainees; and (4) creating new knowledge on OAM-related practices, processes, and outcomes.

Methods: Dedicated pharmacy technicians liaise with prescribers, drug access navigators, and patient support programs to proactively resolve funding issues and facilitate timely medication access. Oncology pharmacists clinically verify each OAM order, perform drug-interaction analyses, and provide tailored education to optimize drug safety and adherence. The OAM Team has developed a variety of clinical tools to guide OAM management and ensures protocolized telephone follow-up for over 60 OAM agents.

Results:
 The OAM Team has enhanced the care of 3007 Oncology patients since 2015 (1108 currently active). Patients of the OAM Program report high rates of satisfaction, excellent rates of medication adherence and reduced rates of grade 3-4 drug toxicities. OAM Program services optimize OAM distribution efficiency, improve patients’ ability to self-manage OAMs, and reduce the risk of severe side effects and unplanned breaks in therapy.

Conclusions: The OAM Program minimizes time-to-access OAM therapy, maximizes time on OAM therapy, and optimizes patient and prescriber convenience. The Program was identified as a Leading Practice in Cancer Care by Accreditation Canada in 2017 and is considered the gold standard / best-practice for OAM care among local oncology professionals.


Medication Assessment Centre Interprofessional Opioid Pain Service (MAC iOPS):

A Novel Approach to Chronic Pain Management

Derek Jorgenson, Katelyn Halpape, Eric Landry, Taylor Raiche, Amy Wiebe
University of Saskatchewan, Medication Assessment Centre, Saskatoon 

Background: One in five Canadians experience chronic pain. Saskatchewan residents have limited access to interdisciplinary chronic pain management. The Medication Assessment Centre Interprofessional Opioid Pain Service (MAC iOPS) was created to fill this gap.

Objectives: To develop, implement, and evaluate an interdisciplinary, pharmacist-led, chronic pain clinic.

Methods: The program development and implementation included securing funding, hiring health professionals, creating a care model, and patient recruitment. Initial program evaluation includes retrospective chart audit and survey of patients and their healthcare professionals.

Results:
MAC iOPS was established, with federal funding, as an interdisciplinary chronic pain service in March 2020. The team includes four pharmacists, one chronic pain physician, one physical therapist, and two social workers. MAC iOPS is available to all Saskatchewan residents and services are delivered virtually or in-person.  MAC iOPS differs from traditional interdisciplinary teams in that pharmacists lead the team. MAC iOPS does not prescribe but works with the patient’s existing prescriber to implement treatment plans. Chart audit results (n=79) found reductions in mean daily morphine equivalents of 37mg and improved Brief Pain Inventory scores of 1.3 points. Eleven patients were provided take home naloxone kits. Patient surveys (n=17) indicated that 65% of patients had improved overall health status and 94% were satisfied with their care. The health professional surveys (n=16) revealed that 100% would recommend MAC iOPS to colleagues and 69% were more confident managing chronic pain after working with MAC iOPS.

Conclusions: MAC iOPS has improved access to interdisciplinary chronic pain management in Saskatchewan, resulting in improved overall self-reported health status of chronic pain patients, reduced opioid intake, and expanded access to take home naloxone. The service has been well received by patients and health professionals.


Improving Decision-Making in Empiric Antibiotic Selection (IDEAS)

Marion Elligsen
Sunnybrook Health Sciences Centre, Toronto

 

Background : Timely initiation of adequate antibiotics has been associated improved patient outcomes.  However, selecting adequate empiric antibiotics is difficult due to rising resistance rates and the competing desire to apply antimicrobial stewardship principles.   

Objectives The objective of this project was to develop, implement and evaluated two interventions to optimize empiric antibiotics using prospective audit and feedback.   

Methods The interventions included providing suggestions to prescribers at two points in the empiric period: (1) prior to availability of any culture results, empiric therapy was altered to ensure concordance with prior cultures that have predictive relevance for future infection; and (2) when Gram-negative bacteremia was identified, previously derived and validated multivariable models were used to recommend the most narrow-spectrum adequate antibiotic. The interventions were evaluated simultaneously using a quasi-experimental design comparing two 9-month periods (pre and post-intervention) at Sunnybrook Health Sciences Centre, Toronto, Ontario. 

Results : The first intervention increased the proportion of patients that received concordant therapy from 73% (72/99) in the control group to 88% (76/86) in the intervention group (p=0.01). The median time to concordant therapy was significantly shorter in the intervention group (25 vs 55 hrs; p<0.001).  The median duration of unnecessary vancomycin therapy was reduced by 1.1 days (95% CI 0.5 – 1.6 days, p<0.001). 

The second intervention increased the proportion of patients who were on the most narrow-spectrum adequate therapy at the time of culture finalization from 44% (88/201) in the control group to 55% (100/182) in the intervention group ( p=0.04).  Time to adequate therapy was similar in the intervention and control groups (5 vs 4 hours; p=0.95) 

Conclusions Together, these interventions demonstrated that systematic decision support interventions can simultaneously improve the adequacy of empiric antibiotic coverage while decreasing overall use of broad-spectrum empiric agents. 

 



Radiology Exam and Postoperative/Post-Sedation Breastfeeding: Internal Initiatives and Information Documents

Nathalie Gagnon
CISSS de l’Outaouais, Gatineau Hospital, Gatineau, QC


 

Background: During breastfeeding, tests and procedures requiring contrast media, anesthetics and analgesics may be prescribed. Too often, the tendency is still to tell women they have to pump and throw away their milk, even though this is rarely necessary. In addition, the information being provided is generally inconsistent between departments or healthcare professionals.


Objectives:
Review the literature on drugs used in radiology, examination room or operating room in breastfeeding context. Develop a protocol or procedure. Provide written information.


Methods:
An internet search was conducted for such documents, but nothing was found. Phone calls to other CISSS, including those holding a “Baby Friendly Initiative” accreditation, were done; none of them had a protocol or procedure in place. Reference books, literature reviews and specialized databases were consulted.


Results:
The use of these drugs in these contexts is a one-time event. They are rapidly eliminated from the plasma compartment, the amount likely to pass into the milk is generally very low with an unlikely digestive absorption in the infant. A resumption of breastfeeding is possible as soon as the patient is in a stable state and has regained a level of alertness authorizing her to stand up.

Conclusions: The procedure “Radiology exam in breastfeeding patient” has been in place since January 2017, while the medical protocol “Postoperative/post-sedation breastfeeding” has been in force since November 2018. The drugs involved are compatible with breastfeeding. The challenge is to widely disseminate these initiatives for the benefit of lactating patients and the children they breastfeed.