DFCM Pearls: What is New
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Top six studies that will impact clinical practice for academic family physicians
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DFCM Pearls: What is New
- 1. DFCM Pearls: What Is New? The top six research studies that will impact clinical practice for academic family physicians Dr. David M. Kaplan MD MSc CCFP Associate Professor, North York General, Department of Family & Community Medicine Primary Care Lead, Central Local Health Integration Network Dr. Tara Kiran MD MSc CCFP Assistant Professor, St. Michael’s Hospital, Department of Family & Community Medicine. Associate Scientist, Centre for Research on Inner City Health, St. Michael’s Hospital Adjunct scientist, Institute for Clinical Evaluative Studies
- 2. DISCLOSURE OF COMMERCIAL SUPPORT • This program has not received financial support
- 3. FACULTY/PRESENTER DISCLOSURE • Faculty: Dr. David M. Kaplan • Relationships with commercial interests: none
- 4. FACULTY/PRESENTER DISCLOSURE • Faculty: Dr. Tara Kiran • Relationships with commercial interests: none
- 5. The 2015 DFCM Pearls Process
- 6. DFCM 2015 – Pearl 1 Missed connections: Unintended consequences of updated cervical cancer screening guidelines on screening rates for sexually transmitted infections Bogler, T., Farber, A., Stall, N., Wijayasinghe, S., Slater, M., Guiang, C. & Glazier, R.H Canadian Family Physician
- 7. The Bottom Line • The introduction of new cervical screening guidelines in 2012 was associated with a 50% decrease in screening for chlamydia and gonorrhea in women age 19 to 25
- 8. The Research Question • To compare rates of Pap testing and screening for STIs among women age 19 to 25 before and after introduction of new cervical cancer screening guidelines • Why this is important? –Rates of chlamydia and gonorrhea are rising in Canada –Family MDs relied on Pap testing to provide an opportunity for a health review
- 9. What the Researchers Did
- 10. What the Researchers Found
- 11. What the Researchers Found
- 12. What This Means for Academic and Clinical Practice • Beware of unintended consequences of guideline changes • Practices (and communities) should implement processes to ensure high-risk women are screened for STIs even if they are not coming in for routine Pap testing
- 13. DFCM 2015 – Pearl 2 The Early Benefits of Human Papillomavirus Vaccination on Cervical Dysplasia and Anogenital Warts Smith, L.M., Strumpf, E.C., Kaufman, J.S., Lofters, A., Schwandt, M. & Levesque, L.E Pediatrics
- 14. The Bottom Line • qHPV vaccination is associated with reduced cervical dysplasia among adolescent girls
- 15. The Research Question • To assess the impact of the qHPV vaccine and Ontario’s grade 8 qHPV vaccination program on cervical dysplasia and anogenital warts • Why this is important? – qHPV vaccination remains controversial for some parents
- 17. What the Researchers Did Population-based cohort of grade 8 girls Exposures: i) Eligible for vaccine program ii) Received 3 doses of the vaccine Outcomes: i) Cervical dysplasia* ii) Anogenital warts* *New cases in gr 10-12Regression discontinuit y design qHPV program introduced
- 18. What the Researchers Found Risk of cervical dysplasia Risk of anogenital warts
- 19. What the Researchers Found • 1 case of cervical dysplasia was prevented for every 431 (95% CI 248 to 1639) girls eligible for publicly funded vaccination and for every 175 (95% CI 101 to 667) girls who received the vaccine • A non-significant reduction in anogenital warts attributable to program eligibility and vaccination
- 20. What This Means for Academic and Clinical Practice • qHPV vaccine is effective in reducing cervical dysplasia and possibly anogenital warts in a real-world setting • Benefits of qHPV vaccine in girls can be seen as early as age 14 to 17 • Vaccination should not be delayed
- 21. DFCM 2015 – Pearl 3 Estimated cost of universal public coverage of prescription drugs in Canada Morgan, S.G., Law, M., Daw, J.R., Abraham, L. & Martin, D Canadian Medical Association Journal
- 22. The Bottom Line • Universal public drug coverage could reduce total spending on prescription drugs in Canada by $7.3 billion per year or 32%
- 23. The Research Question • To model the impact of universal public coverage of prescription drugs in Canada on public sector, private sector and total societal costs • Why this is important? – 1 in 10 Canadians cannot afford to take their medications as prescribed
- 24. What the Researchers Did • Canadian Rx Atlas used to model change in total cost of prescriptions (Product x volume x $) • 3 key factors impacting change in cost: – use of prescription drugs – Cost-effective product selection – Consolidated purchasing power • Other assumptions: – Included small patient copayments – Excluded drugs for ED and fertility
- 25. What the Researchers Found
- 26. What the Researchers Found
- 27. What the Researchers Found
- 28. What This Means for Academic and Clinical Practice • Adds to the evidence supporting universal public coverage of drugs ✓ access ✓ equity ? effective ✓ efficient (financially viable)
- 29. What This Means for Academic and Clinical Practice • Adds to the evidence supporting universal public coverage of drugs ✓ access ✓ equity ? effective ✓ efficient (financially viable)
- 30. DFCM 2015 – Pearl 4 Empowering smokers with a web- assisted tobacco intervention to use prescription smoking cessation medications: a feasibility trial Selby, P., Hussain, S., Voci, S. & Zawertailo, L.
- 31. The Bottom Line • It is feasible to use the Internet and free medication to enable smokers to engage physicians to treat smoking addiction. Implementation of this intervention can be scaled up by leveraging existing healthcare systems to treat smokers on a population level.
- 32. The Research Question • Is it feasible to use a web-assisted tobacco intervention offering free prescription smoking cessation medication by mail to reduce smoking addition? • Why this is important? • In 2013, smoking prevalence in Ontario was 12.6%, below the national average of 14.6%. • FP should strongly advise patients to quit smoking, and use motivational interviewing techniques for patients who are not yet willing to stop smoking • Cochrane review found no demonstrated effect of MD CME training on provision of smoking cessation medications
- 33. Smoking Prevalence in Ontario
- 34. What the Researchers Did • Ontarians >18 who were smoking • >= 10 cigarettes/d • intending to quit within 30 days Excluded those with contraindications to bupropion (Zyban) or varenicline (Champix)
- 35. What the Researchers Did • participants received an electronic personalized printable prescription form for a 12w course of varenicline or bupropion to bring to MD within 3w for authorization • MD faxed prescriptions to an online pharmacy that couriered medication to the patient • Weekly motivational emails were sent during treatment • Completed follow-up questionnaires online at 7, 11, 15 and 41 weeks after enrollment
- 36. What the Researchers Found
- 37. What the Researchers Found
- 38. What the Researchers Found • Novel method maintained advantages of Internet-based treatment delivery (increased efficiency and lower cost) • Overcame a limitation by integrating in-person clinical contact with a physician and brief telephone counselling with a pharmacist • abstinence rate among respondents at 41-week follow-up was 16.2 % for the group that did not receive medication, 30.3 % for the varenicline group and 24.3 % for the bupropion group.
- 39. What This Means for Academic and Clinical Practice • Sending Electronic Communication to our patients via newsletters with online programs such as STOPSTUDY could be a useful way of engaging patients in healthy behaviours outside of regular clinic visits
- 41. DFCM 2015 – Pearl 5 Failure to Cope: The Hidden Curriculum of Emergency Department Wait Times and the Implications for Clinical Training Webster, F., Rice, K., Dainty, K.N., Zwarenstein, M., Durant, S. & Kuper, A.
- 42. The Bottom Line • Ontario wait times policy had unplanned effects on the education of the trainees involved in the consultation process at the study site. • There was a shift in priorities from teaching and learning good clinical care and assessment to meeting organizational performance measures.
- 43. The Research Question • Did the Ontario Wait Times Policy have an effect on the intraprofessional education of trainees? • Why this is important? – Our academic programs ‘live’ in a context that we, as teachers, sometimes do not control. Could there be unintended consequences of policy decisions on the academic mission?
- 44. What the Researchers Did • ethnographic study • from 2010-2011, observed consults between GIM and ED at an urban teaching hospital in Toronto • additional ad hoc interviews were conducted with residents, nurses, and faculty from both departments • formal one-on-one interviews with 12 physicians • data were coded and analyzed using concepts of institutional ethnography
- 45. What the Researchers Found • perception that efficiency was more important than education • efficiency was the new definition of "good" patient care • informal label "failure to cope” describes high- needs patients suggested that in many instances, patients were experienced as a barrier to optimal efficiency • tension during consults as well as reduced opportunities for education
- 46. What This Means for Academic and Clinical Practice • Policies introduced to reduce system inefficiencies can have unintended implications for medical education, and thus for the care that medical trainees will ultimately provide to the public
- 47. DFCM 2015 – Pearl 6 Rates of Anomalous Bupropion Prescriptions in Ontario, Canada Steele, L.S., Macdonald, E.M., Gomes, T., Hollands, S., Paterson, J.M., Mamdani, M.M., Juurlink, D.N.
- 48. The Bottom Line • Although no marked differences were seen for early refills of bupropion relative to its comparators, potentially duplicitous prescriptions have increased dramatically in Ontario, suggesting growing misuse of the drug.
- 49. The Research Question • To explore trends in bupropion prescribing suggestive of misuse or diversion in Ontario, Canada. • Why this is important? – Bupropion is commonly prescribed in FM – Reports of bupropion misuse have increased since it was first reported in 2002
- 50. What the Researchers Did • Administrative Database • serial cross-sectional study • Ontarians < 65 years who received an Rx from the public drug program between 2000-2013
- 51. What the Researchers Did • number of potentially inappropriate prescriptions in each quarter • defined as early refills dispensed within 50% of the duration of the preceding prescription • potentially duplicitous prescriptions • defined as similarly early refills originating from a different prescriber and different pharmacy • analyses replicated for citalopram and sertraline
- 52. What the Researchers Found Early refills for bupropion, sertraline, and citalopram, by quarter
- 53. What the Researchers Found Potentially duplicitous prescriptions for bupropion, sertraline, and citalopram, by quarter
- 54. What This Means for Academic and Clinical Practice • Administrative Rx datasets can be mined to confirm anecdotal observations • Potentially duplicitous prescriptions for a commonly used anti-depressant and smoking cessation aid have increased dramatically in Ontario, suggesting growing misuse of the drug.
- 55. Questions? David M. Kaplan david@davidkaplanmd.com Tara Kiran tara.kiran@utoronto.ca
Notas del editor
- This slide must be visually presented to the audience AND verbalized by the speaker.
- This slide must be visually presented to the audience AND verbalized by the speaker.
- This slide must be visually presented to the audience AND verbalized by the speaker.
- DK to describe the change to the 2015 process
- RAP – Tali and Alison now staff
- New guidelines from CCO introduced May 2012 – delay screening until age 21 and every three years if results are normal – were there unintended consquences
- This may mean coming in more for an annual visit but it may also involve providing women with the means to self-test, e.g with self-administered vaginal swabs
- Alzheimer Disease & Associated Disorders 2014 December; 28(4):311-319.
- Public coverage of medically necessary rx drugs on universal terms with limited copayments and a national formulary 1 in 10 – stat from CCHS survey data – pts reported making their meds last longer, not filling the rx or not renewing the rx. (as high as 3.5/10 for patients who are low income with no insurance)
- Cdn experiences with changes in rx drug coverage Product selection under existing provincial drug plans Comparotor countries Pharmacy dispensing fees and retail markups allowed
- Small increase in expenditure by government and substantial cost savings to individuals and private sector
- Role for physician advocacy
- BMC Family Pract 2014;15:16. Epub ahead of print.(Principal Author)
- Barriers to the use of these medications exist at the patient, system and practitioner level. Patient-level barriers include poor awareness, perceived lack of effectiveness, low desirability including concern regarding adverse effects, and poor accessibility of treatment [11, 12]. Accessibility issues include anticipated difficulties obtaining a prescription from a physician and perceived high cost of medication [11].
- . Study information, including an electronic copy of a recruitment poster that could be printed and posted, was provided to healthcare professionals from public health units, community health centres, family health teams and community pharmacies across Ontario. Physicians were also informed about the study via the Ontario College of Family Physicians newsletter.
- Adult smokers from Ontario, Canada, interested in quitting could enroll at the study website (www.stopstudy.ca; see Additional file 1). Study information, including an electronic copy of a recruitment poster that could be printed and posted, was provided to healthcare professionals from public health units, community health centres, family health teams and community pharmacies across Ontario. Physicians were also informed about the study via the Ontario College of Family Physicians newsletter.
- The cost per patient that received medication was C$409.69. The cost per quitter ranged from approximately C$1003 to C$1835
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- Hospitals are monitored and ranked, and data are publicly provided in “stocktake” reports that are intended to inform a “performance management approach. ED vs GIM The hidden curriculum, rst described in the medical education literature by Hafferty,15 refers to “cultural mores that are transmitted, but not openly acknowledged, through formal and informal educational endeavours.”
- systematic study of people and cultures. It is designed to explore cultural phenomena where the researcher observes society from the point of view of the subject of the study. the resulting field study or a case report reflects the knowledge and the system of meanings in the lives of a cultural group IE explores the social relations that structure people's everyday lives, specifically by looking at the ways that people interact with one another in the context of social institutions (school, marriage, work, for example) and understanding how those interactions are institutionalized. IE is best understood as an ethnography of interactions which have been institutionalized, rather than an ethnography of specific companies, organizations or employment sectors, which would be considered industrial sociology or the sociology of work.
- Policy makers should consider the potential for policies that affect medical practice to also influence medical education through the hidden curriculum, and the impact that the hidden curriculum can ultimately have on patient care. Access, QI, other 'pressures' in FM
- People who misuse bupropion sometimes characterize its effects as a cocaine-like high. Bupropion can be misused by ingestion, nasal insufflation, or intravenous injection, although the latter often produces extensive local tissue necrosis.4–9 Reports of seizures following bupropion misuse have also been documented.10,11 In May 2013, the Chief Coroner for Ontario issued a public health alert following 6 deaths involving bupropion insufflation or injection
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- During the final year of the study, they found 1,502 potentially dupliciitous prescriptions for bupropion .With an average of 32 tablets per prescription, this amount corresponds to approximately 48,000 tablets potentially subject to misuse in our study sample