PHArmacy Students as Educators (PHASE): Implementation and evaluation of an educator's curriculum for pharmacy students.

BACKGROUND AND PURPOSE: Designed to address the Association of Faculties of Pharmacy of Canada's competency "teach pharmacy team members, the public, and other health care professionals," the PHArmacy Students as Educators (PHASE) program was developed by the institute's entry-to-practice doctor of pharmacy program. The program's objective was to support students in developing the necessary skills to fulfill their role as pharmacist-educators. EDUCATIONAL ACTIVITY AND SETTING: We performed a two-year pilot (2017-2019) of the PHASE program which consists of a large-group didactic session followed by an academic half-day (AHD) session. Evaluation was conducted using Likert-scale and qualitative student survey data collected pre- and post-sessions to determine: (1) how the PHASE program supported students as future educators, and (2) students' perceptions and experiences related to teaching and learning. FINDINGS: All students in the 2020 and 2021 graduating cohorts were included in the study following consent. We determined that while respondents agreed to the statement, "A role of a pharmacist includes being an educator" (93.7% and 98.2% for 2020 and 2021 cohorts) at baseline, the proportion of strongly agree responses increased following the didactic session (P < .005). Of note, average Likert-score for respondents' confidence in educating increased following the AHD session (P < .001). Qualitative analysis identified an increase in students' self-rated ability for determining learners' needs, developing and conducting educational sessions, and confidence related to educating others. SUMMARY: Overall, the PHASE program showed positive impact during the first two years of implementation and lessons learned from the pilot are discussed.

Assessing Use of a Standardized Allergy History Questionnaire for Patients with Reported Allergy to Penicillin.

BACKGROUND: Inappropriate allergy labelling is associated with significant clinical and pharmacoeconomic implications. Detailed antimicrobial allergy assessments represent a key component of antimicrobial stewardship and aid in identifying true type I (immediate hypersensitivity) reactions. The allergy history form currently used at the University Hospital of Northern British Columbia (UHNBC), in Prince George, relies on the assessor's ability to ask appropriate prompting questions to obtain a thorough history, but it may not be sufficient to accurately identify true allergies. OBJECTIVE: To compare a standardized allergy history questionnaire and the current allergy history form in terms of the quality and quantity of documentation gathered. METHODS: This prospective observational study involved patients who were admitted to medical and surgical services at UHNBC from November 2018 to January 2019 with a penicillin-class allergy reported on their electronic medical record (EMR). A list of patients with EMR-reported allergies was generated by the hospital's health information software system, and these patients were interviewed using the standardized allergy history questionnaire. RESULTS: A total of 48 patients were assessed during the study period. Nineteen (40%) of the patients had an inappropriate allergy label on their EMR. Only 36 (75%) had an allergic reaction described on their EMR. Furthermore, only 36 (75%) of the 48 patients had the same allergy recorded on the EMR and on the allergy history form contained in their paper chart, of whom 22 had a documented reaction. The mean time to complete the standardized allergy history questionnaire was 2 minutes. CONCLUSIONS: At the study institution, documentation of allergy histories was often incomplete. Detailed allergy assessments are the first step in identifying true immunoglobulin E-mediated hypersensitivity reactions. Utilization of a standardized allergy history questionnaire is feasible and may serve to improve documentation and overall antimicrobial stewardship.

CONTEXTE: L'étiquetage inapproprié de l'allergie est associé à des conséquences cliniques et pharmacoéconomiques importantes. Les évaluations détaillées des allergies antimicrobiennes sont une composante-clé de la gestion antimicrobienne: elles contribuent à déterminer les réactions d'hypersensibilité véritables de type 1 (immédiates). Le formulaire des antécédents d'allergies actuellement utilisé à l'University Hospital of Northern British Columbia (UHNBC), à Prince George, s'appuie sur la capacité de l'évaluateur à poser les questions appropriées pour obtenir un historique détaillé, mais il ne suffit pas de déterminer précisément les véritables allergies. OBJECTIF: Comparer la qualité et la quantité des informations recueillies au moyen d'un questionnaire normalisé sur les antécédents d'allergies avec celles recueillies au moyen des formulaires. MÉTHODES: Cette étude d'observation prospective portait sur des patients admis dans les services médicaux et chirurgicaux à l'UHNBC de novembre 2018 à janvier 2019, dont les dossiers médicaux électroniques (DME) indiquaient une allergie à des médicaments de la classe de la pénicilline. Le logiciel des informations sur la santé a généré une liste des patients présentant les allergies indiquées et ces patients ont été interrogés à l'aide d'un questionnaire normalisé des antécédents d'allergies. RÉSULTATS: Un total de 48 patients a été évalué pendant la période de l'étude. Le DME de dix-neuf (40 %) patients portait une étiquette inappropriée. Seuls 36 DME des patients (75 %) décrivaient une réaction allergique. De plus, seulement 36 (75 %) des 48 patients avaient la même réaction allergique enregistrée à la fois au DME et dans le formulaire des antécédents d'allergies de leur dossier papier, et la réaction de 22 d'entre eux était documentée. Le temps de réponse moyen au questionnaire normalisé sur les antécédents d'allergies était de 2 minutes. CONCLUSION: Dans cette étude, la description des antécédents d'allergies était souvent incomplète. Les évaluations détaillées des allergies sont la première étape permettant de déterminer les réactions véritables d'hypersensibilité à l'immunoglobuline E. L'utilisation d'un questionnaire normalisé des antécédents d'allergies est faisable et pourrait servir à améliorer la documentation ainsi que la gestion globale des antimicrobiens.

Perceptions of Independent Pharmacist Prescribing among Health Authority- and Community-Based Pharmacists in Northern British Columbia.

Pharmacists across Canada have varying degrees of ability to prescribe medications depending on their jurisdiction of licensure. The purpose of this study was to the evaluate attitudes, beliefs, and perceptions of independent pharmacist prescribing among health authority- and community-based pharmacists. This prospective, cross-sectional online survey assessed the perceptions of independent pharmacist prescribing of health authority and community pharmacists practising in northern British Columbia (BC), which was defined as within the geographical boundaries of Northern Health. Responses were analysed using descriptive statistics and a regression analysis. There were 45 respondents to the survey: 22 community pharmacists and 23 health authority pharmacists. Both community and health authority pharmacists held positive perceptions of independent pharmacist prescribing and did not identify any barriers to incorporating independent pharmacist prescribing into their practice. Respondents were highly likely to apply for independent pharmacist prescribing authority, if available. Pharmacists in BC are currently not able to independently prescribe schedule I medications. The provincial regulatory body has proposed a framework for a Certified Pharmacist Prescriber designation, which if approved would allow pharmacists to prescribe in collaborative practice settings. This study provides some insight into the perception of pharmacists in northern BC in pursuing this designation, which may be valuable for planning purposes in case of adoption of the framework. These results are also likely applicable to other non-urban practice settings in Canada. Pharmacists in northern BC perceived independent pharmacist prescribing positively and a high proportion were likely to apply for this authority if it were permitted via legislation.

Engagement of nurse practitioners in primary health care in northern British Columbia: a mixed-methods study.

BACKGROUND: Nurse practitioners (NPs) have been regulated primary care providers in British Columbia since 2005; however, many practices and contributions of NPs, especially those in northern or rural regions, remain unarticulated in primary health care. The objective of this study was to evaluate NP practices in the context of providing primary health care in northern BC. METHODS: This was a qualitative-dominant mixed-methods study. We recruited NP participants working in northern BC; recruitment and data collection occurred between April and June 2018. Participants completed the validated 28-item Primary Health Care Engagement (PHCE) Scale to assess their perceptions of their workplace with 8 attributes of primary health care (quality improvement, community participation, patient-centred care, accessibility, intersectoral team, interdisciplinary collaboration, continuity and population orientation). We also interviewed NPs about their everyday practice. Transcribed data from the interviews were analyzed interpretively. RESULTS: In total, 13 of 30 (43%) eligible NPs participated in the survey and interview. The PHCE Scale results showed that all NPs perceived their workplaces to be highly engaged in patient-centred care, but none reported their workplaces as accessible. Interview data were organized into 5 headings which described how NPs see patients who are medically and socially complex, address inequities in access, practice collaboratively, address local service gaps and improve patient abilities to access care. INTERPRETATION: In interprofessional primary health care teams, NPs are key members and attend to both direct patient care and broader social conditions affecting health. Nurse practitioners can help accelerate advancements to deliver responsive community-based primary health care.

A scoping review of research on Canadian team-based primary care pharmacists.

OBJECTIVES: An ageing population with an increasing prevalence of chronic disease and complex medication regimens has placed a strain on healthcare systems in Canada. A limited number of team-based primary care pharmacists are integrated into primary care clinics across the country, working alongside other members of the health care team to identify and resolve drug therapy problems and improve outcomes. While many studies have been completed in the area, the extent of research on integrated team-based primary care pharmacists in Canada is unknown. The objectives of this work were to describe the literature that exists surrounding pharmacists in a primary health care team setting in Canada. A scoping review of research focusing on pharmacists in team-based primary health care settings in Canada was performed. Thematic analysis was then performed to categorize the identified studies. KEY FINDINGS: The search identified 874 articles, of which 93 met inclusion criteria relevant to the objective. From these 93 studies, 4 themes and 23 subthemes were identified, with some studies having more than one theme or subtheme. Themes identified were the following: primary care pharmacist scope of practice (n = 79 studies), collaboration/communication within the primary care setting (n = 26), chronic disease management (n = 24) and 'other' (n = 15). SUMMARY: This research quantified and categorized 93 studies on pharmacists in interprofessional primary care teams in Canada. As this is an expanding role for pharmacists in Canada, understanding the current state of the literature is an important consideration when developing future team-based primary care roles.

Community pharmacists' evolving role in Canadian primary health care: a vision of harmonization in a patchwork system

Canada's universal public health care system provides physician, diagnostic, and hospital services at no cost to all Canadians, accounting for approximately 70% of the 264 billion CAD spent in health expenditure yearly. Pharmacy-related services, including prescription drugs, however, are not universally publicly insured. Although this system underpins the Canadian identity, primary health care reform has long been desired by Canadians wanting better access to high quality, effective, patient-centred, and safe primary care services. A nationally coordinated approach to remodel the primary health care system was incited at the turn of the 21st century yet, twenty years later, evidence of widespread meaningful improvement remains underwhelming. As a provincial/territorial responsibility, the organization and provision of primary care remains discordant across the country. Canadian pharmacists are, now more than ever, poised and primed to provide care integrated with the rest of the primary health care system. However, the self-regulation of the profession of pharmacy is also a provincial/territorial mandate, making progress toward integration of pharmacists into the primary care system incongruent across jurisdictions. Among 11,000 pharmacies, Canada's 28,000 community pharmacists possess varying authority to prescribe, administer, and monitor drug therapies as an extension to their traditional dispensing role. Expanded professional services offered at most community pharmacies include medication reviews, minor/common ailment management, pharmacist prescribing for existing prescriptions, smoking cessation counselling, and administration of injectable drugs and vaccinations. Barriers to widely offering these services include uncertainties around remuneration, perceived skepticism from other providers about pharmacists' skills, and slow digital modernization including limited access by pharmacists to patient health records held by other professionals. Each province/territory enables pharmacists to offer these services under specific legislation, practice standards, and remuneration models unique to their jurisdiction. There is also a small, but growing, number of pharmacists across the country working within interdisciplinary primary care teams. To achieve meaningful, consistent, and seamless integration into the interdisciplinary model of Canadian primary health care reform, pharmacy advocacy groups across the country must coordinate and collaborate on a harmonized vision for innovation in primary care integration, and move toward implementing that vision with ongoing collaboration on primary health care initiatives, strategic plans, and policies. Canadians deserve to receive timely, equitable, and safe interdisciplinary care within a coordinated primary health care system, including from their pharmacy team

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Community pharmacists' evolving role in Canadian primary health care: a vision of harmonization in a patchwork system.

Canada's universal public health care system provides physician, diagnostic, and hospital services at no cost to all Canadians, accounting for approximately 70% of the 264 billion CAD spent in health expenditure yearly. Pharmacy-related services, including prescription drugs, however, are not universally publicly insured. Although this system underpins the Canadian identity, primary health care reform has long been desired by Canadians wanting better access to high quality, effective, patient-centred, and safe primary care services. A nationally coordinated approach to remodel the primary health care system was incited at the turn of the 21st century yet, twenty years later, evidence of widespread meaningful improvement remains underwhelming. As a provincial/territorial responsibility, the organization and provision of primary care remains discordant across the country. Canadian pharmacists are, now more than ever, poised and primed to provide care integrated with the rest of the primary health care system. However, the self-regulation of the profession of pharmacy is also a provincial/territorial mandate, making progress toward integration of pharmacists into the primary care system incongruent across jurisdictions. Among 11,000 pharmacies, Canada's 28,000 community pharmacists possess varying authority to prescribe, administer, and monitor drug therapies as an extension to their traditional dispensing role. Expanded professional services offered at most community pharmacies include medication reviews, minor/common ailment management, pharmacist prescribing for existing prescriptions, smoking cessation counselling, and administration of injectable drugs and vaccinations. Barriers to widely offering these services include uncertainties around remuneration, perceived skepticism from other providers about pharmacists' skills, and slow digital modernization including limited access by pharmacists to patient health records held by other professionals. Each province/territory enables pharmacists to offer these services under specific legislation, practice standards, and remuneration models unique to their jurisdiction. There is also a small, but growing, number of pharmacists across the country working within interdisciplinary primary care teams. To achieve meaningful, consistent, and seamless integration into the interdisciplinary model of Canadian primary health care reform, pharmacy advocacy groups across the country must coordinate and collaborate on a harmonized vision for innovation in primary care integration, and move toward implementing that vision with ongoing collaboration on primary health care initiatives, strategic plans, and policies. Canadians deserve to receive timely, equitable, and safe interdisciplinary care within a coordinated primary health care system, including from their pharmacy team.

Evaluation of Prescription Adaptation Following Changes to A Provincial Drug Insurance Formulary.

On 1 December 2016, British Columbia's (BC) provincial drug insurance program changed which medications in certain classes would benefit under the insurance program in an attempt to reduce expenditure. As part of the modernization, HMG-CoA reductase inhibitors (Statins), Angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), and dihydropyridine calcium channel blockers (CCB) were affected. Prescribers and pharmacists had six months to discuss the changes with patients, and change medications if deemed necessary. Purpose: To quantify the changes made to prescriptions and to adjust to the Modernized Reference Drug Program. Methods: A retrospective chart review was conducted at two clinics in Prince George, BC. Charts for patients that were prescribed any drugs in the affected classes were reviewed to determine if, and when, they had been changed, and by which health care professional. In December 2016, a clinical pharmacist, integrated within the study clinics, informed prescribers of the changes, and made patient-specific clinical notes within the charts. The notes described the changes and recommended alternative agents and appropriate dosing in order to assist the prescriber to have a conversation with the patient regarding the switch. Results: Out of 429 unique patients, 233 patients were prescribed a Statin, 229 patients an ACEI, 110 an ARB and, 83 a CCB. Sixty-five drug changes were indicated to reflect the modernization, and with guidance from a clinical pharmacist, nurse practitioners (NPs), and family physicians (FPs), 65% of these identified drugs were switched to reflect the modernization. Community pharmacists made no drug changes in the study sample, despite the prescriptive authority and compensation available to do so. Province-wide, approximately 21% to 33% of affected drugs were switched during the same time-frame. Direct collaboration between a clinical pharmacist, working alongside NPs and FPs, was more successful in optimizing these medications when compared to standard practice, or community pharmacists alone.

Applying the guidelines for pharmacists integrating into primary care teams.

BACKGROUND: In 2013, Jorgenson et al. published guidelines for pharmacists integrating into primary care teams. These guidelines outlined 10 evidence-based recommendations designed to support pharmacists in successfully establishing practices in primary care environments. The aim of this review is to provide a detailed, practical approach to implementing these recommendations in real life, thereby aiding to validate their effectiveness. METHODS: Both authors reviewed the guidelines independently and ranked the importance of each recommendation respective to their practice. Each author then provided feedback for each recommendation regarding the successes and challenges they encountered through implementation. This feedback was then consolidated into agreed upon statements for each recommendation. RESULTS AND DISCUSSION: Focusing on building relationships (with an emphasis on face time) and demonstrating value to both primary care providers and patients were identified as key aspects in developing these new roles. Ensuring that the environment supports the practice, along with strategic positioning within the clinic, improves uptake and can maximize the usefulness of a pharmacist in primary care. Demonstrating consistent and competent clinical and documentation skills builds on the foundation of the other recommendations to allow for the effective provision of clinical pharmacy services. Additional recommendations include developing efficient ways (potentially provider specific) to communicate with primary care providers and addressing potential preconceived notions about the role of the pharmacist in primary care. CONCLUSION: We believe these guidelines hold up to real-life integration and emphatically recommend their use for new and existing primary care pharmacists.

Evaluation of a Community Pharmacy-Based Screening Questionnaire to Identify Patients at Risk for Drug Therapy Problems.

STUDY OBJECTIVE: To determine if a short screening questionnaire can identify patients at risk for drug therapy problems (DTPs) in a community pharmacy setting. DESIGN: Self-administered questionnaire. SETTING: Three community pharmacies in Saskatoon, Canada. PATIENTS: Forty-nine adults who were picking up a refill prescription for a medication that had remained stable over the past 6 months (i.e., no changes to drug, dose, or regimen) during 4 consecutive weeks at each of the three pharmacies between November 2013 and February 2014. MEASUREMENTS AND MAIN RESULTS: All patients completed a self-administered screening questionnaire and underwent a blinded comprehensive medication assessment with a clinical pharmacist. Agreement between the screening questionnaire responses and responses based on information from the medication assessment were assessed with Cohen's κ coefficient. The DTPs identified during the medication assessments were categorized in one of the eight standard DTP categories: unnecessary drug therapy, inappropriate drug, subtherapeutic dose, supratherapeutic dose, drug therapy required, adverse drug reaction, noncompliance, and other or unsure. The DTPs were also assigned a severity-mild, moderate, or severe-using adapted Schneider criteria. The number and severity of DTPs identified were compared among patients categorized as high versus low risk for DTPs as determined by the questionnaire responses. Of the 49 patients who completed the study, 18 (37%) were high risk and 31 (63%) low risk. The agreement between risk categorization based on the screening questionnaire and medication assessment was very good (κ = 0.91, p<0.01). Also, patients identified as high risk on the screening questionnaire had a mean of 3.7 (p<0.01) more DTPs than low-risk patients. Seventeen (94%) of the 18 high-risk patients had at least one moderate or severe DTP compared with 15 (48%) of the 31 low-risk patients. CONCLUSION: The screening questionnaire was a reliable method for identifying patients in community pharmacies who have a large number of DTPs.

Interprofessional student-run primary health care clinics: Implications for pharmacy education in Scotland.

INTRODUCTION: Interprofessional student-run primary health care clinics have been a flagship model of health professional education in Canada for many years. The purpose of this study was to determine if there is support for implementing this educational model in the United Kingdom and to highlight the implications for pharmacy education in Scotland. METHOD: A cross-sectional postal survey of 3000 randomly selected citizens of Aberdeen city and shire, Scotland, aged 18 years and older. RESULTS: Of the 824 questionnaires that were returned (response rate 27.5%), more than half of the respondents (62.4%; n = 514) would consider accessing health care from a student-led, walk-in service. The range of services they expect to see includes general health checks (60%; n = 494), help for sexually transmitted diseases (57.5%; n = 474), weight management (56.8%; n = 468), smoking cessation (54.4%; n = 448) and drug misuse services (47.2%; n = 387). Concerns raised pertained to student ability, suitability for children and accessibility. Many comments pertained to the improvement of the current system by offering after-hours care. DISCUSSION: The positive response from the general public towards an interprofessional student-run primary health care clinic in Aberdeen suggests that this Canadian model of interdisciplinary health professional education would likely be a successful addition to the pharmacy curriculum in Scotland.

A functional genomics screen identifies diverse transcription factors that regulate alkaloid biosynthesis in Nicotiana benthamiana.

Biosynthesis of the alkaloid nicotine in Nicotiana species is induced by insect damage and jasmonate application. To probe the transcriptional regulation of the nicotine pathway, we constructed two subtracted cDNA libraries from methyl jasmonate (MeJA)-treated Nicotiana benthamiana roots directly in a viral vector suitable for virus-induced gene silencing (VIGS). Sequencing of cDNA inserts produced a data set of 3271 expressed sequence tags (ESTs; 1898 unigenes), which were enriched in jasmonate-responsive genes, and included 69 putative transcription factors (TFs). After a VIGS screen to determine their effect on nicotine metabolism, six TFs from three different TF families altered constitutive and MeJA-induced leaf nicotine levels. VIGS of a basic helix-loop-helix (bHLH) TF, NbbHLH3, and an auxin response factor TF, NbARF1, increased nicotine content compared with control plants; silencing the bHLH family members, NbbHLH1 and NbbHLH2, an ethylene response factor TF, NbERF1, and a homeobox domain-like TF, NbHB1, reduced nicotine levels. Transgenic N. benthamiana plants overexpressing NbbHLH1 or NbbHLH2 showed increased leaf nicotine levels compared with vector controls. RNAi silencing led to both reduced nicotine and decreased levels of transcript encoding of enzymes of the nicotine pathway. Electrophoretic mobility shift assays showed that recombinant NbbHLH1 and NbbHLH2 directly bind G-box elements identified from the putrescine N-methyltransferase promoter. We conclude that NbbHLH1 and NbbHLH2 function as positive regulators in the jasmonate activation of nicotine biosynthesis.