Describing and Evaluating the Clinical Pharmacist's Role in a Canadian Multiple Sclerosis Clinic.

Background: The current approach to treatment of multiple sclerosis (MS) involves use of disease-modifying therapies to slow progression of the disease, as well as the symptomatic management of fixed neurological deficits. Although pharmacists are uniquely positioned to support MS care teams with all aspects of medication management, their presence is rare among MS ambulatory care teams in Canada. Objectives: To document the pharmacist's contributions and to evaluate the impact of the pharmacist's role following creation of a clinical pharmacist position in a Canadian MS clinic within a large, urban, university-affiliated, tertiary care centre. Methods: This study was conducted in 2 parts: a prospective, descriptive case study of the clinical pharmacist's role and a retrospective assessment of medication-related patient calls before and after implementation of the pharmacist position. Results: The pharmacist performed a variety of clinical activities, with the greatest proportions of time spent on patient care (63.3%), drug access research (15.7%), and development and review of internal documents (9.0%). Patient care primarily involved conducting patient assessments, making medication recommendations, and assisting patients with medication-related issues. The proportion of medication-related issues resolved remained similar at 92.9% before and 95.7% after implementation of the clinical pharmacist (p = 0.48). The median time to resolve medication-related issues was reduced from 4.1 to 2.9 days (p = 0.016) with pharmacist involvement. Conclusions: Pharmacists can support MS care teams through a variety of medication-related clinical activities aligned with their scope and expertise. The presence of a pharmacist on the MS care team significantly reduced turnaround times for resolving medication-related issues, improving the efficiency and timeliness of care.

Contexte: L'approche actuelle du traitement de la sclérose en plaques (SP) implique l'utilisation de traitements modificateurs de la maladie pour ralentir sa progression, ainsi que la prise en charge symptomatique des déficits neurologiques fixes. Bien que les pharmaciens occupent une position unique pour soutenir les équipes de soins de SP dans tous les aspects de la gestion des médicaments, leur présence est rare parmi les équipes de soins ambulatoires en SP au Canada. Objectifs: Documenter les contributions du pharmacien et évaluer l'incidence potentielle de son rôle après la mise en place d'un poste de pharmacien clinicien dans une clinique canadienne de SP au sein d'un grand centre de soins tertiaires urbain affilié à une université. Méthodologie: Cette étude a été menée en 2 parties : une étude de cas prospective et descriptive du rôle du pharmacien clinicien et une évaluation rétrospective des appels des patients liés aux médicaments avant et après la mise en place du poste de pharmacien. Résultats: Le pharmacien effectuait diverses activités cliniques, la plus grande proportion de temps étant consacrée aux soins aux patients (63,3 %), à la recherche sur l'accès aux médicaments (15,7 %) et à l'élaboration et à l'examen de documents internes (9,0 %). Les soins aux patients consistaient principalement à évaluer les patients, à formuler des recommandations en matière de médicaments et à aider les patients confrontés à des problèmes liés aux médicaments. La proportion de problèmes liés aux médicaments résolus est restée similaire, soit 92,9 % avant et 95,7 % après la mise en œuvre du pharmacien clinicien (p = 0,48). Le délai médian nécessaire pour résoudre les problèmes liés aux médicaments a été réduit de 4,1 à 2,9 jours (p = 0,016) avec la participation du pharmacien. Conclusions: Les pharmaciens peuvent soutenir les équipes soignantes de SP grâce à diverses activités cliniques liées aux médicaments, adaptées à leur portée et à leur expertise. La présence d'un pharmacien dans l'équipe de soins de la SP a considérablement réduit les délais d'exécution pour résoudre les problèmes liés aux médicaments, améliorant ainsi l'efficacité et la rapidité des soins.

Real-world use of glucocorticoids and clinical outcomes in adults hospitalized with community-acquired pneumonia on medical wards.

BACKGROUND: Little is known about the real-world use of systemic glucocorticoids to treat patients hospitalized with community-acquired pneumonia (CAP) outside of the intensive care unit (ICU). METHODS: This retrospective cohort study included 11,588 hospitalizations for CAP without chronic pulmonary disease at seven hospitals in Ontario, Canada. We report physician-level variation in the use of glucocorticoids and trends over time. We investigated the association between glucocorticoid prescriptions and clinical outcomes, using propensity score overlap weighting to account for confounding by indication. RESULTS: Glucocorticoids were prescribed in 1283 (11.1%) patients, increasing over time from 10.0% in 2010 to 11.9% in 2020 (p = .008). Physician glucocorticoid prescribing ranged from 2.9% to 34.6% (median 10.0%, inter quartile range [IQR]: 6.7%-14.6%). Patients receiving glucocorticoids tended to be younger (median age 73 vs. 79), have higher Charlson comorbidity scores (score of 2 or more: 42.4% vs. 31.0%), more cancer (26.6% vs. 13.2%), more renal disease (11.5% vs. 6.6%), and less dementia (7.8% vs. 14.8%). Patients treated with glucocorticoids had higher rates of in-hospital mortality (weighted Risk Difference = 1.72, 95% confidence interval [95% CI]: 0.16-3.3, p = .033). Glucocorticoid use was not associated with ICU admission, hospital length-of-stay, or 30-day readmission. CONCLUSION: Glucocorticoids were prescribed in 11.1% of patients hospitalized with CAP outside of ICU and one in four physicians prescribed glucocorticoids in more than 14% of patients. Glucocorticoid use was associated with greater in-hospital mortality, although these findings are limited by large selection effects. Clinicians should exercise caution in prescribing glucocorticoids for nonsevere CAP, and definitive trials are needed in this population.

A simple electronic medical record-based predictors of illness severity in sepsis (sepsis) score.

OBJECTIVE: Current scores for predicting sepsis outcomes are limited by generalizability, complexity, and electronic medical record (EMR) integration. Here, we validate a simple EMR-based score for sepsis outcomes in a large multi-centre cohort. DESIGN: A simple electronic medical record-based predictor of illness severity in sepsis (SEPSIS) score was developed (4 additive lab-based predictors) using a population-based retrospective cohort study. SETTING: Internal medicine services across four academic teaching hospitals in Toronto, Canada from April 2010-March 2015 (primary cohort) and 2015-2019 (secondary cohort). PATIENTS: We identified patients admitted with sepsis based upon receipt of antibiotics and positive cultures. MEASUREMENTS AND MAIN RESULTS: The primary outcome was in-hospital mortality and secondary outcomes were ICU admission at 72 hours, and hospital length of stay (LOS). We calculated the area under the receiver operating curve (AUROC) for the SEPSIS score, qSOFA, and NEWS2. We then evaluated the SEPSIS score in a secondary cohort (2015-2019) of hospitalized patients receiving antibiotics. Our primary cohort included 1,890 patients with a median age of 72 years (IQR: 56-83). 9% died during hospitalization, 18.6% were admitted to ICU, and mean LOS was 12.7 days (SD: 21.5). In the primary and secondary (2015-2019, 4811 patients) cohorts, the AUROCs of the SEPSIS score for predicting in-hospital mortality were 0.63 and 0.64 respectively, which were similar to NEWS2 (0.62 and 0.67) and qSOFA (0.62 and 0.68). AUROCs for predicting ICU admission at 72 hours, and length of stay > 14 days, were similar between scores, in the primary and secondary cohorts. All scores had comparable calibration for predicting mortality. CONCLUSIONS: An EMR-based SEPSIS score shows a similar ability to predict important clinical outcomes compared with other validated scores (qSOFA and NEWS2). Because of the SEPSIS score's simplicity, it may prove a useful tool for clinical and research applications.

Automated identification of unstandardized medication data: a scalable and flexible data standardization pipeline using RxNorm on GEMINI multicenter hospital data.

Objective: Patient data repositories often assemble medication data from multiple sources, necessitating standardization prior to analysis. We implemented and evaluated a medication standardization procedure for use with a wide range of pharmacy data inputs across all drug categories, which supports research queries at multiple levels of granularity. Methods: The GEMINI-RxNorm system automates the use of multiple RxNorm tools in tandem with other datasets to identify drug concepts from pharmacy orders. GEMINI-RxNorm was used to process 2 090 155 pharmacy orders from 245 258 hospitalizations between 2010 and 2017 at 7 hospitals in Ontario, Canada. The GEMINI-RxNorm system matches drug-identifying information from pharmacy data (including free-text fields) to RxNorm concept identifiers. A user interface allows researchers to search for drug terms and returns the relevant original pharmacy data through the matched RxNorm concepts. Users can then manually validate the predicted matches and discard false positives. We designed the system to maximize recall (sensitivity) and enable excellent precision (positive predictive value) with efficient manual validation. We compared the performance of this system to manual coding (by a physician and pharmacist) of 13 medication classes. Results: Manual coding was performed for 1 948 817 pharmacy orders and GEMINI-RxNorm successfully returned 1 941 389 (99.6%) orders. Recall was greater than 0.985 in all 13 drug classes, and the F1-score and precision remained above 0.90 in all drug classes, facilitating efficient manual review to achieve 100% precision. GEMINI-RxNorm saved time substantially compared with manual standardization, reducing the time taken to review a pharmacy order row from an estimated 30 to 5 s and reducing the number of rows needed to be reviewed by up to 99.99%. Discussion and Conclusion: GEMINI-RxNorm presents a novel combination of RxNorm tools and other datasets to enable accurate, efficient, flexible, and scalable standardization of pharmacy data. By facilitating efficient manual validation, the GEMINI-RxNorm system can allow researchers to achieve near-perfect accuracy in medication data standardization.

Variations in long-term care home resident hospitalizations before and during the COVID-19 pandemic in Ontario.

OBJECTIVES: To examine how the COVID-19 pandemic affected the demographic and clinical characteristics, in-hospital care, and outcomes of long-term care residents admitted to general medicine wards for non-COVID-19 reasons. METHODS: We conducted a retrospective cohort study of long-term care residents admitted to general medicine wards, for reasons other than COVID-19, in four hospitals in Toronto, Ontario between January 1, 2018 and December 31, 2020. We used an autoregressive linear model to estimate the change in monthly admission volumes during the pandemic period (March-December 2020) compared to the previous two years, adjusting for any secular trend. We summarized and compared differences in the demographics, comorbidities, interventions, diagnoses, imaging, psychoactive medications, and outcomes of residents before and during the pandemic. RESULTS: Our study included 2,654 long-term care residents who were hospitalized for non-COVID-19 reasons between January 2018 and December 2020. The crude rate of hospitalizations was 79.3 per month between March-December of 2018-2019 and 56.5 per month between March-December of 2020. The was an adjusted absolute difference of 27.0 (95% CI: 10.0, 43.9) fewer hospital admissions during the pandemic period, corresponding to a relative drop of 34%. Residents admitted during the pandemic period had similar demographics and clinical characteristics but were more likely to be admitted for delirium (pandemic: 7% pre-pandemic: 5%, p = 0.01) and were less likely to be admitted for pneumonia (pandemic: 3% pre-pandemic: 6%, p = 0.004). Residents admitted during the pandemic were more likely to be prescribed antipsychotics (pandemic: 37%, pre-pandemic: 29%, p <0.001) and more likely to die in-hospital (pandemic:14% pre-pandemic: 10%, p = 0.04). CONCLUSIONS AND IMPLICATIONS: Better integration between long-term care and hospitals systems, including programs to deliver urgent medical care services within long-term care homes, is needed to ensure that long-term care residents maintain equitable access to acute care during current and future public health emergencies.

Prescription of opioids for opioid-naive medical inpatients.

BACKGROUND: Harms associated with prescription opioids are a major and increasing public health concern. Prescribing of opioids for inpatients may contribute to the problem, especially if primary care practitioners continue opioid therapy that is initiated in hospital. OBJECTIVES: To describe the extent and nature of opioid prescribing for opioid-naive patients (i.e., no use of opioids within 2 weeks before admission) on an internal medicine unit. METHODS: This single-centre study involved chart review for opioid-naive patients admitted to the internal medicine unit of a large academic health sciences centre in Toronto, Ontario. Over 12 weeks, patients were prospectively identified for the study, and charts were later reviewed to characterize opioid use during the hospital stay and upon discharge. The primary outcomes were the proportions of opioid-naive patients for whom opioids were prescribed in hospital and upon discharge. Data on serious adverse events related to opioid use (e.g., need for naloxone or occurrence of falls) were also collected through chart review. RESULTS: From July 4 to September 22, 2011, a total of 721 patients were admitted to the study unit, of whom 381 (53%) were classified as opioid-naive. Opioids were prescribed for 82 (22%) of these opioid-naive patients while they were in hospital. Among the opioid-naive patients, there were a total of 247 opioid prescriptions, with hydromorphone (110 prescriptions) and morphine (92 prescriptions) being the drugs most commonly prescribed. For 23 (28%) of the patients with a prescription for opioids in hospital (6% of all opioid-naive patients), an opioid was also prescribed upon discharge. The indication for opioids was documented in 16 (70%) of the 23 discharge prescriptions. No adverse events or deaths related to opioid use were identified during the hospital stays. CONCLUSIONS: Among opioid-naive patients admitted to the internal medicine unit, opioids were prescribed for about 1 in 5 patients, and less than one-third of these patients were continued on opioids at the time of discharge. These results, if replicated elsewhere, suggest that efforts to improve opioid prescribing and reduce attendant harm should be focused primarily on the outpatient setting.

CONTEXTE: Les préjudices liés aux opioïdes d'ordonnance représentent un enjeu important et croissant en santé publique. Le fait de prescrire des opioïdes aux patients hospitalisés pourrait aggraver le problème, particulièrement si les praticiens de premier recours poursuivent le traitement opioïde amorcé à l'hôpital. OBJECTIFS: Décrire dans quelle mesure l'on prescrit quels opioïdes dans un service de médecine interne à des patients n'ayant pas reçu ces analgésiques au cours des deux semaines précédant leur hospitalisation. MÉTHODES: Cette étude menée dans un seul centre comportait une analyse des dossiers médicaux de patients ayant été admis au service de médecine interne d'un important centre de santé universitaire à Toronto en Ontario et n'ayant pas reçu d'opioïdes au cours des deux semaines précédant l'hospitalisation. Sur une période de douze semaines, ces patients ont été recrutés de façon prospective pour l'étude et leurs dossiers ont été examinés ultérieurement afin de décrire l'utilisation d'opioïdes au cours de leur séjour à l'hôpital et au moment du congé. Les principaux paramètres d'évaluation étaient les proportions de patients n'ayant pas reçu d'opioïdes au cours des deux semaines précédant leur hospitalisation qui s'en sont vu prescrire au cours du séjour et au moment du congé. Des données sur les événements indésirables graves liés à la prise d'opioïdes (p. ex., le recours à la naloxone ou les cas de chutes) ont aussi été recueillies à l'aide de l'analyse des dossiers médicaux. RÉSULTATS: Entre le 4 juillet et le 22 septembre 2011, un total de 721 patients ont été admis dans le service à l'étude et, parmi eux, 381 (53 %) n'avaient pas reçu d'opioïdes au cours des deux semaines précédant leur hospitalisation. Des opioïdes ont été prescrits à 82 de ces derniers (22 %) alors qu'ils séjournaient à l'hôpital. Parmi les patients admissibles à l'étude, on a relevé 247 ordonnances d'opioïdes, dont 110 ordonnances d'hydro-morphone et 92 ordonnances de morphine, les opioïdes les plus couramment prescrits. Vingt-trois (28 %) des patients à qui l'on a prescrit des opioïdes à l'hôpital (6 % de l'ensemble des patients n'ayant pas reçu d'opioïdes au cours des deux semaines précédant leur hospitalisation) ont aussi obtenu une ordonnance pour des opioïdes au moment du congé. Les indications pour les opioïdes ont été consignées dans 16 (70 %) des 23 cas d'ordonnances données au moment du congé. Aucun événement indésirable ou décès lié à l'utilisation d'opioïdes n'a été noté pendant les séjours à l'hôpital. CONCLUSIONS: Parmi les patients n'ayant pas reçu d'opioïdes au cours des deux semaines précédant leur hospitalisation dans le service de médecine interne, un patient sur cinq s'est vu prescrire des opioïdes et moins d'un tiers de ces patients ont vu se poursuivre ce traitement au moment du congé. Les résultats, si cette étude est reproduite ailleurs, suggèrent que les efforts visant à améliorer les pratiques de prescription d'opioïdes et à réduire les risques inhérents pour le patient doivent être axés principalement sur les soins externes. [Traduction par l'éditeur].