A multidisciplinary, multi-sectoral alliance to improve drug use in Nova Scotia
Ingrid Sketris, Dalhousie University
Dawn Frail, Nova Scotia Department of Health
Pam McLean-Veysey, Capital District Health Authority
George Kephart, Dalhousie University
Charmaine Cooke, Dalhousie University
Michael Allen, Dalhousie University
Wayne Putnam, Dalhousie University
Susan Bowles, Dalhousie University
The Drug Evaluation Alliance of Nova Scotia (DEANS) is a multi-sector initiative designed to encourage appropriate drug use by influencing behaviour change. DEANS involves researchers, students, adult educators, health care professionals, decision makers and program administrators in developing multi-faceted, evidence-based educational interventions. The initiative delivers cost effective and cost-saving research: one project played a key role in policy changes worth millions of dollars in savings to the province. DEANS attributes its success to the multi-sector synergy created through the partnerships, and involving researchers who have protected time for rigorous evaluations.
Publicly funded drug programs frequently use policy levers, such as selection of drugs for public reimbursement and payment rules, to encourage or discourage drug utilization.1 While such levers incorporate available evidence and generally manage costs, they have a limited effect on changing attitudes and behaviours among health professionals and patients.
In 1998, the Nova Scotia Department of Health established the Drug Evaluation Alliance of Nova Scotia (DEANS),* with a mission to contribute to the health of Nova Scotians by encouraging appropriate drug use. DEANS was funded to identify critical drug care issues; obtain and analyze information and data relevant to these issues; develop interventions to provide targeted, evidence-based information to health care providers and patients; and to evaluate the impact of initiatives on drug utilization, health professional behaviour and patient outcomes. The Pharmacare Formulary Management Committee reviews drugs for listing in the Pharmacare benefit list, with DEANS operating in concert to provide educational interventions to strengthen policy initiatives.
The KT initiative
DEANS is coordinated by a management committee which includes individuals with expertise in continuing education, family medicine, clinical pharmacy practice, epidemiology, and drug utilization and evaluation. The committee meets monthly to discuss knowledge synthesis and intervention projects, learn of relevant education programs, facilitate information sharing and to build trust among participants.
DEANS develops multi-faceted interventions based on the research literature and local data as well as the knowledge and experience of committee members. The interventions, which include web-based and didactic educational programs, academic detailing, prescribing profiles and pharmacist reflection and feedback, facilitate uptake of evidence by health professionals and patients. Educational initiatives for practicing clinicians are provided through education programs at Dalhousie University or through professional groups, which are viewed as independent, credible sources (in contrast to initiatives provided by government, which can be perceived as mere cost-cutting measures).
At a typical committee meeting, there are academic researchers, drug evaluation experts, health professional adult educators, health care professionals, decision makers and program administrators. Dalhousie University trainees, drug use management and policy residents, undergraduate and graduate students and research fellows also work closely with DEANS.
Results of the KT experience
Three examples of knowledge translation (KT) activities developed by DEANS are provided.
1. Preceding policy change with educational interventions
In 1999, over 700 Nova Scotia seniors were receiving chlorpropamide to treat diabetes, a drug which carries an increased risk of hypoglycaemia in elderly diabetes patients, and which has been widely identified as inappropriate for seniors.2 In late 2000, the Nova Scotia Seniors' Pharmacare Program and the local teaching hospital advised health care professionals and patients that they would remove chlorpropamide as a formulary benefit by June 2001.
DEANS preceded this change by coordinating a broad-based educational intervention to help patients and prescribers convert to different drugs. Adult educators, endocrinologists, family physicians, pharmacists, and educators with the Diabetes Care Program of Nova Scotia were involved. A patient brochure was developed to explain the reasons for change. Physicians were sent a personalized list of their Pharmacare patients receiving chlorpropamide, chart reminders, patient instruction sheets, information on continuing medical education programs, and a one-page recommended approach to selecting drug alternatives. An endocrinologist was also available to discuss difficult switches with physicians.
All Nova Scotia Pharmacare seniors were successfully switched to more appropriate therapy within 12 months.3
2. Partnering across the continuum of care to aid a significant policy change
In 1999, over 5,000 beneficiaries of the Nova Scotia Seniors' Pharmacare Program were receiving respiratory medications to treat lung disease (e.g. asthma, emphysema) by nebulization (by mask). A drug evaluation completed by the Formulary Management Committee concluded that portable inhalers have comparable efficacy, less chance of contamination, and are more convenient and less costly than nebulization.
In 2000, the Nova Scotia Seniors' Pharmacare Program announced that they would limit payment of respiratory medications delivered by wet nebulization to specific patients in six months time, and would immediately add a spacer device to help patients use portable inhalers better. The program also established a professional fee to reimburse pharmacists for providing education on the proper use of the spacer device.
To accompany the policy change, DEANS coordinated multi-faceted educational interventions targeting physicians, hospital and continuing care staff, pharmacists, respiratory technologists and patients to help them manage the transition. Interventions included continuing education programs and support from other provincial partners such as the Nova Scotia Lung Association, which provided a toll-free, 24-hour support line for patients and health professionals.
Many patients were able to switch to portable inhalers, resulting in an estimated drug cost saving of $1 million per year. In October and November 1999, 12% of patients used only wet nebulization; this dropped to 4% in October and November, 2000. This change was not associated with any untoward effects, such as increases in physician visits or hospitalizations.4-9
3. Physician profiling to effect practice change
Physician profiling—providing information on a physician's past patient care activities to influence future decisions—is one tool used to promote change in physician behaviour, but evidence of its effectiveness is conflicting. In 2001, DEANS initiated a project to determine if physician profiling could alter prescribing patterns for topical corticosteroids for skin diseases. A therapeutic class review completed by the Formulary Management Committee had previously identified that mild to moderate topical corticosteroids are preferred in the elderly, and that prices vary greatly between products in the same potency category.
DEANS developed individual-level physician profiles that aimed to convey two main messages to prescribers: the potency of the products being prescribed, and the different costs of the products being prescribed within potency classes. These profiles, and an accompanying cost comparison chart, were mailed to prescribing physicians. The physicians were re-profiled and new profiles were sent the following year. However, the project did not result in any significant difference in prescribing patterns.10
Preceding such a policy change with multi faceted educational interventions provided both health care professionals and patients with sufficient knowledge to adapt to the change.
These examples offer a number of important lessons for future KT initiatives.
First, a policy change such as delisting a formulary drug will impact prescribing patterns. But preceding such a policy change with multi-faceted educational interventions provided both health care professionals and patients with sufficient knowledge to adapt to the change, which generally occurred before the new policy came into effect. We attribute part of our success to utilizing practitioners' usual sources of information as vehicles for KT such as newsletters from Doctors Nova Scotia, the Pharmacy Association of Nova Scotia, and the Capital District Health Authority.
In our second example, participation across the continuum of care, with direct involvement of several types of health care professionals and a health charity, helped to implement a significant policy change with no evident ill effects. The incorporation of a financial incentive for pharmacists to provide an educational service was viewed as important. A qualitative evaluation noted:
"Paying attention to questions at both the broadest possible level (the provincial Pharmacare system) and narrow levels (individual attitudes and behaviours in practice) strengthened this initiative. Policy initiatives that incorporate and reflect research evidence address an important barrier to change, but evidence alone is unlikely to promote change."11
In our third example, mailing physicians unsolicited profiles and prescribing recommendations was ineffective in changing their prescribing behaviour. Other evidence suggests that providing this kind of information in isolation does not typically motivate physicians to change, and that multiple strategies may be required. Physician profiling may be more effective if it is incorporated into educational outreach programs where individual approaches could help to effect change.10,12 We also identified other contributing factors, such as the high safety profiles and low prescribing rates for these drugs, meaning that they are not necessarily recognized as a high priority for practice change.
Physician profiling may be more effective if it is incorporated into educational outreach programs where individual approaches could help to effect change.
As a general lesson, we have found that trainees play a key role in DEANS. As part of their academic programs, they produce various knowledge products, such as reviews of theory, systematic literature reviews, methods development, surveys of other jurisdictions, identification of "smart practices," and qualitative and quantitative evaluations of interventions. By nature, trainees are focused on theories and strengthening methodology, activities that are not necessarily funded with high priority in policy making. Yet a student can spend a year developing a rigorous evaluation method of great value to the Pharmacare programs, at a cost borne entirely by the university or granting agencies. As well, the trainees benefit enormously from their involvement in DEANS by participating in the KT process, experiencing real life challenges of knowledge dissemination and uptake, and learning the language of decision makers.
Conclusions and implications
Trainees benefit enormously from their involvement in DEANS by participating in the KT process, experiencing real life challenges of knowledge dissemination and uptake, and learning the language of decision makers.
In DEANS, decision makers, practitioners and researchers are working together to improve drug prescribing and use. Each partner brings resources, knowledge, skills and experience, creating a multi-sectoral synergy that we believe forms the basis for our success. Researchers and students are funded through CIHR, the Canadian Health Services Research Foundation, other granting agencies, and the university, which allows for the time, resources, and skills to do rigorous evaluations. This work is valued by the policy maker community, and as evidenced by the nebulization policy change, can save the government millions of dollars.
* For more information about DEANS, visit their website.
1 Sketris, I. S., M. G. Brown, and A. L. Murphy. 2004. Policy choices for Pharmacare: The need to examine benefit design, medication management strategies and evaluation. HealthcarePapers 4 (3): 36-45.
2 Morningstar, B. A., I. S. Sketris, G. C. Kephart, and D. A. Sclar. 2002. Trends in oral antihyperglycemic and insulin use in the Nova Scotia senior population (1993-1999). Can J Clin Pharmacol (9) 3: 123-29.
3 Sketris, I. S., G. C. Kephart, D. M. Frail, C. D. Skedgel, and M. J. Allen. 2004. The effective of deinsuring chlorpropamide on prescribing of oral antihyperglycemics for Nova Scotia Seniors' Pharmacare beneficiaries. Pharmacotherapy 24 (6): 784-91.
4 Sketris, I. S., and P. McLean-Veysey. 2000. A provincial program in Nova Scotia to decrease the use of wet nebulization respiratory medications. JMCP 6 (6): 457-62.
5 Bowles, S. K., I. S. Sketris, and G. C. Kephart. 2003. Use of inhaled respiratory medications by wet nebulization in Nova Scotia seniors under Pharmacare's reimbursement guidelines. Plenary presentation. Association of Faculties of Pharmacy Conference, Montreal.
6 Flanagan, P. S., S. K. Bowles, and I. S. Sketris. 2003. Pharmacist claims for a professional fee for the Nova Scotia wet nebulization conversion initiative. Poster presented at the Association of Faculties of Pharmacy Conference, Montreal.
7 Bowles, S. K., I. S. Sketris, and G. C. Kephart. 2001. Use of inhaled respiratory medications by wet nebulization in Nova Scotia seniors under Pharmacare's reimbursement guidelines. Abstracts of the American College of Clinical Pharmacy 2001 Annual Meeting, Tampa, Florida.
8 Murphy, A. L., N. J. MacKinnon, P. S. Flanagan, S. K. Bowles, and I. S. Sketris. 2005. Pharmacists' participation in an inhaled respiratory medication program: Reimbursement of professional fees. Ann Pharmacother 39 (4): 655-61.
9 Kephart, G. C., I. S. Sketris, S. K. Bowles, M. E. Richard, and C. A. Cooke. Forthcoming. Impact of a criteria-based reimbursement policy on the use of respiratory medications delivered by nebulizer and health care services utilization. Pharmacotherapy.
10 Sketris, I. S., G. Kephart, C. A. Cooke, C. D. Skedgel, and P. R. McLean-Veysey. 2005. Use of physician profiles to influence prescribing of topical corticosteroids. Can J Clin Pharmacology 12 (2): e186-97.
11 Twohig, P. L., W. Putnam, and D. Frail. 2005. Qualitative perspectives on a facilitated change in provincial pharmacare coverage. CPJ 138 (2): 30-4.
12 Grimshaw, J., L. M. McAuley, L. A. Bero, R. Grilli, A. D. Oxman, C. Ramsay, L. Vale, and M. Zwarenstein. 2003. Systematic reviews of the effectiveness of quality improvement strategies and programmes. Qual Saf Health Care 12 (4): 298-303.
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