New Article – Lessons from Alberta

by Karen Welds, B.A., B.J. (Journalism), on behalf of the Banting & Best Diabetes Centre (BBDC) Diabetes Pharmacists Network

Pharmacists explored the connections between evidence, advocacy and individual action at the BBDC 5th Annual Diabetes Pharmacists Networking Event at the Diabetes Canada/CSEM Professional Conference in Edmonton, Alberta on November 1, 2017. The keynote speaker was Dr. Ross Tsuyuki, Professor of Medicine and Director of the EPICORE Centre research facility at the University of Alberta, followed by a discussion moderated by Dr. Lori MacCallum, Assistant Professor, Leslie Dan Faculty of Pharmacy and Program Director of Knowledge Translation and Optimizing Care Models at the BBDC, University of Toronto. As the only province in Canada where pharmacists can exercise independent prescribing authority, Alberta can be regarded as a model for the rest of Canada, noted Tsuyuki, one that can offer worthwhile learnings.

Pharmacists Are Primary Healthcare Providers

It’s important that patients, physicians, policy-makers and pharmacists themselves understand that pharmacists are primary healthcare providers. “Primary care is the first point of contact with the healthcare system. People say ‘primary care’ and talk only about physicians, but I say they are missing half of what real primary care is about,” said Tsuyuki.

Pharmacists’ new authorities under expanded scopes of practice and overburdened family physician practices help elucidate pharmacists’ role in primary care. More recently, policy makers are looking to pharmacists and other health providers to bridge persistent gaps in health care. “Emerging data from Alberta show that about 30% of patients with a chronic condition, no matter what the condition, cannot, will not, or otherwise do not see a family physician,” said Tsuyuki.

Case Finding Essential for Success

Pharmacists must seek out patients in need, not wait for patients to come to them. “I don’t care how good a clinician you are, you’re useless if you can’t find the people who actually need your care,” stressed Tsuyuki, adding that “magic” happens when pharmacists employ mechanisms that systematically screen for patients. “We call that case finding, and we’ve found that pharmacists, and most health policymakers, really undervalue its importance. It could be as simple as running a report of people taking metformin to find those with diabetes.”

Prescribing Authority Not for Everyone

When it comes to pharmacists reaching their full potential in primary care, Tsuyuki does not hesitate to state that all provinces should follow Alberta’s example and enable independent prescribing authority. Having said that, not all pharmacists should be expected to take that extra step. “This was never meant for everyone to do. Pharmacists have to be comfortable with being legally responsible for their prescribing decisions, and some have real difficulty with that,” said Tsuyuki.

The Cost of Doing Nothing

As evidence mounts for both the clinical and economic value of pharmacists’ services, the growing question is what happens next. “We’re at a point now where we have strong evidence. History will judge us as healthcare professionals based on what we do, or don’t do, with it. Are we going to use it to change the system? Or are we going to whine and do nothing? Do you find that acceptable?” challenged Tsuyuki. “Rather than clinical care by pharmacists, what if we were talking about a new drug that improves outcomes and saves money to this extent? We would be recommending it and insisting patients have access. How is this any different?”

Translating evidence into grassroots action is a process with many moving parts. For its part, the EPICORE Centre is developing tools for “real-world” pharmacy practice, which can also be used by advocacy groups to help build their case with policy makers (see Making the Case for Pharmacists’ Value, following this article).

Questions & Answers

Question: I work part-time in several pharmacies and most of the pharmacists simply do not want to do more under an expanded scope. We keep hearing about the 20% who are keen and do what it takes to overcome barriers, but how do we get more of the remaining 80% on board?

Tsuyuki: It tends to be a small number of very special people, like those in our studies, who immediately step up and figure everything out. They use pharmacy technicians better, they adjust their work flow, etc. It’s not easy, but they find a way to do it. And then at some point, for other pharmacists, the barriers become excuses. And the reality is that some are just not cut out to be clinicians and pushing them is not going to make any difference.

So we have to work with a coalition of the willing, and I really believe that there are enough pharmacists in that 80% who crave the recognition they deserve for patient care. Sometimes that desire is buried quite deep, but it’s the most exciting thing in the world to see that come out. And the people who are the early adopters are extremely inspiring and infectious. As researchers and employers and pharmacy associations, we can continue to fan these early flames so that motivation spreads and eventually catches fire.

Another important point: the next generation of pharmacists will not stand for inaction. Their enthusiasm and training are incredible and it will be really interesting to see what happens in traditional community pharmacy practice—or outside of it—in the coming years.

What about authorities under an expanded scope that are not reimbursed? How do we turn that around?

If that is the hand that you have been dealt, then the strategy going forward must be to collect data to prove the benefits. That’s a priority for us as researchers. For example, we’re very excited about a study launched a couple of months ago with the provincial pharmacy association in New Brunswick, the only province where pharmacists have specific prescriptive authority for urinary tract infections. More than 40 pharmacies are in the study and the response to recruitment has been unbelievable, with more than 400 patients enrolled. We’re tracking the appropriate use of antibiotics and the time to treatment, and already we’re seeing results that make the case for reimbursement, which will in turn motivate more pharmacists to provide the service.

There is another important thing to keep in mind when it comes to government funding: the money comes out of the drug plan budget, rather than a separate budget for health services. That’s why we don’t get anywhere if we talk only to the person in charge of the drug plan—we have to go to the deputy minister or minister level, where they can see the whole picture and understand that pharmacists’ services will save on hospital or physician visits.

What is the impact of pharmacists’ prescribing authority on team-based care? Does it hurt or help relationships with physicians?

What I’ve seen and what is really inspiring is that the pharmacists who do this are excellent communicators and collaborators. They are not cutting the physician out of the loop, but in fact bringing them much more into the loop. And if physicians are concerned about visits, the pharmacists actually send more patients their way, referring them for more of the services that physicians really want to do. Yes, sometimes the communication doesn’t always work in the very beginning. Pharmacists adapt, and physicians who initially resisted will suddenly start sending their patients to the pharmacist. Prescriptive authority is a blend of independence and collaboration: pharmacists act independently, but they also bring physicians into the loop.

Making the Case for Pharmacists’ Value

As part of his presentation, Dr. Ross Tsuyuki gave highlights from the following studies:

  • RxING, a study with patients with poorly controlled type 2 diabetes that saw an average drop of 1.8% in A1C (from 9.1% to 7.3%) after just six months when pharmacists prescribed insulin;
  • RxACTION, a 2015 clinical trial that saw pharmacists with independent prescribing authority help patients with uncontrolled hypertension achieve an average reduction of 18.3 mm Hg (as compared to 11.8 mm Hg in the control group) in systolic blood pressure;
  • RxEACH, funded by Alberta Health and Alberta Health Services, demonstrated pharmacists’ ability to conduct screenings and follow-up consultations for a number of conditions and risk behaviours; and a 21% reduction in the risk for cardiovascular events.
  • The 2017 economic analysis of the pharmacist’s potential impact in hypertension management, which modelled RxACTION across Canada and conservatively estimated a half million fewer cardiovascular events, about 1 million life years saved, and an unprecedented cost savings of almost $16 billion to the healthcare system over 30 years.

For more details, view or download the presentation.

Tools for Knowledge Translation

The EPICORE Centre recently launched the RxING registry for patients with diabetes, an online patient assessment tool for pharmacists and a “real-world” database for researchers and, hopefully, policy makers.

The registry also incorporates the EPICORE Centre’s risk calculator for cardiovascular events, developed during the RxEACH study. Instead of a numeric value to indicate a person’s risk level, it uses the colours of green, yellow or red. “This visual indicator was really important to ensure patients understood their level of risk,” said Tsuyuki. Patients then become engaged when they use the tool’s “sliders” to see what happens to their risk level when there are changes in behavior, such as smoking cessation. “These sliders became an important component for empowering patients.” Outside of the registry, the risk calculator is available on the EPICORE Centre’s website.

The EPICORE Centre began training pharmacists on the use of the RxING registry in October, and patient enrollment has since begun. “If we have enough pharmacists using this in their daily practice, we can point to the results with policy makers. Can you imagine how powerful that will be? We are capturing the outcomes of real-world care by pharmacists,” stated Tsuyuki, adding that the goal is to integrate the registry into provincial electronic health records. The EPICORE Centre has approached Alberta to be the first to do that, though talks are still in early days.

Members of the Diabetes Pharmacists Network will be able to learn more about both the risk calculator and registry in a new interactive learning module, being developed by the Banting & Best Diabetes Centre in partnership with the EPICORE Centre, and scheduled for release in 2018.

Hypertension Canada Invests in Pharmacists

Look for Canada’s first national hypertension management certification program for pharmacists in early 2018, produced by Hypertension Canada. The organization also produces the clinical guidelines for hypertension management (formerly known as the CHEP Guidelines). As part of its next update, the guidelines will incorporate the role of pharmacists, announced Dr. Ross Tsuyuki, a member of Hypertension Canada’s Board of Directors.