Nova Scotia Seniors Research Articles

A Prescribing Cascade of Proton Pump Inhibitors Following Anticholinergic Medications in Older Adults With Dementia.

Introduction: Prescribing cascade refers to use of a medication to treat a drug-related adverse event. Prescribing cascades increase medication use, cost, and risk of adverse events. Objective: Our objective was to use administrative health data to identify whether use of medications from the anticholinergic cognitive burden scale was associated with proton pump inhibitor (PPI) prescribing consistent with a prescribing cascade in older adults with dementia. Method: The cohort was comprised of Nova Scotia Seniors’ Pharmacare beneficiaries identified to have dementia and medication dispensation data recorded between 1 April 2010, or cohort entry and 31 March 2015. Anticholinergic medications from the anticholinergic cognitive burden scale (ACB) were abstracted. A look back period of 365 days identified if a PPI had been dispensed preceding anticholinergic dispensation. PPI initiation within 30, 60, 90, or 180 days of the anticholinergic medication was assessed. Demographic description of those dispensed anticholinergic medications or PPIs were reported. Risk factors for the prescribing cascade were investigated with logistic regression and Cox proportional hazards modelling including a sex-stratified analysis. Results: We identified 28,952 Nova Scotia Seniors’ Pharmacare beneficiaries with dementia and prescription dispensation data. Anticholinergic medications were frequently dispensed with 63.4% of the cohort dispensed at least one prescription for an anticholinergic medication. The prescribing cascade defined as up to 180-days between anticholinergic medication inititation and PPI dispensation, occurred in 1,845 Nova Scotia Seniors’ Pharmacare beneficiaries with dementia (incidence 6.4%). Multivariate regression showed those experiencing the prescribing cascade after initiating any anticholinergic were younger (OR 0.98, 95%CI [0.97–0.98]), less likely to live in an urban location (OR 0.82, 95%CI [0.74–0.91]), or to be men (OR 0.74, 95%CI [0.67–0.82]). Cox regression demonstrated an increased risk of starting a PPI within 180 days when initiating any medication from the ACB (HR 1.38, 95%CI [1.29–1.58]). Discussion: Regression modelling suggested that anticholinergic medications increased the risk of PPI dispensation consistent with a prescribing cascade in the cohort. The identification of the prescribing cascade in this population of older Nova Scotia Seniors’ Pharmacare Program beneficiaries with dementia using administrative health data highlights how routinely collected health data can be used to identify prescribing cascades.

An examination of three prescribing cascades in a cohort of older adults with dementia

BackgroundPrescribing cascades are a source of inappropriate prescribing for older adults with dementia. We aimed to study three prescribing cascades in older Nova Scotians with dementia using administrative databases.MethodsCohort entry for Nova Scotia Seniors’ Pharmacare Program beneficiaries was the date of dementia diagnosis. Prescription drug dispensing data was extracted for inciting medication and second treatment (cholinesterase inhibitor and bladder anticholinergic, metoclopramide and Parkinson’s disease medication, or calcium channel blocker (CCB) and diuretic) over the six-year period April 1, 2009 to March 31, 2015. In three separate analyses, dispensing an inciting medication signaled a look back of 365 days from the date of first dispensing to confirm that the second treatment was started after the inciting medication. The prescribing cascade was considered when the second treatment was started within 180 days of the inciting treatment. Sex differences in the prescribing cascade were tested using t-tests or chi square tests as appropriate. Both univariate (unadjusted) and multivariate (adjusted) logistic regression (adjusted for age, rurality, and sex) and Cox proportional hazards regression was used to identify risk factors for the prescribing cascade.ResultsFrom March 1, 2005 to March 31, 2015, 28,953 Nova Scotia Seniors' Pharmacare beneficiaries with dementia (NSSPBD) were identified. There were 60 cases of bladder anticholinergics following cholinesterase inhibitors, 11 cases of Parkinson’s disease medication following metoclopramide, and 289 cases of a diuretic following CCB in the cohort. Regression analysis demonstrated that risk of bladder anticholinergics following cholinesterase inhibitors and diuretics following CCBs were associated with female sex. Cox regression suggested that bladder anticholinergics were less often used by those on cholinesterase inhibitors and did not identify CCB use as leading more frequently to diuretic use.ConclusionsThe combination of diuretics following CCB was the most common prescribing cascade and bladder anticholinergics following cholinesterase inhibitors the second most common. However, exposure to the inciting medications did not increase risk of exposure to the second treatments. Combinations of bladder anticholinergics following cholinesterase inhibitors and diuretics following CCBs were more common for women raising concern that women may be at increased risk of these prescribing cascades.

Potentially Inappropriate Drug Duplication in a Cohort of Older Adults with Dementia

BackgroundConcurrent use of 2 nonsteroidal anti-inflammatory drugs, selective serotonin reuptake inhibitors, loop diuretics, angiotensin-converting enzyme inhibitors, or anticoagulants is considered potentially inappropriate by Screening Tool of Older Persons' Prescriptions and Screening Tool to Alert to Right Treatment criteria.ObjectiveThe objective was to examine drug duplication in a cohort of older adults with dementia.MethodsCohort entry for Nova Scotia Seniors’ Pharmacare Program beneficiaries was the date an International Classification of Diseases ninth edition or 10th edition code for dementia was recorded in accessed databases between March 1, 2005, and March 31, 2015. Medication dispensation and sociodemographic data were captured from the Nova Scotia Seniors’ Pharmacare Program database between April 1, 2010, and March 31, 2015. Duplication was considered when 2 drugs from the same class were dispensed such that the supply in the patient's possession could overlap for more than 30 days. We reported number of cases of duplication and duration of overlap. Sex differences in drug duplication were assessed with bivariate logistic regression.ResultsIn the cohort of 28,953 Nova Scotia Seniors’ Pharmacare Program beneficiaries with dementia, we documented concurrent use in 101 (1.7%) nonsteroidal anti-inflammatory drugs users (mean duration = 75.6 days), 95 (1.0%) selective serotonin reuptake inhibitors users (mean duration = 146.6 days), 5 (0.07%) loop diuretic users (mean duration = 530.6 days), 183 (2.0%) angiotensin-converting enzyme inhibitor users (mean duration = 123.9 days), and 160 (3.5%) anticoagulant users (mean duration = 63.6 days). Nonsteroidal anti-inflammatory drug pairs were most commonly celecoxib with naproxen or diclofenac. Selective serotonin reuptake inhibitors duplication was most commonly sertraline with citalopram. No sex differences in risk for drug duplication were identified.ConclusionsDrug duplication was identified in a cohort of older adults with dementia and is a feasible target for intervention. (Curr Ther Res Clin Exp. 2021; 82:XXX–XXX)

Determining proton pump inhibitor prescription dispensing patterns and adherence to STOPP criteria for Nova Scotia Seniors Pharmacare Program beneficiaries.

Proton pump inhibitors (PPIs) are often prescribed potentially inappropriately. The screening tool of older person's potentially inappropriate prescriptions (STOPP) for therapeutic dose PPIs has been adapted to examine PPI discontinuation, dose reduction, or switching to Histamine-2 Receptor Antagonist (H2RA) after 60 days. The objectives of the present study were to (1) describe the use of acid suppression therapy (PPIs and H2RAs) 60 and 90 days after a new PPI dispensing, (2) assess predictors of lack of adherence to adapted STOPP criteria for PPI use, and (3) assess PPI dispensing over time. This was a retrospective cohort study of beneficiaries of the Nova Scotia Seniors Pharmacare (NSSP) aged 66 years or older who were newly dispensed a PPI between January 1, 1997 and March 31, 2011. The main outcome measure was adherence to the adapted STOPP criteria, which was analyzed using logistic regression. A total of 14,453 participants were included: 89.8% beginning on standard dose and 10.2% beginning on high-dose PPI. Of those beginning on high-dose PPI, 26.4% were dispensed high-dose PPI at day 60 and 30.2% were dispensed high-dose PPI at day 90. Predictors of lack of adherence to our adapted STOPP criteria included age ≥86 years, rural residence, and hospitalization within 1 year prior to cohort entry. Many PPI prescriptions dispensed for NSSP beneficiaries fail to adhere to the STOPP criteria. Predictors of lack of adherence to the adapted STOPP criteria were identified.

Antipsychotic Drug Dispensations in Older Adults, Including Continuation After a Fall-Related Hospitalization: Identifying Adherence to Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions Criteria Using the Nova Scotia Seniors' Pharmacare Program and Canadian Institute for Health's Discharge Databases

PurposeDespite well-established concerns regarding adverse drug effects, antipsychotics are frequently prescribed for older adults. Our first objective was to identify trends in antipsychotic dispensations to older Nova Scotians. STOPP (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions) criteria identify antipsychotic use in those with a history of falls as potentially inappropriate. Our second objective was to identify trends, predictors, and adherence with this STOPP criteria by identifying continued antipsychotic dispensations following a fall-related hospitalization.MethodsA descriptive cross-sectional cohort study of Nova Scotia Seniors’ Pharmacare Program (NSSPP) beneficiaries ≥ 66 years with at least one antipsychotic dispensation annually from April 1, 2009 to March 31, 2014 was completed. As well, unique beneficiaries with at least one antipsychotic dispensation in the four-year period between April 1, 2009 and March 31, 2013 were linked to fall-related hospitalizations recorded in the Canadian Institute for Health Information Discharge Database. The relationship of age, sex, fiscal year, days supply and length-of-stay were studied to identify predictors of continued antipsychotic dispensation post-discharge. Descriptive statistics and multivariate logistic analysis were performed. Odds ratios for the association of risk factors and adherence to STOPP criteria were calculated.FindingsWe identified that in each year observed, there were 6% of eligible NSSPP beneficiaries that received at least one antipsychotic dispensation. Approximately 70% of antipsychotic dispensations were for second generation agents, primarily quetiapine and risperidone. Of the unique beneficiaries with at least one antipsychotic dispensation in the four-year period between April 1, 2009 and March 31, 2013 who survived a fall-related hospitalization over 75% were dispensed an antipsychotic in the 100 days following hospital discharge. Logistic regression showed no statistically significant association between potentially inappropriate therapy and potential predictors in multivariate analysis.ImplicationsIn each year from 2009 to 2014, 6% of Nova Scotia Seniors’ Pharmacare beneficiaries were dispensed at least one antipsychotic prescription. Over 75% of the older adults who received an antipsychotic dispensation in the 100 days prior to a fall-related hospitalization, continued the drug class after discharge. This demonstrates that despite the recommendations of quality indicators such as the STOPP criteria, antipsychotics are continued in individuals at a high risk of falling. Future investigations are needed to inform health team, system, and policy interventions to improve concordance with this antipsychotic specific STOPP criterion when appropriate.

The Impact of US FDA and Health Canada Warnings Related to the Safety of High-dose Simvastatin.

IntroductionBetween 2010 and 2012, the US Food and Drug Administration and Health Canada issued warnings to healthcare professionals emphasizing the increased risk of muscle problems with high-dose simvastatin.ObjectiveTo measure the impact of the Health Canada safety warning regarding dose-dependent adverse effects of simvastatin on prescribing of low, medium, and high doses of simvastatin.MethodsAn interrupted time-series design was used to evaluate the impact of a Health Canada safety warning on 7 November 2012 regarding the safety of high-dose simvastatin. Monthly prescription records were analyzed for beneficiaries of the Nova Scotia Seniors’ Pharmacare Program aged 65 years or older who had received > 1 prescription of simvastatin between 1 January 1997 and 31 March 2015. Autoregressive Integrated Moving Average models were used to test changes in the proportion of beneficiaries dispensed a low dose (< 40 mg), medium dose (40 mg to < 80 mg), or high dose (≥ 80 mg) of simvastatin over time.ResultsThere were 219 monthly periods, of which 29 periods occurred after the Health Canada warning. On average during the pre-warning periods there were 2944 simvastatin users per month, of whom 71% were dispensed a low dose, 26% a medium dose, and 2% a high dose. The proportion of beneficiaries dispensed low-dose simvastatin increased by 0.9% (one-sided p value 0.035; 90% CI 0.07–1.65), the proportion dispensed medium-dose simvastatin decreased by 0.7% (one-sided p value 0.0496; 90% CI −1.48 to −0), and there was no significant change in the proportion dispensed high-dose simvastatin (−0.15% change, one-sided p value 0.205; 90% CI −0.45 to 0.15).ConclusionsThe Health Canada Health Care Professional warning had a small effect on increasing the proportion of beneficiaries dispensed low and medium doses of simvastatin but not high doses of simvastatin. Nevertheless, there remain seniors in Nova Scotia receiving high-dose simvastatin for whom the benefit/risk potential may need to be re-evaluated.

Adoption of the Nova Scotia (Canada) Community Pharmacy Medication Management Program, 1-Year Post-Initiation.

Pharmacists conduct medication reviews to optimize drug therapy. Each jurisdiction implements and funds these programs differently. To describe the uptake of the first year of a community pharmacy medication review program reimbursed by the publically insured seniors' drug benefit program in Nova Scotia, Canada. This retrospective analysis included 294 pharmacies and 105,000 beneficiaries enrolled in the Nova Scotia Seniors' Pharmacare Program. Prescription and service claims data from this program were analyzed to determine type and number of beneficiaries receiving a medication review, number and predictors of pharmacies completing reviews, and number of prescribed medications 6-months before and 6-months after the review. 428 medication reviews were conducted and billed by 33% of Nova Scotia pharmacies (1-50 reviews per pharmacy per year). The mean number and range of medications before the review were 10.8 (4-28) and following the review 10.4 (0-24), with an average decrease of 0.4 medications (95% CI 0.1-0.6), p=.0043). Patients receiving a review had a mean age of 75.2 years; 64.9% were female. Most pharmacies conducted reviews when patients reached their annual copayment (93%). Approximately 33% of pharmacies billed at least one medication review in the first year of the program. In spite of a $150 reimbursement per community pharmacy medication review, only 428 reviews were conducted over a 13-month period for a population of over 100,000 seniors. Results suggest financial reimbursement alone is not sufficient to implement a medication management program; health systems need to determine patient, pharmacist, pharmacy and health system level strategies to implement medication reviews more broadly.

Does the Number of Pharmacies a Patient Frequents Affect Adherence to Statins?

We hypothesized that medication adherence is affected by the number of pharmacies a patient frequents. The objective was to estimate the strength of association between the number of pharmacies a patient frequents and adherence to statins. Using administrative data from the Nova Scotia Seniors' Pharmacare program, a retrospective cohort study was conducted among subjects aged 65 years and older first dispensed statin between 1998 and 2008. The Usual Provider of Care (UPC), was defined as the number of dispensation days from the most frequented pharmacy divided by the total number of dispensation days. Estimated adherence of over 80% of the Medication Possession Ratio was defined as adherent. Data were analyzed using hierarchical linear regression. The cohort of 25,641 subjects was 59% female with a mean age of 74 years. During follow-up, subjects filled prescriptions in a median of 2 (mean = 2; standard deviation = 0.88) pharmacies and visited pharmacies a median of 28 (mean = 30) times. During that time, 61% of patients used one pharmacy exclusively. Among subjects using 1 pharmacy, 59% were adherent while 58% using more than one pharmacy were adherent. However, upon adjustment for differences in distributions of age, sex, and other confounders, subjects who used more than one pharmacy had 10% decreased odds of statin adherence (odds ratio: 0.90, 95% confidence interval: 0.86-0.96). These results were robust in sensitivity analyses. Among seniors newly starting statin therapy, using a single community pharmacy was modestly associated with adherence.

Trends in Statin Use in Seniors 1999 to 2013: Time Series Analysis.

PurposeTo examine HMG-CoA reductase inhibitor (statin) drug dispensing patterns to Nova Scotia Seniors' Pharmacare program (NSSPP) beneficiaries over a 14-year period in response to: 1) rosuvastatin market entry in 2003, 2) JUPITER trial publication in 2008, and 3) generic atorvastatin availability in 2010.MethodsAll NSSPP beneficiaries who redeemed at least one prescription for a statin from April 1, 1999 to March 31, 2013 were included. Aggregated, anonymous monthly prescription counts were extracted by the Nova Scotia Department of Health and Wellness (Nova Scotia, Canada) and changes in dispensing patterns of statins were measured. Data were analyzed using descriptive analyses and interrupted time series methods.ResultsThe percentage of NSSPP beneficiaries dispensed any statin increased from 5.3% in April 1999 to 20.7% in March 2013. In 1999, most NSSPP beneficiaries were dispensed either simvastatin (29.5%) or atorvastatin (28.7%). When rosuvastatin was added to the NSSPP Formulary in August 2003, prescriptions dispensed for simvastatin, lovastatin, pravastatin, and fluvastatin declined significantly (slope change, -0.0027; 95% confidence interval (CI), (-0.0046, -0.0009)). This significant decline continued following the publication of JUPITER (level change, -0.1974; 95% CI, (-0.2991, -0.0957)) and the availability of generic atorvastatin (level change, -0.2436; 95% CI, (-0.3314, -0.1558)). Atorvastatin was not significantly affected by any of the three interventions, although it maintained an overall decreasing trend. Only upon the availability of generic atorvastatin did the upward trend in rosuvastatin use decrease significantly (slope change, -0.0010, 95% CI, (-0.0015, -0.0005)).ConclusionsThe type and rate of statins dispensed to NSSPP beneficiaries changed from 1999 to 2013 in response to the availability of new agents and publication of the JUPITER trial. The overall proportion of NSSPP beneficiaries dispensed a statin increased approximately 4-fold during the study period. In 2013, rosuvastatin was the most commonly dispensed statin (44.1%) followed by atorvastatin (39.1%).

Adherence to Guidelines and the Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions Criteria for Colchicine Dosing for Gout Treatment in Beneficiaries of the Nova Scotia Seniors’ Pharmacare Program

PurposeColchicine is commonly used in the management of gout; however, older persons have higher risks of toxicity. Accordingly, the Screening Tool of Older Person’s potentially inappropriate Prescriptions (STOPP) criteria for colchicine consider >3 months of treatment as potentially inappropriate in older persons. Recent evidence also suggests lower dosing of colchicine is as effective and results in fewer toxicities than high-dose colchicine. The objectives of this study were to determine the dose, duration, and prescribers of colchicine and to evaluate adherence to the STOPP criteria and international guidelines for colchicine in older persons. MethodsA retrospective, observational study was conducted from April 1, 2006 to March 31, 2011 to evaluate colchicine use. Nova Scotia Seniors’ Pharmacare Program beneficiaries who met inclusion criteria for an incident case of gout and who filled at least 1 prescription for colchicine during the study period were included. Colchicine dose and duration were reported descriptively. Multivariate logistic regression was used to identify predictors of the study population in making a claim for colchicine >90 and >180 days. FindingsA total of 518 persons were dispensed 1327 courses of colchicine during the study period. The mean daily dose of colchicine ranged from 1.39 to 1.50 mg. Colchicine doses >1.2 mg were prescribed in approximately one-third of the study population. Colchicine was prescribed for >90 days in 14.2% of treatment courses and for >180 days in 8.1% of treatment courses. Female sex was the only predictor of treatment duration >90 days. ImplicationsThis study is the first to report on colchicine dose and duration using STOPP criteria in a specific cohort of older persons with incident gout. Strategies to improve colchicine prescribing in older persons are needed.

A Knowledge Transfer Study of the Utility of the Nova Scotia Seniors’ Mental Health Network in Implementing Seniors’ Mental Health National Guidelines

The Canadian Coalition for Seniors' Mental Health (CCSMH) developed national best-practice guidelines in seniors' mental health. Promoting adoption of new guidelines is challenging, as paper dissemination alone has limited impact on practice change. We hypothesized that the existing knowledge transfer (KT) mechanisms of the Nova Scotia Seniors' Mental Health Network would prove useful in transferring the CCSMH best-practice guidelines. In this observational KT study, CCSMH best-practice guidelines were delivered through two interactive, case-based teaching modules on Depression & Suicide, and Delirium via a provincial tele-education program and local face-to-face sessions. Usefulness of KT was measured using self-report evaluations of material quality and learning. Evaluation results from the two session topics and from tele-education versus face-to-face sessions were compared. Sessions were well attended (N = 347), with a high evaluation return rate (287, 83%). Most participants reported enhanced knowledge in seniors' mental health and intended to apply knowledge to practice. Ratings did not differ significantly between KT session topics or modes of delivery. The KT mechanisms of a provincial seniors' mental health network facilitated knowledge acquisition and the intention of using national guidelines on seniors' mental health among Nova Scotian clinicians. Key elements of accelerating KT used in this initiative are discussed.

The Rate of Prescribing Gastrointestinal Prophylaxis with Either a Proton Pump Inhibitor Or an H2-Receptor Antagonist in Nova Scotia Seniors Starting Nonsteroidal Anti-Inflammatory Drug Therapy

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used agents that can cause serious gastrointestinal (GI) side effects. For patients at increased risk of NSAID-related GI complications, prophylaxis with either a nonselective NSAID plus gastroprotective agent (GPA) or, alternatively, therapy with a cyclooxygenase-2 selective inhibitor with or without a GPA such as a proton pump inhibitor (PPI), is recommended. To describe the rate, timing and duration of GI prophylaxis in Nova Scotia seniors receiving nonselective NSAIDs. The Nova Scotia Seniors' Pharmacare Program beneficiaries for the years 1998 to 2002 were studied. A cohort of incident NSAID and GPA users was selected from all nonselective NSAID users (no prescribed NSAID dispensed 12 months before the index month and no GPA dispensed two months before the index prescription). Monthly coprescribing rates were calculated by dividing the number of patients in the cohort using GPAs by the number of NSAID users. GI prophylactic coprescribing was defined as the coprescribing rate present at the first month (index month) of prescribing an NSAID. The cohort consisted of 12,906 patients. Seventy-five per cent of the nonselective NSAID prescriptions dispensed were for up to two months duration, with only 2.3% longer than one year. GI prophylaxis was given to only 3.8% of patients starting NSAIDs who were not on a GPA in the two months before starting NSAIDs. Of this 3.8%, 92.7% of the patients received H2-receptor antagonists (H2RAs), and 7% received PPIs. The rate of H2RA coprescribing increased with the number of consecutive months on an NSAID from 3.5% in the first month to 24.1% at 48 months. For PPIs, the coprescribing rate increased from 0.3% to 1.9% of all NSAID users in the cohort. The rate of gastroprophylaxis coprescribing for patients receiving NSAIDs did not rise with increasing age. In Nova Scotian seniors using nonselective NSAIDs, the rate of GI prophylaxis was low. Most patients received H2RAs as GPAs despite evidence that they offer insufficient protection.

Administrative claims data analysis of nurse practitioner prescribing for older adults

This paper is a report of a study to identify the patterns of prescribing by primary health care nurse practitioners for a cohort of older adults. The older adult population is known to receive complex pharmacotherapy. Monitoring prescribing to older adults can inform quality improvement initiatives. In comparison to other countries, research examining nurse practitioner prescribing in Canada is limited. Nurse practitioner prescribing for older adults is relatively unexplored in the international literature. Although commonly used to study physician prescribing, few studies have used claims data from drug insurance programmes to investigate nurse practitioner prescribing. Drug claims for prescriptions written by nurse practitioners from fiscal years 2004/05 to 2006/07 for beneficiaries of the Nova Scotia Seniors' Pharmacare programme were analysed. Data were retrieved and analysed in May 2008. Prescribing was described for each drug using the World Health Organization Anatomical Therapeutic Chemical code classification system by usage and costs for each fiscal year. Antimicrobials and non-steroidal anti-inflammatory drugs consistently represented the top ranked groups for prescription volume and cost. Over the three fiscal years, antimicrobial prescription rates declined relative to rates of other groups of medications. Prescription volume per nurse doubled and cost per prescription increased by approximately 20%. Prescription claims data can be used to characterize the prescribing trends of nurse practitioners. Research linking patient characteristics, including diagnoses, to prescriptions is needed to assess prescribing quality. Some potential areas of improvement were identified with antimicrobial and non-steroidal antiinflammatory selection.

Development of the Nova scotia Diabetes Repository: a project of the Nova Scotia Diabetes Repository Advisory Committee

Background: The Diabetes Care Program of Nova Scotia (DCPNS) maintains a comprehensive registry of clinically confirmed diabetes (DM) cases; however, only Diabetes Centre attendees are represented (about 70% of DM population in NS). The Nova Scotia Atlee Perinatal Database (NSAPD) and Nova Scotia Seniors' Pharmacare Database (NSSPD) also contain gold standard DM cases, but for a limited population. The National Diabetes Surveillance System (NDSS) derives nationally comparable DM statistics using administrative data; however, these cases are estimated not clinically confirmed. Combining data from various Programme Databases with routinely collected administrative data could greatly enhance DM case ascertainment. In Nova Scotia, all of these data sources are readily linkable, making the province an ideal sentinel surveillance site for DM in Canada.

The relationship between type of drug therapy and blood glucose self-monitoring test strips claimed by beneficiaries of the Seniors' Pharmacare Program in Nova Scotia, Canada.

BackgroundThe healthcare expenditure on self-monitoring of blood glucose (SMBG) test strips under the Nova Scotia Seniors' Pharmacare Program (NSSPP) has increased significantly in recent years. The objective of this study was to identify the frequency and cost of claims for blood glucose monitoring test strips by NSSPP beneficiaries in the fiscal year 2005/06 and to explore the variation in the use of test strips by type of treatment, age and sex.MethodsRetrospective analysis was conducted using pharmacy administrative claims data for NSSPP beneficiaries. Study subjects were aged ≥ 65 years on October 1, 2004, received SMBG test strips in the 110 days prior to April 1, 2005, and were alive throughout the twelve month study period. Subjects were categorized into four groups: insulin only, oral antihyperglycemic agents (OAA) only, both OAA and insulin; and no reimbursed diabetes medications. Statistical analysis was performed to identify differences in expenditure by medication group and in frequency of SMBG test strips claimed by medication group, age, and sex.ResultsOf 13,564 included beneficiaries, 13.2% were categorized as insulin only, 53.5% OAA only, 7.2% both OAA and insulin, and 26.0% no reimbursed diabetes medications. Over half (58.7%) were femle. The insulin only category had the highest mean (± SD) number of SMBG test strips claimed per day (2.0 ± 1.5) with a mean annual total cost of $615 ± $441/beneficiary. Beneficiaries aged 80 years and above claimed fewer test strips than beneficiaries below 80 years.ConclusionThis population based study shows that in Nova Scotia the SMBG test strips claimed by the majority of seniors were within Canadian guidelines. However, a small proportion of beneficiaries claimed for SMBG test strips infrequently or too frequently, which suggests areas for improvement. The provincial drug plan covers the majority of the costs of test strip utilization, suggesting that the majority of test strips claimed did not exceed the maximum allowable cost (MAC) established in the program's MAC policy. Drug insurance programs need to work with healthcare providers to determine if patients are using test strips optimally; and to determine their impact on patient outcomes. In addition, they need to determine the cost-effectiveness of their SMBG test strip reimbursement policies.

Use of wet nebulized inhaled respiratory medications under criteria-based reimbursement guidelines in a publicly funded seniors' pharmacare program in Nova Scotia, Canada

During the 1999/2000 fiscal year, approximately 19% of beneficiaries in the Nova Scotia Seniors' Pharmacare Program (NSSPP), a publicly funded drug insurance program in Nova Scotia, Canada, received inhaled respiratory medications by wet nebulization. The cost was estimated at more than Can $2 million annually. On August 1, 2000, the NSSPP initiated new criteria-based reimbursement guidelines for wet nebulized respiratory medications, requiring prior authorization. Within the NSSPP, we examined approved reimbursement requests to determine demographic characteristics of those who accessed wet nebulized therapy through exception criteria, compare these factors between those who accessed wet nebulized therapy within the exception criteria and those who fell outside the criteria, identify indications for use of wet nebulization, and determine patterns of wet nebulization use. Two hundred approved requests, received between August 1, 2000, and April 30, 2001, were randomly selected and reviewed for indications and patterns of use. Of 200 requests reviewed, 28 were excluded due to coverage in another Pharmacare program (Community Services). Of the 172 requests reviewed, 27% were for nursing home or other residential care facility residents. Indications and patterns of use differed only by place of residence (P<0.001). The majority of indications (72%) fell within outlined reimbursement criteria, with the most frequently cited indication (56%) being inability to use portable inhalers due to cognitive or physical disability. Almost one third (28%) of exception requests were approved for other reasons (31% of these were for short-term use [ie, <3 months] secondary to an acute respiratory infection or for palliative care; 69% continued to access wet nebulization because of a preference or a perception of greater effectiveness). Examination of patterns of use demonstrated that 36% of beneficiaries, primarily community dwelling (P < 0.001), were using wet nebulized therapy and portable inhalers concurrently. The majority of approved requests for wet nebulization criteria fell within the established reimbursement guidelines. Many approvals outside of guidelines were clinically valid. Approval of requests outside the criteria highlights the need for flexibility in the claims administrative and adjudication system to respond to unique circumstances not covered by established criteria. However, concurrent use of wet nebulization and portable inhalers by some beneficiaries suggests suboptimal use of portable inhalers, the need for portable inhalers for patients using wet nebulization when they leave their residence, and the need for more patient education.

Impact of a Criteria‐Based Reimbursement Policy on the Use of Respiratory Drugs Delivered by Nebulizer and Health Care Services Utilization in Nova Scotia, Canada

In February 2000, the Nova Scotia Seniors' Pharmacare Program announced a change in the reimbursement of respiratory drugs that added specific reimbursement criteria for wet nebulization therapy. Policy implementation coincided with multifaceted interventions to assist patients and providers with the change. To assess the impact of the new policy and associated interventions on the use of wet nebulization and portable inhaler delivery systems of respiratory drugs and on the utilization of health services. The administrative claims database identified all beneficiaries (age > or = 65 yrs) who received at least one respiratory drug prescription in the 12 months before the study. These patients were then grouped into the wet nebulization cohort or the control cohort receiving a metered-dose or a dry-powder inhaler. The study period was from April 1998-February 2002. Use of respiratory drugs, physician visits, and hospitalizations were compared between study cohorts using an interrupted time-series design. A sharp decrease was noted in use of wet nebulization after the policy announcement, along with an increase in use of short-acting beta2-agonists and anticholinergic agents delivered by metered-dose or drypowder inhaler. From December 1999 to December 2001, in the heavy wet nebulization cohort (a subset of the wet nebulization cohort), wet nebulization use dropped from 100% to 35%; in the wet nebulization cohort, wet nebulization use decreased from 67% to 20%. Rates of spacer device use were 42%, 31%, and 17% in the heavy wet nebulization, wet nebulization, and control cohorts, respectively, in December 2001. Rates of general practitioner visits and hospitalizations for respiratory conditions did not increase in the intervention cohorts after the policy announcement. In fact, relative to the control cohort, health services use in response to the policy and interventions in the wet nebulization cohort decreased. The reimbursement policy resulted in decreased use of respiratory drugs delivered by wet nebulization without a negative impact on general practitioner visits and hospitalizations for respiratory conditions.

Use of gastrointestinal preventive therapy among elderly persons receiving antiarthritic agents in Nova Scotia, Canada

Background: Two different strategies, referred to as gastrointestinal (GI) preventive therapy (GIPT), have been recommended for high-risk patients to prevent GI complications associated with antiarthritic therapy with nonsteroidal anti-inflammatory drugs (NSAIDs): (1) use of a gastroprotective agent (GPA) along with the NSAID or (2) use of a cyclooxygenase-2-selective inhibitor (COX-2SI). The COX-2SIs rofecoxib and celecoxib have been shown to be as effective as traditional NSAADs for pain relief, but with an improved GI safety profile. Objective: The purpose of this study was to examine the utilization of GIPT by elderly persons in Nova Scotia who were taking antiarthritic medications and to identify the factors associated with their use of GIPT. Methods: A retrospective, cross-sectional study was conducted using administrative data from the Nova Scotia Seniors' Pharmacare Program database. Study participants were aged ≥65 years and had filled a prescription for a COX-2SI, a traditional NSAID, or high-dose aspirin at some point between January 1, 2001 and August 31, 2002. Subjects with at least 1 risk factor (as defined by our study) who received GIPT were classified as receiving appropriate therapy. Subjects with risk factors who did not receive GIPT were classified as potential underutilizers of GIPT. Subjects without risk factors who received GIPT were classified as potential overutilizers of GIPT. Descriptive statistics were presented, and factors independently associated with receiving GIPT were assessed using logistic regression. Results: The study included 14,587 seniors: 3647 used COX-2SIs, 9412 used traditional NSAIDs alone, and 1528 used traditional NSAADs plus a GPA. Subjects were predominantly female (age range, 65–74 years). In subjects with at least 1 risk factor, 63% were classified as potential underutilizers of GIPT. Thirty-three percent of subjects with no risk factors were classified as potential overutilizers of GIPT. Factors significantly associated with receiving a GIPT included Female gender, annual income >$50,000, urban residence, age ≥75 years, GI complication in the previous year, and concomitant use of warfarin or corticosteroids. Conclusion: Potential under utilization of GIPT in this subject population was more prevalent than potential overutilization of GIPT. Although all hypothesized risk factors were significantly associated with receiving GIPT, physician education on GI risk factors might improve prescribing of GIPT for elderly persons in Nova Scotia.

The effect of deinsuring chlorpropamide on the prescribing of oral antihyperglycemics for Nova Scotia Seniors' Pharmacare beneficiaries.

On behalf of the Nova Scotia Seniors' Pharmacare Program, the Drug Evaluation Alliance of Nova Scotia developed a multicomponent intervention plan to facilitate the removal of chlorpropamide as an insured benefit. Chlorpropamide has caused serious hypoglycemia in seniors to a greater extent than some other agents. Pharmacy administrative claims were used to compute monthly use rates for insulin and each oral antihyperglycemic drug from January 1, 2000-December 30, 2002, in an intervention cohort (patients receiving chlorpropamide) and a control cohort (patients receiving an antihyperglycemic agent other than chlorpropamide). Initially, 630 patients were receiving chlorpropamide therapy. By the time chlorpropamide was deinsured, only 10% of the treatment cohort continued receiving chlorpropamide; shortly after deinsurance, no beneficiaries continued receiving the drug. The antihyperglycemics with the greatest increase in prescription were glyburide and gliclazide. The deinsuring of chlorpropamide and the educational strategies that accompanied it resulted in the selection of more appropriate antihyperglycemics for Nova Scotia seniors.

Topical corticosteroid prescribing patterns following changes in drug benefit status.

To examine changes in prescribing patterns for topical corticosteroid products dispensed to elderly patients in Nova Scotia, Canada, after all but 2 combination topical corticosteroid products were removed from the Nova Scotia Seniors' Pharmacare Program benefit list. Administrative prescription claims from the Nova Scotia Seniors' Pharmacare Program were used to identify the number and costs of topical corticosteroid, antifungal, antibiotic, and combination corticosteroid products dispensed. Time-series analysis was used to compare the periods before (April 1, 1999-March 31, 2000) and after (April 1, 2000-March 31, 2001) the delisting. In 1999-2000, 26,031 of 103 400 eligible elderly patients (25%) and in 2000-2001, 22,837 of 95,550 eligible elderly (24%) received a prescription for a defined topical product. Nova Scotia Seniors' Pharmacare Program expenditures for all topical products decreased from 11.88 to 10.60 Canadian dollars per beneficiary per year (11%) after the policy revision. Topical combination products decreased from 18% of all topical products dispensed to 14%, while the percentage of potent corticosteroid products dispensed increased from 24% to 27% over the study period. Pre- and post-policy time-trend analysis showed statistically significant increasing trends in cost per beneficiary for all topical products and potent corticosteroid products. Combination corticosteroid products showed no change in trends for costs per beneficiary before, and a slight increasing trend after, the policy revision. Prescribing of topical corticosteroid combination products in Nova Scotia decreased following the formulary revision. There was an increase in potent topical corticosteroid prescribing. Future study involving evaluation of patient outcomes would be useful.