Jone Barry, RN (NP)Nurse PractitionerSaskatoon Community Clinic

Saving hips and lives in long-term care

Hip Protectors7pImproving prescription and medication use

Rx for Change8pFrom evidence to integrated formulary decisions

Bridging the Gap10p

4p a new perspective for patients and providers

GLUCOSEOF BLOODMONITORINGSELF-

PERSPECTIVESCanadian Agency for Drugs and Technologies in Health

SPRING-SUMMER 2011

Perspectives is a bi-annual publication of the Canadian Agency for Drugs and Technologies in Health. Its purpose is to share stories of how products developed by CADTH and other HTA producers in Canada are used in the health system to support decision-making in health care.

elcome to our first edition of PERSPECTIVES.

This publication shares the experiences of how our customers are using CADTH’s products to support decision-making — from their perspective. PERSPECTIVES features stories from all sectors of the health care system as part of our commitment to working together in support of the health of Canadians today and tomorrow.

Collaboration and information sharing will become increasingly important given the sheer magnitude in numbers of new health technologies, from drugs and medical devices to new processes and systems. PERSPECTIVES is your window into this fast-paced world.

Enjoy this first edition, and I look forward to reading about your experiences and perspectives in future issues.

Brian O’RourkePresident and CEO

The information in Perspectives is not a substitute for clinical judgment in the care of a particular patient or professional judgment in any decision-making process.

CADTH takes sole responsibility for the final form and content of this document. The statements, conclusions, and views expressed herein do not necessarily represent the view of Health Canada or any provincial or territorial government.

Production of this document is made possible through a financial contribution from Health Canada and the governments of Alberta, British Columbia, Manitoba, New Brunswick, Newfoundland and Labrador, Northwest Territories, Nova Scotia, Nunavut, Ontario, Prince Edward Island, Saskatchewan, and Yukon.

Copyright © CADTH 2011. You are permitted to reproduce this document for non-commercial purposes, provided it is not modified when reproduced and appropriate credit is given to CADTH.

W

On the cover:Jone Barry, a nurse practitioner at the Saskatoon Community Clinic. See article on p. 4. Photo by Heather Fritz.

PersPectives

4New Perspectives on Self-Monitoring of Blood Glucose: Educating Patients and Health Care Providers

7Protecting Canada’s Seniors Saving Hips and Lives

8Educating Prescribers and Consumers on Medication Prescription and Use: What Works and What Doesn’t?

10Collaborating to Mobilize Evidence in British Columbia

4

7

8

10

contentsSPRING-SUMMER 2011

Educating Patients

As one of the first health care co-operatives in Saskatchewan, the Saskatoon Community Clinic is focused on providing care for the whole person, and

on encouraging and helping individuals to play a role in their own health care. Given this orientation, the self-monitoring of blood glucose (SMBG) using test strips is an important part of educating people living with type 2 diabetes. At the same time, the clinic is committed to the prudent use of public health care funding and recognizes that many of the individuals it serves have limited incomes and limited access to supplemental health insurance.

When Jone Barry, a nurse practitioner at the Saskatoon Community Clinic, attended a Canadian Diabetes Association conference, her attention was drawn to a presentation on research into SMBG by the Canadian Agency for Drugs and Technologies in Health (CADTH). Although CADTH’s research had led to four key messages or recommendations, one stood out to Barry: “Most adults with type 2 diabetes controlled by diet alone should not require routine self-monitoring of blood glucose.” Indeed, the message challenges the current practice of most health care providers who treat people with type 2 diabetes. Barry remembers being sceptical: “I was uncomfortable with the recommendations on testing at first.”

Given her commitment to evidence-based health care, Barry investigated further and spoke with Brendalynn Ens, CADTH’s Liaison Officer for Saskatchewan, who shared research reports and answered questions.

“When I reviewed the reports and spoke with Brendalynn, my questions were answered and I saw how the recommendations actually reaffirmed what I was thinking: If the blood sugars of people with type 2 diabetes are normal and stable, why are they testing so often? They’re not learning anything from it at that point.”

4 P E R S P E C T I V E S S P R I N G - S U M M E R 2 0 1 1

New PersPectives on Self-Monitoring of Blood Glucose: Educating Patients and Health Care Providers

“My questions were answered

by a CADTH Liaison Officer and I

saw how the recommendations

actually reaffirmed what I was

thinking: If the type 2 patient’s

blood sugars are normal

and stable, why are they

testing so often? They’re

not learning anything

from it at that point.”

Jone Barry, RN (NP)Nurse Practitioner

Saskatoon Community Clinic

In addition to the research reports, Barry also discovered a series of simple, clear publications that she and her colleagues at the clinic could use to educate patients.

“We share these publications with our patients when they are first diagnosed with type 2 diabetes and come in to learn how to use their glucometers,” she explains. “Some patients are surprised by the information on the publications, but to others, it just makes sense.”

Educating Health Care Providers

Dr. Kerry Mansell is an Assistant Professor of Pharmacy with the College of Pharmacy and Nutrition at the University of Saskatchewan. Given his research interests in diabetes and self-monitoring, Mansell cited CADTH’s research in an article he co-authored in the Canadian Pharmacists Journal.1 The conclusion of Mansell and his co-authors aligned with those of CADTH’s research: “In light of the economic and humanistic burden associated with SMBG, it is reasonable to suggest that certain patients could be advised to reduce their frequency of testing.”

It is no surprise, then, that Mansell is now using CADTH’s recommendations as a guide when educating his students at the University of Saskatchewan. As he sees the effects of CADTH research and recommendations on the next generation of pharmacists, he is confident in the long-term impact of the study:

“As people get more comfortable with the recommendations from CADTH, that’s when we will soon start to see the effects,” he explains. “The first part of it, I think, is educating health care professionals as to when do we need to test and when do we not need to test and then giving them that information, the science behind it, and the rationale for those recommendations to basically arm them to go to talk to their everyday clients.”

Thanks to the efforts of individuals like Jone Barry and Dr. Kerry Mansell, care providers and people living with type 2 diabetes in Canada are now discovering CADTH’s research and reconsidering the role of self-monitoring of blood glucose in the management of type 2 diabetes. An important national conversation has begun on how best to invest public dollars to support people who live with type 2 diabetes.

P E R S P E C T I V E S 5

CADTH’s Four Key Messages

1For people with type 1 or type 2 diabetes using basal-bolus insulin

regimens, self-monitoring of blood glucose should be individualized to guide adjustments in insulin therapy to achieve optimal blood glucose control.

2In adults with type 2 diabetes using basal insulin, self-monitoring

of blood glucose should be individualized, but testing of up to 14 times per week should be sufficient for most patients at most times.

3Most adults with type 2 diabetes managed on oral antidiabetes drugs do not

require routine self-monitoring of blood glucose. Periodic testing in selected patients (e.g., those with unstable glucose levels, acute illness, pharmacotherapy changes, risk of hypoglycemia with insulin secretagogues like glyburide) should be linked to specific patient actions (e.g., prevention or management of hypoglycemia, self-directed dosage adjustment).

4Most adults with type 2 diabetes controlled by diet alone should not require

routine self-monitoring of blood glucose.

The Cost of SMBG in Canada

Ó In 2006, we spent more than $330 million on test strips needed to self-monitor blood glucose.

Ó More than half of that amount is spent on people with type 2 diabetes who are not treated with insulin.2

2 Cameron C, Virani A, Dean H, Evans M, Dolovich L, Dahl M. Utilization and Expenditure on Blood Glucose Test Strips in Canada. Can J Diabetes. 2010; 34(1):34-40.

1 Mansell K, Blackburn D, Eurich D. Do postprandial glucose levels add important clinical information when fasting glucose levels are near normal in non-insulin-dependent patients with type 2 diabetes? Can Pharm Journal 2009; 142:6, 298-302.

“As people get more comfortable with the

recommendations from CADTH, that’s when we

will soon start to see the effects.”

Dr. Kerry MansellAssistant Professor of Pharmacy

College of Pharmacy and Nutrition at the University of Saskatchewan

S P R I N G - S U M M E R 2 0 1 1

6 P E R S P E C T I V E S

Other Efforts to Educate and Exchange Knowledge

The efforts by CADTH to exchange the knowledge generated by this study also include articles by members of the expert review committee and CADTH staff that were published in influential peer-reviewed journals, including the Canadian Medical Association Journal, the Canadian Diabetes Journal, Open Medicine, and the Canadian Pharmacists Journal. Coverage was also generated in the news media, including in The Globe and Mail and The New York Times as well as interviews on Radio-Canada and in local media outlets across the country.

Most recently, CADTH implemented a series of interactive Café Scientifique events in 10 Canadian cities, bringing together panels of diabetes experts, health care providers, and people living with type 2 diabetes and their family members. Together, the events

reached hundreds of Canadians and sparked an important national conversation on how best to invest public health care dollars to support people who live with type 1 and type 2 diabetes.

Thanks to these initiatives and to the efforts of individuals like Jone Barry and Dr. Kerry Mansell, care providers and people living with type 2 diabetes in Canada are now discovering CADTH’s research and reconsidering the role of SMBG in the management of type 2 diabetes.

Most recently, CADTH implemented a series of interactive Café Scientifique events in 10 Canadian cities, bringing together panels of diabetes experts, health care providers, and people living with type 2 diabetes and their

family members. Dr. Adil Virani, Associate Professor in the Faculty of Pharmaceutical Sciences at the University of British Columbia and member of CADTH’s Expert Review Committee, addresses the crowd in Surrey, BC, accompanied by co-panellists Dr. Parmjit Sohal, a family physician in Surrey, and Siobhan Whalley, a Diabetes Nurse Educator in the community.

S P R I N G - S U M M E R 2 0 1 1

P E R S P E C T I V E S 7

1 Hip Protectors in Long-Term Care: A Clinical and Cost-Effectiveness Review and Primary Economic Evaluation, Canadian Agency for Drugs and Technologies in Health, Ottawa ON.

ProtectiNg caNada’s seNiors Saving Hips and Lives

intervention. Winsor and her colleagues took notice

not only of the CADTH research, but also of the tools CADTH created to help educate care providers and patients.

“In July 2010, we ordered 500 pocket cards from CADTH and we ensure they are available in common areas at the facilities alongside an information pamphlet about our new Falls Prevention Program.”

Winsor reported success in preventing hip fractures even at this early stage of the program. The participating sites have been carefully tracking the use of the hip protectors with regard to compliance, comfort, durability, and incidence of hip fractures due to falls. Winsor’s assessment of the program and CADTH’s contribution is positive: “We accept that falls will happen. CADTH’s research and the resulting products into the hip protector devices and the pocket cards they provided are making it easier for our Falls Prevention team to encourage the use of hip protectors amongst residents.”

In Canada, the average societal costs (such as lost productivity and out-of-pocket expenses) in the first year following a hip fracture is more than $27,000 (in 1997 Canadian dollars)

per patient and $34,000 per resident of a long-term care facility. The total annual eco-nomic costs of hip fractures are estimated at $650 million and are expected to rise to $2.4 billion by 2041.1

In Newfoundland, the Central Health Authority has tackled the problem of hip fractures by establishing a Falls Prevention Steering Committee, and working to expand a Falls Prevention Program, that prevent hip fractures to all long-term care and acute care facilities in the region. A key intervention in their work to prevent hip fractures: hip protectors.

Hip protectors consist of an underwear-type garment with pockets in which protective pads are inserted on each side to cushion the hips in the event of a fall.

“We’ve started the hip protector program at sites where there are reported patient falls and incidences of hip fractures,” explained Kathy Winsor who is the Co-Chair of the Falls Prevention Steering Committee in Central Newfoundland Regional Health Authority. “We recognize the long-term health care costs of hip fractures and the slow recovery time for seniors who fall victim to a hip fracture – an injury that often proves fatal.”

The growing hip protector program in the Central Health Authority is being developed using a CADTH Health Technology Assessment product. This product provides expert advice regarding the use and effectiveness of hip protectors, including the economic benefits of this intervention. The research points to a decrease in the number of accidents involving hip fractures when hip protective devices were used by elderly patients in long-term care facilities, leading the expert panel struck by CADTH to recommend their use as a cost-effective

Support for CADTH’s Contribution“I was quite thankful the day I received the hip protector pocket cards and education packet from CADTH. It saves us from having to reinvent the wheel and makes our job easier to know an organization like CADTH is there to provide research and marketing support.”

Kathy Winsor, Co-Chair, Falls Prevention Steering Committee, Central Newfoundland Regional Health Authority

Central Health’s long-term care facilities promote hip protectors to avoid injury due to falls as part of their

new Falls Prevention Program. Left to right above: Doug Keough, Recreation Specialist II, Central Health, Springdale,

Newfoundland and resident Shirley Eastman.

Hip Protectors in British ColumbiaIn British Columbia, the information was used to support a proposal to senior leadership within the Interior Health Authority on the use of hip protectors. The senior leadership team was impressed with the potential for hip protectors in long-term care facilities and fully funded the proposal to implement hip protector kits in every residential facility with funded beds (80 sites), every community care and community mental health office (60 sites), and every acute care hospital (25 sites).

The Fraser Health Authority sent hip protector guidance cards to all 86 residential care sites in their health authority to be included in their hip protector kits.

S P R I N G - S U M M E R 2 0 1 1

8 P E R S P E C T I V E S S P R I N G - S U M M E R 2 0 1 1

In both his professional roles, Dr. Aaron Tejani relies on fact-based information to help health care providers and patients make informed decisions. Tejani is the Coordinator

of Clinical Research and Drug Information with the Fraser Health Pharmacy Services, where he plans one-on-one educational visits to physicians and pharmacists and serves as the principal liaison for pharmaceutical rep-resentatives on behalf of the hospitals in the Fraser Valley Health Authority. He is also a member of the Scientific Information and Education Committee of the Therapeutics Initiative. A part of the University of British Columbia, the mission of the Therapeutics Initiative is to provide physicians and phar-macists in the region with evidence-based information on prescription drug therapy.

Tejani is passionate about the need to provide information that is free of bias: “As clinicians and scientists, we have an obligation to get the best information for the patients that we care for and serve,” he says.

Tejani also knows that information is only as effective as how it is delivered to health care providers and to patients. That’s why he is a frequent user and supporter of the Rx for Change database. As he describes it, “The Rx for Change database is the missing link between having the best information and actually being able to come up with the strategy to practically apply it.”

Educating Prescribers and Consumers on Medication Prescription and Use: What Works and What Doesn’t?

Dr. Aaron TejaniCoordinator of Clinical Research and

Drug Information with the Fraser Health Pharmacy Services

P E R S P E C T I V E S 9

Questions the Rx for Change Database Can Help Answer

óó What’s the most effective way to encourage health care workers to wash their hands regularly?

óó How effective are guidelines at standardizing health care practice?

óó Do computer-based guideline systems make a difference in how providers prescribe and order tests?

óó Will a written action plan help a parent manage his or her child’s asthma?

óó What are the most effective ways to help patients adhere to their prescriptions?

Finding the right strategy is key to ensuring that health care providers and patients remember, understand, and consistently apply the information shared with them. Many such strategies have been developed, ranging from sophisticated online tools and public education campaigns to simple strategies like reminder notes posted in a patient’s charts and foil packs to dispense medications. But do they work? In what circumstances? And, most importantly, how reliable is the scientific evidence that tells us whether or not the strategy works?

The Rx for Change database helps find answers to these questions in two ways. First, the partners behind the database — the Canadian Agency for Drugs and Technologies in Health (CADTH) and two Review Groups of the Cochrane Collaboration — conduct systematic reviews of the available studies, assessing their quality, and drawing conclusions from the combined information gathered. Second, the reviews are gathered into an online database, where policy-makers, health care providers, and researchers can search for evidence on a particular topic.

Tejani has turned to the Rx for Change database a number of times to find the best way to take evidence-based information to front-line clinicians in his region. “When I was planning rounds with physicians and pharmacists, I needed to know if it’s best to just talk to them or best to get them involved and give them exercises,” he recalls. “I found out from the Rx for Change database that I have to make things interactive if it’s going to be effective.”

Tejani has also used evidence from the database to support a number of grant applications for initiatives he and his colleagues planned. “Instead of opting for a didactic lecture, we built our application around interactive workshops because the evidence indicated this interactive approach was most effective. We built our budget accordingly and we’ve been funded three or four times now.” In this way, the Rx for Change database is generating impact in the longer term, helping to direct funding to health education initiatives that are backed by scientific evidence.

By bringing the best evidence to the attention of health professionals like Tejani, the Rx for Change database is helping to make prescribing and medication use more effective.

“The Rx for Change database is the missing link between having the best information and

actually being able to come up with the strategy to practically apply it.”

Quick Facts about the Rx for Change Database•ó Launched in 2007, a joint collaboration of

CADTH and two Cochrane Review Groups: Effective Practice and Organisation of Care (EPOC) and Cochrane Consumers and Communication Review Group (CC&CRG)

•ó Updated regularly

•ó Currently contains more than 200 summarized reviews that distill the findings from thousands of high-quality individual studies

•ó Reviews cover a number of conditions and diseases, and are organized into sections focused on interventions targeting prescribers, consumers, and organization of care (financial, regulatory, and health system organization strategies)

•ó One year after its launch, the database had accumulated more than 25,000 page views

www.rxforchange.ca

S P R I N G - S U M M E R 2 0 1 1

10 P E R S P E C T I V E S

About a year ago, BC’s six health authorities were working on their own to locate information about the cost and clinical effectiveness of

drugs, analyze this data, and reach individual conclusions about whether or not to add the drug to their health authority’s formulary. Today, all health authorities in the province are at the same table, functioning as an integrated Pharmacy and Therapeutics Committee, leveraging the best available evidence, and listing drugs to a single province-wide formulary. The end result of this more coordinated approach: residents in British Columbia benefit from evidence-based formulary decisions and tax payers benefit from not having redundant parallel processes running in each health authority.

This new decision-making process places British Columbia at the forefront of embracing a new “lean” process for reviewing, listing, and utilizing drugs. It optimizes the use of pharmacist, nursing, and physician resources to make the most effective use of the available evidence while helping to ensure best practices are consistently used throughout the province.

As Vice President of Clinical Operations and Strategic Planning with the Fraser Health Authority, Marc Pelletier is clear on the need to more consistently and aggressively use evidence to minimize waste and to focus public spending on the most effective and safest interventions. The impact of this and similar initiatives to more aggressively apply evidence will reach far beyond the border of British Columbia, he predicts: “Resting in the balance is the overall affordability of the Canadian health system.”

Pelletier is also clear that CADTH has played a key role in supporting this shift to a more evidence-based approach. CADTH’s Liaison Officer in British Columbia, Ann Vosilla, has worked to support the health authorities there by bridging the gap between evidence-based research, clinical application, and effective and timely decision-making. Pelletier describes her as a key ally: “There is a lot of research going on internationally, nationally, and locally, and Ann helps to bring the pieces into the health authorities and connect it with the day-to-day reality of our organization,” he explains. “The liaison word I think is key,” he continues. “Ann is a practitioner of knowledge transfer, getting the right health research to the right people, at the right time.”

Through a series of presentations in British Columbia, Vosilla’s message on evidence and its use has cascaded right across the province and her partnerships have grown with each presentation. A registered nurse with a specialty in psychiatry, Vosilla is able to anticipate the information needs of her clients and is a strong advocate for evidence-based decisions.

“Ann is a walking, living, breathing resource of knowledge — a researcher, librarian, communication specialist, networker, and educator all wrapped up in one person,” summarizes Pelletier. “It is not uncommon for her to say ‘I know you’re working on this particular topic, did you know this evidence was just published?’ or ‘How can I help find information that is more relevant to your decision-making?’” This kind of ally in health care is an evangelist for all Canadians.”

Collaborating to Mobilize Evidence in British Columbia

S P R I N G - S U M M E R 2 0 1 1

P E R S P E C T I V E S 11

“Ann is a practitioner of knowledge transfer, getting the right health research to

the right people, at the right time.”

Through a series of presentations in British Columbia, Vosilla’s message on

evidence and integration has cascaded right across the province.

S P R I N G - S U M M E R 2 0 1 1

www.cadth.ca

The Canadian Agency for Drugs and Technologies in Health (CADTH) is an independent not-for-profit organization funded by the federal, provincial, and territorial governments of Canada. CADTH is one of Canada’s leading sources of information and advice about the effectiveness and efficiency of drugs, medical devices, and other health technologies.

Do you have a story to share? We are always interested in hearing about how people are using CADTH’s products. Please email us at requests@cadth.ca and your story could be featured in a future edition of Perspectives!