Resource Experts & Methods

A group of resource experts representing a number of organizations came together to develop the Polypharmacy Toolkit.

Resource Team

  • Michael Allen, MD, MSc, graduated from Dalhousie Medical School in 1975 and practised as a family physician in Nova Scotia until joining Dalhousie Continuing Medical Education. He has been Director of the Dalhousie Academic Detailing Service since its inception in 2001.
  • Sandi Berwick, PDt, BA Psych., MA FSGN, has been an advocate and supporter of many initiatives for culture change in Continuing Care during her 25 year career. The opportunity to participate in this provincial committee for the new diabetes guidelines for the frail elderly in NS LTC homes has proven to be a positive experience for culture change in LTC, as well as representing the health values and best outcomes for our older population in our homes.
  • Brenda Cook, MAEd, PDt, CDE, is a Diabetes Consultant with the Diabetes Care Program of Nova Scotia and served as chair of the Diabetes in Long Term Care Committee from 2005 to its present day.
  • Peggy Dunbar, Med, PDt, CDE, has been the Manager of the  Department of Health and Wellness  Diabetes Care Program of Nova Scotia since its inception in 1991.  A graduate of Dalhousie and Acadia Universities and a Certified Diabetes Educator, her interests include the importance of understanding our target populations, the uptake and use of local data to improve outcomes, self-management and self-management support and encouraging “thinking outside the box” with regards to partnerships, chronic disease management, and integrated approaches to diabetes care and education.
  • Jill Duncan, BSc. Pharm., had worked in the Drug Evaluation Unit for 9 years. She provided consultation to the Academic Detailing program for the development of evidence based materials on appropriate use of antibiotics, including the management of urinary tract infections in the elderly and long term care patients.
  • Isobel Fleming, BSc. Pharm., is the Senior Academic Detailer at the Dalhousie Academic Detailing Service, Office of Continuing Medical Education, Dalhousie University in Halifax, Nova Scotia.
  • Kim Kelly, BSc. Pharm., has worked as a drug evaluation pharmacist for 20 years. Her work primarily involves critical appraisal of the medical literature to assess the efficacy, safety and cost-effectiveness of medications.
  • Laurie Mallery, MD, F.R.C.P.C, is a geriatrician and head of the Division of Geriatric Medicine at Dalhousie University.  Along with Dr. Paige Moorhouse, she has co-founded the Palliative and Therapeutic Harmonization or PATH program.  The PATH model improves appropriateness of care and resource utilization across the healthcare continuum by placing frailty at the forefront of evidence-informed decision making. In addition to clinical programming, the PATH has partnered with other groups to develop evidence-informed guidelines for the treatment of common medical co-morbidities in frailty (hypertension, diabetes, hyperlipidemia, asymptomatic bacteriuria).
  • Paige Moorhouse, MD, MPH FRCPC (Internal Medicine and Geriatrics with a Master’s Degree in Public Health from John Hopkins University) draws on her clinical experience to inspire her research in end of life care, team-based care, vascular cognitive impairment, executive function, and driving and dementia. In her first five years of practice, she designed and implemented a customized EMR team assessment process for a Geriatric Day Hospital, created a public service campaign for driving and dementia, and a companion provincial web resource for primary care physicians. She has applied her expertise in program development, implementation and evaluation in co-founding the Palliative and Therapeutic Harmonization Program (PATH) and the Collaborative Comprehensive Geriatric Assessment method.
  • Tom Ransom, MC, FRCDC, is a staff Endocrinologist with the Division of Endocrinology & Metabolism at the Queen Elizabeth II Health Sciences Centre in Halifax and is an Associate Professor of Medicine at Dalhousie University Faculty of Medicine.  He is from Toronto where he earned undergraduate and graduate degrees in Nutrition with a focus on diabetes and lipids.  He completed his Internal Medicine in Toronto and moved to Halifax to do his fellowship in Endocrinology, as well as a one year research fellowship.  At present, Dr. Ransom is sharing the lead in a Capital Health Obesity Initiative and is currently the Medical Director of the Bariatric Surgery Program. His research interests include obesity, insulin resistance and in-hospital management of diabetes.
  • Cheryl Smith, RN, MN, NP, DNP, CDP, is a Primary Health Care Nurse Practitioner for the Cumberland Health Authority working in long term care (LTC). Cheryl holds registered nurse and nurse practitioner diplomas, Bachelor of Nursing, Master of Nursing, and Doctor of Nursing Practice Degrees. As a Certified Dementia Practitioner she advocates to improve quality of life for LTC residents, with a primary focus in addressing polypharmacy. In addition to her current roles, Cheryl is an adult educator teaching health providers on numerous topics in a variety of settings; local facility based, community college, under graduate and graduate university programs.
  • Brian R Steeves, MD, is a family physician with a special interest in care of the aged. He is Medical Director of the R.K MacDonald LTC facility in Antigonish, Nova Scotia and the District Medical Director of Continuing Care for GASHA. Areas of interest are medication optimization, creating positive environments in LTC and promoting a better understanding of dementia.
  • Pam McLean-Veysey, BSc Pharm, is a Team Leader with the Drug Evaluation Unit at Capital Health. Pam has worked for 17 years as a drug evaluation pharmacist. Her prime areas of interest include the critical appraisal of medical literature and using innovative approaches to enhance the application of evidence to clinical practice.
  • Audrey Weatherbee, RN, is certified in Gerontology and has worked at the Willow Lodge Home for Special Care for 33 years.
  • Special recognition to the members of the Long Term Care Committee of the Diabetes Care Program of Nova Scotia.

Resource Programs

There were a number of programs across the province that provided support for the resource team in their development of the guidelines. They include the Palliative and Therapeutic Harmonization Program (PATH), the Diabetes Care Program, the Dalhousie Academic Detailing Service and the Drug Evaluation Unit.

PATH

logo_path_clinic

Recognized as a leading practice by Accreditation Canada, the PATH   program1,2,3 optimizes decision-making and resource utilization across the healthcare continuum. The program uses a standardized approach to help health professionals, patients, and families consider frailty when making treatment decisions through a 3-step process that consists of (1) assembling the story of frailty by synergizing efforts across different health care disciplines; (2) communicating information about frailty to other health providers, patients and families; and (3) empowering all stakeholders to make decisions based on consideration of frailty prognosis and aimed at preservation of quality of life. Use of the PATH process improves appropriateness of care, with one study demonstrating that its application resulted in a 75% reduction in the demand for interventional treatments for the significantly frail.

For more information on this program, please visit pathclinic.ca

The Diabetes Care Program

logo_diabetes_care

Implemented in 1991, the DCPNS4 is one of eight provincial programs funded by the Nova Scotia Department of Health and Wellness. In pursuit of its aim of improving the care of persons with or at risk of developing diabetes, the DCPNS advises the Department of Health and Wellness on service delivery models; establishes, promotes, and monitors adherence to diabetes guidelines; provides support and resources to health care providers; and collects, analyzes, and disseminates diabetes-related information for and throughout Nova Scotia.

For more information on this program, please visit: http://diabetescare.nshealth.ca/

 Dalhousie Academic Detailing Service

logo_dalhousie

The Dalhousie Academic Detailing Service5 works with the Capital Health Drug Evaluation Unit to research and develop evidence-based educational messages about the treatment of common medical conditions. The messages are then disseminated to family physicians and other health professionals throughout Nova Scotia through one-on-one or small-group sessions. The program operates through the Office of Continuing Medical Education at Dalhousie University. The service is funded by the Nova Scotia Department of Health and Wellness, which does not influence content.

For more information on this service, please visit: http://cme.medicine.dal.ca/ADS.htm

Drug Evaluation Unit (DEU)

deans_capital_healthThe Drug Evaluation Unit (DEU) is located within the Capital Health Pharmacy Department. Pharmacists in the DEU specialize in the critical appraisal of medical literature and collaborate with policy makers, providing evidence-based reports to support drug formulary decisions; continuing pharmacy and medical education, including the Academic Detailing Program, Continuing Medical Education, Dalhousie University and developers of clinical practice guidelines.
 

Methods

To develop guidance, we reviewed the evidence to generate what we call “evidence-informed” guidelines.  For the treatment topics that we considered (hypertension, diabetes, and statin use), none of the randomized controlled trials included frail older adults.  Therefore, we reviewed studies that enrolled older adults, most of whom were healthy. In reviewing evidence and conventional guideline recommendations, we concentrated on the following details:

  • Are conclusions about medication effectiveness based on randomized control trial (RCT) evidence or consensus opinion? For instance, when reviewing the evidence to develop guidance about treating hypertension, we found that the commonly recommended systolic blood pressure target of <140 mm Hg is not  based on RCT evidence, as none of the randomized controlled trials that enrolled older adults to evaluate the benefit of blood pressure lowering achieved this target.
  • Are trial outcomes relevant to the frail?  Many outcome measures that are considered important for healthier adults are not relevant with frailty.  Standard outcome measures such as proteinuria, photocoagulation, asymptomatic myocardial infarctions, and non-disabling strokes have uncertain clinical impact when there is frailty.  Equally, mortality may not be an applicable outcome with frailty, as there are many competing causes for mortality when individuals are frail. Therefore, we cannot assume that a mortality benefit that is demonstrated in non-frail populations applies to frail populations.
  • Is the timeframe needed to achieve benefit congruent with the shortened life expectancy associated with frailty? Treatments that take many years to achieve benefit will not be applicable to the frail.
  • Were medication adverse effects appropriately considered in studies and treatment guidelines?  Since the frail are vulnerable, adverse effects from medications can significantly impact quality of life and health status compared to healthier adults.  Thus, both potential risks and benefits of treatment need to be carefully considered.

We also endorse the following questions, which are modified by Holly Holmes’ work6 on medical appropriateness to clarify whether each medication should be continued:

  1. Is there an indication for the drug?
  2. Is the person’s life expectancy long enough to achieve benefit?
  3. Is the medication effective for the condition and in this age group?
  4. Is there unnecessary duplication with other drugs?
  5. Does the medication match the patient’s goals of care?
  6. Is this drug the least expensive alternative compared with others of equal usefulness?
  7. Is the medication causing bothersome adverse effects?

References

  1. Moorhouse P, Mallery L.  Palliative and Therapeutic Harmonization: A Model for Appropriate Decision-Making in Frail Older Adults.  J Am Geriatr Soc 2012 Dec; 60(12):2326-2332. doi: 10.1111/j.1532-5415.2012.04210.x. Epub 2012 Oct 30.
  2. www.pathclinic.ca
  3. Mallery LH, Moorhouse P. Respecting frailty. J Med Ethics 2011 Feb;37(2):126-128. Epub 2010 Nov 21.
  4. http://diabetescare.nshealth.ca/sites/default/files/files/LTCPocketReference.pdf
  5. Continuing Medical Education, Dalhousie Faculty of Medicine. Available from: http://cme.medicine.dal.ca/ADS.htm
  6. Holmes HM, Hayley DC, Alexander GC, Sachs GA.  Reconsidering medication appropriateness for patients late in life.  Arch Intern Med 2006, Mar 27;166(6):605–609.