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Lessons from the frontlines: A collaborative report on Pandemic H1N1

https://policybase.cma.ca/en/permalink/policy9840
Last Reviewed
2018-03-03
Date
2010-08-26
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2010-08-26
Topics
Population health/ health equity/ public health
Text
Lessons from the frontlines: A report on Pandemic H1N1 from Canadian Medical Association, The College of Family Physicians of Canada, National Specialty Society for Community Medicine One year ago, a novel influenza virus claimed its first victim in Mexico, and soon the world was plunged into its first influenza pandemic in 40 years. Although pandemic H1N1 (pH1N1) swept across the globe, we were fortunate this time as the virus was far less virulent than first feared. Now that pH1N1 has peaked and faded, it is time to look at what we learned and how it will help us plan for the next national public health emergency. The College of Family Physicians of Canada, the National Specialty Society for Community Medicine and the Canadian Medical Association have joined together to present a picture of lessons learned from the front lines of the pandemic. Together we represent over 80,000 physicians, of whom almost 50,000 are family physicians, engaged in all aspects of Canada's health care and public health systems. Canada's experience with SARS in 2003 was a "wake-up call"; much changed in its aftermath. The creation of the Public Health Agency of Canada led by a chief public health officer and the Pan-Canadian Public Health Network increased Canada's ability to respond to a public health emergency like pH1N1. The Canadian Pandemic Influenza Plan for the Health Sector, as well as complementary provincial and territorial plans, provides a framework and approach to responding to a pandemic. In many ways, this planning paid off. Canada mobilized quickly in response to the pH1N1 threat. Morbidity and mortality were lower than feared, and 45% of the population was vaccinated. But this response can also be seen as a "dress rehearsal" for a more severe influenza pandemic or some other national public health emergency: a test of our plans and an opportunity to learn from experience, with the time to incorporate these lessons into our strategic planning. Those on the front lines of response understand how health emergencies test our entire system - public health, acute and primary care and the community-based family physician. The success of our response depends on planning and practice, the effectiveness of public health and clinical countermeasures, our health human resources, the surge capacity within our health care and public health systems and our ability to reach the public. One of our greatest challenges in Canada is also to establish a coherent national and provincial/territorial strategy that can be implemented at a local level. Although we believe that Canada's overall response to pH1N1 produced many success stories, there were circumstances that challenged us as health professionals. Both health care and public health need further strengthening, and their separate infrastructures and the interdependence between these structures need attention and bolstering. The following comments focus on two overarching areas that influenced our ability to respond to the pandemic: communications and health system integration. Communications Communication was a consistent source of concern. Channels of communication among the various levels of public health providers were stronger than those for primary care providers, especially family physicians. On 9 Aug. 2009, following the first wave of pH1N1, our leaders wrote to chief public health officer of Canada Dr. David Butler-Jones on behalf of our members to share their thoughts and recommendations on how to improve communications with physicians. Family physicians in particular, but also other front-line health care providers, needed communication that was tailored to the practice setting, resources that were easy to access, and clear messages written in a manner that allowed rapid implementation into clinical practice during health emergencies because the timing of clinical response was critical. We recommended that front-line clinical practitioners be involved in the development of guidelines and the strategies for their dissemination, so that the content could be linked directly to the clinical setting. Family physicians are part of our first line of defence during infectious disease outbreaks. To ensure optimum patient care, they need clinical guidance quickly. Many physicians felt that the urgent need to provide consistent, clinically relevant information was not well recognized by the Public Health Agency of Canada (PHAC), the Public Health Network and, in some cases, provincial, territorial, regional or local levels. It took three months after recognition of the emerging pandemic to publish Interim Guidance for Ambulatory Care of Influenza-like Illness in the Context of H1N1. The current Public Health Network process of federal/provincial/territorial (FPT) consultation and consensus building seemed ill-suited to the acute national need for clinical information on issues such as the use and prescription of anti-viral medications. As provincial authorities and professional medical organizations moved to fill the void, different approaches and recommendations arose independent from one another. Better integration of primary care response by a national organization such as PHAC and the provincial/territorial health ministries could address the needs of clinical practitioners in concert with public health responses. This would also ensure that care directives are translated into user-friendly formats appropriate to clinical settings. We were pleased to be able to work with PHAC in fall 2009 to produce Pandemic H1N1: Fast Facts for Front-line Clinicians. This resource was highly valued by many of our members, and the collaboration demonstrated how health organizations can work effectively with government to contribute their expertise to the development and distribution of appropriate, clinically relevant information. Nevertheless, our critics declared that it was too little, too late. In situations where scientific evidence is rapidly changing, the processes used to distribute information to both front-line public health and clinical professionals must be designed to avoid confusion. Coordinated, unified communication strategies are needed at the national, provincial/territorial and local levels. Regardless of the official source, the information must be consistent. During the pandemic, many physicians and public health workers complained that multiple levels of government provided similar, but not the same advice. The differences led to skepticism, and the inundation of messages led to overload. The bottom line is that clinically relevant and trustworthy information should be provided on a timely basis, even if levels of certainty are fluctuating. Jurisdictions with effective communication to the primary care sector were characterized by cooperation and consultation between the medical community and the provincial, territorial and regional health authorities, both before and during the crisis. We recommend: 1. That the Public Health Agency of Canada, with the provinces and territories, evaluate the effectiveness of pH1N1 communications between public health and physicians and other front-line primary health care providers, and use the finding of this evaluation to research options for future response to a public health crisis. 2. That federal, provincial/territorial public health authorities and health care professionals and their associations work together in the inter-pandemic period to develop a pan-Canadian communication strategy to be used during health emergencies. 3. The establishment of a pan-Canadian centre within the Public Health Agency of Canada - similar to the Centre for Effective Practice - to undertake timely knowledge translation of clinical management guidelines for clinicians during public health crises. Surveillance and electronic communications The national response to infectious disease would have been greatly facilitated if system-wide communicable disease surveillance had been in place to support the sharing of data between public health and the rest of the health care system, particularly at the regional and local levels of pandemic response. Clinicians' practices are highly influenced by illness patterns that develop regionally and locally within their practice populations; thus, surveillance data are useful in determining appropriate treatment. Real-time data were not available to most physicians and when data did become available, they were already several weeks old. Delayed clinical guidelines were not a suitable substitute for timely surveillance information. Expansion of the use of electronic medical records (EMRs) in primary care, with bi-directional links to public health electronic health records (EHRs), could have facilitated surveillance and communications. Family practice clinics with EMRs were able to quickly identify high-risk patients, communicate with them to schedule vaccination appointments and collect the required data for public health. The varied levels of success of public pH1N1 vaccination clinics were further proof of the need to move to standard use of EMRs and EHRs in the health system. Communications can be enhanced through the sharing of data between the public health and primary care systems. EMRs may help resolve the challenge of collecting data from primary care sites. Collaboration among the PHAC, the Canadian Medical Association and the Information Technology Association of Canada's Health Division led to development of a pilot project to demonstrate the use of primary care EMRs as real-time sentinel surveillance tools for public health action to supplement existing surveillance mechanisms. In addition, after a successful two-year pilot project, the College of Family Physicians of Canada is working with the PHAC, in association with the Canadian Institute for Health Information, to conduct surveillance for five chronic diseases using EMRs, local networks across Canada and a national central repository for standardized data. These studies represent the increasingly important role of electronic information in surveillance and the value of collaboration between public health and primary care. We recommend: 4. That the federal and provincial/territorial governments provide EMR funding to enable clinical care and public health authorities to build interconnectedness and allow real-time information collection and analysis. System issues FPT responsibilities The division of responsibility between federal and provincial/territorial authorities for health care and emergency response influences how we respond to public health emergencies. Provincial/territorial governments have a primary role to play in regulating health matters within their boundaries. At the same time, the federal government has responsibilities related to national public safety and health protection. There can be no disputing the legitimacy of federal involvement in public health matters of an interprovincial/territorial nature. Under International Health Regulations, the federal government also has a responsibility to report and monitor public health emergencies of potential harm to other countries. Since Canada's SARS experience, there has been much progress in building FPT cooperation and increasing consultation on public health matters. However, the division of responsibility has led us to a situation where public health and clinical guidance in each province and territory was similar, yet different. Although the Pandemic Influenza Committee and the Special FPT Advisory Committee on H1N1 Influenza strove for consensus at the national level, individual provinces and territories were under no obligation to implement the guidance agreed to at the FPT level. Consultative and collaborative processes at the FPT level created delays in decision-making and directly interfered with the capacity of front-line professionals to respond to the urgent health needs of their patients. This led to a sense of confusion in the media and a loss of trust among the public and health professionals regarding Canada's capacity to respond to pH1N1. System capacity Canada's health system lacks surge capacity and can be sorely tested during a public health emergency, such as the recent experience with pH1N1. The underdeveloped public health infrastructure also means that it is a challenge to handle more than one national crisis at a time. To mount a response to pH1N1, public health units pulled human resources from other programs and many critical ones were delayed, suspended or cancelled altogether. During the first wave of pH1N1, Manitoba experienced a severe outbreak that stretched the resources of its critical care infrastructure to its limits. Front-line health care providers were inundated with telephone calls from the worried well and an increase in visits from those with flu symptoms. If pH1N1 had been the severe pandemic that was expected and for which Canada had been preparing, our health system would have been brought to its knees. In 2008, the Canadian Coalition for Public Health in the 21st Century noted that Canada remains vulnerable to the risks presented by epidemics and pandemics. This vulnerability remains today, and a long-range plan to build our public health capacity and workforce and to address the lack of surge capacity in our health system must become a priority if we are to be prepared for the next emergency. We recommend: 5. That the federal government increase infrastructure funding to provinces/territories to assist local health emergency preparedness planning and response, to reduce variation across the country and to integrate clinical care structures into public health structures at the local level. 6. That the Public Health Agency of Canada review the recommendations of the 2003 report of the National Advisory Committee on SARS and Public Health (Naylor report) in light of the pH1N1 experience and develop a national action plan to address the persistent gaps. Public health/primary care partnership Family physicians, in particular, understand that primary health care happens at the local level. In fact, so does all public health. During times of public health crisis, it is crucial for public health and primary care to work together, each respecting, supporting and bolstering the efforts of the other. Strengthening local public health and primary care structures and the interface between them would have resulted in improved, shared understanding of each sector's roles and responsibilities during the pH1N1 epidemic, better communications, improved data sharing and, most important, better served populations. Public health measures are directed toward the mitigation of disease through surveillance, research and outbreak management activities, while physicians provide information, education and clinical treatment to their patients. A commitment from both sectors at the local and provincial levels - and the professionals within each sector - to work together in the inter-pandemic period to build on processes that allow sharing of perspectives and information is essential. It is crucial that local public health authorities receive financial resources to increase their ability to collaborate effectively with family physicians, specialist physicians and other front-line providers. A number of the challenges faced by front-line public health workers and front-line physicians during the pH1N1 outbreak could have been lessened if there had been stronger links within the health system. We recommend: 7. That the Public Health Agency of Canada develop a focus on improving the interrelationship between primary care and public health to support collaboration during public health crises. Vaccination A key measure to combat pandemic influenza is mass vaccination. On the whole, Canada mounted an effective campaign: 45% of Canadians were vaccinated, and the proportion was even higher in First Nations communities - a first in Canadian history. Canada was one of the first countries with sufficient vaccine for the population and, with one domestic vaccine supplier, Canada avoided the confusion of multiple formulations as seen in the United States. The outcome was positive, but many public health units were stretched as expectations exceeded the pre-existing constrained resources. Although we recognize that the provinces and territories have quite different approaches to the delivery of their routine immunization programs, there is agreement that the pandemic immunization process did not adequately engage physicians in planning and delivery. A number of difficulties, such as the impact of bulk packaging, manufacturing delays that affected the agreed "sequencing" of patients and the logistics of inventory management, led to friction between front-line public health practitioners and family physicians. These could have been avoided with strengthened interdependence and mutual understanding before this crisis. The great variation in mass vaccination programs between provinces/territories, and even between local public health units, led to public confusion. Recognition of the diversity of primary care settings in which physicians work and bilateral planning in advance of the event is essential, because it is simply not feasible to tailor responses to myriad settings in the heat of the moment. Television broadcasts of long lines of people waiting to be vaccinated contributed to a loss of confidence in the system at a time when public confidence was sorely needed to encourage vaccination. Nationally promulgated clinical practice guidelines had great potential to create consistent clinical responses across the country. Instead, the variation and lack of coordination in providing important clinical information during this crisis eroded the public's confidence in the federal, provincial and territorial response. Ensuring future consistency in clinical approaches will require examination of ethical principles for the allocation of resources, such as anti-virals, vaccines and hospital treatment. Public engagement in the discussion of ethical principles is essential and, as much as possible, the consultative process should be transparent and undertaken in advance. We recommend: 8. That the Public Health Network seek advanced pan-Canadian commitment to a harmonized and singular national response to clinical practice guidelines, including mass vaccination programs, during times of potential public health crisis. Conclusion In 2003, in its submission to the National Advisory Committee on SARS, the Canadian Medical Association noted that the uptake of new information is influenced by many qualitative factors, and that research is needed to determine how best to communicate with individual physicians and other health care providers in emergency situations. Communication processes should be based on sound research and build on existing communication networks and relationships. The College of Family Physicians of Canada has recommended that information networks be strengthened to promote the sharing of the most relevant information among family physicians, other primary care providers and public health at the local level. We believe that PHAC is well positioned to undertake research on how health professionals can best receive information and to catalogue existing communication networks to build them into a well-coordinated national emergency response communication system. We must work together to translate pandemic information into practical messages relevant to front-line providers and employ trusted channels to deliver key messages to our patients and the public. Broad consensus is developing that our experience with the pH1N1 outbreak has shown that one of our greatest needs in preparing for the next public health emergency is for a national communications strategy that involves all levels of government, targets all sectors of our health system and uses the channels with which these targets are most familiar. An effective response to infectious disease outbreaks depends on effective surveillance, data collection and sharing and tracking of clinical interventions. The absence of a national communicable disease/immunization monitoring system is an ongoing problem. In 2003, the report of the National Advisory Committee on SARS and Public Health recommended that "the [Public Health] Agency [of Canada] should facilitate the long term development of a comprehensive and national public health surveillance system that will collect, analyze, and disseminate laboratory and health care facility data on infectious diseases... to relevant stakeholders." In 2010, Canada still does not have a comprehensive national surveillance and epidemiological system. A pan-Canadian electronic health information system is urgently needed and must become a priority during the inter-pandemic phase, with adequate federal funding and provincial/territorial collaboration. Greater adoption of the EMR in primary care and better public health EHRs with the ability to link systems will augment existing surveillance capacity and should be considered essential to a pan-Canadian system. Many of the challenges front-line health practitioners faced during the pH1N1 were also challenges during the SARS outbreak in 2003. The Naylor report proposed a number of measures to improve Canada's readiness and strengthen public health. Although a great deal of work and effort has gone into building links with and between provinces/territories and the federal government within the public health and the health emergency management system, little has trickled down to the front lines. This is not to devalue the much-improved spirit of FPT cooperation and the important achievements that have been made. Rather it is to suggest that, as the roof is no longer leaking, it is time to focus attention on the foundation - the response at the local level. Embedding primary care expertise in public health planning within the PHAC and at provincial/territorial and local levels will help circumvent problems and improve the effectiveness of our health system to respond to public health emergencies. A dialogue between primary care and the emergency management structures will help the response team understand and value the capabilities within primary care and build them into their planning and response systems. At the end of the day, we need to nurture collaborative relations between public health and primary care. Our shared objective is protecting the health of Canadians, recognizing that, in reality, neither system can be successful in isolation. It is essential that we trust each other's professionalism and expertise and work together to ensure that a strong foundation is in place to protect Canadians from future health threats. We have the will and expertise. We need the resources and a firm commitment to move forward. We have had two "wake-up calls" - SARS and pH1N1. Let's not wait for a third to find that we are not yet prepared. Recommendations 1. That the Public Health Agency of Canada, with the provinces and territories, evaluate the effectiveness of pH1N1 communications between public health and physicians and other front-line primary health care providers, and use the finding of this evaluation to research options for future response to a public health crisis. 2. That federal, provincial/territorial public health authorities and health care professionals and their associations work together in the inter-pandemic period to develop a pan-Canadian communication strategy to be used during health emergencies. 3. The establishment of a pan-Canadian centre within the Public Health Agency of Canada - similar to the Centre for Effective Practice - to undertake timely knowledge translation of clinical management guidelines for clinicians during public health crises. 4. That the federal and provincial/territorial governments provide EMR funding to enable clinical care and public health authorities to build interconnectedness and allow real-time information collection and analysis. 5. That the federal government increase infrastructure funding to provinces/territories to assist local health emergency preparedness planning and response, to reduce variation across the country and to integrate clinical care structures into public health structures at the local level. 6. That the Public Health Agency of Canada review the recommendations of the 2003 report of the National Advisory Committee on SARS and Public Health (Naylor report) in light of the pH1N1 experience and develop a national action plan to address the persistent gaps. 7. That the Public Health Agency of Canada develop a focus on improving the interrelationship between primary care and public health to support collaboration during public health crises. 8. That the Public Health Network seek advanced pan-Canadian commitment to a harmonized and singular national response to clinical practice guidelines, including mass vaccination programs, during times of potential public health crisis.
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A Prescription for Optimal Prescribing

https://policybase.cma.ca/en/permalink/policy10016
Last Reviewed
2016-05-20
Date
2010-08-26
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Policy document
Last Reviewed
2016-05-20
Date
2010-08-26
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
This paper presents the position of the Canadian Medical Association on what physicians can do, working with others, to ensure that Canadians are prescribed the drugs that will give them the most benefit. It also makes recommendations for future action that physicians, governments and others might take to foster optimal prescribing practices. CMA believes that optimal prescribing is the prescription of a drug that is: - The most clinically appropriate for the patient's condition; - Safe and effective; - Part of a comprehensive treatment plan; and - The most cost-effective drug available to meet the patient's needs. Choices made by prescribers are subject to a number of influences, including education (undergraduate, residency and continuing); availability of useful point of care information; drug marketing and promotion; patient preferences and participation, and drug cost and coverage. The CMA proposes a "prescription for optimal prescribing" that encompasses six elements, and makes the following recommendations: A National Strategy 1) Governments at all levels should work with prescribers, the public, industry and other stakeholders to develop and implement a nationwide strategy to encourage optimal prescribing and medication use. Element 1: Relevant, Objective Information for Physicians 2) The CMA supports the development and dissemination of prescribing information that is: - based on the best available scientific evidence; -relevant to clinical practice; - easy to incorporate into a physician's workflow. 3) The CMA encourages all medical educational bodies to support a comprehensive program of education in pharmaceuticals, pharmacology and optimal prescribing, at the undergraduate, residency and continuing medical education levels. 4) The CMA and provincial/territorial medical associations call on governments to support and fund impartial continuing medical education programs on optimal prescribing. 5) The CMA calls on appropriate educational bodies to develop policies or guidelines to ensure the objectivity and impartiality of continuing medical education. 6) The CMA recommends that governments, research institutes and other stakeholders fund and conduct ongoing clinical research on the effectiveness of interventions designed to change behaviour, and allocate resources to those interventions that demonstrate the greatest effectiveness. Element 2: Electronic Prescribing 7) The CMA, provincial/territorial medical associations and affiliates encourage governments to give active support to physicians in their transition to electronic prescribing, through a comprehensive strategy that includes financial support for acquisition of hardware and software, and dissemination of appropriate training and knowledge transfer tools. 8) The CMA calls on governments to incorporate into electronic prescribing the following principles: - Measures to ensure patients' privacy and confidentiality, as well as confidentiality of physician prescribing information; - A link with a formulary, to provide physicians with best practice information including drug cost data; - Guidelines for data sharing among health professionals and others; - Standards for electronic signature that are not overly restrictive. Element 3: Programs by Payers 9) The CMA recommends that formularies, in both the public and private sectors, simplify administrative requirements on patients and physicians, reducing paperwork to the minimum necessary to ensure optimal patient care. Element 4: Collaboration among Health Care Providers 10) The CMA recommends that formalized and clearly articulated collaborative arrangements be in place for practitioners who jointly manage a patient's drug therapy. Element 5: Impartial, Evidence-based Information for Patients 11) The CMA calls on governments to fund and facilitate the development and provision of unbiased, up-to-date, practical information to consumers about prescription drugs and their appropriate use, and support physicians and pharmacists in disseminating this information to patients. 12) The CMA calls on the Government of Canada to continue to enforce the current ban on direct-to-consumer prescription drug advertising in Canada, and close the loopholes that currently allow a limited amount of drug promotion. Element 6: Research, Monitoring and Evaluation 13) The CMA calls on those who fund and produce research on drug safety and effectiveness, prescribing guidelines and programs to enhance prescribing practices, to include physicians and medical organizations meaningfully in this activity. 1 Introduction In an ideal world, all patients would be prescribed the drugs that have the most beneficial effect on their condition while doing the least possible harm, at the most appropriate cost to the patient and the health care system. It is generally agreed that we have not yet achieved that ideal. But the Canadian Medical Association (CMA) and the physicians of Canada believe it is a goal worth striving to attain. The CMA has a long-standing commitment to fostering high-quality health care. One of the key elements of the long-term Health Care Transformation project, in which CMA is currently involved, is ensuring that systems are in place to foster health care that is of high quality. One such system would be the active encouragement of optimal prescribing. This paper presents the CMA's position and recommendations on what physicians can do, working with others, to ensure that Canadians are prescribed the drugs that will give them the most benefit. It looks at prescribing mainly from the perspective of the practicing physician who is seeking the most appropriate treatments for individual patients. However it also comments on the effects of prescribing on the broader health care system, both on Canadians' overall health status and on the costs of delivering health care. 2) Optimal Prescribing: CMA's Definition and Principles a) What is Optimal Prescribing? Prescribing is not an exact science; the choice of a particular drug to treat a particular patient depends on that patient's unique circumstances. CMA's proposed definition and principles for optimal prescribing is as follows: Optimal prescribing is the prescription of a drug that is - the most clinically appropriate drug for the patient's condition; - safe and effective; - part of a comprehensive treatment plan; and - the most cost-effective drug available to best meet the patient's needs. b) Principles for Optimal Prescribing CMA believes that in an optimal prescribing environment, the following principles should apply: Principles for Optimal Prescribing 1) The primary goal of prescribing should be to improve or maintain the health of the patient. 2) Prescribing should take place in the context of overall patient care which involves diagnosis of the condition, other forms of treatment including rehabilitation, counselling and lifestyle adjustments, ongoing monitoring and re-evaluation of the patient's condition and treatment to make sure the patient is responding appropriately, ensuring patient adherence to medication regimen, and discontinuation of drug treatment when it is no longer needed. 3) Patients should be actively involved in decisions regarding their drug treatment; for this, useful and practical patient information is required. 4) Prescribing decisions should be based on the best available scientific evidence, which is continually evaluated and updated as need arises. 5) Physicians should retain clinical autonomy in deciding which drugs to prescribe. 6) Prescribing decisions should take into account the cost to the patient, and strive to achieve cost-effectiveness as long as this does not conflict with the goal of optimal patient care. 7) Physicians should be updated on new developments in pharmacotherapy, through an ongoing process of relevant, objective continuing education. 8) Health professionals should take a leadership role in developing and evaluating strategies and tools to enhance best practices in prescribing. Though these principles may also apply to the optimal use of medical devices, prescription drugs are the primary focus of the paper. 3 Why Optimal Prescribing is Important Prescription drugs are an increasingly important part of patient care in Canada. Fifty years ago, they were used mainly for short periods of time to treat acute conditions, and their contribution to overall health care costs was small. But in 2005, Canadians received 14 prescriptions per capita; that number rose to 74 for people 80 years and over.i Many Canadians now take prescription drugs over the long term to manage chronic conditions such as diabetes, osteoporosis or high cholesterol. Increased drug utilization, and the high prices of many new drug therapies, have increased the cost of prescription drugs to Canadians and to the health care system. In 2008 Canadians spent about $25.4 billion on prescription drugs. This, in constant dollars, is roughly triple what was spent in 1985.ii Together, prescription and over-the-counter drugs consume a larger portion of overall costs than do physicians' services; in fact, only hospitals consume a larger share. In many cases prescription drugs have reduced reliance on hospitalization and surgical procedures. For example, over the past decades drugs to treat peptic ulcer disease have changed its treatment profile from one based mainly on surgery to a largely medical one. On the other hand, patients may take certain medications or classes of medications for many years, and this long-term use may have health consequences that are currently unknown. As their role in health care increases, there is increasing public scrutiny over whether the prescription drugs Canadians use are safe and effective, whether they give good value for money, and whether they are being prescribed and taken optimally for maximum patient benefit. As mentioned before, prescribing is not an exact science; what in some cases might be considered "suboptimal" is in other cases quite appropriate. In most instances, drugs are prescribed appropriately. However, evidence suggests that in some areas there is room for improvement. Prescribers can enhance patient care and improve Canadians' health by adopting strategies such as the following: - Reducing overprescribing of certain drugs. For example, overuse of antibiotics is a worldwide concerniii since it may hasten the development of antibiotic resistance, thereby reducing the physician's therapeutic arsenal. - Reducing underprescribing of certain drugs. A study of primary care practices in Ontario found that while 14% of adult patients had dyslipidemia, 63.2 % were untreated and, of those treated, 47.2% were not adequately controlled .iv - Prescribing drugs according to generally accepted clinical practice guidelines to ensure that first-line drugs are used where indicated. Second-line therapies are frequently newer and less established than first-line ones, and are thus more likely to have unidentified safety risks. - Ensuring that drugs are prescribed and taken safely, to reduce the harm caused by adverse interactions with other drugs, natural health products, alcohol or other agents in the patient's system. Activities in support of the above strategies should be included in any program or initiative aimed at improving health care in Canada. CMA believes they will contribute to Canadians' overall health status, and may have the additional benefit of reducing health care costs if the prescribed drugs are the most cost-effective available to appropriately treat patients' conditions. 4) Many Factors Affect Prescribing Prescribing does not occur in a vacuum, but is the result of a number of factors that influence physicians. It may be questioned whether these factors provide the necessary support to physicians as they seek to prescribe optimally. Some of these influences are discussed below: a) The Challenge Of Acquiring Information Our knowledge of prescription drugs and their effects is continually being updated, and physicians are required to absorb new information throughout their careers. But are physicians receiving the information they most need, in such a way that they can easily and painlessly incorporate it into their practices? CMA's answer is: there is room for improvement. The major information sources available to physicians are discussed below: i) Physician Education Medical school and residency training - Medical schools vary in how they discuss pharmacological issues, and critics have questioned whether Canada's current medical school curriculum is training future physicians adequately in the art and science of prescribing.v In some cases, pharmacotherapy is taught in the context of each individual body system - cardiac, renal, etc. - rather than as a discrete subject. With this approach, some valuable unifying elements of pharmacology may go untaught. Continuing medical education (CME) - For physicians, CME is an important source of information on new drugs and new indications for existing drugs. But is it imparting the most necessary or appropriate information? Concerns have been raised as to its impartiality; it is estimated that pharmaceutical industry sponsorship accounts for 65% of the total revenue of CME programs in the U.S. and the figure is assumed to be much the same in Canada.vi ii) Point-of-care information With increasingly heavy patient loads, the time at physicians' disposal for research is limited. Often new information is required at the point of care; for example, in the examination room during a patient encounter, when the physician requires an answer quickly. The clinical practice guidelines and point of care reference guides in common use may not be readily accessible in a concise, user-friendly format when needed. In addition, it is of concern that some experts who develop practice guidelines have ties to pharmaceutical manufacturers, which could affect the guidelines' impartiality. To compound the problem, widely used sources of information may not be giving physicians the material they most need. Physicians often receive new safety information, such as warnings of recently discovered drug risks, in the form of advisories from Health Canada or elsewhere. These advisories may not provide physicians with prescribing advice, or information about other treatment options if the drug is considered too dangerous for use. iii) Drug promotion and marketing Much of physicians' information about drugs and prescribing comes from the pharmaceutical industry representatives who visit them in their offices. Drugs promoted in this manner tend to be newer; consequently they are often more expensive than established medications and less is known about their efficacy and possible side effects. Drug promotion might help instil in some physicians' minds the perception that when it comes to medication, "new" equals "better," when this is not always the case. Industry marketing also comes in more subtle forms, such as: - Free drug samples provided to physicians; since samples tend to be mainly for new drugs, it has been suggested that they encourage these drugs' use at the expense of possibly cheaper and safer alternatives. - Collection, by commercial data management companies, of information on physicians' prescribing patterns , which is then sold to pharmaceutical companies to help tailor sales messages to individual physicians. - Manipulation of the medical publication process, through: design of clinical trials so as to get the most positive results; selective publication of clinical trial results; or "ghostwriting" of scholarly research articles by pharmaceutical industry contractors.vii b) Patient education and participation When considering a patient's drug therapy, the physician must consider the possible effect of the patient's behaviour on treatment. A patient may require counselling on the impact of natural health products, alcohol and other substances when mixed with their prescribed medications; on the importance of adherence to the prescribed treatment; or on the need for changes in behaviour (improved diet, increased physical activity) to augment the medication's benefits. This requires open and honest dialogue between patient and physician. Patient knowledge and preferences can influence both over- and under-prescribing. Some patients may not feel that they have been "treated" unless they leave the doctor's office with a prescription. A physician may prescribe a drug if a patient requests it, despite feeling ambivalent about the choice of treatment.viii On the other hand, a physician may not prescribe a needed medication because a patient insists he or she does not want to be "on drugs." The pharmaceutical industry directs promotional activities at patients as well as physicians. Though direct-to consumer advertising (DTCA) or prescription drugs is technically illegal in Canada, loopholes in the law permit a limited amount of Canadian-based drug promotion, and drug ads are often beamed across the border from the United States, one of only two countries (the other being New Zealand) where DTCA is legal. DTCA has a strong influence on patient behaviour; according to one survey by the U.S. Government Accounting Office, 27% of people who saw prescription drug advertisements, requested and received these drugs from their physicians.ix DTCA has been widely criticized for overstating drugs' benefits, playing down their risks, and contributing to a "pill for every ill" mindset and the "medicalization" of conditions that could be more appropriately managed by lifestyle changes or other non-drug therapies. In addition, the pharmaceutical industry can exert indirect influence on patient attitudes through funding of patient advocacy groups and disease-specific web sites. A patient's social context may also motivate a physician to prescribe a drug that may not be clinically indicated. For example, an antipsychotic may be prescribed to calm a patient with dementia, not so much for the patient's benefit as for that of tired and stressed-out caregivers, despite growing evidence of the drugs' health and safety risks and lack of efficacyx. Ideally, prescribing recommendations and guidelines should take into account the broader context in which a drug is prescribed. c) Drug cost and coverage The physician's prescribing of a drug and the patient's purchase of it are separate and unconnected acts. As a result, physicians may not have access to reliable, convenient information on drug costs; or if they do, they may have little reason to use this information if the patient has insurance coverage. However, rising drug prices, and the increased use of drug therapy, may require them to take cost into consideration more often. Provincial and territorial governments, and increasingly, private insurers as well, can influence physician and patient choice of drugs by restricting what medications are covered on their formularies. In addition, many payers have programs to encourage the prescribing of certain drugs such as generics. If, as not infrequently happens, a patient's condition requires a drug not on the formulary, obtaining coverage for this drug requires time-consuming paperwork. The administrative burden this imposes can be a barrier to optimal prescribing. d) The policy context Canadian decision makers have already recognized that action on prescribing is needed. One of the original nine elements of the federal/provincial/territorial National Pharmaceuticals Strategy (NPS), announced in 2004, was "Enhance action to influence the prescribing behaviour of health care professionals so that drugs are used only when needed and the right drug is used for the right problem." However, this was not considered a priority, and the entire NPS is now dormant. In 2009, the Health Council of Canada recommended that optimal prescribing be a priority element in a revived pharmaceutical strategy, noting the need for easily accessible, evidence-based information on the proper use and risks of each medication, and for national co-ordination of efforts toward improved prescribing.xi 5. The CMA's Prescription The previous sections have described the problems that currently exist with prescribing in Canada, and factors that contribute to these problems. In this section the CMA discusses what can be done to make prescribing optimal. Even as a variety of factors influence prescribing, so a variety of elements can contribute to optimizing it. What should be done to encourage optimal prescribing in Canada? The CMA believes that optimal prescribing should be addressed through the development and implementation of a national strategy comprising the six elements discussed in the following pages: Recommendation 1 Governments at all levels should work with prescribers, the public, industry and other stakeholders to develop and implement a nationwide strategy to encourage optimal prescribing and medication use. Element 1: Relevant, Objective Information for Prescribers As our knowledge base on prescription drugs expands, it is communicated to physicians by many different means. The CMA believes it is possible to improve these communications and make them more relevant and useful to prescribing physicians. Recommendation 2 The CMA supports the development and dissemination of prescribing information that is: o based on the best available scientific evidence o relevant to clinical practice o easy to incorporate into a physician's workflow. a) Undergraduate medical education and residency training A basic grounding in pharmacology is a vital part of undergraduate medical education. Appendix 1, which was taken from a 2009 report prepared by Britain's Royal College of Physicians, contains a specific proposal for a core undergraduate curriculum in therapeutics. Basic education in pharmacology should, among other things, help prepare future physicians for the challenge of maintaining their knowledge base in practice. The academic community has a role to play, during undergraduate training and residency, in providing impartial advice on pharmaceutical matters, and ensuring that students and residents can appraise drug research and prescribing guidance critically. Recommendation 3 The CMA encourages all medical educational bodies to support a comprehensive program of education in pharmaceuticals, pharmacology and optimal prescribing, at the undergraduate, residency and continuing medical education levels. b) Continuing medical education (CME) Traditionally, CME meant face-to-face seminars or conferences; however, studies are demonstrating that Internet-based learning is as effective as face-to-face CME.xii Developers and practitioners are increasingly looking at delivering CME online. Of particular promise are formats that deliver information electronically in short, summary bullet points, presenting the most pertinent information on a single screen where feasible. As mentioned before, a large proportion of CME is sponsored by the pharmaceutical industry. Like pharmaceutical detailing, industry-sponsored CME might steer physicians toward newer drugs which may not be first-line therapies, and which are often less thoroughly evaluated and more expensive than established treatments. Therefore, in order that physicians can be assured of receiving objective information, there is an urgent need for objective funding sources for CME, that are as distant as possible from potential sources of bias. Recommendation 4 The CMA and provincial/territorial medical associations call on governments to support and fund objective and impartial continuing medical education programs on optimal prescribing. Recommendation 5 The CMA calls on appropriate educational bodies to develop policies or guidelines to ensure the objectivity of continuing medical education. CMA's Guidelines for Physicians in Interaction with Industry (2007) proposes ways in which physicians, medical associations and medical educational bodies can minimize bias when collaborating with industry on CME and continuing professional development programs. c) New Forms of Education Besides formal CME, there are many ways of conveying information to physicians with the intent of influencing prescribing behaviour. One promising intervention is academic detailing, in which trained physicians or pharmacists use the personalized, one-on-one techniques employed by pharmaceutical detailers to encourage adoption of a desired behaviour (e.g., prescribing of a particular drug or treatment regimen) rather than specific drugs, to counterbalance marketing by pharmaceutical representatives. Academic detailing has demonstrated some success. Because it is expensive and labour intensive, it has often been difficult to persuade governments to invest in it. However, a growing number of provinces have developed, or are considering, academic detailing programs. Another promising intervention is physician self-directed learning. In Alberta two medical schools are preparing to perform an analysis of physicians' perceived and unperceived learning needs with the intention of developing individualized learning programs to address the needs of physicians in their practices. The effectiveness of various learning programs in changing behaviour is being studied on an ongoing basisxiii, through means such as the Rx for Change database, a collaborative effort between two Cochrane Collaboration groups and the Canadian Agency for Drugs and Technologies in Health. This database summarizes current research evidence, regularly updated, about the effects of strategies to improve drug prescribing practice and drug use. Because different physicians have different needs, goals and styles of learning, multiple formats are required to address them. Though one intervention in and of itself may not produce widespread, immediate or dramatic changes in behaviour, the cumulative effect of multiple messages over time can be very strong. Recommendation 6 The CMA recommends that governments, research institutes and other stakeholders fund and conduct ongoing research on the effectiveness of interventions designed to change clinical behaviour, and allocate resources to those interventions that demonstrate the greatest effectiveness. d) Point-of-care information In addition to formal education programs, information on pharmaceuticals and prescribing is also available to physicians at the point of care. Physicians' preference is for brief summaries of key points, which can be absorbed quickly and be accessed at point of care through hand-held personal digital assistants (PDA's) or, increasingly, through electronic health and prescription records. Drug information compendia are available in electronic and print format. For example, cma.ca provides information about prescription drugs through a program called Lexi-Drugs Online. e-Therapeutics+, developed by the Canadian Pharmacists Association, is another online resource for prescribing and managing drug therapy at the point of care. Online programs are also available that monitor physicians' prescribing habits and compare them to those of their peers. Such programs are to be encouraged if their purpose is to educate rather than to enforce a certain behaviour. However, they will require additional investment, particularly in information technology and software development. Element 2: Electronic Prescribing Electronic prescribing has the potential to dramatically improve drug therapy. For example an effective e-prescribing system has the potential to: - list all the drugs a patient is taking. It could also identify duplicate prescriptions for the same drug from different providers, thus helping to reduce prescription fraud and prescription drug abuse; - provide decision-support tools; for example, a warning could appear on the screen if the physician proposes to prescribe a drug that interacts harmfully with another the patient is already taking. This decision support should ideally be updated in real time so the physician has access to the most current information. - Enable the improvement of patient adherence to drug therapy, perhaps by generating reminders to patients to refill and take prescriptions. - Transmit prescriptions to pharmacies electronically, increasing convenience for the patient and eliminating a major cause of medication errors, illegible handwriting. - Automatically link to a formulary to enable the prescriber to see whether the patient's insurer has approved the medication, or to find the lowest-cost drug in a class. Two-way electronic communication with formulary managers may also help reduce some of the administrative paperwork which is a barrier to optimal prescribing. - Automatically notify physicians of drug shortages, recalls or other urgent situations. In the U.S., e-prescribing is being actively encouraged. Since January 2009, the American Medicare system provides financial incentives for its physicians who adopt e-prescribing. In Canada adoption has been slow;xiv it is estimated that fewer than 10% of physicians e-prescribe. This may be due partly to the expense, and partly because of issues which remain to be addressed, such as: - How do we assure that the confidentiality of patients' health information, and of physicians' prescribing information, is protected? - What information should be shared with other health professionals? - What legally constitutes a "signature," or other means of authenticating a prescription? - Can we ensure that pharmacies as well as physicians' offices are equipped to receive electronic prescriptions? - Can we ensure that e-prescribing software is designed so as to be practical and user-friendly for physicians; for example, that pop-up warnings contain the most important and relevant information? - Can we ensure that e-prescribing protocols simplify a physician's workload rather than adding to it - for example, that they eliminate duplication of prescription writing? E-prescribing is in its early stages, and knowledge and policy in this area are developing rapidly. CMA will continue to study the issue in the coming years. Several provinces maintain electronic prescription databases and others are in development. For example, BC PharmNet provides drug-to-drug interaction checking and patient medication profiles to pharmacists, emergency rooms and physicians with controlled access. In most provinces and territories, medical associations are working with governments on standards to implement e-prescribing. Recommendation 7: The CMA, provincial/territorial medical associations and affiliates encourage governments to give active support to physicians in their transition to electronic prescribing, through a comprehensive strategy that includes financial support for acquisition of hardware and software, and dissemination of appropriate training and knowledge transfer tools. Recommendation 8: The CMA calls on governments to incorporate into electronic prescribing the following principles: - measures to ensure patients' privacy and confidentiality, as well as confidentiality of physician prescribing information - a link with a formulary, to provide physicians with best practice information including drug cost data - guidelines for data sharing among health professionals and others - standards for electronic signature that are not overly restrictive. Element 3: Programs by Payers Government drug plans and, increasingly, private insurance companies, have instituted programs to encourage prescription of certain drugs. Such programs, which are often motivated by the desire to control rising drug costs, can include the following: a) Formularies There are 18 public drug formularies in Canada managed by federal or provincial/territorial governments. These formularies often use various means to help control drug costs. For example, if a generic drug is available to treat a given condition, a payer may reimburse patients only for the generic rather than for brand-name equivalents. Or if several related drugs exist in the same class, a formulary could reimburse only for the lowest-priced drug in that class, as British Columbia's reference-based drug pricing (RDP) program does for five drug categories that contain several drugs with equal efficacy; if patients want to purchase a higher-priced drug they must pay the difference out of pocket. Such programs are not confined to Canada; Britain's National Health Services funds specific treatments only if recommended by the National Institute for Clinical Excellence (NICE) which assesses new drugs for efficacy and cost-effectiveness. Under New Zealand's PHARMAC system the government reimburses only for one drug in each class. A formulary's cost-control objectives can sometimes conflict with the goal of physician and patient to obtain the care they believe will be most optimal. For example, formulary rules limiting the length of chronic prescriptions can make it difficult for physicians to prescribe over the long term to patients who manage their conditions well. It is important that formulary rules be based on the best available scientific evidence. The ideal formulary will be designed to improve clinical care, optimize patients' health outcomes, promote patient safety, and reduce the administrative burden on the physician. Recommendation 9 The CMA recommends that formularies, in both the public and private sectors, simplify administrative requirements on patients and physicians, reducing paperwork to the minimum necessary to ensure optimal patient care. b) Prescribing incentives Sometimes, payers may provide incentives such as reward payments for physicians who prescribe in a desired way (for example, who prescribe more than a certain percentage of a given drug class as generics), or impose a financial penalty for physicians who do not exhibit the desired behaviour. Financial incentives to physicians to provide preventive care services have been used effectively but their effect on prescribing practices is only beginning to be evaluated. A study of U.K. prescribing incentive schemes concluded that reward payments may have contributed to cost control, but their effect on prescribing quality remained uncertain. xv CMA's ongoing Health Care Transformation initiative will provide decision makers with blueprint for a high-performing, patient-centered health care system. Among its other activities over the next few years, this initiative will be examining in greater detail the effect of pay-for-performance schemes on the quality of care in Canada. Element 4: Collaboration Among Health Care Providers No health professional is an island. Increasingly health care providers are working in collaborative teams to manage drug therapy and other forms of patient care. In such teams, for example, pharmacists may perform a variety of functions, such as reviewing patients' medication profiles to catch medication related problems such as inappropriate dosing, duplicate or unnecessary therapies; or managing long-term drug therapy for patients with chronic conditions such as asthma or diabetes. At their most effective, such collaborative arrangements could greatly improve drug therapy, and patient care in general, by allowing the team to draw on a common pool of expertise. However, if improperly implemented, they could lead to breakdown of communication and fragmentation of care. To ensure that collaborative management of a patient's drug therapy functions smoothly, it is important that clearly articulated arrangements be in place. CMA's position statement Achieving Patient-Centered Collaborative Care (2007), includes the following principles: - Patient-centered care. Patient care (including drug therapy) must be aligned around the values and needs of the patient. - Clear communication. Effective communication is essential to ensure safe and coordinated drug therapy and to ensure that the patient is receiving timely, clear and consistent messaging. For example, if a physician and pharmacist are both managing and monitoring a patient with asthma, it is essential that they notify each other if a change is made to a prescription, such as a new drug or a new dosage. Electronic health records have the potential to greatly improve communication among providers. - Clinical leader. CMA's position statement defines a clinical leader as "the individual who, based on his or her training, competency and experience, is best able to synthesize and interpret the evidence and data provided by the patient and the team, make a differential diagnosis and deliver comprehensive care for the patient." In most cases the physician, by virtue of training, knowledge, background and patient relationship, is best positioned to assume this role. Recommendation 10: The CMA recommends that formalized and clearly articulated collaborative arrangements be in place for practitioners who jointly manage a patient's drug therapy. The CMA, recognizing the need for and value of collaboration in the management of drug therapy, will continue to explore and encourage the most effective models for collaborative practice among health professionals. Element 5: Impartial, Evidence-based Information for Patients Canadians have the right to accurate, reliable information on prescription drugs and their uses, so that they can become knowledgeable partners in their care. A good deal of information is already available to patients, and there are ways in which it could be improved and made more accessible and relevant. One way would be to improve its clarity and readability, to address the needs of the estimated 6 in 10 Canadians who lack the health literacy necessary to properly manage their health and engage in preventive practices.xvi Another way would be to provide more information from impartial sources, to reduce the impact of direct-to-consumer advertising. The CMA believes that in general, brand specific advertising is a less than optimal way of providing drug information, and that the laws currently banning direct-to-consumer prescription drug advertising in Canada should remain in effect, and tightened to eliminate existing loopholes. Physicians and other health care providers can also play an important role in providing patients with guidance and with accurate information on the medications they take. CMA and the Canadian Pharmacists Association have collaborated with Canada's Research-based Drug Companies (Rx&D) to produce a pamphlet called "Knowledge is the Best Medicine" which provides consumers with advice on safe medication use, and guidance on how to interact effectively with their physician or pharmacist. Recommendation 11: The CMA calls on governments to fund and facilitate the development and provision of unbiased, up-to-date, practical information to consumers on prescription drugs and their appropriate use, and support physicians and pharmacists in disseminating this information to their patients. Recommendation 12: The CMA calls on the Government of Canada to continue to enforce the current ban on direct-to-consumer prescription drug advertising in Canada, and close the loopholes that currently allow a limited amount of drug promotion. Element 6: Research, Monitoring and Evaluation Drug development is an ongoing process, and the evaluation of drugs and their prescribing should be ongoing as well. Canada already supports a certain amount of research activity in this area. For example, Health Canada funds the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS), a collaborative, pan-Canadian service to identify and promote optimal drug therapy. COMPUS collects and evaluates relevant existing evidence, and provides advice, tools, and strategies to implement and support the adoption of optimal drug therapy. COMPUS has produced, or is producing, evidence-based recommendations for prescribing proton pump inhibitors and drugs for diabetes management. COMPUS has established links to university-based providers of CME, and with academic detailing groups, who help to disseminate its recommendations and materials. It also manages the Rx for Change database previously mentioned. The federal government has recently established and funded a national Drug Safety and Effectiveness Network. This network will link researchers to help coordinate and fund independent research on the risks and benefits of drugs that are on the market. We hope that this signifies a long-term commitment on the country's part to optimal drug therapy. CMA believes Canada should build on this activity by encouraging research on an ongoing basis on: - prescribing guidelines and what drugs work best for which conditions - dissemination of prescribing information - what interventions most effectively influence practice? - effect of changes in prescribing on patient health outcomes, and on utilization of health services; - the safety and effectiveness of drugs, building on what currently exists (such as Health Canada's system for reporting adverse drug reactions and communicating drug safety advisories), so that information derived from post-market surveillance quickly reaches health care providers and patients and becomes part of our body of knowledge. Since the great majority of prescriptions in Canada are written by physicians, it is essential that the medical community participate actively in evaluation of prescribing practices, and disseminating and implementing the results of research. Recommendation 13: The CMA calls on those who fund and produce research on drug safety and effectiveness, prescribing guidelines and programs to enhance prescribing practices, to include physicians and medical organizations meaningfully in this activity. 5 Conclusion It is likely that drug therapy will continue to increase in importance as a component of patient care and that it will continue to become more complex and, in many cases, more costly. As a result, we expect that health professionals and the Canadian public will continue to need readily available and up-to-date information on prescription drugs: the availability of new products; the results of safety and effectiveness studies; and advice on how to prescribe and take these medications for the best health outcome. It is also likely that electronic prescribing systems, formularies and other monitoring methods will continue to be developed, and that these will influence physicians' prescribing habits. To deliver evidence-based prescribing information effectively, and encourage its smooth incorporation into clinical practice, Canada needs a comprehensive, multi-disciplinary strategy in which physicians and other health care providers, governments, patients, industry and other stakeholders work together to encourage and support optimal prescribing, in the interest of achieving the best possible health for Canadians with the most effective use of resources. The CMA is ready to join with others in developing and implementing such a strategy, in the hope that eventually, all patients will receive the prescription drugs they need, when they need them. Appendix 1 A core undergraduate curriculum for prescribers in therapeutics Core knowledge and understanding Basic pharmacology Clinical pharmacokinetics Monitoring drug therapy Adverse drug reactions Drug interactions Medication errors Poisoned patients Prescribing for patients with special requirements (e.g., the elderly, children, women of childbearing potential, pregnant and breastfeeding women, and patients with renal or liver disease) Legal aspects of prescribing drugs Developing new drugs Medicines management Ethics of prescribing Commonly used drugs Common therapeutic problems Complementary and alternative medicine Integration of therapeutics into understanding of disease management. Core skills Taking a drug history Prescription writing Drug administration Prescribing drugs in special groups Prescribing drugs to relieve pain and distress Adverse drug reactions and interactions Drug allergy Clinical pharmacokinetics Monitoring drug therapy Analysing new evidence Obtaining accurate objective information to support safe and effective prescribing Obtaining informed consent to treatment Core attitudes A rational approach to prescribing and therapeutics Risk-benefit analysis Recognizing the responsibilities of a physician as part of the prescribing community Recognizing personal limitations in knowledge Responding to the future SOURCE: Maxwell S, Walley T. Teaching safe and effective prescribing in UK medical schools: a core curriculum for tomorrow's doctors. Br J Clin Pharmacol 2003;55:496-503.100. Cited in Innovating For Health: Patients, physicians, the pharmaceutical industry and the NHS. A report from the Royal College of Physicians (UK) February 2009 References i Metge C, Sketris I. "Pharmaceutical Policy." In MacKinnon NJ, ed. Safe and Effective: the Eight Essential Elements of an Optimal Medication Use System. Canadian Pharmacists Association, 2007. ii Canadian Institute for Health Information. Drug Expenditure in Canada, 1985 to 2009. Released April 2010. Accessed at https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC1428&lang=en&media=0. iii Wang E, Einarson T, Kellner J, Conly. Antibiotic prescribing for Canadian preschool children: evidence of overprescribing for viral respiratory infections. Clin Infect Dis. 1999; 29(1):155-60. iv Petrella R, Merikle E, Jones J. Prevalence and treatment of dyslipidemia in Canadian primary care: a retrospective cohort analysis. Clin Ther. 2007; 29(4):742-50. v Dr. Jean Gray, speaking at the Health Council of Canada symposium, "Safe and Sound: Optimizing Prescribing Behaviours"; Montreal, June 2007 vi Steinman MA, Baron RB. Is continuing medical education a drug promotion tool? Yes. Can Fam Phys 2007: 53(10); 1650-53. vii Angell M. Industry-sponsored clinical research: a broken system. JAMA 2008: 300 (Sept. 3); 1069-1071. viii Mintzes B, Barer ML, Kravitz RL et al. Influence of direct to consumer pharmaceutical advertising and patients' requests on prescribing decisions: a two-site cross-sectional survey. BMJ 2002; 324 (2 February): 278-279. ix "Should Canada allow direct-to-consumer advertising of prescription drugs?" (Debate) Can Fam PhysicianVol. 55, No. 2, February 2009, pp.130 - 133. x Valiyeva E, Herrmann M, Rochon PA. Effect of regulatory warnings on antipsychotic prescription rates among elderly patients with dementia: a population-based time series analysis. Can Med Assoc J 2008; 179(5) doi 10.1503. xi Health Council of Canada. "A commentary on The National Pharmaceuticals Strategy: a Prescription Unfilled." (January 2009) xii Cook DA, Levinson AJ, Garside S et al. Internet-based learning in the health professions: a meta-analysis. JAMA 2008; 300 (10): 1181-1196. xiii Rx for Change database; accessed at http://www.acmts.ca/index.php/en/compus/optimal-ther-resources/interventions. xiv Canadian Medical Association. "Information technology and health care in Canada: 2008 status report." xv Ashworth M, Lee R, Gray H et al. How are primary care organizations using financial incentives to influence prescribing? J Public Health 2004: 26(1); doi: 10.1093. xvi Canadian Council on Learning. Health literacy in Canada: initial results from the International Adult Literacy and Health Skills Survey (September 2007). Accessed at http://www.ccl-cca.ca/ccl/Reports/HealthLiteracy/HealthLiteracy2007.html.
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The role of physicians in prevention and health promotion (Update 2001)

https://policybase.cma.ca/en/permalink/policy179
Last Reviewed
2019-03-03
Date
2001-12-08
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2001-12-08
Replaces
The role of physicians in prevention and health promotion (1995)
Topics
Population health/ health equity/ public health
Text
Health care professionals, including physicians, play an essential role in promoting health and preventing disease among all Canadians. A significant proportion of death, illness and injury in Canada is preventable. These preventable health problems place a substantial burden of suffering on individuals, families and communities as well as a heavy burden on society because they draw on scarce health care resources. The World Health Organization defines health promotion as "the process of enabling people to increase control over and improve their health." Health promotion activities generally seek to influence either a person’s individual behaviours such as smoking and sedentary lifestyle. Effective health promotion also addresses the broader social determinants of health, for example, income, access to services and physical environment. The CMA views prevention and health promotion as a responsibility to be shared among all health care providers, rather than the sole responsibility of any one group or specialty. At a collective level, medical and other health organizations can be involved in prevention and health-promotion activities such as organizing public education campaigns, advocating for legislation that promotes health, such as laws to control pollution and tobacco products, and disseminating clinical practice guidelines to enhance standards of preventive care. At an individual level, the role of physicians in the continuum of patient care is an important one, with the potential for further enhancement, and can include: Health enhancement: As part of daily practice, physicians routinely offer information to support the prevention of disease. These activities include appropriate discussions with patients about nutrition, physical activity and access to social supports. In providing these services, physicians consider the social, economic and environmental conditions in which their patients live. Risk avoidance: Physicians ensure that people take measures that will prevent specific risks of disease. Examples include providing immunizations, promoting breast-feeding, physical activity and the use of bicycle helmets. Risk reduction: Physicians screen, counsel and work with individuals or segments of the population at higher risk of disease or injury to reduce their risk. Examples include screening for risk factors for the development of heart disease or diabetes, such as nutrition, smoking and alcohol use. Early identification: Physicians screen people to detect diseases at an asymptomatic stage, when intervention can improve the outcome. Papanicolaou smears to detect cancer of the cervix and breast exams to detect breast cancer are two types of tests being used in early detection. With the increase in public awareness and interest in prevention, physicians often spend time with their patients discussing the pros and cons of tests such as mammographic screening of women and the prostate-specific antigen screening test for men. Complication reduction: Physicians can prescribe therapy to prevent complications in patients with diagnosed conditions or diseases. For example, the use of medication to reduce the incidence of stroke or myocardial infarction in high risk patients. Recommendations 1) Physicians should continue to incorporate all levels of health promotion and disease prevention into their practices, emphasizing activities for which there is sufficient scientific evidence. 2) Education in prevention and health promotion both at an individual and at a collective level, should be given high priority in undergraduate medical programs, in residency training and in continuing medical education. 3) Physicians should be encouraged to work with other health care professionals in the office setting and the community to enhance delivery of care that incorporates prevention and health promotion. 4) Remuneration systems should support a multidisciplinary approach to the delivery of these services; they should also support the provision of these services by individual physicians. 5) Patients should have access to a family physician who can provide care that includes prevention and health promotion. Family physicians should continue to develop professional relationships with their patients that encourage the long-term promotion and maintenance of good health. 6) Clear, simple and current guidelines for prevention and health promotion services should be widely distributed to physicians. The Canadian Task Force on Preventive Health Care regularly develops and updates guidelines in this area. 7) Simple, easy-to-understand patient guidelines for prevention and health promotion should be developed and made available to the public. Physicians should continue to develop, improve and promote patient-counselling programs and office-management systems that encourage effective delivery of preventive care and health promotion. 8) Governments should give high priority to public policies that take account of the broad range of determinants of health, and proposed legislation should be routinely reviewed for any impact on the health of individuals and the community. CMA, in collaboration with other health professions and governments, will continue to explore means to ensure that public policies are developed with due attention paid to their potential health consequences. Approved by the CMA Board in 2001. Last reviewed and approved by the CMA Board in March 2019.
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