- Email: [email protected]
Pharmacists' Scope of Practice: Supports for Canadians with Diabetes
ARTICLE IN PRESS Can J Diabetes xxx (2017) 1–5
Contents lists available at ScienceDirect
Canadian Journal of Diabetes journal homepage: w w w. c a n a d i a n j o u r n a l o f d i a b e t e s . c o m
Practical Diabetes
Pharmacists’ Scope of Practice: Supports for Canadians with Diabetes Kerry Mansell BSP, PharmD, MBA a,*, Kirsten Edmunds BSP a, Lisa Guirguis BSc Pharm, PhD b a b
College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
Key Messages - Pharmacists in each Canadian province have seen an expanded scope of practice in recent years that is advantageous for people living with diabetes - Depending on the province, pharmacists are able to provide publically-funded medication reviews, vaccinations, renewal of prescriptions, and some pharmacists are able to order and interpret laboratory results (such as A1C) - This article describes services which may be beneficial to diabetes patients that pharmacists can provide in each province
a r t i c l e i n f o
a b s t r a c t
Article history: Received 1 June 2017 Received in revised form 14 July 2017 Accepted 21 August 2017
Objectives: The pharmacists’ role in Canada has significantly advanced over the past decade, resulting in increasing access to primary care services. This study aimed to characterize pharmacists’ expanded scope of practice as it relates to providing services to Canadians with diabetes. Methods: This environmental scan characterized services that could be useful to Canadians with diabetes in each of the provinces (excluding the territories): immunizations, medication prescribing, ordering and interpreting laboratory tests, and medication reviews. Researchers also collected information on pharmacists’ access to health information. Data were collected from regulatory authorities in each province, from pharmacy stakeholders and through a web search. Results: Pharmacists’ scope of practice varies widely across the Canadian provinces. Three provinces have medication-review programs focused specifically on diabetes, and many people with diabetes can access publicly funded medication reviews. Other than in Quebec, pharmacists can provide influenza (publicly funded) and pneumococcal vaccinations (publicly funded in British Columbia, Alberta and Manitoba). All pharmacists in Canadian provinces can renew prescriptions to ensure continuity of therapy. Pharmacists have varying levels of other prescriptive authority. Pharmacists in all provinces (except Ontario) can access provincial prescription information; in 4 provinces, they can access laboratory results, and in 3 provinces, they can order and interpret laboratory results, such as glycated hemoglobin levels. Conclusions: Canadians with diabetes can expect to receive influenza vaccines and have medications renewed at their pharmacies. Many patients with diabetes qualify for a publicly funded medication review, and some provinces allow pharmacists to order and interpret laboratory results. This expanded scope provides greater opportunities for pharmacists to help support patients with diabetes in conjunction with other health-care team members. © 2017 Canadian Diabetes Association.
Keywords: pharmacist scope of practice diabetes pharmacy Canada regulations
* Address for correspondence: Kerry Mansell, BSP, PharmD, MBA, College of Pharmacy and Nutrition, University of Saskatchewan, 104 Clinic Place, Saskatoon, Saskatchewan S7N 5E5, Canada. E-mail address: [email protected] 1499-2671 © 2017 Canadian Diabetes Association. The Canadian Diabetes Association is the registered owner of the name Diabetes Canada. https://doi.org/10.1016/j.jcjd.2017.08.243
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r é s u m é Mots clés : pharmacien champ de pratique diabète pharmacie Canada règlements
Objectifs : Au Canada, le rôle des pharmaciens a considérablement évolué au cours de la dernière décennie, ce qui a entraîné un accès accru aux services de soins primaires. La présente étude a pour but de décrire le champ de pratique élargi des pharmaciens en ce qui touche la prestation des services aux Canadiens diabétiques. Méthodes : Cette enquête sur le milieu a décrit les services susceptibles d’être utiles aux Canadiens diabétiques dans chacune des provinces (sauf les territoires) : immunisation, prescription de médicaments, prescription et interprétation des examens de laboratoire et revue de la médication. Les chercheurs ont également collecté des informations sur l’accès des pharmaciens aux renseignements sur la santé. La collecte de données provenait des organismes de réglementation de chacune des provinces, des intervenants de la pharmacie et d’une recherche sur le Web. Résultats : Le champ de pratique des pharmaciens varie grandement entre les provinces canadiennes. Trois provinces ont des programmes de revue de la médication qui portent particulièrement sur le diabète. Par conséquent, de nombreuses personnes diabétiques ont accès à la revue de la médication financée par les fonds publics. À l’exception du Québec, les pharmaciens peuvent offrir la vaccination antigrippale (programme financé par les fonds publics) et la vaccination antipneumococcique (programme financé par les fonds publics en Colombie-Britannique, en Alberta et au Manitoba). Tous les pharmaciens des provinces canadiennes peuvent renouveler les ordonnances pour assurer la continuité du traitement. Les pharmaciens détiennent un pouvoir variable de prescription. Les pharmaciens de toutes les provinces, excepté l’Ontario, ont accès à un système provincial d’information sur les médicaments prescrits ; dans 4 provinces, ils ont accès aux résultats d’examens de laboratoire, et dans 3 provinces, ils peuvent prescrire et interpréter les résultats d’examens de laboratoire tels que les concentrations de l’hémoglobine glyquée. Conclusions : Les Canadiens diabétiques peuvent s’attendre à recevoir le vaccin antigrippal et à obtenir le renouvellement de leurs médicaments à leur pharmacie. De nombreux patients diabétiques répondentaux critères du programme de la revue de la médication financé par les fonds publics. De plus, dans certaines provinces, les pharmaciens peuvent prescrire et interpréter les résultats d’examens de laboratoire. L’élargissement de leur champ de pratique offre davantage de possibilités aux pharmaciens pour contribuer de manière conjointe avec d’autres membres de l’équipe soignante au soutien des patients diabétiques. © 2017 Canadian Diabetes Association.
Introduction The prevalence of diabetes in Canada continues to grow exponentially, leading Diabetes Canada to believe that an estimated 5 million Canadians will have diabetes by 2025 (1). People with diabetes require access to a wide range of resources and an interprofessional health-care team, including physicians, nurses, dietitians, pharmacists, podiatrists and others, to help manage this chronic, multifaceted condition. As the prevalence of patients with diabetes increases and places additional strain on the health-care system, community-based health-care professionals will need to play greater roles in the management of Canadians with diabetes. Pharmacists play an essential role in the care of patients with diabetes because medications are an integral part of diabetes management. Systematic reviews have shown that pharmacists’ interventions lead to improved health outcomes (for example, in levels of glycated hemoglobin [A1C] and blood pressure) in patients with diabetes (2,3). There are close to 39,000 licensed pharmacists in Canada, of whom about 70% work in community pharmacies (4). Most community pharmacies have evening and weekend hours and do not require appointments to see the pharmacists, so these pharmacists are the most easily accessible health-care professionals in Canada (4). Canadian pharmacists are taking an increasingly active interest in diabetes management as well; there are approximately 2200 certified diabetes educator (CDE) pharmacists in Canada. Pharmacists account for almost half of all CDEs in Canada and represent the fastest growing segment of CDEs of all health-care professionals in Canada (personal communication, Canadian Diabetes Educator Certificate Board). In the past decade, provinces have responded to a growing need for accessible community-based care by expanding pharmacists’ scope of practice. Pharmacists’ roles vary by province and include activities, such as prescribing medications and injecting vaccinations. Several provincial governments have enacted programs that focus care on patients with diabetes.
Despite these new opportunities, Canadians are often not aware of pharmacists’ expanded roles and, subsequently, may not take advantage of these opportunities (5–7). The biggest challenges pharmacists encounter when implementing these practice changes are overcoming patients’ perceptions of pharmacists as dispensers and pharmacists’ hesitancy to promote these services (8). Similarly, health-care professionals may not be aware of pharmacists’ growing scope of practice and the potential benefits for their patients. This article provides an overview of pharmacists’ scope of practice in Canada as well as the implications for patient care.
Methods An environmental scan was conducted to assess pharmacists’ services available to patients with diabetes in Canada. Data were collected about government-funded diabetes-specific services, such as diabetes medication reviews as well as general services that would be useful to Canadians with diabetes: immunizations for influenza and pneumococcal disease, medication prescribing, ordering laboratory tests and medication reviews in general. Researchers also collected information about pharmacists’ access to health information (laboratory values, pharmaceutical records and electronic health records) because these may influence pharmacists’ abilities to provide the services above. In order to determine which activities pharmacists can perform in each of the Canadian provinces, representatives from the regulatory authorities in each province were contacted. Correspondence with these representatives was conducted via e-mail and telephone. Data were also collected from the websites of the provincial regulatory authorities, provincial and national pharmacy advocacy groups, practising pharmacists and provincial eHealth services. Information about financial reimbursement for pharmacist services was obtained from the Canadian Foundation for Pharmacy (9). Expanded-scope activities are not legislated in the
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Canadian territories, so these territories were not included in this review. The data collected are presented in a descriptive manner. The University of Saskatchewan Research Ethics Board provided an exemption from a full ethics submission on the basis of quality assurance.
Results Medication reviews A medication review is generally defined as “a structured evaluation of a patient’s medicines with the aim of optimizing medicines’ use and improving health outcomes” (10). All provinces other than Manitoba and Quebec provide public funding for pharmacistconducted medication reviews. Each province has a unique set of criteria for patient eligibility that typically includes specifications of age, chronic medical conditions and numbers or types of chronic medications (11). Alberta, Ontario, Newfoundland and Prince Edward Island allow patients of any age with type 1 or type 2 diabetes who are taking at least 1 antihyperglycemic medication to be eligible for a publicly funded medication review. Other provinces do not have specific programs for diabetes medication reviews, but people with diabetes may be eligible under various criteria (e.g. an elderly patient taking multiple medications that may include antihyperglycemics). The structure and intent of medication reviews vary across the provinces. For example, a MedsCheck Annual in Ontario addresses patients’ medication understanding, assesses adherence and provides a complete list of medications (12), whereas the Comprehensive Care Plan in Alberta includes “a patient assessment, a Best Possible Medication History, identification of and appropriate response to any drug-therapy problems, agreed goals of medication therapy, as well as a monitoring plan” (13).
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In a collaborative-practice setting, pharmacists in 5 provinces can initiate a new prescription drug and adapt existing prescription medication orders from another prescriber (for example, the dose of the medication or dosage formulation). Alberta is the only province that allows pharmacists independently to initiate, adapt or manage medication therapy if the pharmacists have obtained Additional Prescribing Authorization (14). Pharmacists in most provinces can prescribe medications for smoking cessation and minor ailments, such as cold sores, heartburn and certain fungal infections (Table 1). The types of selflimiting conditions and medications that a pharmacist is authorized to prescribe for varies with the province. Additional training or authorization may be needed in some provinces in order to obtain the authority to perform such activities as adapting a prescription or prescribing a pharmaceutical agent for a minor ailment. Vaccinations Pharmacists in each province, to varying extents, have the legislative authority to provide subcutaneous or intramuscular injections to patients. Provincial regulations dictate which patients are eligible for pharmacist-administered injections (Table 2). Most of the provinces have a universal seasonal influenza program that provides all residents of that province with an influenza vaccine free of charge. Currently, pharmacists in all of the provinces except Quebec can provide government-funded influenza vaccinations to eligible patients. Administration of other publicly funded vaccines for patients with diabetes by a pharmacist is covered by the government in British Columbia, Alberta and Manitoba. In each of these provinces there are certain criteria that a patient must meet to receive the publicly funded pneumococcal vaccine, 1 of which is a diagnosis of diabetes mellitus. In addition to vaccinations, some pharmacists are able (with additional training) to provide injections of medications such as a vitamin B12 injection, for example.
Prescriptive authority
Access to patient information and laboratory values
All pharmacists in the Canadian provinces can renew prescriptions to ensure continuity of care for diabetes-related medications, and pharmacists in 6 provinces are allowed to prescribe medications in emergency situations (Table 1). Currently, pharmacists cannot prescribe medications in the Controlled Drugs and Substances Act (for example, opioids). Otherwise, the level of prescriptive authority varies among provinces.
Community pharmacists have variable access to provincial electronic health records (Table 1). Pharmacists in all provinces except Ontario can access a provincial prescription-tracking system showing which medications have been dispensed through a pharmacy to a patient (provincewide). Pharmacists in most provinces have the ability to view electronic laboratory values. In addition to accessing laboratory values, pharmacists’ expanded scope of practice has
Table 1 Provincial Scope of Practice for Pharmacists in Canada Scope of practice
Medication assessments Prescriptive authority
Injections Access to patient information
Provinces
Standard Diabetes specific Independently initiate and adapt/manage Collaboratively initiate and adapt/manage Minor ailments Smoking/tobacco cessation Emergency situation Renew/extend prescription for continuity of care Vaccines (influenza, pneumococcal) Other drugs Access to provincewide prescription information Access to laboratory results Order and interpret laboratory results
BC
AB
SK
MB
ON
QC
NB
NL
NS
PEI
Y N N N N N N Y Y N Y N N
Y Y Y Y Y Y Y Y Y Y Y Y Y
Y N N Y Y P Y Y Y Y Y Y P
N N N Y Y Y Y Y Y Y Y N† P
Y Y N N N Y N Y Y N* N N N
N N N N Y Y N Y N N* Y Y Y
Y N N Y Y Y Y Y Y Y Y Y P
Y Y N N Y Y N Y Y Y Y N‡ N
Y N N Y Y Y Y Y Y N Y N‡ P
Y Y N N Y Y Y Y Y Y Y N P
Note: Adapted with permission from the Canadian Pharmacists Association. Available at https://www.pharmacists.ca/cpha-ca/assets/File/cpha-on-the-issues/ ScopeofPracticeinCanada_DEC2016.pdf. * In Ontario and Quebec, can inject any drug or vaccine for education and demonstration purposes only. † Community pharmacists currently unable, whereas provisions exist for other pharmacists (i.e. hospital pharmacists). ‡ Can request access but not readily available to all pharmacists. AB, Alberta; BC, British Columbia; MB, Manitoba; N, no; NB, New Brunswick; NL, Newfoundland and Labrador; NS, Nova Scotia; ON, Ontario; P, pending legislative or regulatory approval; PEI, Prince Edward Island; QC, Quebec; SK, Saskatchewan; Y, yes.
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Table 2 Provincial Injection Regulations for Pharmacists in Canada Provinces
Provincial injection regulations for pharmacists Restrictions for vaccines
Restrictions for injectable drugs
Public reimbursement for influenza vaccine
Public reimbursement for other vaccines
Public reimbursement for injectable drugs
BC AB SK MB ON
≥5 years old ≥5 years old ≥9 years old ≥7 years old ≥5 years old
No injection authority for drugs ≥5 years old ≥5 years old ≥5 years old Injection of drugs for demonstration purposes only
All patients All patients All patients All patients All patients
Patients must meet certain criteria Patients must meet certain criteria None Patients must meet certain criteria None
None All patients None None None
QC
Injections for demonstration purposes only Restrictions for influenza vaccine based on age and other risk factors ≥5 years old ≥5 years old Influenza vaccine: ≥5 years old; other vaccines: ≥18 years old
None
None
None
≥5 years old
Patients must meet certain criteria
None
None
≥5 years old No injection authority for drugs ≥5 years old
All patients All patients Patients must meet certain criteria
None None None
None None None
NB
NL NS PEI
AB, Alberta; BC, British Columbia; MB, Manitoba; NB, New Brunswick; NL, Newfoundland and Labrador; NS, Nova Scotia; ON, Ontario; PEI, Prince Edward Island; QC, Quebec; SK, Saskatchewan.
grown to include the ability to order and, to some extent, interpret certain laboratory tests in Alberta and Quebec (Table 1). Legislation to allow this activity is pending in Saskatchewan, Prince Edward Island, Manitoba, New Brunswick and Nova Scotia. The additional training required and the types of laboratory tests that can be ordered by pharmacists differ among the provinces. For instance, in PEI, authorized pharmacists will be able to order laboratory tests for A1C levels and international normalized ratios only once they have been granted this authority. In many of the provinces where legislative or regulatory approval is pending, it is best to refer to the individual provinces to learn which activities will be allowed once approval has been granted.
Discussion Pharmacists’ core role remains ensuring that patients have optimal drug therapy by ascertaining that medications are appropriate for individual patients (i.e. indicated, effective, safe and manageable), but pharmacists’ roles and scope of practice have expanded in the past decade so they can better support the primary healthcare needs of Canadians. Diabetes is a multifaceted disease that requires management of blood glucose levels, vascular protection and other comorbidities, so people with diabetes commonly have complex medication regimens that involve being on an average of 6 medications (15,16). Pharmacists in almost all of the provinces have the ability to see all of the prescription medications a patient has been dispensed provincewide through some form of electronic health record, so they are able to prevent drug interactions and duplication of therapy as well as review individuals’ complete medication therapy for diabetes and comorbid conditions. Unfortunately, these prescription-tracking systems do not capture drug samples handed out in prescribers’ offices, drugs dispensed from another province or, for the most part, over-the-counter and herbal medications. This is the value of medication reviews, whereby pharmacists are expected to collect the best possible medication histories, which include all products taken (e.g. vitamins and herbal supplements), not just those available through the provincial databases. Medication reviews are opportunities for pharmacists to review patients’ medication use, resolve problems and create current medication lists. Although not every province has specific medication-review programs for people with diabetes, in many cases, these patients will still qualify. For example, elderly patients taking
5 medications for diabetes and vascular protection qualify for medication reviews in 8 of 10 provinces. Medication reviews have been shown to reduce drug-related problems, dosages and number of medications (17). Medication reviews alone do not directly improve clinical outcomes (17), but these medication lists allow patients to share more accurate histories and ask questions about their medications and medical conditions, and they allow the pharmacists to assess adherence. In turn, pharmacists are encouraged or required to share this information with other members of the health-care team. Allowing pharmacists to prescribe for continuity of therapy provides timely access to medications for people with diabetes, which is essential for the management of their condition. People with diabetes see their pharmacists more often than any other healthcare professional (18). It is not uncommon for people with diabetes to run out of metformin and not have an appointment with their primary care providers (i.e. physician or nurse practitioner) for another month. Pharmacists have the scope to renew the medication and subsequently notify the original prescriber of this action, thus saving both the patient and the prescriber time and energy and ensuring that the patient continues to receive the necessary medications. Additionally, this could decrease the burden of nonurgent visits to emergency departments for renewals of chronic medications when the primary care providers are unavailable. Appropriate monitoring of laboratory results is crucial in those with diabetes. With access to the laboratory results of such patients’ A1C and serum creatinine levels, pharmacists can more vigilantly monitor medication safety and efficacy in order to help identify when patients need team support. Access to laboratory data can help to ensure that medication dosages are correct in patients not achieving their blood glucose targets and whether there is impaired renal function; this helps to ensure that the correct medications are being used by the right people at the right times. Further, in provinces where it is allowed, some pharmacists may also be able to order certain laboratory tests, which could be of benefit if their patients are unable to see their physicians or nurse practitioners in a timely manner. Up-to-date vaccinations are an important part of the overall management plan for people with diabetes, who are at a higher risk for complications resulting from influenza and pneumococcal disease (19,20); hence, Diabetes Canada recommends these vaccinations in people with diabetes (21). Timely and convenient access to vaccination providers is an important factor in improving vaccination rates (22). Given the accessibility and convenience of community
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pharmacies, this is an important aspect of diabetes management that pharmacists can help to provide. For example, during the most recent influenza season, pharmacists in Saskatchewan administered almost 90,000 flu shots, representing approximately 36% of all of the flu shots administered in Saskatchewan (23). As is illustrated, the provincial variations in the services pharmacists can provide within their scope of practice are substantial. Even within provinces, services may vary from pharmacy to pharmacy. Current pharmacy regulations are enabling, and individual pharmacists may choose whether they wish to practice to the full scope of their practice. For example, some pharmacists may provide dozens of vaccinations a day, whereas others may not provide any. Hence, it is important for patients with diabetes and for pharmacists and other health-care providers to have open communication and be aware of the services that can be provided to help improve the overall health-care experience.
Conclusions Pharmacists in all of the Canadian provinces have seen an expanded scope of practice occur over the past decade, and this has provided an opportunity for greater collaboration and sharing of information with both patients and other health-care providers. Certainly, some of this expanded scope is directly advantageous for people living with diabetes, such as access to publicly funded medication reviews, vaccinations, renewal of prescriptions and access to laboratory results. As such, it is important for health-care providers and people alike to be aware of the services their pharmacists can and do provide so that they can find pharmacists who can support their diabetes management.
References 1. Diabetes Canada. Diabetes Statistics in Canada. 2017. http://www.diabetes.ca/ how-you-can-help/advocate/why-federal-leadership-is-essential/diabetes -statistics-in-canada#_ftnref1. Accessed February 1, 2017. 2. Machado M, Bajcar J, Guzzo GC, Einarson TR. Sensitivity of patient outcomes to pharmacist interventions. Part I: Systematic review and meta-analysis in diabetes management. Ann Pharmacother 2007;41:1569–82. 3. Pousinho S, Morgado M, Falcão A, Alves G. Pharmacist interventions in the management of type 2 diabetes mellitus: A systematic review of randomized controlled trials. J Manag Care Spec Pharm 2016;22:493–515.
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4. Canadian Pharmacists Association. Pharmacy in Canada. 2016. http://www .pharmacists.ca/cpha-ca/assets/File/pharmacy-in-canada/Pharmacy%20in %20Canada.pdf. Accessed May 1, 2017. 5. Faruquee CF, Guirguis LM. A scoping review of research on the prescribing practice of Canadian pharmacists. Can Pharm J 2015;148:325–48. 6. Kelly DV, Young S, Phillips L, Clark D. Patient attitudes regarding the role of the pharmacist and interest in expanded pharmacist services. Can Pharm J 2014;147:239–47. 7. Bishop AC, Boyle TA, Morrison B, et al. Public perceptions of pharmacist expanded scope of practice services in Nova Scotia. Can Pharm J 2015;148:274– 83. 8. Mossialos E, Courtin E, Naci H, et al. From “retailers” to health care providers: Transforming the role of community pharmacists in chronic disease management. Health Policy (New York) 2015;119:628–39. 9. Canadian Foundation for Pharmacy. Provincial Chart of Pharmacy Services. 2017. https://cfpnet.ca/bank/document_en/104-2016-provincial-chart.pdf. Accessed May 20, 2017. 10. Pharmaceutical Care Network Europe. PCNE Working group on medication review. 2017. http://www.pcne.org/working-groups/1/medication-review. Accessed April 21, 2017. 11. Pammett R, Jorgenson D. Eligibility requirements for community pharmacy medication review services in Canada. Can Pharm J 2014;147:20–4. 12. Dolovich L, Consiglio G, MacKeigan L, et al. Uptake of the MedsCheck annual medication review service in Ontario community pharmacies between 2007 and 2013. Can Pharm J 2016;149:293–302. 13. Alberta Health. Compensation Plan for Pharmacy Services. 2014. http://www. health.alberta.ca/documents/MO-23-2014-PharmacyCompensation.pdf. Accessed May 23, 2017. 14. Alberta College of Pharmacists. Guide to receiving additional prescribing authorization. 2013. https://pharmacists.ab.ca/sites/default/files/APAGuide.pdf. Accessed July 11, 2017. 15. Black J, Simmons R, Boothby C, et al. Medication burden in the first 5 years following diagnosis of type 2 diabetes: Findings from the ADDITION-UK trial cohort. BMJ Open Diabetes Res Care 2015;3:e000075. 16. Grant RW, Devita NG, Singer DE, Meigs JB. Polypharmacy and medication adherence in patients with type 2 diabetes. Diabetes Care 2003;26:1408–12. 17. Huiskes VJB, Burger DM, van den Ende CHM, van den Bemt BJF. Effectiveness of medication review: A systematic review and meta-analysis of randomized controlled trials. BMC Fam Pract 2017;18:5. 18. Shiu JR, Simpson SH, Johnson JA, Tsuyuki RT. Quantifying opportunities to affect diabetes management in the community. Can Pharm J 2006;139:37– 8. 19. Groenwold RH, Hoes AW, Hak E. Impact of influenza vaccination on mortality risk among the elderly. Eur Respir J 2009;34:56–62. 20. Muller LM, Gorter KJ, Hak E, et al. Increased risk of common infections in patients with type 1 and type 2 diabetes mellitus. Clin Infect Dis 2005;41:281– 8. 21. Diabetes Canada. Influenza and pneumococcal immunization. 2013. http:// guidelines.diabetes.ca/browse/chapter19#bib1. Accessed February 2, 2017. 22. Gai Y, Feng L. Relationship between pharmacist density and adult influenza vaccination after controlling for individual and neighborhood effects. J Am Pharm Assoc 2017;in press. 23. Saskatchewan College of Pharmacy Professionals. SCOPe newsletter. 2017. http://scp.in1touch.org/document/3426/SCOPe_Newsletter_March2017.pdf. Accessed May 3, 2017.
Contents lists available at ScienceDirect
Canadian Journal of Diabetes journal homepage: w w w. c a n a d i a n j o u r n a l o f d i a b e t e s . c o m
Practical Diabetes
Pharmacists’ Scope of Practice: Supports for Canadians with Diabetes Kerry Mansell BSP, PharmD, MBA a,*, Kirsten Edmunds BSP a, Lisa Guirguis BSc Pharm, PhD b a b
College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
Key Messages - Pharmacists in each Canadian province have seen an expanded scope of practice in recent years that is advantageous for people living with diabetes - Depending on the province, pharmacists are able to provide publically-funded medication reviews, vaccinations, renewal of prescriptions, and some pharmacists are able to order and interpret laboratory results (such as A1C) - This article describes services which may be beneficial to diabetes patients that pharmacists can provide in each province
a r t i c l e i n f o
a b s t r a c t
Article history: Received 1 June 2017 Received in revised form 14 July 2017 Accepted 21 August 2017
Objectives: The pharmacists’ role in Canada has significantly advanced over the past decade, resulting in increasing access to primary care services. This study aimed to characterize pharmacists’ expanded scope of practice as it relates to providing services to Canadians with diabetes. Methods: This environmental scan characterized services that could be useful to Canadians with diabetes in each of the provinces (excluding the territories): immunizations, medication prescribing, ordering and interpreting laboratory tests, and medication reviews. Researchers also collected information on pharmacists’ access to health information. Data were collected from regulatory authorities in each province, from pharmacy stakeholders and through a web search. Results: Pharmacists’ scope of practice varies widely across the Canadian provinces. Three provinces have medication-review programs focused specifically on diabetes, and many people with diabetes can access publicly funded medication reviews. Other than in Quebec, pharmacists can provide influenza (publicly funded) and pneumococcal vaccinations (publicly funded in British Columbia, Alberta and Manitoba). All pharmacists in Canadian provinces can renew prescriptions to ensure continuity of therapy. Pharmacists have varying levels of other prescriptive authority. Pharmacists in all provinces (except Ontario) can access provincial prescription information; in 4 provinces, they can access laboratory results, and in 3 provinces, they can order and interpret laboratory results, such as glycated hemoglobin levels. Conclusions: Canadians with diabetes can expect to receive influenza vaccines and have medications renewed at their pharmacies. Many patients with diabetes qualify for a publicly funded medication review, and some provinces allow pharmacists to order and interpret laboratory results. This expanded scope provides greater opportunities for pharmacists to help support patients with diabetes in conjunction with other health-care team members. © 2017 Canadian Diabetes Association.
Keywords: pharmacist scope of practice diabetes pharmacy Canada regulations
* Address for correspondence: Kerry Mansell, BSP, PharmD, MBA, College of Pharmacy and Nutrition, University of Saskatchewan, 104 Clinic Place, Saskatoon, Saskatchewan S7N 5E5, Canada. E-mail address: [email protected] 1499-2671 © 2017 Canadian Diabetes Association. The Canadian Diabetes Association is the registered owner of the name Diabetes Canada. https://doi.org/10.1016/j.jcjd.2017.08.243
ARTICLE IN PRESS 2
K. Edmunds, L. Guirguis / Can J Diabetes xxx (2017) 1–5
r é s u m é Mots clés : pharmacien champ de pratique diabète pharmacie Canada règlements
Objectifs : Au Canada, le rôle des pharmaciens a considérablement évolué au cours de la dernière décennie, ce qui a entraîné un accès accru aux services de soins primaires. La présente étude a pour but de décrire le champ de pratique élargi des pharmaciens en ce qui touche la prestation des services aux Canadiens diabétiques. Méthodes : Cette enquête sur le milieu a décrit les services susceptibles d’être utiles aux Canadiens diabétiques dans chacune des provinces (sauf les territoires) : immunisation, prescription de médicaments, prescription et interprétation des examens de laboratoire et revue de la médication. Les chercheurs ont également collecté des informations sur l’accès des pharmaciens aux renseignements sur la santé. La collecte de données provenait des organismes de réglementation de chacune des provinces, des intervenants de la pharmacie et d’une recherche sur le Web. Résultats : Le champ de pratique des pharmaciens varie grandement entre les provinces canadiennes. Trois provinces ont des programmes de revue de la médication qui portent particulièrement sur le diabète. Par conséquent, de nombreuses personnes diabétiques ont accès à la revue de la médication financée par les fonds publics. À l’exception du Québec, les pharmaciens peuvent offrir la vaccination antigrippale (programme financé par les fonds publics) et la vaccination antipneumococcique (programme financé par les fonds publics en Colombie-Britannique, en Alberta et au Manitoba). Tous les pharmaciens des provinces canadiennes peuvent renouveler les ordonnances pour assurer la continuité du traitement. Les pharmaciens détiennent un pouvoir variable de prescription. Les pharmaciens de toutes les provinces, excepté l’Ontario, ont accès à un système provincial d’information sur les médicaments prescrits ; dans 4 provinces, ils ont accès aux résultats d’examens de laboratoire, et dans 3 provinces, ils peuvent prescrire et interpréter les résultats d’examens de laboratoire tels que les concentrations de l’hémoglobine glyquée. Conclusions : Les Canadiens diabétiques peuvent s’attendre à recevoir le vaccin antigrippal et à obtenir le renouvellement de leurs médicaments à leur pharmacie. De nombreux patients diabétiques répondentaux critères du programme de la revue de la médication financé par les fonds publics. De plus, dans certaines provinces, les pharmaciens peuvent prescrire et interpréter les résultats d’examens de laboratoire. L’élargissement de leur champ de pratique offre davantage de possibilités aux pharmaciens pour contribuer de manière conjointe avec d’autres membres de l’équipe soignante au soutien des patients diabétiques. © 2017 Canadian Diabetes Association.
Introduction The prevalence of diabetes in Canada continues to grow exponentially, leading Diabetes Canada to believe that an estimated 5 million Canadians will have diabetes by 2025 (1). People with diabetes require access to a wide range of resources and an interprofessional health-care team, including physicians, nurses, dietitians, pharmacists, podiatrists and others, to help manage this chronic, multifaceted condition. As the prevalence of patients with diabetes increases and places additional strain on the health-care system, community-based health-care professionals will need to play greater roles in the management of Canadians with diabetes. Pharmacists play an essential role in the care of patients with diabetes because medications are an integral part of diabetes management. Systematic reviews have shown that pharmacists’ interventions lead to improved health outcomes (for example, in levels of glycated hemoglobin [A1C] and blood pressure) in patients with diabetes (2,3). There are close to 39,000 licensed pharmacists in Canada, of whom about 70% work in community pharmacies (4). Most community pharmacies have evening and weekend hours and do not require appointments to see the pharmacists, so these pharmacists are the most easily accessible health-care professionals in Canada (4). Canadian pharmacists are taking an increasingly active interest in diabetes management as well; there are approximately 2200 certified diabetes educator (CDE) pharmacists in Canada. Pharmacists account for almost half of all CDEs in Canada and represent the fastest growing segment of CDEs of all health-care professionals in Canada (personal communication, Canadian Diabetes Educator Certificate Board). In the past decade, provinces have responded to a growing need for accessible community-based care by expanding pharmacists’ scope of practice. Pharmacists’ roles vary by province and include activities, such as prescribing medications and injecting vaccinations. Several provincial governments have enacted programs that focus care on patients with diabetes.
Despite these new opportunities, Canadians are often not aware of pharmacists’ expanded roles and, subsequently, may not take advantage of these opportunities (5–7). The biggest challenges pharmacists encounter when implementing these practice changes are overcoming patients’ perceptions of pharmacists as dispensers and pharmacists’ hesitancy to promote these services (8). Similarly, health-care professionals may not be aware of pharmacists’ growing scope of practice and the potential benefits for their patients. This article provides an overview of pharmacists’ scope of practice in Canada as well as the implications for patient care.
Methods An environmental scan was conducted to assess pharmacists’ services available to patients with diabetes in Canada. Data were collected about government-funded diabetes-specific services, such as diabetes medication reviews as well as general services that would be useful to Canadians with diabetes: immunizations for influenza and pneumococcal disease, medication prescribing, ordering laboratory tests and medication reviews in general. Researchers also collected information about pharmacists’ access to health information (laboratory values, pharmaceutical records and electronic health records) because these may influence pharmacists’ abilities to provide the services above. In order to determine which activities pharmacists can perform in each of the Canadian provinces, representatives from the regulatory authorities in each province were contacted. Correspondence with these representatives was conducted via e-mail and telephone. Data were also collected from the websites of the provincial regulatory authorities, provincial and national pharmacy advocacy groups, practising pharmacists and provincial eHealth services. Information about financial reimbursement for pharmacist services was obtained from the Canadian Foundation for Pharmacy (9). Expanded-scope activities are not legislated in the
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Canadian territories, so these territories were not included in this review. The data collected are presented in a descriptive manner. The University of Saskatchewan Research Ethics Board provided an exemption from a full ethics submission on the basis of quality assurance.
Results Medication reviews A medication review is generally defined as “a structured evaluation of a patient’s medicines with the aim of optimizing medicines’ use and improving health outcomes” (10). All provinces other than Manitoba and Quebec provide public funding for pharmacistconducted medication reviews. Each province has a unique set of criteria for patient eligibility that typically includes specifications of age, chronic medical conditions and numbers or types of chronic medications (11). Alberta, Ontario, Newfoundland and Prince Edward Island allow patients of any age with type 1 or type 2 diabetes who are taking at least 1 antihyperglycemic medication to be eligible for a publicly funded medication review. Other provinces do not have specific programs for diabetes medication reviews, but people with diabetes may be eligible under various criteria (e.g. an elderly patient taking multiple medications that may include antihyperglycemics). The structure and intent of medication reviews vary across the provinces. For example, a MedsCheck Annual in Ontario addresses patients’ medication understanding, assesses adherence and provides a complete list of medications (12), whereas the Comprehensive Care Plan in Alberta includes “a patient assessment, a Best Possible Medication History, identification of and appropriate response to any drug-therapy problems, agreed goals of medication therapy, as well as a monitoring plan” (13).
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In a collaborative-practice setting, pharmacists in 5 provinces can initiate a new prescription drug and adapt existing prescription medication orders from another prescriber (for example, the dose of the medication or dosage formulation). Alberta is the only province that allows pharmacists independently to initiate, adapt or manage medication therapy if the pharmacists have obtained Additional Prescribing Authorization (14). Pharmacists in most provinces can prescribe medications for smoking cessation and minor ailments, such as cold sores, heartburn and certain fungal infections (Table 1). The types of selflimiting conditions and medications that a pharmacist is authorized to prescribe for varies with the province. Additional training or authorization may be needed in some provinces in order to obtain the authority to perform such activities as adapting a prescription or prescribing a pharmaceutical agent for a minor ailment. Vaccinations Pharmacists in each province, to varying extents, have the legislative authority to provide subcutaneous or intramuscular injections to patients. Provincial regulations dictate which patients are eligible for pharmacist-administered injections (Table 2). Most of the provinces have a universal seasonal influenza program that provides all residents of that province with an influenza vaccine free of charge. Currently, pharmacists in all of the provinces except Quebec can provide government-funded influenza vaccinations to eligible patients. Administration of other publicly funded vaccines for patients with diabetes by a pharmacist is covered by the government in British Columbia, Alberta and Manitoba. In each of these provinces there are certain criteria that a patient must meet to receive the publicly funded pneumococcal vaccine, 1 of which is a diagnosis of diabetes mellitus. In addition to vaccinations, some pharmacists are able (with additional training) to provide injections of medications such as a vitamin B12 injection, for example.
Prescriptive authority
Access to patient information and laboratory values
All pharmacists in the Canadian provinces can renew prescriptions to ensure continuity of care for diabetes-related medications, and pharmacists in 6 provinces are allowed to prescribe medications in emergency situations (Table 1). Currently, pharmacists cannot prescribe medications in the Controlled Drugs and Substances Act (for example, opioids). Otherwise, the level of prescriptive authority varies among provinces.
Community pharmacists have variable access to provincial electronic health records (Table 1). Pharmacists in all provinces except Ontario can access a provincial prescription-tracking system showing which medications have been dispensed through a pharmacy to a patient (provincewide). Pharmacists in most provinces have the ability to view electronic laboratory values. In addition to accessing laboratory values, pharmacists’ expanded scope of practice has
Table 1 Provincial Scope of Practice for Pharmacists in Canada Scope of practice
Medication assessments Prescriptive authority
Injections Access to patient information
Provinces
Standard Diabetes specific Independently initiate and adapt/manage Collaboratively initiate and adapt/manage Minor ailments Smoking/tobacco cessation Emergency situation Renew/extend prescription for continuity of care Vaccines (influenza, pneumococcal) Other drugs Access to provincewide prescription information Access to laboratory results Order and interpret laboratory results
BC
AB
SK
MB
ON
QC
NB
NL
NS
PEI
Y N N N N N N Y Y N Y N N
Y Y Y Y Y Y Y Y Y Y Y Y Y
Y N N Y Y P Y Y Y Y Y Y P
N N N Y Y Y Y Y Y Y Y N† P
Y Y N N N Y N Y Y N* N N N
N N N N Y Y N Y N N* Y Y Y
Y N N Y Y Y Y Y Y Y Y Y P
Y Y N N Y Y N Y Y Y Y N‡ N
Y N N Y Y Y Y Y Y N Y N‡ P
Y Y N N Y Y Y Y Y Y Y N P
Note: Adapted with permission from the Canadian Pharmacists Association. Available at https://www.pharmacists.ca/cpha-ca/assets/File/cpha-on-the-issues/ ScopeofPracticeinCanada_DEC2016.pdf. * In Ontario and Quebec, can inject any drug or vaccine for education and demonstration purposes only. † Community pharmacists currently unable, whereas provisions exist for other pharmacists (i.e. hospital pharmacists). ‡ Can request access but not readily available to all pharmacists. AB, Alberta; BC, British Columbia; MB, Manitoba; N, no; NB, New Brunswick; NL, Newfoundland and Labrador; NS, Nova Scotia; ON, Ontario; P, pending legislative or regulatory approval; PEI, Prince Edward Island; QC, Quebec; SK, Saskatchewan; Y, yes.
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Table 2 Provincial Injection Regulations for Pharmacists in Canada Provinces
Provincial injection regulations for pharmacists Restrictions for vaccines
Restrictions for injectable drugs
Public reimbursement for influenza vaccine
Public reimbursement for other vaccines
Public reimbursement for injectable drugs
BC AB SK MB ON
≥5 years old ≥5 years old ≥9 years old ≥7 years old ≥5 years old
No injection authority for drugs ≥5 years old ≥5 years old ≥5 years old Injection of drugs for demonstration purposes only
All patients All patients All patients All patients All patients
Patients must meet certain criteria Patients must meet certain criteria None Patients must meet certain criteria None
None All patients None None None
QC
Injections for demonstration purposes only Restrictions for influenza vaccine based on age and other risk factors ≥5 years old ≥5 years old Influenza vaccine: ≥5 years old; other vaccines: ≥18 years old
None
None
None
≥5 years old
Patients must meet certain criteria
None
None
≥5 years old No injection authority for drugs ≥5 years old
All patients All patients Patients must meet certain criteria
None None None
None None None
NB
NL NS PEI
AB, Alberta; BC, British Columbia; MB, Manitoba; NB, New Brunswick; NL, Newfoundland and Labrador; NS, Nova Scotia; ON, Ontario; PEI, Prince Edward Island; QC, Quebec; SK, Saskatchewan.
grown to include the ability to order and, to some extent, interpret certain laboratory tests in Alberta and Quebec (Table 1). Legislation to allow this activity is pending in Saskatchewan, Prince Edward Island, Manitoba, New Brunswick and Nova Scotia. The additional training required and the types of laboratory tests that can be ordered by pharmacists differ among the provinces. For instance, in PEI, authorized pharmacists will be able to order laboratory tests for A1C levels and international normalized ratios only once they have been granted this authority. In many of the provinces where legislative or regulatory approval is pending, it is best to refer to the individual provinces to learn which activities will be allowed once approval has been granted.
Discussion Pharmacists’ core role remains ensuring that patients have optimal drug therapy by ascertaining that medications are appropriate for individual patients (i.e. indicated, effective, safe and manageable), but pharmacists’ roles and scope of practice have expanded in the past decade so they can better support the primary healthcare needs of Canadians. Diabetes is a multifaceted disease that requires management of blood glucose levels, vascular protection and other comorbidities, so people with diabetes commonly have complex medication regimens that involve being on an average of 6 medications (15,16). Pharmacists in almost all of the provinces have the ability to see all of the prescription medications a patient has been dispensed provincewide through some form of electronic health record, so they are able to prevent drug interactions and duplication of therapy as well as review individuals’ complete medication therapy for diabetes and comorbid conditions. Unfortunately, these prescription-tracking systems do not capture drug samples handed out in prescribers’ offices, drugs dispensed from another province or, for the most part, over-the-counter and herbal medications. This is the value of medication reviews, whereby pharmacists are expected to collect the best possible medication histories, which include all products taken (e.g. vitamins and herbal supplements), not just those available through the provincial databases. Medication reviews are opportunities for pharmacists to review patients’ medication use, resolve problems and create current medication lists. Although not every province has specific medication-review programs for people with diabetes, in many cases, these patients will still qualify. For example, elderly patients taking
5 medications for diabetes and vascular protection qualify for medication reviews in 8 of 10 provinces. Medication reviews have been shown to reduce drug-related problems, dosages and number of medications (17). Medication reviews alone do not directly improve clinical outcomes (17), but these medication lists allow patients to share more accurate histories and ask questions about their medications and medical conditions, and they allow the pharmacists to assess adherence. In turn, pharmacists are encouraged or required to share this information with other members of the health-care team. Allowing pharmacists to prescribe for continuity of therapy provides timely access to medications for people with diabetes, which is essential for the management of their condition. People with diabetes see their pharmacists more often than any other healthcare professional (18). It is not uncommon for people with diabetes to run out of metformin and not have an appointment with their primary care providers (i.e. physician or nurse practitioner) for another month. Pharmacists have the scope to renew the medication and subsequently notify the original prescriber of this action, thus saving both the patient and the prescriber time and energy and ensuring that the patient continues to receive the necessary medications. Additionally, this could decrease the burden of nonurgent visits to emergency departments for renewals of chronic medications when the primary care providers are unavailable. Appropriate monitoring of laboratory results is crucial in those with diabetes. With access to the laboratory results of such patients’ A1C and serum creatinine levels, pharmacists can more vigilantly monitor medication safety and efficacy in order to help identify when patients need team support. Access to laboratory data can help to ensure that medication dosages are correct in patients not achieving their blood glucose targets and whether there is impaired renal function; this helps to ensure that the correct medications are being used by the right people at the right times. Further, in provinces where it is allowed, some pharmacists may also be able to order certain laboratory tests, which could be of benefit if their patients are unable to see their physicians or nurse practitioners in a timely manner. Up-to-date vaccinations are an important part of the overall management plan for people with diabetes, who are at a higher risk for complications resulting from influenza and pneumococcal disease (19,20); hence, Diabetes Canada recommends these vaccinations in people with diabetes (21). Timely and convenient access to vaccination providers is an important factor in improving vaccination rates (22). Given the accessibility and convenience of community
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pharmacies, this is an important aspect of diabetes management that pharmacists can help to provide. For example, during the most recent influenza season, pharmacists in Saskatchewan administered almost 90,000 flu shots, representing approximately 36% of all of the flu shots administered in Saskatchewan (23). As is illustrated, the provincial variations in the services pharmacists can provide within their scope of practice are substantial. Even within provinces, services may vary from pharmacy to pharmacy. Current pharmacy regulations are enabling, and individual pharmacists may choose whether they wish to practice to the full scope of their practice. For example, some pharmacists may provide dozens of vaccinations a day, whereas others may not provide any. Hence, it is important for patients with diabetes and for pharmacists and other health-care providers to have open communication and be aware of the services that can be provided to help improve the overall health-care experience.
Conclusions Pharmacists in all of the Canadian provinces have seen an expanded scope of practice occur over the past decade, and this has provided an opportunity for greater collaboration and sharing of information with both patients and other health-care providers. Certainly, some of this expanded scope is directly advantageous for people living with diabetes, such as access to publicly funded medication reviews, vaccinations, renewal of prescriptions and access to laboratory results. As such, it is important for health-care providers and people alike to be aware of the services their pharmacists can and do provide so that they can find pharmacists who can support their diabetes management.
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