Sherilyn K. D. Houle

In Ontario, Canada, pharmacists and pharmacy technicians who have completed an approved injection training program are authorized to administer vaccines against 16 vaccine-preventable diseases, with other vaccines requiring an order from a physician or nurse practitioner authorizing their administration to a patient. Authorization to administer vaccines is separate from authorization to dispense vaccines. Some of these vaccines can be dispensed without a prescription, while others require a prescription for the pharmacist to be able to dispense the vaccine and/or to be able to bill the cost of the vaccine to a private insurance plan. Currently, Ontario pharmacists do not have authorization to prescribe any vaccines, whether it be for dispensing or insurance billing purposes. This article describes current practice in Ontario related to vaccine accessibility, summarizes vaccine-prescribing scope of practice adopted by other Canadian provinces and territories, and describes the potential benefits of expanding the pharmacist scope of practice in Ontario to include the prescribing of vaccines.

PURPOSE: To develop evidence-based ambulatory oncology clinical pharmacy key performance indicators (AOcpKPIs). METHODS: A systematic, modified Delphi process was used to reach consensus on AOcpKPIs. Following an environmental scan of current oncology pharmacy practices across Canada, a literature review identified critical activities linked to patient-centered outcomes. A panel of oncology pharmacists engaged in three Delphi rounds and a virtual live meeting, assessing and refining candidate AOcpKPIs on the basis of predefined criteria. A total of 17 candidate AOcpKPIs were evaluated. RESULTS: Consensus was achieved on 14 AOcpKPIs. These AOcpKPIs reflect critical pharmacist activities including clinical order review, patient education, medication adherence assessment, and management of drug therapy problems. This suite of AOcpKPIs provides a standardized approach for evaluating oncology pharmacist activities in ambulatory care, facilitating benchmarking and supporting evidence-based improvements in patient outcomes. CONCLUSION: This study represents a significant advancement in defining quality metrics for ambulatory oncology pharmacy practice. The consensus-based AOcpKPIs provide a foundation for enhanced patient care, professional accountability, and continuous quality improvement within oncology pharmacy. Implementing these AOcpKPIs has the potential to elevate oncology pharmacy practice, supporting pharmacists in meeting evolving health care demands and fostering evidence-based patient outcomes.

Background: Penicillin allergy labels (PALs) affect about 10% of people, are mostly low risk, and more common in females. Sex-based differences in prevalence and characteristics remain unclear. This study examined associations between sex, PAL, and relevant covariates, in an Ontario ambulatory hospital population. Methods: A cross-sectional study of adults ( ≥18 years) seen at the hospital’s Urgent Medicine Clinic from 2015–2024 was conducted. Descriptive statistics compared patients by PAL status. Unadjusted and multivariable logistic regression models evaluated associations between sex and PAL, adjusting for covariates. Results: Among 29,645 patients (59.7% female), 3,026 (10.2%) had a documented beta-lactam allergy, of which 2,777 (9.4%) were PALs, and most (91.7%) were low risk. Females were twice as likely to have a PAL (11.6% vs 6.0%; unadjusted OR 2.17, 95% CI 2.14–2.19) and more often reported multiple medication allergies (30% vs 16%; OR 2.25, P < .05). After adjusting for covariates, female sex (OR 1.47, 95% CI 1.34–1.62), atopic conditions (OR 1.46, 95% CI 1.29–1.66), age ( >80 years [vs <65 years]: OR 1.16, 95% CI 1.02–1.32), and number of other medication allergies (2: OR 10.44, 95% CI 9.28–11.74; ≥3: OR 13.33, 95% CI 11.72–15.16 vs 0 or 1) were associated with higher odds of PAL. Conclusion: Approximately 10% of patients had a PAL, mostly low risk and female predominant. Multivariable analysis identified female sex, atopy, older age, and multiple medication allergies as independent predictors; autoimmune and metabolic conditions were not. Longitudinal studies using validated allergy data and intersectionality can guide equitable evaluation.

Background: Community pharmacies are largely recognized as geographically accessible; yet concerns arise regarding inequitable access to COVID-19 vaccination, especially during early vaccine availability. Objectives: This study aims to investigate the geographic accessibility of community pharmacies offering COVID-19 vaccination in Ontario’s from April to December 2021 considering community-level rurality, material deprivation, and ethnic concentration. Methods: Data from the Ontario Ministry of Health website COVID-19 vaccination pharmacies between April 27, 2021 and December 20, 2021, were analyzed. Pharmacy addresses were geocoded using Environics Analytics Business Data and the Postal Code Conversion File (PCCF+). Material deprivation and ethnic concentration at the Dissemination Area (DA) level were based on Public Health Ontario’s marginalization data and organized into quintiles. Mean geographic accessibility was calculated for each quintile using the 2-Step Floating Catchment Area method using service areas of 1,000, 1,500, or 3,000 m for urban DAs and 10,000 m for rural DAs. Analysis of Variance (ANOVA) was used to compare mean geographic accessibility across eight selected dates reflecting vaccine eligibility and availability changes. Results: Of 15,174 pharmacies identified, 92.9% were successfully linked to geographic coordinates. Three eras of vaccine availability were identified: [1] Intermediate; [2] Scarcity (May 2021); and [3] Abundance (November and December 2021). During vaccine shortages, more deprived and ethnically concentrated urban areas had greater geographic accessibility than less deprived areas, while rural areas had no access. For example, during vaccine scarcity, urban DAs in the highest ethnic concentration quintile had an accessibility score of 6.55 compared to 0.18 in the lowest quintile. During other periods, more deprived urban areas either showed higher geographic accessibility or no significant difference compared to less deprived areas; however, rural deprived areas generally had lower geographic accessibility than urban areas. Conclusions: During COVID-19 vaccine scarcity or abundance, deprived and ethnically concentrated urban areas had similar or higher access compared to less deprived areas. However, rural deprived areas experienced lower geographic accessibility. Access to pharmacies can be enhanced in rural deprived areas by incentivization and outreach. Further research examining whether this geographic accessibility variance influenced vaccine uptake and infection rates.

Introduction: Growing evidence suggests that non-physician providers (NPPs) can effectively and safely manage warfarin therapy. This systematic review and meta-analysis aimed to evaluate warfarin management by NPPs compared to usual medical care (UMC) in ambulatory patients. Methods: We conducted a systematic search of PubMed (MEDLINE), Ovid Embase, Ovid International Pharmaceutical Abstracts, Scopus, CINAHL (EBSCO), and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to January 2024. Studies were included if they were randomized controlled trials or quasi-experimental designs comparing warfarin management across professions. Two independent reviewers performed title and abstract screening, full-text review, data extraction, and risk of bias assessment. Results were pooled using random effects models. Results: Of 19 122 citations identified, 6 met the inclusion criteria. NPPs included pharmacists (4), nurse practitioners (1), and multidisciplinary teams (1). Meta-analysis showed no significant difference in time spent in therapeutic range (TTR) (mean difference [MD] 1.64%; 95% confidence interval [CI]-1.86 to 5.16, I ² = 0%)) for NPPs vs UMC. There were no differences in thrombosis (relative risk [RR] 1.23; 95% CI 0.36 to 4.23, I ² = 0%), hemorrhage (RR = 1.07; 95% CI 0.44 to 2.63, I ² = 0%), mortality (RR = 0.94; 95% CI 0.33 to 2.67, I ² = 0%), or patient satisfaction (standardized mean difference [SMD] 0.56; 95% CI -0.04 to 1.15, I ² = 85%). Conclusion: NPP management resulted in similar TTR as UMC. Due to few thromboembolic and hemorrhagic events, more studies are needed to determine the effects of NPP warfarin management on clinical outcomes.

Background: Oral challenges with amoxicillin or other penicillins are safe and effective for delabeling low-risk penicillin allergy histories. While approximately 90% of reported penicillin allergies can be safely delabeled, detailed data on reaction frequency, types, and timing during and after delabeling interventions remain limited. Such data are crucial to optimizing protocols and integrating oral challenges into routine practice. This study aims to characterize the interventions commonly used for oral challenge, classify reported reactions, and identify reported predictors of hypersensitivity reactions in randomized controlled trials and quasi-experimental studies involving an oral challenge for patients with low-risk penicillin allergies. Methods: This study leverages data from a systematic review and meta-analysis assessing the effectiveness of oral challenge interventions in patients with low-risk penicillin allergies. This descriptive analysis summarizes the adverse reactions experienced among patients in published studies who received oral challenge. Participant demographics, intervention protocols, frequency, type, and timing of post-challenge adverse reactions are reported. Reactions are categorized as immediate, delayed, or other, with frequencies summarized using descriptive statistics. A random effects meta-analysis quantifies a pooled adverse reaction rate. Predictors of hypersensitivity reactions were synthesized narratively. Results: Across 26 studies (2 randomized trials, 24 quasi-experimental studies) evaluating an oral challenge for patients with a low-risk penicillin allergy, the average participant age was 56 years, with a predominance of females (61%) and limited ethnic diversity with 88% reported or identifying as White. Amoxicillin was the most frequenty used oral challenge agent, typically administered as a single 250 mg oral dose. The incidence of reaction or non-delabeling was 4% (95% Confidence Interval 3%, 6%), I ² = 43%, P = .0001. Cutaneous manifestations, such as rashes, were the most frequent reactions. Delayed reactions, primarily mild maculopapular rashes, were uncommon and managed with antihistamines or topical steroids. Risk factors for oral challenge reactions included higher baseline allergy burden and shorter intervals to oral challenge since the index reaction. Conclusion: Oral challenge strategies to delabel low-risk penicillin allergies can involve single doses of amoxicillin or other penicillins with monitoring protocols that can be managed in ambulatory settings. However, although these delabeling strategies are becoming more prevalent, continued study of standardized protocols and follow-up are essential for effective and replicable delabeling strategies. Future research should prioritize diverse populations and equity-driven frameworks to improve generalizability to all individuals and to resource limited settings.

Objective: This study aims to determine the value of including practical experiential learning in a continuing professional development (CPD) course primarily for pharmacists. The Management of Oral Anticoagulation Therapy (MOAT) course blends self-paced online learning with experiential training in an anticoagulation clinic under expert supervision. Methods: An email survey was sent to 186 graduates of MOAT in October 2017. Participants were asked to indicate their confidence in providing anticoagulation services on a seven-point Likert scale prior to taking MOAT, after completing the self-paced online module, and after the experiential component. They were also asked to identify the most important aspect of the course and describe their rationale for this selection. Results: 125 surveys were completed for a response rate of 71.4%. Most respondents were pharmacists who had not completed advanced clinical training or a prior course in anticoagulation therapy management. Participants reported a progressive increase in their confidence in providing anticoagulation services from baseline (mean score, 2.9), after completing the online component (mean score, 5), and after the experiential training (mean score, 6.2) (p < 0.001 for all comparisons). Ninety percent of participants indicated the experiential component was the most important aspect of MOAT, reporting this best prepared them to translate their learning to professional practice in anticoagulation. Conclusions: The experiential component of a blended-learning CPD course in anticoagulation management was a highly valued complement to online case-based learning.