The Ontario Pharmacy Evidence Network Atlas of MedsCheck services

Introduction

Medication-related problems are a significant contributor to morbidity, mortality and health care resource utilization in Canada and globally.^{1 -5} Medication reviews are 1 proposed strategy to help reduce preventable adverse drug events and hospital admissions. ⁶ A medication review consists of a structured, critical examination of a patient’s medications and aims to provide education, improve medication adherence, resolve drug therapy problems and optimize medication management. The ultimate goal is to yield better health outcomes for the patient. ⁷

While informal medication review is encompassed in the scope of practice for all pharmacists across Canada, government reimbursement for these services is not universal. Ontario was the first province to compensate community pharmacies for medication reviews, introducing the MedsCheck program in 2007 and expanding to include patients with diabetes, home-bound patients and residents of long-term care homes in 2010. ⁸ Although the terminology and eligibility of programs vary, 8 provinces reimburse pharmacies for providing medication review services. Please refer to Table 1 in brief and Appendix 1 (available in the online version of the article) for a detailed summary of publicly funded fee-for-service medication review services across Canadian provinces and territories. The purpose of this research brief is to introduce the Ontario Pharmacy Evidence Network (OPEN) Atlas of MedsCheck services and describe changes in the delivery of publicly funded medication review (MedsCheck) services over time in Ontario. Broader considerations across Canada for medication review services are included in the Discussion section.

Table 1.

Summary of publicly funded medication review services across Canada^*

Province/territory	Program start date	Publicly reimbursed medication review program available	All beneficiaries eligible	Medication review programs
				Community	Long-term care	Diabetes	Home
British Columbia	2011/04	✓	✓	✓*	✗	✗	✗
Alberta	2012/07	✓	✓	✓*	✗	✗	✗
Saskatchewan	2013/07	✓	✰	✓*	✗	✗	✓*
Manitoba	n/a	✗	✗	✗	✗	✗	✗
Ontario	2007/04	✓	✓	✓*	✓*	✓*	✓
Quebec	n/a	✗	✗	✗	✗	✗	✗
New Brunswick	2012/06	✓	✰	✓	✗	✗	✗
Prince Edward Island	2013/04	✓	✰	✓*	✗	✓*	✗
Nova Scotia	2008/04	✓	✰	✓*	✗	✗	✗
Newfoundland and Labrador	2012/09	✓	✓	✓	✗	✗	✗
Yukon	n/a	✗	✗	✗	✗	✗	✗
Northwest Territories	n/a	✗	✗	✗	✗	✗	✗
Nunavut	n/a	✗	✗	✗	✗	✗	✗

^*Follow-up service available. n/a = Yukon, Northwest Territories and Nunavut do not currently reimburse for pharmacy medication review services with a professional service fee. A check mark indicates covered. Ontario MedsCheck long-term care service-fee code was delisted effective January 1, 2020, under a capitation model that includes medication annual and quarterly review services ²¹ ; thus, coverage continues yet dates are no longer identifiable. The star symbol indicates that only specific beneficiaries were covered; refer to the details given in Appendix 1. X indicates not reimbursed under the public plan.

Methods

A description of the technical methods for the development of the OPEN Atlas of Professional Pharmacy Services Tool has been previously published. ⁹ MedsCheck services are reimbursed on a fee-for-service model through product identification numbers submitted by pharmacies to the Ontario Drug Benefit Program. The MedsCheck Atlas includes a suite of interactive tools, 1 for each type of the 4 MedsCheck service programs: 1) the original MedsCheck Annual, 2) MedsCheck Diabetes, 3) MedsCheck Home and 4) MedsCheck Long-Term Care.^{8 -10} We created cohorts for each MedsCheck service based on date of first service submitted to the Ontario Drug Benefit Program, through to the end of December 2019. Patient age, sex and postal code were obtained from the Registered Persons Database. These data sets were linked using unique encoded identifiers and analyzed at ICES. Patients who were missing age or sex or who had a recorded death date before the first service were excluded. In addition, pediatric patients (age <18 years) were excluded from MedsCheck Long-Term Care, because only adults are eligible residents of long-term care homes in Ontario. ¹¹ Patients with a missing postal code were excluded from regional analyses. Duplicate claims for the same patient and service month-year were excluded. In this brief, we report the monthly number of services plotted by type of MedsCheck service and summarize descriptive statistics (mean, standard deviation, median, lower quartile, upper quartile) for age by sex. Readers are encouraged to consult the OPEN Atlas Tool for histograms with numbers of claims, histograms of age distributions by sex at the time of first service delivery and maps of standardized rates that are interactive by calendar year and region defined by the Ontario-based Local Health Integration Network system. ¹⁰

Results

A total of 7,753,130 MedsCheck Annual services were delivered to 2,804,559 Ontarians from program launch in April 2007 through to the end of December 2019. Expansion of the medication review program in September 2010 resulted in the delivery of 1,858,805 MedsCheck Diabetes services to 704,026 patients, 229,001 MedsCheck Home services to 146,081 patients and 2,456,667 MedsCheck Long-term Care services to 281,777 residents. MedsCheck services delivered in the community pharmacy (MedsCheck Annual and MedsCheck Diabetes) and patients’ home (MedsCheck Home) demonstrated rapid initial uptake and a steady increase through to 2013, after which monthly service delivery remained relatively stable until October 2016 (Figure 1A-C). As noted previously, ⁸ abrupt policy changes effective October 2016 that added documentation and training requirements resulted in an immediate drop in service delivery. The Atlas Tool includes data through to the end of December 2019, providing evidence that the number of services have yet to recover to previous levels 3 years after the initial policy change in October 2016. Of interest and previously reported, ⁸ there was little change in MedsCheck service delivery in long-term care following the 2016 policy changes (Figure 1D). The recommendation to conduct regular medication review for all long-term care residents in Ontario, ¹² combined with established infrastructure, may largely explain the consistency and resilience of MedsCheck delivery in long-term care.

Figure 1.

Monthly number of MedsCheck services (A: Annual, B: Diabetes, C: Home, D: Long-term Care) delivered in Ontario

Patients receiving MedsCheck services in community pharmacies were on average 62 years of age and shared a similar pattern of age distribution, yet they were on average younger than patients of MedsChecks delivered in the home (mean age = 74.6 years) or in a long-term care facility (mean age = 82.5 years; Table 2). The difference in age distribution was expected, given the unique eligibility criteria for MedsCheck Home and MedsCheck Long-term Care, which capture more vulnerable populations.

Table 2.

Summary statistics of age distribution by sex and type of MedsCheck service, April 2007 to September 2019^*

Service type	Sex	N	Mean	SD	Median	Lower quartile	Upper quartile
Annual	Men	1,289,592	61.6	15.7	64	53	73
	Women	1,514,967	61.5	17.0	64	51	74
Diabetes	Men	382,733	61.9	13.3	63	53	71
	Women	321,293	62.2	14.4	64	53	72
Home	Men	53,936	71.2	18.0	76	61	85
	Women	92,145	76.6	15.1	81	70	87
Long-term Care	Men	96,753	80.0	11.4	82	75	88
	Women	185,024	83.8	10.0	86	80	90

^*Age was calculated based on the first service date of that type over the entire observation period. MedsCheck Annual services have been available since April 2007 and other services since September 2010.

Discussion

The OPEN Atlas of MedsCheck services includes a suite of interactive tools that enable the visualization of descriptive analyses for each publicly funded medication review pharmacy service in Ontario. The Atlas may be of particular value for understanding the uptake and planning for medication review services in Canada. Ontario was the first province in Canada to offer a publicly funded medication review program, with an expanded selection of services targeting different populations in need. In the community setting, all provinces except Quebec and Manitoba offer publicly funded medication reviews to residents meeting certain eligibility requirements, yet eligibility criteria and reimbursement schemes vary. Variation in service delivery across jurisdictions is not unique to Canada. ¹³ Indeed a recent call encourages pharmacies to unite at an international level to better standardize medication review services.^13,14

In 2019, the Canadian Agency for Drugs and Technologies in Health (CADTH) published its review of the clinical utility and cost-effectiveness of pharmacist-led medication reviews. ¹⁵ Examining 4 systematic reviews from across the globe, CADTH reported improvements in glycated hemoglobin (HbA1c) and blood pressure control. In addition, CADTH reviewed an economic evaluation conducted in Spain and found a net benefit to the national health system. However, it is worth noting that direct clinical evidence of medication review programs remains scarce. Studies of various quality report conflicting results.^{6,16 -20} Therefore, it is of high public interest to have more well-designed, rigorous studies to investigate the health outcomes and economic implications of pharmacist-led medication reviews. The data provided by the OPEN Atlas Tool, which leverages health care administrative databases and robust statistical analyses, provides a helpful basis for considering how to design future studies.

It will no longer be possible to monitor the extent of the medication review in Ontario long-term care homes, because the Ontario MedsCheck Long-term Care program was delisted effective January 1, 2020. A new fee-per-bed capitation model has been introduced in long-term care homes that replaces the old fee-for-service model. Under the fee-per-bed capitation model, medication reviews (annual and quarterly), pharmaceutical opinions and smoking cessation are included and thus can no longer be billed separately for patients who reside in long-term care. ²¹ Although we do not anticipate that medication reviews will cease in long-term care, we believe that an ability to track the time from entry into a long-term care facility before medication review is completed could shed some light on the quality of service delivery. Presumably, the earlier a medication review is performed, the better care a new patient is receiving. Similarly, how often regular quarterly medication reviews are completed will no longer be traceable yet is of interest as a marker of medication review service quality.

As evidenced by the OPEN Atlas, atlases of service utilization can be used to identify the susceptibility of publicly funded pharmacy services to policy change, such as the continued impact of the October 2016 changes to MedsCheck services. ⁸ More recently, the Ontario government declared a state of emergency on March 17, 2020, in response to the COVID-19 pandemic.^{22 -24} Emergency measures such as physical distancing have facilitated virtual pharmacy service delivery.^{25 -27} Better understanding of the impact of policy changes on the number and quality of professional pharmacy services is important. Community pharmacy provides a unique opportunity to provide primary care and initiate public health initiatives such as infectious disease testing (e.g., COVID-19) and vaccination programs.^28,29 The transformation of primary health care services prompted by the COVID-19 pandemic may help spearhead coordinated innovative primary health care solutions in community pharmacies. ¹⁴ The data provided by the OPEN Atlas of MedsCheck services demonstrate the widespread delivery of medication review services in Ontario that are susceptible to policy changes. Better integration of community pharmacy services into primary health care systems is encouraged. ■