Background: Older adults hospitalized for major cardiovascular events may have reduced influenza vaccine effectiveness (VE) due to function immunosenescence, multimorbidity, frailty, and chronic medication use. Despite their high burden of cardiovascular disease (CVD), influenza VE has not been specifically evaluated in this population. We estimated influenza VE against laboratory-confirmed influenza infection among older adults hospitalized with cardiovascular conditions and assessed whether VE differed by sex or age. Methods: Using linked health administrative datasets in Ontario, Canada, we applied a test-negative design across six influenza seasons (2010−11 to 2015−16). Adults aged >65 years hospitalized within three days of an acute cardiovascular event (acute myocardial infarction, unstable angina) were included. Multivariable logistic regression models estimated the adjusted odds ratios (ORs) of vaccination among cases versus controls, adjusting for demographic and clinical covariates. VE was derived as (1 − OR) ×100%. Effect modification analysis by sex (male vs. female) and age (≤80 vs. >80 years) was conducted separately. Results: Among 1,159 patients, 50% were vaccinated,14% tested positive for influenza, while 20% of unvaccinated patients tested positive for influenza (p-value 0.013). Adjusted VE was 43% [95% CI, 20% 60%]. No effect modification was observed. Conclusion: Influenza vaccination provided moderate protection comparable to the general population, supporting its use in high-risk older adults hospitalized for cardiovascular events.

Although some studies examined long-term survival following an opioid nonfatal overdose, none assessed whether survival after a nonfatal overdose is linked to socioeconomic status (SES). The objective of this study was to investigate survival rates after opioid-related hospitalizations and the relationship between SES and survival. We used national hospitalization data linked to mortality data to follow patients discharged alive after opioid-related hospitalization in Canada (except Québec) from April 1, 2001, to December 31, 2011, for a minimum of 1 year. SES was measured by quintile of median household income of patient’s area of residence at the Forward Sortation Area. The primary outcome was all-cause mortality, while the secondary outcome was opioid-related mortality, with other causes as a competing risk. Cox proportional hazard models assessed the association between SES and survival, adjusting for age, sex, and comorbidities. Among 49,890 patients, more than 30

Background:International pharmacy graduates (IPGs) are underrepresented in Canadian hospitals. It has been speculated that structural factors, particularly limited access to residency programs, may contribute to IPGs' disproportionate streaming toward community pharmacy practice. Objectives:To review the criteria of accredited hospital pharmacy residency programs in Canada to determine whether IPGs are eligible to apply, to examine the extent of IPGs' participation and success in securing hospital pharmacy residency positions, and to determine the factors that influence success in the matching process. Methods:A policy scan of accredited residency programs that participate in the Canadian Pharmacy Residency Board matching program was conducted in September 2023. In addition, a descriptive cross-sectional study was performed using available application data from the Pharmacy Residency Application and Matching Service in Canada for the 2022/23 matching cycle (January 2023 match). Results:Of the 40 participating residency programs, 7 (17.5%) required graduation from a North American-accredited institution, whereas the others accepted candidates with eligibility for licensure in any Canadian province. Only one program explicitly mentioned and encouraged IPGs to apply. In the matching data, only 19 (6.2%) of 308 applicants were IPGs, of whom 3 (16%) were successfully matched to a program, whereas 131 (45.3%) of 289 domestic graduates were matched. There was a significant association between country of graduation and residency matching, with lower odds of matching for IPGs (adjusted odds ratio 0.230, 95% confidence interval 0.063-0.845). Conclusion:These results show that IPGs are substantially underrepresented in the residency application and matching processes and provides insights into potential systemic barriers that need to be addressed by policy-makers and stakeholders.

PURPOSE:Limited evidence suggests donepezil might pose an increased risk of malignant arrhythmias. We examined whether donepezil initiation was associated with a higher risk of hospitalization for malignant arrhythmia compared to other acetylcholinesterase inhibitors. METHODS:Population-based cohort study using linked administrative databases from seven Canadian provinces (BC, AB, SK, MB, ON, PEI, NL). We included individuals aged ≥ 66 who were new users of donepezil, galantamine, or rivastigmine from April 1st, 2011, to January 31st, 2019. We used multivariable Cox proportional hazards regression to estimate the risk of hospitalization for malignant arrhythmia among new donepezil users compared to new users of galantamine or rivastigmine. RESULTS:We identified 162 616 subjects (mean age 82, 40% male). Most (127 103; 78%) were treated with donepezil, while 25 597 (15.7%) received galantamine, (n = 6541; 4.0%) received oral rivastigmine, and (n = 3375; 2.1%) received transdermal rivastigmine. The median age was 82 years, and 59.8% were women. Baseline characteristics were generally well balanced. During a median follow-up of 386 days (maximum 2616 days), we identified 90 hospitalizations for malignant arrhythmias, including 58 in the donepezil group (23 per 100 000 person-years) and 32 for other AChEIs (44 per 100 000 person-years). Cumulative incidence curves showed a lower risk among donepezil initiators (Log-Rank p = 0.0026; Wilcoxon p = 0.0008). Crude regression suggested a reduced hazard (HR 0.52; 95% CI 0.34-0.80), which persisted after adjustment (aHR 0.55; 95% CI 0.36-0.85). In drug-specific analyses, donepezil initiators had a lower hazard relative to galantamine (aHR 0.49; 95% CI 0.31-0.77) but not rivastigmine (aHR 0.90; 95% CI 0.36-2.27). Sensitivity analyses-including alternative diagnosis field definitions, restricted follow-up, modified exclusion criteria, and propensity score adjustment-yielded consistent findings. No clear dose-response pattern was observed for any AChEI. CONCLUSION:In this population-based cohort study, initiation of donepezil was not associated with an increased risk of malignant arrhythmias compared to initiation of galantamine or rivastigmine.

INTRODUCTION:Even with modern prophylaxis options, people living with haemophilia have significantly lower quality of life and joint health outcomes than those without. AIM:Our goal was to determine if real-world health-system costs are higher for people living with haemophilia A compared to those without and determine how joint-health state impacts this cost. METHODS:We utilized a population-level, retrospective study design using health administrative data to determine the impact of sex and joint-health states on cross-sectional cost. Cases were identified using diagnostic codes. Joint health states were determined in 30-day intervals by stepping forward and backward from joint replacement surgeries. Control groups were established through propensity score matching, aligning participants based on demographic, economic and health-related variables. Direct 30-day medical costs were generated in 2022 CAD. The impact of sex and disease health phases on direct healthcare system costs was analyzed through a two-part regression model. RESULTS:2341 eligible individuals with haemophilia A were identified. 26% were female. In pre-severe joint damage, mean 30-day costs were higher for patients with haemophilia A-$910 (standard deviation SD: $4069) for females and $724 (SD: $3577) for males, compared to $469 (±$2126) and $352 (±$2188) for matched controls, respectively. The regression model showed that current joint health state, number of other comorbidities, haemophilia status and sex were important factors within healthcare system cost. CONCLUSIONS:The results of this study indicate that even with haemophilia treatment there remains an increased healthcare system cost for those with haemophilia A, regardless of sex.

Background Community pharmacies are highly accessed for vaccination and other injection services. The COVID-19 pandemic accelerated changes in work practices and in healthcare delivery, influencing patient preferences for timely and convenient care. Objective This research examines patient-level and organizational factors associated with the administration of injections at Canadian community pharmacies during hours where other primary care providers may not be available. Methods A cross-sectional retrospective analysis of appointments for injection services (vaccines and injectable medications) at community pharmacies through software from MedEssist or MedMe Health from January to December 2023 was performed. Appointments outside the hours of 9am to 5pm on weekdays, on weekends, or on federal or statutory holidays were considered to fall during ‘off-clinic’ hours when other health care settings where injections are provided may not be available. A multivariable logistic regression was performed to identify patient, pharmacy, community, or product factors associated with scheduling appointments during ‘off-clinic’ hours. Results Of 1,226,903 appointments scheduled, 27.0% were during off-clinic hours, ranging from 9.1% among banner or independent pharmacies to 34.0% among chain pharmacies. Scheduling of appointments during ‘off-clinic’ hours was positively associated with younger age (OR 1.74, 95%CI 1.69, 1.79 for age < 18 years vs. 18-49) and male gender (OR 1.05, 95%CI 1.03, 1.07 vs. female) and negatively associated with rural pharmacy location (OR 0.77, 95%CI 0.75, 0.80). Conclusion Community pharmacies often provide care over extended hours, offering convenience and accessibility that can support vaccine uptake and injectable medication adherence. Younger patient age, male gender, and urban pharmacy location are associated with greater use of appointments outside of typical business hours.

Previous research in Canada has examined opioids prescription dispensing at the population level but did not examine the potential relationship with area-level income and rates of opioid dispensing. The aim was to estimate average and annual opioid dispensing rate ratios (RRs) between lowest and highest income quintile geographic areas in Canada. We performed a population-based retrospective study using the National Prescription Drug Utilization Information System (NPDUIS) between 2010 and 2018 that contains prescription records for all public drug plan beneficiaries (65+) in all Canadian provinces, excluding Quebec, Nova Scotia, and New Brunswick. We used census median household income, calculated at the Forward Sortation Area (FSA—the first three letters of the postal code) to assign income quintiles. Morphine milligram equivalent (MME) was calculated for all opioid dispensing and was divided by population of the FSA quintile. Population census year 2016 was used for population and income estimations. We calculated the average and annual RR between lowest and highest quintiles and stratified them by patients’ sex. The significance of the trend of annual RR was tested by linear regression. The average MME per capita for the 65+ population ranged from 2321.8 in quintile 1 to 5831.9 in quintile 5. The RR between highest and lowest quintile was 2.5 (95

Background Estimating the cost of providing healthcare services for minor ailments (MA) is essential to address the impact of newly legislated pharmacist prescribing on the burden these conditions place on healthcare budgets. Objectives This study aims to quantify the healthcare costs associated with minor ailment management in Ontario, describe patient characteristics by cost burden, and identify predictors of high-cost encounters. Methods This study employed a population-based retrospective cohort design, utilizing linked health administrative data from 2011 to 2019. The cost of care, in 2019 Canadian dollars, for up to 30 days after seeing a physician for MA was estimated from the perspective of a public payer. It included expenses from inpatient or physician visits, prescribed medication and emergency department visits. A gamma regression model with a logarithmic link was used to evaluate the impact of age, sex, income, residence, and a history of comorbidities on total cost. Results Over 34 million cases of MA were identified during the study period, with musculoskeletal sprains and strains accounting for 23.7% of these cases. This ailment was also the costliest ($15.8 billion). Inpatient and physician care were the most expensive services. Higher costs were associated with older population groups, males, individuals with lower incomes, those living in urban spaces, and those with comorbidities. Conclusion Hospital and physician-based care pose a substantial financial burden to the Ontario government. An understanding of how the determinants of cost and care pathways influence health budgets is essential to inform decisions on more efficient yet equally effective strategies, such as pharmacist prescribing for MA.

Community pharmacies are largely recognized as geographically accessible; yet concerns arise regarding inequitable access to COVID-19 vaccination, especially during early vaccine availability. 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. 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. Of 15,174 pharmacies identified, 92.9

INTRODUCTION:Haemophilia A negatively affects a patient's quality of life. There is a limited amount of health utility data (a measure of health-related quality of life) available for patients with haemophilia A. This information is crucial for cost-effectiveness analysis for haemophilia A treatment.OBJECTIVES:The goal of this project is to elicit the health utilities and factors impacting utility values for haemophilia A patients in Canada.METHODS:This is a population-based, cross-sectional, retrospective study of health utilities in patients with haemophilia A using Patient Report Outcomes Burdens and Experiences (PROBE) components from the Canadian Bleeding Disorders Registry (CBDR). A review of the mean utilities for three severity states, defined by clotting factor VIII level, was completed. A multiple linear regression analysis was completed to examine the determinants of health utilities including age, treatment type, chronic pain status, number of limited joints, and bleed rate.RESULTS:The average utility values (and standard deviations) for patients with haemophilia A in Canada are .79(.17), .76(.20), and .77(.19) for patients with severe, moderate, and mild haemophilia. The regression showed chronic pain status and the number of additional comorbidities as major significant factors (p-value < .001) in haemophilia A utility. Haemophilia severity was shown to be a major factor with smaller p-value (p-value < .05).CONCLUSIONS:Haemophilia A patients have lower utility than the general population. Chronic pain was shown to be a significant, major factor in health-related quality of life. Our study is essential for valuing health outcomes in haemophilia A-related cost-effectiveness analysis.

Objective: This study examined whether there is an association between opioid-related mortality and surgical procedures. Methods: A case-control study design using deceased controls compared individuals with and without opioid death and their exposure to common surgeries in the preceding 4 years. This population-based study used linked death and hospitalization databases in Canada (excluding Quebec) from January 01, 2008 to December 31, 2017. Cases of opioid death were identified and matched to 5 controls who died of other causes by age (±4 years), sex, province of death, and date of death (±1 year). Patients with HIV infection and alcohol-related deaths were excluded from the control group. Logistic regression was used to determine if there was an association between having surgery and death from an opioid-related cause by estimating the crude and adjusted odds ratios (ORs) with the corresponding 95% confidence interval (CI). Covariates included sociodemographic characteristics, comorbidities, and the number of days of hospitalization in the previous 4 years. Results: We identified 11,865 cases and matched them with 59,345 controls. About 11.2% of cases and 12.5% of controls had surgery in the 4 years before their death, corresponding to a crude OR of 0.89 (95% CI: 0.83–0.94). After adjustment, opioid mortality was associated with surgical procedure with OR of 1.26 (95% CI: 1.17–1.36). Conclusions: After adjusting for comorbidities, patients with opioid mortality were more likely to undergo surgical intervention within 4 years before their death. Clinicians should enhance screening for opioid use and risk factors when considering postoperative opioid prescribing.

Background:It is hypothesized that international pharmacy graduates (IPGs) are underrepresented in more clinically challenging work.Objective:To examine the association between country of qualifying education for pharmacists in Ontario and the likelihood of practising in a hospital setting.Methods:This study was based on publicly available data from the Ontario College of Pharmacists website, specifically records for all Ontario pharmacists with authorization to provide patient care and for whom country of qualifying education and an accredited pharmacy as a place of practice were reported. Pharmacists who met the inclusion criteria were categorized as Canadian graduates or IPGs. The odds ratio (OR) and 95% confidence interval (CI) for reporting hospital pharmacy as a place of practice were estimated by fitting a logistic regression, with adjustment for gender and years since graduation.Results:A total of 14 689 pharmacists were included in the study: 7403 (50.4%) Canadian graduates and 7286 (49.6%) IPGs. These pharmacists worked in a total of 5028 accredited pharmacies (243 hospital pharmacies [4.8%] and 4785 community pharmacies [95.2%]). Among Canadian graduates, 2458 (33.2%) reported at least 1 hospital pharmacy practice site, whereas the proportion was much smaller among IPGs (427, 5.9%). Canadian graduates represented 85.2% (2458/2885) of all pharmacists who reported hospital practice. The estimated crude OR for practice in a hospital pharmacy was 7.98 (95% CI 7.16-8.91), and the adjusted OR was 7.12 (95% CI 6.39-7.98).Conclusions:IPGs may face barriers impeding their ability to practise in a hospital setting. Providing opportunities such as structured clinical training and experiential placements may facilitate integration of IPGs in institutional settings.

Background and Objective The World Health Organization recommends a universal hepatitis B vaccination within the first 24 h of birth. However, hepatitis B vaccines are given during adolescence in many jurisdictions including in Ontario, Canada. The objective of this study was to assess the cost effectiveness of shifting the hepatitis B vaccination timing from adolescence to birth. Methods A state-transition model of 18 health states representing the natural history of acute and chronic hepatitis B was developed to conduct a cost-utility analysis. Most input parameters were obtained from the Canadian literature or publicly available provincial data. The model followed a lifetime model time horizon with health outcomes and costs being discounted at 1.5% annually. Deterministic and probabilistic sensitivity analyses were performed to test the robustness of the model. Analyses were conducted from a public-payer perspective with all costs adjusted to 2021 Canadian dollars. Results Hepatitis B vaccination in newborns dominated the current strategy of adolescent vaccination. The probabilistic analysis showed that the newborn strategy was cost effective in 100% of the iterations at a willingness-to-pay threshold of $50,000/quality-adjusted life-year and cost saving in 79.39% of the iterations. A microsimulation projected that a newborn vaccination may lead to reductions in cases by 16.1% in acute hepatitis B, 43.2% in chronic hepatitis B, 48.2% in hepatocellular carcinoma, and 51.9% in hepatitis B liver-related death. Conclusions Our analysis suggests that changing the age of the hepatitis B vaccination recommendation from adolescent to newborn is cost effective and mostly a cost-saving strategy. Newborn vaccination may lead to cost and health benefits while aligning with best available evidence and guidance from the World Health Organization.

Introduction: Annual influenza vaccination is recommended for individuals with a history of cardiovascular disease (CVD) events. We aimed to examine (1) the time trends for influenza vaccination among Canadians with a CVD event history between 2009 and 2018, and (2) the determinants of receiving the vaccination in this population over the same period. Methods: We used data from the Canadian Community Health Survey (CCHS). The study sample included respondents from 2009 to 2018 who were 30 years of age or more with a CVD event (heart attack or stroke) and who indicated their flu vaccination status. Weighted analysis was used to determine the trend of vaccination rate. We used linear regression analysis to examine the trend and multivariate logistic regression analysis to examine determinants of influenza vaccination, including sociodemographic factors, clinical characteristics, health behaviour and health system variables. Results: Over the study period, in our sample of 42 400, the influenza vaccination rate was overall stable around 58.9%. Several determinants for vaccination were identified, including older age (adjusted odds ratio [aOR] = 4.28; 95% confidence interval [95% CI]: 4.24-4.32], having a regular health care provider (aOR = 2.39; 95% CI: 2.37-2.41), and being a nonsmoker (aOR = 1.48; 95% CI: 1.47-1.49). Factors associated with decreased likelihood of vaccination included working full time (aOR = 0.72; 95% CI: 0.72-0.72). Conclusion: Influenza vaccination is still at less than the recommended level in patients with CVD. Future research should consider the impact of interventions to improve vaccination uptake in this population.

IntroductionLa vaccination annuelle contre la grippe est recommandée aux personnes ayant des antécédents de maladie cardiovasculaire. Nous avons étudié 1) l’évolution de la vaccination antigrippale entre 2009 et 2018 chez les Canadiens ayant été victimes d’une maladie cardiovasculaire et 2) les déterminants de la vaccination dans cette population au cours de la période. MethodsNous avons utilisé des données de l’Enquête sur la santé dans les collectivités canadiennes (ESCC). L’échantillon à l’étude était constitué de répondants de 2009 à 2018, âgés de 30 ans et plus, ayant été victimes d’une maladie cardiovasculaire (infarctus du myocarde ou accident vasculaire cérébral) et ayant fourni leur statut vaccinal contre la grippe. Une analyse pondérée a été effectuée pour déterminer l’évolution du taux de vaccination. Nous avons utilisé une analyse de régression linéaire pour l’évolution et une analyse de régression logistique à plusieurs variables pour les déterminants de la vaccination antigrippale. Les variables choisies étaient des facteurs sociodémographiques, des caractéristiques cliniques, des comportements liés à la santé et les interactions avec le système de santé. ResultsDurant la période à l’étude, le taux de vaccination a été généralement stable dans notre échantillon de 42 000 sujets, se situant aux alentours de 58,9 %. Plusieurs déterminants de la vaccination ont été établis : un âge avancé (rapport de cotes ajusté [RCA] = 4,28; intervalle de confiance à 95 % [IC à 95 %] : 4,24 à 4,32], un accès régulier à un professionnel de la santé (RCA = 2,39; IC à 95 % : 2,37 à 2,41) et le fait de ne pas fumer (RCA = 1,48; IC à 95 % : 1,47 à 1,49). Le seul facteur associé à une diminution de la probabilité de vaccination était le travail à temps plein (RCA = 0,72; IC à 95 % : 0,72 à 0,72). ConclusionLe taux de vaccination antigrippale reste inférieur au niveau recommandé pour les patients ayant des antécédents de maladie cardiovasculaire. D’autres recherches sont à mener sur l’efficacité des interventions pour augmenter la vaccination dans cette population.

Background: Due to workload and competing priorities, vaccination-related interactions in community pharmacies tend to be more reactive than proactive. The aim of this study is to determine the proportion of users of a web-based scheduling system for influenza and COVID-19 vaccines who may be eligible for herpes zoster or human papillomavirus (HPV) vaccination and interested in discussing these vaccines with a pharmacist. Methods: Individuals scheduling an influenza or COVID-19 vaccine at a pharmacy using the MedEssist platform between October 2021 and March 2022 were asked about their vaccination status against HPV (if aged 9-45) or herpes zoster (if aged ≥50). Those who were unvaccinated or unsure were asked to indicate their willingness to discuss this with a pharmacist. Logistic regression was performed to identify patient characteristics associated with responses to these screening questions. Results: Among 36,659 bookings by those aged 9 to 45 and 55,728 by those aged ≥50 that included responses to screening questions, 70.1% and 55.5% were potentially unvaccinated against HPV and herpes zoster, respectively, with approximately 1 in 5 also indicating willingness to have a discussion with the pharmacist. Those scheduling appointments for COVID-19 vaccines were significantly less likely to be vaccinated against HPV or herpes zoster and less willing to discuss this with a pharmacist than those seeking influenza vaccination. Discussion: Automated prompts while booking influenza or COVID-19 vaccinations have the potential to identify vaccine-willing individuals who may benefit from further discussion on their vaccination needs. Conclusion: Community pharmacies can leverage available technology to support the efficient and effective identification of individuals eligible for vaccination.

AimsTo assess post-initiation predictors of discontinuation of sodium-glucose cotransporter-2 (SGLT2) inhibitors compared to dipeptidyl-peptidase-4 (DPP-4) inhibitors in the United Kingdom.Materials and MethodsWe conducted a comparative population-based retrospective cohort study using primary care data from the UK Clinical Practice Research Datalink (CPRD) with linked data to hospital and death records. We included new metformin users who initiated either SGLT2 inhibitors or DPP-4 inhibitors between January 2013 and October 2019. The main outcome was treatment discontinuation, defined as the first 90-day gap after the estimated treatment end date. We used a series of extended Cox models to assess which time-dependent predictors were associated with treatment discontinuation. To test if the hazard ratio of discontinuation for each predictor was statistically different between SGLT2 and DPP-4 inhibitors, an exposure-predictor interaction term was added to each model.ResultsThere were 2550 new users of SGLT2 inhibitors and 8195 new users of DPP-4 inhibitors. Approximately 69% of SGLT2 inhibitor and 74% of DPP-4 inhibitor users had discontinued treatment by the end of follow-up. Occurrence of fractures after treatment initiation was a significant predictor of discontinuation of SGLT2 inhibitors (hazard ratio [HR] 4.13, 95% confidence interval [CI] 2.12-8.06) but not DPP-4 inhibitors (HR 0.93, 95% CI 0.79-1.11). The rate of treatment discontinuation was significantly higher for those with low estimated glomerular filtration rate and minimal contact with the healthcare system. Efficacy endpoints, such as heart failure and glycated haemoglobin level, were not associated with treatment discontinuation.ConclusionsOur findings reflect some discrepancy between the available evidence and prescribing behaviour for SGLT2 inhibitors.

Introduction In 2019, the Ontario government announced that it will introduce a “minor ailments” (referred to in this article as “ambulatory conditions”) management program for pharmacists. Currently, the Ontario Ministry of Health and the Ontario College of Pharmacists are establishing the scope parameters for this program, including eligible conditions and therapeutic options, with remuneration also yet to be established. In previous work by our group, the rate of avoidable emergency department (ED) visits that can potentially be managed by pharmacists with the ability to treat ambulatory conditions in Ontario was estimated using administrative databases. Overall, it was found that more than one-third (34.8%) of avoidable visits could potentially be managed by a pharmacist, representing almost 4.3% of all ED visits. Pharmacists are considered to be highly accessible primary health care providers in Canada, and most Canadians live close to a community pharmacy. This accessibility, coupled with pharmacists practising to full scope, enables them to offer timely clinical services to patients, particularly those who may have significant barriers preventing them from accessing other health care services appropriately, such as low-income populations. However, research in both the United States and Canada has identified that the availability of pharmacy services may be associated with an area’s socioeconomic status. For example, a 2018 study identified geographic disparities in the accessibility of pharmacies in the Greater Toronto Area, and research by our group has also identified that pharmacists in Alberta with additional prescribing authorization are more concentrated in high-income areas. It is currently unknown whether similar disparities exist related to the future management of ambulatory conditions by pharmacists in Ontario. The aim of this study is to determine the spatial pattern of potentially pharmacist-manageable avoidable ED visits in Ontario and to identify whether an association exists between the rate of potentially pharmacist-manageable ED visits for ambulatory conditions and a community’s characteristics, including income level and community pharmacy and other primary care provider availability.

Aim To assess the association between SGLT-2 inhibitors initiation and genital tract infections (GTIs) among patients with type 2 diabetes. Methods A population-based cohort study using administrative healthcare data from Alberta, Canada, and primary care data from the UK's Clinical Practice Research Datalink (CPRD). Among new metformin users, we identified new users of SGLT-2 inhibitors and five active comparator cohorts (new users of dipeptidyl peptidase-4 (DPP-4) inhibitors, sulfonylureas (SU), glucagon-like peptide-1 receptor agonists (GLP-1 RA), thiazolidinediones (TZD) and insulin). The outcome of interest was a composite GTI outcome. In each cohort, we used high-dimensional propensity score matching to adjust for confounding and conditional Cox proportional hazards regression to estimate the hazard ratios (HR). We used random-effects meta-analysis to combine aggregate data across databases. Results The risk of GTI was higher for SGLT-2 inhibitors users compared with DPP4inhibitor users (pooled HR 2.68, 95% CI 2.19 3.28), SU users (3.29, 2.62-4.13), GLP1-RA users (2.51, 1.90-3.31), TZD users (4.17, 2.46-7.08) and insulin users (1.86, 1.27-2.73). Conclusion In five comparative cohorts, SGLT-2 inhibitors initiation is associated with a higher risk of GTIs. These findings from real-world data are consistent with placebo-controlled randomized controlled trials.

Objectives: Sodium-glucose cotransporter-2 (SGLT2) inhibitor-induced glycosuria is hypothesized to increase the risk of urinary tract infections (UTIs). We assessed the risk of UTIs associated with SGLT2 inhibitor initiation in type 2 diabetes. Methods: We conducted a population-based cohort study using primary care data from the United Kingdom's Clinical Practice Research Datalink (CPRD) and administrative health-care data from Alberta, Canada. From a base cohort of new metformin users, we constructed 5 comparative cohorts, wherein the exposure contrast was defined as new use of SGLT2 inhibitors or 1 of 5 active comparators: dipeptidylpeptidase-4 (DPP-4) inhibitors, sulfonylureas (SU), glucagon-like peptide-1 receptor agonists (GLP-1 RA), thiazolidinediones (TZD) and insulin. We defined a composite UTI outcome based on hospitalizations or physician visit records. For each comparative cohort, we used high-dimensional propensity score matching to adjust for confounding and Cox proportional hazards regression to estimate the hazard ratios (HRs) in each database. We meta-analyzed estimates using a random-effects model. Results: SGLT2 inhibitor use was not associated with a higher risk of UTI compared with DPP-4 inhibitors (pooled HR, 1.08; 95% confidence interval [CI], 0.89 to 1.30), SU (pooled HR, 1.08; 95% CI, 0.90 to 1.30), GLP-1 RA (pooled HR, 0.81; 95% CI, 0.61 to 1.09) or TZD (pooled HR, 0.81; 95% CI, 0.55 to 1.19). The risk of UTI was lower compared with insulin (pooled HR, 0.74; 95% CI, 0.63 to 0.87). The risk of UTI did not differ based on the SGLT2 inhibitor agent or dose. Last, SGLT2 inhibitor initiation was not associated with an increased risk of UTI recurrence. Conclusion: SGLT2 inhibitor use is not associated with an increased risk of UTIs, compared with other antidiabetic agents. (C) 2022 The Author(s). Published on behalf of the Canadian Diabetes Association.