Collaboration Across the Spectrum of Formularies in Saskatchewan: The RQHR Perspective Wm. Semchuk, MSc,PharmD,FCSHP Manager, Pharmacy Practice Regina Qu’Appelle Health Region April 13, 2015

2 Speaker Disclosure and Perspective –No relevant real or potential conflicts in relation to this presentation to disclose –Perspective provided as a member of the P and T Committee of the Regina Qu’Appelle Health Region, as well as a member of the Drug Advisory Committee of Saskatchewan

3 Health Authorities in Saskatchewan Provincially in Sask, 13 Health Regions, 5 provincial hospitals, 6 Regional Hospitals, 9 District Hospitals Formularies in Sask SPDP SCA Hospitals…. Limited collaboration

Decision Making Process within RQHR Formulary requests generated by physician or pharmacist Review and Recommendation Process Completed by a pharmacist with expertise within the therapeutic area Consultation and discussion with the requesting Medical Department is the norm CADTH review often but not universally considered Considerations include: Where the drug will be used: Only in hospital, predominantly in hospital, chronic oral conditions largely used in outpatient setting Provincial Formulary Coverage major consideration for chronic oral medications RQHR aligns with provincial coverage in the vast majority of cases 4

Hospital Only Drugs (Usually short term, high cost, ordered by Sub Specialists, eg. eltrombopag) Lack of clarity in alignment across the province for hospital only drugs Many of these agents do not go for CADTH review in a time frame that is consistent with requests for use Consideration is cost per patient per year Generally will require support by Medical Department, P and T and consideration by Senior Management Case by case review may occur and consideration of cost of hospitalization is important Often perceived as having a significant short term effect on patient outcome 5

6 Drugs Used Predominantly in the Hospital, eg. LMWH (dalteparin, enoxaparin, tinzaparin Generally align with provincial formulary criteria and coverage though formulary options may be more restrictive Principle reason for restriction is to ensure medication safety (agents that could create confusion) and contract opportunities Challenge exist as patients are transferred between health regions

Chronic Oral Medications Provincial Formulary Coverage major consideration for chronic oral medications: RQHR aligns with provincial coverage in the vast majority of cases RQHR formulary generally much more restricted than provincial formulary for oral medications carrying several products within a class rather than the entire class Consideration for a late entry into the class for RQHR addition is an estimated 10% market share or greater Rationale: Patient stabilization Patient’s experience and awareness Inventory Residents 7

8 Challenges that may Facilitate Enhanced Collaboration in the Future Transfer of patients between Regions Transfer of patients into and out of Tertiary Care Centers Tertiary Care Centers may send drug with patient as they are transferred out to Regional Sites Tertiary Care Centers may serve as resource to smaller regions

9 Example of Interregional/Provincial Collaboration Ticagrelor initially added to RQHR formulary approximately 6 months prior to provincial coverage –Rationale: approximate 1% reduction in absolute mortality for ACS patients –Concern: will use of agent in hospital, and lack of outpatient coverage lead to nonadherence? –Strategy: Initiate a local registry to assess outcomes When added to SPDP Formulary: Restrictive Coverage provided Provincial Cardiology Groups (RQHR and SDH) voice concern over limitations of coverage Provincial ACS working group struck Sept 2013 which included representatives from: –Interventional Cardiology – Regina and Saskatoon –Internal Medicine – Regina, Saskatoon, Yorkton, Prince Albert –CV Surgeons – Regina –Regina, Saskatoon Cardiology PharmDs

Example of Interregional/Provincial Collaboration ACS Working group provided clinical perspective related to the ACS data and the role of ticagrelor (and many other agents) ACS Working group reviewed data, results of ACS registry and discussed impact of different policies at tertiary care and regional levels ACS working group developed a provincial ACS order set Discussion with Ministry of Health occurred following completion of provincial ACS order set Provincial coverage for ticagrelor changed to align with working group recommendations and moved from approved indication to approved prescriber Educational roll out occurring 10

Challenges and Opportunities Challenges: As the provision of care results in patient movement into and out of hospital as well as between Health authorities, the impact of differing policies, formularies and practices poses risk to best outcomes Differing expert opinions which contrast with policy can further lead to confusion and frustration Opportunities: By aligning evidence review and applying a “clinical lens”, alignment of practice becomes more likely By creating opportunity for policy makers to consult more easily with clinicians the opportunity for alignment of practice becomes more likely By ensuring that multiple health regions are included in the consultation, the opportunity to influence each region to align practice becomes more likely Alignment of practice should decrease challenges and errors as patients transition through the health care setting 11

Summary Collaboration is informal at present, however growing recognition for need of collaboration Best patient care is dependent upon ensuring continuity in coverage of agents across the spectrum of care Given the size of the province, working together is the best solution 12