WEBVTT 00:00:07.529 --> 00:00:09.769 Thank you for joining us on another episode of 00:00:09.769 --> 00:00:13.130 our podcast, The Canadian Breakpoint. So as many 00:00:13.130 --> 00:00:16.149 of you guys know, we are here live today at the 00:00:16.149 --> 00:00:19.769 AMR Symposium in Toronto. Had so many discussions 00:00:19.769 --> 00:00:23.199 this morning and we're actually live. kind of 00:00:23.199 --> 00:00:26.500 feeds and broadcasting onto the podcast today 00:00:26.500 --> 00:00:29.179 as well. And so we have a very special guest 00:00:29.179 --> 00:00:31.800 with us, Dr. Peter Daly, who I'm going to let 00:00:31.800 --> 00:00:34.880 introduce himself and we're going to talk about 00:00:34.880 --> 00:00:38.640 another perspective of AMR. Yes. Hi from Toronto. 00:00:38.740 --> 00:00:41.799 I'm Peter Daly. I'm an adult ID physician and 00:00:41.799 --> 00:00:44.560 medical microbiologist, and I work in St. John's, 00:00:44.560 --> 00:00:47.659 Newfoundland. Perfect. And so I actually just 00:00:47.659 --> 00:00:51.380 tuned into your talk about can build AMR. And 00:00:51.380 --> 00:00:53.979 so for our audience here, who obviously may not 00:00:53.979 --> 00:00:57.619 have been able to tune into the session today, 00:00:57.719 --> 00:01:00.520 can we give a little bit of a background in terms 00:01:00.520 --> 00:01:05.260 of what can build AMR really is? Yes, thank you. 00:01:05.319 --> 00:01:08.640 CanBuild AMR is an intervention designed to change 00:01:08.640 --> 00:01:12.280 family general practice behavior in a sense of 00:01:12.280 --> 00:01:15.420 reducing antimicrobial prescription for patients 00:01:15.420 --> 00:01:18.459 who don't actually need an antimicrobial. And 00:01:18.459 --> 00:01:22.359 we think between a third and a half of all outpatient 00:01:22.359 --> 00:01:25.659 prescription is actually unnecessary. We have 00:01:25.659 --> 00:01:28.400 a long way to go in Canada in reducing unnecessary 00:01:28.400 --> 00:01:31.739 antimicrobial prescription. And that's really 00:01:31.739 --> 00:01:34.239 focused on two primary syndromes, upper respiratory 00:01:34.239 --> 00:01:36.900 tract infection, which is generally viral, and 00:01:36.900 --> 00:01:39.579 urinary tract infection, which is often culture 00:01:39.579 --> 00:01:41.799 positive, but doesn't actually require antibiotic 00:01:41.799 --> 00:01:45.959 therapy. CanBuild is a peer comparison feedback 00:01:45.959 --> 00:01:49.519 that's given to providers, providing them with 00:01:49.519 --> 00:01:52.670 their personal rate of antimicrobial use. in 00:01:52.670 --> 00:01:54.870 a comparison to peers around them in similar 00:01:54.870 --> 00:01:58.829 practice. And this is not a new idea. It's been 00:01:58.829 --> 00:02:01.689 studied many times, especially by Dr. Kevin Schwartz 00:02:01.689 --> 00:02:05.209 in Toronto. And meta -analysis has been put together, 00:02:05.230 --> 00:02:07.349 clearly showing benefits. So at a population 00:02:07.349 --> 00:02:10.770 level, this small amount of feedback can change 00:02:10.770 --> 00:02:14.229 physician behavior, which is reduction in prescription 00:02:14.229 --> 00:02:18.349 use. And it seems to be a suitable way to reach 00:02:18.349 --> 00:02:21.240 primary care providers. that may or may not be 00:02:21.240 --> 00:02:23.139 part of a health system or part of a university 00:02:23.139 --> 00:02:25.879 system that we need to communicate with them 00:02:25.879 --> 00:02:28.400 to benefit them really is to increase quality 00:02:28.400 --> 00:02:31.479 of practice. Okay. And so, yeah, so we definitely 00:02:31.479 --> 00:02:33.860 talked about the audit and feedback processes. 00:02:34.139 --> 00:02:36.699 We heard from many different provinces in terms 00:02:36.699 --> 00:02:38.759 of kind of what their approach has been. So I 00:02:38.759 --> 00:02:40.979 was mentioning they're using the MD snapshot, 00:02:41.280 --> 00:02:44.860 which seems like it's gotten ahead in the steps 00:02:44.860 --> 00:02:48.219 of prescribing and appropriate use of antibiotics. 00:02:48.599 --> 00:02:52.240 And are we looking at... the initial prescribing 00:02:52.240 --> 00:02:55.240 rates or are they getting kind of feedback in 00:02:55.240 --> 00:02:58.639 terms of their kind of length of antibiotics 00:02:58.639 --> 00:03:01.599 and for certain conditions? So is that something 00:03:01.599 --> 00:03:04.280 that's also being looked at? Yeah, the feedback 00:03:04.280 --> 00:03:06.879 to the prescriber can be at multiple levels. 00:03:07.039 --> 00:03:11.370 One is initiation, one is duration. One is indication, 00:03:11.669 --> 00:03:13.810 and most provinces don't actually collect indication, 00:03:14.129 --> 00:03:17.129 so we have no way of judging that. And then the 00:03:17.129 --> 00:03:18.990 fourth would be selection, which would be the 00:03:18.990 --> 00:03:21.990 antimicrobial prescribed. So for instance, in 00:03:21.990 --> 00:03:24.509 our province, Newfoundland and Labrador, we have 00:03:24.509 --> 00:03:27.009 some fairly rudimentary level data, which is 00:03:27.009 --> 00:03:29.949 total antimicrobial prescription. We don't have 00:03:29.949 --> 00:03:33.449 any denominator, which looks at the amount of 00:03:33.449 --> 00:03:36.169 patients seen in the clinic or even the type 00:03:36.169 --> 00:03:38.620 of patients seen. We don't have indications, 00:03:38.740 --> 00:03:41.300 so we don't really know the reason that the physician 00:03:41.300 --> 00:03:44.580 prescribed the antibody. But we feel that even 00:03:44.580 --> 00:03:49.060 with a raw rate per doctor per time, that that 00:03:49.060 --> 00:03:52.360 can be effective as well. Some of the criticism 00:03:52.360 --> 00:03:55.199 that was brought out in the presentation just 00:03:55.199 --> 00:03:58.560 today was a physician may feel that the data 00:03:58.560 --> 00:04:03.780 does not apply to them in some way. practice 00:04:03.780 --> 00:04:07.199 is somehow different or that, you know, the focus 00:04:07.199 --> 00:04:09.419 should be on other prescribers who are more the 00:04:09.419 --> 00:04:13.500 problem than the physician themselves are. And 00:04:13.500 --> 00:04:16.860 so I think tailoring that data more specifically 00:04:16.860 --> 00:04:19.970 to that physician's practice. may be more effective 00:04:19.970 --> 00:04:24.970 than a general educational measurement or intervention 00:04:24.970 --> 00:04:28.750 or a sort of raw total prescriptions, although 00:04:28.750 --> 00:04:31.889 that's personalized at some level. The more personalized 00:04:31.889 --> 00:04:35.029 it is, probably the more effective it is. Right. 00:04:35.129 --> 00:04:37.149 And do you feel like these stewardship initiatives, 00:04:37.389 --> 00:04:39.550 especially like audit and feedback, work better 00:04:39.550 --> 00:04:42.269 in a certain setting, so better in an inpatient 00:04:42.269 --> 00:04:44.589 setting than they do in the community? And do 00:04:44.589 --> 00:04:46.779 we need... better infrastructure, a different 00:04:46.779 --> 00:04:49.300 infrastructure for acute care clinics and community 00:04:49.300 --> 00:04:53.759 care. We know in Canada about 80 % of antimicrobials 00:04:53.759 --> 00:04:56.540 used in the community. So really, of all the 00:04:56.540 --> 00:04:58.300 stewardship work, we should be focusing on the 00:04:58.300 --> 00:05:01.639 outpatient mostly. And in our province, we actually 00:05:01.639 --> 00:05:03.199 have an outpatient stewardship committee and 00:05:03.199 --> 00:05:05.879 an inpatient stewardship committee. Because inpatient 00:05:05.879 --> 00:05:07.759 is different. I mean, you're seeing the patient 00:05:07.759 --> 00:05:09.759 every day. You're getting microbiology results 00:05:09.759 --> 00:05:12.300 back every day. You're looking at x -ray. You're 00:05:12.300 --> 00:05:14.040 looking at surgery. You're examining the patient. 00:05:14.100 --> 00:05:17.560 You're able to serially intervene. Where in the 00:05:17.560 --> 00:05:19.720 clinic, you may discharge the patient with a 00:05:19.720 --> 00:05:22.459 prescription and you don't really know that the 00:05:22.459 --> 00:05:24.720 duration is appropriate. Maybe it's too long. 00:05:24.920 --> 00:05:26.939 Maybe it's the wrong drug. You don't often have 00:05:26.939 --> 00:05:31.750 culture data to use. So to me, the bigger focus 00:05:31.750 --> 00:05:35.529 is on the outpatient. And this is really, I think, 00:05:35.529 --> 00:05:38.430 the best intervention we have for changing outpatient 00:05:38.430 --> 00:05:41.209 prescription. And then I guess my kind of last 00:05:41.209 --> 00:05:43.730 question about CanBuild AMR would be, what kind 00:05:43.730 --> 00:05:45.930 of barriers have you guys faced to make this 00:05:45.930 --> 00:05:50.689 more of a national framework? Yeah, we have plenty 00:05:50.689 --> 00:05:53.449 of barriers. The country is so divided provincially 00:05:53.449 --> 00:05:56.069 with separated health systems that don't talk 00:05:56.069 --> 00:05:58.629 to each other. They don't share data. They don't 00:05:58.629 --> 00:06:02.310 share money for sure. And so in the province 00:06:02.310 --> 00:06:04.370 of Newfoundland and Labrador, we've been very 00:06:04.370 --> 00:06:07.329 slowly developing this. In fact, we're about 00:06:07.329 --> 00:06:09.250 to do this for the first time. So we haven't 00:06:09.250 --> 00:06:12.639 actually done this yet, which is. surveillance 00:06:12.639 --> 00:06:15.360 of antimicrobial use. We needed to at least establish 00:06:15.360 --> 00:06:19.060 a pharmacy network first. Then we had to talk 00:06:19.060 --> 00:06:21.339 to the college about, do they support this idea 00:06:21.339 --> 00:06:23.519 of giving this quality improvement feedback to 00:06:23.519 --> 00:06:25.959 primary care providers? And our college did not. 00:06:26.160 --> 00:06:28.759 It sounds like Alberta College does support this, 00:06:28.860 --> 00:06:32.040 but our province was not supportive. So we had 00:06:32.040 --> 00:06:34.459 to build this slowly. Who writes the letter? 00:06:34.500 --> 00:06:36.860 Who actually signs the letter? We talked to the 00:06:36.860 --> 00:06:38.360 chief medical officer of health and we said, 00:06:38.420 --> 00:06:40.800 would you sign the bottom of this letter? And 00:06:40.800 --> 00:06:45.079 she said no. So it comes to who it's from, which 00:06:45.079 --> 00:06:47.160 is to do with the type of message that's received 00:06:47.160 --> 00:06:50.800 by the provider. So we're still in development 00:06:50.800 --> 00:06:52.620 for this. We've been for many years, but we're 00:06:52.620 --> 00:06:55.259 getting very close. Ours is a collaboration between 00:06:55.259 --> 00:06:57.579 Quality of Care, which is our provincial choosing 00:06:57.579 --> 00:07:00.699 wisely organization, and our health system stewardship 00:07:00.699 --> 00:07:03.740 committee, which is pharmacists and ID physicians 00:07:03.740 --> 00:07:06.779 and everyone else. So we're building this slowly. 00:07:07.290 --> 00:07:09.709 And we're behind other provinces in terms of 00:07:09.709 --> 00:07:12.850 implementation. Okay. So yeah, so lots of barriers 00:07:12.850 --> 00:07:14.769 at lots of levels, but lots of people involved. 00:07:15.920 --> 00:07:18.120 Hopefully that's kind of the creating the tread 00:07:18.120 --> 00:07:21.439 work for the next few years. In fact, in a sense, 00:07:21.459 --> 00:07:23.180 it's building a quality improvement system that 00:07:23.180 --> 00:07:27.259 can be applied in other areas. So then why isn't 00:07:27.259 --> 00:07:29.100 that quality improvement applied to prescription 00:07:29.100 --> 00:07:32.459 of other types of drugs or even applied to other 00:07:32.459 --> 00:07:36.000 quality initiatives? Are you doing a chest X 00:07:36.000 --> 00:07:37.879 -ray when it's appropriate? Are you doing a physical 00:07:37.879 --> 00:07:40.769 examination of the patient? Are you, you know, 00:07:40.769 --> 00:07:43.449 documenting appropriately on your indication 00:07:43.449 --> 00:07:46.149 and this sort of thing? So there's lots that 00:07:46.149 --> 00:07:49.189 can be done. And it's a bit tough in the university 00:07:49.189 --> 00:07:51.709 kind of looking at the primary care providers 00:07:51.709 --> 00:07:53.850 and thinking that they're not doing good enough 00:07:53.850 --> 00:07:56.250 work. And we don't really appreciate all the 00:07:56.250 --> 00:07:58.470 stresses that they're under. But there are some 00:07:58.470 --> 00:08:00.670 fundamental quality improvement systems that 00:08:00.670 --> 00:08:04.250 I think are needed and are beneficial and are 00:08:04.250 --> 00:08:07.610 acceptable. And so for, I guess, the folks out 00:08:07.610 --> 00:08:09.709 there that are listening in terms of who are 00:08:09.709 --> 00:08:12.029 involved in antimicrobial stewardship programs 00:08:12.029 --> 00:08:15.769 in their centers, whether it's community or inpatient, 00:08:15.949 --> 00:08:19.170 are there certain resources or places that they 00:08:19.170 --> 00:08:22.329 can contact CanBuild AMR for support? Because 00:08:22.329 --> 00:08:24.050 I think a lot of the times, like you mentioned, 00:08:24.610 --> 00:08:27.829 it isn't that you don't, nobody wants to do this. 00:08:27.910 --> 00:08:30.889 It's that we need the support system. And so 00:08:30.889 --> 00:08:33.049 it sounds like CanBuild AMR has kind of built 00:08:33.049 --> 00:08:36.500 a good network or at least. from ground up to 00:08:36.500 --> 00:08:41.000 help other systems in Canada. And so are there 00:08:41.000 --> 00:08:44.279 areas where there's room for other provinces 00:08:44.279 --> 00:08:48.960 to join and how does that happen? Yeah. I mean, 00:08:48.980 --> 00:08:50.700 I think most provinces in Canada are already 00:08:50.700 --> 00:08:53.100 engaged at different levels. So he just showed 00:08:53.100 --> 00:08:55.480 a map of each and every province with a color 00:08:55.480 --> 00:08:59.259 on it. So I think most of us are buying in. We're 00:08:59.259 --> 00:09:01.440 in different stages of development or implementation. 00:09:01.820 --> 00:09:06.259 This is supported by CIHR research money, which 00:09:06.259 --> 00:09:11.500 is nice. So Kevin did get a grant from CIHR to 00:09:11.500 --> 00:09:15.029 fund a national program in this direction. COVID 00:09:15.029 --> 00:09:17.529 increased research funding for infectious disease 00:09:17.529 --> 00:09:21.190 quite effectively. So we're in the benefit of 00:09:21.190 --> 00:09:24.230 some federal research funding to implement this, 00:09:24.289 --> 00:09:26.649 although it's not a lot of money. Really, it's 00:09:26.649 --> 00:09:29.710 not an expensive intervention either. You collect 00:09:29.710 --> 00:09:32.750 your usage rates. So you need to know who your 00:09:32.750 --> 00:09:35.049 providers are. You need to have a system to notice 00:09:35.049 --> 00:09:37.980 what their rates of usage are. Somebody stuffs 00:09:37.980 --> 00:09:40.159 that into an envelope and posts it to their office 00:09:40.159 --> 00:09:42.519 and hope that they open the envelope and read 00:09:42.519 --> 00:09:45.500 the feedback. So it's really not a very expensive 00:09:45.500 --> 00:09:48.980 program. And I think, you know, every province 00:09:48.980 --> 00:09:51.340 has a stewardship. committee at some level and 00:09:51.340 --> 00:09:53.659 it should be an important priority for each province. 00:09:53.759 --> 00:09:55.720 And I think it already is. Yeah. Thank you so 00:09:55.720 --> 00:09:57.759 much for a fantastic talk. Thank you for coming 00:09:57.759 --> 00:10:00.799 on the podcast. And I think we'll definitely 00:10:00.799 --> 00:10:04.759 have future episodes that we'd want to do with 00:10:04.759 --> 00:10:07.059 CanBuild AMR to see kind of where the efforts 00:10:07.059 --> 00:10:10.360 have taken us. And thank you for working on such 00:10:10.360 --> 00:10:13.120 an important task. Thanks for the invite. Thanks.