Thank you for joining us on another episode of
our podcast, The Canadian Breakpoint. So as many
of you guys know, we are here live today at the
AMR Symposium in Toronto. Had so many discussions
this morning and we're actually live. kind of
feeds and broadcasting onto the podcast today
as well. And so we have a very special guest
with us, Dr. Peter Daly, who I'm going to let
introduce himself and we're going to talk about
another perspective of AMR. Yes. Hi from Toronto.
I'm Peter Daly. I'm an adult ID physician and
medical microbiologist, and I work in St. John's,
Newfoundland. Perfect. And so I actually just
tuned into your talk about can build AMR. And
so for our audience here, who obviously may not
have been able to tune into the session today,
can we give a little bit of a background in terms
of what can build AMR really is? Yes, thank you.
CanBuild AMR is an intervention designed to change
family general practice behavior in a sense of
reducing antimicrobial prescription for patients
who don't actually need an antimicrobial. And
we think between a third and a half of all outpatient
prescription is actually unnecessary. We have
a long way to go in Canada in reducing unnecessary
antimicrobial prescription. And that's really
focused on two primary syndromes, upper respiratory
tract infection, which is generally viral, and
urinary tract infection, which is often culture
positive, but doesn't actually require antibiotic
therapy. CanBuild is a peer comparison feedback
that's given to providers, providing them with
their personal rate of antimicrobial use. in
a comparison to peers around them in similar
practice. And this is not a new idea. It's been
studied many times, especially by Dr. Kevin Schwartz
in Toronto. And meta -analysis has been put together,
clearly showing benefits. So at a population
level, this small amount of feedback can change
physician behavior, which is reduction in prescription
use. And it seems to be a suitable way to reach
primary care providers. that may or may not be
part of a health system or part of a university
system that we need to communicate with them
to benefit them really is to increase quality
of practice. Okay. And so, yeah, so we definitely
talked about the audit and feedback processes.
We heard from many different provinces in terms
of kind of what their approach has been. So I
was mentioning they're using the MD snapshot,
which seems like it's gotten ahead in the steps
of prescribing and appropriate use of antibiotics.
And are we looking at... the initial prescribing
rates or are they getting kind of feedback in
terms of their kind of length of antibiotics
and for certain conditions? So is that something
that's also being looked at? Yeah, the feedback
to the prescriber can be at multiple levels.
One is initiation, one is duration. One is indication,
and most provinces don't actually collect indication,
so we have no way of judging that. And then the
fourth would be selection, which would be the
antimicrobial prescribed. So for instance, in
our province, Newfoundland and Labrador, we have
some fairly rudimentary level data, which is
total antimicrobial prescription. We don't have
any denominator, which looks at the amount of
patients seen in the clinic or even the type
of patients seen. We don't have indications,
so we don't really know the reason that the physician
prescribed the antibody. But we feel that even
with a raw rate per doctor per time, that that
can be effective as well. Some of the criticism
that was brought out in the presentation just
today was a physician may feel that the data
does not apply to them in some way. practice
is somehow different or that, you know, the focus
should be on other prescribers who are more the
problem than the physician themselves are. And
so I think tailoring that data more specifically
to that physician's practice. may be more effective
than a general educational measurement or intervention
or a sort of raw total prescriptions, although
that's personalized at some level. The more personalized
it is, probably the more effective it is. Right.
And do you feel like these stewardship initiatives,
especially like audit and feedback, work better
in a certain setting, so better in an inpatient
setting than they do in the community? And do
we need... better infrastructure, a different
infrastructure for acute care clinics and community
care. We know in Canada about 80 % of antimicrobials
used in the community. So really, of all the
stewardship work, we should be focusing on the
outpatient mostly. And in our province, we actually
have an outpatient stewardship committee and
an inpatient stewardship committee. Because inpatient
is different. I mean, you're seeing the patient
every day. You're getting microbiology results
back every day. You're looking at x -ray. You're
looking at surgery. You're examining the patient.
You're able to serially intervene. Where in the
clinic, you may discharge the patient with a
prescription and you don't really know that the
duration is appropriate. Maybe it's too long.
Maybe it's the wrong drug. You don't often have
culture data to use. So to me, the bigger focus
is on the outpatient. And this is really, I think,
the best intervention we have for changing outpatient
prescription. And then I guess my kind of last
question about CanBuild AMR would be, what kind
of barriers have you guys faced to make this
more of a national framework? Yeah, we have plenty
of barriers. The country is so divided provincially
with separated health systems that don't talk
to each other. They don't share data. They don't
share money for sure. And so in the province
of Newfoundland and Labrador, we've been very
slowly developing this. In fact, we're about
to do this for the first time. So we haven't
actually done this yet, which is. surveillance
of antimicrobial use. We needed to at least establish
a pharmacy network first. Then we had to talk
to the college about, do they support this idea
of giving this quality improvement feedback to
primary care providers? And our college did not.
It sounds like Alberta College does support this,
but our province was not supportive. So we had
to build this slowly. Who writes the letter?
Who actually signs the letter? We talked to the
chief medical officer of health and we said,
would you sign the bottom of this letter? And
she said no. So it comes to who it's from, which
is to do with the type of message that's received
by the provider. So we're still in development
for this. We've been for many years, but we're
getting very close. Ours is a collaboration between
Quality of Care, which is our provincial choosing
wisely organization, and our health system stewardship
committee, which is pharmacists and ID physicians
and everyone else. So we're building this slowly.
And we're behind other provinces in terms of
implementation. Okay. So yeah, so lots of barriers
at lots of levels, but lots of people involved.
Hopefully that's kind of the creating the tread
work for the next few years. In fact, in a sense,
it's building a quality improvement system that
can be applied in other areas. So then why isn't
that quality improvement applied to prescription
of other types of drugs or even applied to other
quality initiatives? Are you doing a chest X
-ray when it's appropriate? Are you doing a physical
examination of the patient? Are you, you know,
documenting appropriately on your indication
and this sort of thing? So there's lots that
can be done. And it's a bit tough in the university
kind of looking at the primary care providers
and thinking that they're not doing good enough
work. And we don't really appreciate all the
stresses that they're under. But there are some
fundamental quality improvement systems that
I think are needed and are beneficial and are
acceptable. And so for, I guess, the folks out
there that are listening in terms of who are
involved in antimicrobial stewardship programs
in their centers, whether it's community or inpatient,
are there certain resources or places that they
can contact CanBuild AMR for support? Because
I think a lot of the times, like you mentioned,
it isn't that you don't, nobody wants to do this.
It's that we need the support system. And so
it sounds like CanBuild AMR has kind of built
a good network or at least. from ground up to
help other systems in Canada. And so are there
areas where there's room for other provinces
to join and how does that happen? Yeah. I mean,
I think most provinces in Canada are already
engaged at different levels. So he just showed
a map of each and every province with a color
on it. So I think most of us are buying in. We're
in different stages of development or implementation.
This is supported by CIHR research money, which
is nice. So Kevin did get a grant from CIHR to
fund a national program in this direction. COVID
increased research funding for infectious disease
quite effectively. So we're in the benefit of
some federal research funding to implement this,
although it's not a lot of money. Really, it's
not an expensive intervention either. You collect
your usage rates. So you need to know who your
providers are. You need to have a system to notice
what their rates of usage are. Somebody stuffs
that into an envelope and posts it to their office
and hope that they open the envelope and read
the feedback. So it's really not a very expensive
program. And I think, you know, every province
has a stewardship. committee at some level and
it should be an important priority for each province.
And I think it already is. Yeah. Thank you so
much for a fantastic talk. Thank you for coming
on the podcast. And I think we'll definitely
have future episodes that we'd want to do with
CanBuild AMR to see kind of where the efforts
have taken us. And thank you for working on such
an important task. Thanks for the invite. Thanks.