Fellow in Focus: Ingrid Sketris, FCAHS

With Canada’s aging population, pharmaceuticals are one of the fastest growing areas of the country’s health sector expenditures. Canadians receive more than 422 million prescriptions each year at a cost of about $30 billion for prescription and non-prescription drugs. That works out to an annual average cost of $897 per Canadian. Thus it is essential that drug therapy be managed appropriately. As it stands right now, Canada does not have a comprehensive system to monitor whether the right drugs are reaching the right people with optimal effects. A system of this sort would revolutionize health care, resulting in both more effective drug treatments and better value for money.

Enter Dr. Ingrid Sketris, fellow of the Canadian Academy of Health Sciences. Dr. Sketris is a Professor of the College of Pharmacy at Dalhousie University, with appointments in the School of Nursing, School of Health Services Administration and Computer Science, and the Department of Community Health and Epidemiology. She holds a prestigious 10-year Chair in Health Services Research, sponsored by the Canadian Health Services Research Foundation and the Canadian Institutes of Health Research, and co-sponsored by the Nova Scotia Health Research Foundation. This chair, which focuses on pharmaceutical policy and utilization management, enables Dr. Sketris to offer graduate student trainees residency placements with health system decision-makers. The students then conduct research under her guidance and that of her faculty colleagues.

Dr. Sketris knows that she is facing some significant challenges and that there is no silver bullet solution to optimize the Canadian or provincial drug use management systems. That’s why she is focusing her efforts on Nova Scotia, working on initiatives that tackle the issue from every direction, mobilizing decision-makers, prescribers, researchers, non-government organizations, and patients to all do their part to help ensure that the drug use management system is best serving the needs of health-care recipients. “No person or group can do it on their own,” says Dr. Sketris.

One such initiative that Dr. Sketris has been involved with is the Drug Evaluation Alliance of Nova Scotia (DEANS). She started her work with DEANS in 1999 as Founding Chair and now serves as a Member. “DEANS is a government committee that works to identify drug problems and reviews initiatives to solve these problems, resulting in the development of multi-faceted, evidence-based educational interventions,” says Dr. Sketris. DEANS, coordinated by the Nova Scotia Department of Health, has been a model of knowledge transfer, linking researchers, health-care professionals, health system decision-makers, educators, and students together, leading to informed policy and educational program development founded on evidence.

One area where DEANS has made a significant impact has been in the pharmaceutical treatment of lung disease, such as asthma and emphysema. In 1999, over 5,000 beneficiaries of the Nova Scotia Seniors’ Pharmacare Program were receiving pharmaceutical treatment via masks, known as nebulization. Not only is this form of drug treatment time consuming, costly, and inconvenient, but an effective alternative is available. The Nova Scotia government’s Formulary Management Committee conducted a drug evaluation and concluded that portable inhalers, commonly referred to as puffers, were comparable in their efficacy and provided more cost effective and convenient treatment with lower risks of contamination.

In an effort to encourage the use of portable inhalers where appropriate, the Nova Scotia Seniors’ Pharmacare Program announced in 2000 that in six months’ time it would limit compensation for nebulization treatment for patients with specific conditions. To facilitate this transition, the program immediately covered the cost of a spacer device to help patients better use portable inhalers. A professional fee was also established to reimburse pharmacists for providing patients with education on how to use the spacer device.

The interventions did not stop there. DEANS coordinated more approaches to facilitate the policy change, targeting physicians, hospital and continuing care staff, pharmacists, respiratory therapists, and patients. For example, the Nova Scotia Lung Association was brought in as a partner and provided a toll-free, 24-hour support line for patients and health professionals.

As a result, many patients were able to comfortably transition to the portable inhalers without unintended harm such as an increase in physician visits or hospitalizations. Furthermore, this multi-faceted initiative resulted in an estimated drug cost savings of $1 million per year. “Strong leadership and good partnerships were pivotal to the success of this initiative,” says Dr. Sketris. “DEANS had to ensure that the message was appropriately tailored to everyone involved. We took a comprehensive approach so that everyone was adequately supported.”

Dr. Sketris actively supported the DEANS initiative through research projects undertaken by graduate students and trainees in strategic placements. These projects included research on the effect of the policy changes and educational programs, and identification of the barriers to uptake of the portable inhalers in both the community and hospital settings.

As there is no one-size-fits-all approach for any pharmaceutical management initiative, “it’s critical to define the problem in a manner that can be supported by evidence and look at what’s feasible in a context of resource constraints,” says Dr. Sketris.

Although every federal, provincial, and territorial pharmacare system faces its own unique problems, Dr. Sketris’s work in Nova Scotia will serve as a model for pharmaceutical management in the rest of Canada.

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