Introduction
IMPACT: Inclusive Management and Provision of Ancillary Care for Tuberculosis is a student-led community pharmacy-based medication management service. This program is designed to be implemented into an existing community pharmacy practice that provides standard pharmacy dispensary and professional services, while also serving a patient base situated in northern rural and remote communities.
IMPACT exists to partner within global, national, and provincial strategies to reduce incidence by 50% in 2022-2023, and eradicate tuberculosis by 2050, serving populations disproportionately affected by tuberculosis (TB) through the provision of comprehensive and inclusive pharmacy clinical services utilizing innovative videoconferencing and teleconferencing technologies.
IMPACT's mission is to deliver comprehensive pharmacy professional services for tuberculosis and associated illnesses through a patient-centered and culturally-safe approach, improving access to front-line health care services to vulnerable populations in rural and remote communities
As previously mentioned, IMPACT is ideally situated to be implemented into a community pharmacy which serves patients in rural and remote communities that do not have local or regular access to pharmacy services and other health care providers. The program is designed to be collaborative between care providers and the communities IMPACT will serve, while augmenting and supporting existing tuberculosis programming in the province. By exercising an interdisciplinary and comprehensive pharmacy-based approach to TB care, IMPACT will contribute to cure of individual disease and towards eradication. IMPACT will increase the pharmacists' role in the management of pharmacotherapy of TB with associated co-morbidities to ensure optimal outcomes of drug therapy for patients. Key stakeholders in TB management in Saskatchewan include TB Prevention and Control Saskatchewan, the Saskatchewan Health Authority (SHA), the College of Pharmacy and Nutrition, the First Nations and Inuit Health Branch (FNIHB), patients, their families, and the communities they reside in.
IMPACT is designed as a fourth year advanced pharmacy student rotation; this business design is intended to provide specific experiential training and education surrounding the provision of community-based care and management of TB. With efforts directed at the eradication of TB globally, building TB knowledge and capacity in graduating health care practitioners is a current focus of the provincial strategy in TB care. Commonly, there is apprehension and concern surrounding the economic impact a student rotation may have on the financial viability of a community pharmacy. Literature regarding the economic impact of a pharmacy student rotation on a community pharmacy is limited, but available research has demonstrated a neutral impact on a dispensary-business model. As all available research was conducted in a time prior to billable expanded services, there is a new, unstudied opportunity for increasing positive economic impact.
INDUSTRY OVERVIEW
The vision for the post-2015 global tuberculosis strategy is "a world free of tuberculosis", also expressed as "zero deaths, disease and suffering due to tuberculosis".(CITE)
The Millennium Development Goal (CITE) target to "halt and begin to reverse the incidence of tuberculosis by 2015" has been achieved. The similarly-related World Health Organization Stop TB Partnership (CITE) targets of reducing tuberculosis prevalence and death rates by 50% relative to 1990 have been equally successful. With the success of the Millenium Development Goal and the Stop TB Partnership, ambitious global targets are proposed for 2035. These global targets include:
" A 75% reduction in tuberculosis deaths by 2025
" Reaching an equivalent 90% reduction in tuberculosis incidence rate of10 cases/100 000 or less by 2035.
Tuberculosis has a significant impact on federal and provincial health care expenditures. Published national data estimates that approximately $84.4 million was spent on the
treatment of tuberculosis in 2012 (Menzies 2006). These same estimates approximate that treatment of multi-drug resistant (MDR) TB cases can increase costs anywhere from $41,225 to $195,078 per patient. These costs of TB infections does not include the costs associated with screening patients, patient and community education, TB prevention or training efforts; it also does not account for lost productivity time of TB patients and their families, or the economic impact on their communities.
The incidence and prevalence of tuberculosis in Canada is unequally distributed across the country. While tuberculosis rates in Canada are considered generally low from a global perspective, distinct sub-populations continue to show higher rates than the general Canadian population. Specifically, Saskatchewan has the second highest rates of tuberculosis amongst Canadian provinces, and the epidemiology of tuberculosis in Saskatchewan is markedly different from other provinces. In Saskatchewan, the majority of tuberculosis cases are seen in Indigenous and northern populations; this is in contrast to other provinces where the majority of TB cases are seen in foreign-born populations.
There are approximately 1,600 TB cases diagnosed in Canada each year; Saskatchewan had an overall new case rate of 7.5 per 100,000 people as compared to the Canadian national average of 4.7 per 100,000 (Public Health Agency of Canada 2011; see Figure 1). Examining this figure more closely, Saskatchewan citizens with Registered Indian Status had a rate of 42.9/100,000, Métis 29.1/100,000, and immigrant populations had a rate of 14.5/100,000, all of which substantially greater than the Canadian-born (non-Indigenous/non-Métis) rate of 0.6/100,000. This disparity is unacceptable.
The TB Partnership Working Group was established in Saskatchewan to ensure a collaborative and multidisciplinary approach to TB management, prevalence, and incidence in Saskatchewan. Membership includes TB Control Saskatchewan, the Saskatchewan Ministry of Health, the former regional health authorities (now SHA), and FNIHB. The development of this working resulted in the development of the Saskatchewan Provincial Tuberculosis Strategy in 2013, a 5-year plan for tuberculosis in Saskatchewan(effective 2013-2018). The overall target of the Saskatchewan Provincial Tuberculosis Strategy is a 25 per cent reduction in the rate of new and relapsing cases of TB by 2017/2018 and a 50 per cent reduction by 2022/2023. Through collaborative and consistent partnerships spanning multiple disciplines these targets are achievable.
Today, tuberculosis care in Saskatchewan is centrally administered by the Ministry of Health's TB Prevention and Control Saskatchewan. The program is based in Saskatoon with locations in Regina and Prince Albert, and works in collaboration with provincial, federal, and First Nations partners. This program is available for all residents of Saskatchewan with suspected or diagnosed tuberculosis infection or disease. In addition to the three urban locations, the TB clinic also provides approximately 25 mobile clinics in 7 communities. (cite) As all anti-tuberculosis medication is prescribed and dispensed from TB Prevention and Control Saskatchewan, tuberculosis care and management has traditionally been exclusively handled by this program. Services provided by TB Prevention and Control provides includes but is not limited to: provision of ongoing TB education and training, initiation and monitoring of treatment, contact tracing, and coordination with relevant health agencies. Members of the care team at the TB clinic include physicians, nurse clinicians, pharmacy, and program workers. In this program, the pharmacist's role is primarily involved in the technical and drug distribution aspects of pharmaceutical care, while TB physician and nurse are involved in the provision of medication and treatment information. Currently, there is a role for clinical pharmacy in TB care that is not being addressed. IMPACT will increase the role of the pharmacist in the management of patients with tuberculosis and associated illnesses; IMPACT is one piece of the puzzle in tuberculosis prevention and control.
Strengthening and expanding existing relationships between the TB clinic, public health, and other health care partners to encourage an interdisciplinary discussion surrounding TB control Saskatchewan is important. The value of pharmacist involvement in the management of TB and associated illnesses has been demonstrated. Pharmacists are well-equipped to monitor and optimize the efficacy and safety of anti-tuberculosis treatment while improving medication adherence and overall outcomes. In 2012, a pharmacist-run Latent Tuberculosis Infection (LTBI) clinic was established in Philadelphia to improve adherence and completion rates among refugees. Before 2012, LTBI treatment completion rates were less than 30%. Of those referred to the pharmacist-led clinic, 94% successfully completed LTBI treatment within the designated time frame, 40% of whom required an intervention from the pharmacist to remain adherent. IMPACT will increase the involvement of pharmacists and pharmacy interns in the provision of care surrounding TB and associated illnesses.
Risk factors for tuberculosis include several communicable/noncommunicable diseases, and other health conditions; these risk factors include: diabetes mellitus and malnutrition, as well as smoking, harmful alcohol and substance use, and a range of immune-compromising disorders and treatments. Presence of comorbidities may complicate tuberculosis management and result in poor treatment outcomes. Similarly, tuberculosis may worsen or complicate management of other diseases. A good example of comprehensive medication management includes the integration of HIV and TB services. Integrating the delivery of tuberculosis and HIV management has been shown to increase the likelihood that a tuberculosis patient receives appropriate and continued antiretroviral treatment and reduces mortality by almost 40%. It has therefore been suggested that during basic management of tuberculosis, people diagnosed with TB should be routinely assessed for relevant comorbidities. IMPACT is designed to address the complexities surrounding pharmacotherapy and medication management for patients with tuberculosis and associated illnesses/co-morbidities. In efforts to align with the WHO's new End TB Strategy 2016-2035, provincial health ministries and regional health authorities should consider incorporating clinical pharmacists into existing health care teams and implementing programs like IMPACT.
IMPACT strongly aligns with global, national, and provincial areas of focus surrounding tuberculosis care. IMPACT is patient-centered, and will work in a complementary and adjunct collaborative effort with TB Control Saskatchewan, regional health authorities, communities, NIHB, and other health care providers. Building tuberculosis knowledge in current and future health care practitioners is requisite to ensure a consistent and effective TB program in Saskatchewan. Accordingly, IMPACT will focus on providing education related to best practices in appropriate TB and associated illnesses treatment and management.
The emphasis surrounding the economic burden related to the care and treatment of tuberculosis should not be overlooked. Patients with tuberculosis face a large economic burden related to the direct and indirect costs of illness and health care. Adverse social consequences surrounding TB may include stigmatization and social isolation, costs related to travel and accommodation, and loss of employment. With the recent elimination of the Saskatchewan Transportation Company in 2017, these costs and barriers have increased remarkably. The negative consequences can extend to the family of the persons ill with tuberculosis. Even when tuberculosis diagnosis and treatment are offered free of charge, social protection measures are needed to alleviate the burden of income loss and non-medical costs of seeking and staying in care. Different health organizations have placed an emphasis on addressing these unique needs and challenges in northern Saskatchewan.
In addition to the use of mobile health clinics in the north, TeleHealth services and remote presence robotic technologies are being explored and expanded upon to better facilitate patient care. Telehealth specifically works with eHealth Saskatchewan, Regional Health Authorities, Saskatchewan Cancer Agency, First Nation Inuit Health Branch and other health partners to provide this live health care service to Saskatchewan people. Similarly, IMPACT utilizes comparable videoconferencing technologies to directly link patients to front-line pharmacy services and assist in minimizing barriers of distance in rural and remote communities. An indirect benefit of these innovative technologies is facilitating culturally safe care by minimizing displacement of patients from their home communities.
Together, we can make a positive IMPACT on tuberculosis in Saskatchewan