Off limits: Seniors and anti-psychotic drugs

After the CBC aired its stories on the continued use of anti-psychotic drugs despite warnings from Health Canada about increased dangers, an official with the Canadian Institute for Health Information (CIHI) said the organization would take a closer look at the issue.

Michael Hunt, CIHI's manager of pharmaceuticals, said the use of anti-psychotic drugs on seniors is an area that the institute had studied before. But the CBC stories have prompted the institute to take a closer look at the class of drugs to see if there's a way to collect better data that would provide better information on how the drugs are being used.

The following is a transcript of an interview Hunt did with CBC News.

David McKie: When you were saying that you see the reports, you get in a room, and what's your immediate reaction?

Michael Hunt: Our immediate reaction, particularly to this story, is that certainly it's a frame or a group of individuals we have potential data on, so could we look at it? The answer is yes, we have some data on that particular group of people. The question then for us becomes, do we have the data to support the work? Is there scientific background for us to have a look at? Because of course this is a media release and they have their value but does it have the scientific background for us to be able to look at this one? Does it align with an information need that we certainly hear from elsewhere and our own strategic directions? And it probably does. And the question is can we do the work, when can we do it, do we have the capacity to do the work, because these are very complex questions.

So as we look at this one, we would say, get in the room, do we have the data, is it people that we could do work on, if we do our background work and there is sufficient support to do the work, then it certainly would be an area that we would consider.

Again, it becomes seniors, we're very interested in seniors, we're looking at safe prescribings, we've demonstrated this with the Beers work done in the past. And certainly we've heard, certainly in our consultations, that there is concern around the use of the atypicals in the seniors. Certainly from the public plans, they are concerned about cost because they're quite expensive. There's also concerns about them being used appropriately and I think if you look through some of the formularies across the country, there are some restrictions on use around who can have access to these medications. So there are some issues around atypicals that we've seen so we've had discussions in the past as we've looked through topics — could this be work that CIHI could possibly contribute to? There always is work for us to do and there's a lot to do. For us to put this in the priority list, yes we would be considering where we would go with it. For us to brainstorm means to look at the topic and find out if we have the capacity to do the work.

David McKie: So when will you have that brainstorming discussion?

Michael Hunt: We began when it came out. We've had it already. We've certainly had some discussions — even as we initiated the project prior to having data, had some discussions around well this may be an area that would be of interest to us because we knew we had data to look at. Any of the drugs — we'll look at benzodiazepines, we'll look at antipsychotics, any of those drugs that certainly have potential for adverse effects for seniors — are all those we're interested in. And we've certainly had discussions around those that are psychoactive in patients.

We become concerned about falls, cognitive impairment, all the other issues that go along with psychiatric drugs.

David McKie: Just to simplify it, what kinds of data could you look at in order for you to add to the body of knowledge that's already out there?

Michael Hunt: What do we have in-house? We have public drug plan, drug utilization information … which tends to be seniors in this country, we tend to have pretty good coverage for seniors. So we have information around seniors' use, we know the drugs they use, we are able to look at the demographics of patients who use those drugs. We use the WHO's anatomic/therapeutic classification in the background, so we can actually do some coding of the drugs so we can look at them in classes to do some aggregate work around drug utilization, so there is potential to look at what is the pattern of use. And then, what impacts the pattern of use, that tends to impact the missing link or the knowledge gap, and then we would hope that with the work we did around describing the use could then be taken forward by others to look at what those specific impacts were on utilization.

David McKie: So looking into your crystal ball, what could you potentially say about the use of these drugs that is not really being said right now?

Michael Hunt: I think what we don't have is we don't have an aggregate look at what is happening across the country with these particular categories of drugs. We may be able to look at most jurisdictions, we can look at some jurisdictions now, and say, because CIHI's role is bigger, CIHI's role is not individual jurisdictions. The provinces can look at their own drugs and give you those numbers. Our role is to look at what happens overall in health across the country so we would take it that extra move up to a pan-Canadian look as opposed to an individual jurisdiction look because the provinces can do very good work on their own with analysis on their own data.

David McKie: So how would a pan-Canadian look differ with regards to this class of drugs?

Michael Hunt: We know that health is delivered somewhat differently and has different influences in each of the jurisdictions in the country. So a pan-Canadians look begins to put it all together and say overall, how are we delivering this category of drugs to seniors in this country?

David McKie: Is it up or down overall, or not in certain provinces, or some of the reasons for it?

Michael Hunt: We haven't looked at it. We haven't put the numbers together to know whether it's up or down. Certainly, there would be some concerns if it was up. Then again, if we were able to look at those numbers we could get an idea of how it looks overall. We certainly haven't done the work yet.

David McKie: If you take a look at an advisory like that that comes at the tail end of articles and medical journals and so on, what would your expectation be, given the class of drugs, the target audience, what would your expectation be on the impact of drug utilization patterns?

Michael Hunt: Common sense would tell us we'd expect a decrease. Until you do the work, you never really know what those conclusions are going to be.

David McKie: Why is it important for you to be brainstorming around to figure out how you can add to the discussion, how you can collect data, how you can put stuff out there that can push things a little?

Michael Hunt: It's important to CIHI to describe how we deliver health and health services in this country. So anytime that we have an issue that impacts how we deliver health, it really is something that we're interested in at CIHI. Everyone needs to know how we deliver health in this country. You can't improve it if you don't know what you're delivering now.

David McKie: Is there something about this particular class, given their vulnerabilities and so on, that makes it more urgent to look at this?

Michael Hunt: Certainly seniors are a very vulnerable population. They are more susceptible to adverse effects. In the CBC article, there's very catastrophic events that we've talked about but certainly there are issues around blood pressure, cardiovascular effects that may predispose patients to falls, certainly individuals in the seniors group are more predisposed to falls and hip fractures that often really have lifelong effects on their ability to remain independent, to be mobile. And there's a lot of drugs that affect those categories. If we think about aggressively treating blood pressure, well, many of the drugs that we use to aggressively treat blood pressure can also predispose seniors to falls. So there's always a risk-benefit decision to be made. So any drug therapy in seniors probably really needs a second look and fairly significant consideration as we deliver those … what the impact of delivering those to seniors are. Seniors use multiple medications. By the time we're 60 or better, we often have multiple chronic diseases that we're treating and very often they're treated with pharmaceuticals. Every drug has potential for a side effect, whether it's an aspirin or whether it's something for a cough or cold or something you buy over the counter. And they can all be catastrophic to some extent. Especially in a very vulnerable population.

Natalie Johnson (CBC intern): You keep referring to this knowledge gap which makes it difficult to pinpoint which variable it was that had the impact. Do you foresee any solutions or do you recommend anything in order to eliminate that knowledge gap?

Michael Hunt: I don't see a solution to it. We'll always be in that gap between what we know from the use of the pharmaceuticals to absolute application of the pharmaceuticals in the patient, because patients really individually respond to drugs so differently. Without primary registries where you're able to follow individual patients over time and stay in contact with their changes in therapy, it becomes a real challenge. I don't see that we'll ever fill that knowledge gap of what was the real impact of the drug therapy. We tend to look at things in an aggregate way. Overall, did the drugs have a benefit, overall did the drugs have significant risks? But we always have degrees of risk. So those aren't absolutes. There are always degrees of risk. So when you decide to use a drug, there's a number of variables you have to consider. What is the age of the patient, what are the pre-existing diseases of the patient, what's the ability of the patient to be compliant with the drug therapy, what other drugs are available in a similar class? It's a very difficult decision tree when you finally make the decision to use a certain drug in a patient. So it's not as easy as there's risk. It's what else could have an effect on overall response to therapy.

We talk about genomics now, of drug therapy, so there are certainly some interesting research projects around genetically determining which patients you decide to give a particular category or class of drug. So it's a big piece of work that's out there. It's evolving, the science is evolving. Will we do a better job in the future? Absolutely. Good science leads to good results. But will we ever know specifically about that knowledge gap? I don't think so.

Natalie Johnson (CBC intern): When you're saying that a knowledge gap exists because a lot of times there are patient confidentiality issues in terms of why the drug is being prescribed, is that to say that patient confidentiality is that much more important than the data that could eventually have a huge impact on this type of thing?

Michael Hunt: Protecting individual privacy and confidentiality is so important. If you think about what you know about individuals in terms of their disease processes, it could make an individual unemployable simply for insurance reasons. Individuals are not always happy to share or not comfortable sharing their health information. It's a very personal and private piece of information and could have a very significant impact on an individual's ability to work, to get insurance, maybe there's issues in your health that you don't want to share with your family. It's a very personal issue and you can't diminish the need to protect individuals' privacy and confidentiality.

As it affects their health, then you come to a balanced decision about supplying data that people can then turn into information versus protecting an individual's right to have their health information private.

Natalie Johnson (CBC intern): That's what I was interested in. When do you cross that line? When is the health of a lot of people more important than an individual's record?

Michael Hunt: And you're right. Crossing that line is a good analogy. And where is that line? We all struggle with where that line is. Does the protection of an individual's privacy somehow not allow us to look at the bigger pieces around scientific information? Sure it does sometimes. But I think you have to respect that. As Canadians, we're pretty good about sharing our information … StatCan has some surveys of health and people openly share their information and it's identifiable information. We know that in B.C., they collect all claims of all people, they had an opportunity for individuals to opt out and very few did along the way. So for the greater good, individuals certainly will share their health information but they want to make sure that it's used responsibly.

David McKie: You cover five provinces?

Michael Hunt: We have agreements with six. We have up-to-date data currently in the system for four. It's a process. Because we want comparable data we have to make sure that the fields we collect from every province are the same as much as possible. So we're working with two provinces currently with the comparability of their data. Really we have six provinces on board and currently very active with the other provinces. Ontario's very active with us in terms of wanting to submit their data. There's all sorts of processes you need to go on. And that's a very big piece of data.

David McKie: So what are the six provinces?

Michael Hunt: Right now we have Nova Scotia, New Brunswick, an agreement in principle with P.E.I., Manitoba, Saskatchewan and Alberta.

David McKie: And possibly Ontario.

Michael Hunt: Ontario's very active.

David McKie: Which could be a seventh.

Michael Hunt: Which is a big piece of data. Quebec has expressed some interest but they're not really a participating province at this point.

David McKie: When might Ontario be on board?

Michael Hunt: That would be like having a crystal ball. It's a big process. Actually, the provinces have to invest a lot.

David McKie: I can appreciate that.

Michael Hunt: We specify the format that we want data to come to us in. Then the provinces have to actually find people and money to process their data in the way that we're asking for it, so it's a significant investment in their part and within their infrastructure to supply the data to the CIHI.

David McKie: With regards to the brainstorming that you'll do around this particular issue, how many provinces' data would you draw upon?

Michael Hunt: We would draw upon six.

David McKie: The six that you've mentioned?

Michael Hunt: Yes, if it's available and comparable and if we would use it if we have it in-house to do those kinds of work. And that's the other thing when we talk about brainstorming. Brainstorming does not only happen internally with us. We'll certainly have some of these discussions around where analytic work should go with the provinces who supply us data. They also have a vested interest in making sure that their constituents are delivered health in the most efficient way.

David McKie: So it's fair to say that this will prompt some discussion.

Michael Hunt: Absolutely will prompt some discussion.