Towards clinical implementation of pharmacogenomics to improve the treatment of people with depression in BC

In Canada, more than 1 in 10 people will suffer a major form of depression at some point in their lives. There are many effective treatments for depression, including drug therapy. Finding a medication that both works and does not cause severe side effects is often a matter of trial-and-error. This may contribute to the high non-adherence rates and, subsequently, to poorer health outcomes and increased costs. An individual’s genetic makeup is thought to be partly related to whether particular drugs work and whether there are side effects with the drug. “Pharmacogenomic” testing, that is, using the patient’s genetic information to determine which particular drug might work best, at the right dose, with the fewest side effects, is a new and promising approach.

In this study, we want to know if pharmacogenomic testing for depression treatment should be routinely used in British Columbia. Through a series of research activities, we will evaluate how much improved health patients might see, as well as whether the testing is good value for money for the health system. As a whole, the project will provide tools for evaluating and addressing societal and economic considerations for the implementation of pharmacogenomics tools into clinical practice.

Dr. Stirling Bryan (Principal Investigator) is a health economist, Professor in UBC’s School of Population and Public Health, a Senior Scientist at the Centre for Clinical Epidemiology and Evaluation (Vancouver Coastal Health Research Institute), and President of the BC Academic Health Science Network. Dr. Jehannine Austin (co-Principal Investigator) is a genetic counsellor, Professor in Psychiatry & Medical Genetics at UBC and executive director of the BC Mental Health and Substance Use Services Research Institute. The remaining multi-disciplinary Canadian team has expertise in health policy research, simulation modeling, systematic reviewing, knowledge translation, and includes patient partners.

This 2-year study is funded by Genome BC, Genome Canada, and the Michael Smith Foundation for Health Research.

Implementing and evaluating ActionADE to transform medication safety

Medications have transformed the lives of Canadians suffering from many debilitating conditions. However, medications may also cause harm. As medication use has increased, so has the incidence of adverse drug events (ADEs), harmful and unintended events related to medication use. Today, ADEs cause over 2 million emergency department visits across Canada each year, and are a leading cause of admissions. 

Preventing ADEs is not easy. Health care providers often unknowingly expose patients to the same or similar medications as ones that previously caused harm. For example: 

"I saw a diabetic who was discharged from hospital after being admitted for hypoglycemia [low blood sugar] due to glyburide [a blood sugar lowering drug]. The physician asked him to stop the glyburide and put him on gliclazide which has a lower risk of causing hypoglycemia. But he presented [a different hospital] with an even lower blood sugar. When I looked at his blister pack I discovered that both glyburide and gliclazide had been dispensed. The patient had been given a discharge prescription for gliclazide, but no note was made to discontinue glyburide, and neither his [family] doctor nor his pharmacist were aware of what had happened."

Hospital pharmacist, 2012 

Using combined professional and research expertise we will pilot-test, refine, implement and evaluate ActionADE, a new health information technology developed by my team to prevent repeat ADEs.

Evidence-informed decision making in cancer survivorship: evaluating a comprehensive, multi-disciplinary prostate cancer supportive care program

Approximately 24,000 Canadian men were diagnosed with prostate cancer in 2015, and the majority of them will face long-term treatment-related health effects that will impact their quality of life, and have significant cost implications for our health system. Examples of these effects include sexual, urinary and bowel dysfunctions, as well as depression, anxiety and other psychological or psychosocial problems. Comprehensive, evidence-based supportive care programs that address these concerns are needed.

Recognizing this gap prompted the development of a survivorship supportive care program for prostate cancer patients at the Vancouver Prostate Centre. This program addresses both the physical and psychological needs of prostate cancer survivors and their partners from the time of diagnosis. It is comprised of six complementary educational modules and individual clinic visits with providers, and administered by a multi-disciplinary team (urologists, radiation/medical oncologists, and professionals in sexual medicine, psychology, counselling, nutrition, and physiotherapy). This research will assess the costs and benefits of the survivorship program, and will consider the incremental benefits associated with each module in order to improve the program. We will address the following questions: 

  1. Do men who have been diagnosed with prostate cancer and have participated in a program have a different pattern of health services use in the year following primary treatment compared to non-participants?
  2. Do participants of the program self-report better quality of life and symptom management than non-participants?
  3. Is the program cost-effective compared to usual standard of supportive care for individuals with prostate cancer?

The project will use a combination of administrative data, patient medical records, patient self-reported outcomes and primary cost data to develop and populate a simulation model that will track patients along care pathways within/outside the program. The model will provide an overall estimate of the program’s cost-effectiveness.

This evaluation will improve the quality and efficiency of the program and will inform the development of other cancer supportive care programs across BC. Ultimately, it has the potential to have a significant and lasting impact on the landscape of supportive care for cancer survivors.

Outcome-based Performance Metrics in Canadian Health Care: Moving from “How Many” to “How Well”

Performance in the health sector has conventionally been viewed in terms of volumes, such as the number of additional surgeries that were performed in a given year. Unfortunately, health status and outcomes are not routinely assessed in Canada. This is a substantive concern — imagine the case where your car manufacturer's performance metric did not include car safety and performance but merely focused on production volume. Health status is a more appropriate outcome than volume for assessing system performance, and understanding variation in performance of the health system provides the opportunity to improve patients’ health-related quality of life. This study aims to develop a system to assess the performance of the health care system by measuring what it produces in terms of "health," such as health-related quality of life rather than only measuring the "production of health care" — for example, surgical volumes.

Dr. Jennifer Davis' research will address the use and analysis of “performance metrics” within health care, with a particular focus on patient-centred and outcome-based measures using Patient Reported Outcome Measures (PROMs). PROMs are detailed surveys that allow patients to report important changes as a result of a medical intervention and allow the assessment of health-related quality of life. Thus, instead of just measuring that a surgery took place, PROMs measure the patient’s perception of how the surgery has improved their life.

Dr. Davis will be applying knowledge from fields outside the health care sector, such as engineering and education, to improve performance assessment within the health care sector. By determining how specific measures improve performance outcomes in other fields, and by identifying which of these are most effective, she will then specifically determine the potential to adapt these measures as PROMS within the health care context to enhance the health of Canadians. This critical platform will enable the first performance assessments using a patient-centred and outcome-based approach in Canada.

Evaluating Patients’ Preferences for Asthma Therapy Using a Discrete Choice Experiment

Approximately one in 12 Canadians has asthma, a chronic respiratory disease characterized by airway inflammation and variable airflow obstruction. Previous research into how asthma patients manage their disease has found an over-reliance on short-acting beta-agonists (used as needed to quickly relieve symptoms) and an under-use of inhaled corticosteroids (used regularly to prevent asthma attacks). This treatment pattern has been associated with a higher risk of death related to asthma. The overuse of short-acting beta-agonists appears to be linked to socioeconomic status. Despite receiving all drugs at no cost, asthma patients receiving social assistance are more likely to use greater amounts of short-acting beta-agonists than individuals not needing assistance. Helen McTaggart-Cowan is conducting research aimed at identifying the extent to which patients are willing to trade off the immediate symptom relief of short-acting beta-agonists against the ongoing management achieved with inhaled corticosteroids. She is investigating the relative importance of symptom control, cost, side effect minimization and convenience of treatment in an effort to determine the associations between drug preferences and both socioeconomic status and asthma control status. By identifying the factors that result in inappropriate asthma management, Helen’s research will contribute to improved asthma care and provide a foundation for future work aimed at improving treatment efficacy and compliance.

Supporting Success: The Role of Mentorship in Increased Health Services Research Capacity

Research programs in Canada embrace mentorship as a way to increase research capacity, with experienced researchers mentoring more junior investigators. The three major research granting agencies in Canada (CIHR, SSHRC and NSERC) identify mentorship of new researchers as integral to research training. But few questions have been asked about how to make mentorship effective. For example, is an effective mentor someone who oversees career development, or provides guidance for a trainee? Dr. John Egan is evaluating how mentorship works in collaborations between university and community-based researchers. He is examining how mentors and their trainees experience mentorship, in a program jointly funded by the Canadian Institutes of Health Research and MSFHR. This research should identify what creates successful, productive mentoring, and lead to evidence-based practices and policies for effective mentorship