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1 Introduction
1.1 Background and Rationale
Polypharmacy, often defined as the use of five or more medications, is associated with a higher incidence of adverse drug events (ADEs) [1,2,3], and strongly linked to patient falls, cognitive impairment, hospitalizations, and death [1]. Despite these risks, polypharmacy represents a growing problem in many countries [4,5,6,7]. In Canada, approximately two thirds of adults over the age of 65 years take five or more prescription medications, and about a quarter (26.5%) take ten or more [8]. Factors including sex, income, and education are associated with polypharmacy, with higher rates observed in women, people of low income, and of lower education [9]. Polypharmacy is also costly, and represents an environmental burden, with medication production and disposal contributing to the healthcare sector’s carbon footprint [10, 11].
Interventions to improve medication appropriateness offer promising solutions to address polypharmacy and reduce the use of potentially inappropriate medications (PIMs), which are associated with greater risks for certain patients, compared with safer alternatives [12]. Deprescribing is one component of medication appropriateness, referring to the planned and supervised process of reducing or stopping medications that are causing harm, are no longer providing benefit or simply adding to the pill burden [13].
1.2 The Canadian Medication Appropriateness and Deprescribing Network
In 2015, the Canadian Deprescribing Network (CaDeN) was established to unite members of the public, healthcare providers, educators, and researchers from across the country to collectively address the growing problem of polypharmacy and PIMs [14]. Using an ecological approach [14], CaDeN committed to involving individuals, communities, health system organizations, researchers, and government decision makers in its efforts to improve medication appropriateness. Since its foundation, to increase impact, CaDeN worked in partnership with a number of organizations with shared goals of improving medication appropriateness and promoting healthcare resources stewardship in Canada. With this collaborative approach in mind, in 2015, 2016, and 2018, CaDeN hosted three separate national stakeholder summits with key stakeholders to tackle the issues of polypharmacy and PIMs, with a particular emphasis on the health of older adults. These summits brought together healthcare providers, patient advocates, policy makers, and community organizations to identify strategies to increase public awareness and engagement in reducing medication harm, as well as to envision innovative solutions to promote the safer use of medications in Canada [15]. These stakeholder summits were key to the subsequent roll-out of a number of important CaDeN activities, including a national public awareness campaign promoting medication appropriateness [16], the development of healthcare provider tools supporting deprescribing as well as an interprofessional curricular framework [17], putting forward a national strategy for medication appropriateness in Canada [18], and developing and implementing provincial-wide programs aimed at reducing the use of PIMs [19].
In 2022, the network refreshed its purpose to encompass the larger scope of safe and appropriate use of medications for Canadians of all ages and hence was renamed the Canadian Medication Appropriateness and Deprescribing Network (CADeN). In 2023, CADeN, with its expanded scope, united key players once more to build a more structured, pan-Canadian movement to promote medication appropriateness for people of all ages. This event was funded by, and held in partnership with, Health Canada.
1.3 Attendance and Goals of the National Meeting
1.3.1 In Attendance
The CADeN 2023 National Meeting was held on 8 and 9 November in Montreal, QC, Canada, hosting 101 attendees. Attendees included public members, community leaders, healthcare providers, healthcare organization leaders, leaders in medication appropriateness, researchers, trainees, and policy makers from 10 of the 13 Canadian provinces and territories, along with international experts invited from the USA and Australia.
Among government representatives attending the National Meeting were members of the Canadian Drug Agency Transition Office (CDATO). The Government of Canada launched the CDATO in spring of 2021, to work with provinces, territories, and key stakeholders on a vision, mandate, and plan to establish a Canadian Drug Agency (CDA) that would improve pharmaceutical system coordination and support related work. This was supported by a Budget 2019 investment of $35 million CAD over 4 years to establish the CDATO [20]. As a primary stakeholder of Health Canada and of the CDATO, CADeN invited CDATO leaders and members working on medication appropriateness to partner in the National Meeting. Members of the CDATO were encouraged to host consultations with National Meeting attendees to help guide the development of a CDA strategy supporting the appropriate prescribing and use of medications in Canada.
The National Meeting aimed to incorporate the principles of equity, diversity, and inclusion among members of the scientific organizing committee, keynote speakers, and presenters, with representation of early career researchers, healthcare providers, and trainees, as well as the inclusion of the voices of people with lived experience.
1.3.2 Goals of the National Meeting
The goals of the 2-day National Meeting were to (1) establish and strengthen relationships between stakeholders involved in the area of medication appropriateness, (2) encourage attendees to share tools, resources, and disseminate findings from their work, and (3) inform policy and decision-making bodies, including the CDATO, on priority areas and approaches to implement when promoting the appropriate use of medications in Canada. As a highly interactive event, activities and sessions of the National Meeting centered around fostering intersectional discussions between different stakeholders. Notably, the National Meeting provided members of the public and of community organizations opportunities to share their experiences and perspectives on medication appropriateness directly with leaders in the field. Students and health professional trainees also had the opportunity to seek input on their research projects, and policy makers highlighted their priorities and goals, all of which informed the meeting discussions (see Electronic Supplementary Material [ESM]). A cross-cutting theme for the meeting was attention to truth and reconciliation, the commitment to being responsible and accountable to sharing the truthful experiences of First Nations, Inuit, and Métis peoples [21], with key sessions on each day starting with a land acknowledgment (see ESM).
2 National Meeting Day 1: Policy Setting with the CDATO
2.1 Presentation of a Pan-Canadian Strategy for Appropriate Use by the CDATO
The National Meeting was opened by the presentation of a proposed vision of a Pan-Canadian Medication Strategy for Appropriate Use, which would be led by a future Canadian Drug Agency. This strategy is the product of extensive cross-sectoral engagement led by the CDATO with stakeholders from all provinces and territories. Its creation was supported by the Appropriate Use Advisory Committee, a multidisciplinary group created to provide advice and guidance on this issue and on which CADeN participated.
The mission of the Pan-Canadian Medication Strategy for Appropriate Use would be to support partners to enable Canadians to be optimally informed about and have access to prescription medications or alternative therapies that deliver the greatest possible health benefit at the lowest possible cost to individuals, their communities, the health system, and the broader environment. The strategy’s four pillars include: (1) program design, implementation, and delivery (supporting appropriate prescribing and use practices); (2) collaboration (working together to bring cohesion to a fragmented space); (3) policy (strengthening commitment through alignment of planning, policies, and regulatory measures); and (4) research and results (bolstering research and evidence to inform decision making). The future CDA program functions would be developed with the guiding principles of this pan-Canadian Strategy.
Further defining the valued roles of the CDA in this area, attributes whereby this organization could bring value to the appropriate use landscape were described, including building dialogue between patients and partners, developing regional or local capacity to adapt and implement promising initiatives, gathering data and generating evidence to support and develop initiatives, and evaluating initiatives to improve effectiveness, scale, and the spread of promising practices.
As the Appropriate Use Advisory Committee would be finalizing its report and recommendations over the months following the event, the consultations at the National Meeting were identified as helping it continue to grow and take shape. Particularly highlighted was the importance of working with patients such as through CADeN to establish a comprehensive pan-Canadian Appropriate Use program for the CDA.
2.2 CDATO Consultations with Attendees
The CDATO consultations with National Meeting attendees were separated into two segments. In the first segment, attendees were asked: What activities should be a part of a CDA appropriate use program and how should the CDA work with partners, including the public, to deliver these activities? Seated in round tables, attendees collectively identified activities to be given priority by the CDA. Activities and priority areas for the CDA suggested by attendees during this first segment centered around the following topics: engaging the public, increasing knowledge dissemination, strengthening support to healthcare providers, improving access and sharing of patient health information, and improving ADE reporting.
The largest priority area identified by attendees was the inclusion of the voice of patients and other people with lived experience in activities led by the CDA. The importance of collaborating with people from indigenous and other equity-deserving populations when developing initiatives was emphasized. It was noted that this would be an essential first step, to build trust with communities, and should also precede any implementation and/or scaling of existing tools and resources.
Knowledge dissemination was also identified as a priority area to address gaps among providers and patients. Attendees reinforced that knowledge gaps were still important barriers to clinical activities aimed at addressing polypharmacy, such as deprescribing [22, 23]. Specifically, attendees raised the importance of increasing public awareness on the risks of polypharmacy and inappropriate medication use through patient stories and educational resources adapted to different languages and contexts.
Attendees also indicated that healthcare providers would need greater support in their practice to promote medication appropriateness activities such as deprescribing. An example of support included facilitating the integration of medication appropriateness tools within their workflow, given the increasing patient loads managed by healthcare providers. Direct-to-patient educational initiatives were also suggested, to inform and equip patients with knowledge that would facilitate medication reviews with their healthcare providers.
Improving access to patient health information was proposed as a fourth priority, as attendees noted gaps in information transfer between practices and across a patient’s care continuum. These gaps have led to suboptimal care or even patient harms, for example through re-exposures to previously harmful medications. Within this priority area, improving ADE reporting was also put forward so as to prevent patients’ re-exposure to previously harmful medications and to ensure more rigorous tracking of both common and rare ADEs caused by available drugs.
In the second segment of the consultations, attendees were asked: How should the collective impact of Canada’s appropriate use efforts be measured, and what indicators should be used/developed to research and evaluate the effectiveness of programs and initiatives?
To evaluate the impact of the CDATO’s planned medication appropriateness program, attendees identified several key parameters. Population-level parameters were suggested, such as the average number of prescription medications per patient, and the frequency of ADE reporting. Patient-level parameters included quality-of-life assessments, number of deprescribing discussions with a prescriber per year, and patients’ perceived awareness of medication safety. From a research standpoint, attendees suggested tracking the number of ongoing and completed medication appropriateness research projects, and the number of patients reached by different initiatives.
3 National Meeting Day 2: Planting the Seeds for Deprescribing
Under the theme Planting the Seeds for Deprescribing, day 2 objectives included knowledge dissemination and inspiring collective, actionable solutions to promote medication appropriateness, and deprescribing in attendees’ communities or networks. The day was composed of research sessions, keynotes, and a discussion panel, with group activities interspersed to encourage attendees to discuss and apply the knowledge acquired from the different sessions. Attendees also had the opportunity to chat and learn about other stakeholders’ activities, tools, and resources by visiting exhibition booths.
3.1 Research Sessions
3.1.1 Patient-Focused Initiatives
The patient-focused deprescribing initiatives presented during research sessions showed promising benefits. Sleepwell, a knowledge-mobilization program, was developed to help patients safely reduce their use of sedative hypnotics and improve their management of insomnia through cognitive-behavioral approaches [24]. The program offers resources to educate patients on the risks associated with sedative hypnotics, as well as recommendations to help initiate deprescribing discussions with prescribers, allowing patients to have greater agency on the management of their insomnia. The impact of Sleepwell on reducing the use of benzodiazepines has recently been evaluated in a trial [25], with results forthcoming. In what became one of the most engaging and memorable presentations of the day, a Sleepwell patient partner highlighted the benefits of the program by sharing the decades-long negative impact that benzodiazepine usage had on their quality of life. The patient partner narrated that the Sleepwell program helped them safely taper off benzodiazepines and implement cognitive-behavioral strategies, with significant gains observed on quality of life.
SaferMedsNL is a Newfoundland and Labrador-based initiative that aimed to reduce the overuse of sedative hypnotics and proton pump inhibitors [19]. Using a collective-impact approach [26], SaferMedsNL focussed on raising public awareness on the risks associated with these PIMs. Healthcare provider education and engagement was done in parallel to facilitate deprescribing conversations between patients and prescribers. While findings from the SaferMedsNL study remain to be published, the use of a collective approach inspired many attendees who vocally expressed their interest in promoting medication appropriateness in other Canadian provinces and territories through a similar approach.
3.1.2 Leveraging Information Technology to Address PIMs and ADEs
ActionADE is a novel electronic application that bridges gaps in ADE reporting between hospital emergency rooms and dispensing pharmacies. Its integration into PharmaNet, British Columbia’s provincial dispensing system, rendered the reporting of ADEs discovered in the emergency room rapid and easy for healthcare providers. ActionADE’s connection with emergency room reporting aims to prevent the re-dispensing of previously harmful medication to patients, based on the ADEs in their file. A prospective observational study of ActionADE resulted in a reduction in re-exposure to previously harmful medications: when alerted about a previous drug-related ADE, pharmacists did not dispense previously harmful medication in 33% of these instances [27].
MedSafer supports prescribers’ deprescribing decision making by providing point-of-care individualized deprescribing reports for patients. Reports highlight PIMs, the possible degree of harm, potential side effects and association with ADEs, links to patient materials, and when needed, tapering regimens. The MedSafer clinical trial measured the impact of supported deprescribing decision making on ADE incidence and on the proportion of patients who were deprescribed at least one PIM upon discharge from 11 acute hospital centers in Canada. The intervention was found to be safe and effective with a neutral impact on the short-term incidence of ADEs and adverse drug withdrawal events, and with a significant increase in the deprescribing of PIMs (an absolute increase of 22.2%, or a number needed to treat of ~ 4–5) [28].
3.1.3 Short Snapper Research Presentations
The global impact of deprescribing.org’s evidence-based deprescribing guidelines was presented, featuring the recent launch of its Deprescribing Guidelines Repository (DEPOT) for guideline developers around the world, as well as the intentions to develop guidelines for more drug classes, such as statins [29]. Other short research presentations explored key elements of deprescribing information transfer from hospital to community settings from the perspective of Australian community pharmacists, the impacts of patient-facility language discordance on inappropriate prescribing of antipsychotics in Ontario Long-Term Care facilities, and an overview of the Therapeutics Initiative Portrait program [30]. Portrait is an audit and feedback program that aims to improve prescribing practices by encouraging clinicians in British Columbia to review their own prescribing behaviors relative to their peers. To date, portraits have been developed for seven different topics, covering different drug classes and conditions.
3.1.4 Judged Trainee Poster Abstract Session
Future directions in the field of medication appropriateness research were displayed during the judged poster presentations of health professional and health research trainees. During this session, attendees circulated from poster to poster, exchanging ideas and feedback on trainees’ research projects. Presentations from the three winners of the competition pertained to the current gaps in the reporting of adverse drug withdrawal events by physicians, the lack of homogeneity in the scales used to assess medication burden [31] and the evaluation of existing deprescribing tools in special patient populations [32]. Novel areas of research included a portrait of polypharmacy in children and evaluating changes to prescription medication use following the introduction of cannabis for rheumatologic conditions.
3.2 Medication Appropriateness and Indigenous Health
A key goal of the National Meeting was to include voices and perspectives from public members, notably from indigenous communities (First Nations, Métis, and Inuit), in medication appropriateness discussions. It is well established that indigenous communities across Canada face many structural and systemic challenges in healthcare, including racial discrimination, difficulty communicating with providers, avoidance of care and lack of transport to, or availability of, care [33,34,35]. Listening to and learning from indigenous peoples is an important first step in ensuring that healthcare providers deliver culturally respectful, inclusive, and relevant care to these communities.
Members from the Alexander Research Committee described the University of Alberta’s process of establishing and fostering a relationship with Alexander First Nation, and highlighted essential guiding principles when engaging in research with an indigenous community. From their long-standing research partnership of over 15 years, they presented findings that have supported previous relationship-building work, emphasizing that trust must be built before research, discussions, or decisions about health and medications can be addressed. Their research also identified priority areas that pharmacists should learn about in order to engage with these communities. As first-line providers of healthcare, pharmacists are often the most accessible point of contact for healthcare in indigenous communities. Pharmacists also play a vital role in ensuring that patient care is delivered in a culturally relevant and respectful manner within indigenous communities. As such, priority learning areas included knowledge regarding treaties, understanding kinship and the importance of relationships in well-being, or the use of traditional medicines or sacred practices and boundaries in sharing that information.
As an evidence-based and transaction-based profession, pharmacy is rooted in colonial practices that can exclude indigenous perspectives of health and healing. The University of British Columbia’s UPROOT project aims to decolonize pharmacy by integrating indigenous health into professional training through a community-based approach. Through its Two-Eyed Seeing process, UPROOT builds and delivers mandatory and elective indigenous health courses into the university’s 4-year pharmacy program to encourage the practice of pharmacy from both an indigenous and Western lens [36,37,38]. The process of indigenization aims to meaningfully integrate indigenous story-telling and traditional medicines knowledge to create more inclusive and culturally safe educational programming. Collectively, speakers detailed the lessons learned in their education and research collaborations, emphasizing the importance of (1) community-based participatory action research, (2) indigenous data sovereignty, and (3) reciprocity between the academic institution and community partners.
3.3 Keynote Presentations: Health Policy and Research Funding Opportunities
Keynote presentations focused on two areas that would benefit from a greater involvement of governmental bodies: supporting equitable access to medications and increasing funding opportunities for research in the area of deprescribing. Factors such as age, sex, ethnicity, income, racism, and geographic location influence access to healthcare and medications. According to a 2022 report, one in ten Canadians do not adhere to treatments because of medication costs, with non-adherence affecting 17% of Canadians without insurance coverage [39]. To evaluate the health and economic impacts of free access to a list of essential medications, the Carefully Selected and Easily Accessible at No Charge Medicines (CLEAN Meds) clinical trial was conducted [40]. After just 1 year, free access led to an increase in treatment adherence and certain positive health outcomes such as improved blood pressure. After 2 years, the CLEAN Meds trial measured a 10% absolute increase of adherence rates for medications appropriately prescribed, and a 1% absolute decrease of medications identified as potentially inappropriate prescriptions [40, 41]. After 3 years, the free distribution of essential medications led to a mean reduction of $4465 CAD (±$2755 CAD) in healthcare costs in the intervention group [42]. From an economic standpoint, these improvements could represent preventative solutions to reduce government expenditure on healthcare. Findings from the CLEAN Meds study support the creation of a publicly funded short list of essential medications, a recommendation made by the Advisory Council on the Implementation of National Pharmacare [43]. A rigorously created and updated list of publicly funded essential medications could provide clinicians and patients greater guidance on how to best use medications, while granting greater access to Canadians without private insurance.
Deprescribing research is an emerging field with limited funding opportunities, requiring creative strategies [44]. Currently, deprescribing research centers around two behavioral pathways: (1) demonstrating the efficacy of an intervention in supporting deprescribing and its downstream outcomes and (2) how to incentivize people to use interventions widely in everyday practice. Priority areas within these behavioral pathways is understanding the “basic science” of deprescribing, such as optimal methods to catalyze behavioral changes, as well as identifying the needs and gaps in deprescribing within diverse communities. These priority areas provide strategic opportunities to leverage a broader range of funding sources indirectly related to deprescribing. Additionally, involvement of people from different health professions as well as patients is key to ensure that interventions are relevant and amenable to changes in targeted populations.
3.4 Future Planning to Address Medication Overload from Different Angles
A discussion panel was held to allow experts from different spheres to share perspectives on, and solutions to, reducing medication overload from an educational, environmental, and policy perspective. An interprofessional deprescribing competency framework for medicine, pharmacy, and nursing entry-to-practice programs was presented with strategies for incorporating it into curricula [17]. Common barriers to deprescribing within healthcare practices include a lack of knowledge on medication appropriateness and of strategies to confidently and effectively deprescribe PIMs [45, 46]. The framework aims to equip healthcare professionals with the necessary knowledge and skills required to reduce medication overload by effectively deprescribing in their practice. The framework would therefore help program developers and educators integrate deprescribing knowledge and skills into healthcare professional curricula to bridge the knowledge gaps observed in practice. The goal is to shape a future generation of healthcare providers who prescribe selectively and are equipped to review patients’ medications with confidence.
Vanessa’s Law, formally known as the Protecting Canadians from Unsafe Drugs Act, is an example of how policymakers can take concrete action to improve medication safety through regulation. Vanessa’s Law was enacted in Canada in 2014 and came into effect in 2019. It enforces mandatory reporting of serious adverse events and medical device incidents by hospitals. Analysis and shared learning from these reports would contribute to achieving the goal of providing safer healthcare and health products [47].
In this discussion, the intersection of healthcare and environmental efforts was also addressed, and how appropriate medication use should be part of strategies put forward to reduce the carbon footprint of the healthcare sector. Though frequently overlooked, the production of medications and the delivery of healthcare are responsible for considerable quantities of medical waste and carbon emissions. In Canada, healthcare systems are responsible for 4.6% of total carbon emissions and a quarter of this (1.2%) derives from medications [48]. As a dual solution to reduce medication overload and healthcare’s carbon footprint, the addition of “climate scores” on prescription medications could help better communicate the environmental costs of their production.
3.5 Group Activities: Novel Ideas to Reduce Medication Overload and Taking Action
During the first day of the National Meeting, attendees were strategically seated with members from different spheres and experiences to help them establish diverse connections and discover novel perspectives from the start of the event. On day 2, attendees continued to nurture their diverse connections through group activities organized using participatory action research techniques [49]. Attendees were given the opportunity to create and strengthen more ties, and apply the knowledge acquired during the day to generate novel solutions to reduce medication overload in Canada.
The first group activity encouraged attendees to think of limitless solutions to addressing medication overload, drawing from each of their experiences and areas of expertise. Individuals were asked to think of their best idea, then assess them as a group. Novel and preferred ideas emerging from this activity were highly centered on increasing public engagement and awareness. First, the raising of public awareness on medication appropriateness through the production of a “Canadian Heritage Commercial”-style educational video was put forward as an idea, blending humor and emotion to encourage patient empowerment throughout the country. Second, scaling up the SaferMedsNL initiative [19] to encourage each province and territory to adopt a collective impact approach to address medication overload was also highlighted. This would include support to implement evidence-based initiatives, an improved collaboration between healthcare professionals and patients, the integration of deprescribing curriculum in healthcare professional education, and public awareness campaigns. Another important idea was the creation of a “National Medications Spring Cleaning Day”: more than just returning unused or expired medications to the pharmacy, this campaign would aim to encourage the public to initiate medication reviews with a healthcare professional annually.
During the second group activity, attendees were invited to reflect on the ideas and strategies from the 2-day event to identify actionable items in their personal realm to promote medication appropriateness in their communities and network. Shared actionable items included contacting political representatives within their communities, keeping in touch with other attendees, sharing resources with their network and/or initiating medication reviews with their healthcare professionals.
4 Discussion: Overarching Themes from the National Meeting
Sessions from the CADeN 2023 National Meeting highlighted promising directions for future initiatives and areas of research in medication appropriateness and deprescribing, while identifying barriers that continue to persist. Addressing inequities in medication appropriateness was a key priority area to emerge from the National Meeting. Disparities in medication use exist across Canada, with older adults, women, ethnic minorities, and low-income populations experiencing higher rates of inappropriate medication use and subsequently lower health outcomes [8, 50]. Reforms to health policy are possible solutions to addressing these gaps in access for equity-deserving populations [40,41,42]. Furthermore, inequality in access to effective non-pharmacological alternatives to PIMs (e.g., access to cognitive behavioral therapy for insomnia in lieu of sedative hypnotics, as promoted by Sleepwell) remains an important barrier to reducing the healthcare sector’s increasing overuse of medications.
Ensuring equitable and appropriate medication use for indigenous populations was also emphasized as a priority. As illustrated by indigenous members’ testimonies, indigenous peoples are affected by the ongoing impacts of colonization and racism in healthcare, in addition to geographic, cultural, and socioeconomic barriers. It is evident that trust and relationships need to be built between indigenous communities and healthcare systems and researchers prior to identifying and addressing priority areas for medication appropriateness with these communities. Strategies to build relationships will also need to consider the cultural and geographical diversity of indigenous populations across Canada. Inuit, Metis, and First Nations communities from urban, rural, and remote areas may carry different attitudes towards and challenges in healthcare. Overall, engaging with equity-deserving patient populations and, when appropriate, developing and adapting resources to their unique contexts, will be essential in developing more inclusive and intersectional interventions promoting medication appropriateness in the future.
Throughout the National Meeting, patient and public engagement were identified as critical solutions to solving the polypharmacy problem in Canada. The inclusion and promotion of patient stories is a promising approach to getting the message out to the public, as was observed during one of the most powerful sessions of the National Meeting, when a patient partner described how the Sleepwell program helped with successfully stopping long-term benzodiazepines [51]. Demonstrating the interest for content such as this, patient videos uploaded to the Sleepwell website in November 2023 have been viewed over 1400 times to date. Patient collaboration has also been essential in the development of inclusive and culturally sensitive educational material, as demonstrated among indigenous communities and the University of British Columbia’s UPROOT project [38]. This reinforces the importance for organizations promoting medication appropriateness such as CADeN and deprescribing.org to engage with public partners across the country to promote medication appropriateness, as has been done extensively in the past years, working with dozens of community groups from different geographical and cultural backgrounds [16, 52].
The role of technology in promoting medication appropriateness was top of mind during the National Meeting, specifically for improving knowledge dissemination and access to health data. Online knowledge platforms such as the CADeN website [53], deprescribing.org [54], Sleepwell [24], the Therapeutics Initiative [55], and MedSafer [56] allow patients, experts, and healthcare providers to access medication appropriateness resources from any location. The vast dissemination of such resources is essential to build a collective awareness of medication appropriateness, to equip healthcare providers with the necessary tools to deprescribe in their practices, and to inform patients on the risks of inappropriate use. Technological innovations such as MedSafer have also proven to improve medication appropriateness within practices, by facilitating the medication review process for providers, cutting down on the time required to perform a comprehensive medication review [28]. Similarly, Therapeutics Initiative’s Portraits program leverages prescribing data to help healthcare providers evaluate and adjust their own prescribing behaviors if necessary [30]. Finally, the successful integration of ActionADE into British Columbia’s dispensing system PharmaNet demonstrated the potential that electronic information transfer holds in preventing patient harm [27, 57]. These different examples show the incredible potential of integrating technological solutions to large-scale initiatives promoting medication appropriateness for all Canadians.
Finally, the fragmentation of health systems was highlighted throughout sessions of the National Meeting as a very important barrier to medication appropriateness in Canada. Despite the growing availability of resources and initiatives, the health system’s landscape creates gaps in interprofessional collaboration and communication, preventing the large-scale implementation of evidence-based strategies promoting medication appropriateness. Furthermore, the recent publication of an interprofessional curricular framework for deprescribing [17] shows how the roll-out of clinical medication appropriateness activities strongly relies on health professionals’ knowledge of the subject, as well as collaboration with providers who are also involved in the care of their patients in different sectors (e.g., primary care, acute care, long-term care). Initiatives such as the SaferMedsNL [19] in Newfoundland and Labrador have leveraged the immense value of multistakeholder engagement to increase the reach of medication appropriateness initiatives and may help inform future work in this area. In line with these conclusions, the Pan-Canadian Medication Strategy for Appropriate Use, as presented by the CDATO, highlights the importance of focusing on improving collaboration between players of the healthcare system, including patients, healthcare providers, and health organizations.
5 Conclusions and CADeN’s Next Steps
Polypharmacy and inappropriate medication use are multifaceted issues. In 2017, the World Health Organization launched a medication without harm initiative [58], as the problem affects people around the world. Existing initiatives offer solutions to reduce patient harm and overprescribing by increasing public awareness, improving equitable access to medications and effective non-pharmacological therapies, ensuring availability of deprescribing resources for clinicians, streamlining processes in practice settings through increased collaboration and health technology initiatives, and leveraging a collective impact approach to ensure coordination among stakeholders. While these solutions have been promising, more work needs to be done for equity-deserving populations and to expand initiatives nationally, beyond local communities and regions. Changes to health policy, through collaboration between federal, provincial, and territorial collaborations will be essential for bridging these gaps in the future. In parallel, robust research mechanisms should be in place to ensure adequate implementation and evaluation of medication appropriateness processes and interventions.
The conclusions of the National Meeting strongly inform the future activities of CADeN to promote medication appropriateness in Canada. In collaboration with its numerous partners, CADeN will continue to build on the strength of its public voices, including its Public Awareness Committee, working to actively increase the diversity in this committee, and is creating a forum for indigenous perspectives and action through a separate committee formed and led by indigenous peoples. The network will continue to adapt existing resources and create new resources in collaboration with patient partners and communities that will meaningfully address medication-related needs of specific populations. CADeN will mobilize knowledge about its curricular framework for an interprofessional approach to deprescribing and enable academic institutions to incorporate it into curricula. Importantly, future initiatives to address polypharmacy and inappropriate medication use will largely rely on the leadership, coordination, funding, and policy efforts of the CDA to adopt an interdisciplinary, data-driven, and patient-focused approach to medication use for all Canadians. As such, CADeN will continue to work with others to support the CDATO as well as the CDA, including through further evolution of a collaborative that has brought together leading organizations in medication appropriateness in Canada to work towards a common purpose of promoting medication appropriateness using the skills and interests of each organization.
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This work was funded by Health Canada, Accelerating Clinical Trials Canada, and by an operating grant from the Canadian Institutes of Health Research (Grant no. MOP - 130529).
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Tiphaine Pierson has received research support from the Canadian Medication Appropriateness and Deprescribing Network, a health organization that receives funding from Health Canada, Accelerating Clinical Trials Canada, and the Canadian Institute of Health Research. Verna Arcand received travel support and speaker honoraria from the Canadian Medication Appropriateness and Deprescribing Network to attend the National Meeting. Barbara Farrell receives annual honoraria from the US Deprescribing Research Network for her participation as a member of their Scientific Advisory Board, as well as travel expenses from the latter and from the Canadian Medication Appropriateness and Deprescribing Network to attend annual meetings. Camille L. Gagnon is assistant director of the Canadian Medication Appropriateness and Deprescribing Network, a health organization that receives funding from Health Canada, the Canadian Institutes of Health Research, and Accelerated Clinical Trials Canada. Larry Leung received travel support from the Canadian Medication Appropriateness and Deprescribing Network to attend the National Meeting. He serves as a volunteer member of the board of directors for Indigicare Medicines Ltd. Lisa M. McCarthy received travel support from the Canadian Medication Appropriateness and Deprescribing Network to attend the National Meeting, and receives funding from Health Canada, Canadian Institutes of Health Research, Ontario Centres for Learning, Research & Innovation in Long-Term Care, and the University of Toronto. Andrea L. Murphy is a co-lead for Sleepwell and has received funding from the Drug Evaluation Alliance of Nova Scotia, and with the Canadian Medication Appropriateness and Deprescribing Network received funding from the Canadian Drug Agency Transition Office. Nav Persaud received travel support from the Canadian Medication Appropriateness and Deprescribing Network to attend the National Meeting, and receives research funding from the Canadian Institutes of Health Research, Ontario SPOR Support Unit, and St Michael’s Hospital Foundation. Lalitha Raman-Wilms received travel support from the Canadian Medication Appropriateness and Deprescribing Network to attend the National Meeting. James L. Silvius is the executive director of the Canadian Medication Appropriateness and Deprescribing Network, a health organization that receives funding from Health Canada, the Canadian Institutes of Health Research, and Accelerated Clinical Trials Canada. James L. Silvius is also the Provincial Medical Director for Seniors Health and Senior Medical Director at Alberta Health Services, and both the chair of the Canadian Drug Expert Committee and a member of the Formulary Management Expert Committee at Canada’s Drug and Health Technology Agency. Michael A. Steinman received travel support from the Canadian Medication Appropriateness and Deprescribing Network to attend the National Meeting, and receives royalties from UpToDate, as well as honoraria from the American Geriatrics Society. Cara Tannenbaum receives financial compensation through a university interchange in her role as departmental science advisor to Health Canada since 2020. Cara Tannenbaum co-founded CaDeN and was its co-director from 2015–2019. Wade Thompson received travel support from the Canadian Medication Appropriateness and Deprescribing Network to attend the National Meeting, received research funding from Health Canada, the Canadian Institutes of Health Research, Michael Smith Health Research BC, and National Institute on Aging (USA), and received an honorarium from Pharmacy Practice Plus magazine for an article on deprescribing. Johanna Trimble received travel support from the Canadian Medication Appropriateness and Deprescribing Network to attend the National Meeting. Cheryl A. Sadowski received travel support from the Canadian Medication Appropriateness and Deprescribing Network to attend the National Meeting, and received research funding from the Indigenous Wellness Core, the Social Sciences and Humanities Research Council, and the Indigenous Primary Health Care & Policy Research Network. Emily G. McDonald is the scientific director of the Canadian Medication Appropriateness and Deprescribing Network, a health organization that receives funding from Health Canada, the Canadian Institute of Health Research, and Accelerating Clinical Trials Canada. Emily G. McDonald has received funding from the Canadian Institute of Health Research and the Centre for Aging and Brain Health Innovation for her ongoing research evaluating the impact of MedSafer on prescribing practices. Emily G. McDonald is the CEO of MedSafer, the copyright for which is jointly held with McGill University and one other.
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Not applicable, these proceedings are a summary of the discussions and sessions held during the CADeN 2023 National Meeting, which took place in November 2023.
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A pamphlet with a description of the speakers who presented at the CADeN 2023 National Meeting is available from the corresponding author.
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All authors attended or presented at the CADeN 2023 National Meeting. The first draft of the manuscript was written by TP, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Senior authors EMcD and CS contributed equally to this manuscript. All authors read and approved the final version.
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Pierson, T., Arcand, V., Farrell, B. et al. Proceedings of the Canadian Medication Appropriateness and Deprescribing Network’s 2023 National Meeting. Drug Saf (2024). https://doi.org/10.1007/s40264-024-01444-2
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DOI: https://doi.org/10.1007/s40264-024-01444-2