Irfan A Dhalla

Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada

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Publications (56)346.16 Total impact

  • Irfan A Dhalla, Sumit R Majumdar
    Journal of general internal medicine. 09/2014;
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    ABSTRACT: To describe trends in rates of prescribing of high-dose opioid formulations and variations in opioid product selection across Canada.
    Canadian family physician Médecin de famille canadien. 09/2014; 60(9):826-32.
  • Michael Law, Jillian Kratzer, Irfan Dhalla
    07/2014; 186(10):779.
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    ABSTRACT: Background and AimsThe burden of premature mortality due to opioid-related death has not been fully characterized. We calculated temporal trends in the proportion of deaths attributable to opioids and estimated years of potential life lost (YLL) due to opioid-related mortality in Ontario, Canada.DesignCross-sectional study.SettingOntario, Canada.ParticipantsIndividuals who died of opioid-related causes between January 1991 and December 2010.MeasurementsWe used the Registered Persons Database and data abstracted from the Office of the Chief Coroner to measure annual rates of opioid-related mortality. The proportion of all deaths related to opioids was determined by age group in each of 1992, 2001 and 2010. The YLL due to opioid-related mortality were estimated, applying the life expectancy estimates for the Ontario population.FindingsWe reviewed 5935 opioid-related deaths in Ontario between 1991 and 2010. The overall rate of opioid-related mortality increased by 242% between 1991 (12.2 per 1 000 000 Ontarians) and 2010 (41.6 per 1 000 000 Ontarians; P < 0.0001). Similarly, the annual YLL due to premature opioid-related death increased threefold, from 7006 years (1.3 years per 1000 population) in 1992 to 21 927 years (3.3 years per 1000 population) in 2010. The proportion of deaths attributable to opioids increased significantly over time within each age group (P < 0.05). By 2010, nearly one of every eight deaths (12.1%) among individuals aged 25–34 years was opioid-related.Conclusions Rates of opioid-related deaths are increasing rapidly in Ontario, Canada, and are concentrated among the young, leading to a substantial burden of disease.
    Addiction 07/2014; · 4.58 Impact Factor
  • Reena Pattani, Peter E Wu, Irfan A Dhalla
    05/2014;
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    ABSTRACT: Guidance regarding appropriate and cost-effective use of prescription drugs is published in the Ontario Drug Benefit Formulary in the form of "therapeutic notes." We conducted a cross-sectional study of all residents of Ontario aged 66 and older who received a new prescription for one of two drugs, aliskiren or sitagliptin, between December 1, 2008 and March 31, 2012 to determine how frequently such guidance is followed. Approximately half of initial prescriptions for aliskiren and sitagliptin were prescribed in a manner that did not conform to the therapeutic note recommendations (51.4% and 49.3%, respectively). Given this high rate of non-conformance, policy makers may wish to use other mechanisms to influence prescriber behaviour to improve the quality and efficiency of healthcare.
    05/2014; 9(4):20-30.
  • Michael R Law, Jillian Kratzer, Irfan A Dhalla
    Canadian Medical Association Journal 03/2014; · 6.47 Impact Factor
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    ABSTRACT: Generic drugs offer a less expensive and therapeutically equivalent alternative to brand name drugs. Nevertheless, many Canadian private drug plans continue to pay for brand name drugs even after generics become available. The objective of this study was to quantify the excess spending resulting from this practice. We used the IMS Brogan PharmaStat database to study private-plan drug spending in Ontario from 2000 to 2009. We focused on three widely used drug classes: proton pump inhibitors (PPIs), selective serotonin reuptake inhibitors (SSRIs), and angiotensin-converting enzyme (ACE) inhibitors. For each specific molecule, we determined the difference between what private plans spent on the brand name version and what would have been spent if an available generic version of the same molecule had been purchased instead. We found that prescriptions paid for by private drug plans were often filled with brand name drugs after generics became available. This led to excess private spending of more than Can$107.8 million for these three drug classes over our study period: Can$54.4 million for PPIs, Can$32.4 million for SSRIs and Can$21.0 million for ACE inhibitors. Brand name drugs continue to be reimbursed by Canadian private drug plans at higher prices even after less expensive generic alternatives are available. By mandating generic substitution, substantial cost savings on benefit plans could be achieved.
    Applied Health Economics and Health Policy 08/2013;
  • Annals of internal medicine 06/2013; 158(12):923-4. · 13.98 Impact Factor
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    ABSTRACT: OBJECTIVE: To examine the effects of an intensive 2-day course on physicians' prescribing of opioids. DESIGN: Population-based retrospective observational study. SETTING: College of Physicians and Surgeons of Ontario (CPSO) in Toronto. PARTICIPANTS: Ontario physicians who took the course between April 1, 2000, and May 30, 2008. INTERVENTION: A 2-day opioid-prescribing course with a maximum of 12 physician participants. Educational methods included didactic presentations, case discussions, and standardized patients. A detailed syllabus and office materials were provided. MAIN OUTCOME MEASURES: Participants were matched with control physicians using specific variables. The primary outcome was the rate of opioid prescribing, expressed as milligrams of morphine equivalent per quarter. RESULTS: One hundred thirty-eight course participants (120 family physicians, 15 specialists, and 3 physicians whose status was uncertain) were eligible for analysis. Of these, 68.1% were self-referred and 31.9% were referred by the CPSO. Overall, among physicians referred by the CPSO, the rate of opioid prescribing decreased dramatically in the year before course participation compared with matched control physicians. The course had no added effect on the rate of physicians' opioid prescribing in the subsequent 2 years. There was no statistically significant effect on the rate of opioid prescribing observed among the self-referred physicians. Among 15 of the self-referred physicians who, owing to the high quantities of opioids they prescribed, were not matched with control physicians, the rate of opioid prescribing decreased by 43.9% in the year following course completion. CONCLUSION: Physicians markedly reduced the quantities of opioids they prescribed after medical regulators referred them to an opioid-prescribing course. The course itself did not lead to significant additional reductions; however, a subgroup of physicians who prescribed high quantities of opioids might have responded to what was taught in the course.
    Canadian family physician Medecin de famille canadien 05/2013; 59(5):e231-e239. · 1.19 Impact Factor
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    ABSTRACT: Background: Some evidence suggests that chlorthalidone may be superior to hydrochlorothiazide for the treatment of hypertension. Objective: To compare the effectiveness and safety of chlorthalidone and hydrochlorothiazide in older adults. Design: Propensity score–matched observational cohort study with up to 5 years of follow-up. Setting: Ontario, Canada. Patients: All individuals aged 66 years or older who were newly treated with chlorthalidone or hydrochlorothiazide and were not hospitalized for heart failure, stroke, or myocardial infarction in the prior year were eligible for inclusion. Each chlorthalidone recipient was matched to up to 2 hydrochlorothiazide recipients on the basis of age, sex, year of treatment initiation, and propensity score. Measurements: The primary outcome was a composite of death or hospitalization for heart failure, stroke, or myocardial infarction. Safety outcomes included hospitalization with hypokalemia or hyponatremia. Results: A total of 29 873 patients were studied. During follow-up, chlorthalidone recipients (n = 10 384) experienced the primary outcome at a rate of 3.2 events per 100 person-years of follow-up, and hydrochlorothiazide recipients experienced 3.4 events per 100 person-years of follow-up (adjusted hazard ratio, 0.93 [95% CI, 0.81 to 1.06]). Patients treated with chlorthalidone were more likely to be hospitalized with hypokalemia (adjusted hazard ratio, 3.06 [CI, 2.04 to 4.58]) or hyponatremia (adjusted hazard ratio, 1.68 [CI, 1.24 to 2.28]). In 9 post hoc analyses comparing patients initially prescribed 12.5, 25, or 50 mg of chlorthalidone per day with those prescribed 12.5, 25, or 50 mg of hydrochlorothiazide per day, the former were more likely to be hospitalized with hypokalemia for all 6 comparisons in which a statistically significant association was found. The results of other effectiveness and safety outcomes were also consistent with those of the main analysis. Limitation: Unmeasured differences in baseline characteristics or physician treatment approaches or an insufficiently large sample may have limited the ability to detect small differences in the comparative effectiveness of the drugs. Conclusion: As typically prescribed, chlorthalidone in older adults was not associated with fewer adverse cardiovascular events or deaths than hydrochlorothiazide. However, it was associated with a greater incidence of electrolyte abnormalities, particularly hypokalemia. Primary Funding Source: Ontario Ministry of Health and Long-Term Care.
    Annals of internal medicine 03/2013; 158(6):447-455. · 13.98 Impact Factor
  • David N Juurlink, Irfan A Dhalla, Lewis S Nelson
    JAMA The Journal of the American Medical Association 03/2013; 309(9):879-80. · 29.98 Impact Factor
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    ABSTRACT: BACKGROUND Use of opioids may predispose drivers to road trauma, yet the effect of opioid dose on this association is unknown. METHODS We conducted a population-based nested case-control study of patients aged 18 to 64 years who received at least 1 publicly funded prescription for an opioid from April 1, 2003, through March 31, 2011. Cases were defined as having an emergency department visit related to road trauma. Patients without road trauma served as a control group matched to cases by age, sex, index year, prior road trauma, and a disease risk index. We compared the risk of road trauma among patients treated with doses of opioids ranging from very low to very high (<20 to ≥200 morphine equivalents daily). In a subgroup analysis, we stratified our analysis by driver status. RESULTS Among 549 878 eligible adults, we identified 5300 cases with road trauma and matched an equal number of controls. Multivariate adjustment yielded no significant association between escalating opioid dose and odds of road trauma (adjusted odds ratio ranged between 1.00 and 1.09). However, a significant association between opioid dose and road trauma was observed among drivers. Compared with very low opioid doses, drivers prescribed low doses had a 21% increased odds of road trauma (adjusted odds ratio, 1.21 [95% CI, 1.02-1.42]); those prescribed moderate doses, 29% increased odds (1.29 [1.06-1.57]); those prescribed high doses, 42% increased odds (1.42 [1.15-1.76]); and those prescribed very high doses, 23% increased odds (1.23 [1.02-1.49]). CONCLUSIONS Among drivers prescribed opioids, a significant relationship exists between drug dose and risk of road trauma. This association is distinct and does not appear with passengers, pedestrians, and others injured in road trauma.
    JAMA Internal Medicine 01/2013; · 10.58 Impact Factor
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    ABSTRACT: Medication non-adherence frequently leads to suboptimal patient outcomes. Primary non-adherence, which occurs when a patient does not fill an initial prescription, is particularly important at the time of hospital discharge because new medications are often being prescribed to treat an illness rather than for prevention. We studied older adults consecutively discharged from a general internal medicine service at a large urban teaching hospital to determine the prevalence of primary non-adherence and identify characteristics associated with primary non-adherence. We reviewed electronic prescriptions, electronic discharge summaries and pharmacy dispensing data from April to August 2010 for drugs listed on the public formulary. Primary non-adherence was defined as failure to fill one or more new prescriptions after hospital discharge. In addition to descriptive analyses, we developed a logistical regression model to identify patient characteristics associated with primary non-adherence. There were 493 patients eligible for inclusion in our study, 232 of whom were prescribed new medications. In total, 66 (28%) exhibited primary non-adherence at 7 days after discharge and 55 (24%) at 30 days after discharge. Examples of medications to which patients were non-adherent included antibiotics, drugs for the management of coronary artery disease (e.g. beta-blockers, statins), heart failure (e.g. beta-blockers, angiotensin converting enzyme inhibitors, furosemide), stroke (e.g. statins, clopidogrel), diabetes (e.g. insulin), and chronic obstructive pulmonary disease (e.g. long-acting bronchodilators, prednisone). Discharge to a nursing home was associated with an increased risk of primary non-adherence (OR 2.25, 95% CI 1.01-4.95). Primary non-adherence after medications are newly prescribed during a hospitalization is common, and was more likely to occur in patients discharged to a nursing home.
    PLoS ONE 01/2013; 8(5):e61735. · 3.73 Impact Factor
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    ABSTRACT: Most evaluative research is focused on assessing new technologies at the patient level. Comparatively little is focused on assessing how system changes could improve the delivery of healthcare. In this article, the authors describe an opportunity to conduct evaluative trials of system changes affordably and efficiently by using a cluster randomized design and mandatory reporting data, using the prevention of Clostridium difficile infection as an example. They then describe what must be done to make similar trials a regular tool of healthcare policy.
    Healthcare quarterly (Toronto, Ont.) 01/2013; 16(3):22-6.
  • Noah Ivers, Irfan A Dhalla, G Michael Allan
    Canadian family physician Medecin de famille canadien 12/2012; 58(12):e708. · 1.19 Impact Factor
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    ABSTRACT: We used data collected in the 2010 National Physician Survey and public payment data published in the Institute for Clinical and Evaluative Sciences report Payments to Ontario Physicians from Ministry of Health and Long-Term Care Sources 1992/93 to 2009/10 to estimate 2009/2010 net physician income from public payments for Ontario physicians by specialty. Incorporating overhead substantially affects estimates of physician income and changes relative position. For example, ophthalmologists were ranked second when only public payments were considered but eighth when overhead was included. Conversely, hospital-based specialties such as anaesthesia, radiation oncology and emergency medicine rank significantly higher after overhead is included.
    Healthcare policy = Politiques de sante 11/2012; 8(2):30-36.
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    David N Juurlink, Irfan A Dhalla
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    ABSTRACT: The use of opioids for chronic noncancer pain has increased dramatically over the past 25 years in North America and has been accompanied by a major increase in opioid addiction and overdose deaths. The increase in opioid prescribing is multifactorial and partly reflects concerns about the effectiveness and safety of alternative medications, particularly the nonsteroidal anti-inflammatory drugs. However, much of the rise in opioid prescribing reflects the assertion, widely communicated to physicians in the 1990s, that the risks of dependence and addiction during chronic opioid therapy were low, predictable, and could be minimized by the use of controlled-release opioid formulations. In this narrative review, we offer a critical appraisal of the publications most frequently cited as evidence that the risk of addiction during chronic opioid therapy is low. We conclude that very few well-designed studies support the notion that opioid addiction is rare during chronic opioid therapy and that none can be readily generalized to present-day practice. Despite serious methodological limitations, these studies have been repeatedly mischaracterized as showing that the risk of addiction during chronic opioid therapy is rare. These studies are countered by a larger, more rigorous and contemporary body of evidence demonstrating that dependence and addiction are relatively common consequences of chronic opioid therapy, occurring in up to one-third of patients in some series.
    Journal of medical toxicology: official journal of the American College of Medical Toxicology 10/2012;
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    ABSTRACT: Ranjit Kaur is an 83-year-old woman who is brought to the hospital by her son because of worsening shortness of breath over the previous week. The emergency room physician correctly diagnoses a heart failure exacerbation (Wang et al. 2005), initiates appropriate treatment (Felker et al. 2011) and consults the hospitalist physician for admission and ongoing care (Wachter 2004).The hospitalist learns that the patient has been prescribed the various medications recommended by clinical practice guidelines and that her adherence to this medication regimen is excellent. No specific trigger for the heart failure exacerbation is found, and the hospitalist concludes that the most likely explanation is a gradual decline in cardiovascular function, perhaps combined with excessive sodium intake. The day after admission, a dietitian meets with the patient and her daughter-in-law to discuss how her diet could be modified to reduce her sodium intake. Three days after admission, Ms. Kaur is "back to baseline" and ready for discharge. The hospitalist discharges her on a slightly higher dose of her diuretic and instructs Ms. Kaur to see her family physician within a week of discharge. She is sent home with a discharge summary in hand that clearly explains the care provided in hospital and the follow-up plan. In other words, the emergency department and in-patient care are "textbook." The admission is brief and efficient, there are no complications and Ms. Kaur's symptoms are substantially improved. Nevertheless, three weeks after discharge, Ms. Kaur is brought back to the emergency department because of confusion. Her blood work in the emergency department shows a dangerously low sodium level. This adverse event may occur after a change in diuretic dose, and can be prevented or managed with careful follow-up after discharge.
    Nursing leadership (Toronto, Ont.) 04/2012; 15(sp):63-67.
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    ABSTRACT: Many patients do not adhere to treatment because they cannot afford their prescription medications, putting them at increased risk of adverse health outcomes. We determined the prevalence of cost-related nonadherence and investigated its associated characteristics, including whether a person has drug insurance. Using data from the 2007 Canada Community Health Survey, we analyzed the responses of 5732 people who answered questions about cost-related nonadherence to treatment. We determined the national prevalence of cost-related nonadherence and used logistic regression to evaluate the association between cost-related nonadherence and a series of demographic and socioeconomic variables, including province of residence, age, sex, household income, health status and having drug insurance. Cost-related nonadherence was reported by 9.6% (95% confidence interval [CI] 8.5%-10.6%) of Canadians who had received a prescription in the past year. In our adjusted model, we found that people in poor health (odds ratio [OR] 2.64, 95% CI 1.77-3.94), those with lower income (OR 3.29, 95% CI 2.03-5.33), those without drug insurance (OR 4.52, 95% CI 3.29-6.20) and those who live in British Columbia (OR 2.56, 95% CI 1.49-4.42) were more likely to report cost-related nonadherence. Predicted rates of cost-related nonadherence ranged from 3.6% (95% CI 2.4-4.5) among people with insurance and high household incomes to 35.6% (95% CI 26.1%-44.9%) among people with no insurance and low household incomes. About 1 in 10 Canadians who receive a prescription report cost-related nonadherence. The variability in insurance coverage for prescription medications appears to be a key reason behind this phenomenon.
    Canadian Medical Association Journal 02/2012; 184(3):297-302. · 6.47 Impact Factor

Publication Stats

583 Citations
346.16 Total Impact Points

Institutions

  • 2012–2014
    • Institute for Clinical Evaluative Sciences
      Toronto, Ontario, Canada
    • Queen's University
      • Department of Ophthalmology
      Kingston, Ontario, Canada
  • 2002–2014
    • University of Toronto
      • Department of Medicine
      Toronto, Ontario, Canada
  • 2013
    • Women's College Hospital
      Toronto, Ontario, Canada
  • 2009–2012
    • St. Michael's Hospital
      Toronto, Ontario, Canada
  • 2011
    • Sunnybrook Health Sciences Centre
      Toronto, Ontario, Canada
  • 2010
    • University of Alberta
      • Faculty of Medicine and Dentistry
      Edmonton, Alberta, Canada