Other Initiatives

  • Reducing resource use and waste in the OR and reducing the use of environmentally harmful anesthetic gases. Click here to learn more.

  • Identifying opportunities to increase the visibility and impact of sustainability efforts. Click here to learn more.

  • Determining how to assess and harness the environmental benefits of virtual care, learning, and work. Click here to learn more.

  • Ensuring commitment to advancing equitable outcomes both in the areas of climate mitigation and resilience. Click here to learn more.

  • Developing city-healthcare partnerships to explore opportunities for the healthcare sector to support city-led climate action. Click here to learn more.

  • Identifying opportunities to leverage healthcare purchasing for sustainability. Click here to learn more

Working Group

  • Working Group Lead

    • Kimberly Wintemute, Family Physician, Department of Family and Community Medicine, Assistant Professor, University of Toronto

    Working group members

    • Jean Wilson, Assistant Professor, Bloomberg Faculty of Nursing; Primary Health Care Nurse Practitioner

    • Lisa Dolovich, Dean, Leslie Dan Faculty of Pharmacy, UT

    Panelists

    • Samantha Green, Family Physician, Assistant Professor, and Co-Lead in Climate Change and Health, Department of Family and Community Medicine, University of Toronto

    • Brenda Chang, Clinical Pharmacy Practitioner, St. Michael's Hospital Academic Family Health Team

    • Gabrielle Busque, BSc, PharmD

    Secretariat

    • Fiona Miller, Professor, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health; Director, CSHS

    • Naba Khan, Research Assistant, CSHS

  • Working Group Lead

    • Kimberly Wintemute, Family Physician, Assistant Professor, Department of Family and Community Medicine, University of Toronto

    Working group members

    • Samantha Green, Family Physician, Assistant Professor, Department of Family and Community Medicine, University of Toronto

    • Karen Cameron, Assistant Professor and Course Coordinator, Leslie Dan Faculty of Pharmacy, University of Toronto

    Secretariat

    • Fiona Miller, Director, Centre for Sustainable Health Systems, University of Toronto & CASCADES

    • Brittany Maguire, Managing Director, Centre for Sustainable Health Systems, University of Toronto

    • Aileen Liu, PharmD Candidate; Research Assistant, Centre for Sustainable Health Systems

About the Community of Practice Primary Care Sustainability Working Group

The Primary Care Sustainability Working Group is focused on identifying and supporting interventions in primary care that can contribute to:

  1. Climate mitigation through appropriate use of medications (reduction and alternatives). Reducing unnecessary use of metered-dose inhalers was identified as a high impact opportunity for climate mitigation and quality improvement.  

  2. Climate resilience by identifying and providing support to people vulnerable to the impacts of climate change. The Primary Care Working Group is currently working towards developing a pilot intervention.

1. Reducing Unnecessary use of Metered-dose Inhalers

Metered-dose inhalers (MDIs) are common medical devices used to deliver inhaled medication, typically for individuals with asthma or chronic obstructive pulmonary disease (COPD).

MDIs contain high levels of hydrofluorocarbons (HFCs) that act as potent greenhouse gases (GHGs) when released into the atmosphere, contributing to the healthcare sector’s carbon footprint. Hydrofluorocarbons emissions from Metered-dose inhalers mostly come from the use-phase when propellants are released into the atmosphere.

Through continuing professional development and quality improvement, we have been encouraging the following strategies to reduce the carbon impact of inhalers:

  • Encourage suitable prescribing practices for inhalers

  • Encourage environmentally preferable alternatives to MDIs, such as dry-powder inhalers (DPIs), whenever appropriate

  • Facilitate appropriate inhaler technique

  • Practice sustainable recovery and recycling of inhalers

We have sought to facilitate provider awareness about the climate impact of inhalers and to foster understanding of how inhalers can be sustainably prescribed.

  • In 2021, we designed and delivered a peer-to-peer educational intervention and generated resources to support practice change.

    With support from CASCADES to engage patient partners and garner feedback from a National Advisory Committee, our resources were refined and adapted into a Playbook, which can be accessed on the CASCADES website here.

  • To better understand whether local academic primary care teams were positioned to use the materials and resources that had been generated, the Working Group conducted discussions with expert stakeholders across the 14 Family Health Teams affiliated with the Toronto Academic Health Science Network. The results were used to generate a score card and an overview of key change opportunities and challenges. A copy of the score card can be viewed and downloaded here.

The Working Group appreciates the support of the Lawrence S. Bloomberg Faculty of Nursing, the Leslie Dan Faculty of Pharmacy, and the University of Toronto Department of Family and Community Medicine.

2. Building Climate Resilience for Vulnerable Persons

Climate change is associated with an increased frequency and severity of severe weather events, the nature of which depends on local weather patterns. In our region, heat waves are one kind of severe weather event that affects health.

Certain people are more vulnerable to the negative health effects of heat waves. Primary care data may be able to identify these people. Cities and regional municipalities may be positioned to provide services that would protect people from negative health outcomes.

The Working Group is currently exploring how we could work with city and regional partners to protect our vulnerable patients from the negative health consequences of heat waves.

On June 1, 2023 the Working Group hosted a Heat Vulnerability Roundtable with the aim to:

  • Introduce the idea that primary care and community pharmacy can address heat

  • Understand heat risk and vulnerabilities: current knowledge and initiatives

  • Discuss potential ways for primary care and community pharmacy to address

    heat risks, and consider what might be needed to achieve those aspirations

For more details on the presentations and discussion, see the event summary and slides. Please find Health Canada’s presentation deck in French here.


Archived Content

Included below are the educational and practice change resources developed and delivered in 2021. These have been updated and incorporated into the CACSADES Playbook. Please visit CASCADES for the most up-to-date resources.

Educational Webinar on Low-Carbon Inhalers


mdi snapshot.png

Sustainable Inhalers Snapshot

This “snapshot” document details the climate impact of metered dose inhalers (MDIs), low-carbon alternatives, and interventions already in place around the world. It also features an infographic containing key information on the topic.


Screenshot 2021-05-20 234929.jpg

Inhaler Alternative Charts

Charts showing the low-carbon alternative prescriptions for metered-dose inhalers (MDIs). Also features a chart showing the Ontario Drug Benefit coverage options for suggested alternatives.


Prescription Renewal Request Letter

Sample letter to patients requiring an MDI prescription renewal outlining the environmental benefits of switching to a DPI.

Developed by Dr. Kimberly Wintemute.

Dear Patient,

Your pharmacy has asked me to renew your salbutamol (blue inhaler).

OR

I am writing about the inhaler that I have prescribed for you in the past.

I wonder if you would you be open to trying a different type of inhaler that delivers the medication better. You’ve been using the “aerosol” inhaler. We are moving away from these because the aerosol that pushes the puff out of the container is a strong greenhouse gas. These kinds of inhalers are worsening the climate change problem.

A greener alternative to your aerosol puffer would be “Bricanyl Turbuhaler”, which produces 10 times less greenhouse gases. It contains the medication called terbutaline, which works the same as salbutamol. It looks like a small cylinder, and is called a “turbuhaler”. There is no aerosol, so it looks, sounds and feels different. Here is a link to a video that shows you how to use it: www.youtube.com/watch?v=02OPJUlsuhQ

Please let me know if you are OK to try the Bricanyl. If you want to talk more about this, please contact the office to set an appointment with me.

Sincerely,

Your Health Care Provider


Pharmaceutical Opinion Letter

Letter than pharmacists can send to a prescriber for a medication recommendation regarding an ODB patient, which they can bill the government for compensation for the recommendation.

Developed by Ms. Jessica Visentin, South East Toronto Pharmacist.

Dear Dr. _______ {prescriber name},

RE: _________________ {patient name} DOB: ____________

This patient requested a refill of their _______ {inhaler name}. We have filled this prescription for the time being, but would like to suggest a switch to ____________ {new inhaler name} in advance of future refills.

This is in an effort to opt for a more environmentally sustainable option, as MDIs use a propellant that contain a potent greenhouse gas and contributes to climate change. 100 doses MDI = 290 km car ride

For more details, see: https://www.sustainablehealthsystems.ca/inhalers

{if suggesting a switch from Ventolin to Symbicort for asthma patient, include the following}

In addition, the latest GINA guidelines recommend combination formeterol-budesonide (Symbicort) first line as both reliever and controller medication for asthma treatment.

{choose one of the following}

Please note, we have discussed this with the patient and they are open to switching inhalers.

OR

Please note, we have not yet had a chance to discuss this with the patient. If you have the opportunity, we would encourage you to do so.

Regards,

Pharmacy Team


Patient Considerations for Inhaler Choice

Comparison of patient considerations and recommendations for the prescribing of MDIs, MDIs with spacers, and DPIs.


InhalerPosterOP2v3 (2)-1.png

Inhaler Switch Poster

Posters can be put up in offices or sent in online newsletters to encourage patients to consider and inquire about switching from an MDI to a DPI.


Prescription Favourites (EMR)

Typing brand name of a commonly prescribed inhaler will create “pop up” prescription favourite that shows options for alternative prescribing.


Inhaler Prescribing Tracking Tools

These tools have been developed at Unity Health by Dr. Mo Alhaj, Clinical Pharmacist Brenda Chang, Dr. Shima Shakory-Bakhtiar, and Dr. Samantha Green.

This document includes the search parameters used for all the medications that our team classified as inhalers. This search can be used in Practice Solutions EMR to determine the numbers of inhalers that have been prescribed.

This category sheet (.xlsx) further classifies the search output into MDIs and DPIs and can be used to organize the data.


Correct Inhaler Usage Resources

Canadian Lung Association: How to use your inhaler - https://www.lung.ca/lung-health/get-help/how-use-your-inhaler


If you’d like to share any ideas, questions, or resources, please email cshs@utoronto.ca.