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National interventions to promote HMRs, comprising patient‐specific prescriber feedback and tailored educational materials for patients and clinicians, were conducted in 2004, 2006 and 2011 through the Veterans’ Medicines Advice and Therapeutics Education Services (Veterans’ MATES) program. Primary care patients taking multiple medicines were targeted in each intervention, while primary care patients taking multiple medicines who did not receive the intervention served as comparisons. Monthly HMR rates among targeted patients and a comparison group in the 9 months post‐intervention were determined using health claims data from the Australian Government Department of Veterans’ Affairs and compared using log binomial regression models. Overall trends in the rate of HMRs between November 2001 and December 2016 were also determined. Refereed/Peer-reviewed

Background: Problems with achieving the continuum of medicines management are long-standing. Audits are valuable in improving medication management and the quality and safety of healthcare systems. Aim: To evaluate the accuracy and timeliness of electronic discharge summaries (EDS) provided to patients and their primary care providers at discharge. This was a forerunner to the study hospital’s National Accreditation Examination and for routine safety and quality evaluation. Methods: This study was a retrospective audit using an adaptation of the NSW indicator 5.3, ‘Percentage of discharge summaries that include medication therapy changes and explanations for changes’ (National quality use of medicines indicators for Australian Hospitals. ACSQHC, Sydney, NSW, 2014). The additions to the NSW tool included: assessing the completion and timeliness of delivery to primary health care providers, and the accuracy of the information. Results: In patients leaving hospital, 75% had a hospital EDS completed, with 46% completed within the recommended 48 h from discharge. For an EDS to be delivered, a primary healthcare provider must be nominated by the patient. This occurred in 53% of our sample. Accuracy of information on what medicines patients should use post-discharge was also assessed. It indicated 46% accuracy, with the majority of erro rs being omissions of required medicines. None of the EDSs included documented reasons for changes to medicines, in the provided table, to the primary healthcare provider. In patients on a short-term therapy, such as antibiotics, 71% of EDSs had documented a plan for short-term therapies to be completed in the community. Conclusion: The lack of information on the primary care provider recorded in the patient’s clinical system and discharge summaries, limited the timely transfer of essential information on post-discharge medicine management to the patient’s primary care provider. Work has commenced on an educational program to improve data entry of the patient’s primary care provider when they are admitted, and plans to improve compliance with the EDS policy. Results: In patients leaving hospital, 75% had a hospital EDS completed, with 46% completed within the recommended 48 h from discharge. For an EDS to be delivered, a primary healthcare provider must be nominated by the patient. This occurred in 53% of our sample. Accuracy of information on what medicines patients should use post-discharge was also assessed. It indicated 46% accuracy, with the majority of erro rs being omissions of required medicines. None of the EDSs included documented reasons for changes to medicines, in the provided table, to the primary healthcare provider. In patients on a short-term therapy, such as antibiotics, 71% of EDSs had documented a plan for short-term therapies to be completed in the community. Conclusion: The lack of information on the primary care provider recorded in the patient’s clinical system and discharge summaries, limited the timely transfer of essential information on post-discharge medicine management to the patient’s primary care provider. Work has commenced on an educational program to improve data entry of the patient’s primary care provider when they are admitted, and plans to improve compliance with the EDS policy. Conclusion: The lack of information on the primary care provider recorded in the patient’s clinical system and discharge summaries, limited the timely transfer of essential information on post-discharge medicine management to the patient’s primary care provider. Work has commenced on an educational program to improve data entry of the patient’s primary care provider when they are admitted, and plans to improve compliance with the EDS policy. Refereed/Peer-reviewed

Objective: To examine recent trends in the use of secondary stroke prevention medicines by transient ischaemic attack (TIA) and ischaemic stroke survivors. Design, setting and participants: Retrospective observational study of patients aged 65 years who were hospitalised with a TIA or ischaemic stroke between January 2000 and December 2009. Use of antihypertensive, antithrombotic and lipid-lowering medicines by patients was determined monthly, using claims data from the Australian Government Department of Veterans’ Aff airs, commencing in January 2003. Main outcome measure: Monthly prevalence of use of secondary stroke prevention medicines. Results: Between 2003 and 2009, small increases in use (less than 2% relative increase annually) were observed for antihypertensive and antithrombotic medicines among 19 019 patients. There was a 9% relative increase in use of lipid-lowering therapy each year. The proportion of patients dispensed all three recommended medicine classes nearly doubled over the 7-year period. By December 2009, about 80% of patients were dispensed an antihypertensive, 75% received an antithrombotic and 60% were dispensed lipid-lowering therapy. Almost half of the population were dispensed all three recommended classes by the end of the study period. Conclusions: Increased use of secondary stroke prevention medicines was shown in this study, in accordance with national stroke guideline recommendations and initiatives supporting quality use of medicines in Australia. There may be opportunity to further increase use of these medicines among older Australians who have had a TIA or ischaemic stroke. Refereed/Peer-reviewed

Objective To explore South Australian (SA) pharmacy interns' values, beliefs and motivations to study pharmacy and their assessment of how well their pharmacy education has prepared them for activities required of all health professionals under Australia's health care reforms. Methods A postal questionnaire was sent to all 136 SA pharmacy interns enrolled in SA intern training programmes in February 2010 (second month of the intern training programme). Key findings Sixty (44%) of SA pharmacy interns responded; 75% selected pharmacy as a career because of an interest in health-related sciences and 65% valued working with patients. Respondents believed their pharmacy education prepared them for patient care (80%), providing medicine information (72%) and primary health care delivery (68%), but 51% indicated that they were not prepared for multidisciplinary team care. Conclusions The positive values, beliefs and motivations expressed by respondents are significant behavioural precursors to meet the requirements of health professionals in Australia's health care reforms. Respondents indicated that their pharmacy education provided appropriate training in a number of relevant professional areas.

Aim To identify the characteristics of patients who receive home medicines reviews (HMRs). Method A retrospective analysis was conducted of the Department of Veterans' Affairs administrative claims data. Veterans living in the community on 30 June 2009 were included if they had ≥ 1 medicines dispensed in the previous 12 months. The main outcome measure was the number of veterans who received an HMR. Log binomial regression analysis compared characteristics of HMR recipients and non-recipients – age and gender; number of medicines, prescribers, dispensing pharmacies and hospitalisations in the previous year; and conditions where medicine use is potentially problematic, e.g. dementia. Results Of the 175 572 veterans included in the study, 6236 (3.6%) had received an HMR. The likelihood of having an HMR increased with age, number of medicines and number of GP visits. Women were 12% more likely to receive an HMR than men. Veterans who had received an HMR previously were 4 times more likely to have another HMR. Veterans with 1 to 4 hospitalisations were 10% more likely to receive an HMR than those who had not been hospitalised. The likelihood of having an HMR decreased with the number of dispensing pharmacies and specialist visits. Conclusion Patients who received HMRs had characteristics that placed them at risk of medication-related problems. The uptake of HMRs was appropriate in our study population.

To date, the investigation of teratogenic effects of medications has largely focused on physical alterations present at birth (i.e. malformations) as opposed to functional alterations (i.e. neurodevelopment, metabolic function) that may not be apparent at birth but could influence an individual’s health and risk of disease in later life. The use of routinely collected health data represents one approach to better identifying, quantifying, and understanding the long-term risks or benefits of medication use during pregnancy. As such, the objective of this review was to identify and explore opportunities and challenges associated with using routinely collected health data to examine long-term effects of medication use during pregnancy. Drawing on published research several key methodological issues associated with their use in investigating long-term outcomes are reviewed. While significant opportunities exist to make greater use of routinely collected health data, there are a number of key challenges. Identified challenges relate to aspects of study design and analysis, and include obtaining access to data, the ability to match records across datasets and over long periods of time, how medication exposures are ascertained and classified, issues around loss to follow-up how outcomes are ascertained and classified, and the careful interpretation of results in light of study and data limitations. Understanding key challenges associated with using routinely collected health data to investigate long-term effects of medication use during pregnancy is essential in supporting their appropriate use and interpretation, which will contribute to improving the quality of research undertaken and ensure the reliability of results obtained. Refereed/Peer-reviewed

In the absence of randomised controlled trials, knowledge of outcomes associated with medication use during pregnancy is dependent on observational studies. Numerous observational study designs exist, with the decision on which is most appropriate depending on a number of factors, including the exposure and outcome under investigation and knowledge of key methodological issues. This review provides an overview of the key methodological issues involved in undertaking observational studies to investigate medication use during pregnancy, including selection bias, exposure and outcome classification, information bias, confounding and statistical analysis. This review also discusses observational study types used to investigate outcomes associated with medication use during pregnancy and summarises their relative strengths and weaknesses. Knowledge of the strengths, weaknesses and methodological issues associated with observational studies can assist clinicians in making assessments about the validity and applicability of results presented in order to provide the best recommendations to patients. Refereed/Peer-reviewed

Since 2004, the Department of Veterans’ Affairs (DVA) has funded the Veterans’ Medicines Advice and Therapeutics Education Services (MATES) program. The main intervention of the program is quarterly targeted patient-specific prescriber feedback. The feedback comprises a list of relevant medications dispensed to each patient and notes about potential medicationrelated problems specific to the intervention. Supportive educational material is provided to assist general practitioners (GPs) resolve these medication-related problems. Veterans identified in the GP mailing are sent an educational brochure highlighting medication issues and encouraging them to speak with their doctor. To enable pharmacists to support this practice change, educational material is also provided to all pharmacies and accredited pharmacists. The most recent of the 28 interventions implemented to date have addressed osteoporosis, opioid-induced constipation and urinary incontinence. Overall, program materials have been mailed to 249 454 veterans, 34 527 GPs and around 8000 pharmacies and accredited pharmacists. Evaluation has demonstrated a doubling of home medicines review (HMR) rates in the veteran population. Analyses of the DVA data have reported a 45% reduction in hospitalisation for heart failure following HMR among veterans with heart failure (adjusted hazard ratio [HR] 0.6; 95% confidence interval [CI] 0.4–0.8), and a 79% reduction in hospitalisation for haemorrhage (HR 0.2; 95%CI 0.05–0.9) 2 to 6 months after an HMR in veterans dispensed warfarin. Veterans’ MATES has resulted in clinically significant improvements in medication and health service use. J Pharm Pract Res 2011; 41: 316-19.

There is an increasing number of people living with multiple chronic illnesses and consequently taking multiple medicines. More than 50% of these patients will have concomitant diseases that complicate management and will see multiple providers to manage their conditions. This increases their risk of medication-related problems, adverse events and poor treatment outcomes. All of these patients are at high risk of medication misadventure and most will have at least four medication-related problems, of which more than half will be resolvable. The management of medication in these patients will require the increasing involvement of pharmacists to provide a number of cognitive services including medication reconciliation, medication review, adherence services and proactive adverse reaction monitoring. This needs to be integrated into models of practice that coordinate care between multiple providers and accommodate both patient and provider preferences. Refereed/Peer-reviewed

Objective To explore pharmacists' awareness of Australia's health care reforms and their beliefs and attitudes about their current and future roles. Methods Four focus groups were conducted with 32 South Australian pharmacists: two groups included community pharmacists and pharmacy owners; one included hospital pharmacists and another, consultant pharmacists. Key findings Four themes emerged: (1) poor awareness of health care reform agenda; (2) strong adherence to the supply model; (3) lack of appreciation of alternative models; and (4) communication barriers. Conclusions Participants' low awareness of Australia's health care reforms and their expressed beliefs and attitudes to their current role in the health system suggest that they are not well prepared for the potential future roles expected of health professionals in the health care reform agenda.

Purpose To examine the prescribing of prochlorperazine secondary to the prescribing of a medicine which could lead to symptoms for which prochlorperazine is indicated and commonly used. Given the range of potential hypotensive, sedative, dystonic and other extra-pyramidal side effects associated with prochlorperazine, its association with hip fracture was also examined. Methods Prescription/event sequence symmetry analyses were undertaken from 1st January 2003 to 31st December 2006, using administrative claims data from the Department of Veterans' Affairs, Australia. This method assesses asymmetry in the distribution of an incident event (either prescription of another medicine or hospitalization) before and after the initiation of prochlorperazine. Crude and adjusted sequence ratios (ASR) with 95% confidence intervals (CI) were calculated. Results A total of 34 235 persons with incident use of prochlorperazine were identified during the study period. Statistically significant positive associations were found for a number of commonly used medicines, including cardiovascular medicines, NSAIDs, opioids and sedatives and the subsequent initiation of prochlorperazine that ranged from 1.07 (95%CI 1.01–1.14) for diuretics to 1.50 (95%CI 1.40–1.61) for statins. Prescription event analysis showed a 49% (95%CI 1.19–1.86) increased risk of hospitalisation for hip fracture following dispensing of prochlorperazine. Conclusions Prescribers should consider the possible contributing role of newly initiated medicines with the potential to cause of dizziness, and where possible address this through dose reduction or cessation of the medicine, rather than prescribing prochlorperazine. Copyright © 2010 John Wiley & Sons, Ltd.

Background:Depression is one of the leading contributors to the burden of non-fatal diseases in Australia. Although there is an overall increasing trend in antidepressant use, the relationship between use of antidepressants and depressive symptomatology is not clear, particularly in the older population.Methods:Data for this study were obtained from the Australian Longitudinal Study of Ageing (ALSA), a cohort of 2087 people aged over 65 years at baseline. Four waves of home interviews were conducted between 1992 and 2004 to collect information on sociodemographic and health status. Depressive symptoms were measured by the Center for Epidemiologic Studies – Depression Scale. Use of antidepressants was based on self-report, with the interviewer able to check packaging details if available. Longitudinal analysis was performed using logistic generalized estimating equations to detect if there was any trend in the use of antidepressants, adjusting for potential confounding factors.Results:The prevalence of depressive symptoms was 15.2% in 1992 and 15.8% in 2004 (p> 0.05). The prevalence of antidepressant users increased from 6.5% to 10.9% (p< 0.01) over this period. Among people with depressive symptoms, less than 20% were taking antidepressants at any wave. Among people without depressive symptoms, the prevalence of antidepressant use was 5.2% in 1992 and 12.0% in 2004 (p< 0.01). Being female (OR = 1.67, 95%CI: 1.25–2.24), having poor self-perceived health status (OR = 1.17, 95%CI: 1.04–1.32), having physical impairment (OR = 1.48, 95%CI: 1.14–1.91) and having depressive symptoms (OR = 1.62, 95%CI: 1.24–2.13) significantly increased the use of antidepressants, while living in community (OR = 0.51, 95%CI: 0.37–0.71) reduced the risk of antidepressant use.Conclusions:Use of antidepressants increased, while depressive symptoms remained stable, in the ALSA over a 12-year period. Use of antidepressants was low for people with depressive symptoms.

Background: Posttraumatic stress disorder (PTSD) is common among war veterans. Antidepressants are effective in reducing symptoms and associated disability for some patients. Objective: To assess the effectiveness of mirtazapine for combat-related PTSD among veterans treated in an Australian hospital. Methods: This open-label prospective study assessed the effectiveness of mirtazapine as empirical treatment for combat-related PTSD. The initial dose was 15 mg at night, titrated against response to 15–45 mg. PTSD symptoms were assessed using the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder and the Clinician-Administered PTSD Scale (CAPS). Subjects also completed the Hospital Anxiety and Depression Scale (HADS). Body weight and biochemical assessments, including fasting blood glucose (FBG), total serum cholesterol, and serum triglycerides, were also measured. Baseline measurements were repeated after 12 weeks. Results: During the 18-month recruitment phase, 17 subjects were enrolled and 13 completed the protocol. The CAPS measurement decreased from a mean pretreatment score of 87.5 to 64.4 (p = 0.01). In 4 cases, the CAPS score decreased to below the diagnostic cut-point, consistent with a remission of PTSD. The Mississippi scale measurement decreased from a mean pretreatment score of 126.6 to 115.5 (p < 0.01). The mean HADS anxiety score decreased from 15.6 ± 4.2 to 13.5 ± 5.6 (p = 0.016), although the proportion of subjects with scores above the diagnostic cut-point remained high. The mean HADS depression score at baseline was not significantly different from the postintervention score. One subject had a postintervention FBG of 155 mg/dL (consistent with diabetes mellitus), which was increased from the baseline level of 83 mg/dL. All subjects experienced an increase in body weight. One subject had an increase in body weight of 8.75 kg (8.4%) from baseline. Conclusions: Although small and with methodological limitations, this study suggests that mirtazapine is an effective treatment for combat-related PTSD. Additional research incorporating an appropriately powered, double-blind, placebo-controlled study design is required.

Background There has been concerns about the appropriateness of medication use in Australian residential aged-care facilities. Data on overall medication use in aged-care has been unavailable. Aim To examine medication use for Australian war veterans in residential aged-care facilities. Method An observational study using the Department of Veterans' Affairs' pharmacy claims database was undertaken. Veterans resident in aged-care facilities between April and June 2005 were included. Veterans using gastrointestinal, analgesic, psychotropic, antiinfective and cardiac drugs were assessed. Results All 16 126 veterans (5% of the veteran population) identified as residing continuously in aged-care facilities were included (average age 86 years). Those with low-care needs (44%) were dispensed on average 9 (SD 5) different medicines, while those with high-care needs (56%) were dispensed 8 (SD 5) different medicines. More than 50% of veterans were dispensed analgesics, predominantly paracetamol, and over 60% psychotropic drugs. In all, 35% were receiving antidepressants, proton pump inhibitors and antibacterials. Conclusion Veterans residing in aged-care facilities are taking high levels of medications, particularly analgesics, psychotropics, antibacterials, laxatives and proton pump inhibitors, for which studies have demonstrated concerns about their appropriateness.

Objective: To determine whether proton-pump inhibitor (PPI) use is associated with hospitalisations for pneumonia and with antibiotic use. Design and setting: Historical cohort study in the Australian veteran population, conducted from 1 January 2002 to 30 December 2006, comparing veterans exposed to PPIs with those not exposed Participants: All 185 533 veterans who were Gold Card holders (ie, eligible for all health services subsidised by the Department of Veterans’ Affairs) and aged 65 years and over at 1 January 2002 and had been prescribed at least one medicine in the previous 6 months. Main outcome measures: The primary endpoint was hospitalisation for pneumonia. Secondary endpoints included hospitalisation for bacterial pneumonia and dispensings of antibiotics commonly used to treat respiratory tract infections. Results: After adjustment for potential confounders, we found an increased risk of hospitalisation for pneumonia among those exposed to PPIs compared with the unexposed group (rate ratio [RR], 1.16; 95% CI, 1.11–1.22). The risk was not increased for bacterial pneumonia (RR, 1.13; 95% CI, 0.98–1.31), which made up 8% of pneumonia cases. An increased risk of antibiotic dispensings was observed among those exposed to PPIs (RR, 1.23; 95% CI, 1.21–1.24). Conclusions: PPI dispensings were found to be associated with a small but significant increased risk of hospitalisation for pneumonia. While the increased risk is small, the prevalent use of PPIs means that many people could be affected Refereed/Peer-reviewed

Purpose: This study aimed to examine the effect of antidepressant use on persistence with newly initiated oral antidiabetic medicines in older people. Conclusions: The results of this large population-based study demonstrate that depression may be contributing to non-compliance with medicines for diabetes and highlight the need to provide additional services to support appropriate medicine use in those initiating diabetes medicines with co-morbid depression Methods: A retrospective study of administrative claims data from the Australian Government Department of Veterans' Affairs, from 1 July 2000 to 30 June 2008 of new users of oral antidiabetic medicines (metformin or sulfonylurea). Antidepressant medicine use was determined in the 6 months preceding the index date of the first dispensing of an oral antidiabetic medicine. The outcome was time to discontinuation of diabetes therapy in those with antidepressant use compared with those without. Competing risks regression analyses were conducted with adjustment for covariates. Results: A total of 29 710 new users of metformin or sulfonylurea were identified, with 7171 (24.2%) dispensed an antidepressant. Median duration of oral antidiabetic medicines was 1.81 years (95% CI 1.72-1.94) for those who received an antidepressant at the time of diabetes medicine initiation, by comparison to 3.23 years (95% CI 3.10-3.40) for those who did not receive an antidepressant. Competing risk analyses showed a 42% increased likelihood of discontinuation of diabetes medications in persons who received an antidepressant (subdistribution hazard ratio 1.42, 95% CI 1.37-1.47, p

Background The Australian Government Department of Veterans’ Affairs (DVA) funds an ongoing health promotion based program to improve use of medicines and related health services, which implements interventions that include audit and feedback in the form of patient-specific feedback generated from administrative claims records. We aimed to determine changes in medicine use as a result of the program. Methods The program provides targeted patient-specific feedback to medical practitioners. The feedback is supported with educational material developed by a clinical panel, subject to peer review and overseen by a national editorial committee. Veterans who meet target criteria also receive educational brochures. The program is supported by a national call centre and ongoing national consultation. Segmented regression analyses (interrupted time series) were undertaken to assess changes in medication use in targeted veterans pre and post each intervention. Results 12 interventions were included; three to increase medicine use, seven which aimed to reduce use, and two which had combination of messages to change use. All programs that aimed to increase medicine use were effective, with relative effect sizes at the time of the intervention ranging from 1% to 8%. Mixed results were seen with programs aiming to reduce inappropriate medicine use. Highly specific programs were effective, with relative effect sizes at the time of the intervention of 10% decline in use of NSAIDs in high risk groups and 14% decline in use of antipsychotics in dementia. Interventions targeting combinations of medicines, including medicine interactions and potentially inappropriate medicines in the elderly did not change practice significantly. Interventions with combinations of messages targeting multiple components of practice had an impact on one component, but not all components targeted. Conclusions The Veterans’ MATES program showed positive practice change over time, with interventions increasing use of appropriate medicines where under-use was evident and reduced use of inappropriate medicines when single medicines were targeted. Combinations of messages were less effective, suggesting specific messages focusing on single medicines are required to maximise effect. The program provides a model that could be replicated in other settings.

Background Accurate and timely medication information at the point of discharge is essential for continuity of care. There are scarce data on the clinical significance if poor quality medicines information is passed to the next episode of care. This study aimed to compare the number and clinical significance of medication errors and omission in discharge medicines information, and the timeliness of delivery of this information to community-based health practitioners, between the existing Hospital Discharge Summary (HDS) and a pharmacist prepared Medicines Information Transfer Fax (MITF). Method The study used a sample of 80 hospital patients who were at high risk of medication misadventure, and who had a MITF completed in the study period June – October 2009 at a tertiary referral hospital. The medicines information in participating patients’ MITFs was validated against their Discharge Prescriptions (DP). Medicines information in each patient’s HDS was then compared with their validated MITF. An expert clinical panel reviewed identified medication errors and omissions to determine their clinical significance. The time between patient discharge and the dispatching of the MITF and the HDS to each patient’s community-based practitioners was calculated from hospital records. Results DPs for 77 of the 80 patients were available for comparison with their MITFs. Medicines information in 71 (92%) of the MITFs matched that of the DP. Comparison of the HDS against the MITF revealed that no HDS was prepared for 16 (21%) patients. Of the remaining 61 patients; 33 (54%), had required medications omitted and 38 (62%) had medication errors in their HDS. The Clinical Panel rated the significance of errors or omissions for 70 patients (16 with no HDS prepared and 54 who’s HDS was inconsistent with the validated MITF). In 17 patients the error or omission was rated as insignificant to minor; 23 minor to moderate; 24 moderate to major and 6 major to catastrophic. 28 (35%) patients had their HDS dispatched to their community-based practitioners within 48 hours post discharge compared to 80 (100%) of MITFs. Conclusion The MITF is an effective approach for the timely delivery of accurate discharge medicines information to community-based practitioners responsible for the patient’s ongoing care.

Background: Understanding why people choose to leave their professions is important to inform workforce planning to meet community needs. Poor job satisfaction has been linked to health practitioners expressing intentions to leave in other professions such as nursing, occupational therapy and medicine, but little is known about the reasons why pharmacists leave their profession. Conclusion: These findings provide insights to the pharmacy sector, previously unexplored in Australia, and informs future pharmacist workforce planning. To retain experienced, mid-career pharmacists in the profession, strategies to increase opportunities for career progression, better use of pharmacists' knowledge and skills and involvement in patient care are required to increase job satisfaction and improve retention rates. Main outcome measure: Reasons why pharmacists leave the pharmacy profession. Method: A semi-structured interview schedule was developed with probe options which encouraged participants to further explore their responses to questions. De-identified audio records of interviews were transcribed verbatim and thematically analysed. Objective: To explore reasons why Australian pharmacists leave the profession. Results: Five themes emerged: (1) Dissatisfaction with the professional environment; (2) lack of career paths and opportunities; (3) under-utilisation of pharmacists' knowledge and skills; (4) wanting a change; and (5) staying connected with pharmacy. Setting: As part of a survey of the Australian pharmacist workforce, a questionnaire was mailed to all registered pharmacists (n = 7,764) on the registers of the Pharmacy Boards of Victoria and South Australia; 1,627 (21 %) responded. Participants, who were registered but no longer working as a pharmacist, were asked to provide contact details if they were willing to be interviewed for this study; 89 (5.5 %) pharmacists accepted an invitation. A proportionate sample of 20 was selected for the interview. Refereed/Peer-reviewed

Objective: To identify the prevalence of potentially preventable medication-related hospitalizations amongst elderly Australian veterans by applying clinical indicators to administrative claims data. Design and setting: Retrospective cohort study in the Australian veteran population from 1 January 2004 to 31 December 2008. Participants: A total of 109 044 veterans with one or more hospitalizations defined by the medication-related clinical indicator set, during the 5-year study period. Main outcome measure: The prevalence of potentially preventable medication-related hospitalizations as a proportion of all hospitalizations defined by the clinical indicator set. Results: During the 5-year study period, there were a total of 1 630 008 hospital admissions of which 216 527 (13.3%) were for conditions defined by the medication-related clinical indicator set for 109 044 veterans. The overall proportion of potentially preventable medication-related hospitalizations was 20.3% (n= 43 963). Of the 109 044 veterans included in the study, 28 044 (25.7%) had at least one potentially preventable medication-related hospitalization and 7245 (6.6%) veterans had two or more potentially preventable admissions. Conditions with both a high prevalence of hospitalization and preventability included asthma/chronic obstructive pulmonary disorder, depression and thromboembolic cerebrovascular event (23.3, 18.5 and 18.3%, respectively, were potentially preventable). Other hospitalizations that were less common but had a high level of preventability (at least 20%) included hip fracture, impaction, renal failure, acute confusion, bipolar disorder and hyperkalaemia. Conclusions: The results of this study highlight those conditions where hospitalizations could potentially be avoided through improved medication management. Strategies to increase the awareness, identification and resolution of these medication-related problems contributing to these hospitalizations are required in Australia. Refereed/Peer-reviewed

Purpose: The aim of this systematic review was to examine and compare differences in the way medication exposures are classified in studies using linked administrative data to investigate outcomes following medication use during pregnancy. This was undertaken with a focus on studies investigating specific neonatal outcomes following prenatal exposure to selective serotonin reuptake inhibitors (SSRIs). Conclusions: There is a need for greater focus on determining the most effective and accurate way of using linked administrative data to investigate outcomes following medication use during pregnancy in an effort to minimise potential biases. Methods: We searched Medline and Embase to identify studies that used linked administrative data to investigate specific neonatal outcomes (congenital malformations, birth weight, gestational age) following prenatal exposure to SSRIs. Results: Key factors such as dose, duration and timing of exposure were inconsistently addressed in the studies identified. In addition, there was a great deal of variability in the way medication exposures were classified and how women who stop taking their medication before or during early pregnancy are handled in analyses. Furthermore, there are issues in assuming how and when women who receive a dispensing for a medication actually take it during pregnancy. This creates a great deal of uncertainty around medication exposure during pregnancy in studies using linked administrative data, potentially resulting in biased risk estimates. Refereed/Peer-reviewed

The aim of this review was to critically appraise the existing literature with a particular focus on identifying methodological issues associated with studying outcomes following the use of selective serotonin reuptake inhibitors (SSRIs) during pregnancy. Existing studies evaluating outcomes following prenatal SSRI exposure suffer from a number of important methodological limitations that should be taken into account when interpreting their results. The contradictory results obtained from prospective and retrospective cohort studies and case-control studies could be accounted for by dissimilarity between study populations, selection bias, detection bias, confounding, or differences in underlying maternal illness, data sources used, exposure classification, follow-up and statistical power/analysis. Only a small number of studies actually account for underlying maternal illness and how this may lead to adverse pregnancy outcomes. Even when such information is available, studies that include data on maternal illness have small sample sizes, limiting the statistical power to identify statistically and clinically relevant associations. Pregnancy outcomes may be confounded by the higher incidence of smoking, alcohol consumption and substance abuse frequently encountered amongst those suffering from depression, factors that are often insufficiently controlled for. While evidence of associations between prenatal SSRI exposure and adverse pregnancy outcomes are conflicting, there is an urgent need to evaluate how the particular SSRI used, the dose, timing and duration of use, genetics (maternal, paternal and/or fetal), concomitant medication use, maternal characteristics and underlying maternal illness all interact to alter pregnancy outcomes. Refereed/Peer-reviewed

Background: Corticosteroids are recommended as part of guideline therapies for the maintenance and treatment of acute exacerbations in chronic obstructive pulmonary disease (COPD). However, corticosteroid use is associated with decreased blood glucose control. Objectives: To determine if corticosteroid use results in an increased risk of diabetes - related hospitalisations in patients with diabetes and COPD. Methods: A retrospective study was undertaken on administrative claims data from the Department of Veterans' Affairs, Australia from 1st July 2000 - - 30th June 2008 of new users of metformin or sulfonylurea. COPD was defined as two dispensings of tiatropium or ipratropium in the six months preceding the first dispensing of an oral hypoglycaemic. Total corticosteroid use (inhaled and systemic) was measured by DDDs calculated over the 12 month period from study entry. The outcome was time to hospitalisation for a diabetes - related complication. Competing risks regression analyses were conducted with adjustment for a number of covariates. Results: A total of 24,220 new users of metformin or sulfonylurea were identified. 1,504 had COPD and of these, corticosteroids were used by 954. After 5 years of follow up, 20% of those with COPD and corticosteroid use had a diabetes - related hospitalisation. Stratification by dose of corticosteroids, demonstrated a 50% increased likelihood of hospitalisation for a diabetes - related complication for those who received a total DDD of ≥0.3 (SHR 1.50, 95% CI 1.01 - - 2.22, p

Purpose Warfarin management in the elderly population is complex as medicines prescribed for concomitant diseases may further increase the risk of major bleeding associated with warfarin use. We aimed to quantify the excess risk of bleeding-related hospitalisation when warfarin was co-dispensed with potentially interacting medicines. Methods A retrospective cohort study was undertaken over a 4-year period from July 2002 to June 2006 to examine bleeding risk associated with medications co-administered in patients taking warfarin using an administrative claims database from the Australian Department of Veterans and Affairs. All veterans aged 65 years and over who were new users of warfarin were followed until death or study end. Risk of bleeding was assessed using a Poisson GEE model adjusting for age, gender, socioeconomic status, co-morbidity index, previous bleeding related hospitalisations and indicators of health service use. Results Overall, 17661 veterans who used warfarin at any time during the study period were included. The overall incidence rate of bleeding-related hospitalisations was 4.1 (95% CI 3.7-4.6) per 100 person-years in veterans who were not receiving potentially interacting medicines. Bleeding-related hospitalisation rates were significantly increased when warfarin was co-prescribed with low-dose aspirin (Adjusted rate ratio (AdjRR) 1.44, 95% CI 1.00-2.07), clopidogrel (AdjRR 2.23, 95% CI 1.48-3.36), clopidogrel with aspirin (AdjRR 3.44, 95% CI 1.28-9.23), amiodarone (AdjRR 3.33, 95% CI 1.38-8.00) and antibiotics (AdjRR 2.34, 95% CI 1.55-3.54). Conclusions Models assessing bleeding risk with warfarin should take account of the range of potentially harmful medicine combinations used in elderly people with comorbid conditions. Refereed/Peer-reviewed

The aim of this study was to examine the effect of psychotropic medications (antipsychotics, antidepressants, anxiolytics, hypnotics and sedatives) on the risk of falls and fractures in a cohort of elderly people in South Australia. A retrospective cohort study was undertaken using the wave 1 (1992) and wave 3 (1994) data of the Australian Longitudinal Study of Ageing (ALSA). Persistent use of psychotropic medicines was defined as use of one or more psychotropic medications at both wave 1 and wave 3. A comprehensive list of potential confounding variables was individually entered into regression models to examine effects on risk ratios. The results showed that the use of psychotropic medications was associated with an increased risk of falls in females (IRR = 1.47, 95% CI = 1.31-1.64) but not in males (IRR = 1.03, 95% CI = 0.85-1.26). The use of psychotropic medications was also associated with an increased risk of a fracture in females (RR 2.54; CI 1.57-4.11; p < 0.0001) but not in males (RR = 0.66; p = 0.584; CI 0.15-2.86). In both analyses, the body mass index (BMI) was determined to be the only confounding variable. After adjusting for BMI, the IRR in females decreased to 1.22 (95% CI 1.02-1.45; p < 0.015) for falls and the RR decreased to 1.92 (p < 0.015, CI 1.13-3.24) for fractures. Refereed/Peer-reviewed

Background: This study assessed whether the number of comorbid conditions unrelated to diabetes was associated with a delay in therapeutic progression of diabetes treatment in Australian veterans. Conclusions/significance: Increasing numbers of unrelated conditions decreased the likelihood of therapeutic progression in veterans with diabetes. These results have implications for the development of quality measures, clinical guidelines and the construction of models of care for management of diabetes in elderly people with comorbidities. Methodology/principal findings: A retrospective cohort study was undertaken using data from the Australian Department of Veterans' Affairs (DVA) claims database between July 2000 and June 2008. The study included new users of metformin or sulfonylurea medicines. The outcome was the time to addition or switch to another antidiabetic treatment. The total number of comorbid conditions unrelated to diabetes was identified using the pharmaceutical-based comorbidity index, Rx-Risk-V. Competing risk regression analyses were conducted, with adjustments for a number of covariates that included age, gender, residential status, use of endocrinology service, number of hospitalisation episodes and adherence to diabetes medicines. Overall, 20134 veterans were included in the study. At one year, 23.5% of patients with diabetes had a second medicine added or had switched to another medicine, with 41.4% progressing by 4 years. The number of unrelated comorbidities was significantly associated with the time to addition of an antidiabetic medicine or switch to insulin (subhazard ratio [SHR] 0.87 [95% CI 0.84-0.91], P

Background— Randomized controlled trials have demonstrated that collaborative medication reviews can improve outcomes for patients with heart failure. We aimed to determine whether these results translated into Australian practice, where collaborative reviews are nationally funded. Methods and Results— This retrospective cohort study using administrative claims data included veterans 65 years and older receiving bisoprolol, carvedilol, or metoprolol succinate for which prescribing physicians indicated treatment was for heart failure. We compared those exposed to a general practitioner–pharmacist collaborative home medication review with those who did not receive the service. The service includes physician referral, a home visit by an accredited pharmacist to identify medication-related problems, and a pharmacist report with follow-up undertaken by the physician. Kaplan-Meier analyses and Cox proportional hazards models were used to compare time until next hospitalization for heart failure between the exposed and unexposed groups. There were 273 veterans exposed to a home medicines review and 5444 unexposed patients. Average age in both groups was 81.6 years (no significant difference). The median number of comorbidities was 8 in the exposed group and 7 in the unexposed ( P Conclusion— Medicines review in the practice setting is effective in delaying time to next hospitalization for heart failure in those treated with heart failure medicines.

In Australia, there are two categories of non-prescription medicines: pharmacy medicines and pharmacist only medicines. Standards were developed to define and describe the professional activities required for the provision of these medicines at a consistent and measurable level of practice. Objective Our objective was to implement nationally a quality improvement package in relation to the Standards of Practice for the Provision of Non-Prescription Medicines. Methods Approximately 50% of Australian pharmacies (n = 2,706) were randomly selected by local registering authorities. Trained pharmacy educators audited each community pharmacy in the study three times, 7 weeks apart on Standards of Practice for the Provision of Non-Prescription Medicines, Visit 1 involved the educator explaining the project and conducting an assessment of the pharmacy's level of compliance. Behaviour of community pharmacists and their staff in relation to these standards was measured by conducting pseudo-patron visits. Pseudopatron visits were conducted at Visit 2, with the educator providing immediate feedback and coaching and a compliance assessment. Visit 3 involved a compliance assessment, and a second pseudo-patron visit for those pharmacies that had performed poorly at the first visit. Results At Visit 1, the lowest levels of compliance were to the standards relating to the documentation process (44%) and customer care and advice (46%). By Visit 2, more than 80% of pharmacies had met most criteria. At Visit 3, compliance had significantly improved compared to Visits 1 and 2 (P < 0.001). The lowest levels of compliance were to criteria which required written operating procedures for specific tasks, but these also improved significantly over time (P < 0.001). Conclusions Professional practice in relation to the handling of pharmacist only and pharmacy medicines improved considerably as measured by the auditing process, and the results indicate that Australian pharmacies are well-equipped to provide high quality service to consumers of these medicines. The acceptability of national implementation of these standards of practice in Australia indicates that such an approach could be taken internationally. © 2008 Springer Science+Business Media B.V.

Purpose We aimed to determine the duration of first episode of therapy and overall therapy as well as time without treatment for bisphosphonates. Methods Data were extracted from Department of Veterans' Affairs (DVA) dataset for those with at least one dispensing for a bisphosphonate between April 2001 and April 2007. Episodes of use were determined as the number of treatment days between the first and last prescription plus 35 days once a dispensing gap of 105 days had been reached, or where no treatment gaps were recorded, the study end date. Kaplan–Meier analyses were undertaken for the first episode of use, overall duration and time without treatment. Results When considering only the duration of first episode, median bisphosphonate use was 1.19 years. The median duration extended to 3.27 years when all episodes of use were considered. Overall, 52.0% of subjects reached at least 3 years of treatment and 66.5% of existing users had a duration of at least 3 years. Median time without treatment was 1.65 years. Overall, 81% of the cohort had enough medicine dispensed to be considered adherent throughout their duration of use. Conclusion Over 50% of subjects and 66% of existing users had duration consistent with the minimum recommended. Adherence within an episode was high. The focus for improving duration of bisphosphonate use should be on reducing the time without treatment, rather than adherence at the time of use. Studies assessing only the first episode of use in new users of medicines may underestimate duration. Copyright © 2008 John Wiley & Sons, Ltd.

Objective: To compare the demographic, socioeconomic, and medical characteristics of patients who had a General Practitioner Management Plan (GPMP) with those for patients without GPMP. Methods: Cohort study of patients with chronic diseases during the time period 1 July 2006 to 30 June 2008 using the Australian Department of Veterans’ Affairs (DVA) claims database. Results: Of the 88 128 veterans with chronic diseases included in the study, 23 015 (26%) veterans had a GPMP and 11 089 (13%) had a Team Care Arrangement (TCA). Those with a GPMP had a higher number of comorbidities (P < 0.001), and a higher use of services such as health assessment and medicine review (P < 0.001) than did those without GPMP. Diabetes was associated with a significantly increased use of GPMP compared with all other chronic diseases except heart failure. Conclusions: GPMPs are used in a minority of patients with chronic diseases. Use is highest in people with diabetes. What is known about the topic?: Despite the fact that the Chronic Disease Management (CDM) program is appreciated by patients and allied health professionals, limited research has assessed how it is used in practice. What does this paper add?: In the Veteran population, use of a General Practitioner Management Plan (GPMP) was associated with a higher number of comorbidities and of prior hospitalisations. Across chronic diseases use of GPMPs was low but was higher in people with diabetes. What are the implications for practitioners?: Further research into the effect of CDM program on improvement of health outcomes is required. Refereed/Peer-reviewed