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Heart failure (HF) is a growing global health burden increasing in prevalence as the average age of the population rises. HF with preserved ejection fraction (HFpEF) is defined as EF that is ≥50% and represents almost half of the population with HF.We conducted a systematic review and meta-analysis exploring an association between HFpEF and statin use on all-cause mortality and cardiovascular rehospitalisation. Searches were conducted in MEDLINE via Ovid, The Cochrane Library for clinical trials in CENTRAL and Embase via Ovid for articles published between 1 January 2000 and 2 July 2021. Risk of bias was assessed using the Newcastle-Ottawa Scale and evidence rated for quality using the GRADE approach.A total of 19 studies were included in the review. The analysis suggests a risk reduction of 27% for the statin exposed participants compared to the statin non-exposed participants (HR 0.73, 95% CI: 0.68-0.79) with regard to all-cause mortality. There is a low level of heterogeneity (IOur meta-analysis revealed a reduction in all-cause mortality in patients with HFpEF on statin therapy. Considering the outcomes from this meta-analysis there is a need for high level studies to provide quality evidence on the use of statins in patients with HFpEF.

Background Flow diverters (FDs) are neuroendovascular stents indicated for the management of unruptured intracranial aneurysms. Due to their composition, dual antiplatelet therapy (DAPT) is essential during the peri- and post-operative periods to prevent thromboembolic events. However, there is limited consensus within the scientific community regarding which antiplatelets to use and dosing following neuroendovascular treatment of aneurysms. Method A systematic search of four electronic databases was conducted during November 2020 that included studies published between January 2010 and November 2020. Eligibility for inclusion included primary research articles, published in the English language and use of flow-diverting intracranial stents. Studies were excluded if they utilised combined therapies (e.g. FD with stent-assisted coiling), animal studies, clinical trial protocols and study population of less than 10 subjects. Results Eighteen studies were identified for inclusion with a total of 1312 patients with 1355 unruptured intracranial aneurysms treated with FDs. Of these, 13 studies primarily investigated the use of clopidogrel with aspirin with low rates of haemorrhagic and thromboembolic complications. A forest plot of nine of these studies showed average efficacy of 88% at 95% confidence interval (CI) (SD + 5%) with 63% heterogeneity. Conclusions The large proportion of studies investigating clopidogrel and aspirin antiplatelet therapy presents a challenge in comparing antiplatelet regimens. Although prasugrel and ticagrelor have been identified as suitable alternatives to clopidogrel, these were based on studies with small cohort sizes. Glycoprotein IIb/IIIa inhibitors may be efficacious as rescue therapy for intra-procedural thrombosis. Further research is required to determine which antiplatelet is most suitable.

Quality use of anti-hypertensives and cholesterol-lowering medications is crucial for successful cardiovascular disease management. This systematic review aimed to estimate levels of over and underuse of services for primary and secondary prevention of cardiovascular diseases from 2000 to 2020: overprescribing/underprescribing, overtesting/undertesting and overutilisation/ underutilisation of procedures compared to clinical practice guideline recommendations. Thirteen studies from USA, Europe, Asia and Australia were included. Wide practice variation was identified. Six studies reported overuse (e.g. perioperative cardiac consultations, anti-hypertensive overprescribing for normotensive or pre-hypertensive people); and ten studies reported underuse (e.g. under-prescribing of statins when indicated and under-screening for familial hypercholesterolemia). Lifestyle recommendations for cardiovascular disease prevention were largely underused. In summary, lack of adherence to published guidelines was prevalent over the past two decades for both primary and secondary prevention across settings. Further investigation of potentially justifiable deviations from guidelines are warranted to verify the estimates and identify points for intervention.

Introduction The Cancer Urgent Assessment Clinic (CUAC) was an emergency department (ED) avoidance/unscheduled model of care implemented in response to the COVID-19 pandemic. The aim was to reduce the risk of COVID-19 exposure and infection by providing an alternative to ED for cancer patients while undergoing anticancer treatments. Methods The clinic incorporated a telephone triage process and face-to-face appointments 8am to 8pm, 7 days per week. CUAC operated between 23 March '20 and 31 July '20, led by a nurse practitioner candidate, oncology registrars, cancer nurse specialists, and overseen by oncology consultants. Evaluation followed a mixed-methods approach through (1) analysis of CUAC patient data, (2) comparison of ED cancer patient presentation data from a previous period (23 March 2019–31 July 2019), and (3) a patient survey. Results In total, 400 patients were telephone triaged via CUAC, with 166 recorded as having avoided ED. There was a reduction in the number of cancer patient admissions to the ED short stay unit during the clinic period compared with the same time-period in 2019: 130 vs. 234, associated with 615 fewer hours. Patient satisfaction was positive particularly regarding ease of access, time to treatment, confidence in assessment and treatment of cancer-related concerns, and likelihood of presenting to hospital when unwell during the pandemic. Discussion While initially being implemented to reduce the risk of COVID-19 exposure, this evaluation demonstrated the CUAC model was an efficient and potentially cost-saving model of care for the management of cancer patients with mild to moderate severity of disease and treatment-related concerns.

Background Consensus is lacking regarding delivery of public health services in community pharmacy. Objective The objective of this study was to explore pharmacists’ perspectives on public health initiatives in community practice. Method Australian community pharmacists were randomly sampled to participate in face-to-face, semi-structured interviews to explore public health definitions and perceptions. Key findings Nine pharmacists participated early 2020, pre-COVID-19. Mean interview duration was 23 min. Results revealed little distinction between individual and public health services. Barriers to service provision were lack of time, remuneration, training, standards and privacy. Enablers opposed barriers, namely accessibility, improved funding, education, standardised services and consulting rooms. Conclusion Improved clarity is required regarding the role that community pharmacists can assume in provision of public health.

A unique approach was introduced to integrate pharmacy students into a multicentre patient-centred research project predicting medication related harm (MRH) post-discharge. A training framework was developed to prepare students for research participation and integration. The framework aligned research project tasks with the pharmacists’ national competency standards framework. The framework was piloted on four research placement students from two local universities during three hospital placements, from October 2020 to August 2021. Following their initial orientation and training, students collected data from 38 patients and were involved in patient screening processes, interviewing, data collection and analysis. Patients’ MRH risk scores correlated with re-admission rates with 16/38 (42%) of patients re-admitted within eight weeks following discharge. Their participation in the research enabled students to obtain skills in (1) literature searching, (2) maintaining patient confidentiality, (3) interviewing patients, (4) obtaining data from medical records, (5) communicating with patients and clinicians, and (6) the use of clinical information to predict MRH risk.

Background Active engagement in research by healthcare organisations and clinicians is associated with improvements in healthcare performance. Barriers to research engagement by clinician allied health (AH) professionals include competing priorities from high clinical workloads, lack of research skills and confidence, and lack of supportive research relationships. Collaboration with universities on joint clinical research projects is well recognised as a means of building health service research capacity. Research projects undertaken by students as part of their qualifying degree represent one such opportunity. However, there are few reports evaluating these collaborations from the health service perspective. Methods A qualitative study using semi-structured interviews and thematic analysis to explore the experiences of AH professionals in the co-supervision of students completing research placements as part of their professional degree course. Results Fourteen health service employees from six allied health disciplines described collaborations on research projects with 24 students from four different universities. Student placements and projects varied widely in length of placement, extent of collaboration, supervision structure and study design. Three overarching themes were identified in the AH professional co-supervision experience: 1) Professional growth; 2) Mismatch with expectations; and 3) Focus on the student. Project outcomes were categorised from the health system perspective. These were 1) Healthcare performance improvements, including local increases in staff clinical practice knowledge and wider contributions to the evidence base; 2) Research capacity gains within the health service, including research knowledge and skill development, collaborative linkages and opportunity for future research; and 3) Staff-centred outcomes including increased job satisfaction. Conclusions This study demonstrates the potential for AH professional supervision of students on research placements to contribute to healthcare performance improvements and research capacity gains within health services, alongside providing personal benefits for the AH professionals involved. Early consultation with a health service-employed research specialist may support health professional and student learning, team collaboration and project coordination for these student projects.

Background: Community pharmacy staff in rural and remote areas need to have the skills to recognise mental health signs and symptoms, provide support and appropriate advice. Aims: To evaluate the impact of Mental Health First Aid (MHFA) training through collaborative sessions attended by pharmacy staff and community members. Methods: Pharmacy staff, alongside members of the local farming community, attended collaborative MHFA training in four Queensland towns. This study evaluated the training through pre- and post-training questionnaires and email feedback following practice application of skills. Results: Thirty-two pharmacy staff and 14 community members participated in both pre- and post- questionnaires; 10 males and 36 females varying in age between 18 and 65 with the majority (26, 72.2%) aged 30–49 years. Participants’ understanding of the need to ask a person directly about suicide changed significantly through the training. The pre-and post-course surveys demonstrated a difference in knowledge of both the consumers and pharmacy staff members. Community members’ perception about how pharmacy staff can assist with mental health issues changed significantly and pharmacy staff reported an increase in confidence to approach consumers regarding their mental health. Qualitative feedback from consumers and pharmacy staff 8–12 weeks following the training was positive. Conclusion: Pharmacy staff members are well placed to provide mental health support to farming communities. A collaborative mental health training approach in rural and remote areas that involved pharmacy staff and local community members showed improved knowledge, skills and collaboration between staff and consumers. This approach could easily be adapted to other contexts.

Background Community pharmacies provide enhanced (within current scope of practice) and extended (requiring additional credentialing) services, for disease state management and primary care. Objectives To quantify the prevalence and characteristics of extended and enhanced professional services offered by community pharmacies in Western Australia (WA), their frequency of remuneration, facilitators, barriers and factors influencing their provision. Methods A questionnaire was mailed to a random sample of 421/628 (67.0%) community pharmacies in WA. Data collected included demographic information, provision of extended and enhanced pharmacy services and whether remuneration was received. Facilitators and barriers for offering these services used Likert scale responses to proffered questions. Data were entered into SPSS and descriptive statistics were reported. Logistic regression analyses investigated any factors (pharmacist and pharmacy characteristics) associated with the provision of influenza vaccination, or any of nine selected enhanced services. Results The response rate was 205/417 (49.2%). Only one-half or less of respondents provided any extended services. Pharmacist-administered influenza vaccinations (94/205, 45.0%) and Home Medicines Reviews (105/205, 52.0%) were the most prevalent. Remuneration for extended services was received by > 60% of respondents. Of 18 enhanced services >80% of pharmacies provided blood pressure monitoring and needle and syringe programs. Over half of the pharmacies (113/205, 55.1%) were banner (franchise) group members. Belonging to a banner group, having a private consultation area and space for a patient to lie down were positively associated with the provision of influenza vaccination and the selected enhanced services. Facilitators for the provision of services included enhancing patient relationships and the role of pharmacists. Major barriers were time constraints and inadequate remuneration. Conclusions Extended services were limited in scope and provision whilst enhanced services were not uniformly available. Pharmacy organisations should look to increase their scope and provision, including improved government and third-party funding.

BACKGROUND : Discharge medicine lists provide patients, carers and primary care providers a summary of new, changed or ceased medicines when patients discharge from hospital. Hospital pharmacists play an important role in preparing these lists although this process is time consuming. AIM : To measure the time required by hospital pharmacists to complete the various tasks involved in discharge medicine handover. METHOD : Time-and-motion study design was used to (1) determine the time involved for pharmacists to produce discharge medicine lists, (2) explore how pharmacists utilise various software programs to prepare lists, and (3) compare the time involved in discharge medicine handover processes considering confounding factors. An independent observer shadowed 16 pharmacists between 22 February and 12 March 2021 and recorded tasks involved in 50 discharge medicine handovers. Relevant information about each discharge was also collected. RESULTS : Pharmacists observed represented a range of practice experiences and inpatient units. Mean time to complete discharges was 26.2 min (SD 13.6), with over half of this time used to check documentation and prepare discharge medicine lists. A mean of 4.0 min was spent on manually retyping and reconciling medicine lists in different software systems. Medical inpatient unit discharges took 4.6 min longer to prepare compared to surgical ones. None of the 50 discharges involved support from pharmacy assistants; all 50 discharges had changed or ceased medicines. CONCLUSION : There is a need to streamline current discharge processes through optimisation of electronic health software systems and better delegation of technical tasks to trained pharmacy assistants.

Background Antipsychotic polypharmacy ("polypharmacy") is the concurrent prescribing of more than one antipsychotic. It is widely practised, as reported in the literature, and is known to increase the risk of adverse outcomes for patients. Objective To quantify the prevalence and magnitude of polypharmacy in patients with schizophrenia or schizoaffective disorder and identify potential factors contributing to this practice. Setting Armadale Mental Health Service (a public inpatient and outpatient psychiatric facility in Perth, Western Australia). Method A retrospective, cross-sectional study was conducted, evaluating the medical records of adult (18-64 years old) patients fulfilling the established inclusion criteria in the period between August and December 2016. Data collected included the number and doses of antipsychotic(s) prescribed and documented rationale for polypharmacy. Defined daily doses and proportions of maximum licensed daily doses were calculated for all regularly prescribed antipsychotics and were evaluated as measures of antipsychotic load. Main Outcome Measure The percentage prevalence of antipsychotic polypharmacy; defined daily antipsychotic doses and proportions of maximum licensed daily doses. Results Seventy-seven patients were assessed, with a polypharmacy prevalence of 39.0%. Total defined daily doses ranged from 0.9 to 5.9 and maximum licensed daily doses from 0.4 to 2.3. Documented rationales for polypharmacy included poor symptom control, patient's preference, hesitancy to amend other prescribers' management plans, off-label antipsychotic indications and medication cross-titration. Conclusion Antipsychotic polypharmacy occurred in more than one-third of patients. Individual antipsychotics were typically prescribed at doses within the licensed range, however, the total proportion of combined maximum licensed doses and combined daily defined doses often exceeded 100%. Due to suboptimal documentation, prescribing rationale was unclear in the majority of cases. The magnitude of polypharmacy aims to foster a greater appreciation of the prescribed antipsychotic load, increasing clinician self-awareness of prescribing practices and facilitating future opportunities to optimise prescribing.

Background Ordering of computed tomography (CT) scans needs to consideration of diagnostic utility as well as resource utilisation and radiation exposure. Several factors influence ordering decisions, including evidence-based clinical decision support tools to rule out serious disease. The aim of this qualitative study was to explore factors influencing Emergency Department (ED) doctors’ decisions to order CT of the head or cervical spine. Methods In-depth semi-structured interviews were conducted with purposively selected ED doctors from two affiliated public hospitals. An interview tool with 10 questions, including three hypothetical scenarios, was developed and validated to guide discussions. Interviews were audio recorded, transcribed verbatim, and compared with field notes. Transcribed data were imported into NVivo Release 1.3 to facilitate coding and thematic analysis. Results In total 21 doctors participated in semi-structured interviews between February and December 2020; mean interview duration was 35 min. Data saturation was reached. Participants ranged from first-year interns to experienced consultants. Five overarching emerging themes were: 1) health system and local context, 2) work structure and support, 3) professional practices and responsibility, 4) reliable patient information, and 5) holistic patient-centred care. Mapping of themes and sub-themes against a behaviour change model provided a basis for future interventions. Conclusions CT ordering is complex and multifaceted. Multiple factors are considered by ED doctors during decisions to order CT scans for head or c-spine injuries. Increased education on the use of clinical decision support tools and an overall strategy to improve awareness of low-value care is needed. Strategies to reduce low-yield CT ordering will need to be sustainable, sophisticated and supportive to achieve lasting change.

Background: Consumer awareness of emergency contraception is generally poor. School leavers (schoolies) engage in risky behaviours, including casual sex and alcohol and drug consumption. Aim: The aim of this study was to explore the awareness of an at-risk population of schoolies regarding the use and availability of emergency contraception. Methods: An electronic survey was self-administered by participants using Wi-Fi-connected iPads at the Schoolies Wristband Distribution Centre, Surfers Paradise, on the first day of Queensland Schoolies Week, November 2017. Outcomes measured were awareness of the availability of emergency contraception from a pharmacy, maximum time for effective use following unprotected intercourse and whether emergency contraception is harmful to the health of the user. Results: Schoolies completed 498 valid surveys. Most (83.5%) were aged 17 years and 50.8% were aware that emergency contraception is available from community pharmacies with prescription and 36.7% were aware that it is available without prescription; 18.5% were aware of the 72- or 120-h effectiveness window and 38.0% agreed that it is not harmful. All questions were associated with considerable uncertainty. Females were 1.8- to 3.2-fold more likely than males to provide an appropriate response to any emergency contraception statement. Conclusion: Schoolies’ awareness of emergency contraception availability, effectiveness window and safety was low. At-risk schoolies may not access emergency contraception when indicated due to fear of harm, uncertainty about its effectiveness window or a lack of knowledge about timely non-prescription access from community pharmacies. Targeted education may improve current knowledge gaps. The misnomer ‘morning-after pill’ should be abandoned for the clinically appropriate term ‘emergency contraception’.

Objective To investigate how community pharmacists view their responsibility for patient care in a scenario involving opioid use with significant risk of toxicity or misadventure. Methods A case scenario was developed based on an Australian coronial inquiry involving a patient suffering fatal toxicity following misuse of opioids. Community pharmacists working in Brisbane, Queensland, were invited to take part in face-to-face semi-structured interviews at their place of work. Participants were asked how they would respond to the scenario in practice and their perceived responsibilities. Key findings Twenty-one pharmacists were interviewed. Participants identified similar actions in response to the case, and potential barriers and enablers. Participants differed with regard to how they described their perceived scope of practice and degree of responsibility in response to the case. Most participants described their scope of practice in terms of medication management with a focus on patient outcomes. Some participants described a narrower scope of practice that focused on either medicine supply or legal aspects. Participants who described a medication management focus differed in their views regarding their responsibility for patient outcomes in the case. Conclusion Pharmacists in this study varied in terms of their perceived scope of practice and responsibility to patient outcomes in response to a case involving a patient at risk of opioid-related harm. Further work on pharmacist responsibility may reduce this variability.

Background Ethical reasoning informs decision making and professional judgement, is guided by codes of ethics and conduct, and requires navigation through a regulatory framework. Ethical reasoning should evolve throughout the pharmacy internship year and prepare interns for independent practice. Objective To explore the ethical reasoning and processes of Australian pharmacists and pharmacy interns. Setting Queensland community pharmacists and interns. Method A survey to determine use of resources to guide ethical decisions, management of ethical dilemmas, and exposure to potential practice privacy breaches. Participants were recruited at pharmacy intern training events, a pharmacist education session and through telephone contact of randomised community pharmacies. Main outcome measure Comparison between pharmacist and intern responses using 5-point Likert scales, listings and prioritising. Results In total 218 completed surveys were analysed: 121 pharmacy interns and 97 pharmacists. The Code of Ethics was identified as the resource most frequently consulted when faced with ethical dilemmas. Interns were more likely to consult legislation and regulatory authorities whereas pharmacists with colleagues. Responses to ethical vignette scenarios and exposure to privacy breaches varied between interns and pharmacists, with some scenarios revealing significant differences. Most participants had been exposed to a variety of potential privacy breaches in practice. Conclusion Interns focussed on legislation and guidelines when presented with hypothetical ethical dilemmas. In contrast to this positivist approach, pharmacists reported using a social constructionist approach with peers as a reference. Pharmacists avoided ethical scenario options that required complex management. Interns reported more exposure to potential practice privacy breaches.

Background Practising pharmacists continuously develop their ethical reasoning skills, which evolve with practice experience and exposure to challenging scenarios. Considering the recent expansion of the roles of pharmacists and the paradigm shift in pharmacy practice, it is timely to explore community pharmacists' attitudes regarding the importance of ethics and their ethical reasoning. Objective To explore underlying factors influencing community pharmacists' and pharmacy students' ethical reasoning and attitudes towards pharmacy ethics, ethical reasoning processes and perceived current dilemmas. Setting Practising registered community pharmacists, pharmacists with provisional registration (interns) and final year pharmacy students in Australia. Method Two focus group discussions and two interviews were conducted with 16 Western Australian community pharmacists, interns and students. Participants were purposively selected for gender, background, practice setting, and practice experience. Main outcome measure Emerging themes embracing important influences on community pharmacists', interns' and students' ethical reasoning and perceived current ethical dilemmas and challenges. Results Two major themes embraced participants' ethical reasoning processes and conduct: (1) fundamental underpinning, from personal values and practice exposure, and (2) paradigm influenced, such as the changing healthcare landscape, expansion of roles, management of dilemmas, and competence. Increased frequency and complexity of ethical dilemmas related to role expansion. Rural pharmacists experienced unique ethical dilemmas in relation to practice isolation, privacy and confidentiality. Conclusion Changes in the community pharmacy practice environment has increasingly exposed pharmacists to more complex ethical dilemmas. Pharmacists practising in rural communities experience unique challenges. Structured and sound ethical reasoning skills are essential as pharmacists are faced with contemporary challenges.

Background Easy access to effective over-the-counter (OTC) treatments allows self-management of some conditions, however inappropriate or incorrect supply or use of OTC medicines can cause harm. Pharmacy personnel should support consumers in their health-seeking behaviour by utilising effective communication skills underpinned by clinical knowledge. Objective To identify interventions targeted towards improving communication between consumers and pharmacy personnel during OTC consultations in the community pharmacy setting. Methods Systematic review and narrative analysis. Databases searched were MEDLINE, EMBASE, Psycinfo, Cochrane Central Register and Cochrane Database of Systematic Reviews for literature published between 2000 and 30 October 2014, as well as reference lists of included articles. The search was re-run on 18 January 2016 and 25 September 2017 to maximise the currency. Two reviewers independently screened retrieved articles for inclusion, assessed study quality and extracted data. Full publications of intervention studies were included. Participants were community pharmacy personnel and/or consumers involved in OTC consultations. Interventions which aimed to improve communication during OTC consultations in the community pharmacy setting were included if they involved a direct measurable communication outcome. Studies reporting attitudes and measures not quantifiable were excluded. The protocol was published on Prospero Database of Systematic Reviews. Results Of 4978 records identified, 11 studies met inclusion criteria. Interventions evaluated were: face-to-face training sessions (n = 10); role-plays (n = 9); a software decision making program (n = 1); and simulated patient (SP) visits followed by immediate feedback (n = 1). Outcomes were measured using: SP methodology (n = 10) and a survey (n = 1), with most (n = 10) reporting a level of improvement in some communication behaviours. Conclusion Empirical evaluation of interventions using active learning techniques such as face-to-face training with role-play can improve some communication skills. However interventions that are not fully described limit the ability for replication and/or generalisability. This review identified interventions targeting pharmacy personnel. Future interventions to improve communication should consider the consumer's role in OTC consultations.

Community pharmacies are well positioned to participate in harm-minimisation services to reduce harms caused by both licit and illicit substances. Considering developments in pharmacist practices and the introduction of new professional pharmacy services, we identified a need to explore the contemporary role of community pharmacy in harm minimisation. Semi-structured interviews were undertaken to explore the opinions of stakeholders, pharmacy staff, and clients about the role of community pharmacy in harm minimisation, including provision of current services, experiences, and expectations. Participants (n = 28) included 5 stakeholders, 9 consumers, and 14 staff members from seven community pharmacies. Three over-arching themes were identified across the three participants groups: (i) scope and provision, (ii) complexity, and (iii) importance of person-centred advice and support in relation to community pharmacy harm minimisation services. Community pharmacies are valuable healthcare destinations for delivery of harm minimisation services, with scope for service expansion. Further education, support, and remuneration are needed, as well as linkage to other sector providers, in order to ensure that pharmacists and pharmacy staff are well equipped to provide a range of harm minimisation services.

Background: Insulin is a high-risk medicine, associated with hospital medication errors. Pharmacists play an important role in the monitoring of patients on insulin. Objective: To analyse interventions made by hospital pharmacists that were associated with insulin prescribing for inpatients with diabetes.Method: Retrospective audit of pharmacist interventions for adult inpatients for an 8-month period, 1 June 2019 to 31 January 2020. Pharmacist interventions recorded in the electronic medication management system by inpatient unit and dedicated high-risk medicine pharmacists were extracted, screened, and analysed.Results: Of 3,975 pharmacist interventions 3,356 (84.43%) were recorded by high-risk medicine pharmacists and 619 (15.57%) by inpatient unit pharmacists. July and August 2019 had the highest numbers of interventions with 628 and 643 (15.80% and 16.18%) respectively. Most of the interventions, namely 3,410 (85.79%) were classified as medicine optimisation interventions and 565 (14.21%) as prescribing errors. In the medicine optimisation intervention category, 2,985 (75.09%) were due to insulin not charted for ongoing administration.Conclusion: This study provides insights into pharmacist interventions for inpatients on insulin, showing that high-risk medicine pharmacists recorded most interventions. The classification of the insulin interventions into medicine optimisation and prescribing errors provides useful information for the training of prescribers in insulin management.

Background Insulin is a high-risk medicine, associated with hospital medication errors. Pharmacists play an important role in the monitoring of patients on insulin. Objective To analyse interventions made by hospital pharmacists that were associated with insulin prescribing for inpatients with diabetes. Method Retrospective audit of pharmacist interventions for adult inpatients for an 8-month period, 1 June 2019–31 January 2020. Pharmacist interventions recorded in the electronic medication management system by inpatient unit and dedicated high-risk medicine pharmacists were extracted, screened, and analysed. Results Of 3975 pharmacist interventions 3356 (84.43%) were recorded by high-risk medicine pharmacists and 619 (15.57%) by inpatient unit pharmacists. July and August 2019 had the highest numbers of interventions with 628 and 643 (15.80 and 16.18%) respectively. Most of the interventions, namely 3410 (85.79%) were classified as medicine optimisation interventions and 565 (14.21%) as prescribing errors. In the medicine optimisation intervention category, 2985 (75.09%) were due to insulin not charted for ongoing administration. Conclusion This study provides insights into pharmacist interventions for inpatients on insulin, showing that high-risk medicine pharmacists recorded most interventions. The classification of the insulin interventions into medicine optimisation and prescribing errors provides useful information for the training of prescribers in insulin management.

Objectives A major COVID‐19 vaccine strategy is to induce antibodies that prevent interaction between the Spike protein's receptor‐binding domain (RBD) and angiotensin‐converting enzyme 2 (ACE2). These vaccines will also induce T‐cell responses. However, concerns were raised that aberrant vaccine‐induced immune responses may exacerbate disease. We aimed to identify minimal epitopes on the RBD that would induce antibody responses that block the interaction of the RBD and ACE2 as a strategy leading to an effective vaccine with reduced risk of inducing immunopathology. Methods We procured a series of overlapping 20‐amino acid peptides spanning the RBD and asked which were recognised by plasma from COVID‐19 convalescent patients. Identified epitopes were conjugated to diphtheria‐toxoid and used to vaccinate mice. Immune sera were tested for binding to the RBD and for their ability to block the interaction of the RBD and ACE2. Results Seven putative vaccine epitopes were identified. Memory B‐cells (MBCs) specific for one of the epitopes were identified in the blood of convalescent patients. When used to vaccinate mice, six induced antibodies that bound recRBD and three induced antibodies that could partially block the interaction of the RBD and ACE2. However, when the sera were combined in pairs, we observed significantly enhanced inhibition of binding of RBD to ACE2. Two of the peptides were located in the main regions of the RBD known to contact ACE2. Of significant importance to vaccine development, two of the peptides were in regions that are invariant in the UK and South African strains. Conclusion COVID‐19 convalescent patients have SARS‐CoV‐2‐specific antibodies and MBCs, the specificities of which can be defined with short peptides. Epitope‐specific antibodies synergistically block RBD–ACE2 interaction., We identified SARS‐COV‐2 receptor‐binding domain (RBD)‐specific antibodies in convalescent patients, specificities of which could be defined with short peptides. These peptides when used as immunogens, induced neutralising antibodies which synergistically blocked RBD and ACE 2 interaction. Our approach will aid the design of a vaccine containing minimal antigenic material, thus improving the vaccine's safety profile.

Background: Antipsychotic polypharmacy (“polypharmacy”) involves the concurrent prescribing of two or more antipsychotics for managing schizophrenia. It occurs frequently despite there being limited clinical evidence for this practice and an increased risk of adverse events. Little is understood about why it occurs outside of treatment guidelines, highlighting a current research gap. Objective: To explore the factors contributing to non-evidence based polypharmacy practice and possible strategies for addressing these factors. Methods: Three focus groups were conducted between June and August 2018 with doctors and nurses employed at a mental health unit of a Western Australian public hospital. Participants were asked about their perceptions of polypharmacy, why it occurred and what could limit its prevalence. Thematic inductive analysis was mapped to the Theoretical Domains Framework to identify key underlying themes and to establish potential enablers and barriers for practice change. Results: Participants understood the risks of polypharmacy and perceived it to largely be perpetuated by external factors, out of which two key themes emerged: system-related issues (e.g.: communication failures whereby de-prescribing plans are not actioned); and patient-related issues (e.g.: misinformed views translating to medication-seeking behaviour). This led to the third theme: a disconnect between clinicians' knowledge and their practices (i.e.: being aware of Australian evidence-based guideline recommendations yet acknowledging polypharmacy still occurred due to the aforementioned issues). Strategies suggested to address these issues included developing medication management plans to bridge communication gaps and managing patients’ medication expectations with education. Conclusions: Management of schizophrenia is complex, requiring consideration of many patient-related and systemic factors. Polypharmacy has a place in certain contexts, however, must be well considered and closely monitored to allow for early identification of opportunities to rationalise (i.e.: de-prescribe) therapy, where appropriate. Future research objectives will centre on implementing strategies identified from these focus groups to optimise patient outcomes.

Objectives: To assess a clinical training program on management of Type 2 Diabetes Mellitus (T2DM) incorporating a diabetes tool, the Simpler™ tool. Subsequently pharmacists’ experience utilising the tool to deliver structured, consistent, evidence-based T2DM care was explored. Methods: Full-time non-credentialed diabetes pharmacists providing diabetes medication management services in community settings were purposively recruited. Participants had either face-to-face or online training on diabetes management using the tool which took about two hours and 20 minutes to complete. Their diabetes management knowledge was assessed pre- and post-training using quantitative methodology. They were then required to apply the tool in daily practice for one month. Feedback on both the training sessions and tool utilisation were obtained through semi-structured interviews and analysed using a qualitative approach. Results: Twelve pharmacists participated: Six from Australia and six from Malaysia. Before attending the training session, their median test score was 6.5/27, IQR 1.4 (1st marker) and 5.3/27, IQR 2.0 (2nd marker). After training, the scores doubled to 14.3/27, IQR 4.5 (1st marker) and 11.3/27, IQR 3.1 (2nd marker), showing significant improvements (p=0.002). Interview data identified perceived effectiveness factor through use of the tool. Participants found the content relevant, structured, concise and easy to understand; enabled comprehensive medication reviews; focused on achieving glycaemic improvement; facilitated documentation processes and pharmacists’ role in T2DM management; and as a specific aid for diabetes management. Barriers included lack of accessibility to patients’ laboratory data in Australia. Conclusions: The targeted training improved pharmacists’ knowledge on diabetes management and supported the Simpler™ tool use in practice as a structured and beneficial method to deliver evidence-based T2DM care.

Background Reviewing pharmacist diabetes intervention studies revealed a lack of structured process in providing diabetes care, leading to varied results from increased to minimal improvements. The aim of this study was to determine the effectiveness of the Simpler tool, a structured clinical guidelines tool, in the delivery of diabetes care. The primary outcome was significant improvement in HbA1c. Secondary outcomes were improved lipid profiles and blood pressure (BP). Methods Results A 6-month parallel multicenter two-arm, single-blind randomized controlled trial involving 14 pharmacists at seven primary care clinics was conducted in Johor, Malaysia. Pharmacists without prior specialized diabetes training were trained to use the tool. Patients were randomized within each center to either Simpler care (SC), receiving care from pharmacists who used the tool (n =55), or usual care (UC), receiving usual care and dispensing services (n = 69). Compared with UC, SC significantly reduced HbA1c (mean reduction 1.59% [95% confidence interval {CI} -2.2, -0.9] vs 0.25% [95% CI -0.62, 0.11], respectively; P

Background Community pharmacists play a significant role in the provision of non-prescription medicines. There is evidence that women self-medicate and use non-prescription medicines whilst breastfeeding. Studies have demonstrated that breastfeeding women are likely to seek advice from pharmacists, presenting a unique opportunity for pharmacists to provide on-going support of these women especially in relation to the appropriate use of non-prescription medicines. Objectives This study aimed to explore community pharmacists' attitudes and perspectives towards the use of non-prescription medicines during breastfeeding. Methods This exploratory study was conducted through semi-structured interviews with 30 community pharmacists in Western Australia, between July and September 2013. Transcribed data were analysed using descriptive and qualitative approaches. NVivo ® Version 10.0 was used to organise qualitative data and quotations to facilitate thematic analysis. Results Four major themes emerged. Despite the positive attitudes and favourable perceived knowledge level, participants often found themselves in a dilemma when required to make clinical recommendations especially in situations where there was a therapeutic need for treatment but clear guidelines or evidence to suggest safety of the medicines or treatment in lactation was absent. Despite the popularity of complementary medicines, participants felt more confident in providing advice in relation to conventional over complementary medicines. Whilst medication safety is within the field of expertise of pharmacists, the absence of information and safety data was seen as a major challenge and barrier to enable pharmacists to confidently provide evidence-based recommendations. Conclusions This study has enhanced our understanding of the attitudes and perspectives of community pharmacists towards the use of non-prescription, including complementary medicines, during breastfeeding. Future studies are warranted to confirm the safety of commonly used or requested medicines in breastfeeding. University training and continuing education for pharmacists should include the latest information available regarding the use of both conventional and complementary medicines throughout lactation.

Context: Globally, the use of alcohol is a leading cause of mortality and morbidity. Opportunistic screening and brief interventions (SBIs) have been shown to be effective in reducing alcohol consumption in certain primary care settings and provide a means of reaching some of those who do not seek treatment for alcohol-related problems. Further, community pharmacies have the potential to reach consumers at an early stage of their alcohol use and incorporate intervention and advice into their role in providing medications. Aim: The purpose of this review was to inform pharmacists and stakeholders of the evidence base for SBI in community pharmacy settings. To date, there has been limited research on the effectiveness of alcohol SBI in community pharmacies, with a systemic review only identifying two randomized trials. Methods: This narrative review reports on the period 2007-2017, covering feasibility studies, pilot programs, and surveys of consumers and pharmacy staff attitudes relating to alcohol SBI in this setting. Studies were identified via MEDLINE, CINAHL, Google Scholar, and reference lists of relevant publications. Findings: The findings indicated that the provision of community pharmacy alcohol SBI requires training in communication and intervention skills and in some cases increasing confidence and alcohol-related knowledge. Consumers were generally receptive to the SBI approach but requested private areas for delivery of such.Conclusion: The high prevalence of "at risk" alcohol use in many countries and the low level of treatment seeking by this group means that novel approaches to engage opportunistically with these people is imperative in reducing alcohol-related harms. However, before committing routine health funding, these novel approaches need rigorous evaluation.

Background Community pharmacists are in an ideal position to promote and provide mental health medication management services. However, formalised or structured pharmacy services to support consumers with mental health conditions are scarce. Australian mental health consumers indicated a need for targeted community pharmacy mental health services which presented an opportunity to develop an intervention that were integrated with remunerated professional services. Objectives The study aimed to pilot a mental health medication management intervention in Australian community pharmacies. Pharmacists worked in partnership with consumers, carers and mental health workers over three to six months to set and support achievement of individual goals related to medicines use, physical health and mental wellbeing. This paper provides a comparison of community pharmacies that successfully delivered the intervention with those that did not and identifies facilitators and challenges to service implementation. Methods One hundred pharmacies opted to pilot the delivery of the intervention in three Australian states (Queensland, Western Australia and northern New South Wales). Of those, 55 successfully delivered the intervention (completers) whilst 45 were unsuccessful (non-completers). A mixed methods approach, including quantitative pharmacy surveys and qualitative semi-structured interviews, was used to gather data from participating pharmacies. Following intervention development, 142 pharmacists and 21 pharmacy support staff attended training workshops, received resource kits and ongoing support from consumer and pharmacist mentors throughout intervention implementation. Baseline quantitative data was collected from each pharmacy on staff profile, volume of medicines dispensed, the range of professional services delivered and relationships with health professionals. At the completion of the study participants were invited to complete an online exit survey and take part in a semi-structured interview that explored their experiences of intervention implementation and delivery. Twenty-nine staff members from completer pharmacies returned exit surveys and interviews were conducted with 30 staff from completer and non-completer pharmacies. Results Descriptive analyses of quantitative data and thematic analyses of qualitative data were used to compare completers and non-completers. Baseline similarities included numbers of general and mental health prescriptions dispensed and established professional services. However, there was greater prevalence of diabetes management, opioid substitution services, and relationships with mental health services in completer pharmacies. Key facilitators for completers included pharmacy owner/manager support, staff buy-in and involvement, intervention flexibility, recruitment immediately following training, integration of intervention with existing services, changes to workflow, and regular consumer contact. Key barriers for both groups included lack of pharmacy owner/manager support or staff buy-in, time constraints, privacy limitations and pilot project associated paperwork. Conclusions Insights into factors that underpinned successful intervention implementation and delivery should inform effective strategies for similar future studies and allocation of pharmacy mental health service delivery resources.

Aim The objectives of this study were to evaluate clinical interventions recorded by pharmacists in an Australian principal referral and specialist women's and newborns' hospital, as well as to identify common medications involved in each specialty area (neonatology, obstetrics and gynaecology), to assess the risks of medication-related problems (MRPs) likely to have been prevented, and to obtain institution-specific MRPs for future staff education. Methods This retrospective, observational study involved an analysis of all interventions documented by pharmacists from January 2005 to December 2014. The interventions recorded were collated according to ward, medication involved, description of the intervention and the risk classification. Results There were a total of 14 085 interventions documented over 10 years; 60.33% made in obstetric patients, 28.71% in gynaecology patients and 10.96% in neonates. The three main intervention types were: (i) dose/frequency/time incorrect (25.70%, n = 3260); (ii) prescribing clarification (21.77%, n = 3066); and (iii) medicine omission (15.21%, n = 2143). An average of 12.02% of the interventions were regarded as high-risk and 0.85% as extreme-risk. Of the MRPs documented within each specialty, the prevalence of extreme risk interventions was higher in the neonatal ward. Discussion The most common intervention was identifying incorrect medication dose/frequency/time. Common medications involved in the MRPs included: opioids and antihypertensives in gynaecology; parenteral nutrition and gentamicin in neonatology; and opioids and non-steroidal anti-inflammatory drugs (NSAIDs) in obstetrics. The medications involved in high and extreme risk MRPs included gentamicin, opioids and NSAIDs. Conclusion This study demonstrates that hospital pharmacists contribute to the reduction of MRPs, including some potentially fatal adverse medicine events. These findings also enable targeted, site-specific education, which is valuable in improving patient safety.

Background: Studies have explored community pharmacy ethical dilemmas; however, limited research exists on hospital pharmacy ethical issues and pharmacists’ ethical decision-making processes. Research exploring this is timely, considering developments in hospital pharmacy practices, new hospital pharmacist roles, and evolving responsibilities. Aim/objectives: To explore hospital pharmacists’ ethical decision-making and processes for managing ethical challenges in the context of evolving Australian hospital pharmacy practices. Methods: Face-to-face semi-structured interviews with 20 purposively-selected hospital pharmacists from four Queensland Health hospitals. An interview guide with 11 open-ended questions and prompts was developed, validated, and trialed. Pharmacists who consented received the guide prior to interviews. Interviews were audio recorded, transcribed verbatim, and compared with field notes. Transcribed data were imported into NVivo 12 to facilitate coding and thematic analysis. Results: Participants were interviewed January to April 2019; median interview duration was 17.45 min. Data saturation was reached. Participants' experiences ranged from junior level pharmacists to senior management positions, in clinical and non-clinical roles. Emerging themes were: 1) influences on the development of ethical decision-making skills, 2) ethical decision-making is an integral part of the hospital pharmacist's role, and 3) institutional requirements and settings impact on ethical exposure. A wide range of contemporary ethical issues unique to hospital pharmacy practice, mostly involving complex medication management safety, supply, and cost scenarios, were identified. Junior pharmacists indicated they would benefit from additional training, mentorship, and availability of hospital-specific targeted ethics resources. Conclusion: The findings highlighted that hospital pharmacists are regularly faced with ethical issues unique to the hospital pharmacy practice context. Application of sound and structured ethical reasoning and decision-making is, therefore, required in this setting. Participants identified many interrelated factors that impacted their ethical reasoning and behaviour. This study identified gaps that, once addressed, will better support ethical reasoning in hospital pharmacy settings.

Background Australian government funding for Residential Medication Management Reviews and Home Medicines Reviews commenced in 1997 and 2001 respectively. Limited data are available on their provision in Australia. Objective To investigate the extent and characteristics of Home Medicines Review and Residential Medication Management Review services provided by accredited pharmacists practising in Western Australia. Setting Pharmacists in Western Australia accredited by the Australian Association of Consultant Pharmacy or Society of Hospital Pharmacists of Australia. Method A paper questionnaire was developed and sent to 198 accredited pharmacists in Western Australia in June 2017. Simple descriptive statistics summarised demographic information and other responses. Logistic regression evaluated factors associated with the frequency of provision of Home Medicines Reviews. Main outcome measure Frequency and factors influencing services provided. Results Of 102 (51.5%) questionnaires returned, 67 (65.7%) respondents were female. Many were aged between 31 and 40 years (53; 52.0%). Most were accredited by the Australian Association of Consultant Pharmacy (101; 99.0%) and mainly offered Home Medicines Reviews (70; 68.6%). Home Medicines Reviews provided over the previous 12 months were limited in frequency with one quarter providing either 1–10 (27; 26.5%) or 21–50 (28; 27.5%) reviews. The median “average” preparation, interview and report writing times, plus communication with other health professionals aggregated to 175.0 min (interquartile range: 140.0–235.0 min) for Home Medicine Reviews and 110.0 min (90.0–140.0) for Residential Medication Management Reviews. Pharmacists born overseas and those who were accredited for a longer time were associated with performing 51 or more Home Medicines Reviews annually. Only one-third (36/101; 35.6%) agreed the current payment was appropriate. Most agreed their Home Medicines Reviews (92/96; 95.8%) and Residential Medication Management Reviews (26/28; 92.9%) provided improved patient outcomes. Over 97% of accredited pharmacists intended to continue to remain accredited. Conclusions Wide variations were evident in the times taken for tasks associated with performing reviews. Most respondents considered their medication reviews contributed to improved patient outcomes. The wide variation in times taken for the reviews suggests a tiered structure for service provision, with appropriate payment within each tier, since most consider current remuneration inadequate.

Background Careful planning is important for successful implementation and ongoing provision of enhanced and extended pharmacy services. Objective To explore the factors that contributed to the successful implementation and ongoing provision of enhanced and extended services in Western Australian community pharmacies. Methods In-depth semi-structured telephone interviews were conducted with purposively selected pharmacists from various practice settings. Interviews explored experiences and perspectives on the provision of enhanced and extended professional services and continued until saturation was achieved. Analysis focused on prior investigation before implementation of services, perceptions of the impact of the services and factors to be considered. The COM-B (Capability, Opportunity, Motivation and Behaviour) model was applied post hoc to the thematic analysis to explore whether there was an overlap between themes and the model. Results In total 26 pharmacists (16 males, 10 females) participated in semi-structured interviews during October 2017 and February 2018. They classified as 20 community, 13 accredited and 7 specialist pharmacists and 11 pharmacist immunisers (some classified as more than one). Interview duration was 55 min (minimum 22, maximum 91 min). Responses regarding prior investigation/research conducted varied in approach followed and level of enquiry. Opinions about services were overall positive such as enhanced collaboration with other healthcare professionals, positive patient outcomes, increased staff satisfaction and acceptance of pharmacists as primary care providers. New services did not always provide direct financial benefit. Three major themes emerged as factors that impacted on provision of services: 1) pharmacist characteristics, 2) local needs, structures and support, and 3) an enabling practice framework. Conclusions Pharmacists who were successful in the implementation and maintenance of new professional services were familiar with local needs. Both pharmacy and pharmacist aspects should be considered during implementation and maintenance of new professional services. An enabling practice framework is crucial in facilitating new pharmacy services.

Background: Mental health is an Australian national priority area, yet evidence indicates pharmacy staff members focus more frequently on other chronic diseases. A need was identified to facilitate community pharmacy staff engagement with mental health initiatives. Aim: This study explored community pharmacy staff motivations and barriers to working with mental health consumers and carers. Method: A questionnaire assessing baseline attitudes, knowledge and skills towards mental illness was completed by 791 community pharmacy staff members. Participants rated their agreement with statements regarding factors that motivate them (11 items) or present a barrier to working with mental health consumers and carers (12 items) on a 7-point Likert scale. Qualitative comments were invited. Results: In total, 465 pharmacists (58.8%) and 326 support staff (41.2%) completed the questionnaire. Statements reflecting motivations were strongly endorsed: 83% of participants agreed that they were motivated to work with mental health consumers and carers, and 96% agreed that community pharmacists are integral members of the healthcare team. The most frequently endorsed barriers related to lack of training to assist people and belief that consumers feel ashamed about their illness. Themes that emerged from qualitative comments identified staff skills and knowledge as both motivators and barriers. Conclusion: The findings identified that both pharmacists and pharmacy support staff required more training, confidence and practical strategies to support best practice in meeting the needs and expectations of mental health consumers and carers.

Background. We conducted a review of current diabetes intervention studies in type 2 diabetes and identified opportunities for pharmacists to deliver quality diabetes care.Methods. A search on randomised controlled trials (RCT) on diabetes management by healthcare professionals including pharmacists published between 2010 and 2015 was conducted.Results and Discussion. Diabetes management includes multifactorial intervention which includes seven factors as outlined in diabetes guidelines, namely, glycaemic, cholesterol and blood pressure control, medication, lifestyle, education, and cardiovascular risk factors. Most studies do not provide evidence that the intervention methods used included all seven factors with exception of three RCT which indicated HbA1c (glycated hemoglobin) reduction range of 0.5% to 1.8%. The varied HbA1C reduction suggests a lack of standardised and consistent approach to diabetes care. Furthermore, the duration of most studies was from one month to two years; therefore long term outcomes could not be established.Conclusion. Although pharmacists’ contribution towards improving clinical outcomes of diabetes patients was well documented, the methods used to deliver structured, consistent evidence-based care were not clearly stipulated. Therefore, approaches to achieving long term continuity of care are uncertain. An intervention strategy that encompass all seven evidence-based factors will be useful.

This study describes the process undertaken to develop, implement and evaluate a simulation-based training package focused on medication management and reconciliation processes for final year pharmacy students about a patient’s hospital journey. A five module training package was developed following a literature review and consultation with stakeholders. The simulation-based package immersed students in a real-life scenario and was delivered to final year pharmacy students over a six-week period in 2016. Data on knowledge, skills and confidence was collected via a survey in the week preceding engagement with the online training package and 1 week post completion of the training. The mean score was compared across four student categories: three categories incorporated students who had not completed a hospital pharmacy placement and one category comprised students who had completed a hospital placement. Qualitative feedback was collected via an online survey at the conclusion of the training program. Of the 79 participants, 44 (55.7%) completed both the pre and post- test surveys that showed the change in score was statistically significant. There was a significant positive change in mean test scores across all four student categories for the domains of skills, knowledge and confidence. Assessment of students’ confidence according to 16 ranking statements also improved markedly post-training. Thirty-one students provided qualitative feedback that was generally positive. The positive outcomes reinforce the rationale to include online simulation-based methodologies as part of pharmacy education programs. The model provides a reproducible framework for online simulated learning activities that could be applied within various professions and educational environments.