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A recent study found that only 23.8% of blood pressure (BP) devices available for purchase from Australian pharmacies were validated for accuracy. The extent to which pharmacists are aware of this, and other issues related to the accuracy of BP devices, is not known and gathering this information was the aim of this study. An online survey of Australian pharmacists was distributed via the Pharmaceutical Society of Australia between 1 October and 25 November 2020. Questions were focused on the views of pharmacists related to the accuracy of BP devices. Two hundred and ten pharmacists completed the survey. The accuracy of BP devices sold by pharmacists was considered ‘quite’ or ‘extremely important’ to most respondents (94%). However, most respondents (90%) were unaware that less than one-quarter of BP devices sold by Australian pharmacies were validated, and this was ‘quite’ or ‘extremely surprising’ to many (69%). Many respondents (64%) associated a particular brand of BP device with greater accuracy. There was low awareness on proper ways to identify accurate BP devices, such as checking reputable online databases (43%). BP devices were stocked in respondents’ pharmacies based on perceived quality (50%), accuracy (40%), or as determined by the pharmacy chain (36%). In conclusion, providing accurate BP devices to consumers is important to pharmacists, but they were generally unaware that most devices available from pharmacies were not validated for accuracy. Pharmacist education, alongside advocacy for policies including regulations and strategic action, is required to ensure only validated BP devices are sold in Australia.

A recent study found that only 23.8% of blood pressure (BP) devices available for purchase from Australian pharmacies were validated for accuracy. The extent to which pharmacists are aware of this, and other issues related to the accuracy of BP devices, is not known and gathering this information was the aim of this study. An online survey of Australian pharmacists was distributed via the Pharmaceutical Society of Australia between 1 October and 25 November 2020. Questions were focused on the views of pharmacists related to the accuracy of BP devices. Two hundred and ten pharmacists completed the survey. The accuracy of BP devices sold by pharmacists was considered 'quite' or 'extremely important' to most respondents (94%). However, most respondents (90%) were unaware that less than one-quarter of BP devices sold by Australian pharmacies were validated, and this was 'quite' or 'extremely surprising' to many (69%). Many respondents (64%) associated a particular brand of BP device with greater accuracy. There was low awareness on proper ways to identify accurate BP devices, such as checking reputable online databases (43%). BP devices were stocked in respondents' pharmacies based on perceived quality (50%), accuracy (40%), or as determined by the pharmacy chain (36%). In conclusion, providing accurate BP devices to consumers is important to pharmacists, but they were generally unaware that most devices available from pharmacies were not validated for accuracy. Pharmacist education, alongside advocacy for policies including regulations and strategic action, is required to ensure only validated BP devices are sold in Australia.

Using Australian coroners’ inquest findings, this study investigated characteristics of non‐opioid and non‐benzodiazepine accidental drug‐related deaths, and coroners’ recommendations applicable to pharmacists. A retrospective thematic analysis was conducted of narrative text from coronial findings of non‐opioid and non‐benzodiazepine drug‐related deaths (n = 33; 18 males, 15 females; mean (±SD) age 50.3 ± 19.3 and 57.7 ± 22.0 years, respectively) published on the Internet between January 2012 and October 2017. A wide range of drugs was implicated in drug‐related deaths, with drugs relating to mental health conditions (antidepressants, antipsychotics) found to be the most prevalent and increasing over the 5‐year period. A history of mental health illness was common. Coroners’ comments pertaining to pharmacists were limited to the requirement to maintain accurate records. A greater appreciation of the role of pharmacists is required by coroners, with many of the coroners’ recommendations directed to other health professionals relevant to the pharmacists’ role of promoting the safe use of medicines.

(1) Background: My Health Record (MHR) is a relatively new nationwide Australian digital health record system accessible by patients and a range of healthcare professionals. Pharmacists will be key contributors and users of the MHR system, yet little is known about the perceived barriers and benefits of use. (2) Objective: To explore pharmacists&rsquo, perspectives related to potential benefits and barriers associated with use of MHR. (3) Methods: An online survey was developed and face-validated. The survey was advertised to Australian pharmacists on pharmacy professional bodies&rsquo, websites. This was a cross-sectional study using an anonymous questionnaire. Descriptive statistics were used to describe the distribution of the data. Chi-square, Kendall&rsquo, s tau coefficient (tau-c) and Kruskal&ndash, Wallis tests were used to examine the relationships where appropriate. (4) Results: A total of 63 pharmacists completed the survey. The majority of respondents worked in a metropolitan area (74%), and the most common workplace setting was community pharmacy (65%). Perceived benefits identified by responders include that the use of MHR would help with continuity of care (90%), and that it would improve the safety (71%) and quality (75%) of care they provided. Importantly, more than half of pharmacists surveyed agreed that MHR could reduce medication errors during dispensing (57%) and could improve professional relationships with patients (57%) and general practitioners (59%). Potential barriers identified by pharmacists included patients&rsquo, concerns about privacy (81%), pharmacists&rsquo, own concern about privacy (46%), lack of training, access to and confidence in using the system. Sixty six percent of respondents had concerns about the accuracy of information contained within MHR, particularly among hospital and general practice pharmacists (p = 0.016) and almost half (44%) had concerns about the security of information in the system, mainly pharmacists working at general practice and providing medication review services (p = 0.007). Overall satisfaction with MHR varied, with 48% satisfied, 33% neither satisfied nor dissatisfied, and 19% dissatisfied, with a higher satisfaction rate among younger pharmacists (p = 0.032). (5) Conclusions: Pharmacists considered that the MHR offered key potential benefits, notably improving the safety and quality of care provided. To optimize the use of MHR, there is a need to improve privacy and data security measures, and to ensure adequate provision of user support and education surrounding the ability to integrate use of MHR with existing workflows and software.

Background: The COVID-19 pandemic is ongoing. The unprecedented challenges worldwide implore the urgent development of a safe and effective COVID-19 vaccine. Globally, pharmacists have been delivering important public health services as part of the COVID-19 response. It remains to be seen what role they will play once a vaccine is available. This review examines herd immunity and the potential role of the pharmacy profession in mass vaccination against COVID-19, particularly within the Australian context. Aim: A literature review was conducted to review the global development of COVID-19 vaccines, and the Australian healthcare workforce capability and existing policy for mass vaccination and the potential role of the pharmacist. Method: ScienceDirect, Scopus, The National Centre for Biotechnology Information (NCBI), Wiley Online Library, PubMed, and Google Scholar were used to search for relevant literature using keywords COVID-19, vaccines, immunisation, herd immunity, pandemic, pharmacist and Australian healthcare. Results: A large portion of the literature was journal articles, and information from governmental and international bodies such as the World Health Organisation were often referenced. Over 20 million Australians need to be immunised through vaccination or acquire immunity through natural infection for the country to achieve herd immunity for COVID-19. When examining state and territory pandemic plans, pharmacists are underutilised. Modifying legislation to allow pharmacists to administer approved COVID-19 vaccines will enable a trained and skilled workforce to be deployed to increase the rate of mass vaccination. Conclusion: In preparation for a successful COVID-19 vaccine, the Australian Government must consider various elements in their vaccination policy. This includes the estimated herd immunity threshold, methods of vaccine delivery, vaccine clinic locations, staffing arrangements and training, and strategies for vaccine prioritisation. Pharmacists can and should play a key role in the roll out of mass COVID-19 vaccination.

Problems associated with the use of medicines in society continue to be a significant public health burden, with the brunt being borne by older people.1–3 The higher risk of medicine-related adverse events and hospitalisations in older adults is caused primarily by age-related pharmacokinetic and pharmacodynamic changes, and a higher number of chronic conditions and resultant polypharmacy, which is often associated with the use of potentially inappropriate medicines.3–5 Adverse drug events (ADEs) frequently involve predictable high-risk situations, such as multiple drug use in the elderly, which are amenable to prevention through better systems and ways of working by health professionals.

Investigation of organic compounds in ice cores can potentially unlock a wealth of new information in these climate archives. We present results from the first ever ice core drilled on sub‐Antarctic island Bouvet, representing a climatologically important but understudied region. We analyze a suite of novel and more familiar organic compounds in the ice core, alongside commonly measured ions. Methanesulfonic acid shows a significant, positive correlation to winter sea ice concentration, as does a fatty acid compound, oleic acid. Both may be sourced from spring phytoplankton blooms, which are larger following greater sea ice extent in the preceding winter. Oxalate, formate, and acetate are positively correlated to sea ice concentration in summer, but sources of these require further investigation. This study demonstrates the potential application of organic compounds from the marine biosphere in generating multiproxy sea ice records, which is critical in improving our understanding of past sea ice changes., Key Points We analyzed a suite of organic compounds,alongside commonly measured ions, in the first ever shallow ice core from Bouvet IslandMultiple marine‐sourced organic compounds are detected throughout the coreOrganic compounds, alongside MSA, show significant positive correlations with sea ice

This study aims to update and validate quality prescribing indicators (QPIs) for Australian general practice. The study comprised two phases: (1) developing preliminary potential QPIs based on the 2006 National Prescribing Service (NPS) MedicineWise indicators, published literature, international indicators and guidelines, and through qualitative focus group discussions; and (2) validating the proposed QPIs through a two-round online survey using the Delphi technique. The Delphi panel included four GPs, four pharmacists and two clinical pharmacologists. The Delphi panel rated the potential QPIs for their validity, importance and feasibility using a 1–10 Likert scale. In round one, all proposed QPIs presented as ‘prescribing rules’ achieved high scores regarding validity, importance and feasibility No rule was eliminated and three new rules were introduced. Rules were reworded into ‘prescribing indicators’ for round two, which resulted in 35 indicators being accepted and two indicators being eliminated. The final QPIs also include seven drug–drug interactions, which received high scores in round one. In conclusion, 42 QPIs were nominated for use in Australian general practice, based on their validity, importance and feasibility. If implemented, these QPIs have the potential to assist in efforts to improve the quality and safety of medicines management.

Objectives Anecdotal comparisons between rural and urban community pharmacy practice have been frequently reported. Therefore, a narrative systematic review was conducted to examine the published international evidence comparing the nature of services provided from community pharmacies in both settings. A comprehensive literature search was undertaken across four databases. The key criterion for inclusion was a comparison of practice, excluding dispensing and associated counselling. Definitions of ‘rural’ were specific to the country and publication year. Key findings The search yielded 3830 titles, from which 17 publications met the inclusion criteria. The studies investigated current or proposed services and included the provision of pharmaceutical care, public health activities and prescribing. Rural customers were more willing to seek advice and talked longer to the pharmacist, but not always. There was limited evidence that rural pharmacists provided more professional services and they appeared to have better working relationships with prescribers. Many of the authors challenged the validity of their own results, suggesting that other confounding factors accounted for the observed differences. In general, the statistical analyses reported were basic, with multivariate analyses being uncommon. There was some evidence that rural pharmacists were seemingly more willing to take on new professional roles and deliver a higher level of service. However, this conclusion is based on a small number of studies, often with a limited number of respondents and simplistic data analyses. Further high-quality research is required to ascertain and characterise any real differences between rural and urban settings in community pharmacy practice.

The need to develop An Advanced Pharmacy Practice Framework for Australia (the “APPF”) was identified during the 2010 review of the competency standards for Australian pharmacists. The Advanced Pharmacy Practice Framework Steering Committee, a collaborative profession-wide committee comprised of representatives of ten pharmacy organisations, examined and adapted existing advanced practice frameworks, all of which were found to have been based on the Competency Development and Evaluation Group (CoDEG) Advanced and Consultant Level Framework (the “CoDEG Framework”) from the United Kingdom. Its competency standards were also found to align well with the Domains of the National Competency Standards Framework for Pharmacists in Australia (the “National Framework”). Adaptation of the CoDEG Framework created an APPF that is complementary to the National Framework, sufficiently flexible to customise for recognising advanced practice in any area of professional practice and has been approved by the boards/councils of all participating organisations. The primary purpose of the APPF is to assist the development of the profession to meet the changing health care needs of the community. However, it is also a valuable tool for assuring members of the public of the competence of an advanced practice pharmacist and the quality and safety of the services they deliver.

SUMMARY What is known and objectives: About half of all patients taking antihypertensives discontinue treatment by 12 months. There is potential for substantial health gains at both individual and population levels through improved treatment adherence. The objective was to evaluate a community pharmacist intervention to improve adherence with antihypertensive medicines with a view to improving blood pressure (BP) control. Methods: Design: prospective, non-blinded, cluster-randomized, controlled trial. Participants: adults with primary hypertension who obtained antihypertensives in the previous 6 months. Patients with poor refill adherence were preferentially identified with the help of a purpose-built software application. Intervention: package comprising BP monitor; training on BP self-monitoring; motivational interviewing; medication use review; prescription refill reminders. Follow-up: six months. Primary outcome: change in proportion self-reporting medication adherence. Secondary outcome: BP changes. Results: Participants (n = 395; intervention – 207; control – 188) had a mean age of 66.7 years; 51.1% were males. The proportion of adherent participants increased in both groups but was not significantly different between groups [572% to 636% (control) vs. 600% to 735% (intervention), P = 023]. The mean reduction in systolic BP was significantly greater in the intervention group (100 mmHg vs. 46 mmHg; P = 005). The proportion of patients who were non-adherent at baseline and adherent at 6 months was 226% (95%CI 51–400%) higher in the intervention group (618% vs. 392%, P = 0007). Among participants with baseline BP above target, reduction of systolic BP was significantly greater in the intervention group [by 72 mmHg (95%CI 16– 128 mmHg); (P = 001)]. Among participants non-adherent at baseline and above target BP, the proportion reporting adherence at 6 months was significantly greater in the intervention group [568% vs. 359%, P = 0039). What is new and conclusion: This community pharmacist intervention resulted in improved adherence to antihypertensive medication and reduced systolic BP.

Objective To understand the factors influencing persistence with tiotropium in patients with chronic obstructive pulmonary disease (COPD). Methods Patients classified as ‘persistent’ or ‘non-persistent’ with tiotropium were identified from pharmacy dispensing records. Patients were compared for health status, beliefs and behaviours using data from questionnaires and interviews. Key findings Perceptions of the risks and benefits of medication, fear of worsening illness, and the GP's emphasis on the importance of the medication were key determinants of tiotropium persistence. Conclusions Perceptions, attitudes and beliefs of patients and doctors influence persistence with tiotropium. These complex interactions need to be targeted to improve persistence with medicines in COPD.

© 2019 NPS MedicineWise. Digital healthcare records aim to facilitate the delivery of safe, efficient and effective health care while connecting different points of the healthcare system so that information can be shared securely. These records can impact on almost every aspect of healthcare delivery. This includes how healthcare professionals and patients interact with each other, how health information is stored and used, and how patients manage their own health through electronic apps and devices. Due to the rapid evolution of digital health care, today’s health professionals, including pharmacists, need an understanding of the expectations, opportunities and challenges that digital health technologies present.

What is known and Objective: Pharmacists frequently see patients with asthma in the community who have suboptimal management. This study aimed to compare the uptake and effectiveness of pharmacist-initiated mailed and face-to-face interventions for patients whose asthma may not be well managed. Methods: Seventy-one community pharmacies in South Australia, Tasmania and Victoria (Australia) installed a software application that data-mined dispensing records, generating a list of patients who had received six or more asthma reliever inhalers in the preceding 12 months. The pharmacists were randomized, by pharmacy, to perform either a mailed or face-to-face intervention, whereby these patients received educational material and a referral to their general practitioner (GP) for an asthma management review. Matching patients from each pharmacy were also randomly assigned to a control group for ‘usual care’. Results and Discussion: A total of 1483 patients were identified and grouped as follows: 510 (34.4%) mailed intervention, 480 (32.4%) face-to-face intervention and 493 (33.2%) controls. Significantly fewer face-to-face interventions were offered than mailed interventions (66.6% vs. 89.4%, respectively; χ 2 = 64.2, P P

Objective: To identify and resolve discrepancies in admission medication histories, utilizing community pharmacy dispensing data, in newly hospitalized patients and investigate the relationship between unresolved discrepancies and length of hospital stay. Methods: Eligible patients (2 or more chronic conditions, 3 or more chronic medications and aged over 50 years) were randomized to the intervention or control group. Within 24 h of admission, the patient's nominated community pharmacy was contacted, a 6-month dispensing history obtained, patient was interviewed and a current medication list compiled. This was compared with the hospital drug chart. Discrepancies for the intervention group were discussed with the attending doctor. Subsequent resolution of discrepancies was assessed for all patients. Results: 487 patients were included (203 intervention, 284 control). Approximately 66% of all patients had at least one discrepancy between their reconciled list of medications and their initial drug chart, with no significant difference between the groups. Significantly more intervention patients had at least 1 discrepancy resolved in the first 48 h than control patients (intervention 78.1%; control 36.5%; p < 0.0001). A weak correlation was found between the number of discrepancies not acted on and length of hospital stay (Spearman Rho = 0.1, n = 487, p < 0.01). Conclusion: Errors in admission medication histories are common and potentially lead to an increased length of stay. The provision of a 6-month community pharmacy dispensing history at the time of hospital admission is an important addition to ensure an accurate medication chart is compiled.

What is Known and Objective: Warfarin is recognized as a high-risk medication for adverse events, and the risks are particularly heightened in the period immediately following a patient’s discharge from hospital. This qualitative study aimed to explore the experiences of Australian patients and healthcare professionals of warfarin management in the post-discharge period and identify the benefits and deficiencies of existing systems, to inform the development of a model for a new collaborative post-discharge warfarin management service. Methods: Healthcare professionals, professional organization representatives and patients recently discharged from hospital taking warfarin (consumers) were recruited via purposive, criterion-based sampling within two Australian states. Semi-structured telephone interviews were conducted between August and October 2008 using standard discussion guides. Data were manually analyzed to identify emergent themes using a phenomenological approach. Results: Forty-seven participants were involved in the telephone interviews. Three major themes emerged: (i) appropriate warfarin education is integral to effective warfarin management, (ii) problems occur in communication along the continuum of care and (iii) home-delivered services are valuable to both patients and healthcare professionals. Discussion: Although high-quality warfarin education and effective communication at the hospital–community interface were identified as important in post-discharge warfarin management, deficiencies were perceived within current systems. The role of home-delivered services in ensuring timely follow-up and promoting continuity of care was recognized. Previous studies exploring anticoagulation management in other settings have identified similar themes. Post-discharge management should therefore focus on providing patients with a solid foundation to minimize future problems. What is New and Conclusion: Addressing the three identified facets of care within a new, collaborative post-discharge warfarin management service may address the perceived deficiencies in existing systems. Improvements may result in the short- and longer-term health outcomes of patients discharged from hospital taking warfarin, including a reduction in their risk of adverse events.

Background: To assess the long-term impact of the “Reducing Use of Sedatives” (RedUSe) trial on antipsychotic and benzodiazepine prevalence and dosage.Methods: RedUSe was a six-month controlled trial conducted in 25 Tasmanian nursing homes in 2008–9 which led to significant reductions in benzodiazepine and antipsychotic use and a doubling of dose reductions of these agents. In a follow-up study, data on psychotropic use was collected from all nursing homes a year after the final RedUSe measure. Mean daily doses for each home were calculated by converting antipsychotic and benzodiazepine doses to chlorpromazine and diazepam equivalents, respectively. To determine the long-term impact of the project, 6-month and initial baseline data were compared to the 18-month follow-up data.Results: 1578 residents were audited for the follow-up measure. In the 18 months since the RedUSe project was instigated, benzodiazepine prevalence fell by 25% in intervention nursing homes. Similarly, the mean daily diazepam equivalence in these homes had fallen by 24%. In contrast, after a significant reduction during the RedUSe trial, antipsychotic prevalence returned to baseline levels in intervention nursing homes, with mean chlorpromazine equivalence remaining relatively constant with time. There was a delayed reduction in benzodiazepine and antipsychotic use in the control homes.Conclusions: Both benzodiazepine usage and mean daily diazepam equivalence continued to decline in intervention nursing homes in the year following the RedUSe trial. However, the effect of the RedUSe intervention on antipsychotic prevalence and dosage was not sustained.

Drug-related problems (DRPs) are a major burden on health care systems. Community pharmacists are ideally placed to detect, prevent, and resolve these DRPs.To determine the number and nature of DRPs detected and clinical interventions performed by Australian community pharmacists, using an electronic system.An electronic documentation system was designed and integrated into the existing dispensing software of 186 pharmacies to allow pharmacists to record details about the clinical interventions they performed to prevent or resolve DRPs. Participating pharmacies were randomly allocated to 3 groups: group 1 had documentation software, group 2 had documentation software plus a timed reminder to document interventions, and group 3 had documentation software, a timed reminder, and an electronic decision support prompt. Pharmacists classified DRPs, entered recommendations they made, and estimated the clinical significance of the intervention. An observational substudy that included pharmacies without any documentation software was completed to verify intervention rates.Over 12 weeks, 531 participating pharmacists recorded 6230 clinical interventions from 2,013,923 prescriptions, with a median intervention rate of 0.23% of prescriptions. No significant differences were seen between the 3 groups that used documentation software; as expected, however, the pharmacies that used this software had a significantly higher documentation rate compared to the pharmacies without documentation software. The most common interventions were related to drug selection problems (30.8%) and educational issues (24.4%). Recommendations were often related to a change in therapy (40.0%), and 41.6% of interventions were self-rated as highly significant. Drug groups most commonly subject to an intervention included antibiotics, glucocorticoids, nonsteroidal antiinflammatory drugs, and opioids.The documentation system allowed for the determination of the frequency and types of DRPs, as well as the recommendations made to resolve them in community pharmacy practice. Use of the software, including its electronic prompts, significantly increased the documentation of interventions by pharmacists.

Background: Despite the proven effectiveness of antithrombotic therapy for atrial fibrillation (AF), the treatment remains suboptimal. The aim of this study was to implement and evaluate a system to improve the appropriate use of antithrombotics for stroke prevention in AF utilizing a clinical pharmacist as a stroke risk assessor. Method: Hospital in-patients with AF were prospectively identified and they received a formal stroke risk assessment from a pharmacist. The patients’ risk of stroke was assessed and documented according to Australian guidelines and a recommendation regarding antithrombotic therapy was made to the medical team on a specially designed stroke risk assessment form. Results: One hundred and thirty-four stroke risk assessments were performed during the intervention period. For those patients at high risk of stroke and with no contraindication present (warfarin-eligible patients), 98% were receiving warfarin on discharge from hospital compared to 74% on admission ( P < 0.001). Of the 50 (37%) assessments that recommended a change of therapy, 44 (88%) resulted in a change in the patient’s current antithrombotic therapy compared to their admission therapy. Thirty (68%) of the assessments resulted in an ‘upgrade’ to more-effective treatment options for example from no therapy to any agent or from aspirin to warfarin. Discussion and Conclusion: The pharmacist-led stroke risk assessment program resulted in a significant increase in the proportion of patients receiving appropriate thromboprophylaxis for stroke prevention in AF. The methods used in this study should be evaluated in a larger trial, in multiple hospitals, with different pharmacists performing the intervention.

Background and Objective: To assess the public’s perception of pharmacists’ involvement and role in cardiovascular disease prevention and management. Methods: A computer-assisted telephone interview of 505 households was conducted. The survey was administered to metropolitan, rural and remote residents over the age of 30 years. The interview had questions on the patient’s general satisfaction with the quality of service provided by their regular community pharmacy, including factors such as location, professionalism, prices, product range and knowledge of the staff. The participants were asked if they thought pharmacists were capable of providing screening, testing and drug prescribing services for blood pressure and cholesterol, and how likely they would be to use these services through a pharmacy. The interview also included questions on how likely this person would be to seek advice on lifestyle changes and medications from various health professionals, including pharmacists. Results: The majority (97%) were satisfied with the service provided at their regular pharmacy. Those surveyed agreed or strongly agreed that pharmacists are capable of providing screening or testing for raised blood pressure (52%) and diabetes (51%), with a minority (38%) agreeing that pharmacists are capable of testing for raised cholesterol. The pharmacist’s role with perceived highest capability by those surveyed was in providing advice on how to take medicines properly, with 90% of respondents willing to seek this advice from their pharmacist. A limited role by pharmacists was seen in the diagnosis of CVD and prescribing medications. In relation to the prevention of CVD, even though 76% of respondents believed that pharmacists are capable of providing advice on lifestyle changes (e.g. weight loss, smoking and alcohol intake), only 8% of current or past smokers had sought assistance to give up smoking at their pharmacy and while 69% of all respondents had sought help with weight control, only 3% of these had looked towards their pharmacy for assistance. Conclusion: There was belief by those Australians surveyed that community pharmacists are capable of providing screening for hypertension and diabetes. Through these services and in conjunction with counselling on CVD risk reduction, pharmacists may play an important role in the reduction of CVD, ultimately improving public health and decreasing the burden on Australia’s health care system. However, at present pharmacists are not being fully utilized to deliver health promotion advice and contribute to the prevention of CVD.

Objective To assess the suitability of Australian community pharmacies as cardiovascular disease risk profile screening centres and evaluate whether community pharmacists can play an important role in detecting, educating and referring screened individuals at high risk of cardiovascular disease. Setting 14 Australian community pharmacies. Method Opportunistic cardiovascular disease risk profiling for members of the public aged greater than 30 years with no existing cardiovascular diseases was performed. All major cardiovascular risk factors were measured. Exercise habits, existing conditions and therapy, and family history were also assessed. The results were used to calculate each subject’s 10-year risk of developing cardiovascular events, based on Framingham Risk Equations (New Zealand tables). Each subject’s knowledge of cardiovascular risk factors was assessed using a multiple-choice questionnaire. Written educational materials and verbal counselling were provided. Referral to a doctor for further assessment was recommended as appropriate. The screened individuals were followed up via mailed out questionnaire. A random sample of individuals at elevated risk was phoned to assess for outcomes of the screening and referral process. Main outcome measures Risk of developing cardiovascular disease and knowledge of cardiovascular risk factors. Results A total of 655 individuals (71.4% female) were screened for cardiovascular disease risk factors. Ages ranged from 30 to 90 years (median: 54 years) and 14.2% were smokers. Of the individuals screened, 28.1% had a 10-year risk of developing cardiovascular disease greater than 15%, including 6.9% who had a 10-year risk above 30%. The median calculated 10-year risk of developing cardiovascular disease was 9.5%. Approximately one-third of the individuals had elevated blood pressure, and almost two-thirds were either overweight or obese. The mean total serum cholesterol was 5.31 mmol/l, with 40% of individuals having a level above 5.5 mmol/l and 20% having a high-density lipoprotein cholesterol level below 1.0 mmol/l. There was a statistically significant improvement in the knowledge of cardiovascular disease risk factors at follow-up. Almost half of the contacted high-risk subjects reported lifestyle changes or started drug therapy following re-testing by their general practitioner. Conclusion A pharmacy-based cardiovascular disease risk profile screening and education program has the potential to identify and refer many undiagnosed individuals at high risk of cardiovascular events, and help contain the burden of heart disease.

Aim: To examine psychotropic medication review practices in residential aged care facilities. Methods: Psychotropic medicine use data were collected from residents from 40 residential aged care facilities throughout Tasmania. As an indication of review practices, the measure was repeated at 33 of the original facilities a year later. Results: A total of 2389 residents' medication records were examined in 2006. Regular doses of antipsychotics and benzodiazepines were taken by 42% and 21% of residents, respectively. Medication data were available for 1307 of the residents in 2007. Over 60% were taking the same antipsychotic or benzodiazepine agent, at the same dose in 2007, as they were in 2006. Dosage reduction or cessation occurred in less than a quarter of the residents. Conclusion: The utilisation of psychotropic medication is high in Tasmanian residential aged care facilities. Attempts to reduce psychotropic doses happen infrequently. Further research is required to establish the barriers to appropriate psychotropic medication review in this setting.

Background and objective: Although non-drug techniques are recommended to manage sleep disturbance, anxiety and challenging behaviours associated with dementia, several studies in Australia and overseas have noted a high use of psycholeptics (anxiolytics/hypnotics and antipsychotics) in aged care homes to treat these conditions. The aim of this study was to examine the current pattern of psycholeptic use in Tasmanian aged care homes and compare this data with other Australasian research. Methods: Cross-sectional study of residents' psycholeptic use from 40 aged care homes throughout Tasmania during November 2005�January 2007. Results: Two thousand three hundred and eighty-nine residents were included in the study. Of the residents, over half were taking at least one psycholeptic medication regularly; over one-fifth of residents were taking antipsychotics (21%) and 43% were taking anxiolytics/hypnotics. Conclusion: In comparison with other recent Australasian studies, the current level of benzodiazepine use in Tasmanian aged care homes is of major concern, at approximately three times that reported in Sydney and New Zealand. There is also substantial use of multiple psycholeptic agents. Interventions to reduce benzodiazepine use and improve psycholeptic utilization in Tasmania need to be developed urgently. The results demonstrate the value of regular auditing of prescribing to highlight problem areas in prescribing

Background and objective: The aim was to conduct a national cross-sectional survey of randomly selected Australian pharmacists to determine their attitudes towards and involvement in pharmacy practice research. This included the canvassing of perceived barriers and potential solutions to promote research activity in pharmacy practice. Methods: A questionnaire was developed around those used in UK and Australasian studies of general practitioners' attitudes towards research. Questions assessed attitudes to research, involvement in research, barriers and facilitators to involvement, self-assessed understanding of research terminology, and access to and use of electronic bibliographic databases. One thousand pharmacists were randomly and proportionately selected from the State and Territory Pharmacy Board registers to receive the anonymous questionnaire by mail. Non-respondents were sent a follow-up reminder and second copy of the questionnaire after 3 weeks. Results: A response rate of 37% was achieved. Approximately, one-third of responding pharmacists were presently, or had been, involved in research activities, and generally reported positive experiences. Lack of time and never being approached or not being aware of the opportunities were major barriers to pharmacist participation in research. Approximately, one-third of the pharmacists were not interested in participating in research. There was low usage of publicly available electronic bibliographic databases and of scientific journals. Although there was overwhelming recognition of the value of research to the profession, few pharmacists possessed a good understanding of key terms related to research and evidence-based practice (e.g. P-value or number needed to treat). Conclusion: There was overwhelming recognition of the value of research to the pharmacy profession. Important factors encouraging individual pharmacists to participate in research were a desire to improve the profession, the opportunity to learn more about disease management and to provide enhanced services to patients, and personal interest.

Objective In Australia, accredited pharmacists perform medication reviews for patients to identify and resolve drug-related problems. We analysed the drug-related problems identified in reviews for both home-dwelling and residential care-facility patients. The objective of this study was to examine the number and nature of the drug-related problems identified and investigate differences between each type of review. Setting Australian patients living at home or in residential care-facilities. Method We collected a nation-wide sample of medication reviews conducted between 1998 and 2005. These reviews had been self-selected by pharmacists and submitted as part of the reaccreditation process to the primary body responsible for accrediting Australian pharmacists to perform medication reviews. The drug-related problems identified in each review were classified by type and drugs involved. Main outcome measure The number and nature of drug-related problems identified in pharmacist-conducted medication reviews. Results There were 1,038 drug-related problems identified in 234 medication reviews (mean 4.6 (±2.2) problems per review). The number of problems was higher (4.9 ± 2.0 vs. 3.9 ± 2.2; P < 0.001) in reviews for home-dwelling patients compared with care-facility residents. The number of clinically-significant problems was higher (2.1 ± 1.1 vs. 1.5 ± 0.7; P < 0.001) for home-dwelling patients. Oral hypoglycaemics and analgesics/antipyretics were significantly more likely to be associated with problems in home-dwelling patients than in residential care-facility patients. Conclusion These data illustrate the prevalence of drug-related problems and the ability of pharmacists to identify these problems in the Australian models of medication review. The nature and frequency of problems varied between reviews for home-dwelling and care-facility patients. Such information may be used to better focus the training of practitioners based on the most frequently encountered health problems and the nature of common drug-related problems in the two settings.

Objectives: To use community pharmacy medication records to identify patients whose asthma may not be well managed and then implement and evaluate a multidisciplinary educational intervention to improve asthma management. Design, setting and participants: We used a multisite controlled study design. Forty-two pharmacies throughout Tasmania ran a software application that "data-mined" medication records, generating a list of patients who had received three or more canisters of inhaled short-acting в2-agonists in the preceding 6 months. The patients identified were allocated to an intervention or control group. Pre-intervention data were collected for the period May to November 2006 and post-intervention data for the period December 2006 to May 2007. Intervention: Intervention patients were contacted by the community pharmacist via mail, and were sent educational material and a letter encouraging them to see their general practitioner for an asthma management review. Pharmacists were blinded to the control patients’ identities until the end of the post-intervention period. Main outcome measure: Dispensing ratio of preventer medication (inhaled corticosteroids [ICSs]) to reliever medication (inhaled short-acting в2-agonists). Results: Thirty-five pharmacies completed the study, providing 702 intervention and 849 control patients. The intervention resulted in a threefold increase in the preventer-to-reliever ratio in the intervention group compared with the control group (P < 0.01) and a higher proportion of patients in the intervention group using ICS therapy than in the control group (P < 0.01). Conclusions: Community pharmacy medication records can be effectively used to identify patients with suboptimal asthma management, who can then be referred to their GP for review. The intervention should be trialled on a national scale to determine the effects on clinical, social, emotional and economic outcomes for people in the Australian community, with a longer follow-up to determine sustainability of the improvements noted.

Background: Studies have demonstrated that the risk of warfarin-related complications is highest in the first 90 days of treatment, while quality audits suggest that warfarin initiation protocols are not always adhered to. Aim: To improve the quality of anticoagulation for hospital patients initiated on warfarin. Method: A warfarin drug chart, incorporating the hospital's warfarin initiation protocol, was implemented on four target medical and cardiothoracic wards. The chart was used to record international normalised ratios (INRs) and prescribe warfarin, and was faxed to the patient's GP on discharge. Warfarin initiations on the target wards immediately postintroduction of the warfarin drug chart were reviewed and compared to the pre-intervention data collected over a 17month period. Results: The pre-intervention and post-intervention groups included 271 and 183 patients initiated on warfarin, respectively. The intervention was associated with fewer warfarin-related complications (thromboembolism, major bleeding) occurring within a 90-day follow-up period (2.1%vs 11%; adjusted OR 0.24; 95%CI 0.07-0.85; P= 0.03), largely driven by a reduction in the incidence of major bleeding (0.7% vs 7.1 %; adjusted OR 0.17; 95%CI 0.02-1.45; P = 0.05). Adherence to the warfarin initiation protocol improved significantly from 36% to 71%(p < 0.01) in the pre- and post-intervention data collection periods, respectively. Post-intervention, the proportion of patients with an INR > 4 and the proportion of patients who required a warfarin dose to be withheld was reduced from 8.5% and 13%, to 3.8% (p < 0.05) and 6.6% (p = 0.02), respectively. Conclusion: Adherence to an age and disease based warfarin initiation protocol, and improving the quality of discharge information for patients initiated on warfarin, significantly improved patient outcomes.

Background and objective: There is some evidence that the problem of illicit drug use (IDU) is increasing in rural areas of Australia. Lack of access to harm minimization (HM) strategies is potentially exacerbated by a shortage of health care facilities and health care professionals in rural areas. This study was conducted to determine barriers to implementation, access to, and success of HM strategies, as seen by health professionals presently working in rural Australia. Methods: Four hundred rural pharmacists Australia-wide and 425 doctors in rural Victoria and Tasmania were sent postal surveys to assess their opinions on the level of IDU in their area, the types of drugs commonly used, the adequacy of HM strategies and facilities, and the barriers faced by doctors, pharmacists and clients. Results: The overall response rate was almost 50%. Slightly less than half of surveyed health professionals felt that IDU was increasing in their area, with heroin perceived to be the most prevalent drug used in all States except Tasmania and the Northern Territory. Both methadone prescribers and dispensers believed the methadone maintenance programmes were highly valuable to the community, but not without problems (e.g. risk of overdose). A lack of time or staff was the greatest influence on doctors not participating in the methadone programmes, whereas safety concerns were prominent with pharmacists. The majority of doctors felt HM facilities were inadequate, with needle-syringe exchange being the most frequently nominated HM strategy lacking. Conclusion: Despite best intentions, there are still problems with HM strategies in these areas. Improving the number and expertise of health professionals in rural areas, and providing adequate support for them, would address some of these problems.

Background: An Advanced Pharmacy Practice Framework for Australia (the ‘APPF’) was published in October 2012. Further to the release of the APPF, the Advanced Pharmacy Practice Framework Steering Committee planned to develop an advanced practice recognition model for Australian pharmacists. Aim: To gauge the perspectives of the pharmacy profession relating to advanced practice, via an online survey, in order to inform the design of the model. Method: A survey was developed and administered to Australian pharmacists through SurveyMonkey. The survey content was based on findings from a review of national and international initiatives for recognition of advanced practice in pharmacy and other health disciplines, including medicine and nursing. Results: The results of the survey showed that a high proportion of respondents considered they were already working at, or working towards achieving, an advanced level of practice. The responses relating to the assessment methods showed a clear preference for ‘submission of a professional portfolio’. A ‘written examination’ had a low level of support and in relation to an ‘oral examination by a panel’ there was a marked preference for a panel of multidisciplinary health professionals over a panel of pharmacists. Conclusion: The survey outcomes will inform the development of an advanced pharmacy practice recognition model for Australian pharmacists, particularly in relation to the assessment methods. Survey outcomes also demonstrated that there is scope to further enhance the application of the APPF in the development and recognition of advanced practitioners, and to build greater awareness of the breadth of competencies encompassed by ‘advanced practice’. Refereed/Peer-reviewed

The use of warfarin in the elderly, particularly for stroke prevention in chronic atrial fibrillation, is steadily increasing. Although the benefits of warfarin are greatest in the elderly, so are the risk of adverse outcomes and the difficulties of anticoagulant management. Clinical systems need to improve to counter this therapeutic dilemma, as warfarin is likely to remain the only widely available oral anticoagulant for the foreseeable future. Aspects that require attention are: the careful selection of patients in whom treatment with warfarin is appropriate; initiating therapy in a low dose (e.g., 2.5-5 mg/day); thorough education of patients and carers; close monitoring, especially with any change in the patient's regular drug therapy; involving patients more in the management of their warfarin therapy (self-monitoring/management in suitable patients); and ongoing review of the appropriateness of therapy as circumstances change.

Summary Objective: The aim of this project was to assess whether rural pharmacist involvement in the management of patients receiving warfarin has the potential to lead to safer and more effective anticoagulation, and is valued and welcomed by patients and their general practitioners (GPs). Methods: A convenience sample of rural pharmacists was trained in the use of the CoaguChek S International Normalized Ratio (INR) monitor and then conducted pharmacy-based testing for approximately 3 months. Two types of testing were performed in the pharmacy: (i) comparison testing was defined as pharmacy-based tests taken within 4 h of conventional laboratory testing or (ii) additional testing, which was a pharmacy-based test with no direct comparison laboratory test taken. Pharmacists, GPs and patients completed anonymous satisfaction surveys after the completion of the pharmacy-based testing. Results: Pharmacists from 16 rural pharmacies were trained to use the CoaguChek S monitor. During the trial period, 518 INR tests were performed in the pharmacies on 137 different patients. A total of 120 tests were evaluated against results from laboratory testing. The pharmacy-based INR values were significantly correlated with the laboratory INR values (mean of 2·32 ± 0·77 and 2·32 ± 0·59 respectively; r = 0·88, P

Objectives. A number of studies have reported that the risk of bleeding associated with warfarin is highest early in the course of therapy. This study examined the effect of a programme focused on the transition of newly anticoagulated patients from hospital to the community. Design. Open-label randomized controlled trial. Setting. Home-based follow-up of patients discharged from acute care hospital in southern Tasmania, Australia. Subjects. A total of 128 patients initiated on warfarin in hospital and subsequently discharged to general practitioner (GP) care were enrolled in the study. Sixty were randomized to home monitoring (HM) and 68 received usual care (UC). Interventions. HM patients received a home-visit by the project pharmacist and point-of-care international normalized ratio (INR) testing on alternate days on 4 occasions, with the initial visit two days after discharge. The UC group was solely managed by the GP and only received a visit 8 days after discharge to determine anticoagulant control. Results. At discharge, 42% of the HM group and 45% of the UC group had a therapeutic INR. At day 8, 67% of the HM patients had a therapeutic INR, compared with 42% of UC patients (P < 0.002). In addition, 26% of UC patients had a high INR, compared with only 4% of HM patients. Bleeding events were assessed 3 months after discharge and occurred in 15% of HM patients, compared with 36% of the UC group (P < 0.01). Conclusions. This programme improved the initiation of warfarin therapy and resulted in a significant decrease in haemorrhagic complications in the first 3 months of therapy.

The accuracy and reproducibility of the CoaguChek S, and its clinical agreement with conventional laboratory international normalized ratio (INR) determination, were evaluated in an outpatient anticoagulation clinic setting. Forty-three patients provided 248 paired INR measurements for analysis. The paired results were highly correlated (r = 0.90). The mean coefficient of variation for the CoaguChek S for a random sample of 21 patients with three repeated tests each, was 4%. Clinical applicability was also measured by discrepant INR values, as defined in the literature by expanded and narrow agreement, and by INR values resulting in a different clinical decision by a blinded haematology registrar. Expanded agreement and narrow agreement between the two INR values occurred 90 and 88% of the time, respectively. The stricter criteria set down by the clinician resulted in 73% of paired results producing the same dosage decision. The CoaguChek S displayed good correlation with laboratory determination of INR and compared relatively well with expanded and narrow clinical agreement criteria.

Aims: To assess the attitudes of Australian doctors towards the use of antithrombotic drug therapy for stroke prevention in patients with non-valvular atrial fibrillation (AF), and investigate the barriers to prescribing warfarin. Methods: A postal survey was undertaken among approximately 10% of all registered general practitioners (GPs), cardiologists and physicians in Australia. The anonymous questionnaire used case scenarios to assess doctors' knowledge of current guidelines for the therapeutic management of AF and sought opinions on potential barriers to the use of anticoagulation. Results: Completed questionnaires were received from 711 doctors (30% response rate). The GPs performed better than the cardiologists and other specialists in estimating the risk of stroke in case scenarios. However, the cardiologists were more likely to select the recommended treatment, with GPs being more hesitant to use anticoagulation and tending to underestimate its reported benefit for stroke prevention in non-valvular AR The GPs were also more likely to overestimate the reported risk of major bleeds with warfarin. In contrast, over one-third of the cardiologists went as far as to give warfarin to a low-risk patient and they were more likely to overestimate the reported benefit of aspirin and warfarin in AF. Only half the doctors correctly classified a patient without a previous stroke (but with other risk factors) as being at high risk. Increased experience as a registered medical practitioner was generally related to a poorer performance on classifying patients according to the risk of stroke. The principal barriers to the use of anticoagulation were nominated as: (i) active gastrointestinal bleeding, (ii) previous intracranial haemorrhage, (iii) alcoholism, (iv) a history of daily falls, (v) liver disease, (vi) severe anaemia and (vii) concurrent use of non-steroidal anti-inflammatory drugs. Conclusion: There is scope for improvement in doctors' knowledge about the appropriate use of antithrombotic drug therapy in non-valvular AF and awareness of the results of recent clinical trials. Compilation and dissemination of clear guidelines and focused education on some of the other risk factors (apart, from previous stroke or transient ischaemic attacks) in patients with non-valvular AF are important strategies for targeting barriers to the use of anticoagulation for stroke prevention.

Background: The benefits of antithrombotic therapy in chronic atrial fibrillation (AF) have been established in clinical trials, but there is a paucity of data on outcomes in practice. Aims: The objective was to establish a large ongoing database of patients with non-valvular AF, to enable the accurate determination of clinical outcomes. Methods: A retrospective review of the medical records for consecutive patients who had AF documented on electrocardiogram at the major teaching hospital in Tasmania between 1 January 1997 and 30 June 1999 was performed. An extensive range of demographic and clinical variables was recorded for all patients with chronic or paroxysmal non-valvular AF. Results: The 505 patients (60% males) included in the database had a median age of 76 years. According to risk stratification criteria, 79% of the patients with previously diagnosed chronic or paroxysmal AF had a high risk of developing stroke at the time of admission to hospital care. However, only one-third (34%) of these patients were receiving warfarin (or warfarin plus aspirin), with almost one-quarter (24%) receiving no antithrombotic agent. The annual incidence of ischaemic strokes was 3.4% (1.5–6.4%; 95% CI) when taking warfarin, compared to 7.0% (5.2–9.4%) for patients not taking warfarin and 7.8% (5.4–11.1%) for patients taking aspirin. The annual incidence of bleeding complications in patients taking warfarin was 14.2% (10.0–19.5%) overall and 3.4% (1.5–6.4%) for major bleeds. In patients not taking warfarin, the overall annual incidence of bleeds was 8.4% (6.3–10.9%) and 3.9% (2.5–5.7%) for major bleeds. Conclusions: Warfarin is underused in patients with AF. In clinical practice, warfarin confers a similar stroke risk reduction to that observed in trials, with an increase in incidence of only minor bleeding complications. Aspirin did not appear to reduce the risk of stroke. (Intern Med J 2001; 31: 329–336)

BackgroundPoint-of-care international normalized ratio (INR) monitoring devices simplify warfarin management by allowing selected patients to monitor their own therapy in their homes. Patient self-testing (PST) has been shown to improve the clinical outcomes of warfarin therapy compared to usual care. ObjectiveTo compare management of warfarin therapy using PST combined with online supervision by physicians via a custom system with usual warfarin management, which involved laboratory testing and physician dosing. MethodsInterested patients were recruited via community pharmacies to participate in a warfarin PST training program. Participants were required to have a long-term indication for warfarin, have been taking warfarin for at least 6 months, and have Internet access in their home. The training involved two sessions covering theoretical aspects of warfarin therapy, use of the CoaguChek XS, and the study website. Following training, patients monitored their INR once weekly for up to 3 months. Patients and physicians utilized a secure website to communicate INR values, dosage recommendations, and clinical incidents. Physicians provided a 6-12 month history of INR results for comparison with study results. The percentage of time spent within the therapeutic INR range (TTR) was the primary outcome, with participants acting as their own historical controls. The percentage of INR tests in range and participant satisfaction were secondary outcomes. ResultsSixteen patients completed training requirements. The mean age of participants was 69.8 (SD 10.1) years. TTR improved significantly from 66.4% to 78.4% during PST (P=.01), and the number of tests within the target range also improved significantly (from 66.0% at prior to the study to 75.9% during PST; P=.04). Patients and physicians expressed a high degree of satisfaction with the monitoring strategy and online system. ConclusionsPST supported by an online system for supervision was associated with improved INR control compared to usual care in a small group of elderly patients. Further research is warranted to investigate the clinical outcomes and cost-effectiveness of online systems to support patients monitoring medications and chronic conditions in the home.

There is insufficient evidence for the efficacy of comprehensive multiple risk factor interventions by pharmacists in the primary prevention of cardiovascular disease (CVD). Given the proven benefits of pharmacist interventions for individual risk factors, it is essential that evidence for a comprehensive approach to care be generated so that pharmacists remain key members of the health care team for individuals at risk of initial onset of CVD.To establish the feasibility of an intervention delivered by community pharmacists to reduce the risk of primary onset of CVD.A single-cohort intervention study was undertaken in 2008-2009. Twelve community pharmacists from 10 pharmacies who were trained to provide lifestyle and medicine management support to reduce CVD risk recruited 70 at-risk participants aged 50-74 years who were free from diabetes or CVD. Participants received a baseline assessment to establish CVD risk and health behaviors. An assessment report provided to patients and pharmacists was used to collaboratively establish treatment goals and, over 5 sessions, implement treatment strategies. Follow-up assessment at 6 months measured changes in baseline parameters. The primary outcome was the average change to overall 5-year risk of CVD onset.Sixty-seven participants were included in the analysis. The mean participant age was 60 years and 73% were female. We observed a 25% (95% CI 17 to 33) proportional risk reduction in overall CVD risk. Significant reductions also occurred in mean blood pressure (-11/-5 mm Hg) and waist circumference (-1.3 cm), with trends toward improvement for most other observed risk factors.Findings support previous evidence of positive cardiovascular health outcomes following pharmacist intervention in other patient groups; we recommend generating randomized controlled trial evidence for a primary prevention population.

Objective In aged-care facilities (ACFs) monitoring of warfarin can be logistically challenging and International Normalised Ratio (INR control) is often suboptimal. We aimed to determine whether an integrated information and communications technology system and the use of point-of-care (POC) monitors by nursing staff could improve the INR control of aged-care facility residents who take warfarin. Methods Nursing staff identified residents who were prescribed warfarin in participating ACFs. A computer program (MedePOC) was developed to store and transmit INR results from the ACFs to general practitioners (GPs) for dosage adjustment. Nursing staff received training in the use of the CoaguChek XS point-of-care INR monitor and the MedePOC software. Following a run-in phase, eligible patients were monitored weekly for up to 12 weeks. The primary outcome was the change in the time in therapeutic range (TTR) in the intervention phase compared to the TTR in the 12 months preceding the study. All GPs, nursing staff and patients were surveyed for their experiences and opinions of the project. Key findings Twenty-four patients and 19 GPs completed the trial across six ACFs. The mean TTR for all patients improved non-significantly from 58.9 to 60.6% (P = 0.79) and the proportion of INR tests in range improved non-significantly from 57.1 to 64.1% (P = 0.21). The mean TTR improved in 14 patients (58%) and in these patients the mean absolute improvement in TTR was 23.1%. A post hoc analysis of the INR data using modified therapeutic INR ranges to reflect the dosage adjustment practices of GPs suggested that the intervention did lead to improved INR control. The MedePOC program and POC monitoring was well received by nursing staff. Conclusions Weekly POC INR monitoring conducted in ACFs and electronic communication of the results and warfarin doses resulted in non-significant improvements in INR control in a small cohort of elderly residents. Further research involving modification to the communication strategy and a longer follow-up period is warranted to investigate whether this strategy can improve INR control and clinical outcomes in this vulnerable population.

Background: Warfarin remains a high-risk drug for adverse events, especially following discharge from the hospital. New approaches are needed to minimize the potential for adverse outcomes during this period. Objective: To evaluate the clinical outcomes of a collaborative, home-based postdischarge warfarin management service adapted from the Australian Home Medicines Review (HMR) program. Methods: In a prospective, nonrandomized controlled cohort study, patients discharged from the hospital and newly initiated on or continuing warfarin therapy received either usual care (UC) or a postdischarge service (PDS) of 2 or 3 home visits by a trained, HMR-accredited pharmacist in their first 8 to 10 days postdischarge. The PDS involved point-of-care international normalized ratio (INR) monitoring, warfarin education, and an HMR, in collaboration with the patient's general practitioner and community pharmacist. The primary outcome measure was the combined incidence of major and minor hemorrhagic events in the 90 days postdischarge. Secondary outcome measures included the incidences of thrombotic events, combined hemorrhagic and thombotic events, unplanned and warfarin-related hospital readmissions, death, INR control, and persistence with therapy al 8 and 90 days postdischarge. Results: The PDS (n = 129) was associated with statistically significantly decreased rates of combined major and minor hemorrhagic events to day 90 (5.3% vs 14.7%; p = 0.03) and day 8 (0.9% vs 7.2%; p = 0.01) compared with UC (n = 139). The rate of combined hemorrhagic and thrombotic events to day 90 also decreased (6.4% vs 19.0%; p = 0.008) and persistence with warfarin therapy improved (95.4% vs 83.6%; p = 0.004). No significant differences in readmission and death rates or INR control were demonstrated. Conclusions: This study demonstrated the ability of appropriately trained accredited pharmacists working within the Australian HMR framework to reduce adverse events and improve persistence In patients taking warfarin following hospital discharge. Widespread implementation of such a service has the potential to enhance medication safety along the continuum of care. KEY WORDS: adverse drug events, community pharmacy services, international normalized ratio, patient discharge, warfarin.

Background Cardiovascular disease (CVD) is the leading cause of death globally. Community pharmacist intervention studies have demonstrated clinical effectiveness for improving several leading individual CVD risk factors. Primary prevention strategies increasingly emphasise the need for consideration of overall cardiovascular risk and concurrent management of multiple risk factors. It is therefore important to demonstrate the feasibility of multiple risk factor management by community pharmacists to ensure continued currency of their role. Methods/Design This study will be a longitudinal pre- and post-test pilot study with a single cohort of up to 100 patients in ten pharmacies. Patients aged 50-74 years with no history of heart disease or diabetes, and taking antihypertensive or lipid-lowering medicines, will be approached for participation. Assessment of cardiovascular risk, medicines use and health behaviours will be undertaken by a research assistant at baseline and following the intervention (6 months). Validated interview scales will be used where available. Baseline data will be used by accredited medicines management pharmacists to generate a report for the treating community pharmacist. This report will highlight individual patients' overall CVD risk and individual risk factors, as well as identifying modifiable health behaviours for risk improvement and suggesting treatment and behavioural goals. The treating community pharmacist will use this information to finalise and implement a treatment plan in conjunction with the patient and their doctor. Community pharmacists will facilitate patient improvements in lifestyle, medicines adherence, and medicines management over the course of five counselling sessions with monthly intervals. The primary outcome will be the change to average overall cardiovascular risk, assessed using the Framingham risk equation. Discussion This study will assess the feasibility of implementing holistic primary CVD prevention programs into community pharmacy, one of the most accessible health services in most developed countries. Trial registration Australia and New Zealand Clinical Trial Registry Number: ACTRN12609000677202

Background Shorter periods of hospitalisation and increasing warfarin use have placed stress on community-based healthcare services to care for patients taking warfarin after hospital discharge, a high-risk period for these patients. A previous randomised controlled trial demonstrated that a post-discharge service of 4 home visits and point-of-care (POC) International Normalised Ratio (INR) testing by a trained pharmacist improved patients' outcomes. The current study aims to modify this previously trialled service model to implement and then evaluate a sustainable program to enable the smooth transition of patients taking warfarin from the hospital to community setting. Methods/Design The service will be trialled in 8 sites across 3 Australian states using a prospective, controlled cohort study design. Patients discharged from hospital taking warfarin will receive 2 or 3 home visits by a trained 'home medicines review (HMR)-accredited' pharmacist in their 8 to 10 days after hospital discharge. Visits will involve a HMR, comprehensive warfarin education, and POC INR monitoring in collaboration with patients' general practitioners (GPs) and community pharmacists. Patient outcomes will be compared to those in a control, or 'usual care', group. The primary outcome measure will be the proportion of patients experiencing a major bleeding event in the 90 days after discharge. Secondary outcome measures will include combined major bleeding and thromboembolic events, death, cessation of warfarin therapy, INR control at 8 days post-discharge and unplanned hospital readmissions from any cause. Stakeholder satisfaction will be assessed using structured postal questionnaire mailed to patients, GPs, community pharmacists and accredited pharmacists at the completion of their study involvement. Discussion This study design incorporates several aspects of prior interventions that have been demonstrated to improve warfarin management, including POC INR testing, warfarin education and home visits by trained pharmacists. It faces several potential challenges, including the tight timeframe for patient follow-up in the post-discharge period. Its strengths lie in a strong multidisciplinary team and the utilisation of existing healthcare frameworks. It is hoped that this study will provide the evidence to support the national roll-out of the program as a new Australian professional community pharmacy service. Trial Registration Australian New Zealand Clinical Trials Registry Number 12608000334303.

Objective To describe the development, implementation and outcomes of an anticoagulation education program for pharmacists participating in a community-based post-discharge warfarin management service. Setting Australian community pharmacy practice. Method Three education modules were developed in collaboration with medical experts and delivered electronically and via hands-on training sessions to pharmacists in three Australian states. Educational outcomes were assessed via a short answer assignment and evaluation of their warfarin dosing recommendations for five hypothetical scenarios. Consumer and pharmacist perceptions of the adequacy of the training were surveyed using a structured postal questionnaire. Main outcome measure Pharmacists’ score in the short answer assignment and evaluation of their responses to the hypothetical warfarin dosing scenarios. Results Sixty-two pharmacists successfully completed the training program with a mean score for the short answer assignment of 14.3 out of 15 (95.3%; 95% CI 13.8–14.7). The pharmacists’ warfarin management recommendations were very similar to those of two experienced medical specialists. Pharmacists and consumers expressed confidence in the adequacy of the training program. Conclusion This education program successfully up-skilled a cohort of pharmacists for involvement in a post-discharge warfarin management service. These findings support formalisation and further development of the program to facilitate widespread implementation of home-based post-discharge warfarin care.

Background: This study evaluated a multi-faceted, interdisciplinary intervention to reduce the use of benzodiazepines and antipsychotics in nursing homes – the “RedUSe” (Reducing Use of Sedatives) project.Methods: The RedUSe project was a controlled trial conducted in 25 nursing homes in Tasmania, with 13 intervention and 12 control homes. A series of pharmacist-led strategies were provided to intervention homes including two medication audit and feedback cycles, educational sessions for staff and an interdisciplinary sedative review. Data on psychotropic drug use at each nursing home were collected utilizing a customized computer program at baseline, 12 and 26 weeks. The RedUSe project was registered as a controlled trial at the Australian New Zealand Clinical Trials Registry, registration number: ACTRN12608000221358.Results: For each measure, an average of 1591 residents were audited. Over the six-month trial, there was a significant reduction in the percentage of intervention home residents regularly taking benzodiazepines (31.8% to 26.9%, p < 0.005) and antipsychotics (20.3% to 18.6%, p < 0.05), whereas control home psychotropic use did not alter significantly. For residents taking benzodiazepines and antipsychotics at baseline, there were significantly more dose reductions/cessations in intervention homes than in control homes (benzodiazepines: 39.6% vs. 17.6%, p < 0.0001; antipsychotics: 36.9% vs. 20.9%, p < 0.01).Conclusions: RedUSe led to a significant reduction in the proportion of residents in nursing homes taking benzodiazepines and antipsychotics, and a significant increase in the number of dose reductions of these agents. Our findings suggest that a multi-faceted program, coordinated through a community pharmacy, can offer an effective approach in reducing psychotropic use in nursing homes.

Objective To assess the impact of an intervention initiated by community pharmacists, involving the provision of educational material and general practitioner (GP) referral, on asthma knowledge and self-reported asthma control and asthma-related quality of life (QOL) in patients who may have suboptimal management of their asthma, as evidenced by pharmacy dispensing records. Setting Community pharmacies throughout Tasmania, Australia. Methods Forty-two pharmacies installed a software application that data mined dispensing records and generated a list of patients with suboptimal asthma management, as indicated by having three or more canisters of inhaled short-acting beta-2-agonists dispensed in the preceding 6 months. Identified patients were randomised to an intervention or control group. At baseline, intervention patients were mailed intervention packs consisting of a letter encouraging them to see their GP for a review, educational material, asthma knowledge, asthma control and asthma-related QOL questionnaires, and a letter with a dispensing history to give to their GP. Pharmacists were blinded to the control patients’ identities for 6 months, after which time intervention patients were sent repeat questionnaires, and control patients were sent intervention packs. Main outcome measures Asthma knowledge, asthma control and asthma-related QOL scores. Results Thirty-five pharmacies completed the study, providing 706 intervention and 427 control patients who were eligible to receive intervention packs. Intervention patients’ asthma control and asthma-related QOL scores at 6 months were significantly higher compared to the control patients (P < 0.01 and P < 0.05, respectively) and to the intervention patients’ baseline scores (P < 0.001 and P < 0.05, respectively). Symptom-related QOL was significantly higher compared to the control patients (P < 0.01) and activities-related QOL significantly improved compared to baseline (P < 0.05). No significant change was observed in asthma knowledge. Conclusion The results suggest that community pharmacists are ideally placed to identify patients with suboptimal asthma management and refer such patients for a review by their GP. This type of collaborative intervention can significantly improve self-reported asthma control and asthma-related QOL in patients identified as having suboptimal management of their asthma. A larger trial is needed to confirm the effects are real and sustained.

Background and objective: The aim was to develop and evaluate a pilot version of a knowledge-based system that can identify existing and potential medication-related problems from patient information. This intelligent system could directly support pharmacists and other health professionals providing medication reviews. Methods: Rather than being based on static rules to trigger alerts, this system utilizes a multiple classification ripple-down rules approach, which allows the user to build rules incrementally and improve the accuracy of the knowledge base in identifying medication-related problems while the system is in use, with no outside assistance or training. The system contextualizes the potential drug therapy problems by taking into consideration the patient's demographics, and other medical condition and drugs. The system is capable of both being instructed in the domain of medication review through its routine use by an expert, and acting similarly to the expert when analysing genuine medication review cases. The system was handed over to an experienced clinical pharmacist (expert), with no knowledge or conclusions preloaded into the system. The expert was then able to add the case details and generate the rules required for 126 actual medication review cases. Results: Over 250 rules were generated from the review cases, incorporating demographics, medical history, symptoms, medications and pathology results from these cases. At the completion of the cases, more than 80% of the potential medication-related problems identified by the expert were also detected by the system. The false positive rate, or number of incorrect medication-related problems identified by the system, was