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In order to enhance interdisciplinary collaboration and promote better medication management, a partnered pharmacist medication charting (PPMC) model was piloted in the emergency department (ED) of an Australian referral hospital. The primary objective of this study was to evaluate the impact of PPMC on the timeliness of time-critical medicines (TCMs), completeness of medication orders, and assessment of venous thromboembolism (VTE) risk. This concurrent controlled retrospective pragmatic trial involved individuals aged 18 years and older presenting to the ED from 1 June 2020 to 17 May 2021. The study compared the PPMC approach (PPMC group) with traditional medical officer-led medication charting approaches in the ED, either an early best-possible medication history (BPMH) group or the usual care group. In the PPMC group, a BPMH was documented promptly soon after arrival in the ED, subsequent to which a collaborative discussion, co-planning, and co-charting of medications were undertaken by both a PPMC-credentialled pharmacist and a medical officer. In the early BPMH group, the BPMH was initially obtained in the ED before proceeding with the traditional approach of medication charting. Conversely, in the usual care group, the BPMH was obtained in the inpatient ward subsequent to the traditional approach of medication charting. Three outcome measures were assessed -the duration from ED presentation to the TCM's first dose administration (e.g., anti-Parkinson's drugs, hypoglycaemics and anti-coagulants), the completeness of medication orders, and the conduct of VTE risk assessments. The analysis included 321 TCMs, with 107 per group, and 1048 patients, with 230, 230, and 588 in the PPMC, early BPMH, and usual care groups, respectively. In the PPMC group, the median time from ED presentation to the TCM's first dose administration was 8.8 h (interquartile range: 6.3 to 16.3), compared to 17.5 h (interquartile range: 7.8 to 22.9) in the early BPMH group and 15.1 h (interquartile range: 8.2 to 21.1) in the usual care group ( p < 0.001). Additionally, PPMC was associated with a higher proportion of patients having complete medication orders and receiving VTE risk assessments in the ED (both p < 0.001). The implementation of the PPMC model not only expedited the administration of TCMs but also improved the completeness of medication orders and the conduct of VTE risk assessments in the ED.

Introduction: Partnered pharmacist medication charting (PPMC), a process redesign hypothesised to improve medication safety and interdisciplinary collaboration, was trialed in a tertiary hospital's emergency department (ED). Objective: To evaluate the health-related impact and economic benefit of PPMC. Methods: A pragmatic, controlled study compared PPMC to usual care in the ED. PPMC included a pharmacist-documented best-possible medication history (BPMH), followed by a clinical conversation between a pharmacist and a medical officer to jointly develop a treatment plan and chart medications. Usual care included medical officer-led traditional medication charting in the ED, without a pharmacist-obtained BPMH or clinical conversation. Outcome measures, assessed after propensity score matching, were length of hospital or ED stay, relative stay index (RSI), in-hospital mortality, 30-day hospital readmissions or ED revisits, and cost. Results: A total of 309 matched pairs were analysed. The median RSI was reduced by 15.4% with PPMC ( p = 0.029). There were no significant differences between the groups in the median length of ED stay (8 vs . 10 h, p = 0.52), in-hospital mortality (1.3% vs . 1.3%, p > 0.99), 30-day readmission rates (21% vs . 17%; p = 0.35) and 30-day ED revisit rates (21% vs . 19%; p = 0.68). The hospital spent approximately $138.4 for the cost of PPMC care per patient to avert at least one medication error bearing high/extreme risk. PPMC saved approximately $1269 on the average cost of each admission. Conclusion: Implementing the ED-based PPMC model was associated with a significantly reduced RSI and admission costs, but did not affect clinical outcomes, noting that there was an additional focus on medication reconciliation in the usual care group relative to current practice at our study site., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers (MS), at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2023 Atey, Peterson, Salahudeen, Simpson, Boland, Anderson and Wimmer.)

Introduction: A process redesign, partnered pharmacist medication charting (PPMC), was recently piloted in the emergency department (ED) of a tertiary hospital. The PPMC model was intended to improve medication safety and interdisciplinary collaboration by having pharmacists work closely with medical officers to review and chart medications for patients. This study, therefore, aimed to evaluate the impact of PPMC on potentially inappropriate medication (PIM) use. Methods: A pragmatic concurrent controlled study compared a PPMC group to both early best-possible medication history (BPMH) and usual care groups. In the PPMC group, pharmacists initially documented the BPMH and collaborated with medical officers to co-develop treatment plans and chart medications in ED. The early BPMH group included early BPMH documentation by pharmacists, followed by traditional medication charting by medical officers in ED. The usual care group followed the traditional charting approach by medical officers, without a pharmacist-collected BPMH or collaborative discussion in ED. Included were older people (≥65 years) presenting to the ED with at least one regular medication with subsequent admission to an acute medical unit. PIM outcomes (use of at least one PIM, PIMs per patient and PIMs per medication prescribed) were assessed at ED presentation, ED departure and hospital discharge using Beers criteria. Results: Use of at least one PIM on ED departure was significantly lower for the PPMC group than for the comparison groups (χ 2 , p = 0.040). However, PIM outcomes at hospital discharge were not statistically different between groups. PIM outcomes on ED departure or hospital discharge did not differ from baseline within the comparison groups. Discussion: In conclusion, PIM use on leaving ED, but not at hospital discharge, was reduced with PPMC. Close interprofessional collaboration, as in ED, needs to continue on the wards., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers (MS), at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2023 Atey, Peterson, Salahudeen and Wimmer.)

Objective: Little research has evaluated trends in psychotropic prescribing and polypharmacy in primary care patients, especially those with dementia. We sought to examine this in Australia from 2011 to 2020 using the primary care dataset, MedicineInsight., Methods: Ten consecutive serial cross-sectional analyses were performed to evaluate the proportion of patients aged 65 years or more, with a recorded diagnosis of dementia, who were prescribed psychotropic medications within the first six months of each year from 2011 to 2020. This proportion was compared with propensity score-matched control patients without dementia., Results: Before matching, 24,701 patients (59.2% females) with, and 72,105 patients (59.2% females) without, a recorded diagnosis of dementia were included. In 2011, 42% (95% confidence interval [CI] 40.5-43.5%) of patients in the dementia group had at least one recorded prescription of a psychotropic medication, which declined to 34.2% (95% CI 33.3-35.1%; p for trend < 0.001) by 2020. However, it remained unchanged for matched controls (36% [95% CI 34.6-37.5%] in 2011 and 36.7% [95% CI 35.7-37.6%] in 2020). The greatest decline in the dementia groups by medication class was for antipsychotics (from 15.9% [95% CI 14.8-17.0%] to 8.8% [95% CI 8.2-9.4%]; p for trend < 0.001). During this period, the prevalence of psychotropic polypharmacy (use of two or more individual psychotropics) also decreased from 21.7% (95% CI 20.5-22.9%) to 18.1% (95% CI 17.4-18.9%) in the dementia groups, and slightly increased from 15.2% (95% CI 14.1-16.3%) to 16.6% (95% CI 15.9-17.3%) in the matched controls., Conclusions: The decline in psychotropic prescribing, particularly antipsychotics, in Australian primary care patients with dementia is encouraging. However, psychotropic polypharmacy still occurred in almost one in five patients with dementia at the end of the study period. Programs focused on encouraging further reductions in the use of multiple psychotropic drugs in patients with dementia are recommended, particularly in rural and remote regions.

Background: Oral anticoagulants (OACs) are high-risk medications often used in older people with complex medication regimens. This study was the first to assess the association between overall regimen complexity and bleeding in people with atrial fibrillation (AF) initiating OACs., Methods: Patients diagnosed with AF who initiated an OAC (warfarin, dabigatran, rivaroxaban, apixaban) between 2010 and 2016 were identified from the Hong Kong Clinical Database and Reporting System. Each patient's Medication Regimen Complexity Index (MRCI) score was computed. Baseline characteristics were balanced using inverse probability of treatment weighting. People were followed until a first hospitalization for bleeding (intracranial hemorrhage, gastrointestinal bleeding, or other bleeding) and censored at discontinuation of the index OAC, death, or end of the follow-up period, whichever occurred first. Cox regression was used to estimate hazard ratios (HR) between MRCI quartiles and bleeding during initiation and all follow-up., Results: There were 19 292 OAC initiators (n = 9 092 warfarin, n = 10 200 direct oral anticoagulants) with a mean (standard deviation) age at initiation of 73.9 (11.0) years. More complex medication regimens were associated with an increased risk of bleeding (MRCI > 14.0-22.00: aHR 1.17, 95% confidence interval [CI] 0.93-1.49; MRCI > 22.0-32.5: aHR 1.32, 95%CI 1.06-1.66; MRCI > 32.5: aHR 1.45, 95%CI 1.13-1.87, compared to MRCI ≤ 14). No significant association between MRCI and bleeding risk was observed during the initial 30, 60, or 90 days of treatment., Conclusion: In this cohort study of people with AF initiating an OAC, a more complex medication regimen was associated with higher bleeding risk over periods longer than 90 days. Further prospective studies are needed to assess whether MRCI should be considered in OAC prescribing., (© The Author(s) 2022. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Pharmacists have an increasing role as part of the emergency department (ED) team. However, the impact of ED-based pharmacy interventions on the quality use of medicines has not been well characterised., Objective: This systematic review aimed to synthesise evidence from studies examining the impact of interventions provided by pharmacists on the quality use of medicines in adults presenting to ED., Methods: A systematic literature search was conducted in MEDLINE, EMBASE and CINAHL. Two independent reviewers screened titles/abstracts and reviewed full texts. Studies that compared the impact of interventions provided by pharmacists with usual care in ED and reported medication-related primary outcomes were included. Cochrane Risk of Bias-2 and Newcastle-Ottawa tools were used to assess the risk of bias. Summary estimates were pooled using random-effects meta-analysis, along with sensitivity and sub-group analyses., Results: Thirty-one studies involving 13 242 participants were included. Pharmacists were predominantly involved in comprehensive medication review, advanced pharmacotherapy assessment, staff and patient education, identification of medication discrepancies and drug-related problems, medication prescribing and co-prescribing, and medication preparation and administration. The activities reduced the number of medication errors by a mean of 0.33 per patient (95% CI -0.42 to -0.23, I 2 =51%) and the proportion of patients with at least one error by 73% (risk ratio (RR)=0.27, 95% CI 0.19 to 0.40, I 2 =85.3%). The interventions were also associated with more complete and accurate medication histories, increased appropriateness of prescribed medications by 58% (RR=1.58, 95% CI 1.21 to 2.06, I 2 =95%) and quicker initiation of time-critical medications., Conclusion: The evidence indicates improved quality use of medicines when pharmacists are included in ED care teams., Prospero Registration Number: CRD42020165234., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Medication errors are more prevalent in settings with acutely ill patients and heavy workloads, such as in an emergency department (ED). A pragmatic, controlled study compared partnered pharmacist medication charting (PPMC) (pharmacist-documented best-possible medication history [BPMH] followed by clinical discussion between a pharmacist and medical officer to co-develop a treatment plan and chart medications) with early BPMH (pharmacist-documented BPMH followed by medical officer-led traditional medication charting) and usual care (traditional medication charting approach without a pharmacist-collected BPMH in ED). Medication discrepancies were undocumented differences between medication charts and medication reconciliation. An expert panel assessed the discrepancies' clinical significance, with 'unintentional' discrepancies deemed 'errors'. Fewer patients in the PPMC group had at least one error (3.5%; 95% confidence interval [CI]: 1.1% to 5.8%) than in the early BPMH (49.4%; 95% CI: 42.5% to 56.3%) and usual care group (61.4%; 95% CI: 56.3% to 66.7%). The number of patients who need to be treated with PPMC to prevent at least one high/extreme error was 4.6 (95% CI: 3.4 to 6.9) and 4.0 (95% CI: 3.1 to 5.3) compared to the early BPMH and usual care group, respectively. PPMC within ED, incorporating interdisciplinary discussion, reduced clinically significant errors compared to early BPMH or usual care.

Background: This study aimed to investigate the prevalence of hospital readmission for chronic obstructive pulmonary disease (COPD) at 30, 90 and 365 days, and to determine demographic and socioeconomic risk factors for 30-day and 90-day readmission and time to COPD-related readmission within 365 days in Tasmania., Methods: Patients ≥40 years admitted for COPD between 2011 and 2015 were identified using administrative data from all major public hospitals in Tasmania, Australia. Factors associated with readmission and time to readmission were identified using logistic and Cox regression, respectively., Results: The rates of COPD-related readmission were 6.7% within 30 days, 12.2% within 90 days and 23.7% within 365 days. Being male (odds ratio [OR]: 1.49, CI: 1.06-2.09), Indigenous (OR: 2.47, CI: 1.31-4.66) and living in the lower socioeconomic North-West region of Tasmania (OR: 1.80, CI: 1.20-2.69) were risk factors for 30-day readmission. Increased COPD-related (OR: 1.48, CI: 1.22-1.80; OR: 1.52, CI: 1.29-1.78) and non-COPD-related (OR: 1.12, CI: 1.03- 1.23; OR: 1.11, CI: 1.03-1.21) emergency department (ED) visits in the preceding six months were risk factors for both 30-day and 90-day readmissions. Being Indigenous (hazard ratio [HR]: 1.61, CI: 1.10-2.37) and previous COPD-related ED visits (HR: 1.30, CI: 1.21-1.39) decreased, while a higher Charlson Comorbidity Index (CCI) (OR: 0.91, CI: 0.83- 0.99) increased the time to readmission within 365 days., Conclusion: Being male, Indigenous, living in the North-West region and previous ED visits were associated with increased risk of COPD readmission in Tasmania. Interventions to improve access to primary healthcare for these groups may reduce COPD-related readmissions., (© 2022 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Background: Studies investigating the association between the use of oral anticoagulants (OACs) and osteoporosis are limited. We aimed to determine the risk of osteoporosis in patients with atrial fibrillation (AF) and receiving different OACs. Methods: We performed a population-based cohort study using a nationwide primary care dataset, MedicineInsight. Patients aged between 18 and 111 years with AF and newly recorded OAC prescriptions between 1 January 2013 and 31 December 2017 were included and followed until 31 December 2018. We applied propensity score matching to control for patients’ baseline characteristic differences before calculating adjusted hazard ratios (aHRs) for a new diagnosis of osteoporosis, using Cox proportional hazard models. Results: A total of 18,454 patients (1714 prescribed dabigatran, 5871 rivaroxaban, 5248 apixaban and 5621 warfarin) were included. Of these, 39.5% were females, and the overall mean age (standard deviation [SD] was 73.2(10.3) years. Over a mean follow-up of 841 days, 1627 patients (1028 receiving direct-acting oral anticoagulants (DOACs) and 599 warfarin) had a newly recorded diagnosis of osteoporosis. The weighted incidence rates (95% confidence interval; CI) per 100 person-years of treatment were 5.0 (4.7−5.2) for warfarin, 4.3 (3.8−4.8) for dabigatran, 3.6 (3.3−3.8) for rivaroxaban, and 4.4 (4.0−4.7) for apixaban. Overall, DOAC use was associated with a significantly lower risk of a new diagnosis of osteoporosis than warfarin use (aHR, 0.79, 95% confidence interval (CI) 0.74−0.85; p < 0.001). Use of each individual DOAC was associated with a significantly lower risk of osteoporosis compared with warfarin (aHRs, 0.75, 95% CI 0.69−0.82 for rivaroxaban; 0.78, 95% CI 0.71−0.86 for apixaban; 0.88, 95% CI 0.77−0.99 for dabigatran). Conclusion: Compared with warfarin, the use of DOACs was associated with a significantly lower risk of developing osteoporosis in patients with AF. This association remained significant when individual DOACs were compared with warfarin.

Background: We aimed to compare the risk of developing osteoporosis in patients prescribed warfarin or direct-acting oral anticoagulants (DOACs) with those with no therapy., Research Design and Methods: We included 37,632 patients aged between 18 and 111 years with a recorded diagnosis of AF between 1 January 2013 and 31 December 2017. Patients were followed until the diagnosis of osteoporosis, switch or discontinuation of the OAC, last clinical visit, or end of the study period, whichever occurred first. The incidences of new-onset osteoporosis were calculated using the Cox proportional hazards model., Results: Of total, 16,995 (45.2%) had no recorded OAC prescription, and 20,637 had a recorded prescription of warfarin (6,609) or DOAC (14,028). Compared with those not prescribed an OAC, the risk of being diagnosed with new-onset osteoporosis increased in patients prescribed warfarin (HR 2.22, 95% CI 2.00-2.47, p < 0.001) and DOACs (HR 1.42, 95% CI 1.29-1.58, p < 0.001). However, the effect of DOACs was not statistically significant (HR 1.07, 95% CI 0.86-1.33, p < 0.535) after excluding patients with at least one recorded prescription of systemic corticosteroids, antiepileptics, or proton pump inhibitors., Conclusions: Use of warfarin or DOACs was associated with a significantly increased risk of developing osteoporosis compared with no OAC treatment.

A community-based opportunistic screening program was implemented to (i) improve atrial fibrillation (AF) awareness and detection and (ii) assess the performance of the Microlife WatchBP Home A for detecting AF when used in community screening. Screening sessions were conducted among people aged ≥ 65 years with no history of AF at public events across Tasmania, Australia. Participants with positive screening results were referred to their general medical practitioner for assessment. The device's performance was assessed using the positive predictive value. A total of 1704 eligible participants were screened at 79 sessions. Of these people, 50 (2.9%) had a positive screening result. The device correctly identified AF in 22 (46.8%) participants with positive results. Among those with subsequently confirmed AF, 6 (27.3%) had a history of AF but were not aware of the diagnosis, and 16 (72.7%) were identified to have previously undiagnosed AF, with an overall prevalence of 0.9% (95% CI, 0.58 to 1.52). Oral anticoagulation therapy was initiated in 12 (87.5%) eligible participants. The positive predictive value of the device was 46.8% (95% CI, 33.3 to 60.7). Given the relatively low performance of the device, its application in community-based opportunistic screening programs for AF is unlikely to be cost-effective.

Objective: Concerns have been raised over the appropriateness of dosing of direct-acting oral anticoagulants (DOACs) in clinical practice. We investigated this issue in patients who were initiated on a DOAC in Australian general practices., Methods: This was a retrospective study among patients newly diagnosed with atrial fibrillation (AF) who were prescribed DOACs, using data obtained from 417 general practice sites across Australia over 8 years (2011-2019). Direct-acting oral anticoagulant dosing was compared with published recommendations, in relation to age and kidney function., Results: A total of 11,251 patients (mean age, 72.8 y; 46.8% female) newly diagnosed with AF were prescribed a DOAC. Of these, 2667 patients (23.7%) had a recorded prescription of a potentially inappropriate DOAC dosage, of whom 2304 (86.4%) and 283 (10.6%) were prescribed lower and higher than the recommended dosage, respectively. The remaining 80 patients (3.0%) were initiated on DOACs when contraindicated based on renal function. Overall, the proportion of patients who seemed to be initiated on a potentially inappropriate DOAC dose decreased from 38.3% (95% confidence interval, 26.1%-51.8%) in 2012 to 22.7% (95% confidence interval, 19.8%-26.0%; P < 0.001) in 2019. By 2019, 19.4%, 20.3%, and 9.3% of the patients with a recorded prescription of apixaban, rivaroxaban, and dabigatran, respectively, received a lower-than-guideline-recommended dose. The patients were more likely to be prescribed a potentially inappropriate dosage if they were elderly with multiple comorbidities., Conclusions: Potential inappropriate DOAC dosing is a problem in the prevention of stroke associated with AF. Nearly 1 in 5 patients received a lower-than-guideline-recommended dose, indicating a need for strategies to raise awareness among prescribers., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background We compared the dementia incidence rate between users and nonusers of oral anticoagulants (OACs) in a large cohort of primary care patients with atrial fibrillation. Methods and Results We performed a retrospective study using an Australia-wide primary care data set, MedicineInsight. Patients aged ≥18 years and newly diagnosed with atrial fibrillation between January 1, 2010, and December 31, 2017, and with no recorded history of dementia or stroke were included and followed until December 31, 2018. We applied a propensity score for 1:1 pair matching of baseline covariates and Cox regression for comparing the dementia incidence rates for OAC users and nonusers. Data were analyzed for 18 813 patients with atrial fibrillation (aged 71.9±12.6 years, 47.1% women); 11 419 had a recorded OAC prescription for at least 80% of their follow-up time. During the mean follow-up time of 3.7±2.0 years, 425 patients (2.3%; 95% CI, 2.1%-2.5%) had a documented diagnosis of dementia. After propensity matching, the incidence of dementia was significantly lower in OAC users (hazard ratio [HR], 0.59; 95% CI, 0.44-0.80; P <0.001) compared with nonusers. Direct-acting oral anticoagulant users had a lower incidence of dementia than non-OAC users (HR, 0.49; 95% CI, 0.33-0.73; P <0.001) or warfarin users (HR, 0.46; 95% CI, 0.28-0.74; P =0.002). No significant difference was seen between warfarin users and non-OAC users (HR, 1.08; 95% CI, 0.70-1.70; P =0.723). Conclusions In patients with atrial fibrillation, direct-acting oral anticoagulant use may result in a lower incidence of dementia compared with treatment with either warfarin or no anticoagulant.

Background: We aimed to compare renal function changes in patients with atrial fibrillation (AF) prescribed different oral anticoagulants (OACs)., Research Design and Methods: We performed a retrospective analysis of Australian national primary care data. A total of 12,562 patients with AF and initiated OAC between 1 January 2013 and 31 December 2017 were included. Inverse probability of treatment weighting was used for balancing baseline characteristics and the risks of decline in estimated glomerular filtration rate (eGFR) in patients prescribed each OAC were compared., Results: Compared with warfarin, prescribing of direct-acting oral anticoagulants (DOACs) was associated with a lower risk of renal function decline per 1000 person-years: hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.68-0.81, p < 0.001 for ≥30% decline in eGFR; HR 0.28, 95% CI 0.20-0.41, p < 0.001 for eGFR decline to ≤30 mL/min/1.73 m 2 ; and HR 0.45, 95% CI 0.35-0.58, p < 0.001 for serum creatinine doubling. Compared with dabigatran, rivaroxaban use had a significantly lowered risk of decline in eGFR to ≤30 mL/min/1.73 m 2 (HR 0.29, 95% CI 0.13-0.66, p = 0.003) and risk of doubling of serum creatinine (HR 0.62, 95% CI 0.40-0.95, p = 0.030)., Conclusions: The risk of renal function decline appeared to be lower in patients prescribed DOACs versus warfarin.

Restraint use in Australian residential aged care has been highlighted by the media, and investigated by researchers, government and advocacy bodies. In 2018, the Royal Commission into Aged Care selected 'Restraint' as a key focus of inquiry. Subsequently, Federal legislation was passed to ensure restraint is only used in residential aged care services as the 'last resort'. To inform and develop Government educational resources, we conducted qualitative research to gain greater understanding of the experiences and attitudes of aged care stakeholders around restraint practice. Semi-structured interviews were held with 28 participants, comprising nurses, care staff, physicians, physiotherapists, pharmacists and relatives. Two focus groups were also conducted to ascertain the views of residential and community aged care senior management staff. Data were thematically analyzed using a pragmatic approach of inductive and deductive coding and theme development. Five themes were identified during the study: 1. Understanding of restraint; 2. Support for legislation; 3. Restraint-free environments are not possible; 4. Low-level restraint; 5. Restraint in the community is uncharted. Although most staff, health practitioners and relatives have a basic understanding of restraint, more education is needed at a conceptual level to enable them to identify and avoid restraint practice, particularly 'low-level' forms and chemical restraint. There was strong support for the new restraint regulations, but most interviewees admitted they were unsure what the legislation entailed. With regards to resources, stakeholders wanted recognition that there were times when restraint was necessary and advice on what to do in these situations, as opposed to unrealistic aspirations for restraint-free care. Stakeholders reported greater oversight of restraint in residential aged care but specified that community restraint use was largely unknown. Research is needed to investigate the extent and types of restraint practice in community aged care.

Despite changes in antiarrhythmic drug (AAD) choice in patients with atrial fibrillation (AF), trends in AAD prescribing remain not investigated. We aimed to examine these changes using a nationwide Australian general practice data from 2009 to 2018. Over the 10 years, AAD prescribing in patients with AF decreased, which was mainly due to a reduction in the use of amiodarone, sotalol and digoxin. In contrast, the use of beta-blockers and flecainide increased., (© 2021 Royal Australasian College of Physicians.)

Aim: To examine the change in stroke risk over time and determine the proportion of patients with atrial fibrillation (AF) who were initiated on an oral anticoagulant (OAC) as their stroke risk increased from low/moderate to high, using the Australian general practice data set, MedicineInsight., Methods: A total of 2296 patients diagnosed with AF between 1 January 2007 and 31 December 2008, aged 18 years or older and not initiated on an OAC before 2009, were included. We assessed the change in stroke risk and the proportion of patients who had a recorded prescription of an OAC, each year from 1 January 2009 to 31 December 2018., Results: At baseline, 23.9%, 22.9% and 53.2% were categorised as being at low (score = 0), moderate (score = 1) and high stroke risk (score ≥ 2), respectively, using the sexless CHA 2 DS 2 -VASc (CHA 2 DS 2 -VA) score. Overall, the CHA 2 DS 2 -VA score increased by a mean of 1.34 (95% confidence interval, 1.29-1.39) points over the study period. Nearly two-thirds of patients (65%, 412/632) whose stroke risk changed from baseline low/moderate to high were subsequently prescribed an OAC. The median (interquartile range) lag time from becoming high stroke risk to having OAC initiation was 2 (5) years., Conclusions: Nearly one-third of patients reclassified as being at high risk of stroke during the study period were not prescribed OAC therapy. Furthermore, the delay in OAC initiation following classification as being at high risk was a median of 2 years, suggesting that more frequent stroke reassessment is needed., (© 2021 Stichting European Society for Clinical Investigation Journal Foundation. Published by John Wiley & Sons Ltd.)

Background: We investigated factors that influenced oral anticoagulant (OAC) initiation and choice in Australian general practice patients newly diagnosed with AF., Methods: Using an Australian nationally representative general practice dataset, MedicineInsight, we identified patients newly diagnosed with AF between January 2009 and April 2019. Logistic regression analyses were used to examine factors associated with OAC initiation and choice., Results: A total of 63 212 patients with AF (53.7% males, mean age 72.4 years) were identified. Nearly two-thirds of these patients (40 854 [64.6%]) were initiated on an OAC, at a median time of 6 days after the documented diagnosis date. The proportion of patients who were initiated an OAC increased from 44.8% in 2009 to 72.2% in 2019 (P < .001). High risk of stroke (CHA 2 DS 2 -VASc, adjusted odds ratio (AOR), 4.39 [95% CI, 3.99-4.83]), low risk of bleeding (ORBIT, AOR, 1.87 [95% CI, 1.72-2.03]), not having a recorded history of dementia (AOR, 1.81 [95% CI, 1.65-1.98]) and male sex (AOR, 1.29 [95% CI, 1.22-1.35]) were independently associated with OAC initiation. Direct-acting oral anticoagulant (DOAC) use increased from 11.9% in 2011 to 94.0% of all OAC initiations in April 2019 (P < .001)., Conclusions: The proportion of newly diagnosed patients with AF initiated on OAC increased markedly following the introduction of the DOACs. Of those initiated, 9 in 10 were receiving a DOAC at the end of the study period. There is potential underuse in women and individuals with dementia., (© 2020 Stichting European Society for Clinical Investigation Journal Foundation. Published by John Wiley & Sons Ltd.)

Objective: Appropriate use of oral anticoagulants (OACs) reduces the risk of stroke in patients with atrial fibrillation (AF). The study characterized the prescribing of OACs in people with AF in the Australian primary care setting over 10 years. Design: Retrospective population study. Setting and Participants: We performed 10 sequential cross-sectional analyses of patients with a recorded diagnosis of AF between 2009 and 2018 using national general practice data. The proportion of patients with AF who were prescribed an OAC based on their stroke risk was examined. Primary and secondary outcomes: The primary outcome was the proportion of high stroke risk patients who were prescribed an OAC over a decade. The secondary outcome was variation in OAC prescribing among general practices. Results: The sample size of patients with AF ranged from 9,874 in 2009 to 41,751 in 2018. The proportion who were prescribed an OAC increased from 39.5% (95% CI 38.6-40.5%) in 2009 to 52.0% (95% CI 51.5-52.4%) in 2018 ( p for trend < 0.001). During this time, the proportion of patients with AF and high stroke risk who were prescribed an OAC rose from 41.7% (95% CI 40.7-42.8%) to 55.2% (95% CI 54.7-55.8%; p for trend < 0.001) with the direct-acting oral anticoagulants accounting for over three-quarters of usage by 2018. There was substantial variation in OAC prescribing between general practices. In 2018, the proportion of moderate to high stroke risk patients who were prescribed an OAC was 38.6% (95% CI 37.2-40.1%) in the lowest practice site quintiles and 65.6% (95% CI 64.5-66.7%) in the highest practice site quintiles. Conclusions: Over the 10 years, OAC prescribing in high stroke risk patients with AF increased by one-third. There was considerable variation in OAC prescribing between general practices., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Bezabhe, Bereznicki, Radford, Wimmer, Curtain, Salahudeen and Peterson.)

Background: Co-prescribing medications that can interact with direct-acting oral anticoagulants (DOACs) may decrease their safety and efficacy. The aim of this study was to examine the co-prescribing of such medications with DOACs using the Australian national general practice dataset, MedicineInsight, over a five-year period., Methods: We performed five sequential cross-sectional analyses in patients with atrial fibrillation (AF) and a recorded DOAC prescription. Patients were defined as having a drug interaction if they had a recorded prescription of an interacting medication while they had had a recorded prescription of DOAC in the previous six months. The sample size for the cross-sectional analyses ranged from 5333 in 2014 to 19,196 in 2018., Results: The proportion of patients who had potential drug interactions with a DOAC decreased from 45.9% (95% confidence interval (CI) 44.6%-47.4%) in 2014 to 39.9% (95% CI 39.2%-40.6%) in 2018, p for trend < 0.001. During this period, the most frequent interacting class of medication recorded as having been prescribed with DOACs was selective serotonin/serotonin and norepinephrine reuptake inhibitor (SSRI/SNRI) antidepressants, followed by non-steroidal anti-inflammatory drugs (NSAIDs), calcium channel blockers (CCBs) and amiodarone., Conclusions: Overall, potential drug interactions with DOACs have decreased slightly over the last five years; however, the rate of possible interaction with SSRIs/SNRIs has remained relatively unchanged and warrants awareness-raising amongst prescribers.

Background: Chronic obstructive pulmonary disease (COPD) is a leading cause of unplanned readmission. There is need to identify risk factors for, and strategies to prevent readmission in patients with COPD., Aim: To systematically review and summarise the prevalence, risk factors and outcomes associated with rehospitalisation due to COPD exacerbation., Method: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Five databases were searched for relevant studies., Results: Fifty-seven studies from 30 countries met the inclusion criteria. The prevalence of COPD-related readmission varied from 2.6 to 82.2% at 30 days, 11.8-44.8% at 31-90 days, 17.9-63.0% at 6 months, and 25.0-87.0% at 12 months post-discharge. There were differences in the reported factors associated with readmissions, which may reflect variations in the local context, such as the availability of community-based services to care for exacerbations of COPD. Hospitalisation in the previous year prior to index admission was the key predictor of COPD-related readmission. Comorbidities (in particular asthma), living in a deprived area and living in or discharge to a nursing home were also associated with readmission. Relative to those without readmissions, readmitted patients had higher in-hospital mortality rates, shorter long-term survival, poorer quality of life, longer hospital stay, increased recurrence of subsequent readmissions, and accounted for greater healthcare costs., Conclusions: Hospitalisation in the previous year was the principal risk factor for COPD-related readmissions. Variation in the prevalence and the reported factors associated with COPD-related readmission indicate that risk factors cannot be generalised, and interventions should be tailored to the local healthcare environment., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Readmission rates following hospitalisation for COPD exacerbations are unacceptably high, and the contributing factors are poorly understood. Our objective was to summarise and evaluate the factors associated with 30- and 90-day all-cause readmission following hospitalisation for an exacerbation of COPD., Methods: We systematically searched electronic databases from inception to 5 November 2019. Data were extracted by two independent authors in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Study quality was assessed using a modified version of the Newcastle-Ottawa Scale. We synthesised a narrative from eligible studies and conducted a meta-analysis where this was possible using a random-effects model., Results: In total, 3533 abstracts were screened and 208 full-text manuscripts were reviewed. A total of 32 papers met the inclusion criteria, and 14 studies were included in the meta-analysis. The readmission rate ranged from 8.8-26.0% at 30 days and from 17.5-39.0% at 90 days. Our narrative synthesis showed that comorbidities, previous exacerbations and hospitalisations, and increased length of initial hospital stay were the major risk factors for readmission at 30 and 90 days. Pooled adjusted odds ratios (95% confidence intervals) revealed that heart failure (1.29 (1.22-1.37)), renal failure (1.26 (1.19-1.33)), depression (1.19 (1.05-1.34)) and alcohol use (1.11 (1.07-1.16)) were all associated with an increased risk of 30-day all-cause readmission, whereas being female was a protective factor (0.91 (0.88-0.94))., Conclusions: Comorbidities, previous exacerbations and hospitalisation, and increased length of stay were significant risk factors for 30- and 90-day all-cause readmission after an index hospitalisation with an exacerbation of COPD., Competing Interests: Conflict of interest: J.S. Alqahtani has nothing to disclose. Conflict of interest: C.M. Njoku has nothing to disclose. Conflict of interest: B. Bereznicki has nothing to disclose. Conflict of interest: B.C. Wimmer has nothing to disclose. Conflict of interest: G.M. Peterson has nothing to disclose. Conflict of interest: L. Kinsman has nothing to disclose. Conflict of interest: Y.S. Aldabayan has nothing to disclose. Conflict of interest: A.M. Alrajeh has nothing to disclose. Conflict of interest: A.M. Aldahahir has nothing to disclose. Conflict of interest: S. Mandal has nothing to disclose. Conflict of interest: J.R. Hurst reports personal fees and non-financial support from pharmaceutical companies that make medicines to treat COPD, outside the submitted work., (Copyright ©ERS 2020.)

Background: Australian patients with chronic kidney disease (CKD) are routinely managed in general practices with multiple medications. However, no nationally representative study has evaluated the quality of prescribing in these patients. The objective of this study was to examine the quality of prescribing in patients with CKD using nationally representative primary care data obtained from the NPS MedicineWise's dataset, MedicineInsight. Methods: A cross-sectional analysis of general practice data for patients aged 18 years or older with CKD was performed from 1 February 2016 to 1 June 2016. The study examined the proportion of patients with CKD who met a set of 16 published indicators in two categories: (1) potentially appropriate prescribing of antihypertensives, renin-angiotensin system (RAS) inhibitors, phosphate binders, and statins; and (2) potentially inappropriate prescribing of nephrotoxic medications, such as non-steroidal anti-inflammatory drugs (NSAIDs), at least two RAS inhibitors, triple therapy (an NSAID, a RAS inhibitor and a diuretic), high-dose digoxin, and metformin. The proportion of patients meeting each quality indicator was stratified using clinical and demographic characteristics. Results: A total of 44,259 patients (24,165 (54.6%) female; 25,562 (57.8%) estimated glomerular filtration (eGFR) 45-59 mL/1.73 m 2 ) with CKD stages 3-5 were included. Nearly one-third of patients had diabetes and were more likely to have their blood pressure and albumin-to-creatinine ratio monitored than those without diabetes. Potentially appropriate prescribing of antihypertensives was achieved in 79.9% of hypertensive patients with CKD stages 4-5. The prescribing indicators for RAS inhibitors in patients with microalbuminuria and diabetes and in patients with macroalbuminuria were achieved in 69.9% and 62.3% of patients, respectively. Only 40.8% of patients with CKD and aged between 50 and 65 years were prescribed statin therapy. The prescribing of a RAS inhibitor plus a diuretic was less commonly achieved, with the indicator met in 20.6% for patients with microalbuminuria and diabetes and 20.4% for patients with macroalbuminuria. Potentially inappropriate prescribing of NSAIDs, metformin, and at least two RAS inhibitors were apparent in 14.3%, 14.1%, and 7.6%, respectively. Potentially inappropriate prescribing tended to be more likely in patients aged ≥65 years, living in regional or remote areas, or with socio-economic indexes for areas (SEIFA) score ≤ 3. Conclusions: We identified areas for possible improvement in the prescribing of RAS inhibitors and statins, as well as deprescribing of NSAIDs and metformin in Australian general practice patients with CKD.

Assessing and improving public knowledge of atrial fibrillation (AF) could increase its detection rate and the subsequent use of stroke prevention therapies. However, there is no validated AF knowledge assessment tool applicable to the general population, including those at risk of AF. Therefore, we aimed to develop and validate such a tool. The tool was developed from a literature review and discussion with subject matter experts. Content validity was ensured by a ten-member panel of experts comprising cardiologists and pharmacists. An online validation survey was conducted and reported based on the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). The survey evaluated the tool performance by construct validity, internal consistency reliability, item discrimination, difficulty index and ease of readability. The survey participants included 14 general medical specialists, 20 fourth-year and 33 second-year undergraduate pharmacy students, and 122 members of the general public. The tool had satisfactory content validity, with a scale content validity index of 0.8. The mean percentage knowledge scores for general medical specialists and fourth-year pharmacy students were higher than second-year pharmacy students, followed by the general public (92.9%, 87.6%, 68.5% and 53.4%, respectively; p -value < 0.001), supporting construct validity. The tool had good internal consistency reliability (Cronbach's alpha = 0.91). The item-total correlation was in the preferred range of 0.23 to 0.71. The Atrial Fibrillation Knowledge Assessment Tool is a valid instrument and can be used to investigate AF knowledge of the general population.

This study examines the associations between medication adherence and burden, and health-related quality of life (HRQOL) in predialysis chronic kidney disease (CKD). A prospective study targeting adults with advanced CKD (estimated glomerular filtration rate (eGFR) < 30 mL/min/1.73 m 2 ) and not receiving renal replacement therapy was conducted in Tasmania, Australia. The actual medication burden was assessed using the 65-item Medication Regimen Complexity Index, whereas perceived burden was self-reported using a brief validated questionnaire. Medication adherence was assessed using a four-item Morisky-Green-Levine Scale (MGLS) and the Tool for Adherence Behaviour Screening (TABS). The Kidney Disease and Quality of Life Short-Form was used to assess HRQOL. Of 464 eligible adults, 101 participated in the baseline interview and 63 completed a follow-up interview at around 14 months. Participants were predominantly men (67%), with a mean age of 72 (SD 11) years and eGFR of 21 (SD 6) mL/min/1.73 m 2 . Overall, 43% and 60% of participants reported medication nonadherence based on MGLS and TABS, respectively. Higher perceived medication burden and desire for decision-making were associated with nonadherent behaviour. Poorer HRQOL was associated with higher regimen complexity, whereas nonadherence was associated with a decline in physical HRQOL over time. Medication nonadherence, driven by perceived medication burden, was prevalent in this cohort, and was associated with a decline in physical HRQOL over time.

Objective: To examine and identify the scope of research addressing health information overload in consumers., Methods: In accordance with a published protocol, six electronic databases (PubMed, CINAHL, ERIC, PsycINFO, Embase, and Scopus), reference lists of included articles, and grey literature (Google Advanced Search and WorldCat) were searched. Articles in English were included, without any limit on the date of publication., Results: Of the 69 records included for final analysis, 22 studies specifically examined health information overload, whereas the remainder peripherally discussed the concept alongside other concepts. The 22 studies focused on one or more of the following: 1) ways to measure health information overload (multi-item/single-item scales); 2) predictors of health information overload - these included low education level, health literacy, and socioeconomic status; and 3) interventions to address information overload, such as videotaped consultations or written materials. Cancer information overload was a popular topic amongst studies that focused on information overload., Conclusion: Based on the identified studies, there is a clear need for future studies that investigate health information overload in consumers with chronic medical conditions other than cancer., Practice Implications: This review is the initial step in facilitating future efforts to create health information that do not overload consumers., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: The primary objective of this study is to use the Capability, Opportunity, and Motivation Behaviour (COM-B) model to identify potential strategies aimed at improving the early detection of atrial fibrillation (AF) in the general population., Methods: We undertook a review of the literature to identify factors associated with participation in community-based screening for AF, followed by mapping of the factors generated into the components of the COM-B model, and validation of the model by an expert panel. The Behaviour Change Wheel (BCW) was used to nominate potential intervention strategies and steps to guide the design and implementation of community-based screening for AF., Results: A total of 28 factors from 21 studies were mapped into the COM-B model. Based on the BCW approach, 24 intervention strategies and 7 steps that could guide the design and implementation of community-based screening for AF were recommended., Conclusion: The application of the COM-B model demonstrated how factors influencing the participation of individuals with undiagnosed AF in community-based screening could be identified. The model could also serve as a guide for the design and implementation of interventions for improving AF detection in the general population., Competing Interests: Declaration of conflicting interests:The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2019.)

Objectives: Potentially inappropriate medication (PIM) use is associated with increased morbidity and mortality in chronic kidney disease (CKD). However, there is a paucity of data on how hospitalization affects PIM use in older adults with CKD. Therefore, we aimed to measure the impact of hospitalization on PIM use in older CKD patients, and identify factors predicting PIM use., Methods: A retrospective cohort study was conducted in older adults (≥65 years) with CKD admitted to an Australian tertiary care hospital over a 6 month period. PIM use was measured, upon admission and at discharge, using the Medication Appropriateness Index (MAI) and Beers criteria (2015 version) for medications recommended to be avoided in older adults and under certain conditions., Results: The median age of the 204 patients was 83 years (interquartile range (IQR): 76-87 years) and most were men (61%). Overall, the level of PIM use (MAI) decreased from admission to discharge (median [IQR]: 6 [3-12] to 5 [2-9]; p < .01]). More than half of the participants (55%) had at least one PIM per Beers criterion on admission, which was reduced by discharge (48%; p < .01). People admitted with a higher number of medications (β 0.72, 95% CI 0.56-0.88) and lower eGFR values (β - 0.11, 95% CI -0.18 to -0.04) had higher MAI scores after adjusting for age, sex and Charlson's comorbidity index., Conclusions: PIMs were commonly used in older CKD patients. Hospitalization was associated with a reduction in PIM use, but there was considerable scope for improvement in these susceptible individuals.

This study aimed to examine the association between medication-related factors and risk of hospital readmission in older patients with chronic kidney disease (CKD). A retrospective analysis was conducted targeting older CKD ( n = 204) patients admitted to an Australian hospital. Medication appropriateness (Medication Appropriateness Index; MAI), medication regimen complexity (number of medications and Medication Regimen Complexity Index; MRCI) and use of selected medication classes were exposure variables. Outcomes were occurrence of readmission within 30 and 90 days, and time to readmission within 90 days. Logistic and Cox hazards regression were used to identify factors associated with readmission. Overall, 50 patients (24%) were readmitted within 30 days, while 81 (40%) were readmitted within 90 days. Mean time to readmission within 90 days was 66 (SD 34) days. Medication appropriateness and regimen complexity were not independently associated with 30- or 90-day hospital readmissions in older adults with CKD, whereas use of renin‒angiotensin blockers was associated with reduced occurrence of 30-day (adjusted OR 0.39; 95% CI 0.19⁻0.79) and 90-day readmissions (adjusted OR 0.45; 95% CI 0.24⁻0.84) and longer time to readmission within 90 days (adjusted HR 0.52; 95% CI 0.33⁻0.83). This finding highlights the importance of considering the potential benefits of individual medications during medication review in older CKD patients., Competing Interests: The authors declare no conflict of interest.

Background: Chronic kidney disease (CKD) is characterized by high rates of hospital admissions and readmissions. However, there is a scarcity of research into medication-related factors predicting such outcomes in this patient group., Objective: To evaluate the effect of medication regimen complexity at hospital discharge on subsequent readmissions and their timing in older adults with CKD., Methods: This was a 12-month retrospective cohort study of 204 older (⩾65 years) CKD patients in an Australian tertiary care hospital. Medication regimen complexity was quantified using the 65-item medication regimen complexity index (MRCI). The outcomes were the occurrence of readmission in 30 days and time to readmission within 12 months. Logistic regression was used to identify factors predicting 30-day readmission, and a competing risks proportional subdistribution hazard model, accounting for deaths, was used for factors predicting time to readmission., Results: Overall, 50 (24%) patients, predominantly men (72%), were readmitted within 30 days of follow-up. MRCI was not significantly associated with 30-day readmission (odds ratio [OR] = 1.27; 95% CI = 0.94-1.73). The median (interquartile range) time to readmission within 12 months was 145 (31-365) days. On a multivariate analysis, a 10-unit increase in MRCI was associated with a shorter time to readmission within 12 months (subdistribution HR = 1.18; 95% CI = 1.01-1.36). Conclusion and Relevance: Medication regimen complexity was not significantly associated with 30-day readmission; however, it was associated with a significantly shorter time to 12-month readmission in older CKD patients. This finding highlights the importance of medication regimen complexity as a potential target for medical interventions to reduce readmission risks.

Introduction: Adjusting doses of renally cleared medications and/or avoidance of nephrotoxic medications are standard clinical practices in chronic kidney disease (CKD), albeit the prevalence of inappropriate prescribing (IP) in these patients remains high. Therefore, this work sought to systematically review the prevalence of IP and compare the relative effectiveness of available interventions in reducing IP in CKD., Methods: Studies were identified searching PubMed/Medline, EMBASE, Cochrane Library, IPA, Web of Science, Ovid/Medline, CINAHL, and PsychINFO databases. Studies defining CKD based on laboratory markers and quantifying prevalence of IP were included., Results: Forty-nine studies from 23 countries met the inclusion criteria. An IP prevalence of 9.4%-81.1% and 13%-80.50% was reported in hospital and ambulatory settings, respectively; whereas, in long-term care facilities the prevalence ranged between 16% and 37.9%. Unsurprisingly, IP was associated with adverse drug events like increased hospital stay (Mean [SD] of 4.5 [4.8] vs 4.3 [4.5]) and high risk of mortality [40%]. Twenty-one studies reported the impact of interventions on IP; manual and computerised alerts were the main forms of interventions (n=19). The most significant reduction in IP was observed when physicians received immediate concurrent feedback from a clinical pharmacist (P<.001). Polypharmacy, comorbidities, and age were identified as predictors of IP., Conclusion: IP has led to poor patient outcomes. Although pharmacist-based and computer-aided approaches have shown promising results, there is still room for improvement. Future studies should focus on developing a multifaceted intervention to address the widespread prevalence of IP and associated clinical outcomes in CKD patients., (© 2017 John Wiley & Sons Ltd.)

Objectives: To systematically review clinical outcomes associated with medication regimen complexity in older people., Design: Systematic review of EMBASE, MEDLINE, International Pharmaceutical Abstracts, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane library., Setting: Hospitals, home, and long-term care., Participants: English-language peer-reviewed original research published before June 2016 was eligible if regimen complexity was quantified using a metric that considered number of medications and at least one other parameter, regimen complexity was calculated for participants' overall regimen, at least 80% of participants were aged 60 and older, and the study investigated a clinical outcome associated with regimen complexity., Measurements: Quality assessment was conducted using an adapted version of the Joanna Briggs Institute critical appraisal tool., Results: Sixteen observational studies met the inclusion criteria. Regimen complexity was associated with medication nonadherence (2/6 studies) and higher rates of hospitalization (2/4 studies). One study found that participants with less-complex medication administration were more likely to stop medications when feeling worse. One study each identified an association between regimen complexity and higher ability to administer medications as directed, medication self-administration errors, caregiver medication administration hassles, hospital discharge to non-home settings, postdischarge potential adverse drug events, all-cause mortality, and lower patient knowledge of their medication. Regimen complexity had no association with postdischarge medication modification, change in medication- and health-related problems, emergency department visits, or quality of life as rated by nursing staff., Conclusion: Research into whether medication regimen complexity is associated with nonadherence and hospitalization has produced inconsistent results. Moderate-quality evidence from four studies (two each for nonadherence and hospitalization) suggests that medication regimen complexity is associated with nonadherence and higher rates of hospitalization., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Objectives: To investigate the association between polypharmacy and medication regimen complexity with time to first hospitalization, number of hospitalizations, and number of hospital days over a 12-month period., Design: A 12-month prospective cohort study., Participants and Setting: A total of 383 residents of 6 Australian long-term care facilities (LTCFs)., Measurements: The primary exposures were polypharmacy (≥9 regular medications) and the 65-item Medication Regimen Complexity Index (MRCI). Cox proportional hazards regression was used to compute hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between polypharmacy and MRCI with time to first hospitalization. Poisson regression was used to compute incident rate ratios (IRR) and 95% CIs for the association between polypharmacy and MRCI with number of hospitalizations and number of hospital days. Models were adjusted for age, sex, length of stay in LTCF, comorbidities, activities of daily living, and dementia severity., Results: There were 0.56 (95% CI 0.49-0.65) hospitalizations per person-year and 4.52 (95% CI 4.31-4.76) hospital days per person-year. In adjusted analyses, polypharmacy was associated with time to first hospitalization (HR 1.84; 95% CI 1.21-2.79), number of hospitalizations (IRR 1.51; 95% CI 1.09-2.10), and hospital days per person-year (IRR 1.39; 95% CI 1.24-1.56). Similarly, in adjusted analyses a 10-unit increase in MRCI was associated with time to first hospitalization (HR 1.17; 95% CI 1.06-1.29), number of hospitalizations (IRR 1.15; 95% CI 1.06-1.24), and hospital days per person-year (IRR 1.19; 95% CI 1.16-1.23)., Conclusions: Polypharmacy and medication regimen complexity are associated with hospitalizations from LTCFs. This highlights the importance of regular medication review for residents of LTCFs and the need for further research into the risk-to-benefit ratio of prescribing in this setting., (Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study is to investigate the association between polypharmacy with health-related quality of life (HRQoL) and medication regimen complexity with HRQoL in residential aged care facilities (RACFs)., Methods: A cross-sectional study of 383 residents from six Australian RACFs was conducted. The primary exposures were polypharmacy (≥9 regular medications) and the validated Medication Regimen Complexity Index (MRCI). The outcome measure was staff informant rated quality of life assessed using the Quality of Life Alzheimer's disease (QoL-AD) scale. Covariates included age, sex, Charlson's comorbidity index, activities of daily living, and dementia severity. Logistic quantile regression was used to characterize the association between polypharmacy and QoL-AD (model 1) and MRCI and QoL-AD (model 2)., Results: The median age of the 383 residents was 88 years and 297 (78 %) residents were female. In total, 63 % of residents were exposed to polypharmacy and the median MRCI score (range) was 43.5 (4-113). After adjusting for the covariates, polypharmacy was not associated with either higher or lower QoL-AD scores (estimate -0.02; 95 % confidence interval (CI) -0.165, 0.124; p = 0.78). Similarly, after adjusting for the covariates, MRCI was not associated with either higher or lower QoL-AD scores (estimate -0.0009, 95 % CI -0.005, 0.003; p = 0.63)., Conclusions: These findings suggest that polypharmacy and medication regimen complexity are not associated with staff informant rated HRQoL. Further research is needed to investigate how specific medication classes may impact change in quality of life over time.

Purpose: There has been recent interest in deprescribing, particularly among older people. No previous studies have assessed whether residents of aged care facilities are willing to have their medications deprescribed. Understanding residents' attitudes toward deprescribing is important for developing deprescribing interventions., Objective: To investigate residents' willingness to have their medications deprescribed., Methods: This was a cross-sectional survey of 232 residents aged ≥65 years from six residential aged care facilities (RACFs) across metropolitan and regional South Australia. Overall, 163 of the 232 residents (70.3%) took ≥9 regular medications. All participants completed the 10-item Patients' Attitudes Towards Deprescribing (PATD) questionnaire., Results: Overall, 40.5% of residents reported a desire to stop taking one or more of their medications. If their doctor said it was possible, 78.9% of residents were willing to have one or more of their medications deprescribed. Residents taking ≥9 medications were more likely to feel that they were taking a large number of medications compared to residents taking <9 medications (50.3% vs 14.5%, P < 0.01), and were more likely to believe one or more of their medications was causing side effects (14.7% vs 10.1%, P = 0.02). However, residents taking ≥9 regular medications were not significantly more likely to want to reduce their number of medications than residents taking <9 medications., Conclusions: Deprescribing interventions are likely to be acceptable to residents' of RACFs, with a high willingness to discontinue medicines if doctors say it is possible. This highlights the importance of the proactive involvement of health care professionals in an individualized deprescribing process., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Adverse drug events are a leading cause of hospitalization among older people. Up to half of all medication-related hospitalizations are potentially preventable. The objective of this study was to investigate and compare the association between medication regimen complexity and number of medications with unplanned hospitalizations over a 3-year period., Methods: Data were analyzed for 3,348 participants aged 60 years or older in Sweden. Regimen complexity was assessed using the 65-item Medication Regimen Complexity Index (MRCI) and number of medications was assessed as a continuous variable. Cox proportional hazard models were used to compute unadjusted and adjusted hazard ratios with 95% confidence intervals (CIs) for associations between regimen complexity and number of medications with unplanned hospitalizations over a 3-year period. Receiver operating characteristics curves with corresponding areas under the curve were calculated for regimen complexity and number of medications in relation to unplanned hospitalizations. The population attributable fraction of unplanned hospitalizations was calculated for MRCI and number of medications., Results: In total, 1,125 participants (33.6%) had one or more unplanned hospitalizations. Regimen complexity (hazard ratio 1.22; 95% CI 1.14-1.34) and number of medications (hazard ratio 1.07; 95% CI 1.04-1.09) were both associated with unplanned hospitalizations and had similar sensitivity and specificity (area under the curve 0.641 for regimen complexity and area under the curve 0.644 for number of medications). The population attributable fraction was 14.08% (95% CI 9.62-18.33) for MRCI and 17.61% (95% CI 12.59-22.35) for number of medications., Conclusions: There was no evidence that using a complex tool to assess regimen complexity was better at predicting unplanned hospitalization than number of medications., (© The Author 2015. Published by Oxford University Press on behalf of The Gerontological Society of America.)

Objectives: To investigate whether medication regimen complexity and/or polypharmacy are associated with all-cause mortality in older people., Methods: This was a population-based cohort study among community-dwelling and institutionalized people ≥60 years old (n = 3348). Medication regimen complexity was assessed using the 65-item Medication Regimen Complexity Index (MRCI) in 10-unit steps. Polypharmacy was assessed as a continuous variable (number of medications). Mortality data were obtained from the Swedish National Cause of Death Register. Cox proportional hazard models were used to compute unadjusted and adjusted hazard ratios (HRs) and 95% CIs for the association between regimen complexity and polypharmacy with all-cause mortality over a 3-year period. Subanalyses were performed stratifying by age (≤80 and>80 years), sex, and cognition (Mini-Mental State Examination [MMSE] <26 and ≥26)., Results: During follow-up, 14% of the participants (n = 470) died. After adjusting for age, sex, comorbidity, educational level, activities of daily living, MMSE, and residential setting, a higher MRCI was associated with mortality (adjusted HR = 1.12; 95% CI = 1.01-1.25). Polypharmacy was not associated with mortality (adjusted HR = 1.03; 95% CI = 0.99-1.06). When stratifying by sex, both MRCI and polypharmacy were associated with mortality in men but not in women. MRCI was associated with mortality in participants ≤80 years old and in participants with MMSE ≥26 but not in participants >80 years old or with MMSE <26., Conclusion: Regimen complexity was a better overall predictor of mortality than polypharmacy. However, regimen complexity was not predictive of mortality in women, in participants >80 years old, or in those with MMSE<26. These different associations with mortality deserve further investigation., (© The Author(s) 2015.)

Purpose: There is a lack of population-based research about factors associated with medication regimen complexity. This study investigated factors associated with medication regimen complexity in older people, and whether factors associated with regimen complexity were similar to factors associated with number of medications., Methods: This cross-sectional population-based study included 3348 people aged ≥ 60 years. Medication regimen complexity was computed using the validated 65-item Medication Regimen Complexity Index (MRCI). Multinomial logistic regression was used to compute unadjusted and adjusted odds ratios (ORs) with 95 % confidence intervals (CIs) for factors associated with regimen complexity. Multivariable quantile regression was used to compare factors associated with regimen complexity and number of medications., Results: In adjusted analyses, participants in the highest MRCI quintile (MRCI > 20) were older (OR = 1.04, 95 % CI 1.02;1.05), less likely to live at home (OR = 0.35, 95 % CI 0.15;0.86), had greater comorbidities (OR = 2.17, 95 % CI 1.89;2.49), had higher cognitive status (OR = 1.06, 95 % CI 1.01;1.11), a higher prevalence of self-reported pain (OR = 2.85, 95 % CI 2.16;3.76), had impaired dexterity (OR = 2.39, 95 % CI 1.77;3.24) and were more likely to receive help to sort their medications (OR = 4.43 95 % CI 2.39;8.56) than those with low regimen complexity (MRCI > 0-5.5). Similar factors were associated with both regimen complexity and number of medications., Conclusion: Older people with probable difficulties managing complex regimens, including those with impaired dexterity and living in institutional settings, had the most complex medication regimens even after adjusting for receipt of help to sort medications. The strong correlation between regimen complexity and number of medications suggests that clinicians could use a person's number of medications to target interventions to reduce complexity.

Background: Medication-related problems and adverse drug events are leading causes of preventable hospitalizations. Few previous studies have investigated the possible association between medication regimen complexity and unplanned rehospitalization., Objective: To investigate the association between discharge medication regimen complexity and unplanned rehospitalization over a 12-month period., Method: The prospective study comprised patients aged ≥70 years old consecutively admitted to a Geriatrics Evaluation and Management (GEM) unit between October 2010 and December 2011. Medication regimen complexity at discharge was calculated using the 65-item validated Medication Regimen Complexity Index (MRCI). Cox proportional-hazards regression was used to compute unadjusted and adjusted hazard ratios (HRs) with 95% CIs for factors associated with rehospitalization over a 12-month follow-up period., Result: Of 163 eligible patients, 99 patients had one or more unplanned hospital readmissions. When adjusting for age, sex, activities of daily living, depression, comorbidity, cognitive status, and discharge destination, MRCI (HR = 1.01; 95% CI = 0.81-1.26), number of discharge medications (HR = 1.01; 95% CI = 0.94-1.08), and polypharmacy (≥9 medications; HR = 1.12; 95% CI = 0.69-1.80) were not associated with rehospitalization. In patients discharged to nonhome settings, there was an association between rehospitalization and the number of discharge medications (HR = 1.12; 95% CI = 1.01-1.25) and polypharmacy (HR = 2.24; 95% CI = 1.02-4.94) but not between rehospitalization and MRCI (HR = 1.32; 95% CI = 0.98-1.78)., Conclusion: Medication regimen complexity was not associated with unplanned hospital readmission in older people. However, in patients discharged to nonhome settings, the number of discharge medications and polypharmacy predicted rehospitalization. A patient's discharge destination is an important factor in unplanned medication-related readmissions., (© The Author(s) 2014.)

Background: Older people often take multiple medications. It is a policy priority to facilitate older people to stay at home longer. Three-quarters of nursing home placements in the US are preceded by a hospitalization., Objective: To investigate the association between polypharmacy and medication regimen complexity with hospital discharge destination among older people., Methods: This prospective cohort study comprised patients aged ≥70 years consecutively admitted to the Geriatric Evaluation and Management unit at a tertiary hospital in Adelaide, Australia, between October 2010 and December 2011. Medication regimen complexity at discharge was calculated using the 65-item validated Medication Regimen Complexity Index (MRCI). Unadjusted and adjusted relative risks (RRs) with 95 % confidence intervals (CIs) were calculated for medication-related factors associated with discharge directly to home versus non-community settings (rehabilitation, transition care, and residential aged care)., Results: From 163 eligible patients, 87 were discharged directly to home (mean age 84.6 years, standard deviation [SD] 6.9; mean MRCI 26.1, SD 9.7), while 76 were discharged to non-community settings (mean age 85.8 years, SD 5.8; mean MRCI 29.9, SD 13.2). After adjusting for age, sex, comorbidity, and activities of daily living, having a high medication regimen complexity (MRCI >35) was inversely associated with discharge directly to home (RR 0.39; 95 % CI 0.20-0.73), whereas polypharmacy (≥9 medications) was not significantly associated with discharge directly to home (RR 0.97; 95 % CI 0.53-1.58)., Conclusion: Having high medication regimen complexity was inversely associated with discharge directly to home, while polypharmacy was not associated with discharge destination.