INFORM-AF II-Phase 1 pilot randomised controlled trial evaluating the effect of an atrial fibrillation digital education programme: study protocol.

AIM: To evaluate the effect of a novel, co-designed, digital AF educational program, 'INFORM-AF', to reduce re-hospitalisation of people with AF. The secondary aims are to examine the effect of the intervention on: (a) reducing cardiovascular-related hospitalisation, (b) increasing medication adherence, AF-related knowledge, and Atrial fibrillation (AF)-related quality of life and (c) determining the cost-effectiveness of the intervention. BACKGROUND: AF is an increasingly prevalent cardiac arrythmia that involves complex clinical management. Comprehensive education is essential for successful self-management of AF and is associated with positive health-related outcomes. There has been an increase in technology-based education for AF. However, its effects on hospitalisation, medication adherence and patient-reported outcomes are unclear. DESIGN: A prospective, randomised (1:1), open-label, blinded-endpoint, multicentre clinical trial. METHODS: Eligible participants are aged 18 years or above, diagnosed with AF, and own a smartphone. The study will be conducted at two metropolitan hospitals. In the intervention group, participants will receive the AF educational program delivered via Qstream®. In the control group, participants will receive the Stroke Foundation 'Living with AF' booklet. The primary outcome is re-hospitalisation within 12 months from an indexed presentation or hospital admission. CONCLUSION: This clinical trial is part of a developing program of work that will examine mHealth educational-behavioural interventions on cardiovascular outcomes. Findings from this pilot study will inform the development of a digital educational framework for patients living with AF. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: There remain many gaps in providing high-quality patient education for patients with AF. This trial will test a new theory-driven, smartphone-based education program on important clinical outcomes, including rehospitalisation. IMPACT: This study evaluates a novel, co-designed, digital AF educational program, 'INFORM-AF', to reduce the re-hospitalisation of people with AF. Study results are expected to be reported in 2025. Findings are expected to inform practice recommendations for AF patient education that may be included in future clinical practice guideline recommendations. REPORTING METHOD: SPIRIT Checklist. PATIENT OR PUBLICATION CONTRIBUTION: JL is a consumer co-researcher on the project and provided critical input into intervention design, and feedback and input across the study duration.

The protocol for an observational Australian cohort study of CADASIL: The AusCADASIL study.

Introduction: Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) is a rare genetic condition with a broad phenotypic presentation. This study aims to establish the first Australian cohort of individuals affected by CADASIL (AusCADASIL) and examine its clinical features and longitudinal course, and to investigate neuroimaging and blood biomarkers to assist in early diagnosis and identify disease progression. Methods: Participants will be recruited from six study centres across Australia for an observational study of CADASIL. We aim to recruit 150 participants with diagnosed CADASIL, family history of CADASIL or suspected CADASIL symptoms, and 150 cognitively normal NOTCH3 negative individuals as controls. Participants will complete: 1) online questionnaires on medical and family history, mental health, and wellbeing; 2) neuropsychological evaluation; 3) neurological examination and brain MRI; 4) ocular examination and 5) blood sample donation. Participants will have annual follow-up for 4 years to assess their progression and will be asked to invite a study partner to corroborate their self-reported cognitive and functional abilities.Primary outcomes include cognitive function and neuroimaging abnormalities. Secondary outcomes include investigation of genetics and blood and ocular biomarkers. Data from the cohort will contribute to an international consortium, and cohort participants will be invited to access future treatment/health intervention trials. Discussion: AusCADASIL will be the first study of an Australian cohort of individuals with CADASIL. The study will identify common pathogenic variants in this cohort, and characterise the pattern of clinical presentation and longitudinal progression, including imaging features, blood and ocular biomarkers and cognitive profile.

Healthcare Providers' Attitudes and Experiences of the Quality Use of Medications Among Culturally and Linguistically Diverse Patients in Australia: A Systematic Review of Qualitative Studies.

This review aims to identify healthcare providers' (HCPs) experiences with issues related to the quality use of medicines among culturally and linguistically diverse (CALD) patients, the underlying factors, and the enablers of and barriers to providing culturally safe care to promote quality use of medicines. The searched databases were Scopus, Web of Science, Academic search complete, CINHAL-Plus, Google Scholar and PubMed/Medline. The initial search returned 643 articles, of which 14 papers were included. HCPs reported that CALD patients were more likely to face challenges in accessing treatment and sufficient information about treatment. According to the theoretical domains framework, determinants such as social influences due to cultural and religious factors, lack of appropriate resources about health information and cultural needs, lack of physical and psychological capabilities such as lack of knowledge and skills, and lack of motivation could impede HCPs' abilities to provide culturally safe care. Future interventions should deploy multilevel interventions, such as education, training, and organisation structural reforms.

Medicines use issues perceived by Arabic-speaking patients living in English-speaking countries: A systematic review.

OBJECTIVES: Quality use of medicines, or rational medicines use, requires patients' adherence to the quality principles of medication use. There is a limited number of reviews about quality medication use among migrant patients. This review aims to fill this gap by exploring medication-related issues experienced by Arabic-speaking patients living in English-speaking countries. METHODS: The searched databases included WebMD, EMBASE, Scopus, CINHAL, PubMed/Medline and Web of science. KEY FINDINGS: The initial search retrieved 2071 publications and 23 publications met the inclusion criteria. Our review found that the most frequently reported medication-related issues among Arabic-speaking patients residing in English-speaking countries were problems related to decision-making regarding treatment options, inappropriate counselling and lack of information about medicines and diseases, lack of monitoring and follow-up, and intentional and unintentional medication non-adherence. Informed by the bio-psycho-socio-systems model, contributing factors to the medication issues included used coping strategies, ethno-cultural and religious beliefs and ineffective relationships with healthcare providers. CONCLUSIONS: Our review suggests that cultural factors can significantly influence individuals' perceptions and actions around the use of medication. Thus, healthcare providers need to be mindful of the specific cultural affiliations of ethnic minorities and exhibit cultural sensitivity when prescribing medication to migrant patients to foster a better relationship between patients and healthcare providers. Applying a patient-centred approach using shared decision-making can help. Our findings also suggest that pharmacy practice is critical in improving medication safety among Arabic-speaking patients.

Australian community pharmacy service provision factors, stresses and strains: A qualitative study.

Introduction: Despite the desire of pharmacists to provide new and more clinically focused services, strain on the community pharmacist workforce is a known barrier to their service provision. Causes are unclear, although the impact of increased workload, as well as broader role-related and systemic causes have been suggested. Aims: To (1) explore the role strain, stress and systemic factors affecting Australian community pharmacists' provision of cognitive pharmacy services (CPS), using the Community Pharmacist Role Stress Factor Framework (CPRSFF), and (2) adapt the CPRSFF to the local setting. Methods: Semi-structured interviews were conducted with Australian community pharmacists. Transcripts were analysed with the framework method to verify and adapt the CPRSFF. Thematic analysis of particular codes identified personal outcomes and causative patterns in perceived workforce strain. Results: Twenty-three registered pharmacists across Australia were interviewed. CPS role benefits included: helping people, and increased competency, performance, pharmacy financial return, recognition from the public and other health professionals, and satisfaction. However, strain was worsened by organisational expectations, unsupportive management and insufficient resources. This could result in pharmacist dissatisfaction and turnover in jobs, sector or careers. Two additional factors, workflow and service quality, were added to the framework. One factor, "View of career importance versus partner's career", was not apparent. Conclusion: The CPRSFF was found to be valuable in exploring the pharmacist role system and analysing workforce strain. Pharmacists weighed up positive and negative outcomes of work tasks, jobs and roles to decide task priority and personal job significance. Supportive pharmacy environments enabled pharmacists to provide CPS, which increased workplace and career embeddedness. However, workplace culture at odds with professional pharmacist values resulted in job dissatisfaction and staff turnover.

Culturally and linguistically diverse patients' perspectives and experiences on medicines management in Australia: a systematic review.

BACKGROUND: Within the quality use of medicines (QUM)-which entails timely access to, and the rational use of, medicines-medicine safety is a global health priority. In multicultural countries, such as Australia, national medicines policies are focused on achieving QUM, although this is more challenging among their Culturally and Linguistically Diverse (CALD) patients (i.e., those from ethnic minority groups). AIM: This review aimed to identify and explore the specific challenges to achieving QUM, as experienced by CALD patients living in Australia. METHOD: A systematic literature search was conducted using Web of Science, Scopus, Academic search complete, CINHAL, PubMed and Medline. Qualitative studies describing any aspects of QUM among CALD patients in Australia were included. RESULTS: Major challenges in facilitating QUM among CALD patients in Australia were identified, particularly in relation to the following medicines management pathway steps: difficulties around participation in treatment decision-making alongside deficiencies in information provision about medicines. Furthermore, medication non-adherence was commonly observed and reported. When mapped against the bio-psycho-socio-systems model, the main contributors to the medicine management challenges identified related to "social" and "system" factors, reflecting the current health-system's lack of capacity and resourcing to respond to patients' low health literacy levels, communication and language barriers, and cultural and religious perceptions about medicines. CONCLUSION: QUM challenges were different among different ethnic groups. This review suggests a need to engage with CALD patients in co-designing culturally appropriate resources and/or interventions to enable the health-system to address the identified barriers to QUM.

Rural versus metropolitan comparison of processes of care in the community-based management of TIA and minor stroke in Australia (an analysis from the INSIST study).

OBJECTIVES: To compare processes of care and clinical outcomes of community-based management of TIAs and minor strokes (TIAMS) between rural and metropolitan Australia. DESIGN: Inception cohort study between 2012 and 2016 with 12-month follow-up after index event (sub-study of INSIST). SETTING: Hunter and Manning valley regions of New South Wales, within the referral territory of the John Hunter Hospital Acute Neurovascular Clinic (JHHANC). PARTICIPANTS: Consecutive patients of 16 participating general practices, presenting with possible TIAMS to either primary or secondary care. MAIN OUTCOME MEASURES: Processes of care (referrals, key management processes, time-based metrics) and clinical outcomes. RESULTS: Of 613 participants with possible TIAMS who completed the baseline interview, 298 were adjudicated as having TIAMS (119 from rural, 179 from metropolitan). Mean age was 72.3 years (SD, 10.7) and 127 (43%) were women. Rural participants were more likely to be managed solely by a general practitioner (GP) than metropolitan participants (34% v 20%) and less likely to be referred to a JHHANC specialist (13% v 38%) or have brain magnetic resonance imaging (MRI) [24% v 51%]. Those rural participants who were referred, also waited longer (both p < 0.001). Recurrent stroke, myocardial infarction and death at 12 months were not significantly different between rural and metropolitan participants. CONCLUSIONS: Although TIAMS prognosis in rural settings where solely GP care is common is very good, the processes of care in such areas are inferior to metropolitan. This suggests there is further scope to support rural GPs to optimise care of TIAMS patients.

Educational Needs of People Living with Atrial Fibrillation: A Qualitative Study.

Background This study explored the educational and self-management needs of adults living with atrial fibrillation (AF). Methods and Results This is a qualitative study of adults living with AF, clinicians, and expert key stakeholders. Interviews were conducted via a one-to-one semistructured videoconference or phone and transcribed verbatim for thematic analysis. A total of 34 participants were recruited and included in analyses (clinicians n=13; experts n=13, patients n=8). Interviews were on average 40 (range 20-70) minutes in duration. Three key themes were identified: (1) "Patient-centered AF education"; (2) "Prioritizing AF education"; and (3) "Timing AF education." The availability of credible information was perceived as highly variable. Information primarily focused on anticoagulation, or procedural information, as opposed to other aspects of management, such as risk factor reduction. Factors to optimize learning, such as multimedia, apps, case studies, or the use of visuals were perceived as important. Continuity of care, including engagement of caregivers, was important to help develop relationships, and facilitate understanding, while concurrently creating opportunities for timely targeted education. Clinicians described acute care as a suboptimal setting to deliver education. Competing interests aligned with the time-pressured context of acute care were prioritized over patient education. In contrast, patients valued continuity of care. AF education strategies need to pivot from a "one size fits all" approach and modernize to implement a range of approaches. Conclusions There remain many unmet needs in the provision of quality AF education to support self-management. Multimodal offerings and the ability to tailor to individual patient needs are important design considerations for new education programs.

A participatory research approach in community pharmacy research: The case for video-reflexive ethnography.

Video-reflexive ethnography (VRE) is a qualitative methodology that explores the complex nature of healthcare 'as it really is'. Its collaborative and reflexive process invites stakeholders (e.g. pharmacists and pharmacy support staff) to participate in analysing their everyday work practices as captured on video footage. Through close collaboration with practitioners and attention to their work contexts, VRE may be a useful methodology to engage a time-poor pharmacy workforce in research about themselves, encouraging more practitioner involvement in practice-based research. Aside from research, VRE has also been used effectively as an intervention to facilitate learning and change in healthcare settings, and could be effective in provoking change in otherwise resistant pharmacy environments. Much like traditional ethnographic approaches, VRE researchers have relied on being present 'in the field' to observe, record and make sense of practices with participants. The COVID-19 pandemic however, has introduced restrictions around travel and physical distancing, which has required researchers to contemplate the conduct of VRE 'at a distance', and to imagine new ways in which the methodological 'closeness' to stakeholders and their workplace contexts can be maintained when researchers cannot be on site. In this commentary, we outline the rationale for participatory methods, in the form of VRE, in pharmacy research. We describe the underlying principles of this innovative methodology, and offer examples of how VRE can be used in pharmacy research. Finally, we offer a reflexive account of how we have adapted the method for use in community pharmacy research, to adapt to physical distancing, without sacrificing its methodological principles. This paper offers not only a new methodology to examine the complexity of pharmacy work, but demonstrates also the responsiveness of VRE itself to complexity, and the potential breadth of future research applications in pharmacy both during and beyond the current pandemic.

Considerations of Australian community pharmacists in the provision and implementation of cognitive pharmacy services: a qualitative study.

BACKGROUND: Australian federally-funded cognitive pharmacy services (CPS) (e.g. medication management and reconciliation services) have not been translated into practice consistently. These health services are purportedly accessible across all Australian community pharmacies, yet are not delivered as often as pharmacists would like. There are international indicators that pharmacists lack the complete behavioural control required to prioritise CPS, despite their desire to deliver them. This requires local investigation. OBJECTIVE: To explore Australian pharmacists' perspectives [1] as CPS providers on the micro level, and [2] on associated meso and macro level CPS implementation issues. METHODS: Registered Australian community pharmacists were recruited via professional organisations and snowball sampling. Data were collected via an online demographic survey and semi-structured interviews until data saturation was reached. Interview transcripts were de-identified then verified by participants. Content analysis was performed to identify provider perspectives on the micro level. Framework analysis using RE-AIM was used to explore meso and macro implementation issues. RESULTS: Twenty-three participants across Australia gave perspectives on CPS provision. At the micro level, pharmacists did not agree on a single definition of CPS. However, they reported complexity in interactional work and patient considerations, and individual pharmacist factors that affected them when deciding whether to provide CPS. There was an overall deficiency in pharmacy workplace resources reported to be available for implementation and innovation. Use of an implementation evaluation framework suggested CPS implementation is lacking sufficient structural support, whilst reach into target population, service consistency and maintenance for CPS were not specifically considered by pharmacists. CONCLUSIONS: This analysis of pharmacist CPS perspectives suggests slow uptake may be due to a lack of evidence-based, focused, multi-level implementation strategies that take ongoing pharmacist role transition into account. Sustained change may require external change management and implementation support, engagement of frontline clinicians in research, and the development of appropriate pharmacist practice models to support community pharmacists in their CPS roles. TRIAL REGISTRATION: This study was not a clinical intervention trial. It was approved by the University of Technology Sydney Human Research Ethics Committee (UTS HREC 19-3417) on the 26th of April 2019.

Surfactant addition in diesel oil degradation - how can it help the microbes?

PURPOSE: Despite wide research on bioremediation of hydrocarbon-contaminated soil, the mechanisms of surfactant-enhanced bioavailability of the contaminants are still unclear. The presented study was focused on the in-depth description of relationships between hydrocarbons, bacteria, and surfactants. In order to that, the biodegradation experiments and cell viability measurements were conducted, and the properties of cell surface were characterized. METHODS: MTT assay was employed to measure plant extracts toxicity to microbes. Then, membrane permeability changes were evaluated, followed by diesel oil biodegradation in the presence of surfactants measurements by GCxGC-TOFMS and PCR-RAPD analysis. RESULTS: Our study undoubtedly proves that different surfactants promote assimilation of different groups of hydrocarbons and modify cell surface properties in different ways. Increased biodegradation of diesel oil was observed when cultures with Acinetobacter calcoaceticus M1B were supplemented with Saponaria officinalis and Verbascum nigrum extracts. Interestingly, these surfactants exhibit different influences on cell surface properties and their viability in contrast to the other surfactants. Moreover, the preliminary analyses have shown changes in the genome caused by exposure to surfactants. CONCLUSIONS: The results indicated that the benefits of surfactant use may be related to deep modification at the omics level, not only that of cell surface properties and confirms the complexity of the interactions between bacterial cells, pollutants and surfactants.

Patient Feedback on a Warfarin Action Plan Used in a Local Australian Physician Practice Setting.

BACKGROUND: Warfarin is a high-risk medicine, and older persons (those aged 65 years and older)1,2 who take this therapy need medicines information about it that is at a level which is both understandable and comprehensive to improve their knowledge about the risks and benefits of warfarin therapy.3,4 Therefore, the primary objective of this study was to report patient feedback on a Warfarin Action Plan (WAP) (leaflet) and identify patients' preferences regarding its content and format. The secondary objective was to canvass in-depth feedback regarding the participants' information needs and current information-seeking practices with respect to warfarin therapy. METHOD: In an Australian General Practice medical centre setting, a qualitative study comprising 34 individual interviews was conducted. Emergent themes were elicited via a qualitative analysis using manual inductive coding. RESULTS: The majority of participants gave very positive feedback on the WAP leaflet, stating that it was a useful and concise resource. In canvasing this feedback, 4 themes emerged: (1) the need for information about warfarin therapy, (2) reliance on doctors and/or pharmacists for information, (3) the need for information to normalize their daily life, and (4) patients and carers acting on the new information. CONCLUSION: The WAP is a simple and well-received tool that meets the knowledge and education needs about warfarin therapy for older people and their carers.

Exploring the Economic Benefits of Modafinil for Post-Stroke Fatigue in Australia: A Cost-Effectiveness Evaluation.

BACKGROUND: In stroke survivors, post-stroke fatigue predicts dependency in daily living and failure to return to work. Modafinil shows promise as a pharmacotherapy to reduce post-stroke fatigue and related sequelae, e.g., poorer functional and clinical outcomes. AIMS: This study explored the cost-effectiveness of modafinil in treating post-stroke fatigue in the Australian context, by determining its incremental cost-effectiveness ratio (ICER) and by simulating the potential cost-savings on a national scale, through a re-analysis of MIDAS trial data. METHODS: A post hoc cost-effectiveness analysis was undertaken. Part A: patient-level cost and health effect data (Multidimensional Fatigue Inventory (MFI) scores) were derived from the MIDAS trial and analysis undertaken from a health-system perspective. Part B: a secondary analysis simulated the societal impact of modafinil therapy in terms of national productivity costs. RESULTS: Part A: Mean cost of modafinil treatment was AUD$3.60/day/patient for a minimally clinically important change (10 points) in total MFI fatigue score, i.e., AUD$0.36/day/unit change in fatigue score per patient. For the base case scenario, the ICER of using modafinil (versus placebo) was AUD$131.73 ($90.17 - 248.15, for minimum and maximum costs, respectively). Part B: The potential productivity cost-savings to society were calculated as nearly AUD$467 million over 1 year, and up to $383,471,991,248 over 10 years, from the widespread use of modafinil treatment in the Australian population of working-age stroke-survivors, representing a significant societal benefit. CONCLUSIONS: Modafinil is a highly cost-effective treatment for post-stroke fatigue, offering significant productivity gains and potential cost-savings to society from the widespread use of modafinil treatment in the Australian population of working-age stroke-survivors.

Evaluating the Understandability and Actionability of Web-Based Education Materials for Patients Taking Non-vitamin K Oral Anticoagulants.

BACKGROUND: More patients are now taking high-risk medicines such as non-vitamin K oral anticoagulants (NOACs). Hence, patient education materials need to be in an understandable format so that they can be empowered to act on their knowledge. Factors such as health literacy and the design of the medicine information material may influence the patient's ability to understand and act on key information. METHOD: The PRISMA checklist was used to inform the study design. A structured search was conducted to obtain all freely accessible online educational resources designed for patients about the non-vitamin K antagonists (NOACs) during August 2018. Three search engines were used: Google, Yahoo! and Bing, using the search terms "NOAC" and "anticoagulant" combined with "patient/consumer information and patient/consumer resources."We applied the Patient Education Materials Assessment Tool (PEMAT) to evaluate web-based patient education materials in terms of understandability and actionability for patients taking NOACs. RESULTS: Of the 35 materials included, the majority of the materials (n = 32, 91%) were rated as highly understandable (PEMAT score ≥70%), and more than three-quarters of all the materials (n = 29, 83%) were rated as poorly actionable (PEMAT score <70%). For understandability, the majority of materials neither provided a summary of the key points nor used visual aids for several items such as simple tables, illustrations, and photographs. For actionability, few materials provided a tangible tool, such as a checklist, to prompt the user into action (n = 4). Few used visual aids such as nonverbal cues to the written instructions (n = 4). CONCLUSION: To improve the understandability and actionability of most of the NOAC patient education materials, there is a need to include more summaries of information, visual aids, and tangible tools such as checklists. Further research is warranted where patients are involved in providing feedback on the design of medicine information materials for NOACs.

Agreement between units of measure for paediatric antibiotic utilisation surveillance using hospital pharmacy supply data.

BACKGROUND: Drug utilisation studies from paediatric hospitals that do not have access to patient level data on medication use are limited by a lack of standardised units of measures that reflect the varying daily dosage requirements among patients. The World Health Organization's defined daily dose is frequently used in adult hospitals for benchmarking and longitudinal analysis but is not endorsed for use in paediatric populations. OBJECTIVE: Explore agreement between standard adult-based defined daily doses (DDD) and paediatric estimates of daily injectable antibiotic use in a Paediatric Intensive Care Unit that does not have access to individual patient-level data. METHODS: Hospital pharmacy antibiotic use reports and age-specific occupied bed-day data from 1 January 2010 to 31 May 2016 were extracted. Paediatric reference dosages and frequencies for antibiotics were defined and applied to three paediatric units of measure. Measures were applied to extracted data, agreement between antibiotic use measured in the adult DDD and each of the paediatric measures was assessed visually via Bland-Altman plots and linear regression for each antibiotic. RESULTS: Thirty one different antibiotics were used throughout the study period. Despite varying daily dosages in grams, the daily use of vials was unchanged from birth to 18 years for thirteen antibiotics. Agreement between DDD and vial-based measures was closer than the total recommended daily dose that did not account for wastage during preparation and administration. Vial-based measures were unaffected by vial size changes due to drug shortage. CONCLUSIONS: Agreement between the DDD and vial-based measures of use supports the use of DDD for select antibiotics that may be targeted by antimicrobial stewardship programs. Vial based measures should be further explored in hospitals with single vial policies; detailed understanding of hospital practice is needed before inter-hospital comparisons are made.

Pharmaceutical Care in NICUs in Australia and Poland: Attitudes and Perspectives of Doctors and Nurses.

A multidisciplinary and collaborative team network is essential in ensuring positive health outcomes for critically ill neonatal patients. The objective of this study was to investigate the perceptions of neonatal intensive care unit (NICU) doctors and nurses in Australia and Poland toward pharmaceutical care services in the NICU. A cross-sectional, anonymous, electronic-based survey was distributed between January and April 2017 among a sample of NICU doctors, nurses, and midwives. A total of 77 participants from Australia and 93 from Poland completed the survey. Overall, from the perspectives of medical and nursing staff, it is apparent that clinical pharmacy practice on the NICU is more established in Australia than in Poland. Only 8.6% of Polish participants reported that a pharmacist worked directly on the NICU in comparison with 87% of Australian participants (P < .001). The main roles performed by pharmacists in Polish NICUs related to the provision of medicines, whereas Australian pharmacists were highly involved in all aspects of pharmacotherapy, particularly in the clinical and education domains. Future efforts should focus on how practice is structured in each country and what support can be implemented from educational, cultural, and legislative levels to enable better pharmacist integration into the NICU therapeutic team.

Barriers to a full scope of pharmacy practice in primary care: A systematic review of pharmacists' access to laboratory testing.

OBJECTIVES: To describe primary care pharmacists' current scope of practice in relation to laboratory testing. METHOD: A 2-tiered search of key databases (PubMed, EMBASE, MEDLINE) and grey literature with the following MeSH headings: prescribing, pharmacist/pharmacy, laboratory test, collaborative practice, protocols/guidelines. We focused on Canada, the United States, the United Kingdom, New Zealand and Australia for this review. RESULTS: There is limited literature exploring primary care pharmacists' scope of practice in relation to laboratory testing. The majority of literature is from the United States and Canada, with some from the United Kingdom and New Zealand and none from Australia. Overall, there is a difference in regulations between and within these countries, with the key difference being whether pharmacists access and/or order laboratory testing dependently or independently. Canadian pharmacists can access and/or order laboratory tests independently or dependently, depending on the province they practise in. US pharmacists can access and/or order laboratory tests dependently within collaborative practice agreements. In the United Kingdom, laboratory testing can be performed by independent prescribing pharmacists or dependently by supplementary prescribing pharmacists. New Zealand prescribing pharmacists can order laboratory testing independently. Most publications do not report on the types of laboratory tests used by pharmacists, but those that do predominantly resulted in positive patient outcomes. DISCUSSION/CONCLUSION: Primary care pharmacists' scope of practice in laboratory testing is presently limited to certain jurisdictions and is often performed in a dependent fashion. As such, a full scope of pharmacy services is almost entirely unavailable to patients in the United States, the United Kingdom, New Zealand and Australia. Just as in the case for pharmacists prescribing, evidence indicates better patient outcomes when pharmacists can access/order laboratory tests, but more research needs to be done alongside the implementation of local guidelines and practice standards for pharmacists who practise in that realm. Patients around the world deserve to receive a full scope of pharmacists' practice, and lack of access to laboratory testing is one of the major obstacles to this. Can Pharm J (Ott) 2019;152:xx-xx.

Patient Feedback on a Warfarin Action Plan Used in a Local Australian Physician Practice Setting.

BACKGROUND: Warfarin is a high-risk medicine, and older persons (those aged 65 years and older)1,2 who take this therapy need medicines information about it that is at a level which is both understandable and comprehensive to improve their knowledge about the risks and benefits of warfarin therapy.3,4 Therefore, the primary objective of this study was to report patient feedback on a Warfarin Action Plan (WAP) (leaflet) and identify patients' preferences regarding its content and format. The secondary objective was to canvass in-depth feedback regarding the participants' information needs and current information-seeking practices with respect to warfarin therapy. METHOD: In an Australian General Practice medical centre setting, a qualitative study comprising 34 individual interviews was conducted. Emergent themes were elicited via a qualitative analysis using manual inductive coding. RESULTS: The majority of participants gave very positive feedback on the WAP leaflet, stating that it was a useful and concise resource. In canvasing this feedback, 4 themes emerged: (1) the need for information about warfarin therapy, (2) reliance on doctors and/or pharmacists for information, (3) the need for information to normalize their daily life, and (4) patients and carers acting on the new information. CONCLUSION: The WAP is a simple and well-received tool that meets the knowledge and education needs about warfarin therapy for older people and their carers.

Patient-focused interventions to support vulnerable people using oral anticoagulants: a narrative review.

The aim of this review was to identify patient-focused interventions that have been trialed to support vulnerable patient populations taking oral anticoagulants (warfarin and the direct-acting oral anticoagulants (DOACs)) such as older persons (65 years and over), those with limited health literacy, and those from culturally and linguistically diverse (CALD) backgrounds. This review also aimed to report on the effects of these interventions on outcomes relevant to the use of anticoagulant therapy. Original articles published between 1 January 1995 and 30 June 2017 were identified using several electronic databases such as Medline, Ovid, Embase, Scopus, Cochrane, and Google Scholar. The following terms were used for the three-tiered search: Tier 1, elderly, aged, older adult, geriatrics; Tier 2, health literacy, literacy, low health literacy, low English proficiency, patient literacy; and Tier 3, ethnicity, ethnic, ethnic groups, CALD, culturally and linguistically diverse, NESB, non-English speaking background, race, racial groups, religion, religious groups, and minority groups. The terms for each tier were combined with the following terms: anticoagulants, anticoagulation, warfarin, apixaban, dabigatran, rivaroxaban, DOACS, new oral anticoagulants, novel oral anticoagulants, patient care, patient knowledge, comprehension, patient education, patient participation, and communication. A total of 41 studies were identified. Most of the interventions identified included older persons taking warfarin who were monitored using the international normalized ratio (INR) and who received patient education. Many interventions reported a significant positive impact on patients' knowledge, reduction in the number of adverse events caused by hemorrhage, and better INR control. More research on patient-focused interventions is needed that includes patients with limited health literacy, those from CALD backgrounds, and family members and caregivers of patients taking oral anticoagulants.