Evaluation of calling criteria for the rapid response system utilising single versus multiple physiological parameter disturbances.

BACKGROUND: The Adult Deterioration Detection System for Medical Emergency Team (MET) activation is widely used and includes single parameter (SP-MET) and multiple parameter (MP-MET) disturbances. Whether the patient characteristics, interventions and outcomes differ for SP-MET compared with MP-MET is uncertain. AIMS: To describe MET interventions and outcomes of SP versus MP MET in the Acute Medical Unit (AMU) of a tertiary care hospital. METHODS: Retrospective audit over 6 months comparing SP-MET and MP-MET groups. RESULTS: SP-MET constituted 64.1% (168) of 262 AMU MET calls, most commonly for hypotension (35.5%) and tachycardia (14.1%). There were no significant differences in demographic and disease characteristics between the two groups. Common interventions included fluid/electrolyte replacement in 139 (52%), oxygen therapy in 46 (17%) and non-invasive ventilation in 33 (13%) patients. After MET intervention, 82.4% patients stayed on the ward, 8.4% died/were palliated, 6.5% were transferred to the Intensive Care Unit (ICU) and 2.7% patients required urgent transfer to the theatre for intervention. SP-MET patients were more likely to remain on the ward (88.7% vs 71.3%; P = 0.001), receive ward-based interventions (85.1% vs 61.7%; P < 0.001) and less likely to experience death/palliation (4.2% vs 16%, P = 0.001) compared with the MP-MET group. MP-MET were independently associated with negative outcomes (OR 3.10; 95% CI 1.60-6.00). CONCLUSION: SP-MET identify a cohort of patients at lower risk of requiring escalation of care and ICU admission. Given the resource intensity of MET activation, further research is warranted to determine whether alternative response strategies are appropriate for selected SP disturbances.

The Tasmanian Atrial Fibrillation Study (TAFS): Differences in Stroke Prevention According to Sex.

Background: There are limited Australian data on sex differences in oral anticoagulant (OAC) prescribing in atrial fibrillation (AF) and ongoing debate regarding the optimal approach to stroke risk assessment and OAC prescribing in female patients with AF. Objective: The purpose of this study was to investigate sex differences in the prescribing of OACs in patients with AF stratified by stroke risk and in the rate of adverse outcomes. Methods: A retrospective analysis of patients admitted to the Royal Hobart Hospital (Tasmania, Australia) with nonvalvular AF between January 2011 and July 2015 was conducted. Rates of antithrombotic prescribing according to sex and stroke risk were assessed along with a multivariate analysis for predictors of OAC prescribing. Rates of thromboembolism, bleeding, and all-cause mortality were assessed according to sex. Results: A total of 2090 patients were included (44.7% female). Women with a CHA2DS2-VA score ≥2 were less likely to receive an OAC compared with men (56.7% vs 62.2%, P = 0.023). Female sex was an independent negative predictor of OAC prescribing (adjusted odds ratio = 0.83; 95% CI = 0.69-0.99; P = 0.041). There were no sex differences in the incidence rates of thromboembolism, bleeding, or all-cause mortality in patients newly commenced on antithrombotic therapy. Conclusion and Relevance: Female patients with a high stroke risk were less likely to receive guideline-recommended treatment. This study provides new information on prescribing trends within the Australian setting and highlights the opportunity to improve the management of female patients with AF and 1 or more additional stroke risk factors.

Prospective identification versus administrative coding of adverse drug reaction-related hospitalizations in the elderly: A comparative analysis.

PURPOSE: To compare prospective identification of adverse drug reaction (ADR)-related hospital admissions in the elderly with administrative coding using the International Classification of Diseases 10th Revision Australian Modification (ICD-10-AM) coding system. METHODS: We linked the records of 768 enrolled patients from an earlier study, where clinical pharmacists identified ADRs using prospective data collection, to hospital administrative data. We identified patients in the study whose admissions were coded as ADRs using ICD-10-AM codes. We then compared the prevalence and characteristics of ADR-related hospital admissions identified by the two approaches. RESULTS: According to ICD-10-AM coding, 2.7% of patients were admitted due to ADRs, while 15.0% of patients were deemed to have been admitted due to ADRs based on prospective identification by clinical pharmacists. Most (85.7%) patients coded as having an ADR-related hospital admission were also identified as such prospectively. Hematological (23.1%) and metabolic reactions (23.1%) were frequent causes of ADRs identified by coding, whereas cardiovascular ADRs (27.8%) were more common causes of ADRs identified prospectively by pharmacists. Antidepressants (16.7%) and cardiac glycosides (16.7%) were the most commonly implicated drug groups in ADRs identified by coding, whereas diuretics (28.8%) and renin-angiotensin system inhibitors (17.0%) were frequently implicated as causes of ADRs identified prospectively by pharmacists. CONCLUSIONS: Reliance on administrative coding potentially underestimates the extent of the problem of ADRs as a cause of hospitalization in the elderly, and more detailed prospective analysis of admissions provides additional targets for strategies to prevent ADRs. The types of ADRs identified also differ between the two approaches.

Anticoagulation knowledge in patients with atrial fibrillation: An Australian survey.

BACKGROUND: Atrial fibrillation (AF) is the most commonly diagnosed arrhythmia in clinical practice, and is associated with a significant medical and economic burden. Anticoagulants reduce the risk of stroke and systemic embolism by approximately two-thirds compared with no therapy. Knowledge regarding anticoagulant therapy can influence treatment outcomes in patients with AF. OBJECTIVE: To measure the level of anticoagulation knowledge in patients with AF taking oral anticoagulants (OACs), investigate the association between patient-related factors and anticoagulation knowledge, and compare these results in patients taking warfarin and direct-acting oral anticoagulant (DOACs). METHODS: Participants were recruited for an online survey via Facebook. Survey components included the Anticoagulation Knowledge Tool, the Perception of Anticoagulant Treatment Questionnaires (assessing treatment expectations, convenience and satisfaction), a modified Cancer Information Overload scale and the Morisky Medication Adherence Scale. Treatment groups were compared and predictors of OAC knowledge were identified. RESULTS: Participants taking warfarin had a higher knowledge score compared with those taking DOACs (n = 386, 73% ± 13% vs 66% ± 14%, P<.001). Advancing age, type of OAC, health information overload and ease of OAC use (treatment expectation) were significant predictors of knowledge. Treatment expectation, including the belief that OAC treatment would cause bleeding side effects, varied significantly between participants taking warfarin and DOACs (P = .011). CONCLUSION: The study identified knowledge gaps in patients taking OACs, and these deficiencies appeared to be greater in participants taking DOACs. Knowledge assessment should be integrated into patient counselling sessions to help identify and resolve knowledge deficits.

Bleeding-related admissions in patients with atrial fibrillation receiving antithrombotic therapy: results from the Tasmanian Atrial Fibrillation (TAF) study.

PURPOSE: Limited data are available from the Australian setting regarding bleeding in patients with atrial fibrillation (AF) receiving antithrombotic therapy. We aimed to investigate the incidence of hospital admissions due to bleeding and factors associated with bleeding in patients with AF who received antithrombotic therapy. METHODS: A retrospective cohort study was conducted involving all patients with AF admitted to the Royal Hobart Hospital, Tasmania, Australia, between January 2011 and July 2015. Bleeding rates were calculated per 100 patient-years (PY) of follow-up, and multivariable modelling was used to identify predictors of bleeding. RESULTS: Of 2202 patients receiving antithrombotic therapy, 113 presented to the hospital with a major or minor bleeding event. These patients were older, had higher stroke and bleeding risk scores and were more often treated with warfarin and multiple antithrombotic therapies than patients who did not experience bleeding. The combined incidence of major and minor bleeding was significantly higher in warfarin- versus direct-acting oral anticoagulants (DOAC)- and antiplatelet-treated patients (4.1 vs 3.0 vs 1.2 per 100 PY, respectively; p = 0.002). Similarly, the rate of major bleeding was higher in patients who received warfarin than in the DOAC and antiplatelet cohorts (2.4 vs 0.4 vs 0.6 per 100 PY, respectively; p = 0.001). In multivariate analysis, increasing age, prior bleeding, warfarin and multiple antithrombotic therapies were independently associated with bleeding. CONCLUSION: The overall rate of bleeding in this cohort was low relative to similar observational studies. The rate of major bleeding was higher in patients prescribed warfarin compared to DOACs, with a similar rate of major bleeding for DOACs and antiplatelet agents. Our findings suggest potential to strategies to reduce bleeding include using DOACs in preference to warfarin, and avoiding multiple antithrombotic therapies in patients with AF.

Antiretroviral adherence and treatment outcomes among adult Ethiopian patients.

Developing appropriate strategies to sustain optimal medication adherence among the increasing number of HIV-positive patients taking antiretroviral therapy (ART) in sub-Saharan Africa is a major challenge. The objective of this study was to determine patient, regimen, disease, patient-provider, and healthcare-related factors associated with adherence with ART over a one-year period, and assess the impact of adherence on treatment outcomes. We performed a prospective, observational study among 246 patients who were initiated on ART in Ethiopia. Of 172 who completed follow-up, 130 (75.6%) had ≥95% adherence. In the multivariate analyses, a higher baseline BMI (OR, 1.2; 95% CI 1.0, 1.4) and use of reminder devices (OR, 9.1; 95% CI 2.0, 41.6) remained positively associated with adherence, while a higher HIV symptom and adverse drug reaction distress score was an independent negative predictor of adherence (OR, 0.90; 95% CI 0.9, 1.0) CD4 count increase was significantly higher in the adherent patients compared to non-adherent patients at 12 months (159 cells/µL [interquartile range (IQR), 72-324 cells/µL] vs. 132 cells/µL [IQR, 43-190 cells/µL]; p = 0.026). Our findings indicate that interventions aimed at improving adherence and thereby treatment outcomes in patients initiated on ART should promote the use of reminder devices, and monitor HIV symptoms and adverse reaction distress and nutritional status.

Potential use of NOACs in developing countries: pros and cons.

PURPOSE: Although vitamin K antagonists (VKAs) are effective for long-term thromboprophylaxis in atrial fibrillation (AF), their limitations have led to widespread underutilisation, especially in the developing world. Novel oral anticoagulants (NOACs) have emerged as promising alternatives to VKAs, although there are some particular considerations and challenges to their introduction in developing countries. This review summarises the current state of antithrombotic management of AF in the developing world, explores the early evidence for the NOACs and describes some of the special considerations that must be taken into account when considering the role of the NOACs within developing countries' health care systems. METHODS: A literature search was conducted via PubMed and Google Scholar to find articles published in English between the years 2000 to 2014. Search terms used were "atrial fibrillation", "oral anticoagulants", "warfarin", "NOACs", "dabigatran", "rivaroxaban", "apixaban", "edoxaban", "time in therapeutic range", "International Normalized Ratio" "cost-effectiveness", "stroke", "adverse-drug reactions" and "drug-drug interactions", together with the individual names of developing countries as listed by the World Bank. We reviewed the results of randomized clinical trials, relevant retrospective and prospective studies, case-studies and review articles. RESULTS: Many developing countries lack or have sporadic data on the quality of AF management, making it difficult to anticipate the potential impact of NOACs in these settings. The utilisation of anticoagulants for AF appears highly variable in developing countries. Given the issues associated with VKA therapy in many developing countries, NOACs offer some potential advantages; however, there is insufficient evidence to advocate the widespread replacement of warfarin at present. VKAs may continue to have a role in selected patients or countries, especially if alternative monitoring strategies can be utilised. CONCLUSION: The evaluation of the introduction of NOACs should consider safety, budget concerns and the quality of oral anticoagulation care achieved by each country. Prospective registries will be important in developing countries to better elucidate the comparative safety, efficacy and cost-effectiveness of NOACs and VKAs as NOACs are introduced into practice.

Developing community pharmacists' role in the management of type 2 diabetes and related microvascular complications: a nationwide survey in Australia.

Background: Community pharmacists have regular interactions with people living with type 2 diabetes to supply medications, and have a potential role in supporting other primary care professionals in the screening, management, monitoring and facilitation of timely referral of microvascular complications. This study aimed to investigate the contemporary and future roles of community pharmacists in diabetes-related microvascular complication management. Methods: This study involved an online Australian nation-wide survey of pharmacists administered via Qualtrics® and distributed through social media platforms, state and national pharmacy organisations, and via major banner groups. Descriptive analyses were undertaken using SPSS. Results: Among 77 valid responses, 72% of pharmacists already provided blood pressure and blood glucose monitoring services for the management of type 2 diabetes. Only 14% reported providing specific microvascular complication services. Over 80% identified a need for a comprehensive microvascular complication monitoring and referral service, and agreed it is feasible and within the scope of practice of a pharmacist. Almost all respondents agreed that they would implement and provide a monitoring and referral service if provided with appropriate training and resources. Potential barriers to service implementation were competing demands and lack of remuneration and awareness among consumers and health professionals. Conclusions: Type 2 diabetes services in Australian community pharmacies do not currently focus on microvascular complication management. There appears to be strong support for implementing a novel screening, monitoring and referral service via community pharmacy to facilitate timely access to care. Successful implementation would require additional pharmacist training, and identification of efficient pathways for service integration and remuneration.

Patients' Perspectives on Commencing Oral Anticoagulants in Atrial Fibrillation: An Exploratory Qualitative Descriptive Study.

BACKGROUND: Oral anticoagulants (OACs) are prescribed to patients with atrial fibrillation (AF) in order to lower stroke risk. However, patient refusal to commence OACs hinders effective anticoagulation. This study aimed to explore barriers and facilitators to patient agreement to commence OACs from the perspectives of patients with AF attending Australian general practices. METHODS: A qualitative descriptive study utilising semi-structured individual interviews was conducted from March to July 2022. RESULTS: Ten patients (60% male, median age = 78.5 years) completed interviews. Patients' passive roles in decision-making were identified as a facilitator. Other prominent facilitators included doctors explaining adequately and aligning their recommendations with patients' overall health goals, including the prevention of stroke and associated disabilities, and a clear understanding of the pros and cons of taking OACs. Reportedly insufficient explanation from doctors and the inconvenience associated with taking warfarin were identified as potential barriers. CONCLUSION: Addressing factors that influence patient agreement to commence OACs should be an essential aspect of quality improvement interventions. Subsequent studies should also delve into the perspectives of eligible patients with AF who choose not to commence OACs as well as the perspectives of both patients and doctors regarding the decision to continue OAC treatment.

Efficacy and safety of sodium glucose cotransporter 2 inhibitors plus standard care in diabetic kidney disease: A systematic review and meta-analysis.

INTRODUCTION: Many people with type 2 diabetes progress to end-stage diabetic kidney disease (DKD) despite blockade of the renin-angiotensin system, suggesting the need for innovative treatment options for DKD. To capture the findings of recent studies, we performed an updated systematic review and meta-analysis of the efficacy and safety of sodium glucose co-transporter 2 (SGLT2) inhibitors combined with standard care involving angiotensin converting enzyme (ACE) inhibitors and/or angiotensin receptor blockers (ARBs) on the development and progression of DKD in people with type 2 diabetes compared with standard care alone. METHODS: The Cochrane Library, MEDLINE, EMBASE, PubMed and clinical trials registers were systematically searched for randomized controlled trials published before 1 September 2022. Primary outcomes were urine albumin-creatinine ratio (UACR) and estimated glomerular filtration rate (eGFR). Secondary outcomes were glycated hemoglobin (HbA1c) and systolic blood pressure (SBP). Relative risk was calculated for adverse events. RESULTS: Eight studies enrolling 5512 participants were included. In the meta-analysis (n = 1327), SGLT2 inhibitors were associated with a statistically significant reduction in UACR (weighted mean difference [WMD] -105.61 mg/g, 95 % CI -197.25 to -13.98, I2 = 99 %, p = 0.02). There was no statistically significant difference in relation to eGFR (n = 1375; WMD -0.23 mL/min/1.73m2, 95 % CI -4.34 to 3.89, I2 = 94 %, p = 0.91). CONCLUSIONS: SGLT2 inhibitors in addition to standard care including ACE inhibitors and/or ARBs significantly reduced albuminuria, HbA1c and SBP when compared to standard care alone, supporting their routine use in people with type 2 diabetes.

The role of the clinical pharmacist in mental health hospital-in-the-home: A scoping review.

BACKGROUND: The concept of integrating a clinical pharmacist (CP) within a Hospital-in-the-Home (HiTH) program is relatively new. Little is known about the role of a pharmacist in HiTH programs focused on mental health (MH). OBJECTIVES: To describe the role of a CP within an MH-HiTH program, focusing on the specific tasks performed by a pharmacist in this position, their benefits and limitations. METHODS: MEDLINE, CINAHL, EMBASE, Cochrane Database of Systematic Reviews, PsycINFO, Web of Science and the grey literature were searched without any date limits for references in English that included 2 or more of the following key terms (or their synonyms): "HiTH", "clinical pharmacist" and "mental health". Two reviewers independently screened and analysed the data. RESULTS: Of 60,482 screened references, 6 included all 3 key terms: 2 were HiTH guideline documents, 2 were conference abstracts and 2 were journal articles. These papers discussed MH-HiTH programs or similar home-care services where a CP was incorporated in the treating team to address medication management and adherence during a home visit. There is evidence that MH-HiTH CPs identify and resolve medication-related problems (MRPs), as well as improve medication adherence, patient care, hospital admission rates and emergency department presentations. An additional 54 references including 2 key terms provided corroborating evidence of an MH-HiTH CP role focused on improving patient care via 4 key groups of tasks: clinical pharmacy, mental healthcare, home medicines review and facilitation of care transition through medication reconciliation and follow-up. CONCLUSIONS: Although there is currently a paucity of literature describing the incorporation of a CP in an MH-HiTH program, preliminary evidence shows it can improve medication management. This has potential to improve patient outcomes as has been seen in similar home-based settings, but limitations such as time constraints are notable barriers. More robust studies are needed to evaluate these outcomes.

Impact of a clinical pharmacist on medication safety in mental health Hospital-in-the-Home: a retrospective analysis.

BACKGROUND: Integration of clinical pharmacists into multidisciplinary Mental Health Hospital-in-the-Home teams is increasing but little is known about the medication safety contribution these pharmacists make. AIM: To evaluate whether clinical pharmacist involvement in a Mental Health Hospital-in-the-Home service improved medication safety key performance indicators. METHOD: Medical records were retrospectively reviewed of all patients admitted to 2 Western Australian Mental Health Hospital-in-the-Home services from September to November 2015. SITE 1: was a 16-bed service incorporating a clinical pharmacist as part of its multidisciplinary team. SITE 2: was a similarly structured 18-bed service but without clinical pharmacist involvement. The primary outcome measure was completion of medication safety key performance indicators obtained from the Western Australian Government Pharmaceutical Review Policy and mental health-specific best practice guidelines. RESULTS: Key performance indicators from Site 1 (n = 75 records), which incorporated a clinical pharmacist, demonstrated significantly (p < 0.001) higher rates of completion of medication reconciliation [65 (87%) versus 17 (29%)], accurate adverse drug reaction list [73 (97%) versus 34 (58%)], accurate discharge medication list [51 (74%) versus 18 (45%)], accurate medication profile [74 (99%) versus 40 (68%)] and medication chart review [74 (99%) versus 0 (0%)] than Site 2 (n = 59). CONCLUSION: Integrating a clinical pharmacist into a Mental Health Hospital-in-the-Home program significantly improved achievement of medication safety key performance indicators.

Establishment and evolution of a clinical pharmacy mental health hospital-in-the-home service: An autoethnography.

BACKGROUND: Hospital-in-the-Home (HiTH) services provide "inpatient-style" care for patients at home. While relatively well known in non-psychiatric settings, little is known about mental health (MH)-HiTH services, with even less known about the role of a clinical pharmacist (CP) within a MH-HiTH multidisciplinary team (MDT). OBJECTIVE: The aim of this paper is to describe the evolution of the first MH-HiTH MDT in Western Australia and the various facets of the CP's role integrated within the service. METHOD: The integration of a CP into a non-traditional practice setting represents a cultural change in the pharmacy profession. Hence, this paper utilised a descriptive-realistic style of the autoethnographic method, with the narrative written in the first-person point of view of the first author (M.F.). It specifically focused on the tasks performed by the team's CP. A narrative analysis approach was used to reflect on the reason these tasks are performed, the potential benefits and limitations of integrating a CP into the team and subsequent cultural influence on the pharmacy profession. FINDINGS: The service commenced in 2014, consisting of an MDT of a consultant psychiatrist, a psychiatric registrar, clinical nurses, an occupational therapist, a social worker and a CP. Starting with 4 then 8 "virtual beds", it was gradually increased to 16 virtual beds. The MH-HiTH CP combined hospital clinical tasks - e.g. medication reconciliation and therapeutic drug monitoring - with home medication reviews as part of the MH-HiTH MDT. Lessons learnt include proactively integrating and flexibly adapting into a novel practice setting. CONCLUSION: There is scope to embed a CP within an MH-HiTH MDT; the major advantage is the inclusion of a comprehensive medication management service. While this is a promising new area where the pharmacy profession is becoming engaged, more studies are needed to quantify and confirm the stated benefits of such service.

A qualitative exploration of factors contributing to non-guideline adherent antipsychotic polypharmacy.

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

Pharmacists' perceptions on real-time prescription monitoring (RTPM) systems - a cross-sectional survey.

Background: Real-time prescription monitoring (RTPM) systems are an effective tool to help health practitioners monitor opioid use and reduce opioid-related harm but little has been reported about the support required by pharmacists to engage with them effectively in practice. Objective: To evaluate the current understanding and perceptions of Western Australian pharmacists regarding RTPM systems and opioid-related harm, and investigate their self-reported training and support requirements prior to RTPM system implementation. Methods: This cross-sectional, prospective study involved an online Qualtrics survey distributed to Western Australian community or hospital pharmacists involved in dispensing and patient-centred roles via local professional pharmacy newsletters and social media. Data collection included demographic information, responses to authentic case scenarios and Likert-scale questions regarding perceptions and training requirements of a RTPM system, pain management and opioid-related harm. Descriptive analysis was utilised. Result: Sixty-two pharmacists responded to the questionnaire. Most (58/61; 95.1%) had a positive attitude towards RTPM systems, but only 33/61 (54.1%) reported being prepared for its implementation. Perceived barriers to successful implementation included lack of remuneration (46/60; 76.6%), conflict with prescribers (40/60; 66.7%), increased workload (37/60; 61.7%), staff safety concerns (34/60; 56.7%) and lack of knowledge regarding RTPM systems (32/60; 53.3%). Even though most participants were satisfied with training previously received, over 90% reported requiring further training and education, especially regarding RTPM systems (51/57; 96.2%) and opioid-related harm (56/57; 98.2%). Conclusion: Among a small sample of participants, there was a strong positivity regarding the value of RTPM systems and a high degree of receptiveness to further training in preparation for RTPM implementation.

Use of thromboprophylaxis guidelines and risk stratification tools in atrial fibrillation: A survey of general practitioners in Australia.

RATIONALE AND OBJECTIVES: Clinical guidelines produced by cardiology societies (henceforth referred to simply as 'clinical guidelines') recommend thromboprophylaxis with oral anticoagulants (OACs) in patients with atrial fibrillation (AF) who have moderate-to-high stroke risk. However, deviations from these recommendations are observed, especially in the primary healthcare setting. The primary aims of this study were to evaluate the self-reported use of AF clinical guidelines and risk stratification tools among Australian general practitioners (GPs), and their perceptions regarding the available resources. METHOD: We conducted an online survey of Australian GPs. Descriptive statistics were used to summarise the findings. RESULTS: Responses from 115 GPs were included for analysis. Respondents reported various ways of accessing thromboprophylaxis-related information (n = 113), including clinical guidelines (13.3%), 'Therapeutic Guidelines© ' (37.2%) and Royal Australian College of General Practitioners websites (16.8%). Of those who reported reasons against accessing information from clinical guidelines (n = 97), the most frequent issues were: too many AF guidelines to choose from (34.0%; 33/97), different guidelines for different diseases (32.0%; 31/97), time-consuming to read guidelines (21.6%; 21/97), disagreements between different guideline recommendations (20.0%; 19/97), conflict with criteria for government subsidy (17.5%; 17/97) and GPs' busy schedules (15.5%; 15/97). When assessing patients' risk of stroke (n = 112) and bleeding (n = 111), the majority of the respondents reported primarily relying on a formal stroke risk (67.0%) and bleeding risk (55.0%) assessment tools, respectively. Respondents reported using formal stroke and bleeding risk assessment tools mainly when newly initiating patients on therapy (72.4%; 76/105 and 65.3%; 65/101, respectively). CONCLUSION: Among our small sample of Australian GPs, most did not access thromboprophylaxis-related information directly from AF-specific clinical guidelines developed by cardiology societies. Although the majority reported using formal stroke and bleeding assessment tools, these were typically used on OAC initiation only. More focus is needed on formal risk reassessment as clinically indicated and at regular review.

Implementation factor mapping of a pilot study of point-of-care C-reactive protein testing for respiratory tract infections in community pharmacy.

Background: Explicit consideration of implementation factors in community pharmacy service development may facilitate widespread implementation and sustainability. Objectives: This study involved mapping the methodology for the pilot study of point-of-care C-reactive protein (CRP) testing to support pharmacists' management of respiratory tract infections in Western Australian pharmacies against an implementation factor framework, focussing on the resources and training program provided to participating pharmacy staff. Methods: Phase 1 involved post hoc mapping of the pilot study methodology against the framework previously described by Garcia-Cardenas et al.; phase 2 was an a priori evaluation of the resources and training program, involving pre-training, post-training, and post-pilot questionnaires administered to pharmacists and pharmacy assistants/interns. A mixed model analysis compared pharmacists' responses at the three time points. Results: Employment of comprehensive strategies to optimise service feasibility and sustainability was demonstrated across the five domains of 'professional service', 'pharmacy staff', 'pharmacy', 'local environment' and 'system'; further consideration of 'consumer' or 'patient' factors is needed to address issues such as patient refusal. Study pharmacists (n = 10) and pharmacy assistants/interns (n = 5) reported high levels of satisfaction with the training (100% 'good'/'excellent'). Pharmacists reported significantly improved attitudes towards, confidence in, and knowledge about CRP testing and service provision from pre- to post-training (p < 0.05). Positive perceptions were maintained at the post-pilot time point. Conclusions: Post hoc mapping of implementation factors highlighted potential strengths and deficiencies of the current service model. Systematic, prospective mapping, coupled with strategies to explicitly emphasise the patient perspective, may have value in optimising service implementation or modifying future service delivery models.

Point-of-care C-reactive protein testing service for respiratory tract infections in community pharmacy: a qualitative study of service uptake and experience of pharmacists.

Background Targeted interventions in community pharmacies, such as point-of-care C-reactive protein testing, could reduce inappropriate antimicrobial consumption in patients presenting with symptoms of respiratory tract infections, although data regarding Australian pharmacists' perspectives on its provision are limited. Aim To explore pharmacists' experiences and perspectives of point-of-care C-reactive protein testing, including barriers and facilitators, influencing service provision and uptake. Method A point-of-care C-reactive protein testing service for patients presenting with respiratory tract infection symptoms was trialled in five purposively selected community pharmacies in metropolitan Western Australia. Two pharmacists from each pharmacy participated in one-to-one semi-structured telephone interviews, regarding pharmacist demographics, pharmacy characteristics, experience with the point-of-care C-reactive protein service and training/resources. Interviews were audio-recorded and transcribed. Data were imported into NVivo for thematic analysis. Results Interview durations ranged from 28.2 to 60.2 min (mean: 50.7 ± 10.2 min). Of the five themes which emerged, participants reported the point-of-care C-reactive protein testing was simple, fast, reliable and accurate, assisted their clinical decision-making and contributed to antimicrobial stewardship. A major factor facilitating service provision and uptake by consumers was the accessibility and credibility of pharmacists. Barriers included time constraints and heavy documentation. Participants believed there was a public demand for the service. Conclusion Given the global antimicrobial resistance crisis, pharmacists have an important role in minimising the inappropriate use of antimicrobials. The point-of-care C-reactive protein service was readily accepted by the public when offered. However, ensuring efficient service delivery and adequate remuneration are essential for its successful implementation.

Non-adherence to Thromboprophylaxis Guidelines in Atrial Fibrillation: A Narrative Review of the Extent of and Factors in Guideline Non-adherence.

Atrial fibrillation is the most common arrhythmia. It increases the risk of thromboembolism by up to fivefold. Guidelines provide evidence-based recommendations to effectively mitigate thromboembolic events using oral anticoagulants while minimizing the risk of bleeding. This review focuses on non-adherence to contemporary guidelines and the factors associated with guideline non-adherence. The extent of guideline non-adherence differs according to geographic region, healthcare setting, and risk stratification tools used. Guideline adherence has gradually improved over recent years, but a significant proportion of patients are still not receiving guideline-recommended therapy. Physician-related and patient-related factors (such as patient refusals, bleeding risk, older age, and recurrent falls) also contribute to guideline non-adherence, especially to undertreatment. Quality improvement initiatives that focus on undertreatment, especially in the primary healthcare setting, may help to improve guideline adherence.

Reasons for non-adherence to thromboprophylaxis prescribing guidelines in atrial fibrillation in Western Australia: A qualitative descriptive study of general practitioners' views.

BACKGROUND: A significant proportion of the atrial fibrillation (AF) population attending Australian primary care is not receiving guideline-adherent oral anticoagulant (OAC) treatment. This study aimed to explore reasons for non-adherence to thromboprophylaxis guidelines in AF from the perspectives of general practitioners (GPs) and to map these reasons to the Capability, Opportunity, Motivation-Behaviour (COM-B) model to identify potential opportunities to support practice change. METHODS: An exploratory qualitative descriptive study among GPs practising in Western Australia was conducted using semi-structured interviews, from November 2020 to February 2021. The Framework Method was employed to facilitate thematic analysis, using NVivo software. Interview responses were also mapped to the COM-B model. RESULTS: Nine of the 10 GPs initially consented participated in the semi-structured interview (Male = 56%, median age = 52 years, data saturation reached with 6 participants). Two themes emerged from analysis of the interview transcripts: (1) GPs' decision-making process and (2) Patient refusal to take OACs. The COM-B model mapping identified behavioural factors that could impact adherence: capability (GPs' knowledge and understanding of AF guideline recommendations), opportunity (access to a cardiologist, and patients' refusal to take OACs), and motivation (using formal bleeding risk assessment tools). CONCLUSION: GPs identified various reasons contributing to non-adherence to thromboprophylaxis guidelines in patients with AF. Multifaceted interventions should consider behavioural opportunities to improve adherence, including education and training, electronic decision support, clinical audits by allied health professionals, partnership between general practices and local hospitals, and cardiologist-led interventions to support GPs. Further studies are needed to capture patients' reasons for refusing OACs.