Medication management in long-term care: using evidence generated from real-world data to effect policy change in the Australian setting.

Older individuals residing in long-term care facilities (LTCFs) are often living with multimorbidity and exposed to polypharmacy, and many experience medication-related problems. Because randomized controlled trials seldom include individuals in LTCFs, pharmacoepidemiological studies using real-world data are essential sources of new knowledge on the utilization, safety and effectiveness of pharmacotherapies and related health outcomes in this population. In this commentary, we discuss recent pharmacoepidemiological research undertaken to support the investigations and recommendations of a landmark public inquiry into the quality and safety of care provided in the approximately 3,000 Australian LTCFs which house over 240,000 residents annually and informed subsequent national medication-related policy reforms. Suitable sources of real-world data for pharmacoepidemiological studies in long-term care cohorts and methodological considerations are also discussed.

Glucose-lowering medicines use before and after entry into long-term care facilities.

AIM: To examine changes in the use of glucose-lowering medicine (GLM) 12 months before and 12 months after long-term care facility (LTCF) entry among people with diabetes. MATERIALS AND METHODS: A national retrospective cohort study was conducted using linked health and aged care data from the Registry of Senior Australians National Historical Cohort. Residents of LTCFs with diabetes aged 65 years or older from 2015 to 2019 were included. Prevalence of GLM use and the number of defined daily doses (DDDs) dispensed per 1000 resident-days were estimated quarterly (91-day) using Poisson regression models, or negative binomial regression when overdispersion was present. RESULTS: Among the 50 993 residents studied (median age 84 years), the prevalence of GLM use was 58.4% (95% confidence interval [CI] 58.0%-58.8%) in the 9-12 months pre-LTCF entry and 56.3% (95% CI 55.9%-56.8%) in the 9-12 months post-entry. The number of DDDs/1000 resident-days increased from 1015.2 (95% CI 1002.3-1028.1) to 1253.8 (95% CI 1168.4-1339.3) during the same period. GLM use in the 3 months pre-entry was 56.8% (95% CI 56.4%-57.2%) compared with 61.7% (95% CI 61.3%-62.1%) in the 3 months post-entry, with the increased use driven mainly by insulin. No marked changes in the number of GLMs dispensed or GLM type were observed at 9-12 months post-entry compared with 3 months pre-entry. Among 22 792 individuals dispensed a GLM in the 3 months prior to LTCF entry, 50.2% continued the same GLM at 9-12 months post-entry. CONCLUSIONS: GLM use peaked in the first 3 months following LTCF entry, driven mainly by insulin, hence, residents may benefit from close monitoring of diabetes treatment during this period.

National surveillance using a clinical quality indicator for prolonged antipsychotic use among older Australians with dementia who access aged care services.

OBJECTIVES: Dementia guidelines recommend antipsychotics are only used for behavioral and psychological symptoms when non-drug interventions fail, and to regularly review use. Population-level clinical quality indicators (CQIs) for dementia care in permanent residential aged care (PRAC) typically monitor prevalence of antipsychotic use but not prolonged use. This study aimed to develop a CQI for antipsychotic use >90 days and examine trends, associated factors, and variation in CQI incidence; and examine duration of the first episode of use among individuals with dementia accessing home care packages (HCPs) or PRAC. METHODS: Retrospective cohort study, including older individuals with dementia who accessed HCPs (n = 50,257) or PRAC (n = 250,196). Trends in annual CQI incidence (2011-12 to 2015-16) and associated factors were determined using Poisson regression. Funnel plots examined geographical and facility variation. Time to antipsychotic discontinuation was estimated among new antipsychotic users accessing HCP (n = 2367) and PRAC (n = 15,597) using the cumulative incidence function. RESULTS: Between 2011-12 and 2015-16, antipsychotic use for >90 days decreased in HCP recipients from 10.7% (95% CI 10.2-11.1) to 10.1% (95% CI 9.6-10.5, adjusted incidence rate ratio (aIRR) 0.97 (95% CI 0.95-0.98)), and in PRAC residents from 24.5% (95% CI 24.2-24.7) to 21.8% (95% CI 21.5-22.0, aIRR 0.97 (95% CI 0.96-0.98)). Prior antipsychotic use (both cohorts) and being male and greater socioeconomic disadvantage (PRAC cohort) were associated with higher CQI incidence. Little geographical/facility variation was observed. Median treatment duration in HCP and PRAC was 334 (interquartile range [IQR] 108-958) and 555 (IQR 197-1239) days, respectively. CONCLUSIONS: While small decreases in antipsychotic use >90 days were observed between 2011-12 and 2015-16, findings suggest antipsychotic use among aged care recipients with dementia can be further minimized.

Primary, allied health, selected specialists, and mental health service utilisation by home care recipients in Australia before and after accessing the care, 2017-2019.

OBJECTIVES: To examine changes in primary, allied health, selected specialists, and mental health service utilisation by older people in the year before and after accessing home care package (HCP) services. METHODS: A retrospective cohort study using the Registry of Senior Australians Historical National Cohort (≥ 65 years old), including individuals accessing HCP services between 2017 and 2019 (N = 109,558), was conducted. The utilisation of general practice (GP) attendances, health assessments, chronic disease management plans, allied health services, geriatric, pain, palliative, and mental health services, subsidised by the Australian Government Medicare Benefits Schedule, was assessed in the 12 months before and after HCP access, stratified by HCP level (1-2 vs. 3-4, i.e., lower vs. higher care needs). Relative changes in service utilisation 12 months before and after HCP access were estimated using adjusted risk ratios (aRR) from Generalised Estimating Equation Poisson models. RESULTS: Utilisation of health assessments (7-10.2%), chronic disease management plans (19.7-28.2%), and geriatric, pain, palliative, and mental health services (all ≤ 2.5%) remained low, before and after HCP access. Compared to 12 months prior to HCP access, 12 months after, GP after-hours attendances increased (HCP 1-2 from 6.95 to 7.5%, aRR = 1.07, 95% CI 1.03-1.11; HCP 3-4 from 7.76 to 9.32%, aRR = 1.20, 95%CI 1.13-1.28) and allied health services decreased (HCP 1-2 from 34.8 to 30.7%, aRR = 0.88, 95%CI 0.87-0.90; HCP levels 3-4 from 30.5 to 24.3%, aRR = 0.80, 95%CI 0.77-0.82). CONCLUSIONS: Most MBS subsidised preventive, management and specialist services are underutilised by older people, both before and after HCP access and small changes are observed after they access HCP.

Hematological and Other Cancers in People Using Clozapine: Analysis of Australian Spontaneous Reports Between 1995 and 2020.

BACKGROUND: Recent observational study evidence suggests that clozapine, unlike other antipsychotics, may be associated with a small increased risk of hematological malignancy. This study described characteristics of hematological and other cancers in those taking clozapine reported to the Australian Therapeutic Goods Administration. METHODS: We analyzed public case reports for "clozapine," "Clozaril," or "Clopine" from January 1995 to December 2020 classified as "neoplasm benign, malignant and unspecified" by the Australian Therapeutic Goods Administration. Data on age, sex, dose, clozapine start and cessation dates, Medical Dictionary for Regulatory Activities reaction terms, and date of cancer were extracted. RESULTS: Overall, 384 spontaneous reports of cancers in people taking clozapine were analyzed. The mean age of patients was 53.9 years (SD, 11.4 years), and 224 (58.3%) were male. The most frequent cancers were hematological (n = 104 [27.1%]), lung (n = 50 [13.0%]), breast (n = 37 [9.6%]), and colorectal (n = 28 [7.3%]). The outcome was fatal for 33.9% of cancer reports. Lymphoma comprised 72.1% of all hematological cancers (mean patient age, 52.1 years; SD, 11.6 years). The median daily dose of clozapine at the time of hematological cancer report was 400 mg (interquartile range, 300-543.8 mg), and the median duration of clozapine use before hematological cancer diagnosis was 7.0 years (interquartile range, 2.8-13.2 years). CONCLUSIONS: Lymphoma and other hematological cancers are overrepresented in spontaneous adverse event reports compared with other cancer types. Clinicians should be aware of the possible association with hematological cancers and monitor for and report any hematological cancers identified. Future studies should examine histology of lymphomas in people using clozapine and corresponding blood level of clozapine.

Identifying barriers and enablers to participation in infection surveillance in Australian residential aged care facilities.

BACKGROUND: Infection surveillance is a vital part of infection prevention and control activities for the aged care sector. In Australia there are two currently available infection and antimicrobial use surveillance programs for residential aged care facilities. These programs are not mandated nor available to all facilities. Development of a new surveillance program will provide standardised surveillance for all facilities in Australia. METHODS: This study aimed to assess barriers and enablers to participation in the two existing infection and antimicrobial use surveillance programs, to improve development and implementation of a new program. A mixed-methods study was performed. Aged Care staff involved in infection surveillance were invited to participate in focus groups and complete an online survey comprising 17 items. Interviews were transcribed and analysed using the COM-B framework. RESULTS: Twenty-nine staff took part in the focus groups and two hundred took part in the survey. Barriers to participating in aged care infection surveillance programs were the time needed to collect and enter data, competing priority tasks, limited understanding of surveillance from some staff, difficulty engaging clinicians, and staff fatigue after the COVID-19 pandemic. Factors that enabled participation were previous experience with surveillance, and sharing responsibilities, educational materials and using data for benchmarking and to improve practice. CONCLUSION: Streamlined and simple data entry methods will reduce the burden of surveillance on staff. Education materials will be vital for the implementation of a new surveillance program. These materials must be tailored to different aged care workers, specific to the aged care context and provide guidance on how to use surveillance results to improve practice.

Provision of a comprehensive medicines review is associated with lower mortality risk for residents of aged care facilities: a retrospective cohort study.

BACKGROUND: no studies have examined the impact of residential medication management review (RMMR, a 24-year government subsidised comprehensive medicines review program) in Australian residential aged care facilities (RACFs) on hospitalisation or mortality. OBJECTIVE: to examine associations between RMMR provision in the 6-12 months after RACF entry and the 12-month risk of hospitalisation and mortality among older Australians in RACFs. DESIGN: retrospective cohort study. SUBJECTS: individuals aged 65-105 years taking at least one medicine, who entered an RACF in three Australian states between 1 January 2012 and 31 December 2015 and spent at least 6 months in the RACF (n = 57,719). METHODS: Cox regression models estimated adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) for associations between RMMR provision and mortality. Adjusted subdistribution hazard ratios were estimated for associations between RMMR provision and next (i) emergency department (ED) presentation or unplanned hospitalisation or (ii) fall-related ED presentation or hospitalisation. RESULTS: there were 12,603 (21.8%) individuals who received an RMMR within 6-12 months of RACF entry, of whom 22.2% (95%CI 21.4-22.9) died during follow-up, compared with 23.3% (95%CI 22.9-23.7) of unexposed individuals. RMMR provision was associated with a lower risk of death due to any cause over 12-months (aHR 0.96, 95%CI 0.91-0.99), but was not associated with ED presentations or hospitalisations for unplanned events or falls. CONCLUSIONS: provision of an RMMR in the 6-12 months after RACF entry is associated with a 4.4% lower mortality risk over 12-months but was not associated with changes in hospitalisations for unplanned events or falls.

Medicines use before and after comprehensive medicines review among residents of long-term care facilities: a retrospective cohort study.

BACKGROUND: Residential Medication Management Review (RMMR) is a subsidized comprehensive medicines review program for individuals in Australian residential aged care facilities (RACFs). This study examined weekly trends in medicines use in the four months before and after an RMMR and among a comparison group of residents who did not receive an RMMR. METHODS: This retrospective cohort study included individuals aged 65 to 105 years who first entered permanent care between 1/1/2012 and 31/12/2016 in South Australia, Victoria, or New South Wales, and were taking at least one medicine. Individuals with an RMMR within 12 months of RACF entry were classified into one of three groups: (i) RMMR within 0 to 3 months, (ii) 3 to 6 months, or (iii) within 6 to 12 months of RACF entry. Individuals without RMMRs were included in the comparison group. Weekly trends in the number of defined daily doses per 1000 days were determined in the four months before and after the RMMR (or assigned index date in the comparison group) for 14 medicine classes. RESULTS: 113909 individuals from 1979 RACFs were included, of whom 55021 received an RMMR. Across all three periods examined, decreased use of statins and proton pump inhibitors was observed post-RMMR in comparison to those without RMMRs. Decreases in calcium channel blockers, benzodiazepines/zopiclone, and antidepressants were observed following RMMR provision in the 3-6 and 6-12 months after RACF entry. Negligible changes in antipsychotic use were also observed following an RMMR in the 6-12 months after RACF entry by comparison to those without RMMRs. No changes in use of opioids, ACE inhibitors/sartans, beta blockers, loop diuretics, oral anticoagulants, or medicines for osteoporosis, diabetes or the cognitive symptoms of dementia were observed post-RMMR. CONCLUSIONS: For six of the 14 medicine classes investigated, modest changes in weekly trends in use were observed after the provision of an RMMR in the 6-12 months after RACF entry compared to those without RMMRs. Findings suggest that activities such as medicines reconciliation may be prioritized when an RMMR is provided on RACF entry, with deprescribing more likely after an RMMR the longer a resident has been in the RACF.

Fatal poisonings involving clozapine: A 16-year review of Australian coronial investigations.

OBJECTIVE: Concerns about intentional and unintentional poisoning present a barrier to wider use of clozapine in treatment-resistant schizophrenia. The objective of this study was to investigate decedent demographics and trends in fatal poisonings in Australia involving clozapine. METHODS: This was a retrospective case series of all fatal drug toxicity reported to an Australian coroner between 1 May 2000 and 31 December 2016 where toxicological analysis detected clozapine. Cases were identified using the National Coronial Information System. Demographics extracted included age and gender of the decedent, year and location of death, cause and manner of death and drugs detected in post-mortem samples. RESULTS: There were 278 poisoning deaths where clozapine was detected in toxicological analyses. Three-quarters of all cases (n = 207) involved men and the median age at death was 38.5 years (interquartile range: 16 years). Three-quarters of the deaths occurred in the home. Overall, 15.8% of deaths were deemed intentional, 57.5% unintentional and 24.5% of unknown intent. While the annual number of intentional self-poisonings remained constant with <5 per year, the overall number of fatalities increased due to an increase in unintentional poisonings. Multiple drug toxicity was reported in 55.0% of cases and clozapine alone in 45.0% of cases. The most common co-reported medications were antidepressants, benzodiazepines and opioids detected in 47.1%, 44.4% and 41.2% of multiple drug toxicities, respectively. CONCLUSION: This was the first Australia-wide review of all fatal drug poisonings reported to a coroner involving clozapine. Fatalities were most common in men and occurred at home. Multiple drug toxicity generally involved psychotropic, sedative or opioid analgesic medications. Despite increasing clozapine use, rates of intentional poisoning have remained constant and low. Developing a better knowledge of unintentional fatalities presents an opportunity to minimise harm.

National Trends in Antibiotic Use in Australian Residential Aged Care Facilities, 2005-2016.

BACKGROUND: Understanding current patterns of antibiotic use in residential aged care facilities (RACFs) is essential to inform stewardship activities, but limited utilization data exist. This study examined changes in prevalence and consumption of antibiotics in Australian RACFs between 2005-2006 and 2015-2016. METHODS: This population-based, repeated cross-sectional analysis included all long-term permanent residents of Australian RACFs between July 2005 and June 2016 who were aged ≥ 65 years. The yearly prevalence rate of antibiotic use and number of defined daily doses (DDDs) of systemic antibiotics per 1000 resident-days were determined annually from linked pharmaceutical claims data. Trends were assessed using ordinary least squares regression. RESULTS: This study included 502 752 residents from 3218 RACFs, with 424.9 million resident-days analyzed. Antibiotics were dispensed on 5 608 126 occasions during the study period, of which 88% were for oral use. Cefalexin, amoxicillin-clavulanic acid, and trimethoprim were the most commonly dispensed antibiotics. The annual prevalence of antibiotic use increased from 63.8% (95% confidence interval [CI], 63.3%-64.4%) to 70.3% (95% CI, 69.9%-70.7%) between 2005-2006 and 2015-2016 (0.8% average annual increase, P < .001). There was a 39% relative increase in total consumption of systemic antibiotics, with utilization increasing from 67.6 to 93.8 DDDs/1000 resident-days during the study period (average annual increase of 2.8 DDDs/1000 resident-days, P < .001). CONCLUSIONS: This nationwide study showed substantial increases in both prevalence of use and total consumption of antibiotics in Australian RACFs between 2005 and 2016. The increasingly widespread use of antibiotics in Australian RACFs is concerning and points to a need for enhanced efforts to optimize antibiotic use in this setting.

Contribution of facility level factors to variation in antibiotic use in long-term care facilities: a national cohort study.

OBJECTIVES: To examine national variation in systemic antibiotic use in long-term care facilities (LTCFs) and identify facility characteristics associated with antibiotic utilization. METHODS: This retrospective cohort study included 312 375 residents of 2536 Australian LTCFs between 2011 and 2016. LTCFs were categorized as low, medium or high antibiotic use facilities according to tertiles of DDDs of systemic antibiotics dispensed per 1000 resident-days. Multivariable logistic regression estimated the associations between facility characteristics (ownership, size, location, medication quality indicator performance, prevalence of after-hours medical practitioner services) and antibiotic use (low versus high). RESULTS: LTCFs in the lowest and highest antibiotic use categories received a median of 54.3 (IQR 46.5-60.5) and 106.1 (IQR 95.9-122.3) DDDs/1000 resident-days, respectively. Compared with not-for-profit LTCFs in major cities, government-owned non-metropolitan LTCFs were less likely to experience high antibiotic use [adjusted OR (aOR) 0.47, 95% CI 0.24-0.91]. LTCFs with 69-99 residents were less likely to experience high antibiotic use (aOR 0.69, 95% CI 0.49-0.97) than those with 25-47 residents annually. Greater prevalence of medical practitioner services accessed after-hours was associated with high antibiotic use [aOR 1.10 (per 10% increase in after-hours services), 95% CI 1.01-1.21]. South Australian LTCFs (aOR 2.17, 95% CI 1.38-3.39) were more likely, while Queensland (0.43, 95% CI 0.30-0.62) and Western Australian (aOR 0.34, 95% CI 0.21-0.57) LTCFs were less likely to experience high antibiotic use than New South Wales LTCFs. CONCLUSIONS: Considerable facility level variation in systemic antibiotic use was observed across Australian LTCFs. Identification of facility characteristics associated with antibiotic use provides a basis for targeted stewardship initiatives.

The risk of fall-related hospitalisations at entry into permanent residential aged care.

BACKGROUND: Entering permanent residential aged care (PRAC) is a vulnerable time for individuals. While falls risk assessment tools exist, these have not leveraged routinely collected and integrated information from the Australian aged and health care sectors. Our study examined individual, system, medication, and health care related factors at PRAC entry that are predictors of fall-related hospitalisations and developed a risk assessment tool using integrated aged and health care data. METHODS: A retrospective cohort study was conducted on N = 32,316 individuals ≥65 years old who entered a PRAC facility (01/01/2009-31/12/2016). Fall-related hospitalisations within 90 or 365 days were the outcomes of interest. Individual, system, medication, and health care-related factors were examined as predictors. Risk prediction models were developed using elastic nets penalised regression and Fine and Gray models. Area under the receiver operating characteristics curve (AUC) assessed model discrimination. RESULTS: 64.2% (N = 20,757) of the cohort were women and the median age was 85 years old (interquartile range 80-89). After PRAC entry, 3.7% (N = 1209) had a fall-related hospitalisation within 90 days and 9.8% (N = 3156) within 365 days. Twenty variables contributed to fall-related hospitalisation prediction within 90 days and the strongest predictors included fracture history (sub-distribution hazard ratio (sHR) = 1.87, 95% confidence interval (CI) 1.63-2.15), falls history (sHR = 1.41, 95%CI 1.21-2.15), and dementia (sHR = 1.39, 95%CI 1.22-1.57). Twenty-seven predictors of fall-related hospitalisation within 365 days were identified, the strongest predictors included dementia (sHR = 1.36, 95%CI 1.24-1.50), history of falls (sHR = 1.30, 95%CI 1.20-1.42) and fractures (sHR = 1.28, 95%CI 1.15-1.41). The risk prediction models had an AUC of 0.71 (95%CI 0.68-0.74) for fall-related hospitalisations within 90 days and 0.64 (95%CI 0.62-0.67) for within 365 days. CONCLUSION: Routinely collected aged and health care data, when integrated at a clear point of action such as entry into PRAC, can identify residents at risk of fall-related hospitalisations, providing an opportunity for better targeting risk mitigation strategies.

Initiation of antipsychotics after moving to residential aged care facilities and mortality: a national cohort study.

BACKGROUND: There is a high burden of antipsychotic use in residential aged care facilities (RACFs) and there is concern regarding potential inappropriate prescribing of antipsychotics in response to mild behavioural symptoms. Antipsychotic use has been associated with a higher risk of mortality in community-dwelling older adults with dementia, but few studies have examined associations upon RACF entry. AIMS: To examine associations between incident antipsychotic use and risk of mortality for people with and without diagnosed dementia in RACFs. METHODS: A retrospective cohort study, employing a new-user design (individuals did not receive an antipsychotic 6 months before enrolment) of 265,820 people who accessed RACFs in Australia between 1/4/2008 and 30/6/2015 was conducted. Cox regression models were used to examine adjusted associations between antipsychotic use in the first 100 days of RACF entry and mortality. RESULTS: In the 100 days after entering care, 29,455 residents (11.1%) were dispensed an antipsychotic. 180,956 (68.1%) residents died [38,249 (14.4%) were related to cerebrovascular causes] over a median 2.1 years (interquartile range 1.0-3.6) follow-up. Of the residents included, 119,665 (45.0%) had a diagnosis of dementia. Incident antipsychotic use was associated with higher risk of mortality in residents with dementia (adjusted hazard ratio 1.20, 95% confidence interval 1.18-1.22) and without dementia (1.28, 1.24-1.31). CONCLUSION: Initiation of antipsychotics after moving to RACFs is associated with a higher risk of mortality. Careful consideration of the potential benefits and harms should be given when starting a new prescription for antipsychotics for people moving to RACFs.

The dispensing of psychotropic medicines to older people before and after they enter residential aged care.

OBJECTIVE: To examine the prevalence of psychotropic medicine dispensing before and after older people enter residential care. DESIGN: Retrospective national cohort study; analysis of Registry of Senior Australians (ROSA) data. SETTING, PARTICIPANTS: All concession card-holding residents of government-subsidised residential aged care facilities in Australia who entered residential care for at least three months between 1 April 2008 and 30 June 2015. MAIN OUTCOME MEASURES: Proportions of residents dispensed antipsychotic, benzodiazepine, or antidepressant medicines during the year preceding and the year after commencing residential care, by quarter. RESULTS: Of 322 120 included aged care residents, 68 483 received at least one antipsychotic (21.3%; 95% CI, 21.1-21.4%), 98 315 at least one benzodiazepine (30.5%; 95% CI, 30.4-30.7%), and 122 224 residents at least one antidepressant (37.9%; 95% CI, 37.8-38.1%) during their first three months of residential care; 31 326 of those dispensed antipsychotics (45.7%), 38 529 of those dispensed benzodiazepines (39.2%), and 25 259 residents dispensed antidepressants (19.8%) had not received them in the year preceding their entry into care. During the first three months of residential care, the prevalence of antipsychotic (prevalence ratio [PR], 3.37; 95% CI, 3.31-3.43) and antidepressant dispensing (PR, 1.05; 95% CI, 1.04-1.07) were each higher for residents with than for those without dementia; benzodiazepine dispensing was similar for both groups (PR, 1.01; 95% CI, 0.99-1.02). CONCLUSIONS: Dispensing of psychotropic medicines to older Australians is high before they enter residential care but increases markedly soon after entry into care. Non-pharmacological behavioural management strategies are important for limiting the prescribing of psychotropic medicines for older people in the community or in residential care.

Multiple antihypertensive use and risk of mortality in residents of aged care services: a prospective cohort study.

AIMS: The objective of this study is to investigate the association between multiple antihypertensive use and mortality in residents with diagnosed hypertension, and whether dementia and frailty modify this association. METHODS: This is a two-year prospective cohort study of 239 residents with diagnosed hypertension receiving antihypertensive therapy across six residential aged care services in South Australia. Data were obtained from electronic medical records, medication charts and validated assessments. The primary outcome was all-cause mortality and the secondary outcome was cardiovascular-related hospitalizations. Inverse probability weighted Cox models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause mortality. Covariates included age, sex, dementia severity, frailty status, Charlson's comorbidity index and cardiovascular comorbidities. RESULTS: The study sample (mean age of 88.1 ± 6.3 years; 79% female) included 70 (29.3%) residents using one antihypertensive and 169 (70.7%) residents using multiple antihypertensives. The crude incidence rates for death were higher in residents using multiple antihypertensives compared with residents using monotherapy (251 and 173/1000 person-years, respectively). After weighting, residents who used multiple antihypertensives had a greater risk of mortality compared with monotherapy (HR 1.40, 95%CI 1.03-1.92). After stratifying by dementia diagnosis and frailty status, the risk only remained significant in residents with diagnosed dementia (HR 1.91, 95%CI 1.20-3.04) and who were most frail (HR 2.52, 95%CI 1.13-5.64). Rate of cardiovascular-related hospitalizations did not differ among residents using multiple compared to monotherapy (rate ratio 0.73, 95%CI 0.32-1.67). CONCLUSIONS: Multiple antihypertensive use is associated with an increased risk of mortality in residents with diagnosed hypertension, particularly in residents with dementia and among those who are most frail.

Root cause analysis of fall-related hospitalisations among residents of aged care services.

BACKGROUND: Fall-related hospitalisations from residential aged care services (RACS) are distressing for residents and costly to the healthcare system. Strategies to limit hospitalisations include preventing injurious falls and avoiding hospital transfers when falls occur. AIMS: To undertake a root cause analysis (RCA) of fall-related hospitalisations from RACS and identify opportunities for fall prevention and hospital avoidance. METHODS: An aggregated RCA of 47 consecutive fall-related hospitalisations for 40 residents over a 12-month period at six South Australian RACS was undertaken. Comprehensive data were extracted from RACS records including nursing progress notes, medical records, medication charts, hospital summaries and incident reports by a nurse clinical auditor and clinical pharmacist. Root cause identification was performed by the research team. A multidisciplinary expert panel recommended strategies for falls prevention and hospital avoidance. RESULTS: Overall, 55.3% of fall-related hospitalisations were among residents with a history of falls. Among all fall-related hospitalisations, at least one high falls risk medication was administered regularly prior to hospitalisation. Potential root causes of falling included medication initiations and dose changes. Root causes for hospital transfers included need for timely access to subsidised medical services or radiology. Strategies identified for avoiding hospitalisations included pharmacy-generated alerts when medications associated with an increased risk of falls are initiated or changed, multidisciplinary audit and feedback of falls risk medication use and access to subsidised mobile imaging services. CONCLUSIONS: This aggregate RCA identified a range of strategies to address resident and system-level factors to minimise fall-related hospitalisations.

Prescribing of diabetes medications to people with type 2 diabetes and chronic kidney disease: a national cross-sectional study.

BACKGROUND: Previous studies in general practice and hospital settings have identified that prescribing of non-insulin diabetes medications may be sub-optimal in people with type 2 diabetes (T2D) and renal impairment. Since these publications, a number of new medications have become available for the management of T2D. Study aims were to, in a cohort of Australians with T2D and renal impairment attending general practice, (1) investigate whether the prescribing of non-insulin diabetes medications is consistent with dosing adjustments recommended within current Australian Diabetes Society (ADS) guidelines; and (2) identify patient socio-demographic and clinical factors associated with at least one prescription of a non-insulin diabetes medication inconsistent with current ADS guidelines for medication doses. METHODS: Cross-sectional study using data from the MedicineInsight general practice database managed by NPS MedicineWise. Patients with T2D who were aged 18 years and over, with an average eGFR< 60 ml/min/1.73m2 and at least one prescription of a non-insulin diabetes medication between 1st January 2015 and 30th June 2017 were included. Descriptive statistics were used to summarise patient characteristics and medication use. Marginal logistic regression models were used to estimate associations between sociodemographic and clinical factors and prescribing of ≥1non-insulin diabetes medicine not consistent with ADS guidelines. RESULTS: The majority of the 3505 patients included (90.4%) had an average eGFR of 30-59 ml/min/1.73m2. In terms of absolute numbers, metformin was the medication most frequently prescribed at a dose not consistent with current ADS guidelines for dosing in renal impairment (n = 1601 patients), followed by DPP4 inhibitors (n = 611) and sulphonylureas (n = 278). The drug classes with the highest proportion of prescriptions with dosage not consistent with ADS guidelines were SGLT2 inhibitors (83%), followed by biguanides (58%) and DPP4 inhibitors (46%). Higher HbA1c, longer known diabetes duration and diagnosis of retinopathy were associated with receiving ≥1prescription with a dosage not consistent with guidelines. CONCLUSIONS: Prescribing of non-insulin diabetes medications at doses inconsistent with current ADS guideline recommendations for dosing adjustments for people with renal impairment was common. Further research is needed to understand how general practitioners access, interpret and apply the ADS guidelines and the impact this may have on patient outcomes.

Screening and diagnosis of chronic kidney disease in people with type 2 diabetes attending Australian general practice.

Australian guidelines recommend annual screening and monitoring of chronic kidney disease (CKD) in people with type 2 diabetes (T2D). A cross-sectional study utilising data from NPS MedicineWise MedicineInsight program from June 2015 to May 2016 was undertaken to explore: (1) the proportion of patients with T2D attending general practice who have had screening for, or ongoing monitoring of, CKD; (2) the proportion of patients without a documented diagnosis of CKD who have pathology consistent with CKD diagnosis; and (3) the patient factors associated with screening and the recording of a diagnosis of CKD. Of 90550 patients with T2D, 44394 (49.0%) were appropriately screened or monitored. There were 8030 (8.9%) patients with a recorded diagnosis of CKD, whereas 6597 (7.3%) patients had no recorded diagnosis of CKD despite pathology consistent with a diagnosis. Older age and diagnosis of hypertension or hyperlipidaemia were associated with increased odds of CKD diagnosis being recorded. Older patients, males, those with recorded diagnoses of hypertension or hyperlipidaemia and those who had their medical record opened more frequently were more likely to be screened appropriately. Screening and monitoring of CKD appears suboptimal. Research to explore barriers to screening, recording and monitoring of CKD, and strategies to address these, is required.

Medication management policy, practice and research in Australian residential aged care: Current and future directions.

Eight percent of Australians aged 65 years and over receive residential aged care each year. Residents are increasingly older, frailer and have complex care needs on entry to residential aged care. Up to 63% of Australian residents of aged care facilities take nine or more medications regularly. Together, these factors place residents at high risk of adverse drug events. This paper reviews medication-related policies, practices and research in Australian residential aged care. Complex processes underpin prescribing, supply and administration of medications in aged care facilities. A broad range of policies and resources are available to assist health professionals, aged care facilities and residents to optimise medication management. These include national guiding principles, a standardised national medication chart, clinical medication reviews and facility accreditation standards. Recent Australian interventions have improved medication use in residential aged care facilities. Generating evidence for prescribing and deprescribing that is specific to residential aged care, health workforce reform, medication-related quality indicators and inter-professional education in aged care are important steps toward optimising medication use in this setting.

Use of proton pump inhibitors among older Australians: national quality improvement programmes have led to sustained practice change.

OBJECTIVE: To evaluate the impact of national multifaceted initiatives to improve use of proton pump inhibitors (PPIs) on the use of PPIs among older Australians. DESIGN: Interrupted time series analysis using administrative health claims data from the Australian Government Department of Veterans' Affairs (DVA). SETTING: Australia. PARTICIPANTS: All veterans and dependents who received PPIs between January 2003 and December 2013. INTERVENTION(S): National, multifaceted interventions to improve PPI use were conducted by the Australian Government Department of Veterans' Affairs Veterans' MATES programme and Australia's NPS MedicineWise in April 2004, June 2006, May 2009 and August 2012. MAIN OUTCOME MEASURE(S): Trends in monthly rate of use of any PPI among the veteran population, and the monthly rate of use of low strength PPIs among all veterans dispensed a PPI. RESULTS: Interventions in 2004, 2006, 2009 and 2012 slowed the rate of increase in PPI use significantly, with the 2012 intervention resulting in a sustained 0.04% decrease in PPI use each month. The combined effect of all four interventions was a 20.9% (95% CI 7.8-33.9%) relative decrease in PPI use 12 months after the final intervention. The four interventions also resulted in a 42.2% (95% CI 19.9-64.5%) relative increase in low strength PPI use 12 months after the final intervention. CONCLUSIONS: National multifaceted programmes targeting clinicians and consumers were effective in reducing overall PPI use and increasing use of low strength PPIs. Interventions to improve PPI use should incorporate regular repetition of key messages to sustain practice change.