Effect of an ongoing pharmacist service to reduce medicine-induced deterioration and adverse reactions in aged-care facilities (nursing homes): a multicentre, randomised controlled trial (the ReMInDAR trial).

OBJECTIVE: To assess the effectiveness of a pharmacist-led intervention using validated tools to reduce medicine-induced deterioration and adverse reactions. DESIGN AND SETTING: Multicenter, open-label parallel randomised controlled trial involving 39 Australian aged-care facilities. PARTICIPANTS: Residents on ≥4 medicines or ≥1 anticholinergic or sedative medicine. INTERVENTION: Pharmacist-led intervention using validated tools to detect signs and symptoms of medicine-induced deterioration which occurred every 8 weeks over 12 months. COMPARATOR: Usual care (Residential Medication Management Review) provided by accredited pharmacists. OUTCOMES: Primary outcome was change in Frailty Index at 12 months. Secondary outcomes included changes in cognition, 24-hour movement behaviour by accelerometry, grip strength, weight, adverse events and quality of life. RESULTS: 248 persons (median age 87 years) completed the study; 120 in the interventionand, 128 in control arms. In total 575 pharmacist, sessions were undertaken in the intervention arm. There was no statistically significant difference for change in frailty between groups (mean difference: 0.009, 95% CI: -0.028, 0.009, P = 0.320). A significant difference for cognition was observed, with a mean difference of 1.36 point change at 12 months (95% CI: 0.01, 2.72, P = 0.048). Changes in 24-hour movement behaviour, grip strength, adverse events and quality of life were not significantly different between groups. Point estimates favoured the intervention arm at 12 months for frailty, 24-hour movement behaviour and grip strength. CONCLUSIONS: The use of validated tools by pharmacists to detect signs of medicine-induced deterioration is a model of practice that requires further research, with promising results from this trial, particularly with regards to improved cognition.

Medication Regimen Complexity Index Prediction of Adverse Drug Reaction-Related Hospital Admissions.

BACKGROUND: The relationship between the medication regimen complexity index (MRCI) and adverse drug reaction (ADR)-related hospital admissions has not yet specifically been investigated. OBJECTIVE: To evaluate the MRCI and compare with medication count for prediction of ADR-related hospital admissions in older patients. METHODS: This was a retrospective analysis of a prospectively collected convenience sample of 768 unplanned medical admissions of Australians aged 65 years old and older. The sample consisted of 115 (15.0%) ADR-related unplanned hospital admissions and 653 (85.0%) non-ADR-related unplanned medical admissions. The MRCI score was calculated from the medical records and analyzed to predict ADR-related hospital admissions. RESULTS: The cohort had a median age of 81 years, 5 comorbidities, and 11 medications, with a slight majority of women. The MRCI score was not significantly different in patients who had ADR-related admissions compared with other medical admissions-38.5 versus 34.0, respectively; Wilcoxon Rank Sum test W = 33 522; P = 0.067. The medication count was significantly different between the ADR-related admissions compared with other medical admissions: 12 versus 10; W = 32 508; P = 0.021. However, the medication count was not a strong predictor of ADR-related admissions; unadjusted odds ratio = 1.044; 95% CI = 1.006-1.084. CONCLUSION AND RELEVANCE: The MRCI score did not discriminate between ADR-related admissions and other medical admissions despite taking time to calculate with potential for inconsistent application. Medication count is more readily applicable with marginally greater relevance in this cohort; however, both measures do not appear to be useful when used alone for clinicians to identify patients at risk of ADRs.

Strategizing the removal of barriers to community pharmacist's business management capabilities.

The community pharmacist may be challenged by their dual role of being both a health care provider and practice manager. This commentary proposes strategies to address the barriers to the management role of the community pharmacist in practice as perceived by stakeholders: pharmacist owners, pharmacist managers, pharmacists, and pharmacy students. Whilst some community pharmacist owners may believe managerial skills are not required for the profession, all stakeholders for the most part agree on the barriers to the management role of the community pharmacist in practice and the strategies to address these barriers. Three barriers were identified: business versus professional dichotomy, transitioning theoretical learned content into a practice setting, and professional overload. Three strategies are proposed to overcome these barriers: developing a dual thinking process, learning practice management from mentors, and the philosophy of becoming a leader and the team builder. A paradigm shift within the current culture in the profession may be required to overcome the barriers. This commentary also highlights the need to explore leadership in community pharmacy.

"Why Didn't They Teach Us This?" A Qualitative Investigation of Pharmacist Stakeholder Perspectives of Business Management for Community Pharmacists.

Expanding the scope of practice has provided an opportunity to reflect on the business management role of the community pharmacist. This study aimed to determine stakeholder perspectives of what business management skills are required for the community pharmacist, potential barriers impeding changes to management in the pharmacy program or community pharmacy setting, and strategies to improve the business management role of the profession. Purposively selected community pharmacists across two states in Australia were invited to participate in semi-structured phone interviews. A hybrid approach of inductive and deductive coding was used to transcribe and thematically analyse interviews. Twelve stakeholders described 35 business management skills in a community pharmacy, with 13 skills consistently used by participants. Thematic analysis revealed two barriers and two strategies to improve business management skills in both the pharmacy curriculum and community pharmacy. Strategies to improve business management across the profession include pharmacy programs covering recommended managerial content, learning from experience-based education and creation of a standardised mentorship program. There is an opportunity for business management culture change within the profession, and this may require community pharmacists developing a dual thinking process to appropriately balance professionalism and business management.

Pharmacy Students' Perspective on Business Management for the Community Pharmacist.

OBJECTIVE: Pharmacy students are important future stakeholders in community pharmacy, with business management being an integral part of practice. Thus, this study aims to determine pharmacy students' perceptions of the business management skills required of the community pharmacist and how these skills should be taught within the pharmacy curriculum. METHODS: An explanatory sequential mixed-methods design involved the administration of an online survey to pharmacy students in years 1 and 4 across 2 Australian universities, followed by focus groups to gather in-depth perceptions. Survey responses were analyzed using descriptive statistics, and associations between years 1 and 4 and outcomes were explored. A hybrid approach of inductive and deductive thematic analysis was used for focus group transcriptions. RESULTS: A total of 51 pharmacy students responded to the online survey, with 85% agreeing that business management is an essential part of the community pharmacist's skill set. Students indicated a preference for learning management during their community pharmacy placement, university workshops, and via mentorship. Although thematic analysis of student focus groups revealed a preference for learning clinical skills during their university education, business management was also recognized as important. Enthusiasm for management, however, could be increased by exposure to mentors who display leadership and are passionate about business management. CONCLUSION: Pharmacy students considered business management as intrinsic to the role of community pharmacists and recommended a multimethod teaching approach to learning these skills. These findings could be used by pharmacy educators and the profession to inform both the content and the delivery of business management in pharmacy curricula.

Scoping the required business management skills for community pharmacy: Perspectives of pharmacy stakeholders and pharmacy students.

BACKGROUND: The literature is dearth in identification and categorization of business management skills required by community pharmacists. While community pharmacy stakeholders (predominantly community pharmacy owners, managers, and pharmacists) and pharmacy students are valuable sources for identifying business management skills, no review is currently available that synthesizes their knowledge. By identifying currently known business skills and organizing these into a managerial skills framework, this review provides a foundation skillset for community pharmacist business management. METHODS: Six electronic databases were searched for published articles, with titles and abstracts screened according to inclusion criteria. Full articles meeting the specified criteria were assessed and skills identified were mapped to the human, conceptual, and technical skills of a business management framework. RESULTS: Pharmacy stakeholders and students identified 36 business management skills/aptitudes required for community pharmacists. Pharmacy stakeholders most frequently identified the skills of communication, professionalism, general business management, leadership, and teamwork. Although the pharmacy students concurred with many of these skills, they more frequently identified confidence, entrepreneurship, and having prior experience or opportunity in a management role. A substantial number of identified skills/aptitudes were categorized under the human domain of the business management framework. IMPLICATIONS: Community pharmacists require training in effective business management, with particular emphasis on human domain skills. The tertiary education system should consider implementing the skills/aptitudes revealed in this review into the pharmacy curriculum. Recruiting business minded personalities into the profession, particularly targeting students with an attraction to business management, is one strategy to improve management skills within the field.

Preventing Adverse Drug Reactions After Hospital Discharge (PADR-AD): Protocol for a randomised-controlled trial in older people.

BACKGROUND: Adverse drug reactions (ADRs) and adverse drug events (ADEs) in older people contribute to a significant proportion of hospital admissions and are common following discharge. Effective interventions are therefore required to combat the growing burden of preventable ADRs. The Prediction of Hospitalisation due to Adverse Drug Reactions in Elderly Community Dwelling Patients (PADR-EC) score is a validated risk score developed to assess the risk of ADRs in people aged 65 years and older and has the potential to be utilised as part of an intervention to reduce ADRs. OBJECTIVES: This trial was designed to investigate the effectiveness of an intervention to reduce ADR incidence in older people and to obtain further information about ADRs and ADEs in the 12-24 months following hospital discharge. METHODS: The study is an open-label randomised-controlled trial to be conducted at the Royal Hobart Hospital, a 500-bed public hospital in Tasmania, Australia. Community-dwelling patients aged 65 years and older with an unplanned overnight admission to a general medical ward will be recruited. Following admission, the PADR-EC ADR score will be calculated by a research pharmacist, with the risk communicated to clinicians and discussed with participants. Following discharge, nominated general practitioners and community pharmacists will receive the risk score and related medication management advice to guide their ongoing care of the patient. Follow-up with participants will occur at 3 and 12 and 18 and 24 months to identify ADRs and ADEs. The primary outcome is moderate-severe ADRs at 12 months post-discharge, and will be analysed using the cumulative incidence proportion, survival analysis and Poisson regression. SUMMARY: It is hypothesised that the trial will reduce ADRs and ADEs in the intervention population. The study will also provide valuable data on post-discharge ADRs and ADEs up to 24 months post-discharge.

Reducing medicine-induced deterioration and adverse reactions (ReMInDAR) trial: study protocol for a randomised controlled trial in residential aged-care facilities assessing frailty as the primary outcome.

INTRODUCTION: Many medicines have adverse effects which are difficult to detect and frequently go unrecognised. Pharmacist monitoring of changes in signs and symptoms of these adverse effects, which we describe as medicine-induced deterioration, may reduce the risk of developing frailty. The aim of this trial is to determine the effectiveness of a 12-month pharmacist service compared with usual care in reducing medicine-induced deterioration, frailty and adverse reactions in older people living in aged-care facilities in Australia. METHODS AND ANALYSIS: The reducing medicine-induced deterioration and adverse reactions trial is a multicentre, open-label randomised controlled trial. Participants will be recruited from 39 facilities in South Australia and Tasmania. Residents will be included if they are using four or more medicines at the time of recruitment, or taking more than one medicine with anticholinergic or sedative properties. The intervention group will receive a pharmacist assessment which occurs every 8 weeks. The pharmacists will liaise with the participants' general practitioners when medicine-induced deterioration is evident or adverse events are considered serious. The primary outcome is a reduction in medicine-induced deterioration from baseline to 6 and 12 months, as measured by change in frailty index. The secondary outcomes are changes in cognition scores, 24-hour movement behaviour, grip strength, weight, percentage robust, pre-frail and frail classification, rate of adverse medicine events, health-related quality of life and health resource use. The statistical analysis will use mixed-models adjusted for baseline to account for repeated outcome measures. A health economic evaluation will be conducted following trial completion using data collected during the trial. ETHICS AND DISSEMINATION: Ethics approvals have been obtained from the Human Research Ethics Committee of University of South Australia (ID:0000036440) and University of Tasmania (ID:H0017022). A copy of the final report will be provided to the Australian Government Department of Health. TRIAL REGISTRATION NUMBER: Australian and New Zealand Trials Registry ACTRN12618000766213.

Prescribing of psychotropic medication for nursing home residents with dementia: a general practitioner survey.

OBJECTIVE: The aim of this study was to identify factors influencing the prescribing of psychotropic medication by general practitioners (GPs) to nursing home residents with dementia. SUBJECTS AND METHODS: GPs with experience in nursing homes were recruited through professional body newsletter advertising, while 1,000 randomly selected GPs from southeastern Australia were invited to participate, along with a targeted group of GPs in Tasmania. An anonymous survey was used to collect GPs' opinions. RESULTS: A lack of nursing staff and resources was cited as the major barrier to GPs recommending non-pharmacological techniques for behavioral and psychological symptoms of dementia (BPSD; cited by 55%; 78/141), and increasing staff levels at the nursing home ranked as the most important factor to reduce the usage of psychotropic agents (cited by 60%; 76/126). CONCLUSION: According to GPs, strategies to reduce the reliance on psychotropic medication by nursing home residents should be directed toward improved staffing and resources at the facilities.

Vitamin D Supplementation in Tasmanian Nursing Home Residents.

BACKGROUND: It is currently recommended in Australia that nursing home residents are supplemented daily with 1000 IU vitamin D as they are at an increased risk of fractures. Historically, supplementation has been low, and current supplementation prevalence is not known. OBJECTIVE: The aim of this study was to determine the prevalence of vitamin D supplementation amongst nursing home residents in Tasmania, Australia. METHODS: Resident data, including demographics, medical conditions and medications (including vitamin D and calcium supplement use), exercise and sun exposure, were obtained from residents' files and staff in consenting nursing homes. Dietary calcium intake was estimated from the weekly menu of one nursing home and total calcium intake estimated from this and calcium supplement use. The prevalence of vitamin D supplementation was compared by resident characteristics and fracture risk factors. RESULTS: Of 811 residents, 409 (50 %) received daily vitamin D supplementation of at least 1000 IU. Residents receiving vitamin D supplementation were slightly younger (mean 83 vs. 85 years for supplemented and unsupplemented groups, respectively, p = 0.003) and more likely to have osteoporosis (29 vs. 22 % for supplemented and unsupplemented groups, respectively, p = 0.019). Only 43 % of residents with osteoporosis received vitamin D supplements. Most residents (86 %) did not have regular sunlight exposure. The median estimated total calcium intake of 800 ± 275 mg daily was below guideline recommendations of 1000-1300 mg daily. CONCLUSIONS: The prevalence of vitamin D supplementation in nursing home residents was relatively low, suggesting poor adherence to the relevant clinical guidelines. Additionally, most residents do not access sunlight. Interventions addressing this evidence-practice gap are needed.