Development of a list of Australian potentially inappropriate medicines using the Delphi technique.

BACKGROUND: Older people are at high risk of medicines-related harms. otentially inappropriate medicines (PIMs) list has been developed to assist clinicians and researchers to identify medicines with risks that may potentially outweigh their benefits in order to improve medication management and safety. AIM: To develop a list of PIMs for older people specific to Australia. METHODS: The study obtained expert consensus through the utilisation of the Delphi technique in Australia. A total of 33 experts partook in the initial round, while 32 experts engaged in the subsequent round. The primary outcomes encompass medicines assessed as potentially inappropriate, the specific contexts in which their inappropriateness arises and potentially safer alternatives. RESULTS: A total of 16 medicines or medicine classes had one or more medicines deemed as potentially inappropriate in older people. Up to 19 medicines or medicine classes had specific conditions that make them more potentially inappropriate, while alternatives were suggested for 16 medicines or classes. CONCLUSION: An explicit PIMs list for older people living in Australia has been developed containing 19 drugs/drug classes. The PIMs list is intended to be used as a guide for clinicians when assessing medication appropriateness in older people in Australian clinical settings and does not substitute individualised treatment advice from clinicians.

Australian dental students' knowledge on antibiotics prophylaxis for dental procedures.

BACKGROUND: Prescribing medicine is integral to clinical dentistry. Infective endocarditis may be rare but fatal if left untreated. As a result, judicious prescribing of antibiotics should be implemented due to potential. To our knowledge, no Australian study has examined dental students' knowledge and perceptions about antibiotic prophylaxis for dental procedures. METHODS: Australian dental students were invited to undertake the survey comprising case vignettes to investigate their medication knowledge. A total of 117 responses were received. The questions were 12 clinically relevant questions and three perception-based questions. Results were analysed using descriptive statistics as well as the chi-squared test. RESULTS: The 117 respondents had a mean correct response of 7.34 ± 2.64 (range 3-12 out of 12). Out of 117 students, 89 (76%) answered more than half of the questions correctly. Only three students (3%) answered all the questions correctly. Nearly two-thirds felt that they knew about antibiotic prophylaxis used for dental procedures. CONCLUSION: Most respondents answered more than half, but not all, of the clinical questions correctly. It is crucial to highlight that dental student may never receive any more training on antimicrobial stewardship (AMS) at any point in their future careers. It may be ideal that this issue is addressed at the dental school. One way to target this is to potentially nationalised teaching delivery of dental AMS across Australia.

The influence of patients' beliefs about medicines and the relationship with suboptimal medicine use in community-dwelling older adults: a systematic review of quantitative studies.

BACKGROUND: Medication use in older adults is increasing, therefore, reducing the risk of suboptimal medicine use is imperative in achieving optimal therapeutic outcomes. Research suggests that factors such as personal beliefs and beliefs about medicines may be associated with non-adherence and inappropriate medicine use. AIM: To systematically review and identify quantitative research on the influence of beliefs about medicines and the relationship with suboptimal medicine use in older adults. METHOD: Searches were conducted on PubMed, EMBASE, CINAHL, and PsycINFO for quantitative studies (inception to March 2023). INCLUSION CRITERIA: (1) exposure: participants' beliefs (personal, cultural, and medication-related), (2) outcomes: polypharmacy, potentially inappropriate medicines use, or non-adherence, and (3) participants: community-dwelling adults 65 years or above. Study selection, data extraction and quality appraisal (Joanna Briggs Institute critical appraisal checklist) were completed independently by two investigators. Data were combined in a narrative synthesis and presented in a summary of findings table. RESULTS: Nineteen articles were included: 15 cross-sectional and four cohort studies. Outcomes of included papers were as follows; adherence (n = 18) and potentially inappropriate medicine use (n = 1). Ten studies found stronger beliefs in the necessity of medicines and/or fewer concerns led to better adherence, with one paper contradicting these findings. Three studies did not find associations between adherence and beliefs. One study confirmed an association between unnecessary drug use and a lack of belief in a "powerful other" (e.g. doctor). CONCLUSION: Further investigation is necessary to (1) ascertain the importance of necessity or concern beliefs in fostering adherence and, (2) examine the influence of beliefs on polypharmacy and inappropriate medicine use.

Malignant and non-malignant oral lesions classification and diagnosis with deep neural networks.

OBJECTIVES: Given the increasing incidence of oral cancer, it is essential to provide high-risk communities, especially in remote regions, with an affordable, user-friendly tool for visual lesion diagnosis. This proof-of-concept study explored the utility and feasibility of a smartphone application that can photograph and diagnose oral lesions. METHODS: The images of oral lesions with confirmed diagnoses were sourced from oral and maxillofacial textbooks. In total, 342 images were extracted, encompassing lesions from various regions of the oral cavity such as the gingiva, palate, and labial mucosa. The lesions were segregated into three categories: Class 1 represented non-neoplastic lesions, Class 2 included benign neoplasms, and Class 3 contained premalignant/malignant lesions. The images were analysed using MobileNetV3 and EfficientNetV2 models, with the process producing an accuracy curve, confusion matrix, and receiver operating characteristic (ROC) curve. RESULTS: The EfficientNetV2 model showed a steep increase in validation accuracy early in the iterations, plateauing at a score of 0.71. According to the confusion matrix, this model's testing accuracy for diagnosing non-neoplastic and premalignant/malignant lesions was 64% and 80% respectively. Conversely, the MobileNetV3 model exhibited a more gradual increase, reaching a plateau at a validation accuracy of 0.70. The MobileNetV3 model's testing accuracy for diagnosing non-neoplastic and premalignant/malignant lesions, according to the confusion matrix, was 64% and 82% respectively. CONCLUSIONS: Our proof-of-concept study effectively demonstrated the potential accuracy of AI software in distinguishing malignant lesions. This could play a vital role in remote screenings for populations with limited access to dental practitioners. However, the discrepancies between the classification of images and the results of "non-malignant lesions" calls for further refinement of the models and the classification system used. CLINICAL SIGNIFICANCE: The findings of this study indicate that AI software has the potential to aid in the identification or screening of malignant oral lesions. Further improvements are required to enhance accuracy in classifying non-malignant lesions.

Australian community pharmacists' ability to identify the indications for dental prescriptions-a case vignette study.

OBJECTIVES: Pharmacists are known as medicine experts. Dentists can independently prescribe and administer medications related to dental conditions such as antimicrobials, anti-inflammatories and analgesics. However, little is known about pharmacists' knowledge and perceptions of medicines prescribed for dentistry. Therefore, this study aimed to assess community pharmacists' ability to identify the indications for dental prescriptions using hypothetical vignettes. METHODS: Australian community pharmacists were invited through email and social media to undertake a web-based questionnaire consisting of nine case vignettes of dental prescriptions and their indicated uses in dental settings and two perception-based questions. The results were provided as a percentage of the correct answers to the case vignettes. In addition, Pearson chi-square tests were performed to examine associations between categorical variables. KEY FINDINGS: Of the 202 pharmacists who completed the questionnaire, the mean number of correct responses was 5 ± 2 (out of 9). More than three-quarters (78.5%) of pharmacists believed that thorough knowledge of prescriptions for dental ailments was necessary for safe and effective community pharmacy practice. In addition, nearly two-thirds (64.1%) felt confident that they could dispense medicines indicated for dental conditions safely and effectively. CONCLUSIONS: The knowledge demonstrated by participants through correct identification of the indications for dental prescription was less than optimal. Professional development courses for pharmacists in dental ailments could prove beneficial.

Mild cognitive impairment: To diagnose or not to diagnose.

Older people living with mild cognitive impairment (MCI) have a slight but noticeable decline in their cognitive function, though do not meet the diagnostic criteria for dementia. MCI is controversial, with some saying it is a condition that does not require diagnosis, and others stating that it is a genuine clinical syndrome. Many people with MCI will improve, and most will not progress to dementia. Managing co-morbidities and exercising are likely to be the best treatment options. With limited evidence for effective interventions and uncertainty as to the prognostic value of the condition, the benefit of diagnosing MCI remains unclear.

Use of Falls Risk Increasing Drugs in Residents at High and Low Falls Risk in Aged Care Services.

Falls are associated with considerable morbidity and mortality in aged care services and falls risk increasing drugs (FRIDs) are often overlooked as a contributor to falls. This study aims to investigate the association between the risk of falling and use of FRIDs from aged care services. Inverse-probability-weighted multinomial logistic regression was used to estimate the association between falls risk and regular FRIDs in 383 residents from six Australian aged care services. Overall, residents at high and low falls risk had similar prevalence of FRIDs. Prevalence of antipsychotics and sedative-hypnotics was low. Residents at high falls risk had higher adjusted odds of using ≥2 psychotropic medications (odds ratio [OR] = 1.75, 95% confidence interval [CI] = 1.17-2.61) and ≥2 medications that cause/worsen orthostatic hypotension (OR = 3.59, 95% CI = 2.27-5.69). High prevalence of FRIDs was mainly attributable to medications for which residents had clinical indications. Clinicians appeared to have largely avoided FRIDs that explicit criteria deem potentially inappropriate for high falls risk.

Statin use and fall-related hospitalizations among residents of long-term care facilities: A case-control study.

BACKGROUND: Statins are associated with muscle-related adverse events, but few studies have investigated the association with fall-related hospitalizations among residents of long-term care facilities (LTCFs). OBJECTIVE: The objective of the study is to investigate whether statin use is associated with fall-related hospitalizations from LTCFs. METHODS: A case-control study was conducted among residents aged ≥65 years admitted to hospital from 2013 to 2015. Cases (n = 332) were residents admitted for falls and fall-related injuries. Controls (n = 332) were selected from patients admitted for reasons other than cardiovascular and diabetes. Cases and controls were matched 1:1 by age (±2 years), index date of admission (±6 months), and sex. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated using conditional logistic regression, after considering for history of falls, hypertension, dementia, functional comorbidity index, polypharmacy (≥9 regular preadmission medications), and fall-risk medications. Subanalyses were performed for individual statins, dementia, and statin intensity. RESULTS: Overall, 43.1% of cases and 27.1% of controls used statins. Statins were associated with fall-related hospitalizations (aOR = 2.24, 95% CI 1.56-3.23), in particular simvastatin (aOR = 2.26, 95% CI 1.22-4.20) and atorvastatin (aOR = 2.08, 95% CI 1.33-3.24). Statins were associated with fall-related hospitalizations in residents with (aOR = 2.34, 95% CI 1.33-4.11) and without dementia (aOR = 2.30, 95% CI 1.46-3.63). There was no association between statin intensity and fall-related hospitalizations (aOR = 0.78, 95% CI 0.43-1.40). CONCLUSION: This study suggests a possible association between statin use and fall-related hospitalizations among residents living in LTCFs. However, there was minimal evidence for a relationship between statin intensity and fall-related hospitalizations. Further research is required to substantiate these hypothesis-generating findings.

Process, impact and outcomes of medication review in Australian residential aged care facilities: A systematic review.

OBJECTIVE: To systematically review literature reporting processes, impact and outcomes of medication review and reconciliation in Australian residential aged care facilities (RACFs). METHODS: PubMed/MEDLINE, EMBASE, CINAHL, Informit Health and grey literature were searched from 1995 to July 2018. Studies reporting outcomes of a stand-alone medication review or reconciliation interventions in Australian RACFs were included. RESULTS: Thirteen studies investigated medication review, eight of which studied Residential Medication Management Reviews (RMMRs). Five studies reported that medication reviews identified an average of 2.7-3.9 medication-related problems (MRPs) per resident. One study reported medication reviews had no impact on quality of life, hospitalisation or mortality, but was not powered to assess these. Three studies reported general practitioners' acceptance of pharmacists' recommendations to resolve MRPs, ranging between 45 and 84%. CONCLUSIONS: Medication review may be a useful strategy to identify and prompt resolution of MRPs. However, the impact on clinical and resident-centred outcomes remains unclear.

Proton Pump Inhibitors and Infection-Related Hospitalizations Among Residents of Long-Term Care Facilities: A Case-Control Study.

OBJECTIVE: Our objective was to investigate associations between proton pump inhibitor (PPIs) use and infection-related hospitalizations among residents of long-term care facilities (LTCFs). METHODS: This was a case-control study of residents aged ≥ 65 years admitted to hospital between July 2013 and June 2015. Residents admitted for infections (cases) and falls or fall-related injuries (controls) were matched for age (± 2 years), sex, and index date of admission (± 6 months). Conditional logistic regression was used to estimate crude and adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for associations between PPI use and infection-related hospitalizations. Analyses were adjusted for age, sex, polypharmacy, diabetes, heart failure, chronic obstructive pulmonary disease, myocardial infarction, cerebrovascular accident, and concomitant use of cancer and immunosuppressant medications. Subgroup analyses were performed for high- and low/moderate-intensity PPIs and for respiratory and non-respiratory infections. Logistic regression was used to compare the odds of infection-related hospitalizations among users of high- and low/moderate-intensity PPIs. RESULTS: Overall, 181 cases were matched to 354 controls. Preadmission PPI use was associated with infection-related hospitalizations (aOR 1.66; 95% CI 1.11-2.48). In subgroup analyses, the association was apparent only for respiratory infections (aOR 2.26; 95% CI 1.37-3.73) and high-intensity PPIs (aOR 1.93; 95% CI 1.23-3.04). However, the risk of infection-related hospitalization was not significantly higher among users of high- versus low/moderate-intensity PPIs (aOR 1.25; 95% CI 0.74-2.13). CONCLUSION: Residents who use PPIs may be at increased risk of infection-related hospitalizations, particularly respiratory infections. Study findings provide further support for initiatives to minimize unnecessary PPI use in the LTCF setting.

Medications and Prescribing Patterns as Factors Associated with Hospitalizations from Long-Term Care Facilities: A Systematic Review.

BACKGROUND: Residents of long-term care facilities (LTCFs) are at high risk of hospitalization. Medications are a potentially modifiable risk factor for hospitalizations. OBJECTIVE: Our objective was to systematically review the association between medications or prescribing patterns and hospitalizations from LTCFs. METHODS: We searched MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and International Pharmaceutical Abstracts (IPA) from inception to August 2017 for longitudinal studies reporting associations between medications or prescribing patterns and hospitalizations. Two independent investigators completed the study selection, data extraction and quality assessment using the Joanna Briggs Institute Critical Appraisal Tools. RESULTS: Three randomized controlled trials (RCTs), 22 cohort studies, five case-control studies, one case-time-control study and one case-crossover study, investigating 13 different medication classes and two prescribing patterns were included. An RCT demonstrated that high-dose influenza vaccination reduced all-cause hospitalization compared with standard-dose vaccination (risk ratio [RR] 0.93; 95% confidence interval [CI] 0.88-0.98). Another RCT found no difference in hospitalization rates between oseltamivir as influenza treatment and oseltamivir as treatment plus prophylaxis (treatment = 4.7%, treatment and prophylaxis = 3.5%; p = 0.7). The third RCT found no difference between multivitamin/mineral supplementation and hospitalization (odds ratio [OR] 0.94; 95% CI 0.74-1.20) or emergency department visits (OR 1.05; 95% CI 0.76-1.47). Two cohort studies demonstrated influenza vaccination reduced hospitalization. Four studies suggested polypharmacy and potentially inappropriate medications (PIMs) increased all-cause hospitalization. However, associations between polypharmacy (two studies), PIMs (one study) and fall-related hospitalizations were inconsistent. Inconsistent associations were found between psychotropic medications with all-cause and cause-specific hospitalizations (11 studies). Warfarin, nonsteroidal anti-inflammatory drugs, pantoprazole and vinpocetine but not long-term acetylsalicylic acid (aspirin), statins, trimetazidine, digoxin or ß-blockers were associated with all-cause or cause-specific hospitalizations in single studies of specific resident populations. Most cohort studies assessed prevalent rather than incident medication exposure, and no studies considered time-varying medication use. CONCLUSION: High-quality evidence suggests influenza vaccination reduces hospitalization. Polypharmacy and PIMs are consistently associated with increased all-cause hospitalization.

Prioritizing interventions to manage polypharmacy in Australian aged care facilities.

BACKGROUND: Polypharmacy is highly prevalent in residential aged care facilities (RACFs). Although polypharmacy is sometimes unavoidable, polypharmacy has been associated with increased morbidity and mortality. OBJECTIVE: To identify and prioritize a range of potential interventions to manage polypharmacy in RACFs from the perspectives of health care professionals, health policy and consumer representatives. METHODS: Two nominal group technique (NGT) sessions were convened in August 2015. A purposive sample (n = 19) of clinicians, researchers, managers and representatives of consumer, professional and health policy organizations were asked to nominate interventions to address the prevalence and appropriateness of medication use. Participants were then asked to prioritize five interventions suitable for possible implementation at the system level. RESULTS: Six of 16 potential interventions were prioritized highest for possible implementation in clinical practice, with two interventions prioritized as second highest. The top interventions in rank order were 'implementation of a pharmacist-led medication reconciliation service for new residents,' 'conduct facility-level audits and feedback to staff and health care professionals,' 'develop deprescribing scripts to assist clinician-resident discussion,' 'develop or revise prescribing guidelines specific to older people with multimorbidity in RACFs,' 'implement electronic medication charts and records' and 'better support Medication Advisory Committees (MACs) to address medication appropriateness.' CONCLUSION: This study prioritized a range of potential interventions that may be used to assist clinicians and policy makers develop a comprehensive strategy to manage polypharmacy in RACFs.