Pharmacist-delivered asthma management services-what do patients think?

BACKGROUND: Evaluating pharmacy services from the perspective of the end user-patients-is imperative for ensuring the sustainability of services. OBJECTIVES: This study evaluated patient feedback regarding an evidence-based community pharmacist-delivered Pharmacy Asthma Service (PAS), in terms of overall satisfaction, satisfaction with PAS delivery, and perceived impact, and explored determinates of satisfaction. METHODS: All patients who received the 12-month PAS (n = 143) were invited to provide feedback via a project-specific patient evaluation survey upon completion of the final consultation. The survey included a mix of 5-point Likert-type scale items, multiple-choice questions, and free-text response questions. Overall satisfaction was determined by a single 5-point Likert-type scale question. Satisfaction with service delivery and overall impact were assessed using a 4-item and 8-item Likert-type scale, respectively, and a summative score computed for each section. Patient PAS data including demographics and management outcomes were then cross tabulated against overall satisfaction, satisfaction with PAS delivery, and impact. RESULTS: Feedback was received from 71% (n = 101) of patients who completed the PAS. The results indicated high overall patient satisfaction, with 86% of respondents very satisfied with the service. Patients identified positive impacts of the PAS including improved understanding and management of asthma and allergic rhinitis. Similarly, almost all patients were satisfied with service delivery including the pharmacist's knowledge and their ability to assist (98%) and the privacy of the pharmacy setting (91%). Patients who had controlled asthma at the end of the trial had higher levels of overall satisfaction (χ2 = 9.584, df = 5, P = 0.048) and reported greater overall impact on asthma and allergic rhinitis management (U = 1593.5, P = 0.004). CONCLUSION: The diffusion of health services within community pharmacy practice is dependent upon patient receptivity and how the services align with patient needs. The positive satisfaction received indicates that the PAS would be welcomed by patients with asthma in future.

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.

Parental knowledge, beliefs and management of childhood fever in Australia: A nationwide survey.

WHAT IS KNOWN AND OBJECTIVE: Fever, one of the most common symptoms of illness experienced by children, often creates undue parental anxiety about the consequences of fever, which can lead to overtreatment. The full extent of this problem in Australia is not known. This study aimed to describe parents' knowledge, beliefs and perceptions about childhood fever and its management, and identify any predictors of the burden on parents when children are febrile. METHODS: This was a cross-sectional web-based survey of parents living in Australia. Parents with at least 1 child <6 years were recruited via Facebook. Demographic information, parental fever knowledge and beliefs and responses to the Parent Fever Management Scale, a measure of parental burden, were collected and analysed. RESULTS AND DISCUSSION: Of the 12 179 parents who completed the survey, 42.0% knew that a temperature above 38°C constitutes a fever, with 33.4% underestimating the temperature of a fever. Parents believed that there were many harms associated with untreated fever, namely seizures (71.8%), dehydration (63.6%), serious illness (43.0%) and brain damage (36.8%). Phobic beliefs were more common among parents who underestimated the temperature of a fever. Identification of health professionals as a main information source about fever did not significantly improve knowledge or reduce fears. Up to 65.0% of respondents indicated that they practice non-evidence-based strategies to reduce temperature. The belief that 'every child with a fever should be treated with medication to lower temperature' was the strongest predictor of parental burden (ß = 0.245, P < 0.001). WHAT IS NEW AND CONCLUSION: Poor parental knowledge and misconceptions surrounding fever and its management are still common among parents throughout Australia. Large-scale, sustainable educational interventions are needed to dispel misconceptions and concerns about fever, encourage appropriate and safe care of febrile children.

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.

Emergency department presentations of febrile children to an Australian public hospital.

AIM: We investigated the presentations of children with unspecified fever to an Australian emergency department (ED): (i) to determine the proportion of these presentations that could be classified as potentially avoidable and (ii) to identify factors associated with an increased risk of hospital admission. METHODS: This study retrospectively identified and described children aged <6 years who presented to the Royal Hobart Hospital (Tasmania, Australia) ED with unspecified fever (ICD-10-AM code R50.9) between January 2013 and December 2015, using data from the ED information system and digital medical records. The Australian Institute of Health and Welfare method was used to estimate the number of potentially avoidable general practitioner-type presentations. Predictors of hospital admission were determined using multivariate logistic regression. RESULTS: A total of 459 patients aged <6 years presented to the ED with a primary diagnosis description of unspecified fever. Of these, 30.7% were classed as potentially avoidable general practitioner-type presentations. Overall, 26.1% of presentations resulted in admission to hospital. Administration of intravenous fluids in the ED and a longer treat time were identified as significant predictors of a child with non-specific fever being admitted to hospital. Older age, administration of antipyretics in the ED and presentations triaged as semi-urgent and non-urgent significantly reduced the probability of admission. CONCLUSIONS: To our knowledge, this is the first Australian study that has assessed the impact of unspecified childhood fever on an Australian ED. Further investigation of presentations classified as potentially avoidable is warranted to investigate whether these could be managed in the primary care setting.

Factors associated with overestimation of asthma control: A cross-sectional study in Australia.

OBJECTIVE: To investigate actual and perceived disease control in Australians with asthma, and identify factors associated with overestimation of asthma control. METHODS: This was a cross-sectional study of Australian adults with asthma, who were recruited via Facebook to complete an online survey. The survey included basic demographic questions, and validated tools assessing asthma knowledge, medication adherence, medicine beliefs, illness perception and asthma control. Items that measured symptoms and frequency of reliever medication use were compared to respondents' self-rating of their own asthma control. Predictors of overestimation of asthma control were determined using multivariate logistic regression. RESULTS: Of 2971 survey responses, 1950 (65.6%) were complete and eligible for inclusion. Overestimation of control was apparent in 45.9% of respondents. Factors independently associated with overestimation of asthma control included education level (OR = 0.755, 95% CI: 0.612-0.931, P = 0.009), asthma knowledge (OR = 0.942, 95% CI: 0.892-0.994, P = 0.029), total asthma control, (OR = 0.842, 95% CI: 0.818-0.867, P < 0.001), agreement that most medications are addictive (OR = 1.144, 95% CI: 1.017-1.287, P = 0.025), and increased feelings of control over asthma (OR = 1.261, 95% CI: 1.191-1.335), P < 0.001). CONCLUSIONS: Overestimation of asthma control remains a significant issue in Australians with asthma. The study highlights the importance of encouraging patients to express their feelings about asthma control and beliefs about medicines, and to be more forthcoming with their asthma symptoms. This would help to reveal any discrepancies between perceived and actual asthma control.

Initial diagnosis and management of chronic obstructive pulmonary disease in Australia: views from the coal face.

BACKGROUND: Early diagnosis and management can mitigate the long-term morbidity and mortality of chronic obstructive pulmonary disease (COPD). AIMS: To gain insights into the initial diagnostic process and early management of COPD by Australian general practitioners (GP). METHODS: A random sample of Australian GP was invited to complete a postal survey, which assessed familiarity with and use of contemporary practice guidelines, diagnostic criteria and management preferences for COPD. RESULTS: A total of 233 GP completed the survey. While most GP based a COPD diagnosis on smoking history (94.4%), symptoms (91.0%) and spirometry (88.8%), only 39.9% of respondents recorded a formal diagnosis of COPD after the patient's first symptomatic presentation. Tiotropium was the preferred treatment in 77.3% of GP for the initial management of COPD, while only 27.5% routinely recommended pulmonary rehabilitation. GP routinely recorded patients' smoking status and offered smoking cessation advice, but the timing of this advice varied. Less than half of the respondents routinely used COPD management guidelines or tools and resources provided by the Australian Lung Foundation. CONCLUSION: There is scope for major improvement in GP familiarity with and use of COPD management guidelines and readily available tools and resources. Some systematic issues were highlighted in the Australian primary care setting, such as a reactive and relatively passive and delayed approach to diagnosis, potentially delayed smoking cessation advice and underutilisation of pulmonary rehabilitation. There is an urgent need to devise strategies for improving patient outcomes in COPD using resources that are readily available.

Adherence to management guidelines for childhood asthma in Australia.

BACKGROUND: Little is known about doctors' treatment preferences for childhood asthma. OBJECTIVE: The aim of this study was to investigate adherence to management guidelines for childhood asthma. METHODS: One thousand general practitioners (GPs) and paediatric specialists in Australia were invited to take part in a survey, which collected demographic details and explored their familiarity with and adherence to childhood asthma management guidelines. RESULTS: Two hundred doctors (20% response rate) responded and were eligible for inclusion in the survey. Approximately half (54.5%) of the respondents were very familiar with at least one of the childhood asthma management guidelines. The majority of respondents (86.8%) followed guideline recommendations when prescribing initial maintenance therapy for childhood asthma, while 89.2% and 68.0% followed guideline recommendations regarding step-up and step-down therapy respectively. DISCUSSION: Overall familiarity with childhood asthma management guidelines could be improved. There is scope for improvement in the adherence to these guidelines when prescribing medication in childhood asthma, particularly for step-down therapy.

Review of the management of childhood asthma in Tasmania.

AIM: To review the supply of medications to children with asthma and parent-reported management of childhood asthma in Tasmania and highlight evidence-practice gaps for future interventions. METHODS: Participating pharmacies ran a software application that extracted data from dispensing records and helped to identify children with asthma. Parents of identified children were mailed a survey evaluating components of asthma management. Dispensing and survey data were analysed. RESULTS: A total of 939 children from 23 pharmacies were identified by the software and deemed eligible for inclusion. Surveys were received from 353 (37.6%) parents. In the past year, short-acting beta-2 agonists were supplied to 56.1% of the cohort, preventers to 76.5% (inhaled corticosteroids 52.3%; leukotriene receptor antagonists 31.3%; inhaled cromones 0.6%), long-acting beta-2 agonists (LABAs) to 25.7% and oral corticosteroids to 21.5%. Approximately half of the children receiving inhaled corticosteroids were concurrently receiving a LABA. Among children with indicators of inadequately controlled asthma, up to 73.7% of their parents reported that their asthma was adequately controlled, up to 38.2% did not possess an Asthma Action Plan, up to 36.8% were not regularly using a spacer and up to 22.8% had not received a preventer. CONCLUSION: These results indicate gaps in childhood asthma management, in particular, undersupply of preventers in high-risk patient groups, high supply of LABAs and insufficient spacer and asthma action plan usage. These areas should be targeted for interventions to improve childhood asthma management.

Healthcare expenditure and its socio-demographic and clinical predictors in Australians with poorly controlled asthma.

INTRODUCTION: Asthma has substantial and increasing health and economic burden worldwide. This study aimed to estimate healthcare expenditure and determine the factors that increase expenditure in Australians with poorly controlled asthma. METHODS: Individuals ≥18 years of age with poorly controlled asthma, as determined by a score ≥1.5 on the Asthma Control Questionnaire, were included in the study. Healthcare utilization costs from medical services and medications were estimated over an average follow-up of 12 months from administratively linked data: the Medicare Benefits Schedule and Pharmaceutical Benefits Scheme. A generalized linear model with gamma distribution and log link was used to predict participants' key baseline characteristics associated with variations in healthcare costs. RESULTS: A total of 341 participants recruited through community pharmacies were included. The mean (standard deviation, SD) age of participants was 56.6 (SD 17.6) years, and approximately 71% were females. The adjusted average monthly healthcare expenditure per participant was $AU386 (95% CI: 336, 436). On top of the average monthly costs, an incremental expenditure was found for each year increase in age ($AU4; 95% CI: 0.78, 7), being unemployed ($AU201; 95% CI: 91, 311), one unit change in worsening quality of life ($AU35; 95% CI: 9, 61) and being diagnosed with depression and anxiety ($AU171; 95% CI: 36, 306). CONCLUSIONS: In a cohort of Australian patients, characterized by poor asthma control and co-morbidities individuals impose substantial economic burden in terms of Medicare funded medical services and medications. Programs addressing strategies to improve the quality of life and manage co-morbid anxiety and depression and encourage asthma patients' engagement in clinically tolerable jobs, may result in significant cost savings to the health system.

Persistence of Adverse Drug Reaction-Related Hospitalization Risk Following Discharge.

This retrospective cohort study analyzed the administrative hospital records of 91,500 patients with the aim of assessing adverse drug reaction (ADR)-related hospital admission risk after discharge from ADR and non-ADR-related admission. Patients aged ≥18 years with an acute admission to public hospitals in Tasmania, Australia between 2011 and 2015 were followed until May 2017. The index admissions (n = 91,550) were stratified based on whether they were ADR-related (n = 2843, 3.1%) or non-ADR-related (n = 88,707, 96.9%). Survival analysis assessed the post-index ADR-related admission risk using (1) the full dataset, and (2) a matched subset of patients using a propensity score analysis. Logistic regression was used to identify the risk factors for ADR-related admissions within 90 days of post-index discharge. The patients with an ADR-related index admission were almost five times more likely to experience another ADR-related admission within 90 days (p < 0.001). An increased risk persisted for at least 5 years (p < 0.001), which was substantially longer than previously reported. From the matched subset of patients, the risk of ADR-related admission within 90 and 365 days more than doubled in the patients with an ADR-related index admission (p < 0.0001). These admissions were often attributed to the same drug class as the patients' index ADR-related admission. Cancer was a major risk factor for ADR-related re-hospitalization within 90 days; other factors included heart failure and increasing age.

Hospital Readmission Due to Chronic Obstructive Pulmonary Disease: A Longitudinal Study.

BACKGROUND: This study aimed to investigate the prevalence of hospital readmission for chronic obstructive pulmonary disease (COPD) at 30, 90 and 365 days, and to determine demographic and socioeconomic risk factors for 30-day and 90-day readmission and time to COPD-related readmission within 365 days in Tasmania. METHODS: Patients ≥40 years admitted for COPD between 2011 and 2015 were identified using administrative data from all major public hospitals in Tasmania, Australia. Factors associated with readmission and time to readmission were identified using logistic and Cox regression, respectively. RESULTS: The rates of COPD-related readmission were 6.7% within 30 days, 12.2% within 90 days and 23.7% within 365 days. Being male (odds ratio [OR]: 1.49, CI: 1.06-2.09), Indigenous (OR: 2.47, CI: 1.31-4.66) and living in the lower socioeconomic North-West region of Tasmania (OR: 1.80, CI: 1.20-2.69) were risk factors for 30-day readmission. Increased COPD-related (OR: 1.48, CI: 1.22-1.80; OR: 1.52, CI: 1.29-1.78) and non-COPD-related (OR: 1.12, CI: 1.03- 1.23; OR: 1.11, CI: 1.03-1.21) emergency department (ED) visits in the preceding six months were risk factors for both 30-day and 90-day readmissions. Being Indigenous (hazard ratio [HR]: 1.61, CI: 1.10-2.37) and previous COPD-related ED visits (HR: 1.30, CI: 1.21-1.39) decreased, while a higher Charlson Comorbidity Index (CCI) (OR: 0.91, CI: 0.83- 0.99) increased the time to readmission within 365 days. CONCLUSION: Being male, Indigenous, living in the North-West region and previous ED visits were associated with increased risk of COPD readmission in Tasmania. Interventions to improve access to primary healthcare for these groups may reduce COPD-related readmissions.

Integrating Pharmacy and Registry Data Strengthens Clinical Assessments of Patient Adherence.

Background: Accurate clinical assessment of patient adherence using reliable and valid measures is essential in establishing the presence of adherence issues and support practices for pharmacists. Objective: This investigation aims to conduct a novel assessment of patient adherence to asthma controller therapy by combining 1) patient-specific dosage data found in pharmacy dispensing data with 2) centrally collected administrative claims records, to determine the added value of using both sources of data. Methods: A total of 381 clinically uncontrolled asthma patients, from 95 community pharmacies across three Australian States were recruited and provided consent for the retrieval of their claims records and pharmacy dispensing data. Patients were stratified as multiple or single pharmacy users and adherence scores were calculated via the proportion of days covered (PDC) method using 1) patient claims records, 2) patient pharmacy dispensing data, and 3) combined claims records and pharmacy dispensing data. Cohort and subgroup adherence estimates were then compared. Results: Low levels of adherence were evident amongst the cohort irrespective of the data source used. PDC estimates based on claims records alone or combined claims records and pharmacy dispensing data were significantly higher than estimates based on pharmacy dispensing data for the total cohort (56%, 52%, 42% respectively, p < 0.001) and more noticeably for multiple pharmacy users (67%, 64%, 35% respectively, p < 0.001). PDC estimates based on combined claims records and pharmacy dispensing data were significantly lower than estimates based on claims records alone, indicating that perhaps standard daily dose is not a robust proxy for prescribed dosage to inhaled respiratory devices in adherence approximations. Poorer adherence was found amongst single pharmacy users than multiple pharmacy users when combined claims records and pharmacy dispensing data (46% compared to 64% respectively, p < 0.001) or claims records alone (51% compared to 67% respectively, p < 0.001) were compared. Conclusion: Access to routine collected data increases clinical acuity over patient adherence to asthma controller medications and is a valuable resource for health care professionals. A policy of secure accessibility of such data at the patient-pharmacist or patient-GP interface may allow real-time intervention and assist in decision making across numerous therapeutic areas.

Patient uptake and outcomes following pharmacist-initiated referrals to general practitioners for asthma review.

Uptake and outcomes of pharmacist-initiated general practitioner (GP) referrals for patients with poorly controlled asthma were investigated. Pharmacists referred at-risk patients for GP assessment. Patients were categorized as action takers (consulted their GP on pharmacist's advice) or action avoiders (did not action the referral). Patient clinical data were compared to explore predictors of uptake and association with health outcomes. In total, 58% of patients (n = 148) received a GP referral, of whom 78% (n = 115) were action takers, and 44% (n = 50) reported changes to their asthma therapy. Patient rurality and more frequent pre-trial GP visits were associated with action takers. Action takers were more likely to have an asthma action plan (P = 0.001) at month 12, and had significantly more GP visits during the trial period (P = 0.034). Patient uptake of pharmacist-initiated GP referrals was high and led to GP review and therapy changes in patients with poorly controlled asthma.

Rethinking the gold standard - The feasibility of randomized controlled trials within health services effectiveness research.

BACKGROUND: An evidence-based randomized controlled trial for a novel Pharmacy Asthma Service was tested in 3 Australian states. Positive asthma outcomes were achieved after the 12-month intervention, albeit in both the intervention and comparator arms. The current investigation uses a mixed methods approach to 1) qualitatively explore how comparator arm pharmacists implemented the trial protocol and 2) quantitatively examine how this may have impacted patient outcomes in this trial. METHODS: Post-intervention semi-structured qualitative interviews were conducted with 20 pharmacists, representing 21 of 37 (57%) comparator arm pharmacies that completed the trial. Based on these interviews, pharmacies were classified as 'adherent' to the trial protocol (reporting no interventions other than general practitioner referral) or 'non-adherent' (reporting at least one extra intervention to the trial protocol), or 'inconclusive'. These subgroups were compared descriptively in relation to patient outcomes. RESULTS: Overall, 33% (n = 8/24) of the comparator pharmacies who were interviewed (n = 21) or determined to have monitoring by a project officer to ensure adherence to the protocol (n = 3) were classified as adherent), 58% (n = 14/24) as non-adherent, 8% inconclusive (n = 2/24). While all patients commenced with uncontrolled asthma (Asthma Control Questionnaire score (ACQ) > 1.5), after 12 months the mean ACQ score for patients from adherent comparator pharmacies ('true control') was 1.8 (still uncontrolled asthma) compared to a score of 1.4 (controlled asthma) in the non-adherent comparator group. Quality of life significantly improved in the non-adherent comparator group over the 12 months of the trial. CONCLUSION: The majority of pharmacists in the comparator arm who were interviewed, introduced their own interventions, which may have influenced the outcomes of the trial. The naturalistic setting of the study was not protective against these confounders. These findings question the feasibility of comparator arms within primary care settings and that alternative study designs should be considered when designing future intervention studies in pharmacy practice.

A Multi-Mode Education Program to Enhance Asthma Care by Pharmacists.

Objective. To provide optimal asthma care, community pharmacists must have advanced, contemporary knowledge, and the skills to translate that knowledge into practice. The development and evaluation of an innovative multi-mode education program to enhance pharmacists' clinical knowledge and practical skills is described.Methods. The online education modules were collaboratively developed alongside asthma and pharmacy organizations. The education program was comprised of five evidence-based education modules delivered online and a skills review conducted either in-person with real-time feedback (urban pharmacists) or via video upload and scheduled video-conference feedback (regional and remote pharmacists). A mixed methods approach was used to evaluate the feedback obtained from pharmacists to assess the content, efficacy, and applicability of the education.Results. Ninety-seven pharmacists opted into the program and successfully completed all education requirements. A larger proportion of pharmacists did not pass trial protocol-based education modules on their first attempts compared to the number that passed the asthma and medication knowledge-based modules. Prior to skills review, the proportion of pharmacists demonstrating device technique competency was suboptimal. Pharmacists rated the education modules highly in both quantitative and qualitative evaluations and reported that the program adequately prepared them to better deliver care to asthma patients.Conclusion. We developed, implemented, and evaluated a novel multi-mode asthma education program for community pharmacists that supports knowledge and practical skill development in this crucial area of patient care. The education program was well received by pharmacists. This form of education could be used more broadly in international collaborative trials.

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.

Implementation of mouth rinsing after use of inhaled corticosteroids in Australia.

BACKGROUND: Clinical guidelines recommend that patients using inhaled corticosteroids should rinse their mouth following inhalation. There is however, a paucity of research regarding patient implementation of this recommendation and the impact it has on the occurrence of adverse effects. OBJECTIVE: The aim of this study was to determine how well patients implement mouth rinsing after using inhaled corticosteroids in practice and their understanding of the rationale, information sources and the impact of mouth rinsing on adverse effects. SETTING: Australians aged 18 years and over with a diagnosis of asthma and/or chronic obstructive pulmonary disease who were currently using an inhaled corticosteroid. METHOD: Participants were recruited via Facebook to complete an online survey. MAIN OUTCOME MEASURE: Implementation of a mouth rinse which aligned to current guideline recommendations. RESULTS: Of 380 eligible responses, 30.5% of patients reported suboptimal mouth rinsing after using inhaled corticosteroids. Receiving advice on mouth rinsing from a healthcare professional increased the likelihood of correct implementation (P < 0.001) and improved patient understanding of the rationale (P = 0.01). Whilst most (90.0%) patients were aware rinsing may reduce oropharyngeal adverse effects, few (5.5%) were aware of its potential to reduce systemic adverse effects. Patients were more likely to report their rinsing procedure had a positive impact if they had experienced oral candidiasis (P < 0.001) or sore mouth/throat (P = 0.01), compared to cough or hoarse voice. CONCLUSION: Almost one-third of patients reported a suboptimal mouth rinsing procedure after using an inhaled corticosteroid. Interventions are required to improve awareness and correct implementation of mouth rinsing.