Unplanned Rehospitalisation due to Medication Harm following an Acute Myocardial Infarction.

INTRODUCTION: The contribution of medication harm to rehospitalisation and adverse patient outcomes after an acute myocardial infarction (AMI) needs exploration. Rehospitalisation is costly to both patients and the healthcare facility. Following an AMI, patients are at risk of medication harm as they are often older and have multiple comorbidities and polypharmacy. This study aimed to quantify and evaluate medication harm causing unplanned rehospitalisation after an AMI. METHODS: This was a retrospective cohort study of patients discharged from a quaternary hospital post-AMI. All rehospitalisations within 18 months were identified using medical record review and coding data. The primary outcome measure was medication harm rehospitalisation. Preventability, causality, and severity assessments of medication harm were conducted. RESULTS: A total of 1,564 patients experienced an AMI, and 415 (26.5%) were rehospitalised. Eighty-nine patients (5.7% of total population; 6.0% of those discharged) experienced a total of 101 medication harm events. Those with medication harm were older (p = 0.007) and had higher rates of heart failure (p = 0.005), chronic kidney disease (p = 0.046), chronic obstructive pulmonary disease (p = 0.037), and a prior history of ischaemic heart disease (p = 0.005). Gastrointestinal bleeding, acute kidney injury, and hypotension were the most common medication harm events. Forty percent of events were avoidable, and 84% were classed as "serious." Furosemide, antiplatelets, and angiotensin-converting enzyme inhibitors were the most commonly implicated medications. The median time to medication harm rehospitalisation was 79 days (interquartile range: 16-200 days). CONCLUSION: Medication harm causes unplanned rehospitalisation in 5.7% of all AMI patients (1 in 17 patients; 6.0% of those discharged). The majority of harm was serious and occurred within the first 200 days of discharge. This study highlights that measures to attenuate the risk of medication harm rehospitalisation are essential, including post-discharge medication management.

Advanced-scope pharmacist roles in medical outpatient clinics: a cost-consequence analysis.

BACKGROUND: There is a growing body of evidence that supports the clinical effectiveness of pharmacist roles in outpatient settings. However, limited studies have investigated the economic efficiency of advanced-scope outpatient pharmacist roles, particularly in the Australian setting. Assessing the overall costs and benefits of these outpatient pharmacist roles is needed to ensure service sustainability. AIMS: To use a cost-consequence approach to evaluate the advanced-scope outpatient pharmacist roles across multiple clinic disciplines from the hospital perspective. METHODS: A cost-consequence analysis was undertaken using data from a previous clinical-effectiveness study. All outpatient pharmacist consults conducted from 1 June 2019 to 31 May 2020 across 18 clinic disciplines were evaluated. Consequences from the pharmacist services included number of consults conducted, number of medication-related activities and number of resolved recommendations. RESULTS: The overall cost to the hospital for the outpatient pharmacist service across all clinics was AU$1 991 122, with a potential remuneration of AU$3 895 247. There were 10 059 pharmacist consults undertaken for the 12-month period. Medication-related activities performed by pharmacists primarily included 6438 counselling and education activities and 4307 medication list activities. When the specialist pharmacist roles were added to the outpatient clinics, several health service benefits were also realised. CONCLUSIONS: The addition of pharmacist roles to outpatient clinics can increase the cost of services; however, they also can increase medication optimisation activities. Future research should examine a societal perspective that includes broader cost and effectiveness outcomes. This study could justify the implementation of advanced-scope outpatient pharmacist roles in other Australian hospitals.

Prevalence of risk factors for venous thromboembolism and aspirin resistance in Australian patients undergoing total hip and knee arthroplasty.

INTRODUCTION: Aspirin is used for venous thromboembolism (VTE) prophylaxis after total hip and knee arthroplasty (THA/TKA). However, its efficacy is unclear in patients with multiple VTE risk factors and at risk of aspirin resistance (AR). BACKGROUND AND AIMS: To determine the prevalence of risk factors for VTE and AR in patients after THA/TKA and to determine the relationship between risk factors and drugs prescribed for thromboprophylaxis. METHODS: A retrospective cohort study of elective-THA/TKA in six Australian hospitals over a 1-year period. Medical records were manually reviewed to determine demographics, thromboprophylaxis regimen and presence of risk factors. The relationship between individual and cumulative risk factors with the thromboprophylaxis regimen was determined. RESULTS: In total, 1011 patients were included with a mean (SD) age of 65.9 (±11.0) years, and 56.4% were female. The five most prevalent risk factors were obesity (59.1%), age ≥65 years (58.2%), hypertension (45.3%), dyslipidaemia (35.9%) and diabetes (19.7%). Most patients had ≥1 risk factor for VTE (93.6%) and AR (93.6%), with 49.0% and 35.0% having ≥3 concurrent VTE and AR risk factors, respectively. The only significant relationship between risk factors and drugs was diabetes (P < 0.01). Rivaroxaban was more commonly used as the number of concurrent VTE risk factors increased (P < 0.05). CONCLUSION: Patients had a high prevalence of VTE and AR risk factors, suggesting aspirin may not be beneficial in many patients. Only diabetes was linked to the selection of thromboprophylaxis. Patients who received rivaroxaban had a greater average number of VTE risk factors. Guidelines should promote individualised prescribing in higher-risk patients.

Impact of pharmacists during in-hospital resuscitation or medical emergency response events: A systematic review.

BACKGROUND: We sought to determine the impact of the presence of a pharmacist on medication and patient related outcomes during the emergency management of critically ill patients requiring resuscitation or medical emergency response team care in a hospital setting. METHODS: We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search of databases from January 1995 to April 2023 was conducted to identify studies of contemporary pharmacist practice. Results were extracted and analysed for included studies, those evaluating the impact of the presence of a pharmacist on medication and patient related outcomes during the emergency management of critically ill hospitalised patients requiring resuscitation or medical emergency response team care. To determine risk of bias, the Newcastle-Ottowa Quality Assessment scale was used for non-randomised studies and the Revised Cochrane risk-of-bias tool for randomised trials. RESULTS: Of 1345 studies identified, 54 were selected for full text review, and 30 were included in the final analysis. There were 29 cohort studies and one randomised controlled trial. The studies reported the impact of a pharmacist for a variety of patient presentations. The study team assigned each study to one of eight patient cohorts: acute stroke, cardiac arrest, rapid response calls, S-T segment elevation myocardial infarction, acute haemorrhage, major trauma resuscitation, sepsis and status epilepticus. The most frequently reported outcome, associated with a statistically significant benefit in 23 studies, was time to medication administration. Few studies reported a significant difference in patient outcome measures such as mortality. Only 8 of the 30 studies were assessed to have a low risk of bias. CONCLUSIONS: The results of this systematic review provide support for a beneficial impact of a pharmacist presence and intervention during resuscitation or medical emergency response team care, with significant improvements in outcomes such as time to initiation of time-critical medications, medication appropriateness and guideline compliance. However, studies were predominantly small and retrospective and were not powered to detect differences in patient related measures such as length of stay and mortality. Future research should investigate the clinical impacts of the pharmacist in ED resuscitation settings in controlled, prospective studies with robust sampling methods.

Pharmacists reducing medication risk in medical outpatient clinics: a retrospective study of 18 clinics.

BACKGROUND: The role of pharmacists in hospital inpatient settings is well recognised; however, pharmacists are relatively new to outpatient clinic settings in Australia. Evidence to justify the clinical effectiveness of pharmacists, in terms of identifying and resolving medication-related problems in an outpatient setting in Australia is limited. AIMS: To investigate the clinical effectiveness of outpatient clinic pharmacists across multiple medical disciplines. METHODS: A retrospective observational study was conducted by auditing medical records for patients who had an outpatient clinic pharmacist consult between June 2019 and February 2020 in a large quaternary hospital. All pharmacist recommendations targeting a medication-related problem were audited. Recommendations were considered 'resolved' if accepted and actioned by the patient and/or a clinician. The resolved recommendations were risk rated using a validated tool for medication-related patient harm. RESULTS: There were 18 clinic pharmacist roles across multiple medical disciplines, of which 46 pharmacists conducted outpatient consults. A total of 7599 consults was conducted and a purposeful random sample of 572 (8%) consults was audited for 552 unique patients. There were 399 recommendations recorded in the notes by clinic pharmacists, a mean (standard deviation) of 0.95 (0.97) per patient. Of these, 328 (82%) were resolved; 269 (82%) were classified as low or moderate risk and 59 (18%) were classified as high-risk recommendations. CONCLUSIONS: Clinic pharmacists in multidisciplinary outpatient clinics are effective at identifying and resolving medication-related problems. Our research demonstrated that 18% of these resolved recommendations prevented a high-risk medication-related harm event.

Evaluation of two European risk models for predicting medication harm in an Australian patient cohort.

PURPOSE: To externally evaluate the performance of two European risk prediction models, for identifying patients at high-risk of medication harm, in an Australian hospital setting. METHODS: This was a secondary analysis of a pre-existing cohort study described in a recently published study by Falconer et al. (Br J Clin Pharmacol 87(3):1512-1524, 2021) describing the development of a predictive risk model for inpatient medication harm. We retrospectively extracted relevant variables using the electronic health records of general medical and geriatric patients admitted to a quaternary hospital, in Brisbane, over 6 months from July to December 2017. This dataset was used to externally evaluate the two European models, The Brighton Adverse Drug Reaction Risk (BADRI) model by Tangiisuran et al. and a risk model developed by Trivalle et al. The variables were entered into both models and the patients' risk of medication harm was calculated, and compared with actual patient outcomes. Predictive performance was evaluated by measuring area under the receiver operative characteristic (AuROC) curves. RESULTS: The Australian patient cohort included 1982 patients (median age 74 years), of which 136 (7%) patients experienced ≥ 1 medication harm event(s). External evaluation of the two European models identified that both the BADRI and the Trivalle models had reduced predictive performance in an Australian patient cohort, compared with their original studies (AuROC of 0.63 [95% CI: 0.58-0.68] and 0.60 [95% CI: 0.55-0.65], respectively). CONCLUSION: Neither model demonstrated sufficient discrimination to warrant further evaluation in our local setting. This is likely a result of variations between the development and the validation cohorts, and the change in healthcare systems over time, and highlights the need for an up-to-date and context-specific risk prediction model.

Treatment strategies for clozapine-induced nocturnal enuresis and urinary incontinence: a systematic review.

BACKGROUND: Clozapine is the most effective medication for treatment-refractory schizophrenia but is associated with significant adverse drug reactions, including nocturnal enuresis and urinary incontinence. This side effect can be burdensome and lead to medication nonadherence and psychotic relapse. Evidence to guide treatment of clozapine-induced nocturnal enuresis and urinary incontinence is sparse. We therefore aimed to synthesize the evidence base to guide management for clinicians, patients, and their carers. METHODS: We systematically searched PubMed, Embase, PsycInfo, CINAHL, and the Cochrane Trial Registry databases from inception to May 2021 for publications on management of clozapine-induced nocturnal enuresis and urinary incontinence using a PROSPERO preregistered search strategy. RESULTS: We identified 22 case reports and case series describing 74 patients. Interventions included clozapine dose reduction, nonpharmacological treatment, and pharmacological treatments. Among pharmacological treatments, desmopressin, oxybutynin, trihexyphenidyl, tolterodine, imipramine, amitriptyline, ephedrine, pseudoephedrine, aripiprazole, and verapamil were associated with complete resolution of nocturnal enuresis and urinary incontinence. Balancing evidence for effectiveness against risk of adverse effects, we developed a management framework for clozapine-induced nocturnal enuresis and urinary incontinence. CONCLUSIONS: Following assessment of urological, psychiatric, pharmacological, and common comorbid medical issues, first-line treatments should be nonpharmacological, including bathroom alarms, voiding before bedtime, and nocturnal fluid restriction. If these interventions do not provide adequate relief, aripiprazole should be trialed. Desmopressin may be considered for severe refractory cases, but monitoring for hyponatremia is essential.

Platelet Function Assays for the Diagnosis of Aspirin Resistance.

Aspirin, an antiplatelet drug, is commonly used at low doses for numerous indications, including prophylaxis of cardiovascular, neurovascular, and venous thromboembolic events. Due to review articles suggesting that aspirin resistance may result in poorer outcomes, interest in assessing platelet function is increasing. Despite this, platelet function tests are rarely used as part of routine clinical practice and therefore, a basic understanding of these tests may be lacking. Although aspirin resistance can be categorized as clinical or laboratory resistance, determining laboratory resistance is the only way to determine resistance before treatment failure occurs. Therefore, knowledge of platelet assays to determine aspirin resistance is of importance. The following review aims to provide a framework for clinicians to understand the main principles of platelet function tests. This includes comparison of the most frequently used platelet assays to diagnose aspirin resistance, including the basic mechanism, methodology, reference ranges, inter-assay comparison, and their respective clinical considerations when using.

Development and validation of the Adverse Inpatient Medication Event model (AIME).

AIMS: Medication harm has negative clinical and economic consequences, contributing to hospitalisation, morbidity and mortality. The incidence ranges from 4 to 14%, of which up to 50% of events may be preventable. A predictive model for identifying high-risk inpatients can guide a timely and systematic approach to prioritisation. The aim of this study is to develop and internally validate a risk prediction model for prioritisation of hospitalised patients at risk of medication harm. METHODS: A retrospective cohort study was conducted in general medical and geriatric specialties at an Australian hospital over six months. Medication harm was identified using International Classification of Disease (ICD-10) codes and the hospital's incident database. Sixty-eight variables, including medications and laboratory results, were extracted from the hospital's databases. Multivariable logistic regression was used to develop the final risk model. Performance was evaluated using area under the receiver operative characteristic curve (AuROC) and clinical utility was determined using decision curve analysis. RESULTS: The study cohort included 1982 patients with median age 74 years, of which 136 (7%) experienced at least one adverse medication event(s). The model included: length of stay, hospital re-admission within 12 months, venous or arterial thrombosis and/or embolism, ≥ 8 medications, serum sodium < 126 mmol/L, INR > 3, anti-psychotic, antiarrhythmic and immunosuppressant medications, and history of medication allergy. Validation gave an AuROC of 0.70 (95% CI: 0.65-0.74). Decision curve analysis identified that the AIME may be clinically useful to help guide decision making in practice. CONCLUSION: We have developed a predictive model with reasonable performance. Future steps include external validation and impact evaluation.

Systematic review of machine learning models for personalised dosing of heparin.

AIM: To identify and critically appraise studies of prediction models, developed using machine learning (ML) methods, for determining the optimal dosing of unfractionated heparin (UFH). METHODS: Embase, PubMed, CINAHL, Web of Science, International Pharmaceutical Abstracts and IEEE Xplore databases were searched from inception to 31 January 2020 to identify relevant studies using key search terms synonymous with artificial intelligence or ML, 'prediction', 'dose', 'activated partial thromboplastin time (aPTT)' and 'UFH.' Studies had to have used ML methods for developing models that predicted optimal dose of UFH or target therapeutic aPTT levels in the hospital setting. The CHARMS Checklist was used to assess quality and risk of bias of included studies. RESULTS: Of 8393 retrieved abstracts, 61 underwent full text review and eight studies met inclusion criteria. Four studies described models for predicting aPTT, three studies described models predicting optimal dose of heparin during dialysis and one study described a model that used surrogate outcomes of clotting and bleeding to predict a therapeutic aPTT. Studies varied widely in reporting of study participants, feature characterisation and selection, handling of missing data, sample size calculations and the intended clinical application of the model. Only one study conducted an external validation and no studies evaluated model impacts in clinical practice. CONCLUSION: Studies of ML models for UFH dosing are few and none report a model ready for routine clinical use. Existing studies are limited by low methodological quality, inadequate reporting of study factors and absence of external validation and impact analysis.

Defining and classifying terminology for medication harm: a call for consensus.

PURPOSE: The multiplicity in terms and definitions of medication-related harm has been a long-standing challenge for health researchers, clinicians, and regulatory bodies. The purpose of this narrative review was to report the diversity of terms; compare definitions, classifications, and models describing medication harm; and suggest which may be useful in both clinical practice and the research setting. METHODS: A narrative review of key studies defining and/or classifying medication harm terminology was undertaken. RESULTS: This review found that numerous terms are used to describe medication harm, and that there is a lack of consistency in current definitions, classifications, and applications. This lack of consistency applied across clinical jurisdictions and regulatory terminologies. A number of limitations in current definitions and classifications were identified. These included the exclusion of key types of medication harm events, ambiguous wording, and a lack of clarity and consensus on subclassifications. In general, there was some overlap in key models from the literature and these were presented to describe similarities and differences. CONCLUSION: Without uniformity quantifying, comparing, combining, or extrapolating medication harm data, such as a rate of harm in a specific population, is a challenge for those involved in medication safety and pharmacovigilance. There is a pressing need for further discussion and international consensus on this topic. Adoption of standard descriptors by practitioner groups, regulatory and policy organisations would foster quality improvement and patient safety.

Systematic review of interventions to improve safety and quality of anticoagulant prescribing for therapeutic indications for hospital inpatients.

PURPOSE: Anticoagulation-associated adverse drug events are common in hospitalised patients and result in morbidity, mortality, increased length of hospital stay and higher costs of care. Many are preventable. We reviewed the literature to identify and assess interventions intended to improve safety or quality anticoagulant prescribing. METHODS: A systematic search of EMBASE, MEDLINE, the Cochrane Library, Pretty Darn Quick-Evidence and Health Systems Evidence was undertaken to identify controlled studies assessing system-level interventions to improve prescribing of oral or parenteral therapeutic anticoagulation for any indication in hospitalised adults. Data were extracted for safety and quality outcomes, with studies grouped by intervention type for meta-analysis and narrative review. RESULTS: Of 10,640 records screened, 19 trials evaluating 12,742 participants were included for analysis. No study specifically evaluated prescribing of low molecular weight heparins (LMWHs) or direct acting oral anticoagulants (DOACs). Our findings suggest that physician-led anticoagulation consultation services may reduce bleeding rates in high-risk patients. On meta-analysis, decision supported warfarin dosing resulted in higher proportion of time with international normalised ratio in therapeutic range (p = 0.0007). Studies of other clinical decision support systems and heparin monitoring systems did not demonstrate improved safety, and quality findings were inconsistent. Systematic education and feedback programs were not efficacious. CONCLUSIONS: There is currently insufficient high-quality evidence to recommend any reviewed intervention, though several warrant closer evaluation. Adequately powered controlled trials assessing safety outcomes and evidence-based quality markers in high-risk patient groups and studies of interventions to improve safety of LMWH and DOAC prescribing are needed.

Evaluation of weight based enoxaparin dosing on anti-Xa concentrations in patients with obesity.

Current treatment dose of enoxaparin is based on total body weight (TBW), however dosage in obesity remains unclear. "Dose capping" commonly occurs if TBW > 100 kg minimising bleeding risk. However, this may result in under-dosing and increasing embolisation risk. The primary objective evaluated efficacy of current dosing strategies in obese patients and determined if resultant anti-Xa concentrations (aXaC) were therapeutic. The secondary objective was to investigate if an uncapped 0.75-0.85 mg/kg (TBW) twice daily dose, advocated by previous authors, results in therapeutic aXaC (0.5-1.0 IU/ml). This retrospective study included 133 patients with a median TBW of 128 kg, producing 59% therapeutic, 15% sub-therapeutic and 26% supra-therapeutic aXaC. Approximately 60% of patients in each dose group (< 0.75, 0.75-0.85 and > 0.85 mg/kg) had a therapeutic aXaC, however the percentage of sub-therapeutic versus supra-therapeutic was higher in the < 0.75 (27% vs 9%) and > 0.85 mg/kg (10% vs 34%) groups respectively. Most patients who weighed 100-119 kg (TBW) received doses > 0.85 mg/kg, however 32% had toxic aXaC. Those between 120 and 139 kg (TBW) had a high percentage of therapeutic aXaC (87%) when dosed < 0.75 mg/kg and a high percentage of supra-therapeutic aXaC (71%) when dosed > 0.85 mg/kg; although numbers were low. Dose reduction occurred in patients > 140 kg (TBW), however < 0.75 mg/kg resulted in higher percentage of sub-therapeutic aXaC (42%). Dosing at 0.75-0.85 mg/kg results in 62% of therapeutic, 14% sub-therapeutic and 24% supra-therapeutic aXaC. This appears to be a "safe" starting dose-range, however all obese patients should have aXaC monitoring due to high inter-patient variability.

Systematic review of predictive risk models for adverse drug events in hospitalized patients.

AIM: An emerging approach to reducing hospital adverse drug events is the use of predictive risk scores. The aim of this systematic review was to critically appraise models developed for predicting adverse drug event risk in inpatients. METHODS: Embase, PubMed, CINAHL and Scopus databases were used to identify studies of predictive risk models for hospitalized adult inpatients. Studies had to have used multivariable logistic regression for model development, resulting in a score or rule with two or more variables, to predict the likelihood of inpatient adverse drug events. The Checklist for the critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies (CHARMS) was used to critically appraise eligible studies. RESULTS: Eleven studies met the inclusion criteria and were included in the review. Ten described the development of a new model, whilst one study revalidated and updated an existing score. Studies used different definitions for outcome but were synonymous with or closely related to adverse drug events. Four studies undertook external validation, five internally validated and two studies did not validate their model. No studies evaluated impact of risk scores on patient outcomes. CONCLUSION: Adverse drug event risk prediction is a complex endeavour but could help to improve patient safety and hospital resource management. Studies in this review had some limitations in their methods for model development, reporting and validation. Two studies, the BADRI and Trivalle's risk scores, used better model development and validation methods and reported reasonable performance, and so could be considered for further research.

A randomized trial of olanzapine versus palonosetron versus infused ondansetron for the treatment of breakthrough chemotherapy-induced nausea and vomiting in patients undergoing hematopoietic stem cell transplantation.

PURPOSE: The primary aim of this study was to compare the effectiveness of olanzapine, palonosetron and ondansetron infusion (standard of care) for the treatment of breakthrough chemotherapy-induced nausea and vomiting (CINV) in patients undergoing hematopoietic stem cell transplantation (HSCT). METHOD: It was a randomized open-label prospective study. Sixty-two patients were randomized to receive either ondansetron 32-mg infusion over 24 h, or olanzapine wafer 10 mg once daily in addition to ondansetron 8 mg IV three times a day or a single dose of palonosetron 0.25 mg IV instead of ondansetron. All groups were allowed rescue antiemetics. The primary endpoint was a composite outcome of no emesis, no use of rescue medication, and nausea score reduction of ≥50 %. The secondary endpoint was nausea score reduction of ≥50 %. Both endpoints were measured at 24 and 48 h after initiation of the study treatment. Statistical analysis was conducted using a double-sided Fisher's exact test. RESULT: The primary endpoint was achieved in 6, 45, and 18 %, and 6, 64, and 18 % of ondansetron versus olanzapine versus palonosetron patient groups at 24 and 48 h, respectively. The secondary outcome was observed in 17, 60, and 62 %, and 35, 71, and 43 % of ondansetron versus olanzapine versus palonosetron patient groups at 24 and 48 h, respectively. Serious adverse drug reactions were not reported in any arms. Time to engraftment was not significantly different between the arms. CONCLUSIONS: Olanzapine was an effective treatment of breakthrough CINV. A single dose of palonosetron significantly reduced nausea up to 24 h.

Individualised medicine: why we need Bayesian dosing.

Individualised drug dosing has been shown to improve patient outcomes and reduce adverse drug events. One method of individualised medicine is the Bayesian approach, which uses prior information about how the population responds to therapy, to inform clinicians about how a specific individual is responding to their current therapy. This information is then used to make changes to the dose. Studies using a Bayesian approach to adjust drug dosing have shown that clinicians are able to achieve a therapeutic range quicker than standard practice. If concentration is related to a pharmacodynamic end-point, this means that the drug will be more effective, and the side-effects will be minimised. Unfortunately, the software options to assist with Bayesian dosing in Australia are limited. The aims of this article are to demystify the concepts of Bayesian dosing, set the context of the Bayesian approach using reference to other dosing strategies and discuss its benefits over current dosing methods for a number of drugs. The article is targeted to medical and pharmacy clinicians, and there is a practical clinical case to demonstrate how this method could be used in everyday clinical practice.

Investigating strategies used by hospital pharmacists to effectively communicate with patients during medication counselling.

BACKGROUND: Medication counselling opportunities are key times for pharmacists and patients to discuss medications and patients' concerns about their therapy. Communication Accommodation Theory (CAT) describes behavioural, motivational and emotional processes underlying communication exchanges. Five CAT strategies (approximation, interpretability, discourse management, emotional expression and interpersonal control) permit identification of effective communication. OBJECTIVE: To invoke CAT to investigate communication strategies used by hospital pharmacists during patient medication counselling. DESIGN: This was a theory-based, qualitative study using transcribed audiorecordings of patients and hospital pharmacists engaged in medication counselling. SETTING AND PARTICIPANTS: Recruited pharmacists practised in inpatient or outpatient settings. Eligible patients within participating pharmacists' practice sites were prescribed at least three medications to manage chronic disease(s). MAIN OUTCOME MEASURES: The extent to which pharmacists accommodate, or not, to patients' conversational needs based on accommodative behaviour described within CAT strategies. RESULTS: Twelve pharmacists engaged four patients (48 total interactions). Exemplars provided robust examples of pharmacists effectively accommodating or meeting patients' conversational needs. Non-accommodation mainly occurred when pharmacists spoke too quickly, used terms not understood by patients and did not include patients in the agenda-setting phase. Multiple strategy use resulted in communication patterns such as "information-reassurance-rationale" sandwiches. DISCUSSION AND CONCLUSIONS: Most pharmacists effectively employed all five CAT strategies to engage patients in discussions. Pharmacists' communication could be improved at the initial agenda-setting phase by asking open-ended questions to invite patients' input and allow patients to identify any medication-related concerns or issues.

Bayesian Estimation of Tobramycin Exposure in Patients with Cystic Fibrosis.

Fixed tobramycin (mg/kg) dosing is often inappropriate in patients with cystic fibrosis (CF), as pharmacokinetics are highly variable. The area under the concentration-time curve (AUC) is an exposure metric suited to monitoring in this population. Bayesian strategies to estimate AUC have been available for over 20 years but are not standard practice in the clinical setting. To assess their suitability for use in clinical practice, three AUC estimation methods using limited sampling were compared to measured true exposure by using intensive sampling tobramycin data. Adults prescribed once daily intravenous tobramycin had eight concentrations taken over 24 h. An estimate of true exposure within one dosing interval was calculated using the trapezoidal method and compared to three alternate estimates determined using (i) a two-sample log-linear regression (LLR) method (local hospital practice); (ii) a Bayesian estimate using one concentration (AUC1); and (iii) a Bayesian estimate using two concentrations (AUC2). Each method was evaluated against the true measured exposure by a Bland-Altman analysis. Twelve patients with a median (range) age and weight of 25 (18 to 36) years and 66.5 (51 to 76) kg, respectively, were recruited. There was good agreement between the true exposure and the three alternate estimates of AUC, with a mean AUC bias of <10 mg/liter · h in each case, i.e., -8.2 (LLR), 3.8 (AUC1), and 1.0 (AUC2). Bayesian analysis-based and LLR estimation methods of tobramycin AUC are equivalent to true exposure estimation. All three methods may be suitable for use in the clinical setting; however, a one-sample Bayesian method may be most useful in ambulatory patients for which coordinating blood samples is difficult. Suitably powered, randomized clinical trials are required to assess patient outcomes.

Compliance With Enoxaparin Dosing and Monitoring Guidelines and the Impact on Patient Length of Stay: A Pilot Study.

BACKGROUND: To investigate the compliance of prescribers with the state-wide Queensland Health (QH) guidelines for dosing and monitoring of enoxaparin, and to examine the effect that compliance has on the patients' length of stay (LOS) in hospital. METHODS: A 4-week retrospective study of consecutive inpatients who were administered enoxaparin for the treatment of an embolic disease. Data collected included influential patient demographics such as weight, renal function; details of antifactor Xa (aXa) monitoring, and patient LOS. All dosing and monitoring for each patient was compared to the current QH guidelines for enoxaparin usage; a multidisciplinary consensus document. The reasons for noncompliance were quantified and explored. RESULTS: A total of 67 inpatients were recruited. The median (range) age, weight, and creatinine clearance of patients were 66 years (18-92), 78.5 kg (47.6-182), and 64 mL/min (16-180), respectively. Only 20 (30%) patients received enoxaparin in compliance with QH guidelines, leaving 47 (70%) noncompliant. The median (range) LOS was 7 (2-58) days for the compliant group versus 15 days (2-101) for the noncompliant (P = 0.06, Mann-Whitney U test). A total of 10 (15%) patients were monitored for aXa; none of whom were monitored correctly. Twenty-eight patients did not receive monitoring when indicated (moderate or severe renal impairment, weight >105 kg, or extended duration of therapy). In these patients, the median (range) LOS was 16.5 days (2-101). CONCLUSIONS: Current prescribing of enoxaparin does not match state guidelines. Although not significant, there was a trend toward noncompliant patients having a greater LOS in hospital. The quality of aXa monitoring is suboptimal and barriers need to be explored. Larger studies are warranted.