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.

Cost-Consequence Analysis of Deprescribing to Optimize Health Outcomes for Frail Older People: A Within-Trial Analysis.

OBJECTIVES: The structured, clinically supervised withdrawal of medicines, known as deprescribing, is one strategy to address inappropriate polypharmacy. This study aimed to evaluate the costs and consequences of deprescribing in frail older people living in residential aged care facilities (RACFs) in Australia. DESIGN: A within-trial cost-consequence analysis of a deprescribing intervention-Opti-Med. The Opti-Med double-blind randomized controlled trial of deprescribing included 3 groups: blinded control, blinded intervention, and an open intervention group. SETTING AND PARTICIPANTS: Seventeen RACFs in Western Australia and New South Wales. Participants were 303 older people living in participating RACFs from March 2014 to February 2019. METHODS: Analysis was conducted from the health sector perspective. Health economic outcomes assessed include cost saved from deprescribed medicines and the incremental quality-adjusted life-years. Costs were presented in 2022 Australian dollars. RESULTS: The total cost of the Opti-Med intervention was $239.13 per participant. The costs saved through deprescribed medicines over 12 months after adjusting for mortality within the trial period was $328.90 per participant in the blinded intervention group and $164.00 per participant in the open intervention group. On average, the cost of the intervention was more than offset by the cost saved from deprescribed medicines. Extrapolating these findings to the Australian population suggests a potential net cost saving of about $1 to $16 million per annum for the health system nationally. The incremental quality-adjusted life-years were very similar across the 3 groups within the trial period. CONCLUSIONS AND IMPLICATIONS: Deprescribing for frail older people living in RACFs can be a cost-saving intervention without reducing the quality of life. Systemwide implementation of deprescribing across RACFs in Australia has the potential to improve health care delivery through the cost savings, which could be reapplied to further optimize care within RACFs.

Factors influencing pharmacist interest and preparedness to work as on-site aged care pharmacists: Insights from qualitative analysis of free-text survey responses.

BACKGROUND: High rates of suboptimal medication use exist in residential aged care facilities (RACFs). Pharmacist interventions can improve medication appropriateness. In 2023 there will be a phased implementation of pharmacists working on-site in Australian RACFs. OBJECTIVE: To explore factors influencing Australian pharmacists' interest and perceived preparedness to work as on-site pharmacists in RACFs. METHODS: A national cross-sectional anonymous online survey of Australian pharmacists was conducted. Pharmacists were recruited using a broad advertising strategy. The 36-question survey included three free-text questions that are the focus of this study. The questions asked participants (1) what influenced their interest in the role, (2) what influenced how prepared they felt for the role, and (3) if they had any other comments about the role. Responses were thematically analysed by two investigators using an inductive approach. RESULTS: Most survey respondents (n=546, 84.9%) answered at least one free-text questions. Four factors influenced interest: on-site pharmacist role, aged care setting, individual pharmacist circumstances and employment model. Four factors influenced preparedness: familiarity with aged care setting, resident-level clinical skills; ability to communicate and work with a multidisciplinary team, and experience with system-level quality use of medicines activities. Four factors important for successful roll-out emerged from the 'other comments': pharmacist attributes, pharmacist workforce planning, resources and support, and RACF stakeholder engagement. CONCLUSION: Key factors influencing pharmacist interest and preparedness to work on-site in RACFs and factors important for success were identified. These findings will support the national roll-out of the role, particularly as most identified factors are currently modifiable.

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 patterns and implications of potentially suboptimal medicine regimens among older adults: a narrative review.

In the context of an ageing population, the burden of disease and medicine use is also expected to increase. As such, medicine safety and preventing avoidable medicine-related harm are major public health concerns, requiring further research. Potentially suboptimal medicine regimens is an umbrella term that captures a range of indicators that may increase the risk of medicine-related harm, including polypharmacy, underprescribing and high-risk prescribing, such as prescribing potentially inappropriate medicines. This narrative review aims to provide a background and broad overview of the patterns and implications of potentially suboptimal medicine regimens among older adults. Original research published between 1990 and 2021 was searched for in MEDLINE, using key search terms including polypharmacy, inappropriate prescribing, potentially inappropriate medication lists, medication errors, drug interactions and drug prescriptions, along with manual checking of reference lists. The review summarizes the prevalence, risk factors and clinical outcomes of polypharmacy, underprescribing and potentially inappropriate medicines. A synthesis of the evidence regarding the longitudinal patterns of polypharmacy is also provided. With an overview of the existing literature, we highlight a number of key gaps in the literature. Directions for future research may include a longitudinal investigation into the risk factors and outcomes of extended polypharmacy, research focusing on the patterns and implications of underprescribing and studies that evaluate the applicability of tools measuring potentially inappropriate medicines to study settings. Plain Language Summary: A review on potentially inappropriate medicine regimens Medicine use in older age is common. Older adults with more than one chronic condition are likely to use multiple medicines to manage their health. However, there are times when taking multiple medicines may be unsafe and the number of medicines, or the combination of medicines used, may increase the risk of poor health outcomes. The term medicine regimens is used to describe all the medicines an individual takes. There are several ways to measure when a medicine regimen may be inappropriate and, therefore, potentially harmful. Much research has been published looking into potentially inappropriate medicine regimens. To bring together the current research, this review provides a background on the different measures of potentially inappropriate medicine regimens. It also summarizes how many people may experience potentially inappropriate medicine regimens, the impact it is having on their health and who may be at greater risk. In doing so, we found a number of gaps in the existing evidence, indicating that our understanding of potentially inappropriate medicine regimens is incomplete. This review highlights gaps in knowledge that can be addressed by future research. With an improved understanding of potentially inappropriate medicine regimens, we may be able to better identify those at greater risk to prevent or minimize the impact of poorer health outcomes related to unsafe medicine use.

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.

Applicability of explicit potentially inappropriate medication lists to the Australian context: A systematic review.

OBJECTIVES: To determine i) the similarity of potentially inappropriate medications specified in and between existing explicit lists and ii) the availability in Australia of medications included on existing lists to determine their applicability to the Australian context. METHODS: This systematic review identified explicit potentially inappropriate medication lists that were published on EMBASE (1974 - April 2021), MEDLINE (1946 - April 2021) and Elsevier Scopus (2004 - April 2021). The reference lists of seven previously published systematic reviews were also manually reviewed. Lists were included if they were explicit, and the most recent version and the complete list were published in English. Lists based on existing lists were excluded if no new items were added. Potentially inappropriate medications identified on each list were extracted and compared to the medications available on the Australian Register of Therapeutic Goods and Australian Pharmaceutical Benefits Schemes. RESULTS: Thirty-five explicit published lists were identified. A total of 645 unique potentially inappropriate medications were extracted, of which 416 (64%) were available in Australia and 262 (41%) were subsided by the general Pharmaceutical Benefits Scheme. Applicability of each explicit list ranged from 50-96% according to medications available in Australia and 25-83% according to medications available under subsidy. CONCLUSIONS: Pooling data from different lists may help to identify potentially inappropriate medications that may be applicable to local settings. However, if selecting a list for use in the Australian context, consideration should also be given to the intended purpose and setting for application.

Utilization of social media communities for caregiver information support in stroke recovery: An analysis of content and interactions.

BACKGROUND: Caregivers often use the internet to access information related to stroke care to improve preparedness, thereby reducing uncertainty and enhancing the quality of care. METHOD: Social media communities used by caregivers of people affected by stroke were identified using popular keywords searched for using Google. Communities were filtered based on their ability to provide support to caregivers. Data from the included communities were extracted and analysed to determine the content and level of interaction. RESULTS: There was a significant rise in the use of social media by caregivers of people affected by stroke. The most popular social media communities were charitable and governmental organizations with the highest user interaction-this was for topics related to stroke prevention, signs and symptoms, and caregiver self-care delivered through video-based resources. CONCLUSION: Findings show the ability of social media to support stroke caregiver needs and practices that should be considered to increase their interaction and support.

Use of professional practice guidance resources in pharmacy: a cross-sectional nationwide survey of pharmacists, intern pharmacists, and pharmacy students.

BACKGROUND: Variations in practice are commonplace in healthcare where health professionals, such as pharmacists act as autonomous practitioners. This is evident in simulated patient studies, where pharmacists practice does not meet widely accepted standards for medicines supply or treatment of an ailment. To promote best pharmacy practice a myriad of guidance resources including practice guidelines, codes and standards are produced by professional organisations. These resources provide a framework for pharmacy practice and endeavour to facilitate consistency in provision of pharmacy-based services to consumers. Despite their role in specifying essential pharmacist behaviours, there is limited research exploring if and how these resources are used in practice. OBJECTIVE: To characterise Australian pharmacists' use of the Pharmaceutical Society of Australia's Code of Ethics, Professional Practice Guidelines and Professional Practice Standards. METHODS: A cross-sectional, self-administered, electronic survey of registered pharmacists, intern pharmacists and pharmacy students living in Australia was conducted in July 2020. Questions considered use of professional practice resources (by resource group) in the preceding 12 months. Data were analysed descriptively. RESULTS: Of 601 responses included in the analysis 462 (76.9%) of respondents were registered pharmacists, 88 (14.6%) pharmacy students and 51 (8.5%) intern pharmacists. Interns and students accessed overarching practice resources, such as the Professional Practice Standards, Code of Ethics and Dispensing Practice Guidelines more frequently than practising pharmacists. Pharmacists accessed professional practice guidelines, such as Practice Guidelines for the Provision of Immunisation Services Within Pharmacy, more often than students. More pharmacists than interns and students indicated that they would access guidelines to resolve practice and patient care issues. All resources except the Professional Practice Standards for Pharmacists (67.4%) were accessed by less than 50% of respondents in the preceding 12-month period. Reasons for not accessing resources varied between participant and resource groups, and generally were due to a lack of awareness of the resource or not considering them necessary for the individual's practice. CONCLUSION(S): Access and use patterns for professional practice guidance resources change with experience. Professional organisations responsible for developing resources should consider these patterns when designing and reviewing resources and related policies. To ensure resources are meeting the needs of the profession, students, interns, and pharmacists should be involved in the review of and design of further resources.

Regular use of proton-pump inhibitors and risk of stroke: a population-based cohort study and meta-analysis of randomized-controlled trials.

BACKGROUND: Although randomized controlled trials (RCTs) have suggested a non-significant increased risk of stroke among proton pump inhibitor (PPI) users, the association has not been confirmed. We evaluated the association between regular use of PPIs and incident stroke and identified population groups at high net risk. METHODS: This is a prospective analysis of 492,479 participants free of stroke from the UK biobank. Incident stroke was identified through linkage to hospital admission and death registries using the International Classification of Diseases (ICD)-10 codes (I60, I61, I63, and I64). We evaluated hazard ratios (HRs) adjusting for demographic factors, lifestyle habits, prevalent comorbidities, concomitant use of medications, and indications of PPIs. We assessed the risk differences (RDs) according to the baseline Framingham Stroke Risk Score. In the meta-analysis, we searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials (from 1988 to 1 June 2020) for randomized trials comparing PPIs with other interventions, placebo, or no treatment on stroke risk. Results were combined using a fix-effect meta-analysis (Mantel-Haenszel method). RESULTS: We documented 5182 incident strokes over 3,935,030 person-years of follow-up. Regular PPI users had a 16% higher risk of stroke than non-users (HR 1.16, 95% CI 1.06 to 1.27). The estimated effect was similar to our meta-analysis of nine RCTs (case/participants 371/26,642; RR 1.22, 95% CI 1.00 to 1.50; quality of evidence: moderate). The absolute effect of PPI use on stroke increased with the baseline Framingham Stroke Risk Score, with an RD of 1.34‰, 3.32‰, 4.83‰, and 6.28‰ over 5 years for the lowest, quartile 2, quartile 3, and the highest quartile, respectively. CONCLUSIONS: Regular use of PPIs was associated with an increased risk of stroke, with a higher absolute risk observed in individuals with high baseline stroke risk. Physicians should therefore exercise caution when prescribing PPIs. An assessment of the underlying stoke risk is recommended for individualized use of PPIs.

Anticholinergics and clinical outcomes amongst people with pre-existing dementia: A systematic review.

Many medicines have anticholinergic properties, which have previously been correlated with a range of adverse effects, including cognitive impairment, hallucinations and delirium. These effects are potentially of concern for people with dementia. This systematic review investigated the effect of anticholinergic medicines on the health outcomes of people with pre-existing dementia. Embase, Medline and the Cochrane Library were searched from January 2000 to January 2021. Studies were included if they matched the following criteria: (1) the intervention involved anticholinergic medications; (2) the study was conducted in people with pre-existing dementia; (3) there was at least one comparator group; and (4) the outcome of interest was clinically measurable. A total of 14 studies met the inclusion criteria. Most studies used an anticholinergic burden scale to measure anticholinergic exposure. Five high-quality studies consistently identified a strong association between anticholinergic medications and all-cause mortality. Anticholinergics were also found to be associated with longer hospital length of stay in three studies. Inconsistent findings were reported for cognitive function (in 4 studies) and neuropsychiatric functions (in 2 studies). In single studies, anticholinergic medications were associated with the composite outcome of stroke and mortality, pneumonia, delirium, poor physical performance, reduced health-related quality of life and treatment modifications due to reduced treatment response or symptom exacerbation. While the evidence suggests that anticholinergic medication use for people with dementia has a strong association with all-cause mortality, the association with cognitive and other clinical outcomes remains uncertain. Hence, further studies are needed to substantiate the evidence for other outcomes.

Attitudes to Drug Use in Residential Aged Care Facilities: A Cross-Sectional Survey of Nurses and Care Staff.

BACKGROUND: Residential aged care facility (RACF) staff are well placed to identify opportunities for more appropriate prescribing. However, little is known about their views of polypharmacy, deprescribing and specific medications. OBJECTIVE: The objective of this study was to establish the beliefs and attitudes of RACF staff towards polypharmacy and medication use in residents. METHODS: A cross-sectional survey was conducted on RACF staff in metropolitan New South Wales, Australia using a self-administered questionnaire. The questionnaire was drafted based on the available literature and research team expertise and then piloted by a mixed group of 13 RACF staff. The final version of the questionnaire consisted of 28 questions. A total of 38 RACFs were contacted about the study. The questionnaire was distributed to eligible RACF staff between October 2017 and October 2019. The RACF staff were eligible if they provided direct patient care to residents or worked as a facility manager. Participants were excluded if they had insufficient English language skills. The results were presented in two groups, the nursing and care staff, using descriptive statistics. RESULTS: A total of 176 individuals from nine RACFs completed the questionnaire of whom 160 were eligible for study inclusion. Most considered polypharmacy to be five or more different tablets and capsules per day (95% nursing and 82% care staff respectively). A wide range of beliefs about medication use and deprescribing that centred on what constitutes appropriate polypharmacy was identified. Most thought that preventive medications were essential for residents. Most nurses agreed that sleeping tablets and pharmacological management of verbal aggression and wandering behaviours should be used less frequently whilst most care staff agreed that medications should be used more frequently to manage physical aggression. CONCLUSIONS: To successfully and sustainably optimise medication use in RACF residents, it is important to consider the variation in views of nurses and care staff.

Exploring the practice, confidence and educational needs of hospital pharmacists in reviewing antimicrobial prescribing: a cross-sectional, nationwide survey.

BACKGROUND: Antimicrobial stewardship (AMS) programs are usually limited in resources and scope. Therefore, wider engagement of hospital pharmacists in reviewing antimicrobial orders is necessary to ensure appropriate prescribing. We assessed hospital pharmacists' self-reported practice and confidence in reviewing antimicrobial prescribing, and their knowledge in making AMS interventions. METHODS: We conducted an Australia-wide, cross-sectional survey in October 2017. A link to the online survey was emailed to hospital pharmacists via the Society of Hospital Pharmacists of Australia. Factors associated with higher knowledge scores were explored using linear regression models. RESULTS: There were 439 respondents, of whom 272 (61.7%) were from metropolitan public hospitals. Pharmacists were more likely to assess the appropriateness of intravenous, broad-spectrum or restricted antibiotics than narrow-spectrum, oral antibiotics within 24-72 h of prescription; p < 0.001. Fifty percent or fewer respondents were confident in identifying AMS interventions related to dose optimization based on infection-specific factors, bug-drug mismatch, and inappropriate lack of spectra of antimicrobial activity. The median knowledge score (correct answers to knowledge questions) was 6 out of 9 (interquartile range, 5-7); key gaps were noted in antimicrobials' anaerobic spectrum, beta-lactam allergy assessment and dosing in immunocompromised patients. Clinical practice in inpatient areas, registration for 3-5 years and receipt of recent AMS education were associated with higher knowledge scores. More interactive modes of education delivery were preferred over didactic modes; p ≤ 0.01. CONCLUSION: Gaps in practice, confidence and knowledge among hospital pharmacists were identified that could inform the design of educational strategies to help improve antimicrobial prescribing in Australian hospitals.

Analysis of the demographics and characteristics of the Australian pharmacist workforce 2013-2018: decreasing supply points to the need for a workforce strategy.

OBJECTIVES: An adequate workforce is necessary for health care delivery. The last official analysis of the Australian pharmacist workforce was in 2014 and the results of recent studies are contradictory. The objective of this work was to determine current demographic details and recent trends of the pharmacy workforce and assess the impact of changes in student numbers and migration policy. METHODS: Longitudinal and descriptive analysis was undertaken of National Health Workforce Datasets and registrant data available from the Australian Health Practitioner Regulation Agency and the Pharmacy Board of Australia from 2013 to 2018. KEY FINDINGS: There was an increase in females and a trend towards hospital practice but no change in the geographic distribution of pharmacists over the period. However, the pharmacist workforce grew more slowly than comparable health professions and while the youngest pharmacist cohort (20-34 years) remains the largest, the next oldest cohort increased at a greater rate. The youngest cohort reported a decrease in intention to remain working in pharmacy. CONCLUSIONS: A fall in student numbers and changes to immigration policy have contributed to a low growth rate and ageing of the pharmacist workforce compared with other professions. Whether these factors along with the intentions of young pharmacists will result in a shortage is dependent on developments in demand for pharmacists and a workforce strategy is required to monitor these developments.

Exploring stakeholder roles in medication management for people living with dementia.

BACKGROUND: Therapeutic decision making, prescribing, administering and managing medications can be difficult for people with dementia. OBJECTIVES: To explore stakeholder roles in medication management for people with dementia, including barriers and enablers to achieving those roles. METHODS: Focus groups were held with stakeholders (consumers, general practitioners, nurses and pharmacists) from both rural and metropolitan communities in two Australian states. Focus groups were audio-recorded, transcribed and thematically analysed using an inductive approach. RESULTS: Nine focus groups were held with 55 participants. Four major themes were identified: supporting the role of the person with dementia, carer roles and challenges, health professional roles, and process and structure barriers to medication management. Stakeholders discussed the importance of advance care planning, and the potential benefits of early implementation of dose administration aids to support patients in self-managing their medication. Carers were seen to have a vital role as patient advocates, but carer burden and changes in the patient-carer roles acted as barriers to this role. General practitioners were perceived as the main care coordinator for a person with dementia, with effective interprofessional collaboration and communication with allied health professionals and specialists further enabling optimisation of medication use. A lack of evidence, guidelines and practitioner training to guide prescribing and deprescribing decisions in people with dementia were mentioned as barriers to medication management. CONCLUSION: Medication management is increasingly challenging for people with dementia and each stakeholder perceives that they have a different role and faces different barriers and enablers. Future research should focus on improving the evidence base to guide prescribing, facilitating stakeholder communication and ensuring early documentation of patient wishes for the future.

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.

Dispensing patterns of medicines prescribed by Australian dentists from 2006 to 2018 - a pharmacoepidemiological study.

OBJECTIVES: Dentists are independent prescribers that can prescribe subsidised medicines under the Australian Pharmaceutical Benefits Scheme (PBS). It is hypothesised that increased dental prescribing can partly be accounted for by the growth in both the Australian population and the number of practising dentists. This pharmacoepidemiological study aims to determine the dispensing patterns of medications amongst dentists and to identify trends over time. MATERIALS AND METHODS: Data on dental medications under PBS from 2006 to 2018 were accessed. All the dentist-prescribed concessional medicines dispensed at pharmacies in 2018 were included for time trend analysis. Cumulative dispensing counts and defined daily dose (DDD) per 1,000 concessional population days (DPD) were analysed for time trend analysis. RESULTS: Out of the 56 medications within the dental PBS schedule, the top 20 medicines had a total cumulative dispensing count of 5,058,556, which accounts for 97.4% of the total dispensing count. Eleven out of 20 medicines were antibiotics. Overall, increases were observed for seven out of 20 medicines (amoxicillin + clavulanic acid, clindamycin, ibuprofen, diazepam, oxycodone, tramadol, naproxen) in both dispensing count and trend, as expressed per DPD. CONCLUSION: This study highlights the increasing dispensing pattern and trends of dentist-prescribed antibiotics, opioids and benzodiazepines. Further investigation may be required to determine whether the medicine use is appropriate. In the future, this could provide new educational opportunities on the appropriate use of medicines for dentists.

Undiagnosing: Correcting the medical record to prevent over-intervention.

•Over-diagnosis can lead to over-intervention and over-prescribing, particularly among older adults.•Undiagnosing is a strategy to review diagnostic labels and remove those that are unnecessary or no longer beneficial.•Undiagnosing relies on accurate and comprehensive medical records to inform a thorough review of diagnoses•Effective communication and collaborative decision making regarding undiagnosing are essential to ensure consumer centered care.

Patterns of High-Dose and Long-Term Proton Pump Inhibitor Use: A Cross-Sectional Study in Six South Australian Residential Aged Care Services.

AIM: While proton pump inhibitors (PPIs) are generally considered safe and well tolerated, frail older people who take PPIs long term may be susceptible to adverse events. This study characterized PPI use and determined factors associated with high-dose use among older adults in residential aged care services (RACSs). METHODS: A cross-sectional study of 383 residents of six South Australian RACSs within the same organization was conducted. Clinical, diagnostic, and medication data were collected by study nurses. The proportions of residents who took a PPI for > 8 weeks and without documented indications were calculated. Factors associated with high-dose PPI use compared to standard/low doses were identified using age- and sex-adjusted logistic regression models. RESULTS: 196 (51%) residents received a PPI, with 45 (23%) prescribed a high dose. Overall, 173 (88%) PPI users had documented clinical indications or received medications that can increase bleeding risk. Three-quarters of PPI users with gastroesophageal reflux disease or dyspepsia had received a PPI for > 8 weeks. High-dose PPI use was associated with increasing medication regimen complexity [odds ratio (OR) 1.02; 95% confidence interval (CI) 1.01-1.04 per one-point increase in Medication Regimen Complexity Index score] and a greater number of medications prescribed for regular use (OR 1.11; 95% CI 1.01-1.21 per additional medication). CONCLUSIONS: Half of all residents received a PPI, of whom the majority had documented clinical indications or received medications that may increase bleeding risk. There remains an opportunity to review the continuing need for treatment and consider "step-down" approaches for high-dose PPI users.

Trends and Predictors of Oral Anticoagulant Use in People with Alzheimer's Disease and the General Population in Australia.

BACKGROUND: People with Alzheimer's disease (AD) are less likely to use oral anticoagulants than people without AD. OBJECTIVE: We investigated incidence and prevalence of warfarin and direct oral anticoagulant (DOAC) use, and determined predictors of DOAC and warfarin initiation in older people with AD and the general population. METHODS: Australian Pharmaceutical Benefits Scheme data for 356,000 people aged ≥65 years dispensed warfarin or DOACs during July 2013-June 2017 were analyzed. Changes in annual incidence and prevalence were estimated using Poisson regression. Predictors of DOAC versus warfarin initiation were estimated using multivariable logistic regression separately for people with AD and the general population. RESULTS: Oral anticoagulant prevalence increased from 8% in people with AD and 9% in the general population to 12% in both groups from 2013/2014 to 2016/2017. DOAC prevalence increased (from 2.4% to 7.8% in people with AD, 3.2% to 7.7% in the general population) while warfarin prevalence declined (6.6% to 4.5%, 7.0% to 4.3%, correspondingly). The incidence of warfarin use decreased by 45-55%. In people with AD, women were less likely to initiate DOACs than men, whereas presence of arrhythmias or pain/inflammation increased likelihood of initiating DOACs. Age ≥85 years, cardiovascular diseases, gastric acid disorder, diabetes, and end-stage renal disease were associated with lower odds of DOAC initiation in the general population. CONCLUSION: DOAC introduction has coincided with increased anticoagulation rates in people with AD. Rates are now similar in older people with AD and the general population. Compared to previous years, DOACs are now more likely to be initiated, particularly for those aged ≥85 years.