Taxonomy development for term standardization in activity resulting from medication review processes: a Delphi study.

BACKGROUND: Medication review (MR) is the systematic assessment of a patient's medications for safety and effectiveness by a healthcare professional. The language used to describe MR activity, such as stopped medicine and increased dose, should be consistent across studies to assist researchers compare how different services operate and identify their mechanism of impact. AIM: To develop an international taxonomy of standardized terms and activity definitions related to medication reviews. METHOD: This was a three-stage Delphi-based consensus study with international medication review experts. A systematic review provided MR activity terms for the survey. Experts rated their consensus on each activity term and its definition on a Likert scale and provided written feedback. The consensus was 75% panel agreement. At each stage, consensus elements were retained, and feedback was used to revise definitions. RESULTS: Seven experts were recruited for the study (response rate 15.2%) from four countries: the United Kingdom (n = 4), New Zealand (n = 1), Australia (n = 1), and Malaysia (n = 1). The following terms achieved consensus: the term Medication as a descriptor for MR terms; discontinue medication, start medication, dose increase, dose decrease, dosage form change, and medication safety and efficacy monitor to describe MR activity; Educate to describe the delivery of healthcare professionals and patients/carers education. CONCLUSION: Standardized medication review activity terms and definitions have been selected for universal adoption in all future MR research to facilitate a meaningful comparison of process evaluations within different settings.

Assessing implementation fidelity of an on-site pharmacist intervention within Australian residential aged care facilities: A mixed methods study.

BACKGROUND: An on-site pharmacist (OSP) intervention was implemented which sought to improve medication management within residential aged care facilities (RACFs) in the Australian Capital Territory, Australia. The objectives of this mixed methods study were to evaluate the implementation fidelity of the OSP intervention and to determine the moderating factors which influenced delivery of this intervention. METHODS: This convergent parallel mixed methods study was underpinned by Hasson's conceptual framework for implementation fidelity. Implementation fidelity for seven intervention RACFs was quantitatively assessed using three quantitative data sets: (1) range of OSP intervention activities delivered; (2) random sample of 10% of medication reviews assessed for quality; (3) proportion of residents who received at least one medication review. Semi-structured interviews (n = 14) with managers and OSPs across the intervention RACFs were conducted to identify moderating factors which may have influenced OSP intervention delivery. RESULTS: The OSP intervention was generally delivered as intended with overall medium levels of implementation fidelity. This delivery was supported by a range of facilitation strategies with most participants perceiving that the intervention was delivered to a high standard. RACF managers and OSPs were mostly well engaged and responsive. A number of potential barriers (including the part-time OSP role, COVID-19 pandemic, RACFs spread out over a large area with significant distance between resident dwellings) and facilitators (including the pharmacist support meetings, OSPs who took time to establish relationships, RACF managers who actively supported OSPs and worked with them) for OSP intervention delivery were identified which have potential implications for the roll out of OSPs within Australian RACFs. CONCLUSION: In this study, the implementation fidelity of OSP intervention delivery was assessed with overall medium levels of fidelity found across the intervention RACFs. This suggested that the OSP intervention can generally be delivered as intended in real world RACFs. OSP intervention delivery was influenced by a range of moderating factors, some of which posed barriers and others which facilitated the OSP intervention being delivered as intended.

Impact of on-site pharmacists in residential aged care facilities on the quality of medicines use: a cluster randomised controlled trial (PiRACF study).

Residents of residential aged care facilities (RACFs) have a high prevalence of use of potentially inappropriate medications (PIMs) and resultant medicines-related harm. This study investigated the effect of an on-site pharmacist model on PIMs use and other medication outcomes for residents in RACFs. A multi-facility, non-blind, cluster randomised controlled trial, with randomisation at the facility level, was conducted. Fifteen facilities enrolled and participated in the study, 7 facilities (560 residents) were allocated to the intervention arm and 8 facilities (737 residents) were allocated to the control arm. Each facility in the intervention arm employed an on-site pharmacist for 12 months to perform medication management activities as part of an interdisciplinary care team. The primary outcome was the proportion of residents taking at least one PIM according to the 2019 Beers® Criteria. Using generalised linear mixed-effects models, accounting for confounders and clustering, there was a significant reduction in the proportion of residents prescribed at least one PIM (odds ratio 0.50, 95% confidence interval, 0.335-0.750; p = 0.001) in the intervention arm. There were also significant decreases in the Anticholinergic Cognitive Burden scale and chlorpromazine equivalent daily dose of antipsychotics. The on-site pharmacist intervention significantly improved the appropriateness of medicines use in RACFs.

Interprofessional collaboration between prescribers, managers, nursing staff and on-site pharmacists within residential aged care facilities: a mixed-methods study.

BACKGROUND: A new on-site pharmacist (OSP) intervention within residential aged care facilities (RACFs) is being investigated to help improve medication management. Interprofessional collaboration amongst prescribers, nursing staff and pharmacists is critical to improving RACF medication management. OBJECTIVE: To explore the extent of interprofessional collaboration and the nature of the working relationships between OSPs and prescribers, managers and nursing staff. METHODS: A mixed-methods study was undertaken within the context of a 12-month cluster randomised controlled trial. Semi-structured interviews were conducted with data analysed using framework analysis, and a survey based upon the Physician-Pharmacist Collaboration Index (PPCI) was distributed at two time points (T1 at 3 months and T2 at 9 months after OSP commencement) across seven intervention RACFs. RESULTS: The qualitative data (n = 33 interviews) findings related to the processes supportive of these relationships e.g. on-site proximity, OSP personality and perceived (or beneficial) benefits of OSPs working with health care team members (such as OSPs being trusted and providing reassurance to RACF health care team members). The PPCI survey mean scores at T1 (n = 33) and T2 (n = 19) suggested that OSPs were able to establish positive working relationships at 3 months and that positive relationships also existed at 9 months. The integrated findings suggested that the working relationships between OSPs and health care team members were generally positive. CONCLUSIONS: This study is the first to explore interprofessional collaboration between OSPs and health-care team members in RACFs. The findings suggest that OSPs can positively contribute to interprofessional collaborative care within RACFs.

The role of on-site pharmacist in residential aged care facilities: findings from the PiRACF study.

BACKGROUND: Residents in residential aged care facilities (RACFs) have a high number of medication-related problems. Integrating on-site pharmacists (OSPs) into this setting is a possible solution and is currently gaining traction in Australia and internationally. The Pharmacists in Residential Aged Care Facilities (PiRACF) cluster-randomised controlled trial integrated pharmacists into the RACF care team to improve medication management. The aim of this descriptive observational study is to explore the activities of OSPs when they are integrated into multidisciplinary care team in RACFs. METHOD: An online survey tool was developed to record the activities of OSPs in RACFs using the Qualtrics© software. OSPs were asked questions about their activities in RACFs under categories that included description, time spent, outcomes where applicable and who the pharmacists communicated with to undertake the activity. RESULTS: Six pharmacists were integrated into 7 RACFs. Overall, they recorded 4252 activities over 12 months. OSPs conducted 1022 (24.0%) clinical medication reviews; 48.8% of medication reviews identified and discussed potentially inappropriate medications with prescribers and 1025 other recommendations were made to prescribers. Overall, the prescriber accepted 51.5% of all recommendations made by OSPs. The most frequently accepted outcome was deprescribing of medications (47.5% for potentially inappropriate medications and 55.5% for other recommendations). OSPs performed facility-level activities including staff education (13.4%), clinical audits (5.8%), and quality improvement activities (9.4%). OSPs spent a large proportion of their time communicating (23.4%) extensively with prescribers, RACF's healthcare team, and residents. CONCLUSION: OSPs successfully performed a wide range of clinical activities aimed both at improving residents' medication regimens, and organisational-level quality improvement. The OSP model presents an opportunity for pharmacists to enhance medication management in the residential aged care setting. Trial registration The trial was registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) (ACTRN: ACTRN12620000430932) on April 1, 2020.

Evaluating the potential outcomes of pharmacist-led activities in the Australian general practice setting: a prospective observational study.

BACKGROUND: Pharmacists have been co-located in general practice teams to support the quality use of medicines and optimise patient health outcomes. Evidence of the impact of pharmacist-led activities in Australian general practices is sparse. AIM: This study aimed to evaluate the potential outcomes of pharmacist-led activities in Australian general practices. METHOD: A prospective observational study was conducted in eight general practices in the Australian Capital Territory, where each general practice employed a pharmacist on a part-time basis for 18 months. A recommended, but flexible, list of activities was provided for pharmacists. Descriptive information on general practice pharmacist-led activities, collected with an online diary, was analysed. The potential clinical, economic, and organisational impact of pharmacist-led clinical activities was evaluated using the CLinical Economic Organisational (CLEO) tool, with a modified economic dimension. RESULTS: Nine pharmacists reported 4290 activities over 3918.5 work hours in general practice. Medication management services were the primary clinical activity of pharmacists. In medication reviews, 75% of the pharmacists' recommendations were fully accepted by general practitioners. Conducting clinical audits, updating patients' medical records, and providing information to patients and staff were other major activities of pharmacists. Of 2419 clinical activities, around 50% had the potential for a moderate or major positive clinical impact on patients. Sixty-three per cent of activities had the potential to decrease healthcare costs. Almost all the pharmacist-led clinical activities had a positive organisational impact. CONCLUSION: Most pharmacist-led clinical activities in general practice had the potential for a positive impact on patients and reduction in healthcare costs, supporting the expansion of this model in Australia.

Factors contributing to pharmacists leaving employment in general practice in Australia: an exploratory study.

OBJECTIVE: To identify perceived factors contributing to pharmacists leaving employment in general practice. METHODS: Qualitative semi-structured interviews were conducted with pharmacists who had left employment in general practice within 12 months of commencing (5 pharmacists out of 14 recruited into these roles) in Canberra, Australia. Thematic analysis was undertaken. KEY FINDINGS: The main specific reasons cited for leaving were lack of utilisation and part-time hours, while the over-arching themes identified were: challenges of the new role, poor role definition, professional relationships and job satisfaction. CONCLUSIONS: In this cohort of newly appointed general practice pharmacists, employment turnover was relatively high. The interview findings indicated a need for strategies, including having clear role descriptions that are understood by all members of the practice team, so that pharmacists with appropriate skillsets can be supported and retained in the general practice setting.

Interprofessional collaboration within general practice teams following the inclusion of non-dispensing pharmacists.

BACKGROUND: Pharmacists have been included in general practice teams to provide non-dispensing services in the Australian Capital Territory (ACT) since 2016. Interprofessional collaboration and team effectiveness are key considerations in providing high-quality patient care. These concepts have not been well studied following the inclusion of a pharmacist in general practice teams. METHODS: A mixed methods study was conducted to explore collaboration between pharmacists and health professionals in eight general practices in the ACT, where pharmacists were included in their teams. A validated survey instrument was adapted and utilised to assess the changes in interprofessional collaboration over time following the addition of a pharmacist. Another validated survey was utilised to explore team effectiveness at the end of the study. Semi-structured interviews, with a thematic analysis, were conducted with a purposeful sample of general practice staff members to understand the factors influencing the development of interprofessional collaboration. RESULTS: In total, 56 and 41 participants completed the baseline and follow-up survey, including 26 who completed both surveys to assess the change in collaboration over time. Interprofessional collaboration scores were high initially and did not change over time. Team effectiveness was also high at the end of the study. Twenty-one individuals participated in interviews, which generated four main interrelated themes related to interprofessional collaboration: professional working relationships, trust, commitment to collaboration, and barriers to collaboration. Trust was integral to professional working relationships and commitment to collaboration. The barriers to collaboration included not having a role description for pharmacists, inadequate interest to initiate working relationships, lack of dedicated time for interaction, lack of utilisation, and poor awareness of pharmacist-led activities in general practice. CONCLUSION: Interprofessional collaboration was initially high and not influenced by the addition of a pharmacist, perhaps reflecting the inherent nature of the general practices willing to include a pharmacist within their team. Introducing a clear job description for pharmacists, and dedicating time to interact with pharmacists, could be beneficial in improving trust and professional working relationships and enhancing collaboration between the pharmacists and other general practice team members.

Quality Use of Medicines Indicators and Associated Factors in Residential Aged Care Facilities: Baseline Findings from the Pharmacists in RACF Study in Australia.

Prescribing potentially inappropriate medications (PIMs), including antipsychotics and benzodiazepines, has been used as an indicator of the quality use of medicines in residential aged care facilities (RACFs). PIMs are associated with an increased risk of falls and hospitalisations in the elderly. The purpose of this study is to assess the extent of prescribing of PIMs in RACFs at baseline in the Pharmacists in residential aged care facilities (PiRACF) study and examine the association of resident and system factors with the number of PIMs. A cross-sectional analysis of 1368 participants from 15 Australian RACFs was performed to detect PIMs using the American Geriatrics Society 2019 Beers® criteria. Most residents (68.1%) were taking at least one regular PIM; 16.9% were taking regular antipsychotics and 11.1% were taking regular benzodiazepines. Long-term proton pump inhibitors were the most frequent class of PIMs. History of falls and higher Charlson Comorbidity Index were associated with an increased number of prescribed PIMs, while dementia diagnosis and older age (85 years or more) were associated with decreased number of PIMs (p-value <0.05). Residents in facilities with lower nurse-to-resident ratios were more likely to have an increased number of PIMs (p value = 0.001). This study indicates that potentially inappropriate prescribing is common in RACFs and interventions to target residents at highest risk are needed.

Patients' Opinions towards the Services of Pharmacists Based in General Practice.

Pharmacists have been included in general practice teams to provide non-dispensing services for patients. In Australia, pharmacists' role in general practice has been slowly expanding. However, there is a paucity of research to explore patients' opinions toward pharmacist-led services in general practice. This study aimed to assess patient awareness, perceived needs, and satisfaction with these services. A cross-sectional survey was conducted with a purposeful sample of patients who visited six general practices in the Australian Capital Territory that included pharmacists in their team. The survey was informed by the literature and pre-tested. The survey was distributed to two samples: patients who had seen a pharmacist and those who had not seen a pharmacist. Of 100 responses received, 86 responses were included in the analysis: patients who had seen a pharmacist (n = 46) and patients who had not seen a pharmacist (n = 40). Almost all the patients who utilised pharmacist-led services were highly satisfied with those services. Among patients who had not seen a pharmacist, 50% were aware of the existence of general practice pharmacists. Patients who had visited the pharmacist rated higher scores for perceived needs. Patient satisfaction towards the pharmacist-led services in general practices was very high, and patients supported the expansion of these services. However, awareness of the availability of general practice pharmacist services could be improved.

Evaluation approaches, tools and aspects of implementation used in pharmacist interventions in residential aged care facilities: A scoping review.

BACKGROUND: The medication expertise of pharmacists is widely acknowledged and there is ongoing interest in their potential role to reduce medication-related harm amongst residents living in residential aged care facilities (RACFs). An increased understanding of how these interventions are evaluated could support adoption of these interventions in the real world. OBJECTIVE: To systematically explore the application of evaluation approaches, evaluation tools and aspects of implementation (implementation factors i.e. barriers and facilitators, and assessing implementation fidelity) used in pharmacist intervention in RACF peer-reviewed literature. METHODS: A search strategy was applied to MEDLINE, CINAHL, Cochrane Library and Web of Science databases for publications between 1 January 2000 and 27 August 2020 based on defined inclusion and exclusion criteria. Articles that reported on evaluated pharmacist interventions impacting residents in RACFs or which outlined study participant perspectives in relation to these interventions were included. RESULTS: 2003 published articles were identified, out of which 56 articles met the inclusion criteria. Fifty-three articles reported on outcome evaluations. Four articles used evaluation guidance with 1 article explicitly guided by an evaluation framework. Relationships, trust and respect between pharmacists and RACF health care team members were one of the most reported factors influencing intervention success. None of the 56 articles used a theory or model, assessed implementation fidelity or employed a logic model. CONCLUSIONS: To date there appears to be sparse utilisation of available evaluation approaches, evaluation tools and implementation aspects in pharmacist intervention in RACF peer-reviewed literature. By embracing these evaluation approaches, evaluation tools and aspects of implementation, pharmacy practice researchers have an opportunity to contribute to evaluation research in RACFs and beyond.

Interprofessional Collaboration and Team Effectiveness of Pharmacists in General Practice: A Cross-National Survey.

As team-based care continues to evolve, pharmacists have been included in general practice teams in many countries, to varying extents, to improve medication use and patient safety. However, evidence on interprofessional collaboration and team effectiveness of pharmacists in general practice is sparse. This study aimed to compare the extent of interprofessional collaboration and team effectiveness of general practice pharmacists in Australia with international sites (Canada and the UK), and identify the factors associated with interprofessional collaboration and team effectiveness. General practice pharmacists from Australia, Canada, and the UK were identified through professional organisations and networks, and invited to participate in an online survey, adapted from existing validated tools. The survey explored interprofessional collaboration through four sub-domains (professional interactions, relationship initiation, trust and role clarity, and commitment to collaboration) and team effectiveness of general practice pharmacists. Of the 101 respondents (26 from Australia, 44 from Canada and 31 from the UK), 79% were female and 78% were aged below 50 years. Interprofessional collaboration and team effectiveness appeared to be high and similar between countries. Total scores for collaboration of pharmacists were 86.1 ± 7.4 in Australia, 88.5 ± 7.5 in the UK, and 89.1 ± 7.3 in Canada (mean ± SD, where higher scores represent more advanced collaboration), while the team effectiveness scores of the pharmacists were 88.6 ± 14.6 in Canada, 91.8 ± 14.6 in Australia and 97.5 ± 14.0 in the UK. Pharmacists who had worked in general practice for a longer time showed advanced interprofessional collaboration while those who worked exclusively in general practice had higher scores for team effectiveness. Overall, general practice pharmacists in the three countries were highly collaborative with general practitioners. Long-term employment and longer work hours could enhance interprofessional collaboration and team effectiveness in general practice pharmacists by improving trust and working relationships over time.

How Do Pharmacists Practice in Aged Care? A Narrative Review of Models from Australia, England, and the United States of America.

Medication management in residential aged care facilities (RACFs) is complex and often sub-optimal. Pharmacist practice models and services have emerged internationally to address medication-related issues in RACFs. This narrative review aimed to explore pharmacist practice models in aged care in Australia, England and the USA, and identify key activities and characteristics within each model. A search strategy using key terms was performed in peer-reviewed databases, as well as the grey literature. Additionally, experts from the selected countries were consulted to obtain further information about the practice models in their respective countries. Thirty-six documents met the inclusion criteria and were included in the review. Four major pharmacist practice models were identified and formed the focus of the review: (1) the NHS's Medicine Optimisation in Care Homes (MOCH) program from England; (2) the Australian model utilising visiting accredited pharmacists; (3) the Centers for Medicare and Medicaid (CMS) pharmacy services in long-term care from the USA; and (4) the Medication Therapy Management (MTM) program from the USA. Medication reviews were key activities in all models, but each had distinct characteristics in relation to the comprehensiveness, who is eligible, and how frequently residents receive medication review activity. There was heterogeneity in the types of facility-level activities offered by pharmacists, and further research is needed to determine the effectiveness of these activities in improving quality use of medicines in the aged care setting. This review found that in some models, pharmacists have a limited level of collaboration with other healthcare professionals, emphasising the need to trial innovative models with integrated services and increased collaboration to achieve a holistic patient-centred approach to medication management.

General practice pharmacists in Australia: A systematic review.

BACKGROUND: The inclusion of pharmacists into general practices in Australia has expanded in recent years. This systematic review aimed to synthesise the literature of qualitative and quantitative studies, and identify the knowledge gaps, related to pharmacists working in general practice in Australia. METHODS: This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, EBSCOhost, EMBASE, and the Cochrane Library were searched from the inception of databases to January 2021. The search was focused on studies investigating general practice pharmacists in Australia. The quality of each study was appraised using the Mixed Method Appraisal Tool criteria. The narrative synthesis approach was utilised to describe data due to the heterogeneity among study designs and measures. RESULTS: Twenty-five studies were included in this review. General practice pharmacists engaged in various non-dispensing patient care services, with medication management reviews being the primary activity reported. General practice pharmacists' characteristics and an environment with a willingness of collaboration were the notable influencing factors for successfully including pharmacists in general practices. Factors that posed a challenge to the adoption of general practice pharmacists were lack of funding and other resources, poorly defined roles, and absence of mentoring/training. CONCLUSION: This review has summarised the characteristics, activities, benefits, barriers, and facilitators of including pharmacists in general practices in Australia. General practice pharmacists are well accepted by stakeholders, and they can engage in a range of patient-centred activities to benefit patients. There is a need for more robust research to explore the patient and economic outcomes related to clinical activities that a pharmacist can perform in general practice, as a foundation to developing an appropriate and sustainable funding model. The findings of this review will be beneficial for pharmacists, researchers, policymakers, and readers who wish to implement the role of general practice pharmacists in the future.

Treatment Guidelines for PTSD: A Systematic Review.

BACKGROUND: The aim of this review was to assess the quality of international treatment guidelines for post-traumatic stress disorder (PTSD), and identify differences between guideline recommendations, with a focus on the treatment of nightmares. METHODS: Guidelines were identified through electronic searches of MEDLINE, CINAHL, PubMed, Embase and Science Direct, as well as web-based searches of international guideline repositories, websites of psychiatric organisations and targeted web-searches for guidelines from the three most populous English-speaking countries in each continent. Data in relation to recommendations were extracted and the AGREE II criteria were applied to assess for quality. RESULTS: Fourteen guidelines, published between 2004-2020, were identified for inclusion in this review. Only five were less than 5 years old. Three guidelines scored highly across all AGREE II domains, while others varied between domains. Most guidelines consider both psychological and pharmacological therapies as first-line in PTSD. All but one guideline recommended cognitive behavioural therapy (CBT) as first-line psychological treatment, and selective serotonin reuptake inhibitors (SSRIs) as first-line pharmacological treatment. Most guidelines do not mention the targeted treatment of nightmares as a symptom of PTSD. Prazosin is discussed in several guidelines for the treatment of nightmares, but recommendations vary widely. Most PTSD guidelines were deemed to be of good quality; however, many could be considered out of date. Recommendations for core PTSD symptoms do not differ greatly between guidelines. However, despite the availability of targeted treatments for nightmares, most guidelines do not adequately address this. CONCLUSIONS: Guidelines need to be kept current to maintain clinical utility. Improvements are most needed in the AGREE II key domains of 'applicability', 'rigour of development' and 'stakeholder involvement'. Due to the treatment-resistant nature of nightmares, guideline development groups should consider producing more detailed recommendations for their targeted treatment. More high-quality trials are also required to provide a solid foundation for making these clinical recommendations for the management of nightmares in PTSD.

Clinical interventions for tungiasis (sand flea disease): a systematic review.

Tungiasis (sand flea disease) is an epidermal parasitic skin disease occurring in resource-limited communities. There is no standard treatment for tungiasis, and available treatment options are scarce. To our knowledge, this is the first systematic review aimed to assess randomised controlled trials (RCTs) investigating interventions for tungiasis. We systematically searched databases including MEDLINE (EBSCOhost), CENTRAL, CINAHL, PubMed, Web of Science, SciELO, LILACS and Embase (Scopus) for RCTs in any language, from inception of the databases until June 12, 2021. RCTs exploring preventive and therapeutic interventions for tungiasis were eligible. We used the revised Cochrane Collaboration's risk of bias tool to assess the risk of bias and Jadad scale to quantify the methodological quality of the RCTs. Of the 1839 identified records, only eight RCTs involving 808 participants were included, and several methodological deficiencies were identified in most of the trials. Trial interventions included: oral drugs niridazole and ivermectin and topical interventions of ivermectin lotion, metrifonate lotion, thiabendazole lotion, thiabendazole ointment, dimeticones (NYDA), and a neem seed and coconut oils-based mixture for treatment and coconut oil-based lotion (Zanzarin) for prevention. The coconut oil-based lotion for prevention and dimeticones for treatment of tungiasis have displayed the most promise. Most of the RCTs included in this study had low methodological quality. There is a clear unmet need for high-quality RCTs examining safe and effective prevention and treatment alternatives of tungiasis in endemic settings.

Mass drug administration campaigns for scabies and impetigo: protocol for a systematic review and meta-analysis.

Introduction: Scabies is recognised as a neglected tropical disease, disproportionately affecting the most vulnerable populations around the world. Impetigo often occurs secondarily to scabies. Several studies have explored mass drug administration (MDA) programmes, with some showing positive outcomes-but a systematic evaluation of such studies is yet to be reported. The main aim of this systematic review is to generate comprehensive evidence on the effect and feasibility of MDA programmes in reducing the burden of scabies and impetigo. Methods and analysis: A systematic review and meta-analysis will be conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. Electronic databases to be searched will include CINAHL EBSCOhost, Medline Ovid, ProQuest, Science Direct, PubMed and SCOPUS. In addition, grey literature will be explored via the Australian Institute of Health and Welfare, Australian Indigenous HealthInfoNet, Informit, OaIster database and WHO. No language restrictions will be applied. All treatment studies following an MDA protocol, including randomised/quasi-controlled trials, and prospective before-after interventional studies, will be considered. The main outcome is the change in prevalence of scabies and impetigo The Cochrane collaboration risk of bias assessment tool will be used for assessing the methodological quality of studies. A random-effect restricted maximum likelihood meta-analysis will be performed to generate pooled effect (OR) using STATA V.16. Appropriate statistical tests will be carried out to quantify heterogeneity between studies and publication bias. Ethics and dissemination: Ethical approval is not required since data will be extracted from published works. The findings will be communicated to the scientific community through a peer-reviewed journal publication. This systematic review will present an evidence on the effect of MDA interventions on scabies and impetigo, which is instrumental to obtain a clear understanding of the treatments widely used in these programmes. PROSPERO registration number: CRD42020169544.

Treatment of tungiasis using a tea tree oil-based gel formulation: protocol for a randomised controlled proof-of-principle trial.

INTRODUCTION: Tungiasis (sand flea disease or jigger infestation) is a neglected tropical disease caused by penetration of female sand fleas, Tunga penetrans, in the skin. The disease inflicts immense pain and suffering on millions of people, particularly children, in Latin America, the Caribbean and sub-Saharan Africa. Currently, there is no standard treatment for tungiasis, and a simple, safe and effective tungiasis treatment option is required. Tea tree oil (TTO) has long been used as a parasiticidal agent against ectoparasites such as headlice, mites and fleas with proven safety and efficacy data. However, current data are insufficient to warrant a recommendation for its use in tungiasis. This trial aims to generate these data by comparing the safety and efficacy of a 5% (v/w) TTO proprietary gel formulation with 0.05% (w/v) potassium permanganate (KMnO4) solution for tungiasis treatment. METHODS AND ANALYSIS: This trial is a randomised controlled trial (RCT) in primary schools (n=8) in South-Western Kenya. The study will include school children (n=88) aged 6-15 years with a confirmed diagnosis of tungiasis. The participants will be randomised in a 1:1 ratio to receive a 3-day two times a day treatment of either 5% TTO gel or 0.05% KMnO4 solution. Two viable embedded sandflea lesions per participant will be targeted and the viability of these lesions will be followed throughout the study using a digital handheld microscope. The primary outcome is the proportion of observed viable embedded sand fleas that have lost viability (non-viable lesions) by day 10 (9 days after first treatment). Secondary outcomes include improvement in acute tungiasis morbidities assessed using a validated severity score for tungiasis, safety assessed through adverse events and product acceptability assessed by interviewing the participants to rate the treatment in terms of effectiveness, side effects, convenience, suitability and overall satisfaction. ETHICS AND DISSEMINATION: The trial protocol has been reviewed and approved by the University of Canberra Human Research Ethics Committee (HREC-2019-2114). The findings of the study will be presented at scientific conferences and published in a peer-reviewed journal. TRIAL REGISTRATION NUMBERS: Australian New Zealand Clinical Trials Registry (ACTRN12619001610123); PACTR202003651095100 and U1111-1243-2294.

Integrating pharmacists into aged care facilities to improve the quality use of medicine (PiRACF Study): protocol for a cluster randomised controlled trial.

BACKGROUND: Medication management in residential aged care facilities is an ongoing concern. Numerous studies have reported high rates of inappropriate prescribing and medication use in aged care facilities, which contribute to residents' adverse health outcomes. There is a need for new models of care that enhance inter-disciplinary collaboration between residential aged care facility staff and healthcare professionals, to improve medication management. Pilot research has demonstrated the feasibility and benefits of integrating a pharmacist into the aged care facility team to improve the quality use of medicines. This protocol describes the design and methods for a cluster randomised controlled trial to evaluate the outcomes and conduct economic evaluation of a service model where on-site pharmacists are integrated into residential aged care facility healthcare teams to improve medication management. METHODS: Intervention aged care facilities will employ on-site pharmacists to work as part of their healthcare teams 2 to 2.5 days per week for 12 months. On-site pharmacists, in collaboration with facility nurses, prescribers, community pharmacists, residents and families will conduct medication management activities to improve the quality use of medicines. Aged care facilities in the control group will continue usual care. The target sample size is 1188 residents from a minimum of 13 aged care facilities. The primary outcome is the appropriateness of prescribing, measured by the proportion of residents who are prescribed at least one potentially inappropriate medicine according to the 2019 Beers Criteria. Secondary outcomes include hospital and emergency department presentations, fall rates, prevalence and dose of antipsychotics and benzodiazepines, Anticholinergic Cognitive Burden Score, staff influenza vaccination rate, time spent on medication rounds, appropriateness of dose form modification and completeness of resident's allergy and adverse drug reaction documentation. A cost-consequence and cost-effectiveness analysis will be embedded in the trial. DISCUSSION: The results of this study will provide information on clinical and economic outcomes of a model that integrates on-site pharmacists into Australian residential aged care facilities. The results will provide policymakers with recommendations relevant to further implementation of this model. TRIAL REGISTRATION: ACTRN12620000430932 . Registered on 1 April 2020 with ANZCTR.

Evaluation of General Practice Pharmacists: Study Protocol to Assess Interprofessional Collaboration and Team Effectiveness.

The inclusion of pharmacists into general practices has expanded in Australia. However, there is a paucity of research examining interprofessional collaboration and team effectiveness after including a pharmacist into the general practice team in primary or community care. This is a protocol for a cross-national comparative mixed-methods study to (i) investigate interprofessional collaboration and team effectiveness within the general practice team after employing pharmacists in general practices in the Australian Capital Territory (ACT) and (ii) to compare interprofessional collaboration and team effectiveness of pharmacists in general practice across Australia with international sites. The first objective will be addressed through a multiphase sequential explanatory mixed-method design, using surveys and semi-structured interviews. The study will recruit general practice pharmacists, general practitioners, and other health professionals from eight general practices in the ACT. Quantitative and qualitative results will be merged during interpretation to provide complementary perspectives of interprofessional collaboration. Secondly, a quantitative descriptive design will compare findings on interprofessional collaboration (professional interactions, relationship initiation, exchange characteristics, and commitment to collaboration) and team effectiveness of general practice pharmacists in Australia with international sites from Canada and the United Kingdom. The results of the study will be used to provide recommendations on how to best implement the role of general practice pharmacists across Australia.