Redesigning Medication Management in the Emergency Department: The Impact of Partnered Pharmacist Medication Charting on the Time to Administer Pre-Admission Time-Critical Medicines, Medication Order Completeness, and Venous Thromboembolism Risk Assessment.

In order to enhance interdisciplinary collaboration and promote better medication management, a partnered pharmacist medication charting (PPMC) model was piloted in the emergency department (ED) of an Australian referral hospital. The primary objective of this study was to evaluate the impact of PPMC on the timeliness of time-critical medicines (TCMs), completeness of medication orders, and assessment of venous thromboembolism (VTE) risk. This concurrent controlled retrospective pragmatic trial involved individuals aged 18 years and older presenting to the ED from 1 June 2020 to 17 May 2021. The study compared the PPMC approach (PPMC group) with traditional medical officer-led medication charting approaches in the ED, either an early best-possible medication history (BPMH) group or the usual care group. In the PPMC group, a BPMH was documented promptly soon after arrival in the ED, subsequent to which a collaborative discussion, co-planning, and co-charting of medications were undertaken by both a PPMC-credentialled pharmacist and a medical officer. In the early BPMH group, the BPMH was initially obtained in the ED before proceeding with the traditional approach of medication charting. Conversely, in the usual care group, the BPMH was obtained in the inpatient ward subsequent to the traditional approach of medication charting. Three outcome measures were assessed -the duration from ED presentation to the TCM's first dose administration (e.g., anti-Parkinson's drugs, hypoglycaemics and anti-coagulants), the completeness of medication orders, and the conduct of VTE risk assessments. The analysis included 321 TCMs, with 107 per group, and 1048 patients, with 230, 230, and 588 in the PPMC, early BPMH, and usual care groups, respectively. In the PPMC group, the median time from ED presentation to the TCM's first dose administration was 8.8 h (interquartile range: 6.3 to 16.3), compared to 17.5 h (interquartile range: 7.8 to 22.9) in the early BPMH group and 15.1 h (interquartile range: 8.2 to 21.1) in the usual care group (p < 0.001). Additionally, PPMC was associated with a higher proportion of patients having complete medication orders and receiving VTE risk assessments in the ED (both p < 0.001). The implementation of the PPMC model not only expedited the administration of TCMs but also improved the completeness of medication orders and the conduct of VTE risk assessments in the ED.

Clinical and economic impact of partnered pharmacist medication charting in the emergency department.

Introduction: Partnered pharmacist medication charting (PPMC), a process redesign hypothesised to improve medication safety and interdisciplinary collaboration, was trialed in a tertiary hospital's emergency department (ED). Objective: To evaluate the health-related impact and economic benefit of PPMC. Methods: A pragmatic, controlled study compared PPMC to usual care in the ED. PPMC included a pharmacist-documented best-possible medication history (BPMH), followed by a clinical conversation between a pharmacist and a medical officer to jointly develop a treatment plan and chart medications. Usual care included medical officer-led traditional medication charting in the ED, without a pharmacist-obtained BPMH or clinical conversation. Outcome measures, assessed after propensity score matching, were length of hospital or ED stay, relative stay index (RSI), in-hospital mortality, 30-day hospital readmissions or ED revisits, and cost. Results: A total of 309 matched pairs were analysed. The median RSI was reduced by 15.4% with PPMC (p = 0.029). There were no significant differences between the groups in the median length of ED stay (8 vs. 10 h, p = 0.52), in-hospital mortality (1.3% vs. 1.3%, p > 0.99), 30-day readmission rates (21% vs. 17%; p = 0.35) and 30-day ED revisit rates (21% vs. 19%; p = 0.68). The hospital spent approximately $138.4 for the cost of PPMC care per patient to avert at least one medication error bearing high/extreme risk. PPMC saved approximately $1269 on the average cost of each admission. Conclusion: Implementing the ED-based PPMC model was associated with a significantly reduced RSI and admission costs, but did not affect clinical outcomes, noting that there was an additional focus on medication reconciliation in the usual care group relative to current practice at our study site.

The impact of partnered pharmacist medication charting in the emergency department on the use of potentially inappropriate medications in older people.

Introduction: A process redesign, partnered pharmacist medication charting (PPMC), was recently piloted in the emergency department (ED) of a tertiary hospital. The PPMC model was intended to improve medication safety and interdisciplinary collaboration by having pharmacists work closely with medical officers to review and chart medications for patients. This study, therefore, aimed to evaluate the impact of PPMC on potentially inappropriate medication (PIM) use. Methods: A pragmatic concurrent controlled study compared a PPMC group to both early best-possible medication history (BPMH) and usual care groups. In the PPMC group, pharmacists initially documented the BPMH and collaborated with medical officers to co-develop treatment plans and chart medications in ED. The early BPMH group included early BPMH documentation by pharmacists, followed by traditional medication charting by medical officers in ED. The usual care group followed the traditional charting approach by medical officers, without a pharmacist-collected BPMH or collaborative discussion in ED. Included were older people (≥65 years) presenting to the ED with at least one regular medication with subsequent admission to an acute medical unit. PIM outcomes (use of at least one PIM, PIMs per patient and PIMs per medication prescribed) were assessed at ED presentation, ED departure and hospital discharge using Beers criteria. Results: Use of at least one PIM on ED departure was significantly lower for the PPMC group than for the comparison groups (χ2, p = 0.040). However, PIM outcomes at hospital discharge were not statistically different between groups. PIM outcomes on ED departure or hospital discharge did not differ from baseline within the comparison groups. Discussion: In conclusion, PIM use on leaving ED, but not at hospital discharge, was reduced with PPMC. Close interprofessional collaboration, as in ED, needs to continue on the wards.

Ten-Year Trends in Psychotropic Prescribing and Polypharmacy in Australian General Practice Patients with and without Dementia.

OBJECTIVE: Little research has evaluated trends in psychotropic prescribing and polypharmacy in primary care patients, especially those with dementia. We sought to examine this in Australia from 2011 to 2020 using the primary care dataset, MedicineInsight. METHODS: Ten consecutive serial cross-sectional analyses were performed to evaluate the proportion of patients aged 65 years or more, with a recorded diagnosis of dementia, who were prescribed psychotropic medications within the first six months of each year from 2011 to 2020. This proportion was compared with propensity score-matched control patients without dementia. RESULTS: Before matching, 24,701 patients (59.2% females) with, and 72,105 patients (59.2% females) without, a recorded diagnosis of dementia were included. In 2011, 42% (95% confidence interval [CI] 40.5-43.5%) of patients in the dementia group had at least one recorded prescription of a psychotropic medication, which declined to 34.2% (95% CI 33.3-35.1%; p for trend < 0.001) by 2020. However, it remained unchanged for matched controls (36% [95% CI 34.6-37.5%] in 2011 and 36.7% [95% CI 35.7-37.6%] in 2020). The greatest decline in the dementia groups by medication class was for antipsychotics (from 15.9% [95% CI 14.8-17.0%] to 8.8% [95% CI 8.2-9.4%]; p for trend < 0.001). During this period, the prevalence of psychotropic polypharmacy (use of two or more individual psychotropics) also decreased from 21.7% (95% CI 20.5-22.9%) to 18.1% (95% CI 17.4-18.9%) in the dementia groups, and slightly increased from 15.2% (95% CI 14.1-16.3%) to 16.6% (95% CI 15.9-17.3%) in the matched controls. CONCLUSIONS: The decline in psychotropic prescribing, particularly antipsychotics, in Australian primary care patients with dementia is encouraging. However, psychotropic polypharmacy still occurred in almost one in five patients with dementia at the end of the study period. Programs focused on encouraging further reductions in the use of multiple psychotropic drugs in patients with dementia are recommended, particularly in rural and remote regions.

Impact of Partnered Pharmacist Medication Charting (PPMC) on Medication Discrepancies and Errors: A Pragmatic Evaluation of an Emergency Department-Based Process Redesign.

Medication errors are more prevalent in settings with acutely ill patients and heavy workloads, such as in an emergency department (ED). A pragmatic, controlled study compared partnered pharmacist medication charting (PPMC) (pharmacist-documented best-possible medication history [BPMH] followed by clinical discussion between a pharmacist and medical officer to co-develop a treatment plan and chart medications) with early BPMH (pharmacist-documented BPMH followed by medical officer-led traditional medication charting) and usual care (traditional medication charting approach without a pharmacist-collected BPMH in ED). Medication discrepancies were undocumented differences between medication charts and medication reconciliation. An expert panel assessed the discrepancies' clinical significance, with 'unintentional' discrepancies deemed 'errors'. Fewer patients in the PPMC group had at least one error (3.5%; 95% confidence interval [CI]: 1.1% to 5.8%) than in the early BPMH (49.4%; 95% CI: 42.5% to 56.3%) and usual care group (61.4%; 95% CI: 56.3% to 66.7%). The number of patients who need to be treated with PPMC to prevent at least one high/extreme error was 4.6 (95% CI: 3.4 to 6.9) and 4.0 (95% CI: 3.1 to 5.3) compared to the early BPMH and usual care group, respectively. PPMC within ED, incorporating interdisciplinary discussion, reduced clinically significant errors compared to early BPMH or usual care.

Impact of pharmacist interventions provided in the emergency department on quality use of medicines: a systematic review and meta-analysis.

BACKGROUND: Pharmacists have an increasing role as part of the emergency department (ED) team. However, the impact of ED-based pharmacy interventions on the quality use of medicines has not been well characterised. OBJECTIVE: This systematic review aimed to synthesise evidence from studies examining the impact of interventions provided by pharmacists on the quality use of medicines in adults presenting to ED. METHODS: A systematic literature search was conducted in MEDLINE, EMBASE and CINAHL. Two independent reviewers screened titles/abstracts and reviewed full texts. Studies that compared the impact of interventions provided by pharmacists with usual care in ED and reported medication-related primary outcomes were included. Cochrane Risk of Bias-2 and Newcastle-Ottawa tools were used to assess the risk of bias. Summary estimates were pooled using random-effects meta-analysis, along with sensitivity and sub-group analyses. RESULTS: Thirty-one studies involving 13 242 participants were included. Pharmacists were predominantly involved in comprehensive medication review, advanced pharmacotherapy assessment, staff and patient education, identification of medication discrepancies and drug-related problems, medication prescribing and co-prescribing, and medication preparation and administration. The activities reduced the number of medication errors by a mean of 0.33 per patient (95% CI -0.42 to -0.23, I2=51%) and the proportion of patients with at least one error by 73% (risk ratio (RR)=0.27, 95% CI 0.19 to 0.40, I2=85.3%). The interventions were also associated with more complete and accurate medication histories, increased appropriateness of prescribed medications by 58% (RR=1.58, 95% CI 1.21 to 2.06, I2=95%) and quicker initiation of time-critical medications. CONCLUSION: The evidence indicates improved quality use of medicines when pharmacists are included in ED care teams. PROSPERO REGISTRATION NUMBER: CRD42020165234.

Medication Regimen Complexity and Risk of Bleeding in People Who Initiate Oral Anticoagulants for Atrial Fibrillation: A Population-Based Study.

BACKGROUND: Oral anticoagulants (OACs) are high-risk medications often used in older people with complex medication regimens. This study was the first to assess the association between overall regimen complexity and bleeding in people with atrial fibrillation (AF) initiating OACs. METHODS: Patients diagnosed with AF who initiated an OAC (warfarin, dabigatran, rivaroxaban, apixaban) between 2010 and 2016 were identified from the Hong Kong Clinical Database and Reporting System. Each patient's Medication Regimen Complexity Index (MRCI) score was computed. Baseline characteristics were balanced using inverse probability of treatment weighting. People were followed until a first hospitalization for bleeding (intracranial hemorrhage, gastrointestinal bleeding, or other bleeding) and censored at discontinuation of the index OAC, death, or end of the follow-up period, whichever occurred first. Cox regression was used to estimate hazard ratios (HR) between MRCI quartiles and bleeding during initiation and all follow-up. RESULTS: There were 19 292 OAC initiators (n = 9 092 warfarin, n = 10 200 direct oral anticoagulants) with a mean (standard deviation) age at initiation of 73.9 (11.0) years. More complex medication regimens were associated with an increased risk of bleeding (MRCI > 14.0-22.00: aHR 1.17, 95% confidence interval [CI] 0.93-1.49; MRCI > 22.0-32.5: aHR 1.32, 95%CI 1.06-1.66; MRCI > 32.5: aHR 1.45, 95%CI 1.13-1.87, compared to MRCI ≤ 14). No significant association between MRCI and bleeding risk was observed during the initial 30, 60, or 90 days of treatment. CONCLUSION: In this cohort study of people with AF initiating an OAC, a more complex medication regimen was associated with higher bleeding risk over periods longer than 90 days. Further prospective studies are needed to assess whether MRCI should be considered in OAC prescribing.

Incidence of Osteoporosis in Primary Care Patients with Atrial Fibrillation Receiving Different Oral Anticoagulants.

Background: Studies investigating the association between the use of oral anticoagulants (OACs) and osteoporosis are limited. We aimed to determine the risk of osteoporosis in patients with atrial fibrillation (AF) and receiving different OACs. Methods: We performed a population-based cohort study using a nationwide primary care dataset, MedicineInsight. Patients aged between 18 and 111 years with AF and newly recorded OAC prescriptions between 1 January 2013 and 31 December 2017 were included and followed until 31 December 2018. We applied propensity score matching to control for patients' baseline characteristic differences before calculating adjusted hazard ratios (aHRs) for a new diagnosis of osteoporosis, using Cox proportional hazard models. Results: A total of 18,454 patients (1714 prescribed dabigatran, 5871 rivaroxaban, 5248 apixaban and 5621 warfarin) were included. Of these, 39.5% were females, and the overall mean age (standard deviation [SD] was 73.2(10.3) years. Over a mean follow-up of 841 days, 1627 patients (1028 receiving direct-acting oral anticoagulants (DOACs) and 599 warfarin) had a newly recorded diagnosis of osteoporosis. The weighted incidence rates (95% confidence interval; CI) per 100 person-years of treatment were 5.0 (4.7−5.2) for warfarin, 4.3 (3.8−4.8) for dabigatran, 3.6 (3.3−3.8) for rivaroxaban, and 4.4 (4.0−4.7) for apixaban. Overall, DOAC use was associated with a significantly lower risk of a new diagnosis of osteoporosis than warfarin use (aHR, 0.79, 95% confidence interval (CI) 0.74−0.85; p < 0.001). Use of each individual DOAC was associated with a significantly lower risk of osteoporosis compared with warfarin (aHRs, 0.75, 95% CI 0.69−0.82 for rivaroxaban; 0.78, 95% CI 0.71−0.86 for apixaban; 0.88, 95% CI 0.77−0.99 for dabigatran). Conclusion: Compared with warfarin, the use of DOACs was associated with a significantly lower risk of developing osteoporosis in patients with AF. This association remained significant when individual DOACs were compared with warfarin.

Risk of osteoporosis in patients with atrial fibrillation with and without oral anticoagulant therapy.

BACKGROUND: We aimed to compare the risk of developing osteoporosis in patients prescribed warfarin or direct-acting oral anticoagulants (DOACs) with those with no therapy. RESEARCH DESIGN AND METHODS: We included 37,632 patients aged between 18 and 111 years with a recorded diagnosis of AF between 1 January 2013 and 31 December 2017. Patients were followed until the diagnosis of osteoporosis, switch or discontinuation of the OAC, last clinical visit, or end of the study period, whichever occurred first. The incidences of new-onset osteoporosis were calculated using the Cox proportional hazards model. RESULTS: Of total, 16,995 (45.2%) had no recorded OAC prescription, and 20,637 had a recorded prescription of warfarin (6,609) or DOAC (14,028). Compared with those not prescribed an OAC, the risk of being diagnosed with new-onset osteoporosis increased in patients prescribed warfarin (HR 2.22, 95% CI 2.00-2.47, p < 0.001) and DOACs (HR 1.42, 95% CI 1.29-1.58, p < 0.001). However, the effect of DOACs was not statistically significant (HR 1.07, 95% CI 0.86-1.33, p < 0.535) after excluding patients with at least one recorded prescription of systemic corticosteroids, antiepileptics, or proton pump inhibitors. CONCLUSIONS: Use of warfarin or DOACs was associated with a significantly increased risk of developing osteoporosis compared with no OAC treatment.

Improving Knowledge and Early Detection of Atrial Fibrillation through a Community-Based Opportunistic Screening Program: What's Your Beat?

A community-based opportunistic screening program was implemented to (i) improve atrial fibrillation (AF) awareness and detection and (ii) assess the performance of the Microlife WatchBP Home A for detecting AF when used in community screening. Screening sessions were conducted among people aged ≥ 65 years with no history of AF at public events across Tasmania, Australia. Participants with positive screening results were referred to their general medical practitioner for assessment. The device's performance was assessed using the positive predictive value. A total of 1704 eligible participants were screened at 79 sessions. Of these people, 50 (2.9%) had a positive screening result. The device correctly identified AF in 22 (46.8%) participants with positive results. Among those with subsequently confirmed AF, 6 (27.3%) had a history of AF but were not aware of the diagnosis, and 16 (72.7%) were identified to have previously undiagnosed AF, with an overall prevalence of 0.9% (95% CI, 0.58 to 1.52). Oral anticoagulation therapy was initiated in 12 (87.5%) eligible participants. The positive predictive value of the device was 46.8% (95% CI, 33.3 to 60.7). Given the relatively low performance of the device, its application in community-based opportunistic screening programs for AF is unlikely to be cost-effective.

Eight-Year Trends in Direct-Acting Oral Anticoagulant Dosing, Based on Age and Kidney Function, in Patients With Atrial Fibrillation.

OBJECTIVE: Concerns have been raised over the appropriateness of dosing of direct-acting oral anticoagulants (DOACs) in clinical practice. We investigated this issue in patients who were initiated on a DOAC in Australian general practices. METHODS: This was a retrospective study among patients newly diagnosed with atrial fibrillation (AF) who were prescribed DOACs, using data obtained from 417 general practice sites across Australia over 8 years (2011-2019). Direct-acting oral anticoagulant dosing was compared with published recommendations, in relation to age and kidney function. RESULTS: A total of 11,251 patients (mean age, 72.8 y; 46.8% female) newly diagnosed with AF were prescribed a DOAC. Of these, 2667 patients (23.7%) had a recorded prescription of a potentially inappropriate DOAC dosage, of whom 2304 (86.4%) and 283 (10.6%) were prescribed lower and higher than the recommended dosage, respectively. The remaining 80 patients (3.0%) were initiated on DOACs when contraindicated based on renal function. Overall, the proportion of patients who seemed to be initiated on a potentially inappropriate DOAC dose decreased from 38.3% (95% confidence interval, 26.1%-51.8%) in 2012 to 22.7% (95% confidence interval, 19.8%-26.0%; P < 0.001) in 2019. By 2019, 19.4%, 20.3%, and 9.3% of the patients with a recorded prescription of apixaban, rivaroxaban, and dabigatran, respectively, received a lower-than-guideline-recommended dose. The patients were more likely to be prescribed a potentially inappropriate dosage if they were elderly with multiple comorbidities. CONCLUSIONS: Potential inappropriate DOAC dosing is a problem in the prevention of stroke associated with AF. Nearly 1 in 5 patients received a lower-than-guideline-recommended dose, indicating a need for strategies to raise awareness among prescribers.

Comparing the renal outcomes in patients with atrial fibrillation receiving different oral anticoagulants.

BACKGROUND: We aimed to compare renal function changes in patients with atrial fibrillation (AF) prescribed different oral anticoagulants (OACs). RESEARCH DESIGN AND METHODS: We performed a retrospective analysis of Australian national primary care data. A total of 12,562 patients with AF and initiated OAC between 1 January 2013 and 31 December 2017 were included. Inverse probability of treatment weighting was used for balancing baseline characteristics and the risks of decline in estimated glomerular filtration rate (eGFR) in patients prescribed each OAC were compared. RESULTS: Compared with warfarin, prescribing of direct-acting oral anticoagulants (DOACs) was associated with a lower risk of renal function decline per 1000 person-years: hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.68-0.81, p < 0.001 for ≥30% decline in eGFR; HR 0.28, 95% CI 0.20-0.41, p < 0.001 for eGFR decline to ≤30 mL/min/1.73 m2; and HR 0.45, 95% CI 0.35-0.58, p < 0.001 for serum creatinine doubling. Compared with dabigatran, rivaroxaban use had a significantly lowered risk of decline in eGFR to ≤30 mL/min/1.73 m2 (HR 0.29, 95% CI 0.13-0.66, p = 0.003) and risk of doubling of serum creatinine (HR 0.62, 95% CI 0.40-0.95, p = 0.030). CONCLUSIONS: The risk of renal function decline appeared to be lower in patients prescribed DOACs versus warfarin.

Oral Anticoagulant Treatment and the Risk of Dementia in Patients With Atrial Fibrillation: A Population-Based Cohort Study.

Background We compared the dementia incidence rate between users and nonusers of oral anticoagulants (OACs) in a large cohort of primary care patients with atrial fibrillation. Methods and Results We performed a retrospective study using an Australia-wide primary care data set, MedicineInsight. Patients aged ≥18 years and newly diagnosed with atrial fibrillation between January 1, 2010, and December 31, 2017, and with no recorded history of dementia or stroke were included and followed until December 31, 2018. We applied a propensity score for 1:1 pair matching of baseline covariates and Cox regression for comparing the dementia incidence rates for OAC users and nonusers. Data were analyzed for 18 813 patients with atrial fibrillation (aged 71.9±12.6 years, 47.1% women); 11 419 had a recorded OAC prescription for at least 80% of their follow-up time. During the mean follow-up time of 3.7±2.0 years, 425 patients (2.3%; 95% CI, 2.1%-2.5%) had a documented diagnosis of dementia. After propensity matching, the incidence of dementia was significantly lower in OAC users (hazard ratio [HR], 0.59; 95% CI, 0.44-0.80; P<0.001) compared with nonusers. Direct-acting oral anticoagulant users had a lower incidence of dementia than non-OAC users (HR, 0.49; 95% CI, 0.33-0.73; P<0.001) or warfarin users (HR, 0.46; 95% CI, 0.28-0.74; P=0.002). No significant difference was seen between warfarin users and non-OAC users (HR, 1.08; 95% CI, 0.70-1.70; P=0.723). Conclusions In patients with atrial fibrillation, direct-acting oral anticoagulant use may result in a lower incidence of dementia compared with treatment with either warfarin or no anticoagulant.

Interdisciplinary Perspectives on Restraint Use in Aged Care.

Restraint use in Australian residential aged care has been highlighted by the media, and investigated by researchers, government and advocacy bodies. In 2018, the Royal Commission into Aged Care selected 'Restraint' as a key focus of inquiry. Subsequently, Federal legislation was passed to ensure restraint is only used in residential aged care services as the 'last resort'. To inform and develop Government educational resources, we conducted qualitative research to gain greater understanding of the experiences and attitudes of aged care stakeholders around restraint practice. Semi-structured interviews were held with 28 participants, comprising nurses, care staff, physicians, physiotherapists, pharmacists and relatives. Two focus groups were also conducted to ascertain the views of residential and community aged care senior management staff. Data were thematically analyzed using a pragmatic approach of inductive and deductive coding and theme development. Five themes were identified during the study: 1. Understanding of restraint; 2. Support for legislation; 3. Restraint-free environments are not possible; 4. Low-level restraint; 5. Restraint in the community is uncharted. Although most staff, health practitioners and relatives have a basic understanding of restraint, more education is needed at a conceptual level to enable them to identify and avoid restraint practice, particularly 'low-level' forms and chemical restraint. There was strong support for the new restraint regulations, but most interviewees admitted they were unsure what the legislation entailed. With regards to resources, stakeholders wanted recognition that there were times when restraint was necessary and advice on what to do in these situations, as opposed to unrealistic aspirations for restraint-free care. Stakeholders reported greater oversight of restraint in residential aged care but specified that community restraint use was largely unknown. Research is needed to investigate the extent and types of restraint practice in community aged care.

Ten-year trends in prescribing of antiarrhythmic drugs in Australian primary care patients with atrial fibrillation.

Despite changes in antiarrhythmic drug (AAD) choice in patients with atrial fibrillation (AF), trends in AAD prescribing remain not investigated. We aimed to examine these changes using a nationwide Australian general practice data from 2009 to 2018. Over the 10 years, AAD prescribing in patients with AF decreased, which was mainly due to a reduction in the use of amiodarone, sotalol and digoxin. In contrast, the use of beta-blockers and flecainide increased.

Ten-Year Trends in the Use of Oral Anticoagulants in Australian General Practice Patients With Atrial Fibrillation.

Objective: Appropriate use of oral anticoagulants (OACs) reduces the risk of stroke in patients with atrial fibrillation (AF). The study characterized the prescribing of OACs in people with AF in the Australian primary care setting over 10 years. Design: Retrospective population study. Setting and Participants: We performed 10 sequential cross-sectional analyses of patients with a recorded diagnosis of AF between 2009 and 2018 using national general practice data. The proportion of patients with AF who were prescribed an OAC based on their stroke risk was examined. Primary and secondary outcomes: The primary outcome was the proportion of high stroke risk patients who were prescribed an OAC over a decade. The secondary outcome was variation in OAC prescribing among general practices. Results: The sample size of patients with AF ranged from 9,874 in 2009 to 41,751 in 2018. The proportion who were prescribed an OAC increased from 39.5% (95% CI 38.6-40.5%) in 2009 to 52.0% (95% CI 51.5-52.4%) in 2018 (p for trend < 0.001). During this time, the proportion of patients with AF and high stroke risk who were prescribed an OAC rose from 41.7% (95% CI 40.7-42.8%) to 55.2% (95% CI 54.7-55.8%; p for trend < 0.001) with the direct-acting oral anticoagulants accounting for over three-quarters of usage by 2018. There was substantial variation in OAC prescribing between general practices. In 2018, the proportion of moderate to high stroke risk patients who were prescribed an OAC was 38.6% (95% CI 37.2-40.1%) in the lowest practice site quintiles and 65.6% (95% CI 64.5-66.7%) in the highest practice site quintiles. Conclusions: Over the 10 years, OAC prescribing in high stroke risk patients with AF increased by one-third. There was considerable variation in OAC prescribing between general practices.

Stroke risk reassessment and oral anticoagulant initiation in primary care patients with atrial fibrillation: A ten-year follow-up.

AIM: To examine the change in stroke risk over time and determine the proportion of patients with atrial fibrillation (AF) who were initiated on an oral anticoagulant (OAC) as their stroke risk increased from low/moderate to high, using the Australian general practice data set, MedicineInsight. METHODS: A total of 2296 patients diagnosed with AF between 1 January 2007 and 31 December 2008, aged 18 years or older and not initiated on an OAC before 2009, were included. We assessed the change in stroke risk and the proportion of patients who had a recorded prescription of an OAC, each year from 1 January 2009 to 31 December 2018. RESULTS: At baseline, 23.9%, 22.9% and 53.2% were categorised as being at low (score = 0), moderate (score = 1) and high stroke risk (score ≥ 2), respectively, using the sexless CHA2 DS2 -VASc (CHA2 DS2 -VA) score. Overall, the CHA2 DS2 -VA score increased by a mean of 1.34 (95% confidence interval, 1.29-1.39) points over the study period. Nearly two-thirds of patients (65%, 412/632) whose stroke risk changed from baseline low/moderate to high were subsequently prescribed an OAC. The median (interquartile range) lag time from becoming high stroke risk to having OAC initiation was 2 (5) years. CONCLUSIONS: Nearly one-third of patients reclassified as being at high risk of stroke during the study period were not prescribed OAC therapy. Furthermore, the delay in OAC initiation following classification as being at high risk was a median of 2 years, suggesting that more frequent stroke reassessment is needed.

Factors influencing oral anticoagulant use in patients newly diagnosed with atrial fibrillation.

BACKGROUND: We investigated factors that influenced oral anticoagulant (OAC) initiation and choice in Australian general practice patients newly diagnosed with AF. METHODS: Using an Australian nationally representative general practice dataset, MedicineInsight, we identified patients newly diagnosed with AF between January 2009 and April 2019. Logistic regression analyses were used to examine factors associated with OAC initiation and choice. RESULTS: A total of 63 212 patients with AF (53.7% males, mean age 72.4 years) were identified. Nearly two-thirds of these patients (40 854 [64.6%]) were initiated on an OAC, at a median time of 6 days after the documented diagnosis date. The proportion of patients who were initiated an OAC increased from 44.8% in 2009 to 72.2% in 2019 (P < .001). High risk of stroke (CHA2 DS2 -VASc, adjusted odds ratio (AOR), 4.39 [95% CI, 3.99-4.83]), low risk of bleeding (ORBIT, AOR, 1.87 [95% CI, 1.72-2.03]), not having a recorded history of dementia (AOR, 1.81 [95% CI, 1.65-1.98]) and male sex (AOR, 1.29 [95% CI, 1.22-1.35]) were independently associated with OAC initiation. Direct-acting oral anticoagulant (DOAC) use increased from 11.9% in 2011 to 94.0% of all OAC initiations in April 2019 (P < .001). CONCLUSIONS: The proportion of newly diagnosed patients with AF initiated on OAC increased markedly following the introduction of the DOACs. Of those initiated, 9 in 10 were receiving a DOAC at the end of the study period. There is potential underuse in women and individuals with dementia.

Risk factors and associated outcomes of hospital readmission in COPD: A systematic review.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a leading cause of unplanned readmission. There is need to identify risk factors for, and strategies to prevent readmission in patients with COPD. AIM: To systematically review and summarise the prevalence, risk factors and outcomes associated with rehospitalisation due to COPD exacerbation. METHOD: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Five databases were searched for relevant studies. RESULTS: Fifty-seven studies from 30 countries met the inclusion criteria. The prevalence of COPD-related readmission varied from 2.6 to 82.2% at 30 days, 11.8-44.8% at 31-90 days, 17.9-63.0% at 6 months, and 25.0-87.0% at 12 months post-discharge. There were differences in the reported factors associated with readmissions, which may reflect variations in the local context, such as the availability of community-based services to care for exacerbations of COPD. Hospitalisation in the previous year prior to index admission was the key predictor of COPD-related readmission. Comorbidities (in particular asthma), living in a deprived area and living in or discharge to a nursing home were also associated with readmission. Relative to those without readmissions, readmitted patients had higher in-hospital mortality rates, shorter long-term survival, poorer quality of life, longer hospital stay, increased recurrence of subsequent readmissions, and accounted for greater healthcare costs. CONCLUSIONS: Hospitalisation in the previous year was the principal risk factor for COPD-related readmissions. Variation in the prevalence and the reported factors associated with COPD-related readmission indicate that risk factors cannot be generalised, and interventions should be tailored to the local healthcare environment.

Five-Year Trends in Potential Drug Interactions with Direct-Acting Oral Anticoagulants in Patients with Atrial Fibrillation: An Australian-Wide Study.

BACKGROUND: Co-prescribing medications that can interact with direct-acting oral anticoagulants (DOACs) may decrease their safety and efficacy. The aim of this study was to examine the co-prescribing of such medications with DOACs using the Australian national general practice dataset, MedicineInsight, over a five-year period. METHODS: We performed five sequential cross-sectional analyses in patients with atrial fibrillation (AF) and a recorded DOAC prescription. Patients were defined as having a drug interaction if they had a recorded prescription of an interacting medication while they had had a recorded prescription of DOAC in the previous six months. The sample size for the cross-sectional analyses ranged from 5333 in 2014 to 19,196 in 2018. RESULTS: The proportion of patients who had potential drug interactions with a DOAC decreased from 45.9% (95% confidence interval (CI) 44.6%-47.4%) in 2014 to 39.9% (95% CI 39.2%-40.6%) in 2018, p for trend < 0.001. During this period, the most frequent interacting class of medication recorded as having been prescribed with DOACs was selective serotonin/serotonin and norepinephrine reuptake inhibitor (SSRI/SNRI) antidepressants, followed by non-steroidal anti-inflammatory drugs (NSAIDs), calcium channel blockers (CCBs) and amiodarone. CONCLUSIONS: Overall, potential drug interactions with DOACs have decreased slightly over the last five years; however, the rate of possible interaction with SSRIs/SNRIs has remained relatively unchanged and warrants awareness-raising amongst prescribers.