Towards Optimizing Hospitalized Older adults' MEdications (TO HOME): Multi-centre study of medication use and outcomes in routine care.

AIMS: Comprehensively investigate prescribing in usual care of hospitalized older people with respect to polypharmacy; potentially inappropriate medications (PIMs) according to Beers criteria; and cumulative anticholinergic and sedative medication exposure calculated with Drug Burden Index (DBI). Specifically, to quantify exposure to these measures on admission, changes between admission and discharge, associations with adverse outcomes and medication costs. METHODS: Established new retrospective inpatient cohort of 2000 adults aged ≥75 years, consecutively admitted to 6 hospitals in Sydney, Australia, with detailed information on medications, clinical characteristics and outcomes. Conducted cross-sectional analyses of index admission data from cohort. RESULTS: Cohort had mean (standard deviation) age 86.0 (5.8) years, 59% female, 21% from residential aged care. On admission, prevalence of polypharmacy was 77%, PIMs 34% and DBI > 0 in 53%. From admission to discharge, mean difference (95% confidence interval) in total number of medications increased 1.05 (0.92, 1.18); while prevalence of exposure to PIMs (-3.8% [-5.4, -2.1]) and mean DBI score (-0.02 [-0.04, -0.01]) decreased. PIMs and DBI score were associated with increased risks (adjusted odds ratio [95% confidence interval]) of falls (PIMs 1.63 [1.28, 2.08]; DBI score 1.21[1.00, 1.46]) and delirium (PIMs 1.76 [1.38, 1.46]; DBI score 1.42 [1.19, 1.71]). Each measure was associated with increased risk of adverse drug reactions (polypharmacy 1.42 [1.19, 1.71]; PIMs 1.87 [1.40, 2.49]; DBI score 1.90 [1.55, 2.15]). Cost (AU$/patient/hospital day) of medications contributing to PIMs and DBI was low ($0.29 and $0.88). CONCLUSION: In this large cohort of older inpatients, usual hospital care results in an increase in number of medications and small reductions in PIMs and DBI, with variable associations with adverse outcomes.

Evaluation of the Victorian Healthy Homes Program: protocol for a randomised controlled trial.

INTRODUCTION: The evaluation of the Victorian Healthy Homes Program (VHHP) will generate evidence about the efficacy and cost-effectiveness of home upgrades to improve thermal comfort, reduce energy use and produce health and economic benefits to vulnerable households in Victoria, Australia. METHODS AND ANALYSIS: The VHHP evaluation will use a staggered, parallel group clustered randomised controlled trial to test the home energy intervention in 1000 households. All households will receive the intervention either before (intervention group) or after (control group) winter (defined as 22 June to 21 September). The trial spans three winters with differing numbers of households in each cohort. The primary outcome is the mean difference in indoor average daily temperature between intervention and control households during the winter period. Secondary outcomes include household energy consumption and residential energy efficiency, self-reported respiratory symptoms, health-related quality of life, healthcare utilisation, absences from school/work and self-reported conditions within the home. Linear and logistic regression will be used to analyse the primary and secondary outcomes, controlling for clustering of households by area and the possible confounders of year and timing of intervention, to compare the treatment and control groups over the winter period. Economic evaluation will include a cost-effectiveness and cost-benefit analysis. ETHICS AND DISSEMINATION: Ethical approval was received from Victorian Department of Human Services Human Research Ethics Committee (reference number: 04/17), University of Technology Sydney Human Research Ethics Committee (reference number: ETH18-2273) and Australian Government Department of Veterans Affairs. Study results will be disseminated in a final report and peer-reviewed journals. TRIAL REGISTRATION NUMBER: ACTRN12618000160235.

Paying for value: options for value-based payment reform in Australia.

Value-based health care has gained increasing prominence among funders and providers in efforts to improve the outcomes important to patients relative to the resources used to deliver care. In Australia, the value-based healthcare agenda has focused on reducing the use of 'low-value' interventions, redesigning models of care to improve integration between providers and increasing the use of patient-reported measures to drive improvement; all have occurred within existing payment structures. In this paper we describe options for value-based payment reform and highlight two challenges critical for success: attributing financial risk fairly and organisational structures. What is known about the topic? 'Fee for service' is the dominant payment method in Australia and creates incentives to increase service volume, rewarding inputs rather than improvements in longer-term health outcomes. There is increasing recognition that payment reform is needed to support the shift to value-based health care in Australia. What does this paper add? This paper describes the three main options for value-based payment reform: episode-based bundled payments chronic condition bundled payments and comprehensive capitation payments. Each involves some degree of funds pooling, and the shifting of risk from the funder to provider to stimulate the more efficient use of resources. What are the implications for practitioners? We conclude that local hospital authorities in the states, private health insurers and primary health networks could implement reform as payment holders, but that capacity development in coordination and risk adjustment will be required. Successful implementation of payment reform will also require investment in data collection and information technology to track patients' care and measure outcomes and costs.

A stakeholder co-design approach for developing a community pharmacy service to enhance screening and management of atrial fibrillation.

BACKGROUND: Community pharmacies provide a suitable setting to promote self-screening programs aimed at enhancing the early detection of atrial fibrillation (AF). Developing and implementing novel community pharmacy services (CPSs) is a complex and acknowledged challenge, which requires comprehensive planning and the participation of relevant stakeholders. Co-design processes are participatory research approaches that can enhance the development, evaluation and implementation of health services. The aim of this study was to co-design a pharmacist-led CPS aimed at enhancing self-monitoring/screening of AF. METHODS: A 3-step co-design process was conducted using qualitative methods: (1) interviews and focus group with potential service users (n = 8) to identify key needs and concerns; (2) focus group with a mixed group of stakeholders (n = 8) to generate a preliminary model of the service; and (3) focus group with community pharmacy owners and managers (n = 4) to explore the feasibility and appropriateness of the model. Data were analysed qualitatively to identify themes and intersections between themes. The JeMa2 model to conceptualize pharmacy-based health programs was used to build a theoretical model of the service. RESULTS: Stakeholders delineated: a clear target population (i.e., individuals ≥65 years old, with hypertension, with or without previous AF or stroke); the components of the service (i.e., patient education; self-monitoring at home; results evaluation, referral and follow-up); and a set of circumstances that may influence the implementation of the service (e.g., quality of the service, competency of the pharmacist, inter-professional relationships, etc.). A number of strategies were recommended to enable implementation (e.g.,. endorsement by leading cardiovascular organizations, appropriate communication methods and channels between the pharmacy and the general medical practice settings, etc.). CONCLUSION: A novel and preliminary model of a CPS aimed at enhancing the management of AF was generated from this participatory process. This model can be used to inform decision making processes aimed at adopting and piloting of the service. It is expected the co-designed service has been adapted to suit existing needs of patients and current care practices, which, in turn, may increase the feasibility and acceptance of the service when it is implemented into a real setting.

A multilevel stakeholder approach for identifying the determinants of implementation of government-funded community pharmacy services at the primary care level.

BACKGROUND: A key early step to enhance the integration of community pharmacy services (CPSs) into primary care practice is identifying key determinants of practice (i.e., critical circumstances that influence the implementation of such services). Involving relevant stakeholders in identifying key determinants enables findings to be more relevant to the context in which CPSs will be implemented. OBJECTIVE: To identify key determinants of practice that can influence the implementation of government-funded CPSs in a primary health network in Australia. METHODS: A stakeholder collaborative approach was used, encompassing two phases. In the first phase, semi-structured interviews were conducted with ground-level stakeholders in Western Sydney between August 2016 to October 2016. Framework analysis was used to code and analyse the data from the interviews into determinants of pharmacy practice. In the second phase, a workshop was conducted with a mixed-group of ground-level and system-level stakeholders from the primary health network to identify key determinants. A four-quadrant prioritization matrix was employed in the workshop to classify determinants based on their importance and feasibility. RESULTS: Sixty-five determinants of practice that can influence CPS implementation were identified in Phase 1. These determinants were allocated at different levels of the healthcare system, and can exist as a barrier or facilitator or both. Twenty-two key determinants were selected in Phase 2, of which three were agreed to be addressed initially: (1) Patient understanding of the aims of the service; (2) Commitment of the organization and its leaders to provide services; (3) Coordination of the healthcare system to prompt collaboration between pharmacists and GPs. CONCLUSIONS: This collaborative stakeholder approach identified a set of key determinants of pharmacy practice in this Australian primary care setting. To enhance the implementation of CPSs in this region, initial efforts should be aimed at developing implementation strategies based on these key determinants of practice.

Qualitative meta-synthesis of barriers and facilitators that influence the implementation of community pharmacy services: perspectives of patients, nurses and general medical practitioners.

OBJECTIVES: The integration of community pharmacy services (CPSs) into primary care practice can be enhanced by assessing (and further addressing) the elements that enable (ie, facilitators) or hinder (ie, barriers) the implementation of such CPSs. These elements have been widely researched from the perspective of pharmacists but not from the perspectives of other stakeholders who can interact with and influence the implementation of CPSs. The aim of this study was to synthesise the literature on patients', general practitioners' (GPs) and nurses' perspectives of CPSs to identify barriers and facilitators to their implementation in Australia. METHODS: A meta-synthesis of qualitative studies was performed. A systematic search in PubMed, Scopus and Informit was conducted to identify studies that explored patients', GPs' or nurses' views about CPSs in Australia. Thematic synthesis was performed to identify elements influencing CPS implementation, which were further classified using an ecological approach. RESULTS: Twenty-nine articles were included in the review, addressing 63 elements influencing CPS implementation. Elements were identified as a barrier, facilitator or both and were related to four ecological levels: individual patient (n=14), interpersonal (n=24), organisational (n=16) and community and healthcare system (n=9). It was found that patients, nurses and GPs identified elements reported in previous pharmacist-informed studies, such as pharmacist's training/education or financial remuneration, but also new elements, such as patients' capability to follow service's procedures, the relationships between GP and pharmacy professional bodies or the availability of multidisciplinary training/education. CONCLUSIONS: Patients, GPs and nurses can describe a large number of elements influencing CPS implementation. These elements can be combined with previous findings in pharmacists-informed studies to produce a comprehensive framework to assess barriers and facilitators to CPS implementation. This framework can be used by pharmacy service planners and policy makers to improve the analysis of the contexts in which CPSs are implemented.

Use of Intervention Mapping to Enhance Health Care Professional Practice: A Systematic Review.

BACKGROUND: Intervention Mapping is a planning protocol for developing behavior change interventions, the first three steps of which are intended to establish the foundations and rationales of such interventions. AIM: This systematic review aimed to identify programs that used Intervention Mapping to plan changes in health care professional practice. Specifically, it provides an analysis of the information provided by the programs in the first three steps of the protocol to determine their foundations and rationales of change. METHOD: A literature search was undertaken in PubMed, Scopus, SciELO, and DOAJ using "Intervention Mapping" as keyword. Key information was gathered, including theories used, determinants of practice, research methodologies, theory-based methods, and practical applications. RESULTS: Seventeen programs aimed at changing a range of health care practices were included. The social cognitive theory and the theory of planned behavior were the most frequently used frameworks in driving change within health care practices. Programs used a large variety of research methodologies to identify determinants of practice. Specific theory-based methods (e.g., modelling and active learning) and practical applications (e.g., health care professional training and facilitation) were reported to inform the development of practice change interventions and programs. DISCUSSION: In practice, Intervention Mapping delineates a three-step systematic, theory- and evidence-driven process for establishing the theoretical foundations and rationales underpinning change in health care professional practice. CONCLUSION: The use of Intervention Mapping can provide health care planners with useful guidelines for the theoretical development of practice change interventions and programs.

A Systematic Review of Evidence-Based Community Pharmacy Services Aimed at the Prevention of Cardiovascular Disease.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death worldwide and has a substantial impact on people's health and quality of life. CVD also causes an increased use of health care resources and services, representing a significant proportion of health care expenditure. Integrating evidence-based community pharmacy services is seen as an asset to reduce the burden of CVD on individuals and the health care system. OBJECTIVES: To (a) identify community pharmacy evidence-based services designed to help prevent CVD and (b) provide fundamental information that is needed to assess their potential adaptation to other community pharmacy settings. METHODS: This review used the DEPICT database, which includes 488 randomized controlled trials (RCT) that address the evaluation of pharmacy services. Articles reviewing these RCTs were identified for the DEPICT database through a systematic search of the following databases: MEDLINE, Scopus, SciELO (Scientific Electronic Library Online), and DOAJ (Directory of Open Access Journals). The DEPICT database was reviewed to identify evidence-based services delivered in the community pharmacy setting with the purpose of preventing CVD. An evidence-based service was defined as a service that has been shown to have a positive effect (compared with usual care) in a high-quality RCT. From each evidence-based service, fundamental information was retrieved to facilitate adaptation to other community pharmacy settings. RESULTS: From the DEPICT database, 14 evidence-based community pharmacy services that addressed the prevention of CVD were identified. All services, except 1, targeted populations with a mean age above 60 years. Pharmacy services encompassed a wide range of practical applications or techniques that can be classified into 3 groups: activities directed at patients, activities directed at health care professionals, and assessments to gather patient-related information in order to support the previous activities. CONCLUSIONS: This review provides pharmacy service planners and policymakers with a comprehensive list of evidence-based services that have the potential to be adapted to different settings from which they were originally implemented and evaluated in order to reduce the burden of CVD. DISCLOSURES: Funding for this review was provided by the University of Technology Sydney Chancellor's Postdoctoral Fellowship awarded to Sabater-Hernández. No other potential conflict of interest was declared. Study concept and design were contributed by Sabater-Hernández, Fernandez-Llimos, Rotta, and Correr. Sabater-Galindo and Sabater-Hernández took the lead in data collection, along with Franco-Trigo and Rotta. Data interpretation was performed by Sabater-Hernández, Durks, and Lopes. The manuscript was written primarily by Sabater-Hernández, along with Hossain, and revised by Fernandez-Llimos, Rotta, and Benrimoj, with assistance from Durks, Sabater-Galindo, Franco-Trigo, and Correr.