A Longitudinal Study of the Use and Effects of Fall-Risk-Increasing Drugs in Residential Aged Care.

OBJECTIVES: Fall-risk-increasing drugs (FRIDs)-psychotropics and cardiovascular disease (CVD) drugs-may elevate the risk of falling, with strong evidence observed in psychotropic FRIDs, whereas findings from cardiovascular disease (CVD) FRIDs remain inconclusive. Existing studies on FRIDs and falls are often hampered by methodologic limitations. Leveraging longitudinal observational data, we aimed to determine the long-term patterns of FRID use and their association with falls in residential aged care (RAC) homes. DESIGN: A retrospective longitudinal cohort study. SETTING AND PARTICIPANTS: A total of 4207 permanent residents newly admitted to 27 RAC homes in Sydney, Australia. METHOD: The outcomes were incidence of all and injurious falls. We measured exposure to each FRID over 60 months using the Proportion of Days Covered (PDC) metric. We used group-based multitrajectory modeling to determine concurrent usage patterns of psychotropics and CVD FRIDs and applied negative binomial regression to assess their associations with the outcomes. RESULTS: A total of 83.6% (n = 3516) and 77.3% (n = 3254) residents used psychotropic and CVD FRIDs, respectively. The PDC values ranged from 67.3% (opioids) to 86.9% (antidepressants) for specific psychotropics and 79.0% (α-adrenoceptor antagonists) to 89.6% (ß blockers) for CVD FRIDs. We identified 4 groups: group 1, low psychotropics-low CVDs use (16.7%, n = 701); group 2, low psychotropics-high CVDs (25.0%, n = 1054); group 3, high psychotropics-high CVDs (41.0%, n = 1723); and group 4, high psychotropics-low CVDs (17.3%, n = 729). Group 4 had a significantly higher rate of falls than the other groups for both outcomes, including relative to group 3, in which exposure to both FRID classes was high. CONCLUSIONS AND IMPLICATIONS: Our findings reveal concerningly high FRID use in RAC homes and highlight a critical difference in the impact of the 2 major FRID classes on falls. Psychotropics were strongly associated with falls, whereas the studied CVD FRIDs did not elevate risk of falling.

Child Age and Risk of Medication Error: A Multisite Children's Hospital Study.

OBJECTIVE: The objective of this study was to examine associations between patient age and medication errors among pediatric inpatients. STUDY DESIGN: Secondary analysis of data sets generated from 2 tertiary pediatric hospitals: (1) prescribing errors identified from chart reviews for patients on 9 general wards at hospital A during April 22 to July 10, 2016, June 20 to September 20, 2017, and June 20 to September 30, 2020; prescribing errors from 5 wards at hospital B in the same periods and (2) medication administration errors assessed by direct prospective observation of 5137 administrations on 9 wards at hospital A. Multilevel models examined the association between patient age and medication errors. Age was modeled using restricted cubic splines to allow for nonlinearity. RESULTS: Prescribing errors increased nonlinearly with patient age (P = .01), showing little association from ages 0 to 3 years and then increasing with age until around 10 years and remaining constant through the teenage years. Administration errors increased with patient age, with no association from 0 to around 8 years and then a steady rise with increasing age (P = .03). The association differed by route: linear for oral, no association for intravenous infusions, and U-shaped for intravenous injections. CONCLUSIONS: Older age is an unrecognized risk factor for medication error on general wards in pediatric hospitals. Contributors to risk may be the clinical profiles of these older children or the general level of attention paid to medication practices for this group. Further investigation may allow the design of more targeted interventions to reduce errors.

Paediatric medication incident reporting: a multicentre comparison study of medication errors identified at audit, detected by staff and reported to an incident system.

OBJECTIVES: To compare medication errors identified at audit and via direct observation with medication errors reported to an incident reporting system at paediatric hospitals and to investigate differences in types and severity of errors detected and reported by staff. METHODS: This is a comparison study at two tertiary referral paediatric hospitals between 2016 and 2020 in Australia. Prescribing errors were identified from a medication chart audit of 7785 patient records. Medication administration errors were identified from a prospective direct observational study of 5137 medication administration doses to 1530 patients. Medication errors reported to the hospitals' incident reporting system were identified and matched with errors identified at audit and observation. RESULTS: Of 11 302 clinical prescribing errors identified at audit, 3.2 per 1000 errors (95% CI 2.3 to 4.4, n=36) had an incident report. Of 2224 potentially serious prescribing errors from audit, 26.1% (95% CI 24.3 to 27.9, n=580) were detected by staff and 11.2 per 1000 errors (95% CI 7.6 to 16.5, n=25) were reported to the incident system. Although the prescribing error detection rates varied between the two hospitals, there was no difference in incident reporting rates regardless of error severity. Of 40 errors associated with actual patient harm, only 7 (17.5%; 95% CI 8.7% to 31.9%) were detected by staff and 4 (10.0%; 95% CI 4.0% to 23.1%) had an incident report. None of the 2883 clinical medication administration errors observed, including 903 potentially serious errors and 144 errors associated with actual patient harm, had incident reports. CONCLUSION: Incident reporting data do not provide an accurate reflection of medication errors and related harm to children in hospitals. Failure to detect medication errors is likely to be a significant contributor to low error reporting rates. In an era of electronic health records, new automated approaches to monitor medication safety should be pursued to provide real-time monitoring.

The relationship between participation in leisure activities and incidence of falls in residential aged care.

BACKGROUND: Active engagement in leisure activities has positive effects on individuals' health outcomes and social functioning; however, there is limited understanding of the link between participation in leisure activities, particularly non-exercise activities, and falls in older adults. This study aimed to determine the relationship between participation in leisure activities and the incidence of falls, and the variation of this relationship by dementia status in residential aged care facilities (RACFs). METHODS: A retrospective longitudinal cohort study utilising routinely collected data (January 2021-August 2022) from 25 RACFs in Sydney, Australia, was conducted. The cohort included 3,024 older permanent residents (1,493 with dementia and 1,531 without) aged ≥65 and with a stay of ≥1 week. The level of participation in leisure activities was measured using the number of leisure activities per 1,000 resident days and divided into quartiles. Outcome measures were the incidence rate of all falls and injurious falls (i.e., number of falls per 1,000 resident days). We used multilevel negative binary regression to examine the relationship between leisure participation and fall incidence. RESULTS: For the whole sample, leisure participation was significantly inversely associated with the incidence rate of all falls and injurious falls. For example, residents in the high leisure participation group were 26% less likely to experience a fall compared to those in the low leisure participation group after controlling for confounders (incidence rate ratio = 0.74, 95% confidence interval = 0.60, 0.91). Such inverse relationship was observed in both exercise and non-exercise activities and was stronger among residents without dementia. CONCLUSIONS: Leisure participation is associated with a lower rate of falls, a key quality indicator by which RACFs are benchmarked and funded in Australia and many other countries. More recognition and attention are needed for the currently underfunded leisure activities in RACFs in future funding arrangement.

Developing a process to measure actual harm from medication errors in paediatric inpatients: From design to implementation.

AIMS: The potential harm associated with medication errors is widely reported, but data on actual harm are limited. When actual harm has been measured, assessment processes are often poorly described, limiting their ability to be reproduced by other studies. Our aim was to design and implement a new process to assess actual harm resulting from medication errors in paediatric inpatient care. METHODS: Prescribing errors were identified through retrospective medical record reviews (n = 26 369 orders) and medication administration errors through direct observation (n = 5137 administrations) in a tertiary paediatric hospital. All errors were assigned potential harm severity ratings on a 5-point scale. Multidisciplinary panels reviewed case studies for patients assigned the highest three potential severity ratings and determined the following: actual harm occurrence and severity level, plausibility of a link between the error(s) and identified harm(s) and a confidence rating if no harm had occurred. RESULTS: Multidisciplinary harm panels (n = 28) reviewed 566 case studies (173 prescribing related and 393 administration related) and found evidence of actual harm in 89 (prescribing = 22, administration = 67). Eight cases of serious harm cases were found (prescribing = 1, administration = 7) and no cases of severe harm. The panels were very confident in 65% of cases (n = 302) where no harm was found. Potential and actual harm ratings varied. CONCLUSIONS: This harm assessment process provides a systematic method for determining actual harm from medication errors. The multidisciplinary nature of the panels was critical in evaluating specific clinical, therapeutic and contextual considerations including care delivery pathways, therapeutic dose ranges and drug-drug and drug-disease interactions.

Risk Factors Associated with Medication Administration Errors in Children: A Prospective Direct Observational Study of Paediatric Inpatients.

INTRODUCTION: Limited evidence exists regarding medication administration errors (MAEs) on general paediatric wards or associated risk factors exists. OBJECTIVE: The aim of this study was to identify nurse, medication, and work-environment factors associated with MAEs among paediatric inpatients. METHODS: This was a prospective, direct observational study of 298 nurses in a paediatric referral hospital in Sydney, Australia. Trained observers recorded details of 5137 doses prepared and administered to 1530 children between 07:00 h and 22:00 h on weekdays and weekends. Observation data were compared with medication charts to identify errors. Clinical errors, potential severity and actual harm were assessed. Nurse characteristics (e.g. age, sex, experience), medication type (route, high-risk medications, use of solvent/diluent), and work variables (e.g. time of administration, weekday/weekend, use of an electronic medication management system [eMM], presence of a parent/carer) were collected. Multivariable models assessed MAE risk factors for any error, errors by route, potentially serious errors, and errors involving high-risk medication or causing actual harm. RESULTS: Errors occurred in 37.0% (n = 1899; 95% confidence interval [CI] 35.7-38.3) of administrations, 25.8% (n = 489; 95% CI 23.8-27.9) of which were rated as potentially serious. Intravenous infusions and injections had high error rates (64.7% [n = 514], 95% CI 61.3-68.0; and 77.4% [n = 188], 95% CI 71.7-82.2, respectively). For intravenous injections, 59.7% (95% CI 53.4-65.6) had potentially serious errors. No nurse characteristics were associated with MAEs. Intravenous route, early morning and weekend administrations, patient age ≥ 11 years, oral medications requiring solvents/diluents and eMM use were all significant risk factors. MAEs causing actual harm were 45% lower using an eMM compared with paper charts. CONCLUSION: Medication error prevention strategies should target intravenous administrations and not neglect older children in hospital. Attention to nurses' work environments, including improved design and integration of medication technologies, is warranted.

The Economics of Medication Safety: A Cost-Benefits Analysis Framework for Evaluating an Electronic Medication System.

Medication prescribing in paediatrics is complex and compounded by the need to provide age and weight related doses, and errors continue to be problematic. Electronic medication systems (EMS) can reduce errors through dosing calculators and computerised decision support. However, evidence on costs and benefits of these systems is limited, particularly in paediatric hospitals. This paper presents the development of a cost-benefit analysis (CBA) framework to assess the impact of an EMS implementation in a paediatric tertiary hospital. An innovative component of the framework is the incorporation of the impact of the effects of the EMS for both the health system as well as for patients and their wider family networks, allowing a net social benefit assessment. We describe the impact of non-clinical out-of-pocket costs of admission and use discrete choice experiments to measure both medication related harm and the importance of medication safety to families and members of the community.

Stepped-Wedge Cluster RCT to Assess the Effects of an Electronic Medication System on Medication Administration Errors.

Medication errors are a leading cause of preventable harm in hospitals. Electronic medication systems (EMS) have shown success in reducing the risk of prescribing errors, but considerable less evidence is available about whether these systems support a reduction in medication administration errors in paediatrics. Using a stepped wedge cluster randomized controlled trial we investigated changes in medication administration error rates following the introduction of an EMS in a paediatric referral hospital in Sydney, Australia. Direct observations of 284 nurses as they prepared and administered 4555 medication doses was undertaken and observational data compared against patient records to identify administration errors. We found no significant change in administration errors post EMS (adjusted Odds Ratio [aOR] 1.09; 95% CI 0.89-1.32) and no change in rates of potentially serious administration errors (aOR 1.18; 95%CI 0.9-1.56), or those resulting in actual harm (aOR 0.92; 95%CI 0.34-2.46). Errors in administration of medications by some routes increased post EMS. In the first 70 days of EMS use medication administration error rates were largely unchanged.

The Health Innovation Series: Translating Research Evidence into Practice.

Electronic medication systems (EMS) improve medication safety in hospitals; however require modifications to optimize their performance. Drawing on a five-year program of research, we developed the Health Innovation Series to disseminate recommendations arising from our research to a wide audience. Each issue contains EMS optimization tips that can be actioned by EMS managers and system vendors, as well as user tips for health professionals including nurses, doctors and pharmacists. Five issues were released by 30 Nov 2022, via two email campaigns, with further issues planned. The five issues had 2,035 downloads by March 2023. The most recent email campaign open and click rates indicate very good audience engagement.

Designing an Informatics Infrastructure for a National Aged Care Medication Roundtable.

In the residential aged care sector medication management has been identified as a major area of concern contributing to poor outcomes and quality of life for residents. Monitoring medication management in residential aged care in Australia has been highly reliant on small, internal audits. The introduction of electronic medication administration systems provides new opportunities to establish improved methods for ongoing, timely and efficient monitoring of a range of medication indicators, made more meaningful by linking medication data with resident characteristics and outcomes. Benchmarking contemporary medication indicators provides a further opportunity for improvement and is most effective when indicator data are adjusted to take account of confounding factors, such as residents' characteristics and health conditions. Roundtables provide a structure for sharing and discussing indicator data in a trusted and supportive environment and encourage the identification of strategies which may be effective in improving medication management. This paper describes a new project to establish, implement and evaluate a National Aged Care Medication Roundtable.

Allied health service delivery in residential aged care and the impact of the coronavirus (COVID-19) pandemic: a survey of the allied health workforce.

Objectives Industry reports suggest that routine and essential care in Australian residential aged care (RAC), including allied health (AH) services, were disrupted during the coronavirus diseas 2019 (COVID-19) pandemic. This study aimed to explore whether AH services in RAC were paused during the pandemic, factors associated with a pause in care delivery, and qualitative details on how COVID-19 impacted AH service delivery. Methods A 26-question survey was distributed via social media, health service providers, and AH networks between February and April 2022. Participation was restricted to AH professionals and assistants with experience in RAC during the pandemic. A mix of closed and open-ended response questions was used to collect demographic data and experiences of delivering care during the pandemic. Quantitative responses were analysed with descriptive statistics and a probit model. Content analysis was performed on open-ended questions. Results One hundred and four AH professionals and assistants responded to the survey. Fifty-five percent of participants (n = 51) were contractually or casually employed. AH services were negatively impacted by the pandemic with 52% of respondents experiencing a pause in service delivery and 78% reporting poorer AH care quality. In a probit model, contracted/casually employed respondents were more likely to experience a pause in care delivery (1.03, P < 0.05) compared to permanently employed AH professionals. Conclusion Insecure work arrangements may have exacerbated inconsistent care during the pandemic (impacting residents) and may have negative implications on the RAC AH workforce. In the future, an AH inclusive workforce policy including data collection and research is required to monitor and plan the RAC workforce.

Usability and Acceptability of Clinical Dashboards in Aged Care: Systematic Review.

BACKGROUND: The use of clinical dashboards in aged care systems to support performance review and improve outcomes for older adults receiving care is increasing. OBJECTIVE: Our aim was to explore evidence from studies of the acceptability and usability of clinical dashboards including their visual features and functionalities in aged care settings. METHODS: A systematic review was conducted using 5 databases (MEDLINE, Embase, PsycINFO, Cochrane Library, and CINAHL) from inception to April 2022. Studies were included in the review if they were conducted in aged care environments (home-based community care, retirement villages, and long-term care) and reported a usability or acceptability evaluation of a clinical dashboard for use in aged care environments, including specific dashboard visual features (eg, a qualitative summary of individual user experience or metrics from a usability scale). Two researchers independently reviewed the articles and extracted the data. Data synthesis was performed via narrative review, and the risk of bias was measured using the Mixed Methods Appraisal Tool. RESULTS: In total, 14 articles reporting on 12 dashboards were included. The quality of the articles varied. There was considerable heterogeneity in implementation setting (home care 8/14, 57%), dashboard user groups (health professionals 9/14, 64%), and sample size (range 3-292). Dashboard features included a visual representation of information (eg, medical condition prevalence), analytic capability (eg, predictive), and others (eg, stakeholder communication). Dashboard usability was mixed (4 dashboards rated as high), and dashboard acceptability was high for 9 dashboards. Most users considered dashboards to be informative, relevant, and functional, highlighting the use and intention of using this resource in the future. Dashboards that had the presence of one or more of these features (bar charts, radio buttons, checkboxes or other symbols, interactive displays, and reporting capabilities) were found to be highly acceptable. CONCLUSIONS: A comprehensive summary of clinical dashboards used in aged care is provided to inform future dashboard development, testing, and implementation. Further research is required to optimize visualization features, usability, and acceptability of dashboards in aged care.

Just visiting: A qualitative study of Australian allied health professionals' experiences working in residential aged care facilities during the COVID-19 pandemic.

OBJECTIVES: Internationally, the COVID-19 pandemic has negatively impacted health professionals' experiences of delivering effective care. The experiences of health professionals are important: poor experience has been associated with poorer patient outcomes and high staff turnover. This study aimed to narratively explore the impact of the COVID-19 pandemic on the experience of delivering allied health (AH) care in Australian residential aged care (RAC). METHODS: Semistructured interviews were conducted in February-May 2022 with AH professionals who had experience working in RAC during the pandemic. Interviews were audio-recorded, transcribed verbatim and thematically analysed in NVivo 20. Twenty-five per cent of interview transcripts were independently analysed by three researchers to create a coding structure. RESULTS: Three themes were identified from interviews with 15 AH professionals to describe experiences delivering care pre-COVID-19, during COVID-19, and perceptions of care delivery in future. Prepandemic AH in RAC was believed to be under-resourced, delivering low-quality and reactive care. During the pandemic, pauses in, and the slow resumption of, AH services exacerbated professionals' feelings of being undervalued in resident care and in the workforce. Participants were optimistic about the impact AH could have in RAC in future if practice was embedded, multidisciplinary and funded appropriately. CONCLUSIONS: AH professionals' experiences of delivering care in RAC are often poor, regardless of the pandemic. Further research on multidisciplinary practice and health professional experience in RAC is needed.

Effectiveness of non-interruptive nudge interventions in electronic health records to improve the delivery of care in hospitals: a systematic review.

OBJECTIVES: To describe the application of nudges within electronic health records (EHRs) and their effects on inpatient care delivery, and identify design features that support effective decision-making without the use of interruptive alerts. MATERIALS AND METHODS: We searched Medline, Embase, and PsychInfo (in January 2022) for randomized controlled trials, interrupted time-series and before-after studies reporting effects of nudge interventions embedded in hospital EHRs to improve care. Nudge interventions were identified at full-text review, using a pre-existing classification. Interventions using interruptive alerts were excluded. Risk of bias was assessed using the ROBINS-I tool (Risk of Bias in Non-randomized Studies of Interventions) for non-randomized studies or the Cochrane Effective Practice and Organization of Care Group methodology for randomized trials. Study results were summarized narratively. RESULTS: We included 18 studies evaluating 24 EHR nudges. An improvement in care delivery was reported for 79.2% (n = 19; 95% CI, 59.5-90.8) of nudges. Nudges applied were from 5 of 9 possible nudge categories: change choice defaults (n = 9), make information visible (n = 6), change range or composition of options (n = 5), provide reminders (n = 2), and change option-related effort (n = 2). Only one study had a low risk of bias. Nudges targeted ordering of medications, laboratory tests, imaging, and appropriateness of care. Few studies evaluated long-term effects. DISCUSSION: Nudges in EHRs can improve care delivery. Future work could explore a wider range of nudges and evaluate long-term effects. CONCLUSION: Nudges can be implemented in EHRs to improve care delivery within current system capabilities; however, as with all digital interventions, careful consideration of the sociotechnical system is crucial to enhance their effectiveness.

The relationship between fall incidents and place of birth in residential aged care facilities: a retrospective longitudinal cohort study.

BACKGROUND: Older populations in residential aged care facilities (RACFs) in many immigrant-receiving countries are now being increasingly culturally and linguistically diverse (CALD). CALD populations require tailored social and health services to support their needs and improve health outcomes. Falls among the elderly are common and can have significant health and psychosocial consequences. There is some evidence to suggest that country of birth may influence risk of falls among older people, but such evidence has been scarce. This study aimed to determine the association between place of birth and the incidence of falls in RACFs. METHODS: Routinely collected incident data relating to 5,628 residents aged ≥ 65 years in 25 RACFs in Sydney, New South Wales, Australia were used. RACF residents were classified into two groups, Australia-born (N = 4,086) and overseas-born (N = 1,542). Overseas-born RACF residents were further categorised into two subgroups: overseas-English-speaking-country (N = 743) and overseas-non-English-speaking-country (N = 799). Outcomes measures were rate of all falls, injurious falls and falls requiring hospitalisation. Multilevel binary negative regression was used to examine the relationship between fall risk and place of birth. RESULTS: Incidence rates of all falls, injurious falls and falls requiring hospitalisation were 8.62, 3.72 and 1.07 incidents per 1,000 resident days, respectively, among the Australia-born RACF residents, but were higher at 11.02, 4.13 and 1.65, respectively, among the overseas-born RACF residents. Within those born overseas, fall rates were higher among the overseas-non-English-speaking-country-born residents (11.32, 4.29 and 2.22, respectively) than those overseas-English-speaking-country-born (10.70, 3.96 and 1.05, respectively). After controlling for confounders, the overseas-born RACF residents overall experienced a higher risk of all three types of falls (incidence rate ratios: [IRR] = 1.278, 95% confidence interval [CI] = 1.131, 1.443; injurious falls: IRR = 1.164 [95% CI = 1.013, 1.338]; falls requiring hospitalisation: IRR = 1.460 [95% CI = 1.199, 1.777]) than the Australia-born RACF residents. Among the overseas-born RACF residents, males, respite residents and those overseas-non-English-speaking-country-born experienced higher rates of falls. CONCLUSIONS: Fall incidence in RACFs varies significantly by place of birth. With increasingly diverse RACF populations, fall intervention and prevention programs should consider cultural and linguistical backgrounds of RACF residents. Greater attention to understand the mechanisms for the differences by place of birth in risk profiles is warranted.

Opioid prescribing among aged care residents during the first year of the COVID-19 pandemic: an analysis using general practice health records in Australia.

BACKGROUND: Opioid use is common among adults 65 years and older, while long-term use of opioids remains controversial and poses risks of drug dependence and other adverse events. The acute disease caused by the SARS-CoV-2 (COVID-19) pandemic has created new challenges and barriers to healthcare access, particularly for long-term care residents. Australia had a relatively low incidence and deaths due to COVID-19 during the first year of the pandemic compared to most OECD countries. In this context, we examined opioid prescribing rates and their dosage in residential aged care facilities (RACFs) before (2019) and during the COVID-19 pandemic (2020) from March to December in Australia. METHODS: We conducted a retrospective cohort using general practice electronic health records. This includes 17,304 RACF residents aged 65 years and over from 361 general practices in New South Wales and Victoria. Number of opioid prescriptions and percentage of opioids over 50 mg/day of oral morphine equivalent (OME) were described. Multivariate generalized estimating equations were applied to estimate odds ratios [aORs (95% confidence intervals)] for 1) opioids prescribed per consultation and 2) prescription opioids over 50 mg/day OME. RESULTS: In 2020 among 11,154 residents, 22.8% of 90,897 total prescriptions were opioids, and of the opioids, 11.3% were over 50 mg/day OME. In 2019 among 10,506 residents, 18.8% of 71,829 total prescriptions were opioids, of which 10.3% were over 50 mg/day OME. Year [2020 vs. 2019: aOR (95% CI):1.50 (1.44, 1.56); 1.29 (1.15, 1.46)] and regionality [rural/regional vs. metropolitan: 1.37 (1.26, 1.49); 1.40 (1.14, 1.71)] were associated with higher odds of prescription opioids and OME > 50 mg/day, respectively. Similar results were found when limited to the same residents (n = 7,340) recorded in both years. CONCLUSIONS: Higher prescription rates of opioids were observed during the COVID-19 pandemic in 2020 than in 2019 in Australian RACFs. The higher odds of prescription opioids and higher dosing in rural/regional than metropolitan areas indicate a widening of the gap in the quality of pain management during the pandemic. Our findings contribute to the limited data that indicate increased opioid prescriptions in long-term care facilities, likely to continue while COVID-19 pandemic restrictions remain.

Nudge interventions to reduce unnecessary antibiotic prescribing in primary care: a systematic review.

OBJECTIVES: Antibiotic prescribing in primary care contributes significantly to antibiotic overuse. Nudge interventions alter the decision-making environment to achieve behaviour change without restricting options. Our objectives were to conduct a systematic review to describe the types of nudge interventions used to reduce unnecessary antibiotic prescribing in primary care, their key features, and their effects on antibiotic prescribing overall. METHODS: Medline, Embase and grey literature were searched for randomised trials or regression discontinuity studies in April 2021. Risk of bias was assessed independently by two researchers using the Cochrane Effective Practice and Organisation of Care group's tool. Results were synthesised to report the percentage of studies demonstrating a reduction in overall antibiotic prescribing for different types of nudges. Effects of social norm nudges were examined for features that may enhance effectiveness. RESULTS: Nineteen studies were included, testing 23 nudge interventions. Four studies were rated as having a high risk of bias, nine as moderate risk of bias and six as at low risk. Overall, 78.3% (n=18, 95% CI 58.1 to 90.3) of the nudges evaluated resulted in a reduction in overall antibiotic prescribing. Social norm feedback was the most frequently applied nudge (n=17), with 76.5% (n=13; 95% CI 52.7 to 90.4) of these studies reporting a reduction. Other nudges applied were changing option consequences (n=3; with 2 reporting a reduction), providing reminders (n=2; 2 reporting a reduction) and facilitating commitment (n=1; reporting a reduction). Successful social norm nudges typically either included an injunctive norm, compared prescribing to physicians with the lowest prescribers or targeted high prescribers. CONCLUSIONS: Nudge interventions are effective for improving antibiotic prescribing in primary care. Expanding the use of nudge interventions beyond social norm nudges could reap further improvements in antibiotic prescribing practices. Policy-makers and managers need to be mindful of how social norm nudges are implemented to enhance intervention effects.

Allied health in residential aged care: Using routinely collected data to improve funding opportunities.

Consumers and providers have long been advocating for increased access to and delivery of allied health services in Australian residential aged care (RAC). There is significant evidence that allied health interventions are effective; however, there is limited evidence on the benefit of routine day-to-day allied health service delivery in RAC. This information is critical to effectively inform funders and policy advisors of the necessity of allied health in RAC. To improve arguments for future funding opportunities, providers, facilities and consumers need to partner together to use routinely collected, yet disparate, data, in electronic health and billing records, to improve data collection practices and evidence generation on allied health in aged care.

Measuring quality of gout management in residential aged care facilities.

Objective: Gout, a common form of arthritis, can be controlled successfully with pharmacotherapy and is thus an ideal model for examining chronic disease management. Our aim was to examine treatment of gout evaluated in accordance with general management guidelines for gout as applied to Australian residential aged care facilities. Methods: Electronic health record data linked with aged care clinical notes and electronic medication administration information (11 548 residents in 68 residential aged care facilities, >65 years of age) were interrogated to identify people with gout, other chronic conditions and gout medication use. The outcomes examined were the proportion receiving urate-lowering therapy (ULT; preventative medication) and/or colchicine/non-steroidal anti-inflammatory drug (NSAID) (to treat gout flares), the number of ULT and colchicine/NSAID treatment episodes (periods of continuous days of medication use) and the duration of these treatment episodes. Results: The cohort included 1179 residents with gout, of whom 62% used a ULT, with a median of one episode of use for a very short duration [median = 4 days, median of use in total (i.e. repeated use) = 52 days]. Among residents with gout, 9% also used colchicine or an NSAID. Female residents were less likely to receive ULT and for shorter periods. Conclusion: Nearly one-third of residents with gout did not receive ULT. In those receiving ULT, recurrent short courses were common. Overall, management of gout in aged care residents appears to be suboptimal, largely owing to intermittent and short exposure to ULT, and with female residents at greater risk of poor gout management.