A Digitally Enabled, Pharmacist service to detecT medicine harms in residential aged care (nursing home) (ADEPT): protocol for a feasibility study.

INTRODUCTION: This feasibility study aims to develop and test a new model of practice in Australia using digital technologies to enable pharmacists to monitor early signs and symptoms of medicine-induced harms in residential aged care. METHODS AND ANALYSIS: Thirty residents will be recruited from an aged care facility in South Australia. The study will be conducted in two phases. In phase I, the study team will work with aged care software providers and developers of digital technologies (a wearable activity tracker and a sleep tracking sensor) to gather physical activity and sleep data, as well as medication and clinical data from the electronic medication management system and aged care clinical software. Data will be centralised into a cloud-based monitoring platform (TeleClinical Care (TCC)). The TCC will be used to create dashboards that will include longitudinal visualisations of changes in residents' health, function and medicine use over time. In phase II, the on-site pharmacist will use the centralised TCC platform to monitor each resident's medicine, clinical, physical activity and sleep data to identify signs of medicine-induced harms over a 12-week period.A mixed methods process evaluation applying the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) evaluation framework will be used to assess the feasibility of the service. Outcome measures include service reach, changes in resident symptom scores (measured using the Edmonton Symptom Assessment System), number of medication adverse events detected, changes in physical activity and sleep, number of pharmacist recommendations provided, cost analysis and proportion of all pharmacists' recommendations implemented at 4-week, 8-week and 12-week postbaseline period. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the University of South Australia's Human Research Ethics Committee (205098). Findings will be disseminated through published manuscripts, conference presentations and reporting to the study funder. TRIAL REGISTRATION NUMBER: ACTRN12623000506695.

Knowledge, attitudes and self-confidence with skills required for providing dementia care in physicians at primary healthcare settings in Vietnam.

BACKGROUND: Dementia is a global public health priority. The World Health Organization adopted a Global Action Plan on Dementia, with dementia awareness a priority. This study examined the knowledge, attitudes, and self-confidence with skills required for providing dementia care among primary health care providers in Vietnam. METHODS: A cross-sectional study was conducted with 405 primary health care providers who worked at commune health stations and district health centers in eight provinces across Vietnam. RESULTS: The results showed that primary health care providers had poor knowledge and little confidence but more positive attitudes toward dementia care and management. CONCLUSIONS: The results suggest the training needs for building capacity amongst primary health care providers, which will be critical as Vietnam's population ages.

Data-Driven Interventions for an Emergency Preparedness System: A National Experience in Australia.

Natural disasters and health emergencies disproportionally affect vulnerable populations causing disruptions to usual care and increasing chronic disease burden. Data and digital technologies are important tools to identify and mitigate indirect effects of emergencies. In this paper, we describe the methods used in the development of a series of digital emergency preparedness interventions to mitigate the direct and indirect consequences of the COVID-19 pandemic in the veteran community in Australia. The case studies demonstrate the use of data for surveillance, patient phenotyping, data-driven decision support and stakeholder communication in primary care. The intervention successfully increased appropriate healthcare use by vulnerable individuals and could be expanded to other populations.

To test or to not test: A retrospective cross-sectional study on potentially inappropriate use of pathology testing in South Australian hospitals.

OBJECTIVES: To measure rates of potentially inappropriate pathology testing in the hospital setting. METHODS: Retrospective cross-sectional study in hospital setting from July 2021 to December 2021. We examined 3 potentially inappropriate uses: overordering, selection errors, and unnecessary repeat testing. Overordering included vitamin D and lipids (rarely required in acute hospital care). Selection error was the ratio of iron studies to standalone ferritin requests. Unnecessary repeats included any repeat vitamin D, lipids, iron, or ferritin in an episode of care or C-reactive protein (CRP) repeated within 3 days and N-terminal pro-brain natriuretic peptide (NT-proBNP) within 7 days and repeated previously abnormal CRP and NT-proBNP tests. Costs of inappropriate tests were estimated using the Australian Medicare Benefits Schedules. RESULTS: Among 55,904 test requests, 15% (n = 8120) were potentially inappropriate. Vitamin D was frequently ordered (n = 4498), as were lipids (n = 2872). Ratio of iron studies to standalone ferritin was 36. Of 19,233 repeat CRPs, 36% (n = 6947) were within 3 days and 62% (n = 179) of repeat NT-proBNPs were within 7 days of the first test. For initially abnormal tests, 89% of CRPs and 97% of NT-proBNPs remained abnormal. Inappropriate test costs accounted for 12% to 30% of costs. CONCLUSIONS: Frequent potential inappropriate use and selection of pathology tests was observed in South Australian hospitals.

Temporal trends in percutaneous coronary intervention in Australia: A retrospective analysis from 2000-2021.

OBJECTIVE: The aim of this study was to describe the trend in percutaneous coronary intervention (PCI) with insertion of a stent in Australia from 2000/01 to 2020/21 and investigate trends in same-day versus non-same-day discharge following PCI. A secondary aim was to compare the rate of coronary artery bypass grafting (CABG) with PCI procedures, while a third aim was to compare marked PCI trend changes with the PCI guidelines during the study period. BACKGROUND: PCI with stent deployment is the most common form of interventional treatment for coronary artery disease, and its use has been expanding since 2000. However, there is a lack of descriptive studies of the national trend in Australia. METHODS: All procedures for PCI and CABG were extracted across 21 years (2000/01 to 2020/21) from the Australian Institute of Health and Welfare data. Age-standardized rates were calculated using the Australian standard population as of June 2001. The ratio of PCI to CABG procedures was also calculated. Trends for PCI were stratified by age, gender, and same-day or overnight discharge episodes. Linear regression analysis was done to compare the age-standardized rates across different age categories. Segmented regression analysis was performed to ascertain the change in the age-standardized rates of PCI during the study period. Whether the changepoints in the trend were matched with guideline updates was also assessed. RESULTS: There were 751 728 PCI procedures in persons aged 30 years and above between 2000/01 and 2020/21. The age-standardized rate for the study period showed that persons aged 60-74 years had a higher rate of procedures (102.7) compared to persons aged 30-59 years (81.3) and 75 years and older (61.8) (P < 0.001). There were two statistically significant changepoints in the overall trend; 2005/06 and 2013/14, matched with the change in PCI guidelines. Despite the lower number of procedures for same-day discharge episodes, there has been an increasing trend since 2014/15. More than two-thirds of all stenting procedures were the insertion of a single stent. PCI to CABG procedure ratio increased from 0.6 in 2000/01 to 1.8 in 2020/21. CONCLUSIONS: There was a varying trend in the age-standardized rate of PCI with a peak in 2005/06. The trend appears to be stabilizing in the later part of the study period, but the rate for same-day discharge episodes showed an increasing trend after 2014/15. There is consistency with changepoints in the trend and updated PCI guideline recommendations. The ratio of PCI with insertion of a stent to CABG procedure increased substantially across the study period.

Opportunities for clinical decision support targeting medication safety in remote primary care management of chronic kidney disease: A qualitative study in Northern Australia.

INTRODUCTION: This study aimed to identify opportunities for clinical decision support targeting medication safety in remote primary care, by investigating the relationship between clinical workflows, health system priorities, cognitive tasks, and reasoning processes in the context of medicines used in people with chronic kidney disease (CKD). METHODS: This qualitative study involved one-on-one, semistructured interviews. The participants were healthcare professionals employed in a clinical or managerial capacity with clinical work experience in a remote health setting for at least 1 year. RESULTS: Twenty-five clinicians were interviewed. Of these, four were rural medical practitioners, nine were remote area nurses, eight were Aboriginal health practitioners, and four were pharmacists. Four major themes were identified from the interviews: (1) the need for a clinical decision support system to support a sustainable remote health workforce, as clinicians were "constantly stretched" and problems may "fall through the cracks"; (2) reliance on digital health technologies, as medical staff are often not physically available and clinicians-on-duty usually "flick an email and give a call so that I can actually talk it through to our GP"; (3) knowledge gaps, as "it takes a lot of mental space" to know each patient's renal function and their medication history, and clinicians believe "mistakes can be made"; and (4) multiple risk factors impacting CKD management, including clinical, social and behavioural determinants. CONCLUSIONS: The high prevalence of CKD and reliance on digital health systems in remote primary health settings can make a clinical decision support system valuable for supporting clinicians who may not have extensive experience in managing medicines for people with CKD.

Vietnam's Responses to Dementia - An Assessment of Service Delivery.

BACKGROUND: This study was conducted to assess Vietnam's dementia service delivery. METHODS: Using WHO methodology, website searches of key organisations focused on three aspects of Vietnam's healthcare system: (1) Health and social workforce; (2) Services, supports and treatment programs; and (3) Promotion of awareness and understanding. Data were analysed using content analysis. RESULTS: While key members of the healthcare workforce receive some education in dementia competencies during their training, the skill-mix of staff in the current workforce appears inadequate to address the complex needs of people with dementia. Although Vietnam's general healthcare system comprises a good variety of service types, there is a lack of dementia-specific services. Available diagnosis and treatment services are concentrated in the hospital system and are mainly located in metropolitan areas, impacting their accessibility. While both community-based and institutional long-term care is available, institutional care is not universally accessible and home-based care is mainly provided by family carers who don't have access to dementia care training. There is no active dementia prevention or public awareness campaign. CONCLUSIONS: To improve the ability of Vietnam's service delivery to meet the needs of people with dementia and their carers, the skill-mix of the healthcare workforce should be strengthened by ensuring that dementia core competencies are embedded within undergraduate and graduate education programs and making post-qualification dementia care training available. The capacity of existing community-level health and social services should be expanded to ensure that integrated, specialised and comprehensive health and social services are accessible to all people with dementia. Expanding access to institutional long-term care and making dementia education available to family and other informal carers could increase choice and improve quality of care. Finally, Vietnam could look to other countries in the region with regards to the development of a dementia prevention and public awareness campaign.

Pharmacists as patient advocates: A series of case studies illustrating the impacts of a regular pharmacist service in residential aged care (nursing homes).

Background: Medicine-related problems are common in older people living in residential aged care facilities (RACFs). Recognising the significant medicine-related problems, the Australian government has announced a $345 million funding package to employ on-site pharmacists in RACFs starting in 2023. The new on-site pharmacists are to provide a range of clinical services to reduce medicine-related adverse events, promote quality use of medicines, and improve clinical governance and education. Underpinning these services, the authors argue that pharmacists play the critical role as resident advocates. Objective: This study aims to demonstrate how pharmacists can enhance their advocacy responsibility within and beyond the clinical environment to not only reduce medicine-related adverse events but also improve residents' overall health and quality of life. Methods: This study uses a case series methodology to demonstrate pharmacists' diverse roles in advocating for residents and their families. The case studies were based on participants enrolled in the Reducing Medicine-Induced Deterioration and Adverse Reactions (ReMInDAR) trial, a randomised controlled trial testing the effects of a regular pharmacist service across the Australian RACFs. Results: Pharmacists' advocacy ranged from persistence in follow-up with a resident's general practitioner (GP) to ensure the GP was aware that a patient was experiencing bleeding and bruising while on an anticoagulant, to advocating for a new bed for a resident with peripheral oedema who had been sleeping in his chair due to fear of falling out of his current bed. Conclusions: Our trial focussed on pharmacists serving as the residents' advocate to improve their overall health and quality of life, rather than just addressing a list of medicine-related problems. The pharmacist model used in the ReMInDAR trial supports pharmacists to work to their full scope of practice, helps guide the Australian government's new on-site pharmacist program, and serves as an exemplar pharmacist in aged care model internationally.

Reducing opioid use for chronic non-cancer pain in primary care using an evidence-based, theory-informed, multistrategic, multistakeholder approach: a single-arm time series with segmented regression.

BACKGROUND: Many countries have high opioid use among people with chronic non-cancer pain. Knowledge about effective interventions that could be implemented at scale is limited. We designed a national intervention that included audit and feedback, deprescribing guidance, information on catastrophising assessment, pain neuroscience education and a cognitive tool for use by patients with their healthcare providers. METHOD: We used a single-arm time series with segmented regression to assess rates of people using opioids before (January 2015 to September 2017), at the time of (October 2017) and after the intervention (November 2017 to August 2019). We used a cohort with historical comparison group and log binomial regression to examine the rate of psychologist claims in opioid users not using psychologist services prior to the intervention. RESULTS: 13 968 patients using opioids, 8568 general practitioners, 8370 pharmacies and accredited pharmacists and 689 psychologists were targeted. The estimated difference in opioid use was -0.51 persons per 1000 persons per month (95% CI -0.69, -0.34; p<0.001) as a result of the intervention, equating to 25 387 (95% CI 24 676, 26 131) patient-months of opioid use avoided during the 22-month follow-up. The targeted group had a significantly higher rate of incident patient psychologist claims compared with the historical comparison group (rate ratio: 1.37, 95% CI 1.16, 1.63; p<0.001), equating to an additional 690 (95% CI 289, 1167) patient-months of psychologist treatment during the 22-month follow-up. CONCLUSIONS: Our intervention addressed the cognitive, affective and sensory factors that contribute to pain and consequent opioid use, demonstrating it could be implemented at scale and was associated with a reduction in opioid use and increasing utilisation of psychologist services.

Prevalence and Preventability of Adverse Medicine Events in a Sample of Australian Aged-Care Residents: A Secondary Analysis of Data from the ReMInDAR Trial.

BACKGROUND: Aged care residents are vulnerable to the harmful effects of medicines; however, data on the prevalence and preventability of adverse medicine events in aged care residents are scarce. AIM: To determine the prevalence and preventability of adverse medicine events in Australian aged care residents. METHODS: A secondary analysis of data from the Reducing Medicine-Induced Deterioration and Adverse Reactions (ReMInDAR) trial was conducted. Potential adverse medicine events were identified and independently screened by two research pharmacists to produce a short-list of potential adverse medicine events. An expert clinical panel reviewed each potential adverse medicine to determine the likelihood that the event was medicine related (based on the Naranjo Probability Scale criteria). The clinical panel assessed preventability of medicine-related events using Schumock-Thornton criteria. RESULTS: There were 583 adverse events due to medicines, involving 154 residents (62% of the 248 study participants). There was a median of three medication-related adverse events (interquartile range [IQR] 1-5) per resident over the 12-month follow-up period. The most common medication-related adverse events were falls (56%), bleeding (18%) and bruising (9%). There were 482 (83%) medication-related adverse events that were preventable, most commonly falls (66% of preventable adverse medicine events), bleeding (12%) and dizziness (8%). Of the 248 residents, 133 (54% of the cohort) had at least one preventable adverse medicine event, with a median of 2 (IQR 1-4) preventable adverse medicine events per resident. CONCLUSION: In total, 62% of aged care residents in our study had an adverse medicine event and 54% had a preventable adverse medicine event in a 12-month period.

Using wrist-worn accelerometers to identify the impact of medicines with anticholinergic or sedative properties on sedentary time: A 12-month prospective analysis.

INTRODUCTION: Studies have shown that use of medicines with sedative or anticholinergic properties is associated with a decline in physical function; however, the effects have not been quantified, and it is not known how and which specific physical movements are affected. This prospective study quantified the impact of a change in sedative or anticholinergic load over time on 24-hour activity composition. METHODS: This study used data collected from a randomised trial assessing an ongoing pharmacist service in residential aged care. The 24-hour activity composition of sleep, sedentary behaviour, light-intensity physical activity, and moderate to vigorous physical activity was derived from 24-hour accelerometry bands. Mixed effect linear models were used to regress the multivariate outcome of 24-hour activity composition on medication load at baseline and at 12 months. A fixed effect interaction between trial stage and medication load was included to test for differing sedative or anticholinergic load effects at the two trial stages. RESULTS: Data for 183 and 85 participants were available at baseline and 12 months respectively. There was a statistically significant interaction between medication load and time point on the multivariate outcome of 24-hour activity composition (sedative F = 7.2, p < 0.001 and anticholinergic F = 3.2, p = 0.02). A sedative load increase from 2 to 4 over the 12-month period was associated with an average increase in daily sedentary behaviour by an estimated 24 min. CONCLUSION: As sedative or anticholinergic load increased, there was an increase in sedentary time. Our findings suggest wearable accelerometry bands are a possible tool for monitoring the effects on physical function of sedative and anticholinergic medicines. TRIAL REGISTRATION: The ReMInDAR trial was registered on the Australian and New Zealand Trials Registry ACTRN12618000766213.

Precision public-health intervention for care coordination: a real-world study.

BACKGROUND: Health emergencies disproportionally affect vulnerable populations. Digital tools can help primary care providers find, and reach, the right patients. AIM: To evaluate whether digital interventions delivered directly to GPs' clinical software were more effective at promoting primary care appointments during the COVID-19 pandemic than interventions delivered by post. DESIGN AND SETTING: Real-world, non-randomised, interventional study involving GP practices in all Australian states. METHOD: Intervention material was developed to promote care coordination for vulnerable older veterans during the COVID-19 pandemic, and sent to GPs either digitally to the clinical practice software system or in the post. The intervention material included patient-specific information sent to GPs to support care coordination, and education material sent via post to veterans identified in the administrative claims database. To evaluate the impact of intervention delivery modalities on outcomes, the time to first appointment with the primary GP was measured; a Cox proportional hazards model was used, adjusting for differences and accounting for pre-intervention appointment numbers. RESULTS: The intervention took place in April 2020, during the first weeks of COVID-19 social distancing restrictions in Australia. GPs received digital messaging for 51 052 veterans and postal messaging for 26 859 veterans. The digital group was associated with earlier appointments (adjusted hazard ratio 1.38 [1.34 to 1.41]). CONCLUSION: Data-driven digital solutions can promote care coordination at scale during national emergencies, opening up new perspectives for precision public-health initiatives.

Experiences and perceptions of dementia in Vietnam and among the Vietnamese diaspora: a systematic review of qualitative studies.

Objectives: This paper aimed to review and synthesise the qualitative research evidence on the experiences and perceptions of dementia in Vietnam and among the Vietnamese diaspora.Methods: Systematic searches were conducted in June 2019 using Medline, Embase, Emcare, PsycINFO and Cochrane electronic databases, as well as grey literature. Keywords and Medical Subject Headings [MeSH terms] for dementia and associated terms were combined with keywords for Vietnam and its provinces. Qualitative research articles published in English or Vietnamese were included to examine evidence on the life experiences of Vietnamese people with dementia using thematic analysis.Results: Our searches resulted in 3,940 papers, from which 21 qualitative research studies were included for final analysis. The majority of research has not been undertaken in Vietnam but with the Vietnamese diaspora in Western countries and has taken a cultural perspective to analyses. Research in Western countries has focused on the need for culturally adapted and culturally sensitive models of care. Emerging themes about the life experiences of Vietnamese people with dementia identified from the studies included: many people do not have diagnostic terms for dementia but use the descriptive language of symptoms; stigma was a reported problem and on occasions can be observed in the descriptive language used for people with dementia; cultural and traditional values create both an opportunity and a barrier, supporting compassion, family care and relaxation, but creating barriers to accessing health services or long-term residential care.Conclusions: This is the first systematic review reporting qualitative evidence on the life experiences of people with dementia in Vietnam and among the Vietnamese diaspora. Future research is needed on the voice of people with dementia themselves and their caregivers particularly in Vietnam, and low and middle-income countries with regards to living with dementia, pathways to care from diagnosis, treatment, care and support, additional social care and preparedness for end of life care for people with dementia.

Risk factors predictive of adverse drug events and drug-related falls in aged care residents: secondary analysis from the ReMInDAR trial.

BACKGROUND: Residents of aged-care facilities have high rates of adverse drug events. This study aimed to identify risk factors for adverse drug events in aged-care residents. METHOD: This was a secondary study using data from a multicentre randomised controlled trial. Data from 224 residents for whom there was 6 months of baseline information were analysed. We assessed the risk of adverse drug events and falls (post hoc) in the subsequent 6 months. Adverse events were identified via a key word search of the resident care record and adjudicated by a multidisciplinary panel using a modified version of the Naranjo criteria. Covariates identified through univariable logistic regression, including age, sex, medicines, physical activity, cognition (Montreal Cognitive Assessment), previous adverse events and health service use were included in multivariable models. RESULTS: Overall, 224 residents were included, with a mean age of 86 years; 70% were female. 107 (48%) residents had an adverse drug event during the 6-month follow-up. Falls and bleeding were experienced by 73 (33%) and 28 (13%) residents, respectively. Age (odds ratio [OR] 1.05, 95% confidence interval [CI] 1.01-1.10), weight (OR 1.02, 95% CI 1.002-1.04), previous fall (OR 2.58, 95% CI 1.34-4.98) and sedative or hypnotic medicine use (OR 1.98, 95% CI 1.52-2.60) were associated with increased risk of adverse drug events. Increased cognition (OR 0.89, 95% CI 0.83-0.95) was protective. Risk factors for falls were previous fall (OR 3.27, 95% CI 1.68-6.35) and sedative or hypnotic medicines (OR 3.05, 95% CI 1.14-8.16). Increased cognition (OR 0.88, 95% CI 0.83-0.95) was protective. CONCLUSION: Our results suggest residents with a previous fall, reduced cognition, and prescription of sedative or hypnotic medicines were at higher risk of adverse drug events and should be considered for proactive prevention.

Wrist accelerometer temporal analysis as a prognostic tool for aged care residents: A sub-study of the ReMInDAR trial.

BACKGROUND: Objective measures for screening, prioritizing, and planning care for frail individuals are essential for appropriate aged care provision. This study evaluates metrics derived from actigraphy measures (captured by wrist accelerometer) as a digital biomarker to identify frail individuals at risk of adverse outcomes, including death, hospitalization, and cognitive decline. METHODS: This was a secondary study using data from a randomized controlled trial assessing the effectiveness of an ongoing pharmacist service in residential aged care facilities. Three metrics are studied and compared: the Frailty Index, the daily time spent in light time activity, and the temporal correlation of the actigraphy signal, measured by detrended fluctuation analysis. The association between actigraphy-derived metrics at baseline and adverse events within 12 months (death, cognitive decline, and hospitalizations) was assessed using logistic regression. RESULTS: Actigraphy records were available for 213 participants living in aged-care, median age of 85 years. Individuals with higher temporal correlation (activity is less random) were at lower risk of death (Standardized OR: 0.49; 95% CI 0.34, 0.7, p < 0.001) and hospitalization (Standardized OR: 0.57; 95% CI 0.42, 0.77, p < 0.001) in 12 months, but there was no difference in cognitive decline (Standardized OR: 1; 95% CI 0.74, 1.35, p = 0.98). The predictive model that included temporal correlation had an area under the curve of 0.70 (CI 0.60-0.80) for death and 0.64 (CI 0.54-0.72) for hospitalization. CONCLUSION: Temporal correlation of the actigraphy signal from aged care residents was strongly associated with death and hospitalization, but not cognitive decline. Digital biomarkers may have a place as an objective, accurate, and low-cost patient metric to support risk stratification and clinical planning.

Frailty trajectory over one year among residential aged care (nursing home) residents.

Objectives: Large population-based studies examining frailty trajectory found a linear increase in frailty over time. The pattern in which frailty changes over time for an individual person is less well-described. We examined the frailty trajectory of older adults living in aged-care in Australia. Materials and methods: This secondary study used data from a randomised controlled trial involving 39 aged-care facilities in Australia. The trial intervention was an on-going pharmacist-led intervention occurring every 8 weeks over 12 months aimed at preventing medicine-induced deterioration and adverse reactions. Frailty was assessed using the Frailty Index. Participants were categorised as non-frail, pre-frail and frail. Individual frailty trajectory over 12 months was visualised using the alluvial plot. Case notes were examined to explore reasons for any rapid transitions in frailty status. Results: A total of 248 participants was included. At baseline, 40.3% were non-frail and 59.7% were pre-frail. The proportion of participants who were non-frail and pre-frail decreased over time; 15.7% were frail at 6 months and 23.4% were frail at 12 months. Overall, twenty different combinations of frailty transitions were identified over 12 months. Retrospective analysis of case notes suggest that death or transition from non-frail to frail was often preceded by hospitalisation, falls, medication change or clinically significant deterioration in grip strength or cognition. Conclusion: The degree of frailty increased over time, but there were variations in the individual trajectories. Regular monitoring of events that precede changes in frailty status is needed to identify strategies to prevent further deterioration in residents' conditions.

Medicine-Induced Acute Kidney Injury Findings from Spontaneous Reporting Systems, Sequence Symmetry Analysis and a Case-Control Study with a Focus on Medicines Used in Primary Care.

INTRODUCTION: Primary care provides an opportunity to prevent community acquired, medicine or drug-induced acute kidney injury. One of the barriers to proactive prevention of medicine-induced kidney injury in primary care is the lack of a list of nephrotoxic medicines that are most problematic in primary care, particularly one that provides a comparison of risks across medicines. OBJECTIVE: The aim of this study was to consolidate evidence on the risks associated with medicines and acute kidney injury, with a focus on medicines used in primary care. METHOD: We searched the MEDLINE and EMBASE databases to identify published studies of all medicines associated with acute kidney injury identified from spontaneous report data. For each medicine positively associated with acute kidney injury, as identified from spontaneous reports, we implemented a sequence symmetry analysis (SSA) and a case-control design to determine the association between the medicine and hospital admission with a primary diagnosis of acute kidney injury (representing community-acquired acute kidney injury). Administrative claims data held by the Australian Government Department of Veterans' Affairs for the study period 2005-2019 were used. RESULTS: We identified 89 medicines suspected of causing acute kidney injury based on spontaneous report data and a reporting odds ratio above 2, from Japan, France and the US. Spironolactone had risk estimates of 3 or more based on spontaneous reports, SSA and case-control methods, while furosemide and trimethoprim with sulfamethoxazole had risk estimates of 1.5 or more. Positive association with SSA and spontaneous reports, but not case control, showed zoledronic acid had risk estimates above 2, while candesartan telmisartan, simvastatin, naproxen and ibuprofen all had risk estimates in SSA between 1.5 and 2. Positive associations with case-control and spontaneous reports, but not SSA, were found for amphotericin B, omeprazole, metformin, amlodipine, ramipril, olmesartan, ciprofloxacin, valaciclovir, mycophenolate and diclofenac. All with the exception of metformin and omeprazole had risk estimates above 2. CONCLUSION: This research highlights a number of medicines that may contribute to acute injury; however, we had an insufficient sample to confirm associations of some medicines. Spironolactone, furosemide, and trimethoprim with sulfamethoxazole are medicines that, in particular, need to be used carefully and monitored closely in patients in the community at risk of acute kidney injury.

Medicine-related problems: A recurrent issue among residents living in nursing homes.

Aim: To examine the incidence and nature of medicine-related problems over time experienced by nursing home residents. Method: We analyzed records collected in the Reducing Medicine-Induced Deterioration and Adverse Events (ReMInDAR) trial. The trial pharmacists provided services to reduce medicine-induced deterioration and adverse reactions for residents every 8-weeks over a year. The problems identified by the pharmacists were documented in reports and subsequently classified independently by research pharmacists using the D.O.C.U.M.E.N.T system. The number and type of problems at each service and time to develop a new problem post first session were assessed. All analyses were performed using R software (Version 4.1.1). Results: The cohort was 115 nursing home residents who received 575 services. In the 12-months, a total of 673 medicine-related problems or symptom reports were identified in 112 residents. Most residents (75%) experienced a new medicine-related problem by the fourth month post the first assessment. After the first session, the proportion of residents with a new medicine-related problem or symptom report declined at each repeated pharmacy session (59% at visit 2 vs. 28% at visit 6, p < 0.01). Conclusion: Residents living in nursing homes frequently experience medicine-related problems. Our results suggest clinical pharmacist services performed every 4-months may have the potential to reduce the medicine-related problems in nursing homes.