Pharmacist-led interventions to reduce adverse drug events in older people living in residential aged care facilities: A systematic review.

AIMS: We aimed to investigate the efficacy and effectiveness of pharmacist-led interventions to reduce adverse drug events (ADEs) in older people living in residential aged care facilities (RACFs). METHODS: We systematically searched MEDLINE via PubMed, Embase, Cochrane Central Register of Controlled Trials and PsycINFO from their inceptions to July 2020. We investigated experimental study designs that employed a control group, or quasi-experimental studies conducted in RACFs. RESULTS: We screened 3826 records and included 23 studies. We found seven single-component and 16 multicomponent pharmacist-led interventions to reduce ADEs in older people living in RACFs. The most frequent single-component pharmacist-led intervention was medication review. Medication review and education provision to healthcare professionals were the most common components in many pharmacist-led multicomponent interventions. Thirteen studies (56%) showed no effect, whereas ten studies (43%) reported significant reductions in ADEs following pharmacist-led interventions either as a sole intervention or as a part of a multi-component intervention. Many interventions focused on reducing the incidence of falls (39%). CONCLUSIONS: This systematic review suggests that pharmacist-led interventions have the potential to reduce the incidence of ADEs in older people living in RACFs. Medication review and educational programmes, particularly academic detailing, either as a single component or as part of multicomponent interventions were the most common approaches to reducing drug-related harm in older people living in RACFs. The lack of a positive association between interventions and ADE in many studies suggests that targeted and tailored pharmacist-led interventions are required to reduce ADEs in older people in RACFs.

Outcomes of Medication Misadventure Among People With Cognitive Impairment or Dementia: A Systematic Review and Meta-analysis.

OBJECTIVE: To investigate mortality and hospitalization outcomes associated with medication misadventure (including medication errors [MEs], such as the use of potentially inappropriate medications [PIMs], and adverse drug events [ADEs]) among people with cognitive impairment or dementia. DATA SOURCES: Ovid MEDLINE, Ovid EMBASE, Ovid International Pharmaceutical Abstracts, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials were searched from inception to December 2019. STUDY SELECTION AND DATA EXTRACTION: Relevant studies using any study design were included. Reviewers independently performed critical appraisal and extracted relevant data. DATA SYNTHESIS: The systematic review included 10 studies that reported the outcomes of mortality or hospitalization associated with medication misadventure, including PIMs (n=5), ADEs (n=2), a combination of MEs and ADEs (n=2), and drug interactions (n=1). Five studies examining the association between PIMs and mortality/hospitalization were included in the meta-analyses. Exposure to PIMs was not associated with either mortality (odds ratio [OR]=1.36; 95%CI=0.79-2.35) or hospitalization (OR=1.02; 95%CI=0.83-1.26). In contrast, single studies indicated that ADEs with cholinesterase inhibitors were associated with mortality and hospitalization. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: Individuals with cognitive impairment or dementia are at increased risk of medication misadventure; based on relatively limited published data, this does not necessarily translate to increased mortality and hospitalization. CONCLUSIONS: Overall, medication misadventure was not associated with mortality or hospitalization in people with cognitive impairment or dementia, noting the limited number of studies, difficulty in controlling potential confounding variables, and that most studies focus on PIMs.

Anticoagulation knowledge in patients with atrial fibrillation: An Australian survey.

BACKGROUND: Atrial fibrillation (AF) is the most commonly diagnosed arrhythmia in clinical practice, and is associated with a significant medical and economic burden. Anticoagulants reduce the risk of stroke and systemic embolism by approximately two-thirds compared with no therapy. Knowledge regarding anticoagulant therapy can influence treatment outcomes in patients with AF. OBJECTIVE: To measure the level of anticoagulation knowledge in patients with AF taking oral anticoagulants (OACs), investigate the association between patient-related factors and anticoagulation knowledge, and compare these results in patients taking warfarin and direct-acting oral anticoagulant (DOACs). METHODS: Participants were recruited for an online survey via Facebook. Survey components included the Anticoagulation Knowledge Tool, the Perception of Anticoagulant Treatment Questionnaires (assessing treatment expectations, convenience and satisfaction), a modified Cancer Information Overload scale and the Morisky Medication Adherence Scale. Treatment groups were compared and predictors of OAC knowledge were identified. RESULTS: Participants taking warfarin had a higher knowledge score compared with those taking DOACs (n = 386, 73% ± 13% vs 66% ± 14%, P<.001). Advancing age, type of OAC, health information overload and ease of OAC use (treatment expectation) were significant predictors of knowledge. Treatment expectation, including the belief that OAC treatment would cause bleeding side effects, varied significantly between participants taking warfarin and DOACs (P = .011). CONCLUSION: The study identified knowledge gaps in patients taking OACs, and these deficiencies appeared to be greater in participants taking DOACs. Knowledge assessment should be integrated into patient counselling sessions to help identify and resolve knowledge deficits.

Factors associated with overestimation of asthma control: A cross-sectional study in Australia.

OBJECTIVE: To investigate actual and perceived disease control in Australians with asthma, and identify factors associated with overestimation of asthma control. METHODS: This was a cross-sectional study of Australian adults with asthma, who were recruited via Facebook to complete an online survey. The survey included basic demographic questions, and validated tools assessing asthma knowledge, medication adherence, medicine beliefs, illness perception and asthma control. Items that measured symptoms and frequency of reliever medication use were compared to respondents' self-rating of their own asthma control. Predictors of overestimation of asthma control were determined using multivariate logistic regression. RESULTS: Of 2971 survey responses, 1950 (65.6%) were complete and eligible for inclusion. Overestimation of control was apparent in 45.9% of respondents. Factors independently associated with overestimation of asthma control included education level (OR = 0.755, 95% CI: 0.612-0.931, P = 0.009), asthma knowledge (OR = 0.942, 95% CI: 0.892-0.994, P = 0.029), total asthma control, (OR = 0.842, 95% CI: 0.818-0.867, P < 0.001), agreement that most medications are addictive (OR = 1.144, 95% CI: 1.017-1.287, P = 0.025), and increased feelings of control over asthma (OR = 1.261, 95% CI: 1.191-1.335), P < 0.001). CONCLUSIONS: Overestimation of asthma control remains a significant issue in Australians with asthma. The study highlights the importance of encouraging patients to express their feelings about asthma control and beliefs about medicines, and to be more forthcoming with their asthma symptoms. This would help to reveal any discrepancies between perceived and actual asthma control.

Pain and Functionality Following Sternotomy: A Prospective 12-Month Observational Study.

OBJECTIVE: To document pain levels, functionality, and analgesic use in the 12 months following a sternotomy to identify factors associated with the development of persistent post-sternotomy pain. DESIGN: Prospective observational study. SETTINGS: Royal Hobart Hospital, Australia. SUBJECTS: Patients undergoing a sternotomy between January and November 2013. METHODS: One hundred and ten patients were recruited and followed for 12 months, with telephone calls at 10 days, 6 weeks, 3 months, and 12 months. An initial survey was completed at the point of recruitment including patient history, depression and anxiety scales, self-rated health, and pain catastrophizing scale. RESULTS: The mean age of participants was 69.6 years, with the majority of participants being male (84.5%). The proportion of patients reporting pain in the early post-discharge period was high, with 30% of patients experiencing on average moderate-severe pain in the 10 days following discharge and 11% experiencing on average moderate-severe pain at 6 weeks. At 12 months, 15.5% of participants reported on average mild pain and 0.9% an average of moderate-severe pain in the preceding week at their sternotomy site. Pain of neuropathic origin was reported by 41.2% of those with on average daily pain at 12 months. CONCLUSION: This study highlights the need for further research to investigate whether more intensive pain management in the post-discharge period following sternotomy as well as the early identification of patients with neuropathic pain symptoms can reduce the incidence of persistent post-operative pain at 12 months.

Use of Opioid Analgesics in Older Australians.

OBJECTIVE: To identify potential medication management issues associated with opioid use in older Australians. DESIGN: Retrospective cross-sectional review of the utilization of analgesics in 19,581 people who underwent a medication review in Australia between 2010 and 2012. SUBJECTS: Australian residents living in the community deemed at risk for adverse medication outcomes or any resident living fulltime in an aged care facility. METHODS: Patient characteristics in those taking regularly dosed opioids and not and those taking opioid doses >120 mg and ≤120 mg MEQ/day were compared. Multivariable binary logistic regression was used to analyze the association between regular opioid and high dose opioid usage and key variables. Additionally, medication management issues associated with opioids were identified. RESULTS: Opioids were taken by 31.8% of patients, with 22.1% taking them regularly. Several major medication management issues were identified. There was suboptimal use of multimodal analgesia, particularly a low use of non-opioid analgesics, in patients taking regular opioids. There was extensive use (45%) of concurrent anxiolytics/hypnotics among those taking regular opioid analgesics. Laxative use in those prescribed opioids regularly was low (60%). Additionally, almost 12% of patients were taking doses of opioid that exceeded Australian recommendations. CONCLUSIONS: A significant evidence to practice gap exists regarding the use of opioids amongst older Australians. These findings highlight the need for a quick reference guide to support prescribers in making appropriate decisions regarding pain management in older patients with persistent pain. This should also be combined with patient and caregiver education about the importance of regular acetaminophen to manage persistent pain.

Review of the management of childhood asthma in Tasmania.

AIM: To review the supply of medications to children with asthma and parent-reported management of childhood asthma in Tasmania and highlight evidence-practice gaps for future interventions. METHODS: Participating pharmacies ran a software application that extracted data from dispensing records and helped to identify children with asthma. Parents of identified children were mailed a survey evaluating components of asthma management. Dispensing and survey data were analysed. RESULTS: A total of 939 children from 23 pharmacies were identified by the software and deemed eligible for inclusion. Surveys were received from 353 (37.6%) parents. In the past year, short-acting beta-2 agonists were supplied to 56.1% of the cohort, preventers to 76.5% (inhaled corticosteroids 52.3%; leukotriene receptor antagonists 31.3%; inhaled cromones 0.6%), long-acting beta-2 agonists (LABAs) to 25.7% and oral corticosteroids to 21.5%. Approximately half of the children receiving inhaled corticosteroids were concurrently receiving a LABA. Among children with indicators of inadequately controlled asthma, up to 73.7% of their parents reported that their asthma was adequately controlled, up to 38.2% did not possess an Asthma Action Plan, up to 36.8% were not regularly using a spacer and up to 22.8% had not received a preventer. CONCLUSION: These results indicate gaps in childhood asthma management, in particular, undersupply of preventers in high-risk patient groups, high supply of LABAs and insufficient spacer and asthma action plan usage. These areas should be targeted for interventions to improve childhood asthma management.

Ten-year trends in adverse drug reaction-related hospitalizations among people with dementia.

Aim: Trends in the incidence of adverse drug reaction (ADR)-related hospitalizations have been studied in the general population, but not specifically in people with dementia. This study aimed to investigate trends in the incidence of ADR-related hospitalizations among people with dementia, and identify the most commonly implicated drugs and diagnoses in these admissions. Methods: This study utilized the administrative data of all adults admitted to the four major public hospitals of Tasmania, Australia, with a primary or secondary diagnosis of dementia from July 2010 to December 2019. ADR-related hospitalizations were identified by using diagnosis-based and external cause codes. The Cochran-Armitage test was used to examine trends in the incidence of ADR-related hospitalizations. Results: Of the 7552 people with dementia admitted to the hospital at least once within the study period, 1775 (23.5%) experienced at least one ADR-related hospitalization. The estimated annual incidence of ADR-related hospitalizations increased 18% (1484-1760 per 100,000 population with dementia, p for trend <0.05) from 2010 to 2019. For those ADR-related admissions with a drug code recorded, 19.3% were due to antithrombotics and 11.5% to antihypertensives. The most frequent ADR-related admission diagnoses were renal diseases (72.9%). Length of hospital stay and in-hospital mortality were both significantly greater for ADR-related, relative to non-ADR-related, admissions (median 7 versus 5 days and 11% versus 6.7%, respectively; p < 0.001). Conclusion: The annual incidence of ADR-related hospitalizations in people with dementia increased between 2010 and 2019. Antithrombotics were the most commonly implicated drug class. The ADR-related hospitalizations were associated with increased length of stay and greater mortality. Plain Language Summary: Adverse drug reaction-related hospitalizations among people with dementia. Introduction: This study aimed to investigate trends in hospitalizations associated with medication problems among people with dementia, and identify the most commonly implicated drugs and diagnoses in these admissions. Methods: This study utilized the administrative data of all adults admitted to the four major public hospitals of Tasmania, Australia, with dementia from July 2010 to December 2019. Results: The annual incidence of hospitalizations associated with medication problems among people with dementia increased nearly 20% over 10 years. The length of hospital stay and in-hospital mortality were significantly greater for hospitalizations related to medication problems. Conclusion: The incidence of hospitalizations associated with medication problems in people with dementia increased between 2010 and 2019.

Clinical outcomes of a collaborative, home-based postdischarge warfarin management service.

BACKGROUND: Warfarin remains a high-risk drug for adverse events, especially following discharge from the hospital. New approaches are needed to minimize the potential for adverse outcomes during this period. OBJECTIVE: To evaluate the clinical outcomes of a collaborative, home-based postdischarge warfarin management service adapted from the Australian Home Medicines Review (HMR) program. METHODS: In a prospective, nonrandomized controlled cohort study, patients discharged from the hospital and newly initiated on or continuing warfarin therapy received either usual care (UC) or a postdischarge service (PDS) of 2 or 3 home visits by a trained, HMR-accredited pharmacist in their first 8 to 10 days postdischarge. The PDS involved point-of-care international normalized ratio (INR) monitoring, warfarin education, and an HMR, in collaboration with the patient's general practitioner and community pharmacist. The primary outcome measure was the combined incidence of major and minor hemorrhagic events in the 90 days postdischarge. Secondary outcome measures included the incidences of thrombotic events, combined hemorrhagic and thombotic events, unplanned and warfarin-related hospital readmissions, death, INR control, and persistence with therapy at 8 and 90 days postdischarge. RESULTS: The PDS (n=129) was associated with statistically significantly decreased rates of combined major and minor hemorrhagic events to day 90 (5.3% vs 14.7%; p=0.03) and day 8 (0.9% vs 7.2%; p=0.01) compared with UC (n=139). The rate of combined hemorrhagic and thrombotic events to day 90 also decreased (6.4% vs 19.0%; p=0.008) and persistence with warfarin therapy improved (95.4% vs 83.6%; p=0.004). No significant differences in readmission and death rates or INR control were demonstrated. CONCLUSIONS: This study demonstrated the ability of appropriately trained accredited pharmacists working within the Australian HMR framework to reduce adverse events and improve persistence in patients taking warfarin following hospital discharge. Widespread implementation of such a service has the potential to enhance medication safety along the continuum of care.

A role for pharmacists in community-based post-discharge warfarin management: protocol for the 'the role of community pharmacy in post hospital management of patients initiated on warfarin' study.

BACKGROUND: Shorter periods of hospitalisation and increasing warfarin use have placed stress on community-based healthcare services to care for patients taking warfarin after hospital discharge, a high-risk period for these patients. A previous randomised controlled trial demonstrated that a post-discharge service of 4 home visits and point-of-care (POC) International Normalised Ratio (INR) testing by a trained pharmacist improved patients' outcomes. The current study aims to modify this previously trialled service model to implement and then evaluate a sustainable program to enable the smooth transition of patients taking warfarin from the hospital to community setting. METHODS/DESIGN: The service will be trialled in 8 sites across 3 Australian states using a prospective, controlled cohort study design. Patients discharged from hospital taking warfarin will receive 2 or 3 home visits by a trained 'home medicines review (HMR)-accredited' pharmacist in their 8 to 10 days after hospital discharge. Visits will involve a HMR, comprehensive warfarin education, and POC INR monitoring in collaboration with patients' general practitioners (GPs) and community pharmacists. Patient outcomes will be compared to those in a control, or 'usual care', group. The primary outcome measure will be the proportion of patients experiencing a major bleeding event in the 90 days after discharge. Secondary outcome measures will include combined major bleeding and thromboembolic events, death, cessation of warfarin therapy, INR control at 8 days post-discharge and unplanned hospital readmissions from any cause. Stakeholder satisfaction will be assessed using structured postal questionnaire mailed to patients, GPs, community pharmacists and accredited pharmacists at the completion of their study involvement. DISCUSSION: This study design incorporates several aspects of prior interventions that have been demonstrated to improve warfarin management, including POC INR testing, warfarin education and home visits by trained pharmacists. It faces several potential challenges, including the tight timeframe for patient follow-up in the post-discharge period. Its strengths lie in a strong multidisciplinary team and the utilisation of existing healthcare frameworks. It is hoped that this study will provide the evidence to support the national roll-out of the program as a new Australian professional community pharmacy service. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry Number 12608000334303.

Effect of a Fucoidan Extract on Insulin Resistance and Cardiometabolic Markers in Obese, Nondiabetic Subjects: A Randomized, Controlled Trial.

OBJECTIVES: To determine whether a fucoidan extract reduced insulin resistance and/or altered other cardiometabolic markers in an obese, nondiabetic population. DESIGN: Single-site, double-blinded, placebo-controlled, randomized controlled trial. SETTING/LOCATION: Hobart, Tasmania, Australia. SUBJECTS: Eligible subjects were obese, with no history of diabetes, and ages between 18 and 65 years. INTERVENTIONS: Subjects were randomly assigned, in even blocks of 10, to either active fucoidan 500 mg or placebo capsules twice daily for 90 days, with identical measurements performed at baseline and follow-up. OUTCOME MEASURES: The primary outcome was insulin resistance, defined by the homeostasis model of assessment (HOMA) values. Secondary outcomes were lipid profile, glycosylated hemoglobin, urea electrolytes and creatinine, liver function tests, full/complete blood count, fasting insulin, fasting glucose, quantitative insulin sensitivity check index, glucose area under the curve, weight, body mass index, waist circumference, and systolic and diastolic blood pressure. The trial was registered with the Australian New Zealand Clinical Trial Registry (ACTRN12614000495628) and the Therapeutic Goods Administration (2014/0348), and was funded by Marinova Pty. Ltd. RESULTS: There were no differences in the 90-day outcome measures between placebo and active treatment in the intention-to-treat-analysis (n = 35 for active, n = 37 for placebo). The mean change in HOMA scores was 0 for the placebo and -0.1 for the active groups (p = 0.73). Self-reported adherence was high, consistent with capsule counting at the conclusion of the trial. CONCLUSIONS: Fucoidan taken twice daily for a period of 90 days did not markedly affect insulin resistance or other measured parameters of cardiometabolic health in an obese, nondiabetic cohort. This could be due to an intrinsic lack of efficacy, lower than measured adherence, or because longer therapy and/or higher baseline insulin resistance are required to exert a significant effect.

Anticoagulant Use in Patients With Nonvalvular Atrial Fibrillation: Has Prescribing Improved?

Discordance between international guideline recommendations and anticoagulant prescribing patterns among patients with nonvalvular atrial fibrillation (NVAF) has been frequently reported. This study was designed to compare the anticoagulant utilization pattern to earlier data in the same population and identify predictors of anticoagulant prescribing among patients with NVAF. We reviewed patients with NVAF admitted to Tasmania's 3 major hospitals between January 2011 and June 2012 and compared the anticoagulant utilization pattern to earlier data. Patients were excluded if they had only 1 episode of NVAF that reverted spontaneously or upon cardioversion. Multivariate logistic regression analysis was used to identify predictors of anticoagulant prescribing. Overall, 53.8% of patients received anticoagulant treatment compared to 40.4% 15 years ago. Among eligible patients at high-risk of stroke, 52.5% were receiving anticoagulant therapy (vs 42.1% 15 years ago). Approximately 10% of patients with a CHADS2 score ≥2 were not receiving any antithrombotic treatment, reduced from 18.2% in the earlier cohort, whereas anticoagulant use increased among those at low risk (score 0) to 48.5% from 14.2%. Younger age (odds ratio [OR] 0.99, 95% confidence interval [CI] 0.97-1.0; P = .04); CHADS2 = 1, relative to 0 (OR 1.68, 95% CI 1.07-2.63; P = .02); CHF (OR 1.56, 95% CI 1.12-2.15; P = .008); and embolic disease history (OR 1.77, 95% CI 1.09-2.86; P = .02) were significant predictors of anticoagulant prescribing. While there has been improvement over the past 15 years, suboptimal use of anticoagulant therapy among high-risk patients with NVAF remains common. There is significant potential for improvement in the quality of stroke prophylaxis in patients with NVAF.

Patient Characteristics and Antithrombotic Prescribing Patterns in Patients With Atrial Fibrillation in Tasmania.

Limited data are available on atrial fibrillation (AF) and its clinical management and outcomes from an Australian perspective. This study was designed to examine the patient characteristics and antithrombotic treatment patterns among patients with AF in Tasmania, Australia. This retrospective observational study reviewed and followed patients with AF admitted to Tasmania's 3 major hospitals between January 2011 and June 2012. Patients were excluded if they had only 1 episode of AF that reverted spontaneously or upon cardioversion without any documented recurrences. We reviewed the records of 2502 patients (≥18 years), and1469 were subsequently included in the study. The mean (±standard deviation [SD]) age of the patients was 76 (±12.3) years. The mean (± SD) CHADS2 score was 2.1 (±1.3), and 65.7% had a score ≥2. In total, only 55.6% of patients with CHADS2 score ≥2 were receiving anticoagulation and 9.9% were not receiving any antithrombotic treatment, whereas 85.4% of those at low risk (score 0) were on antithrombotic therapy. Hospitalization was associated with a significant increase in the rate of combination (antiplatelet plus anticoagulant) therapy ( P < .001). Suboptimal use of antithrombotic therapy highlights the need to improve AF management in our jurisdiction.

The relationship between knowledge, health literacy, and adherence among patients taking oral anticoagulants for stroke thromboprophylaxis in atrial fibrillation.

BACKGROUND: Patients' knowledge regarding their oral anticoagulant (OAC) treatment for stroke prevention in atrial fibrillation (AF), their level of medication adherence, and health literacy are known to affect treatment outcomes. However, contemporary data regarding the relationships between these variables are lacking. OBJECTIVE: To investigate the relationships between anticoagulant knowledge, health literacy, and self-reported adherence in patients taking warfarin and the directly acting oral anticoagulants. METHODS: A cross-sectional survey was conducted in 48 patients with AF identified from general practices. The Anticoagulation Knowledge Tool (AKT) was used to assess anticoagulation knowledge; the Short Test of Functional Health Literacy in Adults (s-TOFHLA) for health literacy; and the 8-item Morisky Medication Adherence Scale (MMAS) for medication adherence. RESULTS: Participants had mean scores of 61.6 ± 15.8, 7.2 ± 1.1, and 24.7 ± 9.5 for the AKT, MMAS-8 and s-TOFHLA, respectively. Significant correlations were observed between anticoagulation knowledge and health literacy with medication adherence (0.37, P < .01 and .30, P < .05, respectively). Participants with inadequate health literacy had a significantly lower mean knowledge score than those with adequate health literacy (55.8 ± 15.9 vs 66.1 ± 14.4, P < .05). Participants who self-reported adherence to their OAC had significantly higher knowledge scores than those who did not (67.5 ± 13.3 vs 56.1 ± 16.2, P < .05). CONCLUSION: Significant correlations between health literacy, OAC knowledge, and adherence were observed, and these relationships should to be considered by health professionals responsible for monitoring patients who are prescribed anticoagulants. We also observed serious gaps in OAC knowledge. Interventions designed to optimize the outcomes of anticoagulant treatment need to address these factors.

Development and Validation of an Oral Anticoagulation Knowledge Tool (AKT).

BACKGROUND: Assessing and improving patients' anticoagulation knowledge can lead to better treatment outcomes. While validated knowledge instruments exist for use in people taking warfarin, these tools are not necessarily applicable to patients taking direct-acting oral anticoagulants. OBJECTIVE: To develop and validate an oral anticoagulation knowledge instrument that is applicable to all oral anticoagulant medications. METHODS: Ten anticoagulation experts participated in the development of the Anticoagulation Knowledge Tool to ensure content validity. The knowledge instrument was administered to three groups of participants comprising of 44 pharmacists, 50 patients and 50 members of the general public. A subgroup of participants in the patient and pharmacist group were retested approximately 2-3 months after the initial testing. Statistical tests were conducted to determine the validity and reliability of the scale, and item analysis was used to determine the performance of individual questions. RESULTS: The 28-item instrument developed had a scale content validity index of 0.92, supporting content validity. The pharmacist group's mean score was significantly higher than that of the patient group, and the patient group scored significantly higher than the general public group (94% vs 62% vs 20%, respectively; p<0.001), supporting construct validity. Internal consistency reliability was acceptable with a Cronbach's α value of > 0.7 across the three groups, and the test-retest reliability was confirmed with a Pearson's correlation coefficient of 0.72 and 0.78 for the pharmacist and patient groups, respectively. CONCLUSION: The Anticoagulation Knowledge Tool is a valid and reliable instrument that can be used in routine clinical practice to assess patients' anticoagulation knowledge.

A Summary of the Literature Evaluating Adherence and Persistence with Oral Anticoagulants in Atrial Fibrillation.

Atrial fibrillation (AF) is a growing public health concern and remains an independent risk factor for ischemic stroke. Warfarin, a commonly used oral anticoagulant, is associated with a 60-70 % relative reduction in stroke risk and a reduction in mortality of 26 %. However, warfarin has several limitations, including a narrow therapeutic window, variable dose response, multiple interactions with other drugs and concurrent illnesses, and the need for frequent laboratory monitoring. In recent years, the direct acting oral anticoagulants (DOACs), including dabigatran, rivaroxaban, apixaban and edoxaban, have been developed to overcome the limitations of warfarin therapy. These treatment strategies are either comparable or superior to warfarin in stroke prevention in AF. Despite the documented effectiveness of oral anticoagulants in AF, patients may not derive optimal benefit if they fail to adhere or fail to continue with their medication. This may lead to treatment failure, increased hospitalization and mortality. This review summarizes the literature regarding adherence and persistence (or discontinuation) rates with oral anticoagulants in the management of AF; the impact of non-adherence and non-persistence on treatment outcomes; and the effectiveness of strategies to improve adherence and persistence with oral anticoagulant therapy.

Adverse-Drug-Reaction-Related Hospitalisations in Developed and Developing Countries: A Review of Prevalence and Contributing Factors.

Adverse drug reactions (ADRs) are one of the leading causes of hospital admissions and morbidity in developed countries and represent a substantial burden on healthcare delivery systems. However, there is little data available from low- and middle-income countries. This review compares the prevalence and characteristics of ADR-related hospitalisations in adults in developed and developing countries, including the mortality, severity and preventability associated with these events, commonly implicated drugs and contributing factors. A literature search was conducted via PubMed, Scopus, Web of Science, Embase, ProQuest and Google Scholar to find articles published in English from 2000 to 2015. Relevant observational studies were included. The median (with interquartile range [IQR]) prevalence of ADR-related hospitalisation in developed and developing countries was 6.3 % (3.3-11.0) and 5.5 % (1.1-16.9), respectively. The median proportions of preventable ADRs in developed and developing countries were 71.7 % (62.3-80.0) and 59.6 % (51.5-79.6), respectively. Similarly, the median proportions of ADRs resulting in mortality in developed and developing countries were 1.7 % (0.7-4.8) and 1.8 % (0.8-8.0), respectively. Commonly implicated drugs in both settings were antithrombotic, non-steroidal anti-inflammatory and cardiovascular drugs. Older age, female gender, number of medications, renal impairment and heart failure were reported to be associated with an increased risk for ADR-related hospitalisation in both settings while HIV/AIDS was implicated in developing countries only. The majority of ADRs were preventable in both settings, highlighting the importance of improving medication use, particularly in vulnerable patient groups such as the elderly, patients with multiple comorbidities and, in developing countries, patients with HIV/AIDS.

Medication Adherence Following Acute Coronary Syndrome: Does One Size Fit All?

Guideline-based management of acute coronary syndrome (ACS) is well established, yet some may challenge that strict implementation of guideline recommendations can limit the individualization of therapy. The use of all recommended medications following ACS places a high burden of responsibility and cost on patients, particularly when these medications have not been previously prescribed. Without close attention to avoiding non-adherence to these medications, the full benefits of the guideline recommendations will not be realized in many patients. Using a case example, we discuss how the recognition of adherence barriers can be an effective and efficient process for identifying patients at risk of non-adherence following ACS. For those identified as at risk, the World Health Organization's model of adherence barriers is explored as a potentially useful tool to assist with individualization of therapy and promotion of adherence.