Perceptions of pharmacists on the quality of automated blood pressure devices: a national survey.

A recent study found that only 23.8% of blood pressure (BP) devices available for purchase from Australian pharmacies were validated for accuracy. The extent to which pharmacists are aware of this, and other issues related to the accuracy of BP devices, is not known and gathering this information was the aim of this study. An online survey of Australian pharmacists was distributed via the Pharmaceutical Society of Australia between 1 October and 25 November 2020. Questions were focused on the views of pharmacists related to the accuracy of BP devices. Two hundred and ten pharmacists completed the survey. The accuracy of BP devices sold by pharmacists was considered 'quite' or 'extremely important' to most respondents (94%). However, most respondents (90%) were unaware that less than one-quarter of BP devices sold by Australian pharmacies were validated, and this was 'quite' or 'extremely surprising' to many (69%). Many respondents (64%) associated a particular brand of BP device with greater accuracy. There was low awareness on proper ways to identify accurate BP devices, such as checking reputable online databases (43%). BP devices were stocked in respondents' pharmacies based on perceived quality (50%), accuracy (40%), or as determined by the pharmacy chain (36%). In conclusion, providing accurate BP devices to consumers is important to pharmacists, but they were generally unaware that most devices available from pharmacies were not validated for accuracy. Pharmacist education, alongside advocacy for policies including regulations and strategic action, is required to ensure only validated BP devices are sold in Australia.

A pilot study evaluating multiple risk factor interventions by community pharmacists to prevent cardiovascular disease: the PAART CVD pilot project.

BACKGROUND: There is insufficient evidence for the efficacy of comprehensive multiple risk factor interventions by pharmacists in the primary prevention of cardiovascular disease (CVD). Given the proven benefits of pharmacist interventions for individual risk factors, it is essential that evidence for a comprehensive approach to care be generated so that pharmacists remain key members of the health care team for individuals at risk of initial onset of CVD. OBJECTIVE: To establish the feasibility of an intervention delivered by community pharmacists to reduce the risk of primary onset of CVD. METHODS: A single-cohort intervention study was undertaken in 2008-2009. Twelve community pharmacists from 10 pharmacies who were trained to provide lifestyle and medicine management support to reduce CVD risk recruited 70 at-risk participants aged 50-74 years who were free from diabetes or CVD. Participants received a baseline assessment to establish CVD risk and health behaviors. An assessment report provided to patients and pharmacists was used to collaboratively establish treatment goals and, over 5 sessions, implement treatment strategies. Follow-up assessment at 6 months measured changes in baseline parameters. The primary outcome was the average change to overall 5-year risk of CVD onset. RESULTS: Sixty-seven participants were included in the analysis. The mean participant age was 60 years and 73% were female. We observed a 25% (95% CI 17 to 33) proportional risk reduction in overall CVD risk. Significant reductions also occurred in mean blood pressure (-11/-5 mm Hg) and waist circumference (-1.3 cm), with trends toward improvement for most other observed risk factors. CONCLUSIONS: Findings support previous evidence of positive cardiovascular health outcomes following pharmacist intervention in other patient groups; we recommend generating randomized controlled trial evidence for a primary prevention population.

Utilizing community pharmacy dispensing records to disclose errors in hospital admission drug charts.

OBJECTIVE: To identify and resolve discrepancies in admission medication histories, utilizing community pharmacy dispensing data, in newly hospitalized patients and investigate the relationship between unresolved discrepancies and length of hospital stay. METHODS: Eligible patients (2 or more chronic conditions, 3 or more chronic medications and aged over 50 years) were randomized to the intervention or control group. Within 24 h of admission, the patient's nominated community pharmacy was contacted, a 6-month dispensing history obtained, patient was interviewed and a current medication list compiled. This was compared with the hospital drug chart. Discrepancies for the intervention group were discussed with the attending doctor. Subsequent resolution of discrepancies was assessed for all patients. RESULTS: 487 patients were included (203 intervention, 284 control). Approximately 66% of all patients had at least 1 discrepancy between their reconciled list of medications and their initial drug chart, with no significant difference between the groups. Significantly more intervention patients had at least 1 discrepancy resolved in the first 48 h than control patients (intervention 78.1%; control 36.5%; p < 0.0001). A weak correlation was found between the number of discrepancies not acted on and length of hospital stay (Spearman Rho = 0.1, n = 487, p < 0.01). CONCLUSION: Errors in admission medication histories are common and potentially lead to an increased length of stay. The provision of a 6-month community pharmacy dispensing history at the time of hospital admission is an important addition to ensure an accurate medication chart is compiled.

Drug-related problems detected in Australian Community Pharmacies: The PROMISe Trial.

BACKGROUND: Drug-related problems (DRPs) are a major burden on health care systems. Community pharmacists are ideally placed to detect, prevent, and resolve these DRPs. OBJECTIVE: To determine the number and nature of DRPs detected and clinical interventions performed by Australian community pharmacists, using an electronic system. METHODS: An electronic documentation system was designed and integrated into the existing dispensing software of 186 pharmacies to allow pharmacists to record details about the clinical interventions they performed to prevent or resolve DRPs. Participating pharmacies were randomly allocated to 3 groups: group 1 had documentation software, group 2 had documentation software plus a timed reminder to document interventions, and group 3 had documentation software, a timed reminder, and an electronic decision support prompt. Pharmacists classified DRPs, entered recommendations they made, and estimated the clinical significance of the intervention. An observational substudy that included pharmacies without any documentation software was completed to verify intervention rates. RESULTS: Over 12 weeks, 531 participating pharmacists recorded 6230 clinical interventions from 2,013,923 prescriptions, with a median intervention rate of 0.23% of prescriptions. No significant differences were seen between the 3 groups that used documentation software; as expected, however, the pharmacies that used this software had a significantly higher documentation rate compared to the pharmacies without documentation software. The most common interventions were related to drug selection problems (30.8%) and educational issues (24.4%). Recommendations were often related to a change in therapy (40.0%), and 41.6% of interventions were self-rated as highly significant. Drug groups most commonly subject to an intervention included antibiotics, glucocorticoids, nonsteroidal antiinflammatory drugs, and opioids. CONCLUSIONS: The documentation system allowed for the determination of the frequency and types of DRPs, as well as the recommendations made to resolve them in community pharmacy practice. Use of the software, including its electronic prompts, significantly increased the documentation of interventions by pharmacists.

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.

Evaluation of a community pharmacy-based intervention for improving patient adherence to antihypertensives: a randomised controlled trial.

BACKGROUND: The majority of patients using antihypertensive medications fail to achieve their recommended target blood pressure. Poor daily adherence with medication regimens and a lack of persistence with medication use are two of the major reasons for failure to reach target blood pressure. There is no single intervention to improve adherence with antihypertensives that is consistently effective. Community pharmacists are in an ideal position to promote adherence to chronic medications. This study aims to test a specific intervention package that could be integrated into the community pharmacy workflow to enable pharmacists to improve patient adherence and/or persistence with antihypertensive medications--Hypertension Adherence Program in Pharmacy (HAPPY). METHODS/DESIGN: The HAPPY trial is a multi-centre prospective randomised controlled trial. Fifty-six pharmacies have been recruited from three Australian states. To identify potential patients, a software application (MedeMine CVD) extracted data from a community pharmacy dispensing software system (FRED Dispense). The pharmacies have been randomised to either 'Pharmacist Care Group' (PCG) or 'Usual Care Group' (UCG). To check for 'Hawthorne effect' in the UCG, a third group of patients 'Hidden Control Group' (HCG) will be identified in the UCG pharmacies, which will be made known to the pharmacists at the end of six months. Each study group requires 182 patients. Data will be collected at baseline, three and six months in the PCG and at baseline and six months in the UCG. Changes in patient adherence and persistence at the end of six months will be measured using the self-reported Morisky score, the Tool for Adherence Behaviour Screening and medication refill data. DISCUSSION: To our knowledge, this is the first research testing a comprehensive package of evidence-based interventions that could be integrated into the community pharmacy workflow to enable pharmacists to improve patient adherence and/or persistence with antihypertensive medications. The unique features of the HAPPY trial include the use of MedeMine CVD to identify patients who could potentially benefit from the service, control for the 'Hawthorne effect' in the UCG and the offer of the intervention package at the end of six months to patients in the UCG, a strategy that is expected to improve retention. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry ACTRN12609000705280.

Engaging community pharmacists in the primary prevention of cardiovascular disease: protocol for the Pharmacist Assessment of Adherence, Risk and Treatment in Cardiovascular Disease (PAART CVD) pilot study.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death globally. Community pharmacist intervention studies have demonstrated clinical effectiveness for improving several leading individual CVD risk factors. Primary prevention strategies increasingly emphasise the need for consideration of overall cardiovascular risk and concurrent management of multiple risk factors. It is therefore important to demonstrate the feasibility of multiple risk factor management by community pharmacists to ensure continued currency of their role. METHODS/DESIGN: This study will be a longitudinal pre- and post-test pilot study with a single cohort of up to 100 patients in ten pharmacies. Patients aged 50-74 years with no history of heart disease or diabetes, and taking antihypertensive or lipid-lowering medicines, will be approached for participation. Assessment of cardiovascular risk, medicines use and health behaviours will be undertaken by a research assistant at baseline and following the intervention (6 months). Validated interview scales will be used where available. Baseline data will be used by accredited medicines management pharmacists to generate a report for the treating community pharmacist. This report will highlight individual patients' overall CVD risk and individual risk factors, as well as identifying modifiable health behaviours for risk improvement and suggesting treatment and behavioural goals. The treating community pharmacist will use this information to finalise and implement a treatment plan in conjunction with the patient and their doctor. Community pharmacists will facilitate patient improvements in lifestyle, medicines adherence, and medicines management over the course of five counselling sessions with monthly intervals. The primary outcome will be the change to average overall cardiovascular risk, assessed using the Framingham risk equation. DISCUSSION: This study will assess the feasibility of implementing holistic primary CVD prevention programs into community pharmacy, one of the most accessible health services in most developed countries. TRIAL REGISTRATION: Australia and New Zealand Clinical Trial Registry Number: ACTRN12609000677202.

Cardiovascular risk screening program in Australian community pharmacies.

OBJECTIVE: To assess the suitability of Australian community pharmacies as cardiovascular disease risk profile screening centres and evaluate whether community pharmacists can play an important role in detecting, educating and referring screened individuals at high risk of cardiovascular disease. SETTING: 14 Australian community pharmacies. METHOD: Opportunistic cardiovascular disease risk profiling for members of the public aged greater than 30 years with no existing cardiovascular diseases was performed. All major cardiovascular risk factors were measured. Exercise habits, existing conditions and therapy, and family history were also assessed. The results were used to calculate each subject's 10-year risk of developing cardiovascular events, based on Framingham Risk Equations (New Zealand tables). Each subject's knowledge of cardiovascular risk factors was assessed using a multiple-choice questionnaire. Written educational materials and verbal counselling were provided. Referral to a doctor for further assessment was recommended as appropriate. The screened individuals were followed up via mailed out questionnaire. A random sample of individuals at elevated risk was phoned to assess for outcomes of the screening and referral process. MAIN OUTCOME MEASURES: Risk of developing cardiovascular disease and knowledge of cardiovascular risk factors. RESULTS: A total of 655 individuals (71.4% female) were screened for cardiovascular disease risk factors. Ages ranged from 30 to 90 years (median: 54 years) and 14.2% were smokers. Of the individuals screened, 28.1% had a 10-year risk of developing cardiovascular disease greater than 15%, including 6.9% who had a 10-year risk above 30%. The median calculated 10-year risk of developing cardiovascular disease was 9.5%. Approximately one-third of the individuals had elevated blood pressure, and almost two-thirds were either overweight or obese. The mean total serum cholesterol was 5.31 mmol/l, with 40% of individuals having a level above 5.5 mmol/l and 20% having a high-density lipoprotein cholesterol level below 1.0 mmol/l. There was a statistically significant improvement in the knowledge of cardiovascular disease risk factors at follow-up. Almost half of the contacted high-risk subjects reported lifestyle changes or started drug therapy following re-testing by their general practitioner. CONCLUSION: A pharmacy-based cardiovascular disease risk profile screening and education program has the potential to identify and refer many undiagnosed individuals at high risk of cardiovascular events, and help contain the burden of heart disease.

Training Australian pharmacists for participation in a collaborative, home-based post-discharge warfarin management service.

OBJECTIVE: To describe the development, implementation and outcomes of an anticoagulation education program for pharmacists participating in a community-based post-discharge warfarin management service. SETTING: Australian community pharmacy practice. METHOD: Three education modules were developed in collaboration with medical experts and delivered electronically and via hands-on training sessions to pharmacists in three Australian states. Educational outcomes were assessed via a short answer assignment and evaluation of their warfarin dosing recommendations for five hypothetical scenarios. Consumer and pharmacist perceptions of the adequacy of the training were surveyed using a structured postal questionnaire. MAIN OUTCOME MEASURE: Pharmacists' score in the short answer assignment and evaluation of their responses to the hypothetical warfarin dosing scenarios. RESULTS: Sixty-two pharmacists successfully completed the training program with a mean score for the short answer assignment of 14.3 out of 15 (95.3%; 95% CI 13.8-14.7). The pharmacists' warfarin management recommendations were very similar to those of two experienced medical specialists. Pharmacists and consumers expressed confidence in the adequacy of the training program. CONCLUSION: This education program successfully up-skilled a cohort of pharmacists for involvement in a post-discharge warfarin management service. These findings support formalization and further development of the program to facilitate widespread implementation of home-based post-discharge warfarin care.

Does rural and urban community pharmacy practice differ? A narrative systematic review.

OBJECTIVES: Anecdotal comparisons between rural and urban community pharmacy practice have been frequently reported. Therefore, a narrative systematic review was conducted to examine the published international evidence comparing the nature of services provided from community pharmacies in both settings. A comprehensive literature search was undertaken across four databases. The key criterion for inclusion was a comparison of practice, excluding dispensing and associated counselling. Definitions of 'rural' were specific to the country and publication year. KEY FINDINGS: The search yielded 3830 titles, from which 17 publications met the inclusion criteria. The studies investigated current or proposed services and included the provision of pharmaceutical care, public health activities and prescribing. Rural customers were more willing to seek advice and talked longer to the pharmacist, but not always. There was limited evidence that rural pharmacists provided more professional services and they appeared to have better working relationships with prescribers. Many of the authors challenged the validity of their own results, suggesting that other confounding factors accounted for the observed differences. In general, the statistical analyses reported were basic, with multivariate analyses being uncommon. There was some evidence that rural pharmacists were seemingly more willing to take on new professional roles and deliver a higher level of service. However, this conclusion is based on a small number of studies, often with a limited number of respondents and simplistic data analyses. Further high-quality research is required to ascertain and characterise any real differences between rural and urban settings in community pharmacy practice.

Pharmacists' Perspectives on the Use of My Health Record.

(1) Background: My Health Record (MHR) is a relatively new nationwide Australian digital health record system accessible by patients and a range of healthcare professionals. Pharmacists will be key contributors and users of the MHR system, yet little is known about the perceived barriers and benefits of use. (2) Objective: To explore pharmacists' perspectives related to potential benefits and barriers associated with use of MHR. (3) Methods: An online survey was developed and face-validated. The survey was advertised to Australian pharmacists on pharmacy professional bodies' websites. This was a cross-sectional study using an anonymous questionnaire. Descriptive statistics were used to describe the distribution of the data. Chi-square, Kendall's tau coefficient (tau-c) and Kruskal-Wallis tests were used to examine the relationships where appropriate. (4) Results: A total of 63 pharmacists completed the survey. The majority of respondents worked in a metropolitan area (74%), and the most common workplace setting was community pharmacy (65%). Perceived benefits identified by responders include that the use of MHR would help with continuity of care (90%), and that it would improve the safety (71%) and quality (75%) of care they provided. Importantly, more than half of pharmacists surveyed agreed that MHR could reduce medication errors during dispensing (57%) and could improve professional relationships with patients (57%) and general practitioners (59%). Potential barriers identified by pharmacists included patients' concerns about privacy (81%), pharmacists' own concern about privacy (46%), lack of training, access to and confidence in using the system. Sixty six percent of respondents had concerns about the accuracy of information contained within MHR, particularly among hospital and general practice pharmacists (p = 0.016) and almost half (44%) had concerns about the security of information in the system, mainly pharmacists working at general practice and providing medication review services (p = 0.007). Overall satisfaction with MHR varied, with 48% satisfied, 33% neither satisfied nor dissatisfied, and 19% dissatisfied, with a higher satisfaction rate among younger pharmacists (p = 0.032). (5) Conclusions: Pharmacists considered that the MHR offered key potential benefits, notably improving the safety and quality of care provided. To optimize the use of MHR, there is a need to improve privacy and data security measures, and to ensure adequate provision of user support and education surrounding the ability to integrate use of MHR with existing workflows and software.

Drug-related problems identified in medication reviews by Australian pharmacists.

OBJECTIVE: In Australia, accredited pharmacists perform medication reviews for patients to identify and resolve drug-related problems. We analysed the drug-related problems identified in reviews for both home-dwelling and residential care-facility patients. The objective of this study was to examine the number and nature of the drug-related problems identified and investigate differences between each type of review. SETTING: Australian patients living at home or in residential care-facilities. METHOD: We collected a nation-wide sample of medication reviews conducted between 1998 and 2005. These reviews had been self-selected by pharmacists and submitted as part of the reaccreditation process to the primary body responsible for accrediting Australian pharmacists to perform medication reviews. The drug-related problems identified in each review were classified by type and drugs involved. MAIN OUTCOME MEASURE: The number and nature of drug-related problems identified in pharmacist-conducted medication reviews. RESULTS: There were 1,038 drug-related problems identified in 234 medication reviews (mean 4.6 (+/-2.2) problems per review). The number of problems was higher (4.9 +/- 2.0 vs. 3.9 +/- 2.2; P < 0.001) in reviews for home-dwelling patients compared with care-facility residents. The number of clinically-significant problems was higher (2.1 +/- 1.1 vs. 1.5 +/- 0.7; P < 0.001) for home-dwelling patients. Oral hypoglycaemics and analgesics/antipyretics were significantly more likely to be associated with problems in home-dwelling patients than in residential care-facility patients. CONCLUSION: These data illustrate the prevalence of drug-related problems and the ability of pharmacists to identify these problems in the Australian models of medication review. The nature and frequency of problems varied between reviews for home-dwelling and care-facility patients. Such information may be used to better focus the training of practitioners based on the most frequently encountered health problems and the nature of common drug-related problems in the two settings.

Accuracy and clinical utility of the CoaguChek XS portable international normalised ratio monitor in a pilot study of warfarin home-monitoring.

AIM: To evaluate the accuracy of the CoaguChek XS international normalised ratio (INR) monitor compared with the laboratory method. METHODS: The accuracy and ease of use of the recently marketed CoaguChek XS portable INR monitor was evaluated in 17 patients involved in a trial of warfarin home monitoring. INR results from the monitor were compared with those from the laboratory method. Clinical applicability was measured by discrepant INR values, defined in the literature by expanded and narrow agreement criteria, and by the proportion of INR values differing by >15% and by >20% from those derived by the laboratory method. RESULTS: Participants provided 59 comparison INR measurements for analysis. The paired results were highly correlated (r = 0.91). Expanded and narrow agreement between paired INR values occurred 100% of the time. Only three CoaguChek XS (5.1%) results differed by >15% compared with the laboratory method; no results differed by >20% or were discrepant by >0.5 INR units. CONCLUSIONS: In the hands of patients the CoaguChek XS showed good correlation with laboratory determination of INR and compared well with expanded and narrow clinical agreement criteria. Both patients and doctors were highly satisfied with the accuracy and ease of use of the CoaguChek XS.

Describing drivers of and barriers to persistence with tiotropium in patients with chronic obstructive pulmonary disease: a mixed-methods approach.

OBJECTIVE: To understand the factors influencing persistence with tiotropium in patients with chronic obstructive pulmonary disease (COPD). METHODS: Patients classified as 'persistent' or 'non-persistent' with tiotropium were identified from pharmacy dispensing records. Patients were compared for health status, beliefs and behaviours using data from questionnaires and interviews. KEY FINDINGS: Perceptions of the risks and benefits of medication, fear of worsening illness, and the GP's emphasis on the importance of the medication were key determinants of tiotropium persistence. CONCLUSIONS: Perceptions, attitudes and beliefs of patients and doctors influence persistence with tiotropium. These complex interactions need to be targeted to improve persistence with medicines in COPD.

Improving the management of warfarin in aged-care facilities utilising innovative technology: a proof-of-concept study.

OBJECTIVE: In aged-care facilities (ACFs) monitoring of warfarin can be logistically challenging and International Normalised Ratio (INR control) is often suboptimal. We aimed to determine whether an integrated information and communications technology system and the use of point-of-care (POC) monitors by nursing staff could improve the INR control of aged-care facility residents who take warfarin. METHODS: Nursing staff identified residents who were prescribed warfarin in participating ACFs. A computer program (MedePOC) was developed to store and transmit INR results from the ACFs to general practitioners (GPs) for dosage adjustment. Nursing staff received training in the use of the CoaguChek XS point-of-care INR monitor and the MedePOC software. Following a run-in phase, eligible patients were monitored weekly for up to 12 weeks. The primary outcome was the change in the time in therapeutic range (TTR) in the intervention phase compared to the TTR in the 12 months preceding the study. All GPs, nursing staff and patients were surveyed for their experiences and opinions of the project. KEY FINDINGS: Twenty-four patients and 19 GPs completed the trial across six ACFs. The mean TTR for all patients improved non-significantly from 58.9 to 60.6% (P=0.79) and the proportion of INR tests in range improved non-significantly from 57.1 to 64.1% (P=0.21). The mean TTR improved in 14 patients (58%) and in these patients the mean absolute improvement in TTR was 23.1%. A post hoc analysis of the INR data using modified therapeutic INR ranges to reflect the dosage adjustment practices of GPs suggested that the intervention did lead to improved INR control. The MedePOC program and POC monitoring was well received by nursing staff. CONCLUSIONS: Weekly POC INR monitoring conducted in ACFs and electronic communication of the results and warfarin doses resulted in non-significant improvements in INR control in a small cohort of elderly residents. Further research involving modification to the communication strategy and a longer follow-up period is warranted to investigate whether this strategy can improve INR control and clinical outcomes in this vulnerable population.

Violence in community pharmacy in Australia: incidence and implications.

OBJECTIVE: To estimate the frequency, nature and impact of violent incidents in Australian community pharmacies. SETTING: A sample of Australian community pharmacists. METHOD: A survey of Australian pharmacists sought to estimate the frequency of exposure to an array of violent incidents in the preceding 12 months. The sample population was drawn from all pharmacists currently registered in Australia, with a proportionate number from each state and territory surveyed. The selected pharmacists were sent a letter of explanation, the questionnaire and the reply-paid envelope. The questionnaire was developed specifically for this study with extensive testing among a small number of community pharmacists. MAIN OUTCOME MEASURE: Frequency of violent incidents experienced in the 12 months prior to the survey. RESULTS: Surveys were mailed to 1000 randomly selected pharmacists registered in Australia in 2007. In total, 248 eligible replies were received resulting in a usable response rate of 25%. The majority of respondents (91%) had experienced or witnessed some form of violence in community pharmacy within the preceding 12 months. Of all respondents, approximately one-third (33%) had been subjected to verbal abuse on at least a once-monthly basis. One-fifth of all respondents experienced or witnessed incidents of bullying/intimidation at least monthly, while one-tenth of all respondents had been exposed to sexual harassment/assault at least once-monthly. The impact of violent incidents was significant, with approximately one in ten respondents who had experienced violent incidents having changed employment as a direct result of these violent incidents; the majority of these pharmacists changed to a different community pharmacy (95%). A large proportion of respondents claimed that they either 'sometimes' or 'never' reported violent incidents. Over half of all respondents claimed that they received no post-incident support regardless of the type of violence experienced. CONCLUSION: Recognising the likelihood of selection bias in responding to the survey, the results nevertheless indicate that violence appears a real and common problem in Australian community pharmacies. The under-utilisation of violence preventative strategies, the lack of violence management by employers, under-reporting of violence and the lack of post-violence support need to be addressed.