Impact of pharmacist interventions provided in the emergency department on quality use of medicines: a systematic review and meta-analysis.

BACKGROUND: Pharmacists have an increasing role as part of the emergency department (ED) team. However, the impact of ED-based pharmacy interventions on the quality use of medicines has not been well characterised. OBJECTIVE: This systematic review aimed to synthesise evidence from studies examining the impact of interventions provided by pharmacists on the quality use of medicines in adults presenting to ED. METHODS: A systematic literature search was conducted in MEDLINE, EMBASE and CINAHL. Two independent reviewers screened titles/abstracts and reviewed full texts. Studies that compared the impact of interventions provided by pharmacists with usual care in ED and reported medication-related primary outcomes were included. Cochrane Risk of Bias-2 and Newcastle-Ottawa tools were used to assess the risk of bias. Summary estimates were pooled using random-effects meta-analysis, along with sensitivity and sub-group analyses. RESULTS: Thirty-one studies involving 13 242 participants were included. Pharmacists were predominantly involved in comprehensive medication review, advanced pharmacotherapy assessment, staff and patient education, identification of medication discrepancies and drug-related problems, medication prescribing and co-prescribing, and medication preparation and administration. The activities reduced the number of medication errors by a mean of 0.33 per patient (95% CI -0.42 to -0.23, I2=51%) and the proportion of patients with at least one error by 73% (risk ratio (RR)=0.27, 95% CI 0.19 to 0.40, I2=85.3%). The interventions were also associated with more complete and accurate medication histories, increased appropriateness of prescribed medications by 58% (RR=1.58, 95% CI 1.21 to 2.06, I2=95%) and quicker initiation of time-critical medications. CONCLUSION: The evidence indicates improved quality use of medicines when pharmacists are included in ED care teams. PROSPERO REGISTRATION NUMBER: CRD42020165234.

Community Pharmacists' Role in Reducing the Incidence of Cardiometabolic Adverse Drug Events in Schizophrenia: Insights from Mental Health Professionals.

Background and Objectives: Schizophrenia, a debilitating mental illness, is often associated with significant physical health risks. Many second-generation antipsychotics increase the risk of metabolic syndrome and cardiovascular disease. Community pharmacists are highly accessible and could play a role in monitoring cardiometabolic adverse drug events in people with schizophrenia. However, it remains uncertain whether mental health professionals perceive this as valuable. This study aimed to explore the opinions of mental healthcare professionals regarding the role of community pharmacists in reducing the incidence of cardiometabolic adverse events in people with schizophrenia and their integration into a multidisciplinary mental health team. Materials and Methods: Qualitative semi-structured interviews were conducted with Australian psychiatrists, mental health nurses and mental health pharmacists. Transcription of the interviews underwent thematic analysis using an inductive approach. Results: Eleven mental healthcare professionals from metropolitan and regional areas across Australia were interviewed, leading to the identification of five overarching themes. These themes encompassed the following aspects: the benefits of community pharmacists' involvement in managing cardiometabolic adverse drug events in people with schizophrenia, improving communication pathways with community pharmacists, defining roles and responsibilities for monitoring cardiometabolic parameters and managing adverse cardiometabolic drug events, fostering collaboration between community pharmacists and mental health care professionals, and recognising the acceptance of community pharmacists' integration within a multidisciplinary team. Mental health professionals believed that community pharmacists could play a role in reducing the incidence of cardiometabolic adverse events in schizophrenia. However, they underscored the need for enhanced communication and collaboration pathways with other healthcare professionals, emphasised the importance of more comprehensive mental health first aid training, and identified potential barriers for community pharmacists such as remuneration, workload, and staff resources. Conclusions: Mental health professionals acknowledged the benefits of incorporating community pharmacists into multidisciplinary teams as a strategy to reduce the incidence of adverse events among individuals with schizophrenia. They recognise the competence of community pharmacists in monitoring cardiometabolic adverse events. However, these professionals have also highlighted specific perceived barriers to the complete integration of community pharmacists within these teams. Notably, there are concerns related to remuneration, staff resources, time constraints, acceptance by other healthcare professionals and patients, and the need for improved communication pathways. Addressing these barriers and providing targeted training could facilitate the valuable inclusion of community pharmacists in the comprehensive care of people with schizophrenia.

Stroke risk reassessment and oral anticoagulant initiation in primary care patients with atrial fibrillation: A ten-year follow-up.

AIM: To examine the change in stroke risk over time and determine the proportion of patients with atrial fibrillation (AF) who were initiated on an oral anticoagulant (OAC) as their stroke risk increased from low/moderate to high, using the Australian general practice data set, MedicineInsight. METHODS: A total of 2296 patients diagnosed with AF between 1 January 2007 and 31 December 2008, aged 18 years or older and not initiated on an OAC before 2009, were included. We assessed the change in stroke risk and the proportion of patients who had a recorded prescription of an OAC, each year from 1 January 2009 to 31 December 2018. RESULTS: At baseline, 23.9%, 22.9% and 53.2% were categorised as being at low (score = 0), moderate (score = 1) and high stroke risk (score ≥ 2), respectively, using the sexless CHA2 DS2 -VASc (CHA2 DS2 -VA) score. Overall, the CHA2 DS2 -VA score increased by a mean of 1.34 (95% confidence interval, 1.29-1.39) points over the study period. Nearly two-thirds of patients (65%, 412/632) whose stroke risk changed from baseline low/moderate to high were subsequently prescribed an OAC. The median (interquartile range) lag time from becoming high stroke risk to having OAC initiation was 2 (5) years. CONCLUSIONS: Nearly one-third of patients reclassified as being at high risk of stroke during the study period were not prescribed OAC therapy. Furthermore, the delay in OAC initiation following classification as being at high risk was a median of 2 years, suggesting that more frequent stroke reassessment is needed.

Factors influencing oral anticoagulant use in patients newly diagnosed with atrial fibrillation.

BACKGROUND: We investigated factors that influenced oral anticoagulant (OAC) initiation and choice in Australian general practice patients newly diagnosed with AF. METHODS: Using an Australian nationally representative general practice dataset, MedicineInsight, we identified patients newly diagnosed with AF between January 2009 and April 2019. Logistic regression analyses were used to examine factors associated with OAC initiation and choice. RESULTS: A total of 63 212 patients with AF (53.7% males, mean age 72.4 years) were identified. Nearly two-thirds of these patients (40 854 [64.6%]) were initiated on an OAC, at a median time of 6 days after the documented diagnosis date. The proportion of patients who were initiated an OAC increased from 44.8% in 2009 to 72.2% in 2019 (P < .001). High risk of stroke (CHA2 DS2 -VASc, adjusted odds ratio (AOR), 4.39 [95% CI, 3.99-4.83]), low risk of bleeding (ORBIT, AOR, 1.87 [95% CI, 1.72-2.03]), not having a recorded history of dementia (AOR, 1.81 [95% CI, 1.65-1.98]) and male sex (AOR, 1.29 [95% CI, 1.22-1.35]) were independently associated with OAC initiation. Direct-acting oral anticoagulant (DOAC) use increased from 11.9% in 2011 to 94.0% of all OAC initiations in April 2019 (P < .001). CONCLUSIONS: The proportion of newly diagnosed patients with AF initiated on OAC increased markedly following the introduction of the DOACs. Of those initiated, 9 in 10 were receiving a DOAC at the end of the study period. There is potential underuse in women and individuals with dementia.

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.

Ten-year trends in prescribing of antiarrhythmic drugs in Australian primary care patients with atrial fibrillation.

Despite changes in antiarrhythmic drug (AAD) choice in patients with atrial fibrillation (AF), trends in AAD prescribing remain not investigated. We aimed to examine these changes using a nationwide Australian general practice data from 2009 to 2018. Over the 10 years, AAD prescribing in patients with AF decreased, which was mainly due to a reduction in the use of amiodarone, sotalol and digoxin. In contrast, the use of beta-blockers and flecainide increased.

Drug-associated non-pyrogenic hyperthermia: a narrative review.

PURPOSE: Hyperthermia occurs when heat accumulation surpasses the body's ability for heat dissipation. Many drugs may affect thermoregulation. This narrative review aimed to provide an overview of the current literature concerning reports of drug-associated non-pyrogenic hyperthermia. METHODS: A comprehensive search was performed across 5 databases covering the period of inception to March 2019, for publications that reported hyperthermia associated with drug use. Studies that reported potential drug association with hyperthermia due to altered thermoregulatory mechanisms were included. Case reports of less than 3 cases were excluded, as well as hyperthermia due to other causes, such as hypersensitivity, malignant hyperthermia and neuroleptic malignant syndrome. The primary outcomes of interest were hospitalisation and mortality. RESULTS: The literature search initially identified a total of 2609 records. Based on full-text analysis, 11 articles met the inclusion criteria, of which there were 5 case-control studies, 2 case series and 4 retrospective analyses. Studies reported heat-related hospitalisations or emergency department presentations associated with the use of psychotropics (antipsychotics, antidepressants and anxiolytics), anticholinergics, antihistamines, diuretics, cardiovascular agents, non-steroidal anti-inflammatory drugs and anticoagulants. Psychotropic drugs were reported to be associated with increased heat-related mortality, other than through neuroleptic malignant syndrome, but findings varied among the studies. CONCLUSION: Given the relative lack of publications, more research is necessary to study specific effects of drugs on body temperature and the likelihood of inducing non-pyrogenic hyperthermia. In particular, psychotropics, anticholinergics, diuretics and cardiovascular agents are of interest for future studies.

Association between anticholinergic drug burden and mortality in older people: a systematic review.

PURPOSE: The purpose of the study is to conduct a systematic review of studies examining the association between anticholinergic burden and mortality in older individuals. METHODS: A literature search was performed to identify relevant studies, using MEDLINE, EMBASE, PsycINFO and CENTRAL, from January 1990 to December 2018. We included studies of patients with a mean age of 65 years or older where the anticholinergic burden was estimated using anticholinergic risk assessment tools, and associations between anticholinergic load and mortality were investigated. The primary outcome of interest was the association between anticholinergic burden and mortality. RESULTS: Twenty-seven studies were included. These were three cross-sectional, one nested case-control and 23 prospective or retrospective cohort studies. Most studies were determined to be of good quality. A total of 15 studies reported a positive correlation between anticholinergic burden and mortality, while the remaining 10 studies did not report a significant association. Eighteen out of 27 studies (80%) had a short follow-up period of 1 year or less. Among the five high-quality studies that met all the domains of the quality assessment criteria, four showed a positive association. CONCLUSION: The variation in results could relate to the quality of the studies, follow-up period, anticholinergic risk assessment tool used and the study setting. Sixty-three percent (n = 17) of all the included studies, but almost all of the high-quality studies with an extended follow-up, reported a positive correlation between anticholinergic burden and mortality. Further high-quality research, using standardized measures and with adequate follow-up periods, is required to confirm the relationship between anticholinergic burden and mortality.

Drug-associated hyperthermia: A longitudinal analysis of hospital presentations.

WHAT IS KNOWN AND OBJECTIVE: Hyperthermia occurs when heat accumulation surpasses the body's ability for heat dissipation. Many drugs can affect thermoregulation through mechanisms including altering the neurotransmitters that cause increased heat production or decreased heat loss and may, therefore, be associated with hyperthermia. This study aimed to examine hospitalizations and emergency department (ED) presentations due to hyperthermia and to investigate the potential association with drug therapy. METHODS: A retrospective analysis of ED presentations and hospitalizations due to hyperthermia in all four major hospitals in Tasmania, Australia, between July 2010 and December 2018 was performed. Data of patients aged ≥18 years were extracted from the hospital digital medical records and analysed for the prevalence, trends and various potential risk factors for hyperthermia, such as age, environmental temperature and drug therapy. RESULTS: This study included 224 patients. The data illustrated a trend with time, albeit not statistically significant, towards increasing hospital presentations due to hyperthermia. Antiepileptics (P = .03) and furosemide (P = .04) were the most frequently used drugs in patients with primary hyperthermia. The high use of levothyroxine in the study population (6.7%) stood out compared with the estimated national average (2.1%). Various drug classes associated with hyperthermia were used significantly more in the age group ≥60 years, suggesting polypharmacy in the elderly as a contributing factor for hyperthermia. WHAT IS NEW AND CONCLUSION: This study reports a possible association of some drugs, particularly diuretics (furosemide), antiepileptics and levothyroxine, with hyperthermia. Healthcare professionals should be aware of the increasing prevalence of hyperthermia and the possible involvement of drugs.

A Systematic Review Evaluating the Use of the interRAI Home Care Instrument in Research for Older People.

Objective: To summarize studies that used the international Resident Assessment home care instrument (interRAI HC) to examine study outcomes for older people. Methods: A comprehensive systematic search was performed to identify relevant studies, using five databases from 1990 until October 2016. The Cochrane Risk-Bias assessment tool and Newcastle-Ottawa Scale was used to assess the quality of RCTs and non-RCTs, respectively. Results: Based on the full-text analysis, 40 studies met the inclusion criteria out of 506 total records. The review included 6 RCTs, 2 quasi-experimental, 17 prospective and retrospective studies, 13 cross-sectional and 2 longitudinal studies. A series of interventions and/or applications were identified from this review that employed the use of interRAI HC instrument: (a) in health services, (b) as a new integrated care model and for implementing machine learning algorithm, (c) as a comprehensive geriatric assessment tool, (d) in case management, (e) for care planning and screening, (f) in drug therapy assessment, (g) to assess caregiver burden, and (h) for various risk assessments. Studies that employed the interRAI HC instrument reported an array of health-outcome measures mostly related to functional, cognition, hospitalization and mortality. Conclusions: Application of the interRAI HC tool varied markedly across all studies, and the outcomes measures were heterogeneous. Future research directions are discussed. Clinical Implications: The results from this study facilitate the use of interRAI HC as a tool to measure an intervention's effect that leads to improvements in specific geriatric-related health outcome measures emphasizes on functional status and quality of life and ascertain its utility as a quality indicator for the care of older individuals.

An overview of pharmacodynamic modelling, ligand-binding approach and its application in clinical practice.

The study of the magnitude and variation of drug response is defined as pharmacodynamics (PDs). PD models examine plasma concentration and effect relationship. It can predict the archetypal effect ([Formula: see text]) of a drug as a function of the drug concentration ([Formula: see text]) and estimate an unknown PD parameter ([Formula: see text]). The PD models have been described as fixed, linear, log-linear, [Formula: see text], sigmoid [Formula: see text], and indirect PD response. Ligand binding model is an example of a PD model that works on the underpinning PD principle of a drug, eliciting its pharmacological effect at the receptor site. The pharmacological effect is produced by the drug binding to the receptor to either activate or antagonise the receptor. Ligand binding models describe a system of interacting components, i.e. the interaction of one or more ligands with one or more binding sites. The [Formula: see text] model is the central method that provides an empirical justification for the concentration/dose-effect relationship. However, for ligand binding models justification is provided by theory of receptor occupancy. In essence, for ligand binding models, the term [Formula: see text] is best used to describe the fraction of receptors occupied at a particular ligand concentration. It is stated that the [Formula: see text], which means the effect of a drug should depend on the fraction of receptors that are occupied. In the future, network-based systems pharmacology models using ligand binding principles could be an effective way of understanding drug-related adverse effects. This will facilitate and strengthen the development of rational drug therapy in clinical practice.

Temporal Trends in Polypharmacy and Hyperpolypharmacy in Older New Zealanders over a 9-Year Period: 2005­2013.

BACKGROUND: Polypharmacy and hyperpolypharmacy are proxy indicators for inappropriate medicine use. Inappropriate medicine use in older people leads to adverse clinical outcomes. OBJECTIVE: The objectives of this study were to investigate the prevalence and trends of polypharmacy and hyperpolypharmacy in older people in New Zealand from 2005 to 2013, analyzing the pharmaceutical collections maintained by the Ministry of Health. METHODS: A repeated cross-sectional analysis of population-level dispensing data was conducted from January 1, 2005 to December 31, 2013. Polypharmacy and hyperpolypharmacy in individuals were defined as the use of 5-9 medicines and ≥10 medicines, respectively, dispensed concurrently for a period of ≥90 days. Differences in polypharmacy and hyperpolypharmacy between 2005 and 2013 were examined. A multinomial regression model was used to predict sociodemographic characteristics associated with polypharmacy and hyperpolypharmacy. RESULTS: Polypharmacy and hyperpolypharmacy were found to be higher in 2013 compared to 2005 (polypharmacy: 29.5 vs. 23.4%, p<0.001; hyperpolypharmacy: 2.1 vs. 1.3%, p<0.001). The risk of polypharmacy and hyperpolypharmacy was higher in females, in those aged 80-84 years, in the Maori population (for polypharmacy) and the Middle Eastern, Latin American, or African population (for hyperpolypharmacy), in people living in the Southern-district health board, and in individuals with increasing deprivation. CONCLUSION: The population of New Zealand is aging and the number of older people with multiple chronic conditions is increasing. The proportion of older people exposed to polypharmacy and hyperpolypharmacy has increased in 2013 compared to 2005. Our study provides important information to alert health policy makers, researchers, and clinicians about the dire need to reduce the medication burden in older New Zealanders.

Anticholinergic burden quantified by anticholinergic risk scales and adverse outcomes in older people: a systematic review.

BACKGROUND: The cumulative effect of taking multiple medicines with anticholinergic properties termed as anticholinergic burden can adversely impact cognition, physical function and increase the risk of mortality. Expert opinion derived risk scales are routinely used in research and clinical practice to quantify anticholinergic burden. These scales rank the anticholinergic activity of medicines into four categories, ranging from no anticholinergic activity (= 0) to definite/high anticholinergic activity (= 3). The aim of this systematic review was to compare anticholinergic burden quantified by the anticholinergic risk scales and evaluate associations with adverse outcomes in older people. METHODS: We conducted a literature search in Ovid MEDLINE, EMBASE and PsycINFO from 1984-2014 to identify expert opinion derived anticholinergic risk scales. In addition to this, a citation analysis was performed in Web of Science and Google Scholar to track prospective citing of references of selected articles for assessment of individual scales for adverse anticholinergic outcomes. The primary outcomes of interest were functional and cognitive outcomes associated with anticholinergic burden in older people. The critical appraisals of the included studies were performed by two independent reviewers and the data were extracted onto standardised forms. RESULTS: The primary electronic literature search identified a total of 1250 records in the 3 different databases. On the basis of full-text analysis, we identified 7 expert-based anticholinergic rating scales that met the inclusion criteria. The rating of anticholinergic activity for medicines among these rating scales was inconsistent. For example, quetiapine was rated as having high anticholinergic activity in one scale (n = 1), moderate in another scale (n = 1) and low in two other scales (n = 2). Citation analysis of the individual scales showed that the Anticholinergic Cognitive Burden (ACB) scale was the most frequently validated expert based anticholinergic scale for adverse outcomes (N = 13). CONCLUSIONS: In conclusion, there is not one standardised tool for measuring anticholinergic burden. Cohort studies have shown that higher anticholinergic burden is associated with negative brain effects, poorer cognitive and functional outcomes.

Medication-Related Hospital Admissions and Emergency Department Visits in Older People with Diabetes: A Systematic Review.

Limited data are available regarding adverse drug reactions (ADRs) and medication-related hospitalisations or emergency department (ED) visits in older adults with diabetes, especially since the emergence of newer antidiabetic agents. This systematic review aimed to explore the nature of hospital admissions and ED visits that are medication-related in older adults with diabetes. The review was conducted according to the PRISMA guidelines. Studies in English that reported on older adults (mean age ≥ 60 years) with diabetes admitted to the hospital or presenting to ED due to medication-related problems and published between January 2000 and October 2023 were identified using Medline, Embase, and International Pharmaceutical Abstracts databases. Thirty-five studies were included. Medication-related hospital admissions and ED visits were all reported as episodes of hypoglycaemia and were most frequently associated with insulins and sulfonylureas. The studies indicated a decline in hypoglycaemia-related hospitalisations or ED presentations in older adults with diabetes since 2015. However, the associated medications remain the same. This finding suggests that older patients on insulin or secretagogue agents should be closely monitored to prevent potential adverse events, and newer agents should be used whenever clinically appropriate.

Adverse clinical outcomes associated with drug-related hospitalizations in people with dementia.

BACKGROUND: This study aimed to determine the clinical impact associated with adverse drug reactions (ADRs) in patients with dementia. RESEARCH DESIGN AND METHODS: This case-control, propensity score-matched study utilized administrative data of people with dementia admitted to major public hospitals in Tasmania, Australia, from July 2010 to December 2019. RESULTS: Acute renal failure constituted the most common ADR. The length of hospital stay was greater for people with an ADR index admission, versus non-ADR index admission (median [IQR]: 9 [4-18] versus 6 [2-12]; p < 0.001). In-hospital mortality and combined in-hospital and post-hospital mortality within 30, 60 and 90 days were higher for those whose index admission was ADR-related (in-hospital: HR 1.40, 95% CI 1.11-1.77, p-value <0.001; 30 days: HR 1.25, 95% CI 1.05-1.49, p-value <0.001; 60 days: HR 1.27, 95% CI 1.08-1.49, p-value <0.001; 90 days: HR 1.29, 95% CI 1.10-1.50, p-value <0.001). Subsequent ADR admission within 30, 60 and 90 days of index discharge was 9 to 10 times greater for people with dementia (30 days: OR 10.0, 95% CI 6.04-16.8, p-value <0.001; 60 days: OR 8.96, 95% CI 5.57-14.4, p-value <0.001; 90 days: OR 9.31, 95% CI 5.79-14.9, p-value <0.001). CONCLUSION: Safe prescribing and vigilant monitoring of ADRs is pivotal to mitigate adverse outcomes in people with dementia.

Predictors of Adverse Drug Reaction-Related Hospitalisations Among People with Dementia: A Retrospective Case-Control Study.

INTRODUCTION: Adverse drug reactions (ADRs) are common among people with dementia; however, little is known about the magnitude and predictors associated with ADR-related hospitalisation among these individuals. This study aimed to determine the magnitude, types, drugs implicated and predictors of ADRs associated with hospitalisation among people with dementia. METHODS: This retrospective case-control study analysed medical records of individuals aged ≥ 65 years with dementia admitted to major public hospitals in Tasmania, Australia, from July 2010 to July 2021. Adverse drug reactions and implicated drugs were identified using administrative data and cross-checked with hospital medical records, with consensus reached among the research team. RESULTS: Of the 7928 people admitted to hospital at least once within the study period, 1876 (23.7%) experienced at least one ADR-related hospitalisation. Of these, 300 case patients with 311 ADRs and 300 control patients were randomly selected. The most common types of ADRs were renal (acute kidney injury; AKI) (36.0%), followed by neuropsychiatric (17.6%), cardiovascular (16.0%) and haematological (13.1%). Diuretics, renin-angiotensin system (RAS) inhibitors and anti-thrombotics constituted the main implicated drug classes. The ADR-related hospitalisation was associated with: chronic kidney disease (CKD) (OR 8.00, 95% CI 2.63-24.28, p < 0.001), Australian-born (OR 1.62, 95% CI 1.08-2.43, p = 0.019), hypertension (OR 1.48, 95% CI 1.01-2.17, p = 0.044) and the number of medicines (OR 1.06, 95% CI 1.00-1.12, p = 0.022). Potentially inappropriate medication use and anticholinergic burden did not predict ADR-related hospitalisation. CONCLUSIONS: These predictors could help identify the individuals at the highest risk and enable targeted interventions to be designed.

Influence of Potentially Inappropriate Medication Use on Older Australians' Admission to Emergency Department Short Stay.

Older people in the emergency department (ED) often pose complex medical challenges, with a significant prevalence of polypharmacy and potentially inappropriate medicines (PIMs) in Australia. A retrospective analysis of 200 consecutive patients aged over 65 years admitted to the emergency short stay unit (ESSU) aimed to identify polypharmacy (five or more regular medications), assess PIM prevalence, and explore the link between pre-admission PIMs and ESSU admissions. STOPP/START version 2 criteria were used for the PIM assessment, with an expert panel categorizing associated risks. Polypharmacy was observed in 161 patients (80.5%), who were older (mean age 82 versus 76 years) and took more regular medications (median 9 versus 3). One hundred and eighty-five (92.5%) patients had at least one PIM, 81 patients (40.5%) had STOPP PIMs, and 177 patients (88.5%) had START omissions. Polypharmacy significantly correlated with STOPP PIM (OR 4.8; 95%CI: 1.90-12.1), and for each additional medication the adjusted odds of having a STOPP PIM increased by 1.20 (95%CI: 1.11-1.28). Nineteen admissions (9.5%) were attributed to one or more PIMs (total 21 PIMs). Of these PIMs, the expert panel rated eight (38%) as high risk, five (24%) as moderate risk, and eight (38%) as low risk for causing hospital admission. The most common PIMs were benzodiazepines, accounting for 14 cases (73.6%). Older ESSU-admitted patients commonly presented with polypharmacy and PIMs, potentially contributing to their admission.

Adverse Drug Event-Related Hospital Admissions among Australian Aged Care Residents: A Cross-Sectional Study.

OBJECTIVES: To investigate the proportion, characteristics, causality, severity, preventability, and independently associated factors for adverse drug event (ADE)-related admissions in aged care residents admitted to the major public hospitals in Tasmania, Australia. DESIGN: Retrospective cross-sectional study. SETTING AND PARTICIPANTS: Residential aged care facility (RACF) patients aged ≥65 years who had an unplanned admission to one of the 4 Tasmanian public hospitals between July 1, 2018, and June 30, 2021. METHODS: We accessed the medical records of RACF patients. The ADEs were initially identified via chart review and a trigger tool. Hospitalizations attributable to ADEs were then determined by expert consensus. The causality, preventability, and severity of each ADE admission were assessed using standard criteria. RESULTS: Ninety-one residents (18.2%) of 500 randomly selected experienced potential ADE-related hospitalizations. ADEs were considered possible (n = 58, 64%) or definite/probable (n = 33, 36%). The most common ADEs were falls (n = 19, 21%), hypotension (n = 16, 18%), and confusion or delirium (n = 10, 11%). ADEs were frequently associated with renin-angiotensin system inhibitors (n = 43, 47.3%), opioids (n = 43, 47.3%), and diuretics (n = 40, 44%). Most ADEs were of moderate severity (n = 90, 99%) and considered not preventable (n = 60, 66%). Rheumatologic disease [odds ratio (OR) 1.89, 95% CI 1.09-3.30; P = .024] and previous adverse drug reaction (ADR) (OR 12.91, 95% CI 6.84-24.37; P < .001) were associated with ADE hospitalizations. CONCLUSIONS AND IMPLICATIONS: This study highlights that hospitalization for moderately severe ADEs is common among RACF residents. Opioids and antihypertensives were the common drug classes associated with harm. Rheumatologic disease (due to opioids) and previous ADR were identified as independently associated factors, which may warrant tailored interventions.

Redesigning Medication Management in the Emergency Department: The Impact of Partnered Pharmacist Medication Charting on the Time to Administer Pre-Admission Time-Critical Medicines, Medication Order Completeness, and Venous Thromboembolism Risk Assessment.

In order to enhance interdisciplinary collaboration and promote better medication management, a partnered pharmacist medication charting (PPMC) model was piloted in the emergency department (ED) of an Australian referral hospital. The primary objective of this study was to evaluate the impact of PPMC on the timeliness of time-critical medicines (TCMs), completeness of medication orders, and assessment of venous thromboembolism (VTE) risk. This concurrent controlled retrospective pragmatic trial involved individuals aged 18 years and older presenting to the ED from 1 June 2020 to 17 May 2021. The study compared the PPMC approach (PPMC group) with traditional medical officer-led medication charting approaches in the ED, either an early best-possible medication history (BPMH) group or the usual care group. In the PPMC group, a BPMH was documented promptly soon after arrival in the ED, subsequent to which a collaborative discussion, co-planning, and co-charting of medications were undertaken by both a PPMC-credentialled pharmacist and a medical officer. In the early BPMH group, the BPMH was initially obtained in the ED before proceeding with the traditional approach of medication charting. Conversely, in the usual care group, the BPMH was obtained in the inpatient ward subsequent to the traditional approach of medication charting. Three outcome measures were assessed -the duration from ED presentation to the TCM's first dose administration (e.g., anti-Parkinson's drugs, hypoglycaemics and anti-coagulants), the completeness of medication orders, and the conduct of VTE risk assessments. The analysis included 321 TCMs, with 107 per group, and 1048 patients, with 230, 230, and 588 in the PPMC, early BPMH, and usual care groups, respectively. In the PPMC group, the median time from ED presentation to the TCM's first dose administration was 8.8 h (interquartile range: 6.3 to 16.3), compared to 17.5 h (interquartile range: 7.8 to 22.9) in the early BPMH group and 15.1 h (interquartile range: 8.2 to 21.1) in the usual care group (p < 0.001). Additionally, PPMC was associated with a higher proportion of patients having complete medication orders and receiving VTE risk assessments in the ED (both p < 0.001). The implementation of the PPMC model not only expedited the administration of TCMs but also improved the completeness of medication orders and the conduct of VTE risk assessments in the ED.