Andrew L. Gilbert

The Effectiveness of Collaborative Medicine Reviews in Delaying Time to Next Hospitalization for Patients With Heart Failure in the Practice Setting Results of a Cohort Study

Background—Randomized controlled trials have demonstrated that collaborative medication reviews can improve outcomes for patients with heart failure. We aimed to determine whether these results translated into Australian practice, where collaborative reviews are nationally funded. Methods and Results—This retrospective cohort study using administrative claims data included veterans 65 years and older receiving bisoprolol, carvedilol, or metoprolol succinate for which prescribing physicians indicated treatment was for heart failure. We compared those exposed to a general practitioner–pharmacist collaborative home medication review with those who did not receive the service. The service includes physician referral, a home visit by an accredited pharmacist to identify medication-related problems, and a pharmacist report with follow-up undertaken by the physician. Kaplan-Meier analyses and Cox proportional hazards models were used to compare time until next hospitalization for heart failure between the exposed and unexposed groups. There were 273 veterans exposed to a home medicines review and 5444 unexposed patients. Average age in both groups was 81.6 years (no significant difference). The median number of comorbidities was 8 in the exposed group and 7 in the unexposed (P<0.0001). Unadjusted results showed a 37% reduction in rate of hospitalization for heart failure at any time (hazard ratio, 0.63; 95% CI, 0.44 to 0.89). Adjusted results showed a 45% reduction (hazard ratio, 0.55; 95% CI, 0.39 to 0.77) among those who had received a home medicines review compared with the unexposed patients. Conclusion—Medicines review in the practice setting is effective in delaying time to next hospitalization for heart failure in those treated with heart failure medicines.

The Effectiveness of Collaborative Medicine Reviews in Delaying Time to Next Hospitalization for Patients With Heart Failure in the Practice SettingCLINICAL PERSPECTIVE

Background—Randomized controlled trials have demonstrated that collaborative medication reviews can improve outcomes for patients with heart failure. We aimed to determine whether these results translated into Australian practice, where collaborative reviews are nationally funded. Methods and Results—This retrospective cohort study using administrative claims data included veterans 65 years and older receiving bisoprolol, carvedilol, or metoprolol succinate for which prescribing physicians indicated treatment was for heart failure. We compared those exposed to a general practitioner–pharmacist collaborative home medication review with those who did not receive the service. The service includes physician referral, a home visit by an accredited pharmacist to identify medication-related problems, and a pharmacist report with follow-up undertaken by the physician. Kaplan-Meier analyses and Cox proportional hazards models were used to compare time until next hospitalization for heart failure between the exposed and unexposed groups. There were 273 veterans exposed to a home medicines review and 5444 unexposed patients. Average age in both groups was 81.6 years (no significant difference). The median number of comorbidities was 8 in the exposed group and 7 in the unexposed (P<0.0001). Unadjusted results showed a 37% reduction in rate of hospitalization for heart failure at any time (hazard ratio, 0.63; 95% CI, 0.44 to 0.89). Adjusted results showed a 45% reduction (hazard ratio, 0.55; 95% CI, 0.39 to 0.77) among those who had received a home medicines review compared with the unexposed patients. Conclusion—Medicines review in the practice setting is effective in delaying time to next hospitalization for heart failure in those treated with heart failure medicines.

Crushing or altering medications: what's happening in residential aged‐care facilities?

Objectives: To determine the extent to which medications are altered or crushed prior to administration to residents of aged‐care facilities, the medications involved and the methods employed.

Collaborative home medicines review delays time to next hospitalization for warfarin associated bleeding in Australian war veterans

What is known and background:  Unintended bleeds are a common complication of warfarin therapy. We aimed to determine the impact of general practitioner–pharmacist collaborative medication reviews in the practice setting on hospitalization‐associated bleeds in patients on warfarin.

Potentially inappropriate prescribing among Australian veterans and war widows/widowers.

This study examined the extent of potentially inappropriate medicine, as defined by explicit criteria, dispensed to Australian veterans using the Repatriation Pharmaceutical Benefits Scheme Pharmacy Claims database. Twenty‐one per cent of the 192 363 veterans aged 70 years, with an eligible gold card, were dispensed at least one potentially inappropriate medicine in the first 6 months of 2005. Long‐acting benzodiazepines, amitriptyline, amiodarone, oxybutynin and doxepin were the medicines most commonly implicated. Strategies to support quality prescribing of medicines to the elderly must include a focus on these medicines.

Use of non‐steroidal anti‐inflammatory drugs and risk of incident myocardial infarction and heart failure, and all‐cause mortality in the Australian veteran community

AIMS We studied the association between either non-selective NSAIDs (ns-NSAIDs), selective COX-2 inhibitors, or any NSAID and risk of incident myocardial infarction (MI) and heart failure (HF), and all-cause mortality in elderly subjects. METHODS We conducted a retrospective nested case-control study on Australian veterans using nationwide hospital admission and pharmacy dispensing data. We estimated adjusted odds ratios (OR) with 95% confidence intervals (CI) for the risk of events for three different measures of prescription supply exposure over the last 2 years: (i) supplied at least once, (ii) supply frequency: supplied more than twice within the last 30 days, once or twice within the last 30 days, and once or more 30 days to 2 years and (iii) total supplies. RESULTS We identified 83 623 cases and 1 662 099 matched controls (1:20) contributing 3 862 931 persons-years of observation. NSAID use at least once within the last 2 years did not significantly affect the risk of MI (OR 1.00, 95% CI 0.96, 1.04) but was associated with a mildly reduced risk of HF (OR 0.95, 95% CI 0.92, 0.98). There was a reduced all-cause mortality with at least one supply of either ns-NSAIDs (OR 0.94, 95% CI 0.90, 0.97), selective COX-2 inhibitors (OR 0.90, 95% CI 0.88, 0.93), or any NSAID (OR 0.87, 95% CI 0.85, 0.90). Risk of death was also inversely associated with the number of prescription supplies. CONCLUSIONS NSAID use is not associated with an increased risk of incident MI and HF but is associated with a reduction in all-cause mortality in Australian veterans.

Prevalence of preventable medication-related hospitalizations in Australia: an opportunity to reduce harm.

OBJECTIVE To identify the prevalence of potentially preventable medication-related hospitalizations amongst elderly Australian veterans by applying clinical indicators to administrative claims data. DESIGN AND SETTING Retrospective cohort study in the Australian veteran population from 1 January 2004 to 31 December 2008. PARTICIPANTS A total of 109 044 veterans with one or more hospitalizations defined by the medication-related clinical indicator set, during the 5-year study period. MAIN OUTCOME MEASURE The prevalence of potentially preventable medication-related hospitalizations as a proportion of all hospitalizations defined by the clinical indicator set. RESULTS During the 5-year study period, there were a total of 1 630 008 hospital admissions of which 216 527 (13.3%) were for conditions defined by the medication-related clinical indicator set for 109 044 veterans. The overall proportion of potentially preventable medication-related hospitalizations was 20.3% (n= 43 963). Of the 109 044 veterans included in the study, 28 044 (25.7%) had at least one potentially preventable medication-related hospitalization and 7245 (6.6%) veterans had two or more potentially preventable admissions. Conditions with both a high prevalence of hospitalization and preventability included asthma/chronic obstructive pulmonary disorder, depression and thromboembolic cerebrovascular event (23.3, 18.5 and 18.3%, respectively, were potentially preventable). Other hospitalizations that were less common but had a high level of preventability (at least 20%) included hip fracture, impaction, renal failure, acute confusion, bipolar disorder and hyperkalaemia. CONCLUSIONS The results of this study highlight those conditions where hospitalizations could potentially be avoided through improved medication management. Strategies to increase the awareness, identification and resolution of these medication-related problems contributing to these hospitalizations are required in Australia.

Comorbid chronic diseases, discordant impact on mortality in older people: a 14-year longitudinal population study

Objectives To determine the impact of comorbid chronic diseases on mortality in older people. Design Prospective cohort study (1992–2006). Associations between numbers of chronic diseases or mutually exclusive comorbid chronic diseases on mortality over 14 years, by Cox proportional hazards model adjusting for sociodemographic variables or Kaplan–Meier analyses, respectively. Setting Population based, Australia. Participants 2087 randomly selected participants aged ≥65 years old, living in the community or institutions. Main results Participants with 3–4 or ≥5 diseases had a 25% (95% CI 1.05 to 1.5, p=0.01) and 80% (95% CI 1.5 to 2.2, p<0.0001) increased risk of mortality, respectively, by comparison with no chronic disease, after adjusting for age, sex and residential status. When cardiovascular disease (CVD), mental health problem or diabetes were comorbid with arthritis, there was a trend towards increased survival (range 8.2–9.5 years) by comparison with CVD, mental health problem or diabetes alone (survival 5.8–6.9 years). This increase in survival with arthritis as a comorbidity was negated when CVD and mental health problems or CVD and diabetes were present in disease combinations together. Conclusion Older people with ≥3 chronic diseases have increased risk of mortality, but discordant effects on survival depend on specific disease combinations. These results raise the hypothesis that patients who have an increased likelihood of opportunity for care from their physician are more likely to have comorbid diseases detected and managed.

Neonatal outcomes after late-gestation exposure to selective serotonin reuptake inhibitors.

Objective This study aimed to investigate neonatal outcomes after prenatal exposure to selective serotonin reuptake inhibitors (SSRIs) during late-gestation. Methods A retrospective cohort study was conducted using linked records from the Women’s and Children’s Health Network in South Australia, Australia, including the Perinatal Statistics Collection and the Hospital Pharmacy Dispensing Records. Women were eligible to participate if they gave birth to singleton, live-born infants between September 2000 and December 2008 (n = 33,965). Women were excluded if they received a dispensing for antidepressants other than SSRIs (n = 93) or an antipsychotic (n = 81). We estimated odds ratios (ORs) and 95% confidence intervals (CIs) for preterm delivery, low birth weight, small-for-gestational age, neonatal hospitalization and length of hospital admission, adjusting for sociodemographic, lifestyle, and medical factors. Results Two hundred twenty-one women received a dispensing for an SSRI during pregnancy, 1566 had a psychiatric illness but did not receive a dispensing for an SSRI, and 32,004 did not have a psychiatric illness and did not receive a dispensing for an SSRI. Compared to infants of women with a psychiatric illness but no SSRI use, infants of women exposed to SSRIs had an increased risk of preterm delivery (adjusted OR, 2.68; 95% CI, 1.83–3.93), low birth weight (adjusted OR, 2.26; 95% CI, 1.31–3.91), admission to hospital (adjusted OR, 1.92; 95% CI, 1.39–2.65), and length of hospital stay longer than 3 days (adjusted OR, 1.93; 95% CI, 1.11–3.36) but not small-for-gestational age (adjusted OR, 1.13; 95% CI, 0.65–1.94). Psychiatric illness but no SSRI use during pregnancy was only associated with an increased likelihood of neonatal hospital admission (adjusted OR, 1.21; 95% CI, 1.07–1.38). Conclusions These results add to the growing body of evidence of an association between SSRI exposure during pregnancy and a range of adverse neonatal outcomes, but the potential for confounding according to severity of underlying maternal psychiatric illness requires further investigation.

Developing and evaluating a model for pharmaceutical care in Australian community pharmacies

Objective — To develop and evaluate a medication management service. The service was based on the principles of pharmaceutical care and targeted patients at risk of medication misadventure, primarily elderly patients, in five community pharmacies.