Jeff Hughes

Long-term proton pump inhibitor therapy and falls and fractures in elderly women: a prospective cohort study.

Proton pump inhibitors (PPIs) are widely used in the elderly. Recent studies have suggested that long‐term PPI therapy is associated with fractures in the elderly, however the mechanism remains unknown. We investigated the association between long‐term PPI therapy ≥1 year and fracture risk factors including bone structure, falls, and balance‐related function in a post hoc analysis of a longitudinal population‐based prospective cohort of elderly postmenopausal women and replicated the findings in a second prospective study of falling in elderly postmenopausal women. Long‐term PPI therapy was associated with increased risk of falls and fracture‐related hospitalizations; adjusted odds ratio (AOR) 2.17; 95% CI, 1.25–3.77; p = 0.006 and 1.95; 95% CI, 1.20–3.16; p = 0.007, respectively. In the replication study, long‐term PPI use was associated with an increased risk of self‐reported falling; AOR, 1.51; 95% CI, 1.00–2.27; p = 0.049. No association of long‐term PPI therapy with bone structure was observed; however, questionnaire‐assessed falls‐associated metrics such as limiting outdoor activity (p = 0.002) and indoor activity (p = 0.001) due to fear of falling, dizziness (p < 0.001) and numbness of feet (p = 0.017) and objective clinical measurement such as Timed Up and Go (p = 0.002) and Romberg eyes closed (p = 0.025) tests were all significantly impaired in long‐term PPI users. Long‐term PPI users were also more likely to have low vitamin B12 levels than non‐users (50% versus 21%, p = 0.003). In conclusion, similar to previous studies, we identified an increased fracture risk in subjects on long‐term PPI therapy. This increase in fracture risk in elderly women, already at high risk of fracture, appears to be mediated via increased falls risk and falling rather than impaired bone structure and should be carefully considered when prescribing long‐term PPI therapy.

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.

The Palliative Care Interdisciplinary Team: Where Is the Community Pharmacist?

Palliative care emphasizes an interdisciplinary approach to care to improve quality of life and relieve symptoms. Palliative care is provided in many ways; in hospices, hospital units, and the community. However, the greatest proportion of palliative care is in the community. In hospice and palliative care units in hospitals, clinical pharmacists are part of the interdisciplinary team and work closely with other health care professionals. Their expertise in the therapeutic use of medications is highly regarded, particularly as many palliative care patients have complex medication regimens, involving off-label or off-license prescribing that increases their risk for drug-related problems. However, this active involvement in the palliative care team is not reflected in the community setting, despite the community pharmacist being one of the most accessible professionals in the community, and visiting a community pharmacist is convenient for most people, even those who have limited access to private or public transport. This may be due to a general lack of understanding of skills and knowledge that particular health professionals bring to the interdisciplinary team, a lack of rigorous research supporting the necessity for the community pharmacists involvement in the team, or it could be due to professional tensions. If these barriers can be overcome, community pharmacists are well positioned to become active members of the community palliative care interdisciplinary team and respond to the palliative care needs of patients with whom they often have a primary relationship.

Clinical setting influences off-label and unlicensed prescribing in a paediatric teaching hospital

Purpose To estimate the prevalence of off-label and unlicensed prescribing during 2008 at a major paediatric teaching hospital in Western Australia. Methods A 12-month retrospective study was conducted at Princess Margaret Hospital using medication chart records randomly selected from 145,550 patient encounters from the Emergency Department, Inpatient Wards and Outpatient Clinics. Patient and prescribing data were collected. Drugs were classified as off-label or unlicensed based on Australian registration data. A hierarchical system of age, indication, route of administration and dosage was used. Drugs were classified according to the Anatomical Therapeutic Chemical Code. Results A total of 1,037 paediatric patients were selected where 2,654 prescriptions for 330 different drugs were prescribed to 699 patients (67.4%). Most off-label drugs (n = 295; 43.3%) were from the nervous system; a majority of unlicensed drugs were systemic hormonal preparations excluding sex hormones (n = 22, 32.4%). Inpatients were prescribed more off-label drugs than outpatients or Emergency Department patients (p < 0.0001). Most off-label prescribing occurred in infants and children (31.7% and 35.9% respectively) and the highest percentage of unlicensed prescribing (7.2%) occurred in infants (p < 0.0001). There were 25.7% of off-label and 2.6% of unlicensed medications prescribed across all three settings. Common reasons for off-label prescribing were dosage (47.4%) and age (43.2%). Conclusion This study confirmed off-label and unlicensed use of drugs remains common. Further, that prevalence of both is influenced by the clinical setting, which has implications in regards to medication misadventure, and the need to have systems in place to minimise medication errors. Further, there remains a need for changes in the regulatory system in Australia to ensure that manufacturers incorporate, as it becomes available, evidence regarding efficacy and safety of their drugs in children in the official product information.

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 patients 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.

Nationwide collaborative development of learning outcomes and exemplar standards for Australian pharmacy programmes

Internationally, the preparation of pharmacy graduates for professional practice has evolved from educating for capacities for practice, to a focus on competencies, and most recently, on assuring graduate outcomes. Consequently, there is an increasing emphasis on the specification of and accountability around student learning outcomes. This, in turn, has implications for teaching and assessment. The aim of the study was to harmonise the various expectations and regulatory requirements for Australian pharmacy education programmes through the development of learning outcomes and exemplar standards for all entry‐level pharmacy graduates.

Health Service Discovery and Composition in Ambient Assisted Living: the Australian Type 2 Diabetes Case Study

This paper is situated in the Ambient Assisted Living (AAL) services domain and offers a twofold contribution to the state of the art. We contribute to the health informatics domain by applying a service value network (SVN) approach to automatically match medical practice recommendations based on patient sensor data in a home care monitoring context to health services provided by a network of service providers. We contribute to the area of SVN composition by replacing current assumptions that customers are actively involved in explicating their service requirements with a more tacit approach where requirements are derived from patterns in sensor readings (and corollary diagnosis) based on validated rules on the customer side as well as on the supplier side. We demonstrate our contributions with an SVN composition based on an initial set of 493 patient profiles in the context of Type 2 Diabetes management in Australia.

Stability studies of lincomycin hydrochloride in aqueous solution and intravenous infusion fluids

Purpose The purpose of this study was to evaluate the chemical stability of Lincocin® (lincomycin hydrochloride) in commonly used intravenous fluids at room temperature (25°C), at accelerated-degradation temperatures and in selected buffer solutions. Materials and methods The stability of Lincocin® injection (containing lincomycin 600 mg/2 mL as the hydrochloride) stored at 25°C±0.1°C in sodium lactate (Hartmann’s), 0.9% sodium chloride, 5% glucose, and 10% glucose solutions was investigated over 31 days. Forced degradation of Lincocin® in hydrochloric acid, sodium hydroxide, and hydrogen peroxide was performed at 60°C. The effect of pH on the degradation rate of lincomycin hydrochloride stored at 80°C was determined. Results Lincomycin hydrochloride w as found to maintain its shelf life at 25°C in sodium lactate (Hartmann’s) solution, 0.9% sodium chloride solution, 5% glucose solution, and 10% glucose solution, with less than 5% lincomycin degradation occurring in all intravenous solutions over a 31-day period. Lincomycin hydrochloride showed less rapid degradation at 60°C in acid than in basic solution, but degraded rapidly in hydrogen peroxide. At all pH values tested, lincomycin followed first-order kinetics. It had the greatest stability near pH 4 when stored at 80°C (calculated shelf life of 4.59 days), and was least stable at pH 2 (calculated shelf life of 0.38 days). Conclusion Lincocin® injection was chemically found to have a shelf life of at least 31 days at 25°C when added to sodium lactate (Hartmann’s) solution, 0.9% sodium chloride solution, 5% glucose solution, and 10% glucose solution. Solutions prepared at approximately pH 4 are likely to have optimum stability.

Snapshot versus continuous documentation of pharmacists’ interventions: are snapshots worthwhile?

The documentation of pharmacists’ interventions is important but there are limited studies evaluating the different methods of documentation.

Establishing and Evaluating Interprofessional Student-Led Wellness Assessment Services Focused on the Elderly

Whilst the notion that health professionals should ‘learn to work together’ is not new (Carpenter & Dickinson 2014; Leathard, 1994; Szasz, 1969), the popularity of interprofessional education (IPE) has certainly grown noticeably over recent years. There is a trend towards an increased interest in IPE not only amongst tertiary education providers and researchers but also policymakers as well (Reeves et al., 2008). In this regard, the World Health Organization (WHO) (WHO, 2010) has been emphasising the need for policymakers around the world to engage in IPE and hence better prepare their health professionals for future challenges. A variety of reasons can be attributed towards this increased interest in IPE, including increasing complexity of health care, an ageing population and increased prevalence of chronic diseases requiring multidisciplinary approaches (Reeves et al., 2008). In this regard, interprofessional collaboration and communication in practice is crucial. Interprofessional practice should be patient-focused and is expected to provide more efficient and effective patient care, including more active patient involvement in decision-making processes regarding their health (King, Shaw, Orchard, & Miller, 2010; Orchard, Curran, & Kabene, 2005).