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AIMS: To determine the prevalence of potentially inappropriate medication (PIM) use at hospital admission and discharge, and the contribution to hospital admission among residential aged care facility (RACF) residents with and without dementia. METHODS: We conducted a secondary analysis using data from a multi‐hospital prospective cohort study involving consecutively admitted older adults, aged 75 years or older, who were taking five or more medications prior to hospital admission and discharged to a RACF in South Australia. PIM use was identified using the 2015 Screening Tool for Older Persons’ Prescription (STOPP) and 2019 Beers Criteria. An expert panel of clinicians with geriatric medicine expertise evaluated the contribution of PIM to hospital admission. RESULTS: In total, 181 participants were included, the median age was 87.5 years and 54.7% were female. Ninety‐one (50.3%) had a diagnosis of dementia. Participants with dementia had less PIMs, according to at least one of the two screening criteria, than those without dementia, at admission (dementia: 76 (83.5%) vs no dementia: 84 (93.3%), p=0.04) and discharge (78 (85.7%) vs 83(92.2%), p=0.16). PIM use was causal or contributory to the admission in 28.1% of study participants (n=45) who were taking at least one PIM at admission. CONCLUSIONS: Over 80% of acutely admitted older adults took PIMs at hospital admission and discharge and for over a quarter of these people the admissions were attributable to PIM use. Hospitalisation presents an opportunity for comprehensive medication reviews, and targeted interventions that enhance such a process could reduce PIM use and related harm. Refereed/Peer-reviewed

Objective: To determine the prevalence of medication- related hospitalisations pre-ceded by potentially suboptimal processes of care in aged care residents Method: We conducted a retrospective analysis of administrative claims data from the Australian Government Department of Veterans’ Affairs (DVA). We identified all hospital admissions for aged care residents between 1 July 2014 and 30 June 2019. The proportion of hospital admissions preceded by potentially suboptimal medication- related processes of care was determined Results: A total of 18874 hospitalisations were included, and 46% were preceded by potentially suboptimal medication- related care. One- quarter of fracture admissions occurred in residents at risk of fracture who were not using a medicine to prevent fracture, and 87% occurred in residents using falls- risk medicines. Thirty per cent of heart failure admissions occurred in patients who were not using an angiotensin- converting enzyme inhibitor or angiotensin receptor blocker Conclusion: Nearly half of hospital admissions were preceded by potentially sub-optimal medication- related processes of care. Interventions to improve use of medi-cines for aged care residents in these areas are warranted. Refereed/Peer-reviewed

Background: Delirium is a serious condition in which medications are just one of a number of potential predisposing or precipitating factors. Adequate knowledge of delirium among all healthcare professionals, including pharmacists, may assist in effective prevention and management. However, little is known about the knowledge of pharmacists regarding delirium. Aim: To assess Australian hospital pharmacists’ knowledge of risk factors, symptoms, prevention and treatment of delirium in elderly patients. Method: A cross-sectional survey was conducted via a web-based questionnaire to collect information on participants’ demographics, knowledge of delirium risk factors, symptoms, prevention and treatment. A link to the survey was included in the newsletters of The Society of Hospital Pharmacists of Australia, Australasian Delirium Association and New South Wales Therapeutic Advisory Group and distributed to hospital pharmacists in Australia via email. Results: One-hundred and six responses from hospital pharmacists were available for analysis. Nine of 11 questions assessing basic knowledge were correctly answered by more than half of respondents. Seven of the eight questions related to delirium prevention strategies were correctly answered by more than half of pharmacists. However, only three of the eight questions about risk factors for delirium were answered correctly by more than half of pharmacists. Conclusion: Pharmacists’ basic knowledge about delirium and prevention strategies was good; however, their knowledge of risk factors and symptoms of delirium needs to be improved. Delirium-specific educational programs for pharmacists should be considered for improving their knowledge and understanding regarding delirium. Refereed/Peer-reviewed

Objective: To identify demographic and medication-related predictors of unplanned hospitalisation and combine them into a hospitalisation risk score.Methods: Patients aged ≥65 years from an outpatient multimorbidity clinic were included. Hospitalisation predictors within a year of clinic discharge were identified using logistic regression. A risk score was developed. The area under the curve(AUC) was used to assess its predictive ability, compared to that of the medicines count (definition of polypharmacy). Results: A total of 598 patients were included (median age of 80.0 years). 58.0%(n = 347) were hospitalised within a year of clinic discharge. The AUC for the risk score incorporating age, medicines count, heart failure (HF), atherosclerotic disease and systemic steroids was 0.67 [95% CI 0.62-0.71], compared to 0.62 [95% CI 0.58-0.67] for the medicines count. Conclusion: A hospitalisation risk score incorporating demographics, medicines,namely steroids, and diseases such as HF had increased predictive ability compared to the medicines count, providing guidance for developing future polypharmacy tools. Refereed/Peer-reviewed

Objectives: To examine the risk of dementia associated with posttraumatic stress disorder (PTSD) and the contribution of antipsychotic use to this risk. Design: Retrospective cohort study Setting: Australia. Administrative claims data from the Australian Government Department of Veterans' Affairs were used. Participants: Male Vietnam veterans aged 55 to 65 at baseline (2001-02) with no preexisting dementia diagnosis (N = 15,612). Measurements: The association between PTSD and dementia was assessed over 12 years of follow-up. Dementia was identified as a hospital diagnosis, dementia record in service disability data, or dispensing of medicines for dementia. Cox-proportional hazards models were used, with age as the time-scale. Results were stratified according to baseline antipsychotic use. Results: No greater risk of dementia was observed with PTSD. In veterans who received antipsychotics, dementia risk was significantly higher than in those who did not (hazard ratio (HR) = 2.1, 95% confidence interval (CI) = 1.4-3.3). Dementia risk was significantly greater in veterans hospitalized for PTSD who received antipsychotics (HR = 2.2, 95% CI = 1.1-4.6) and veterans without PTSD who received antipsychotics (HR = 4.3, 95% CI = 2.1-8.6) than in those without PTSD with no antipsychotic use. Conclusion: Antipsychotic use may be a contributor to dementia risk. These findings should be interpreted with caution because the study design was observational. Further research using prospective study designs in settings where diagnostic data, cognitive function, and disease severity are available are required. Refereed/Peer-reviewed

Purpose The objective of this study was to analyse spontaneous adverse event (SAE) reports associated with the oral anticoagulant dabigatran from Australia, Canada and USA and to examine concomitant medicine use. Methods Spontaneous adverse event national databases from Australia, Canada and the USA were used to examine all reports of adverse events associated with dabigatran from 1st August 2005 to 31st March 2013. Disproportionality analysis was conducted for the quantitative detection of signals using the USA database. Concomitant medicine use was examined to identify potentially inappropriate medicines, which may place the patient at increased risk for adverse events. Results There were a total of 1039, 1333 and 13 788 SAE reports associated with dabigatran from Australia, Canada and USA, respectively. Gastrointestinal (GI) disorders were the most commonly reported adverse event, ranging from 27.5% for Australia and up to 40.5% for USA. Of these, GI haemorrhage accounted for 81.5% of Australian, 71.5% of Canadian and 42% of the USA adverse event reports for GI disorders. Positive signals were confirmed in the USA data (GI haemorrhage; PRR 18.18, χ2 40993.51 and ROR 19.55 95% CI 18.77–20.36). Use of concomitant medicines with the potential to increase bleeding risk across all three countries ranged from 34.1% for Australia to 51.1% for the USA. Conclusions A large proportion of adverse events were associated with concomitant therapies, which may have placed the patient at increased risk of harm. This highlights the need for pharmacovigilance by the prescribing clinician to minimise risk and ensure the safe and effective integration of dabigatran into routine clinical practice. Copyright © 2014 John Wiley & Sons, Ltd.

Aim To identify the characteristics of patients who receive home medicines reviews (HMRs). Method A retrospective analysis was conducted of the Department of Veterans' Affairs administrative claims data. Veterans living in the community on 30 June 2009 were included if they had ≥ 1 medicines dispensed in the previous 12 months. The main outcome measure was the number of veterans who received an HMR. Log binomial regression analysis compared characteristics of HMR recipients and non-recipients – age and gender; number of medicines, prescribers, dispensing pharmacies and hospitalisations in the previous year; and conditions where medicine use is potentially problematic, e.g. dementia. Results Of the 175 572 veterans included in the study, 6236 (3.6%) had received an HMR. The likelihood of having an HMR increased with age, number of medicines and number of GP visits. Women were 12% more likely to receive an HMR than men. Veterans who had received an HMR previously were 4 times more likely to have another HMR. Veterans with 1 to 4 hospitalisations were 10% more likely to receive an HMR than those who had not been hospitalised. The likelihood of having an HMR decreased with the number of dispensing pharmacies and specialist visits. Conclusion Patients who received HMRs had characteristics that placed them at risk of medication-related problems. The uptake of HMRs was appropriate in our study population.

Purpose To determine the validity of sequence symmetry analysis (SSA) method to detect adverse drug reactions from an administrative claims database. Methods Published randomised controlled trials (RCTs) of 19 medicines were identified through search databases, product information (PI) or the US Food and Drug Administration Web site. All adverse events (AEs) in the RCTs and the PI for the medicines were extracted. AEs were considered ‘gold standard positive events’ if they were reported as being statistically significant events in adequately powered RCTs. The remaining AEs were considered ‘gold standard negative events’ if the event was not listed as an AE in the PI for that medicine or any other medicine in its class. Indicators of AEs were identified by consensus from two clinical researchers. SSA was run for each medicine–indicator pair using four different time windows: 3, 6, 9 and 12 months. Results A total of 120 randomised placebo controlled trials were reviewed for the 19 tested medicines. A total of 165 medicine–indicator pairs (44 positive and 121 negative events) were identified and tested by SSA. At the 12-month time window, the sensitivity, specificity, positive and negative predictive values of SSA were 61% (95%CI 0.46–0.74), 93% (95%CI 0.87–0.96), 77% (95%CI 0.61–0.88) and 87% (95%CI 0.80–0.92), respectively. Using a 3-month time window, the SSA had a lower sensitivity (52%). Conclusions The SSA technique was found to have moderate sensitivity and high specificity for detecting ADRs. These results suggest that SSA is a potential tool for detecting ADRs using administrative claims data that could complement existing pharmacosurveillance methods. Copyright © 2013 John Wiley & Sons, Ltd.

Since 2004, the Department of Veterans’ Affairs (DVA) has funded the Veterans’ Medicines Advice and Therapeutics Education Services (MATES) program. The main intervention of the program is quarterly targeted patient-specific prescriber feedback. The feedback comprises a list of relevant medications dispensed to each patient and notes about potential medicationrelated problems specific to the intervention. Supportive educational material is provided to assist general practitioners (GPs) resolve these medication-related problems. Veterans identified in the GP mailing are sent an educational brochure highlighting medication issues and encouraging them to speak with their doctor. To enable pharmacists to support this practice change, educational material is also provided to all pharmacies and accredited pharmacists. The most recent of the 28 interventions implemented to date have addressed osteoporosis, opioid-induced constipation and urinary incontinence. Overall, program materials have been mailed to 249 454 veterans, 34 527 GPs and around 8000 pharmacies and accredited pharmacists. Evaluation has demonstrated a doubling of home medicines review (HMR) rates in the veteran population. Analyses of the DVA data have reported a 45% reduction in hospitalisation for heart failure following HMR among veterans with heart failure (adjusted hazard ratio [HR] 0.6; 95% confidence interval [CI] 0.4–0.8), and a 79% reduction in hospitalisation for haemorrhage (HR 0.2; 95%CI 0.05–0.9) 2 to 6 months after an HMR in veterans dispensed warfarin. Veterans’ MATES has resulted in clinically significant improvements in medication and health service use. J Pharm Pract Res 2011; 41: 316-19.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT * Up to 21% of adverse drug event related hospital admissions are due to drug interactions. Clinical significance of drug interactions varies. * Studies which only identified drug interactions of potentially major clinical significance found lower prevalence, of between 2 and 16%. * Prevalence of drug interactions defined 'potentially hazardous' has had limited study, with no publications identified for the Australian population. WHAT THIS STUDY ADDS * In the study population of 287 074, 1.5% of subjects were dispensed potentially hazardous interacting drug pairs. * However, limited to populations on specific medicines, it was found that for patients dispensed verapamil, methotrexate, amiodarone, lithium, warfarin, cyclosporin and itraconazole, potentially hazardous interactions occurred at a rate greater than 5%. * These patients should be the focus of medication review programmes to avoid potentially serious adverse drug events. BACKGROUND Up to 21% of adverse drug event-related hospital admissions are due to drug interactions. Clinical significance of drug interactions varies, and drug interactions defined 'potentially hazardous' are more likely to contribute to morbidity and mortality. AIM The aim of this study was to assess the prevalence of potentially hazardous drug interactions in an elderly Australian veteran population. METHODS This study assessed the prevalence of potentially hazardous drug interactions, where hazardous was defined in three or more international drug interaction references, using Repatriation Pharmaceutical Benefits Scheme pharmacy claims data. Analysis was limited to patients who received regular concurrent dispensings of potentially hazardous interacting medicines. RESULTS Of the 287 074 subjects included in the study, 1.5% were dispensed potentially hazardous interacting drug pairs. For patients dispensed cyclosporin, concomitant use of a statin was common (47%); as was statin use with those dispensed itraconazole (31%). Of those dispensed methotrexate, 24% also received a non-steroidal anti-inflammatory drug; of those on lithium, 18% also received an ACE inhibitor or angiotensin 2 receptor blocker; of those on warfarin, 7.2% and 5.9% were co-dispensed an non-steroidal anti-inflammatory drugs or antiplatelets respectively; for those on verapamil, 5.3% were co-dispensed a beta-blocker, while for those on amiodarone 6.2% were co-dispensed digoxin. CONCLUSIONS Overall prevalence of potentially serious drug interactions appears to be low in the Australian veteran population. However, patients taking cyclosporine, itraconazole, methotrexate, lithium, warfarin, verapamil and amiodarone appear to be most at risk and their medicine use should be regularly reviewed to prevent potentially hazardous drug interactions.

Background/Aims: Enhanced communication and transfer of information between healthcare providers and healthcare settings can reduce medication and healthcare errors post-hospital discharge. The timeframes within which patients access community healthcare providers post-hospital discharge are not well studied. This study aimed to determine length of time from hospital discharge until a general practice, pharmacy or specialist visit, or care planning service. Methods: We conducted a retrospective analysis of Department of Veterans' Affairs health claims data. All 109 860 veterans hospitalized in 2006 were included. Main outcome measures were time from first hospital discharge to first claim for a general practice, pharmacy, specialist visit and/or care planning service. Results: Within 30 days of hospital discharge 71% of subjects visited a general practitioner (GP), 86% had medicines dispensed from a community pharmacy and 44% saw a specialist. Median time to first pharmacy visit was 6 days (interquartile range 2–14) and 12 days for a GP visit (interquartile range 4–31). Less than 2% of the cohort received a discharge plan, case conference or medication review in the month after discharge. Conclusions: With 25% of patients having a claim for a GP service within 4 days of discharge, discharge summaries need to reach community-based health professionals within this time. Most patients visited their community pharmacy within 2 weeks of hospital discharge and before they saw their GP. Pharmacists are not routinely advised of hospitalization or provided with discharge summaries. More active engagement of this professional group in the continuum of care might improve care after hospital discharge.