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Background: Atrial fibrillation (AF) is associated with increased risk of cardiovascular disease (CVD) complications including stroke. We investigated the assessment and management of cardiovascular risk among patients with AF aged 35-74years, by ethnic group, in a large cohort of people receiving a CVD risk assessment in primary care (PREDICT)., Methods: PREDICT was linked to national dispensing, hospitalisation and mortality records. AF was present if recorded in PREDICT or during a prior hospitalisation; medications were those dispensed ≤6months before or after a PREDICT assessment; the CHA 2 DS 2 -VASc score and a New Zealand (NZ) adjusted Framingham CVD risk were calculated. Data were linked to outcomes of stroke or major adverse cardiovascular event (MACE)., Results: 12,739 (2.8%) of 447,020 people aged 35-74years had AF. Māori, the indigenous population of NZ, had the highest proportion of AF, which by age group, was similar to that among Europeans 10years older. 77% were at high stroke risk, of whom 42% received anticoagulation; 54% were at high CVD risk, of whom 67% received both lipid- and blood pressure-lowering medication. Per category of predicted risk, stroke risk was overestimated and risk of MACE was underestimated., Conclusions: The burden of AF and risk factors differed by ethnic group thus recommendations to screen for AF above a universal age threshold may introduce inequity in the detection and management of associated risk. The high burden of comorbidities at younger ages among many ethnic groups contributes to the poor performance of available risk assessment tools, further compounding potential inequity., (Copyright © 2017 Elsevier Ireland Ltd. All rights reserved.)

A number of initiatives aimed at improving medication safety in and across New Zealand public hospitals have been introduced over recent years. Clinicians, policymakers and patients now want to know whether patients are safer today from medicine use than they have been in the past. The challenge has been determining exactly what should be measured. In this viewpoint, we critically examine the suitability of adverse drug events (ADE) as a primary metric for assessing the progress of medication safety improvement. We provide an overview of contemporary dialogue on medication safety measurement and highlight the emergent challenges. Finally, we reflect on how New Zealand has approached medication safety measurement so far and argue the need for a multi-stakeholder informed conceptual framework with a view to further enhancing meaningful assessment of medication safety., Competing Interests: Dr Ng and Dr Harrison report grants from NZ Pharmacy Education Research Fund (NZPERF) during the conduct of the study.

Background: Patients with stable angina not controlled by monotherapy with nitrates, beta blockers, or calcium channel blockers are often treated with combinations of these drugs. There may be adverse effects from, or contraindications to, the use of combinations. In low risk groups, medical treatment appears to be as good an option as percutaneous transluminal coronary angioplasty in terms of averting myocardial infarction, death, or subsequent revascularization. Revascularization procedures are too costly or inaccessible for many patients in developing countries therefore effective and safe medical treatment is needed. Trimetazidine is a less well known anti-anginal drug that controls myocardial ischaemia through intracellular metabolic changes. Trimetazidine has been reported, in some studies, to be better tolerated than combined anti-anginal therapy; however it is not considered in published guidelines., Objectives: To determine the efficacy and tolerability of trimetazidine in patients with stable angina., Search Methods: We searched The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, LILACS and SCISEARCH, without language restriction, from inception to October 2003. Experts in the field were contacted to locate unpublished studies., Selection Criteria: Randomised studies comparing trimetazidine with placebo, or other anti-angina drug in adults with stable angina., Data Collection and Analysis: Two reviewers independently applied the inclusion criteria, assessed trial quality and extracted data., Main Results: Twenty-three studies (1378 patients) met the inclusion criteria. There was a paucity of information about mortality, cardiovascular events and quality of life. Trimetazidine, compared with placebo, reduced the number of weekly angina attacks ( mean difference -1.44, 95% CI -2.10 to -0.79; P < 0.0001), reduced weekly nitroglycerin tablet consumption (95% CI -1.47 to -2.20, -0.73; P < 0.0001) and improved exercise time to 1 mm segment depression (P = 0.0002). Four small trials (263 patients) compared trimetazidine against other anti-anginal agents. One favoured trimetazidine over nitrates. Three tended to favour alternative regimens but with confidence intervals consistent with both major increases and decreases in frequency of angina episodes. In this subgroup, adverse events were considered in 5 trials (448 patients) and totals of 2 versus 12 drop outs due to adverse events were observed in the trimetazidine and alternative regimens respectively, but this was mostly driven by a single trial., Authors' Conclusions: Trimetazidine is effective in the treatment of stable angina compared with placebo, alone or combined with conventional anti-anginal agents. Trimetazidine may result in fewer dropouts due to adverse events. Large, long term trials comparing trimetazidine with other anti-anginal drugs assessing clinically relevant important outcomes are required to establish its role in clinical management.

Over 230 million surgical procedures are conducted worldwide each year with numbers increasing. Pain, undesirable inflammation and infection are common complications experienced by patients following surgery. Opioids, non-steroidal anti-inflammatory drugs (NSAIDs), local anaesthetics (LAs) and antibiotics are the commonly administered drugs peri-operatively to manage these complications. Post-operative pharmacotherapy is typically achieved using immediate-release dosage forms of drugs, which lead to issues around fluctuating plasma concentrations, systemic adverse effects and poor patient adherence. Controlled release (CR) systems for certain medicines including opioids, NSAIDs and antibiotics have demonstrably enhanced treatment efficacy in the post-surgical setting. However, challenges remain to ensure patient safety while achieving individual therapeutic needs. Newer CR systems in the research and development pipeline have a high level of control over medicine release, which can be initiated, tuned or stopped on-demand. Future systems will self-regulate drug release in response to biological markers providing precise individualized therapy. In this review, we cover currently adopted CR systems in post-operative pharmacotherapy, including drug eluting medical devices, and highlight a series of examples of novel CR technologies that have the potential for translation into post-surgical settings to improve medication efficacy and enhance post-surgical recovery.

Objectives: Despite the introduction of new oral anticoagulants, vitamin K antagonists remain the mainstay of the prevention and treatment of thromboembolism. The advent of affordable point-of-care testing presents an opportunity for community pharmacists to provide anticoagulation management services, better utilizing their training, reducing the workload on medical practices and improving accessibility and convenience for patients. This study aimed to determine the effectiveness of anticoagulation management by community pharmacists., Methods: All patients enrolled in a pilot programme for a community pharmacy anticoagulation management service using point-of-care international normalized ratio testing and computer-assisted dose adjustment were included in a follow-up study, including before-after comparison. Outcomes included time in therapeutic range (TTR), time above and below range, number and proportion of results outside efficacy and safety thresholds, and a comparison of care led by pharmacists and care led by a primary-care general practitioner (GP)., Key Findings: A total of 693 patients were enrolled, predominantly males over 65 years of age with atrial fibrillation. The mean TTR was 78.6% (95% CI 49.3% to 100%). A subgroup analysis (n = 221) showed an increase in mean TTR from 61.8% under GP-led care to 78.5% under pharmacist-led care (P < 0.001), reflecting a reduction in the time above and, in particular, below the range. The mean TTR by pharmacy ranged from 71.4% to 84.1%. The median number of tests per month was not statistically different between GP- and pharmacist-led care., Conclusions: Community-pharmacist-led anticoagulation care utilizing point-of-care testing and computerized decision support is safe and effective, resulting in significant improvements in TTR. Our results support wider adoption of this model of collaborative care., (© 2014 Royal Pharmaceutical Society.)

Objective: To examine attitudes towards a new collaborative pharmacy-based model of care for management of warfarin treatment in the community. As background to the study, the New Zealand health authorities are encouraging greater clinical involvement of community pharmacists., Methods: Fifteen community pharmacies in New Zealand took part in a community pharmacist-led anticoagulation management service (CPAMS). Participants (patients, general practitioners, practice nurses, pharmacists) were surveyed on their views on accessibility, convenience, confidence in the service, impact on warfarin control, impact on workloads, effect on relationships and whether the service should be further implemented. A small number from each group was interviewed on the same topics., Key Findings: Patients reported improved access, convenience, a preference for capillary testing, and the immediacy of the test result and dose changes. They indicated that they had a better understanding of their health problems. While sample sizes were small, the majority of general practitioners and practice nurses felt there were positive benefits for patients (convenience) and themselves (time saved) and expressed confidence in pharmacists' ability to provide the service. There were some concerns about potential loss of involvement in patient management. Pharmacists reported high levels of satisfaction with better use of their clinical knowledge in direct patient care and that their relationships with both patients and health professionals had improved., Conclusions: The new model of care was highly valued by patients and supported by primary care practitioners. Wider implementation of CPAMS was strongly supported. Pharmacists and general practitioners involved in CPAMS reported a pre-existing collaborative relationship, and this appears to be important in effective implementation., (© 2014 Royal Pharmaceutical Society.)

Objectives: The purpose of this study was to identify the type and frequency of drug-related problems (DRPs) that are encountered when dispensing secondary care prescriptions in community pharmacy., Methods: A cross-sectional study was conducted attempting to recruit all patients presenting with secondary care prescriptions to a single community pharmacy in New Zealand over a 3-month period. The DRPs were recorded to allow analysis of the types and frequencies of the problems seen., Key Findings: During the 3-month period 401 patients consented to participate and 840 prescription items were analysed. DRPs were identified in 20% of prescription items analysed (n = 172), affecting 38% patients (n = 155). Bureaucratic interventions concerning product availability and payment issues accounted for 55% and affected 11% of the prescription items analysed. The remaining 45% of DRPs concerned clinical and patient issues and affected 9% of prescription items., Conclusions: This study has shown that the secondary-primary interface is problematic with respect to DRPs. Although pharmacists are in a position to identify and act on these DRPs, access to basic patient notes such as a discharge summary and including pharmacists in the communication between secondary and primary providers should assist in achieving seamless care for the patient and help to identify and prevent DRPs., (© 2013 Royal Pharmaceutical Society.)

Poor adherence to long-term prescription medication is a frequent problem that undermines pharmacological control of important risk factors such as hypertension. A medication possession ratio (MPR) can be calculated from Practice Management System (PMS) data to provide a convenient indicator of adherence. We investigate how well prior MPR predicts later MPR, taking MPR&lt;80% as indicative of 'non-adherence,' to assess the potential value of MPR calculation on PMS data for targeting adherence promotion activities by general practices. We examine PMS data for two New Zealand metropolitan general practices, one with a predominantly Pacific caseload, across 2008 and 2009. We find prevalence of non-adherence in 2009 to be 51.63% (95% confidence interval [CI] 47.9-55.3) for patients at the Pacific practice and 28.09% (95% CI 25.0-31.1) at the other practice for patients who are demonstrably active with the practice in 2009. The positive predictive value (PPV) of 2008 non-adherence for 2009 non-adherence is 71.80% (95% CI, 66.5-77.1) and negative predictive value (NPV) 61.52% (95% CI 56.9-66.1) for the Pacific practice; PPV is 61.38% (95% CI 54.6-68.2) and NPV is 82.19% (95% CI 79.2-85.2) for the other practice. The results indicate good potential for decision support tools to target adherence promotion.

The aim of our paper is to expose the challenges primary health care reform is exerting on community pharmacy and other groups. Our paper is underpinned by the notion that a broad understanding of the issues facing pharmacy will help facilitate engagement by pharmacy and stakeholders in primary care. New models of remuneration are required to deliver policy expectations. Equally important is redefining the place of community pharmacy, outlining the roles that are mooted and contributions that can be made by community pharmacy. Consistent with international policy shifts, New Zealand primary health care policy outlines broad directives which community pharmacy must respond to. Policymakers are calling for greater integration and collaboration, a shift from product to patient-centred care; a greater population health focus and the provision of enhanced cognitive services. To successfully implement policy, community pharmacists must change the way they think and act. Community pharmacy must improve relationships with other primary care providers, District Health Boards (DHBs) and Primary Health Organisations (PHOs). There is a requirement for DHBs to realign funding models which increase integration and remove the requirement to sell products in pharmacy in order to deliver services. There needs to be a willingness for pharmacy to adopt a user pays policy. General practitioners (GPs) and practice nurses (PNs) need to be aware of the training and skills that pharmacists have, and to understand what pharmacists can offer that benefits their patients and ultimately general practice. There is also a need for GPs and PNs to realise the fiscal and professional challenges community pharmacy is facing in its attempt to improve pharmacy services and in working more collaboratively within primary care. Meanwhile, community pharmacists need to embrace new approaches to practice and drive a clearly defined agenda of renewal in order to meet the needs of health funders, patients and other primary care providers. There are significant barriers to change. Some of these are financial but many are professional and organisational and require a genuine commitment from the whole primary health care sector.

Introduction: Thromboprophylaxis is highly effective, safe and cost-effective. However, data from international studies have shown that many at-risk hospitalised patients do not receive appropriate prophylaxis, leaving them at risk of venous thromboembolism (VTE) and its consequences., Aims: To assess whether patients readmitted with a VTE to the North Shore Hospital, Auckland, received appropriate thromboprophylaxis during their index admission., Methods: Discharge coding was used to identify all patients admitted for VTE-related events between 1 July 2005 to 30 June 2007. Further analysis identified those patients hospitalised for any cause in the 3 months prior to the VTE event. Data were collected on patient characteristics, risk factors for VTE and the thromboprophylaxis regimen prescribed. The seventh American College of Chest Physicians (ACCP) guidelines on the prevention of venous thromboembolism were used to assess VTE risk and to determine whether patients received appropriate prophylaxis., Results: Of the 962 patients admitted with a VTE event, 243 (25%) had been hospitalised within the preceding 3 months. 108 patients were eligible for inclusion in the study; 58 were categorized as medical admissions and 50 as surgical. Using the ACCP-defined criteria, 29 (50%) medical and 38 (76%) surgical patients were identified as being at increased risk of VTE. Only one third of at-risk patients received ACCP-recommended prophylaxis during their index hospital admission. More surgical patients received recommended prophylaxis than medical patients, although this was not statistically significant (37% vs 24%, p=0.3, Fisher's exact test)., Conclusions: A significant number of at-risk patients, who subsequently developed VTE after discharge from hospital, failed to receive appropriate thromboprophylaxis during their index admission. Implementing national and local strategies, to improve the use of thromboprophylaxis in hospitalised patients, may help to reduce the burden of VTE.

Objective of the Study: To describe the dimensions of organisational culture within a selection of community pharmacies., Setting: Community pharmacy in the New Zealand primary care sector which is partially government funded and currently undergoing major reform. Community pharmacy is under pressure to take on new roles, integrate within the wider primary care team and deliver the expectations of contemporary health policy., Method: The mixed methods approach of concept mapping was undertaken with 10 representatives from six community pharmacies selected as case sites. The process was split into three parts (a) face to face brainstorming to generate statements describing culture, followed by (b) statement reduction, piloting and approval of statement list by participants, followed by (c) sorting the statements into 'like' groups. Multidimensional scaling analysis of participant sorting allows the development of discrete clusters of statements that describe aspects of organizational culture., Results: A set of 105 statements were generated at the brainstorming meeting. Eight clusters of organisational culture resulted from participant sorting: leadership and staff management; valuing each other and the team; free thinking, fun and open to challenge; trusted behaviour; customer relations; focus on external integration; providing systematic advice; embracing innovation., Conclusion: Community pharmacy is under pressure to take on new roles and deliver and there is some evidence organisational culture of pharmacy may be a barrier. Our paper outlines the development of a survey instrument for describing organisational culture through Concept mapping, a tool borrowed from social sciences. This tool can be used for exploration of aspects of culture that may be important in the change management process for improving the effectiveness of community pharmacy as expected by contemporary primary health care policy.

Purpose: To assess the predictive value of general practice electronic prescribing records with respect to adherence to long-term medications as compared to claims-based pharmacy dispensing data., Methods: A total of 29772 electronic prescribing records relating to 2713 patients attending a New Zealand general medical practice were linked by national health identifier to 63 833 dispensing records used for community pharmacy reimbursement. Individual possession ratios-prescription possession ratio (PPR) for prescribing and medication possession ratio (MPR) for dispensing-were calculated for the 15-month period from 1 January 2006 to 30 March 2007 based on each data source for the common long-term medications simvastatin, metoprolol succinate, bendrofluazide, felodipine, cilazapril and metformin., Results: Out of 646 patients prescribed at least one of the six medications by the practice during the 15-month period, 50% of patients maintained high adherence (MPR > or = 80%) to all (out of the 6) medications that they were prescribed over the period, with rates of high adherence to individual medications ranging from 68 (felodopine) to 55% (metformin). In 93% of 4043 cases where there was a prescription in the general practice data, a subsequent dispensing record for the same patient and drug was present with a time-stamp no more than seven days later. PPR < 80% demonstrated a positive predictive value (PPV) of 81.4% (95%CI 78-85%) and negative predictive value (NPV) of 76.3% (95%CI 73-79%) for MPR < 80%., Conclusion: There is potential for general practices to identify substantial levels of long-term medication adherence problems through their electronic prescribing records. Significant further adherence problems could be detected if an e-pharmacy network allowed practices to match dispensing against prescriptions., (2009 John Wiley & Sons, Ltd.)

Throughout the developed world, community pharmacy is under considerable pressure to play a greater part in delivering effective primary health care. The requirement to adopt new roles continues to challenge community pharmacy and drive change. The factors that determine the ability of community pharmacy to effectively deliver services for health gain are complex and include; policy, professional, financial and structural elements. There is also evidence to suggest that organisational culture may influence the effectiveness of an organisation. In order to address this there is a need to understand the dimensions of organisational culture that lead to successful implementation of the change necessary for community pharmacy to become a more effective primary health care organisation. In this commentary, we introduce the concept of organisational culture, outline two frameworks for studying culture, and argue the benefits of pursuing an organisational culture research agenda for the evolution of pharmacy practice and research.

Introduction: People with mental illness have higher rates of morbidity and mortality, largely due to increased rates of cardiovascular disease (CVD). Metabolic syndrome is well recognised but rarely expressed as a need to assess and manage cardiovascular risk factors; furthermore there is confusion about whose role this is. This study explores health practitioners' knowledge, attitudes, barriers/solutions towards cardiovascular risk assessment and management in mental health patients., Method: A survey of mental health practitioners (MHPs n = 421) and general practitioners (GPs n = 232), Results: Three-quarters of respondents agreed mental illness predisposes to CVD. Fifty-five percent of MH doctors agreed they could effectively assess CVD risk compared to 67% of GPs. Only 21% of MH doctors agreed they could effectively manage CVD risk compared to 57% of GPs. Seventy-nine percent of MHPs believed that assessing CVD risk was a joint responsibility between GP and MHP, compared to 33% of GPs; 62% of GPs believed it was their sole responsibility. Forty-six percent of MHPs believed managing CVD risk was a joint responsibility compared with 29% of GPs; 58% of GPs saw this as their role. Only 13% of MHPs and fewer than 4% of GPs agreed that MH services were effectively assessing and managing CVD risk. MHPs identified lack of knowledge and skills (58%) and poor communication between primary-secondary care (53%) as the main barriers. GPs identified barriers of poor communication (64%) and patient compliance with health care management (71%). The top two solutions proposed by MHPs were provision of GP subsidies (47%) and training (43%). GPs also identified provision of a subsidy (66%) and collaborative management between GPs and MH (44%) as solutions., Conclusion: There is widespread recognition of increased risk of CVD in MH patients. MHPs do not believe they have the knowledge and skills to manage this risk. GPs believe this is their responsibility. Both groups recognise communication with, and access to, primary care for MH patients as key barriers.