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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: To identify the extent of use of medicines recommended to be used with caution in glaucoma patients with specified comorbidities and to determine evidence of associated harm. Methods: Retrospective cohort analysis from administrative claims data and prescription/event sequence symmetry analysis. Participants: Australian Government Department of Veterans' Affairs treatment card holders dispensed glaucoma eye-drops. Main outcome measures: Proportion of veterans with glaucoma and diabetes, airways disease, heart failure, ischemic heart disease or depression, dispensed glaucoma eye drops which should be used with caution. For harms, outcome measures were hospitalizations for airways disease and heart disease. Results: The cohort analysis included 25,984 veterans. Of these, 88% with airways disease were dispensed glaucoma eye drops with the potential to aggravate airways disease, 43% with heart failure were dispensed topical beta-blockers and 49% with depression received glaucoma eye drops which should be used cautiously in those with depression. We found increased risk of initiation of inhaled beta-agonist following timolol (adjusted sequence ratio (ASR) 1.48, 99% CI 1.22-1.78) and latanoprost (ASR 1.24, 99% CI 1.11-1.38) initiation. We found increased risk of inhaled corticosteroid initiation following initiation of timolol (ASR 1.43, 99% CI 1.13-1.81). There was increased risk of antidepressant initiation following timolol initiation (ASR 1.24, 99% CI 1.07-1.43), and latanoprost (ASR 1.16, 99% CI 1.03-1.31). There was also increased risk of hospitalization for bradycardia following timolol initiation (ASR 2.22,99% CI 1.15-4.31). Conclusion: Use of glaucoma eye drops recommended to be used with caution in co-morbidities is common and was associated with adverse outcomes. Awareness of co-morbidities is required in the selection and prescription of glaucoma eye drops. Refereed/Peer-reviewed

Background The Australian Government Department of Veterans’ Affairs (DVA) funds an ongoing health promotion based program to improve use of medicines and related health services, which implements interventions that include audit and feedback in the form of patient-specific feedback generated from administrative claims records. We aimed to determine changes in medicine use as a result of the program. Methods The program provides targeted patient-specific feedback to medical practitioners. The feedback is supported with educational material developed by a clinical panel, subject to peer review and overseen by a national editorial committee. Veterans who meet target criteria also receive educational brochures. The program is supported by a national call centre and ongoing national consultation. Segmented regression analyses (interrupted time series) were undertaken to assess changes in medication use in targeted veterans pre and post each intervention. Results 12 interventions were included; three to increase medicine use, seven which aimed to reduce use, and two which had combination of messages to change use. All programs that aimed to increase medicine use were effective, with relative effect sizes at the time of the intervention ranging from 1% to 8%. Mixed results were seen with programs aiming to reduce inappropriate medicine use. Highly specific programs were effective, with relative effect sizes at the time of the intervention of 10% decline in use of NSAIDs in high risk groups and 14% decline in use of antipsychotics in dementia. Interventions targeting combinations of medicines, including medicine interactions and potentially inappropriate medicines in the elderly did not change practice significantly. Interventions with combinations of messages targeting multiple components of practice had an impact on one component, but not all components targeted. Conclusions The Veterans’ MATES program showed positive practice change over time, with interventions increasing use of appropriate medicines where under-use was evident and reduced use of inappropriate medicines when single medicines were targeted. Combinations of messages were less effective, suggesting specific messages focusing on single medicines are required to maximise effect. The program provides a model that could be replicated in other settings.

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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. Refereed/Peer-reviewed

Objective: To determine the risk of stroke associated with non-steroidal anti-inflammatory drug (NSAID) use. Design, setting and participants: Retrospective cohort study of 162 065 Australian veterans with incident dispensing of an NSAID between 1 January 2001 and 31 December 2008, using prescription event sequence symmetry analysis. Main outcome measures: Hospitalisation for stroke, ischaemic stroke or haemorrhagic stroke. Results: The absolute risk of stroke was low: 7.1/1000 people/year. Incident use of NSAIDs was associated with a 1.88 times increased risk (95% CI, 1.70-2.08) of hospitalisation for stroke (ischaemic or haemorrhagic) following first ever dispensing of an NSAID. This equates to an increased absolute risk of 13.4 strokes/1000 people/year. Significant positive associations between starting an NSAID and having a hospitalisation for stroke were found for most NSAIDs, with adjusted sequence ratios ranging from 1.44 (95% CI, 1.16-1.80) for indomethacin to 1.80 (95% CI, 1.59-2.04) for rofecoxib. Conclusions: Incident use of NSAIDs was associated with an increased risk of stroke. Increased awareness of the potential for serious adverse cardiovascular events, together with individual assessment of cardiovascular risk, careful deliberation of the balance between risk and benefits and appropriate supervision, is required when initiating NSAID therapy. Refereed/Peer-reviewed

Refereed/Peer-reviewed

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 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.

Objective To determine the proportion of veterans with diabetes who had claims for recommended processes of diabetes care in 2005. Design Observational study of 19,810 veterans' dispensed medicines indicative of diabetes. Claims to the Department of Veterans' Affairs for HbA 1c , microalbuminuria, ophthalmology or optometry services, podiatry services, diabetes care plans, medication reviews, case conferences and GP management plans were assessed. Results Overall 63% had at least one HbA 1c claim in the year under review, while 40% had a microalbuminuria claim. The majority (87%) had a claim for an ophthalmology or optometry service, while two-thirds had a podiatry service claim. Only one-fifth had claims for an annual diabetes care plan. Just under half had a claim for any type of care plan, including medication review, discharge plan, case conference, GP management plan or health care plan. Veterans resident in aged-care facilities were significantly less likely to have claims for any of these services apart from medication review. Conclusions While administrative claims data may under-represent some processes of care carried out routinely in general practice, this study suggests under-utilisation of services for veterans with diabetes, particularly those resident in aged-care facilities.