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BackgroundMany countries have high opioid use among people with chronic non-cancer pain. Knowledge about effective interventions that could be implemented at scale is limited. We designed a national intervention that included audit and feedback, deprescribing guidance, information on catastrophising assessment, pain neuroscience education and a cognitive tool for use by patients with their healthcare providers.MethodWe used a single-arm time series with segmented regression to assess rates of people using opioids before (January 2015 to September 2017), at the time of (October 2017) and after the intervention (November 2017 to August 2019). We used a cohort with historical comparison group and log binomial regression to examine the rate of psychologist claims in opioid users not using psychologist services prior to the intervention.Results13 968 patients using opioids, 8568 general practitioners, 8370 pharmacies and accredited pharmacists and 689 psychologists were targeted. The estimated difference in opioid use was −0.51 persons per 1000 persons per month (95% CI −0.69, –0.34; pConclusionsOur intervention addressed the cognitive, affective and sensory factors that contribute to pain and consequent opioid use, demonstrating it could be implemented at scale and was associated with a reduction in opioid use and increasing utilisation of psychologist services.

Introduction and aims: Mental health disorders and substance abuse are risk factors that both precede and follow chronic opioid use. We predicted that incident opioid users would have lower rates of mental health comorbidities than chronic opioid users, but that incident chronic opioid users would have lower rates of mental health comorbidities than prevalent chronic users.Design and methods: We used administrative health claims data to evaluate differences in lifetime mental health and substance abuse comorbidity profiles of people who were prevalent and incident chronic opioid users, as well as those who used opioids acutely. Results were stratified by age.Results: Over 5,188 people were prevalent chronic opioid users at study entry. Of the 10,079 people who initiated opioids, 10.2 percent had a subsequent chronic episode (incident chronic) and the remainder stopped within 90 days (incident acute). In prevalent chronic users compared to incident chronic users, rates of depression and anxiety were higher across all age groups (odds ratio (OR) across age groups range from = 1.60, 95 percent confidence interval (CI) = 1.35,1.89, to OR = 6.66, 95 percent CI = 3.02, 14.69) and prevalence of alcohol abuse was higher in those aged 55 to 74 years (OR = 5.11, 95 percent CI = 1.83, 14.24, p = 0.002). Acute users were less likely than incident chronic users to have depression and anxiety in those aged over 74 years (depression OR = 0.82, 95 percent CI = 0.70, 0.95; anxiety OR = 0.82, 95% CI 0.70, 0.98).Conclusions: Mental health morbidities commonly associated with chronic opioid use increase in prevalence as chronic use continues. 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

Introduction: Renal function testing should be performed prior to initiating medicines that require dose adjustment in renal impairment, with ongoing monitoring in continued use, particularly in older people. There is little evidence regarding the extent to which renal function monitoring is performed in older Australians dispensed medicines requiring renal function monitoring. Objective: The aim of this study was to determine the extent of renal function testing in older people dispensed medicines requiring renal function monitoring. Methods: A retrospective analysis of administrative claims data from the Australian Government Department of Veterans’ Affairs was conducted for people aged 65 years or older who were dispensed one or more medicines requiring renal function monitoring, from 1 June 2019 to 30 September 2019, to investigate the proportion of people with a claim for a pathology test that included creatinine levels in the 6–12 months before or after dispensing of a medicine requiring renal function monitoring. Results: There were 100,113 people who were dispensed at least one medicine requiring renal function monitoring during the study period, of whom 15% had a history of renal impairment and 16% had diabetes mellitus. Sixty-one percent had a claim for a test in the prior 6 months; this increased to 80% of participants with a claim for a test in the prior 12 months. The rate of claims for testing was lower in aged care facility residents compared with people living in the community (54% vs 62% in the previous 6 months; p < 0.001), and was higher in people with diabetes (75% vs 58%; p < 0.001), history of renal impairment (91% vs 59%; p < 0.001) or heart failure (77% vs 60%; p < 0.001) compared with those without these conditions. Conclusion: Medicines that require renal function monitoring are commonly used in older Australians, and while the majority have claims for tests that include renal function, some are missing out. Refereed/Peer-reviewed

Background: Most studies assessing the effect of central nervous system (CNS)-acting medicines on cognitive disturbances have focused on the use of individual medicines. The impact on cognitive function when another CNS-acting medicine is added to a patient's treatment regimen is not well known. Objective: To determine risk of hospitalization for confusion, delirium, or dementia in older people associated with increasing numbers of CNS-acting medicines taken concurrently, as well as the number of standard doses taken each day (measured as defined daily doses). Design: Retrospective cohort study, from July 2011 to June 2012, using health claims data. Setting: Australian veteran population. Participants: A total of 74,321 community-dwelling individuals aged 65 years and over, who were dispensed at least 1 CNS-acting medicine in the year before study entry. Patients with prior hospitalization for confusion or delirium, and those with dementia or receiving palliative care, were excluded. Main outcome measure: Hospitalization for confusion, delirium, or dementia. Results: Over the 1-year study period, 401 participants were hospitalized with confusion, delirium, or dementia. Adjusted analyses showed the risk of hospitalization was 2.4 times greater with the use of 2 CNS-acting medicines compared with no use [incident rate ratio (IRR) 2.39, 95% confidence interval (CI) 1.79-3.19, P < .001], and more than 19 times greater when 5 or more CNS-acting medicines were taken concurrently (IRR 19.35, 95% CI 11.10-33.72, P < .001). Similarly, the risk of hospitalization was significantly increased among patients taking between 1.0 and 1.9 standard doses per day (IRR 2.64, 95% CI 1.99-3.50, P < .001) and between 2.0 and 2.9 standard doses per day (IRR 3.43, 95% CI 2.07-5.69, P < .001) compared with no use. Conclusions: Use of multiple CNS-acting medicines or higher doses is associated with an increased risk of hospitalization for confusion, delirium, or dementia. Health care professionals need to be alert to the contribution of CNS-acting medicines among patients presenting with confusion or delirium and consider strategies to reduce treatment burden where possible. Refereed/Peer-reviewed

Background:The Australian Government Department of Veterans' Affairs (DVA) Veterans' Medicines Advice and Therapeutics Education Services (Veterans' MATES) programme conducted two intervention (March 2009, follow-up intervention June 2012) both of which aimed to reduce hypnotic use among Australian veterans. We evaluated the effectiveness of the interventions, and estimated the associated health consequences Methods:Both interventions targeted veterans who had been dispensed hypnotics prior to the intervention.Patient-specific prescriber feedback containing patient details and the volume of hypnotics dispensed, along with tailored educational information, was mailed to general practitioners. Veterans, pharmacists and directors of care in residential aged care facilities were mailed tailored educational information. Interrupted time-series and segmented regression modelling were used to determine the effect of the two interventions on the rate of hypnotics dispensing. The cumulative patient-months of hypnotic treatment avoided as a result of the interventions was calculated. We estimated improvements in health consequences of as a result of hypnotic treatment avoided based on the results of cohort studies in the same population identifying the association between hypnotic and sedativeuse on the outcomes of falls, and confusion Results:After the first Veterans' MATES intervention in March 2009, hypnotic use declined by 0.2% each month,when compared to the baseline level (p= 0.006). The intervention effect was attenuated after one year, and use of hypnotics was found to increase by 0.2% per month after March 2010. Following the second intervention in June2012, there was a further significant decline in use of 0.18% each month over the 12 months of follow up (p=0.049). The cumulative effect of both interventions resulted in 20,850 fewer patient-months of treatment with hypnotics. This cumulative reduction in hypnotic use was estimated to lead to a minimum of 1 fewer hospital admissions for acute confusion and 7 fewer hospital admissions due to falls. Conclusions:The Veterans' MATES insomnia interventions which involved multiple stakeholders were effective in reducing hypnotic use among older Australians. Repetition of key messages led to sustained practice change Refereed/Peer-reviewed

National interventions to promote HMRs, comprising patient‐specific prescriber feedback and tailored educational materials for patients and clinicians, were conducted in 2004, 2006 and 2011 through the Veterans’ Medicines Advice and Therapeutics Education Services (Veterans’ MATES) program. Primary care patients taking multiple medicines were targeted in each intervention, while primary care patients taking multiple medicines who did not receive the intervention served as comparisons. Monthly HMR rates among targeted patients and a comparison group in the 9 months post‐intervention were determined using health claims data from the Australian Government Department of Veterans’ Affairs and compared using log binomial regression models. Overall trends in the rate of HMRs between November 2001 and December 2016 were also determined. Refereed/Peer-reviewed

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.

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.

OBJECTIVE To evaluate whether systematic asthma care involving a register-recall system, postcard prompts for review, and education for general practitioners and staff in Australian general practice improves the quality of care and health outcomes for adult patients with moderate to severe asthma. DESIGN AND SETTING Cluster randomised controlled trial in 40 general practices in urban and rural South Australia and New South Wales over the 2 years 2004 and 2005; practices were randomly allocated to the intervention or control group. PARTICIPANTS 565 adult patients of these randomly allocated practices who had doctor-diagnosed moderate to severe asthma and were taking inhaled corticosteroids. MAIN OUTCOME MEASURES Clinical asthma indicators, quality of care, acceptability of the intervention to patients, quality of life, and asthma self-management skills at baseline, 6 months and 12 months. RESULTS Although 46% of patients in the intervention group practices responded to the postcard prompts, only 32% actually attended for their asthma review. At 12 months, there was a statistically significant difference in provision of written asthma action plans (rate ratio, 1.9; 95% CI, 1.0-3.5; P = 0.04) for intervention group patients compared with control group patients; there was no significant difference in other indicators. CONCLUSION We found little objective evidence of improvement in patient management and outcomes resulting from a systematic model of asthma care. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12605000091606.

Background:Depression is one of the leading contributors to the burden of non-fatal diseases in Australia. Although there is an overall increasing trend in antidepressant use, the relationship between use of antidepressants and depressive symptomatology is not clear, particularly in the older population.Methods:Data for this study were obtained from the Australian Longitudinal Study of Ageing (ALSA), a cohort of 2087 people aged over 65 years at baseline. Four waves of home interviews were conducted between 1992 and 2004 to collect information on sociodemographic and health status. Depressive symptoms were measured by the Center for Epidemiologic Studies – Depression Scale. Use of antidepressants was based on self-report, with the interviewer able to check packaging details if available. Longitudinal analysis was performed using logistic generalized estimating equations to detect if there was any trend in the use of antidepressants, adjusting for potential confounding factors.Results:The prevalence of depressive symptoms was 15.2% in 1992 and 15.8% in 2004 (p> 0.05). The prevalence of antidepressant users increased from 6.5% to 10.9% (p< 0.01) over this period. Among people with depressive symptoms, less than 20% were taking antidepressants at any wave. Among people without depressive symptoms, the prevalence of antidepressant use was 5.2% in 1992 and 12.0% in 2004 (p< 0.01). Being female (OR = 1.67, 95%CI: 1.25–2.24), having poor self-perceived health status (OR = 1.17, 95%CI: 1.04–1.32), having physical impairment (OR = 1.48, 95%CI: 1.14–1.91) and having depressive symptoms (OR = 1.62, 95%CI: 1.24–2.13) significantly increased the use of antidepressants, while living in community (OR = 0.51, 95%CI: 0.37–0.71) reduced the risk of antidepressant use.Conclusions:Use of antidepressants increased, while depressive symptoms remained stable, in the ALSA over a 12-year period. Use of antidepressants was low for people with depressive symptoms.

Objective: To evaluate the impact of national multifaceted initiatives to improve use of proton pump inhibitors (PPIs) on the use of PPIs among older Australians.Design: Interrupted time series analysis using administrative health claims data from the Australian Government Department of Veterans’ Affairs (DVA).Setting: Australia.Participants: All veterans and dependents who received PPIs between January 2003 and December 2013.Intervention(s): National, multifaceted interventions to improve PPI use were conducted by the Australian Government Department of Veterans’ Affairs Veterans’ MATES programme and Australia's NPS MedicineWise in April 2004, June 2006, May 2009 and August 2012.Main outcome measure(s): Trends in monthly rate of use of any PPI among the veteran population, and the monthly rate of use of low strength PPIs among all veterans dispensed a PPI.Results: Interventions in 2004, 2006, 2009 and 2012 slowed the rate of increase in PPI use significantly, with the 2012 intervention resulting in a sustained 0.04% decrease in PPI use each month. The combined effect of all four interventions was a 20.9% (95% CI 7.8–33.9%) relative decrease in PPI use 12 months after the final intervention. The four interventions also resulted in a 42.2% (95% CI 19.9–64.5%) relative increase in low strength PPI use 12 months after the final intervention.Conclusions: National multifaceted programmes targeting clinicians and consumers were effective in reducing overall PPI use and increasing use of low strength PPIs. Interventions to improve PPI use should incorporate regular repetition of key messages to sustain practice change. Refereed/Peer-reviewed

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