Navigating competing tensions: A qualitative study of experiences and perceptions of leadership among emergency medicine doctors.

OBJECTIVES: Emergency medicine (EM) doctors are often required to manage a diverse set of complex challenges; navigating direct patient care, systemic issues and inter-professional interactions. Leadership is well recognised as crucial in optimising both the delivery and the quality of patient care. There is a clear need to gain greater understanding of the reality of EM leadership through exploring doctors' experience and perception of leadership in EM, yet there is a paucity of research focusing on this area. The objective of the present study was to explore the research question: 'What are the experiences and perceptions of leadership by EM doctors?' METHODS: This single-site qualitative study was undertaken using semi-structured in-depth individual interviews to collect data. Interviews were audio recorded, transcribed and de-identified. Reflexive thematic analysis was performed by the research team with the aid of DelveTool software. RESULTS: Our sample included nine participants incorporating consultants and registrars. Three major themes were identified: (i) situational tensions, (ii) relational tensions and (iii) leadership style tensions. Each of these was further explored with subthemes discussed separately. CONCLUSIONS: Leadership within the ED is complex and multifaceted, with doctors required to navigate many competing tensions. The present study highlighted key areas for future leadership development, including situational awareness, emotional intelligence and a fluid approach to leadership styles. The present study provides an important step towards enhancing the development of targeted leadership training for EM doctors.

Medicines Regimens Charted for Older People Living in Residential Aged Care: A Repeated Cross-Sectional Study Describing the Number of Medicines, Regimen Complexity, High-Risk Prescribing, and Potential Underprescribing.

OBJECTIVE: We aimed to explore medicines regimens charted for older people living in residential aged care facilities (RACFs). DESIGN: Repeated cross-sectional study using routinely collected data sampled in a cross-sectional manner at 11 time points (day of admission, then at 1, 3, 7, 14, and 30 days, and 3, 6, 12, 18, and 24 months post admission). SETTING AND PARTICIPANTS: The cohort is set in 34 RACFs managed by a single Australasian provider. People aged ≥65 years admitted to permanent care between January 1, 2017, and October 1, 2021, with medicines charted on the date of admission. METHODS: Medicines charted were evaluated for potentially suboptimal prescribing including number of medicines, high-risk prescribing (eg, potentially inappropriate medicines, anticholinergic burden), and potential underprescribing. RESULTS: The 3802 residents in the final cohort had a mean age of 84.9 ± 7.2 years at admission. At least 1 example of suboptimal prescribing was identified in 3479 (92%) residents at admission increasing to 1410 (97%) at 24 months. The number of medicines charted for each resident increased over time from 6.0 ± 3.8 regular and 2.8 ± 2.7 as required medicines at admission to 8.9 ± 4.1 regular and 8.1 ± 3.7 as required medicines at 24 months. Anticholinergic drug burden increased from 1.6 ± 2.4 at admission to 3.0 ± 2.8 at 24 months. Half the residents (2173; 57%) used at least 1 potentially inappropriate medicine at admission, which rose to nearly three-quarters (1060; 73%) at 24 months admission. CONCLUSION AND IMPLICATIONS: The total number of medicines charted for older adults living in RACFs increases with length of stay, with charted as required medicines nearly tripling. Effective interventions to optimize medicines use in this vulnerable population are required.

The patterns and implications of potentially suboptimal medicine regimens among older adults: a narrative review.

In the context of an ageing population, the burden of disease and medicine use is also expected to increase. As such, medicine safety and preventing avoidable medicine-related harm are major public health concerns, requiring further research. Potentially suboptimal medicine regimens is an umbrella term that captures a range of indicators that may increase the risk of medicine-related harm, including polypharmacy, underprescribing and high-risk prescribing, such as prescribing potentially inappropriate medicines. This narrative review aims to provide a background and broad overview of the patterns and implications of potentially suboptimal medicine regimens among older adults. Original research published between 1990 and 2021 was searched for in MEDLINE, using key search terms including polypharmacy, inappropriate prescribing, potentially inappropriate medication lists, medication errors, drug interactions and drug prescriptions, along with manual checking of reference lists. The review summarizes the prevalence, risk factors and clinical outcomes of polypharmacy, underprescribing and potentially inappropriate medicines. A synthesis of the evidence regarding the longitudinal patterns of polypharmacy is also provided. With an overview of the existing literature, we highlight a number of key gaps in the literature. Directions for future research may include a longitudinal investigation into the risk factors and outcomes of extended polypharmacy, research focusing on the patterns and implications of underprescribing and studies that evaluate the applicability of tools measuring potentially inappropriate medicines to study settings. Plain Language Summary: A review on potentially inappropriate medicine regimens Medicine use in older age is common. Older adults with more than one chronic condition are likely to use multiple medicines to manage their health. However, there are times when taking multiple medicines may be unsafe and the number of medicines, or the combination of medicines used, may increase the risk of poor health outcomes. The term medicine regimens is used to describe all the medicines an individual takes. There are several ways to measure when a medicine regimen may be inappropriate and, therefore, potentially harmful. Much research has been published looking into potentially inappropriate medicine regimens. To bring together the current research, this review provides a background on the different measures of potentially inappropriate medicine regimens. It also summarizes how many people may experience potentially inappropriate medicine regimens, the impact it is having on their health and who may be at greater risk. In doing so, we found a number of gaps in the existing evidence, indicating that our understanding of potentially inappropriate medicine regimens is incomplete. This review highlights gaps in knowledge that can be addressed by future research. With an improved understanding of potentially inappropriate medicine regimens, we may be able to better identify those at greater risk to prevent or minimize the impact of poorer health outcomes related to unsafe medicine use.

Health literacy and cardiovascular disease prevention: a systematic scoping review protocol.

INTRODUCTION: Health literacy is 'The skills and resources of a person to access, understand and use information to make decisions, and take action on their own health and healthcare'. Literature investigating cardiovascular disease (CVD) prevention and health literacy often exist in silos, only exploring one element of prevention. This protocol aims to establish a scoping method of articles investigating health literacy and CVD preventive practices or knowledge in lay populations. METHODS AND ANALYSIS: A scoping review was deemed the most appropriate study design. The topic was conceptualised, with preliminary searching informing subsequent development of search strings. A search of the following databases will be conducted on 31 January 2022: MEDLINE, Global Health, PubMed, Embase, PsycINFO and CINAHL. Studies included will be published in English, of appropriate design, measuring health literacy and some aspect of primary CVD prevention in lay-populations. These criteria will be tested against 25 'pilot' articles from the results, undergoing necessary review before screening commences. A secondary author will screen 10% of abstracts, with a third subject-matter expert reviewing conflicts. ETHICS AND DISSEMINATION: This review will be disseminated through peer-reviewed scholarly networks, most likely including journal publication and conference presentation. ARTICLE SUMMARY: CVD is the leading cause of death around the world. This paper proposes an exploration of health literacy's relationship with CVD prevention as a whole, contrasting with the more segmented reviews currently published.

Applicability of explicit potentially inappropriate medication lists to the Australian context: A systematic review.

OBJECTIVES: To determine i) the similarity of potentially inappropriate medications specified in and between existing explicit lists and ii) the availability in Australia of medications included on existing lists to determine their applicability to the Australian context. METHODS: This systematic review identified explicit potentially inappropriate medication lists that were published on EMBASE (1974 - April 2021), MEDLINE (1946 - April 2021) and Elsevier Scopus (2004 - April 2021). The reference lists of seven previously published systematic reviews were also manually reviewed. Lists were included if they were explicit, and the most recent version and the complete list were published in English. Lists based on existing lists were excluded if no new items were added. Potentially inappropriate medications identified on each list were extracted and compared to the medications available on the Australian Register of Therapeutic Goods and Australian Pharmaceutical Benefits Schemes. RESULTS: Thirty-five explicit published lists were identified. A total of 645 unique potentially inappropriate medications were extracted, of which 416 (64%) were available in Australia and 262 (41%) were subsided by the general Pharmaceutical Benefits Scheme. Applicability of each explicit list ranged from 50-96% according to medications available in Australia and 25-83% according to medications available under subsidy. CONCLUSIONS: Pooling data from different lists may help to identify potentially inappropriate medications that may be applicable to local settings. However, if selecting a list for use in the Australian context, consideration should also be given to the intended purpose and setting for application.

Discussing diabetes, palliative and end of life care: choosing the 'right' language.

BACKGROUND: Palliative care and advance care planning are important components of diabetes and other chronic disease management plans. Most people with diabetes do not have conversations about palliative/end of life (EOL) care or advance care directives; often because diabetes clinicians are reluctant to discuss these issues. Guidelines for conversations and decision aids can assist shared decision-making for both clinicians and patients. The aim was to co-design information with older people with diabetes, families and clinicians to facilitate conversations about palliative and EOL care and to identify the language (words) people with diabetes, families and diabetes clinicians use to discuss death and dying. METHODS: We co-designed and tailored the information with advisory groups: (I) older people with diabetes/families, (II) interdisciplinary expert clinicians and undertook a scoping literature review to identify relevant content. The penultimate versions were independently evaluated in focus groups and via written feedback from representative stakeholder clinicians, people with diabetes and international experts in communication, palliative care and diabetes. RESULTS: The information met design and language criteria: 62 people participated in focus groups (48 clinicians, 14 older people with diabetes and 4 family members). There were important differences between people with diabetes and diabetes clinicians concerning the words used to refer to death: 'the language of death'. Diabetes clinicians choose soft words/euphemisms such as 'passed away' and 'gone' and indicated they mirrored patient language. People with diabetes preferred clear language and indicated euphemisms were confusing and misleading. Diabetes clinicians, rarely encountered death in their practice and indicated they lacked education about how to discuss diabetes EOL care. CONCLUSIONS: Co-design with key end-users improved relevance to these groups. Diabetes clinicians prefer to use euphemisms for death and would benefit from education and strategies to help them initiate conversations about EOL diabetes care.