Determinants of usefulness in professional behaviour change interventions: observational study of a 15-year national program.

OBJECTIVE: Educational, and audit and feedback interventions are effective in promoting health professional behaviour change and evidence adoption. However, we lack evidence to pinpoint which particular features make them most effective. Our objective is to identify determinants of quality in professional behaviour change interventions, as perceived by participants. DESIGN: We performed a comparative observational study using data from the Veterans' Medicines Advice and Therapeutics Education Services program, a nation-wide Australian Government Department of Veterans' Affairs funded program that provides medicines advice and promotes physician adoption of best practices by use of a multifaceted intervention (educational material and a feedback document containing individual patient information). SETTING: Primary care practices providing care to Australian veterans. PARTICIPANTS: General practitioners (GPs) targeted by 51 distinct behaviour change interventions, implemented between November 2004 and June 2018. PRIMARY AND SECONDARY OUTCOME MEASURES: We extracted features related to presentation (number of images, tables and characters), content (polarity and subjectivity using sentiment analysis, number of external links and medicine mentions) and the use of five behaviour change techniques (prompt/cues, goal setting, discrepancy between current behaviour and goal, information about health consequences, feedback on behaviour). The main outcome was perceived usefulness, extracted from postintervention survey. RESULTS: On average, each intervention was delivered to 9667 GPs. Prompt and goal setting strategies in the audit and feedback were independently correlated to perceived usefulness (p=0.030 and p=0.005, respectively). The number of distinct behaviour change techniques in the audit and feedback was correlated with improved usefulness (Pearson's coefficient 0.45 (0.19, 0.65), p=0.001). No presentation or content features in the educational material were correlated with perceived usefulness. CONCLUSIONS: The finding provides additional evidence encouraging the use of behaviour change techniques, in particular prompt and goal setting, in audit and feedback interventions.

Use of Medicines that May Exacerbate Heart Failure in Older Adults: Therapeutic Complexity of Multimorbidity.

BACKGROUND: Multimorbidity is common in older patients with heart failure (HF), complicating therapeutic management and increasing the risk of harm. OBJECTIVE: This study sought to examine the prevalence of medicines for the treatment of comorbid conditions potentially associated with harm in older people, before and after HF hospitalization. METHODS: A retrospective cohort study of older people hospitalized with a primary diagnosis of HF over a 12-month period was conducted using administrative health claims data from the Department of Veterans' Affairs (DVA) Australia. We examined the prevalence of medicines that may exacerbate or worsen HF as defined by the American Heart Association (AHA) and Australian HF clinical guidelines, in the 30 days prior and 120 days before and after discharge for HF. RESULTS: A total of 4069 older adults were hospitalized for HF during the study period; almost 60% (n = 2435) received at least one medicine associated with an increased risk of harm before hospitalization, with the majority (66.7%, n = 1623) dispensed in the 30 days prior. A small but significant reduction after hospitalization was observed, but 56% (n = 1638) received at least one of these medicines after hospitalization (p = 0.001). Over one-quarter received two or more medicines before hospitalization, and this only reduced to 22% post-hospitalization (p < 0.0001). CONCLUSIONS: Little change in the prescribing of potentially harmful medicines for HF was observed; 56% of older adults received at least one following hospitalization for HF, highlighting the therapeutic complexity of multimorbidity in HF. Use of the AHA list to facilitate identification of potentially harmful medicines, followed by prioritization of treatment goals and appropriate risk mitigation are needed to facilitate reduction in hospitalization for patients with HF with multimorbidity.

Reducing hypnotic use in insomnia management among Australian veterans: results from repeated national interventions.

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 sedative use 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 June 2012, 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.

The validity of the Rx-Risk Comorbidity Index using medicines mapped to the Anatomical Therapeutic Chemical (ATC) Classification System.

OBJECTIVES: To provide a map of Anatomical Therapeutic Chemical (ATC) Classification System codes to individual Rx-Risk comorbidities and to validate the Rx-Risk Comorbidity Index. DESIGN: The 46 comorbidities in the Rx-Risk Index were mapped to dispensing's indicative of each condition using ATC codes. Prescription dispensing claims in 2014 were used to calculate the Rx-Risk. A baseline logistic regression model was fitted using age and gender as covariates. Rx-Risk was added to the base model as an (1) unweighted score, (2) weighted score and as (3) individual comorbidity categories indicating the presence or absence of each condition. The Akaike information criterion and c-statistic were used to compare the models. SETTING: Models were developed in the Australian Government Department of Veterans' Affairs health claims data, and external validation was undertaken in a 10% sample of the Australian Pharmaceutical Benefits Scheme Data. PARTICIPANTS: Subjects aged 65 years or older. OUTCOME MEASURES: Death within 1 year (eg, 2015). RESULTS: Compared with the base model (c-statistic 0.738, 95% CI 0.734 to 0.742), including Rx-Risk improved prediction of mortality; unweighted score 0.751, 95% CI 0.747 to 0.754, weighted score 0.786, 95% CI 0.782 to 0.789 and individual comorbidities 0.791, 95% CI 0.788 to 0.795. External validation confirmed the utility of the weighted index (c-statistic=0.833). CONCLUSIONS: The updated Rx-Risk Comorbidity Score was predictive of 1-year mortality and may be useful in practice to adjust for confounding in observational studies using medication claims data.

Apixaban, concomitant medicines and spontaneous reports of haemorrhagic events.

INTRODUCTION: Little is known about the potential safety issues associated with apixaban in clinical practice and their reporting in spontaneous adverse event (SAE) databases. OBJECTIVE: To describe SAE reports associated with the oral anticoagulant apixaban from Australia, Canada and USA and to examine associated concomitant medicine use. METHODS: SAE report databases from Australia, Canada and the USA were examined for all reports of adverse events associated with apixaban and concomitant medicines from 1 January 2012 to 30 September 2014. Disproportionality analysis (proportional reporting ratio (PRR) and reporting odds ratio (ROR)) was conducted for the quantitative detection of signals using the USA database. RESULTS: There were 97 SAE reports associated with apixaban from Australia, 77 from Canada and 2877 from the USA. Reporting of haemorrhage (any type) was common, ranging from 18% for USA to 31% for Australia. Gastrointestinal (GI) haemorrhage was the most commonly reported haemorrhage, accounting for approximately 10% of adverse event reports across all countries. Positive signals were confirmed in the USA data (haemorrhage (any type) PRR, 12.1; χ2, 5582.2 and ROR, 13.4; 95% CI: 12.13-14.6; GI haemorrhage PRR, 11.8; χ2, 2325.4 and ROR, 12.3; 95% CI, 10.8-14.0). Reporting of concomitant use of medicines with the potential to increase bleeding risk ranged from 47.6% in Canada to 65.5% in Australia. CONCLUSION: A large proportion of adverse event reports for apixaban were associated with use of concomitant medicines which may have increased the risk of haemorrhage.

Understanding 30-day re-admission after hospitalisation of older patients for diabetes: identifying those at greatest risk.

OBJECTIVE: To identify factors that contribute to older Australians admitted to hospital with diabetes being re-hospitalised within 30 days of discharge. DESIGN, SETTING AND PARTICIPANTS: A retrospective cohort study of Department of Veterans' Affairs administrative data for all patients hospitalised for diabetes and discharged alive during the period 1 January - 31 December 2012. MAIN OUTCOME MEASURES: Causes of re-hospitalisation and prevalence of clinical factors associated with re-hospitalisation within 30 days of discharge. METHODS: Multivariate logistic regression analysis (backward stepwise) was used to identify characteristics predictive of 30-day re-hospitalisation. RESULTS: 848 people were hospitalised for diabetes; their median age was 87 years (interquartile range, 77-89 years) and 60% were men. 209 patients (24.6%) were re-hospitalised within 30 days of discharge, of whom 77.5% were re-admitted within 14 days of discharge. 51 re-hospitalisations (24%) were for diabetes-related conditions; 41% of those re-admitted within 14 days had not seen their general practitioner between discharge and re-admission. Factors predictive of re-hospitalisation included comorbid heart failure (adjusted odds ratio [aOR], 1.49; 95% confidence interval [CI], 1.03-2.17; P = 0.036), numbers of prescribers in previous year (aOR [for each additional prescriber], 1.06; 95% CI, 1.01-1.08; P = 0.031), and two or more hospitalisations in the 6 months before the index admission (aOR, 1.79; 95% CI 1.15-2.78; P = 0.009). CONCLUSION: Older people hospitalised for diabetes who have comorbid heart failure, multiple recent hospitalisations, and multiple prescribers involved in their care are at greatest risk of being re-admitted to hospital within 30 days. Targeted follow-up during the initial 14 days after discharge may facilitate appropriate interventions that avert re-admission of these at-risk patients.

Posttraumatic Stress Disorder, Antipsychotic Use and Risk of Dementia in Veterans.

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.

Use of proton pump inhibitors among older Australians: national quality improvement programmes have led to sustained practice change.

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.

Central Nervous System-Acting Medicines and Risk of Hospital Admission for Confusion, Delirium, or Dementia.

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.

Commitment questions targeting patients promotes uptake of under-used health services: Findings from a national quality improvement program in Australia.

RATIONALE: Interventions asking patients to commit to speaking with their doctor about a health-related issue could be used to improve quality of care. OBJECTIVE: To evaluate the impact of commitment questions targeting patients on the uptake of recommended health services within a national quality improvement program (Veterans' MATES). METHODS: Patients targeted in the home medicines reviews (HMRs), dose administration aids (DAAs), renal function testing and diabetes interventions were posted educational information and response forms which asked whether they intended to talk to their general practitioner (GP) about the targeted service. Uptake of the service after each intervention was determined using health claims data. Log binomial regression models compared the monthly rate of service use in the nine months post-intervention among patients answering 'yes' to a commitment question with non-responders and patients answering 'no' or 'unsure'. RESULTS: Each intervention targeted up to 58,000 patients. The average response rate was 28%. Positive responses were associated with increased uptake of HMRs (rate ratio (RR) 2.64, 95% CI 2.39-2.92; p < 0.0001), dose administration aids (RR 2.53, 95% CI 2.29-2.79; p < 0.0001), renal function tests (RR 1.18, 95% CI 1.13-1.24; p < 0.0001), GP management plans (RR 1.30, 95% CI 1.14-1.48; p < 0.0001) and diabetes care plans (RR 1.47, 95% CI 1.24-1.75; p < 0.0001) compared to non-responders. Similar increases in uptake were also observed among positive responders when compared to patients responding 'no' or 'unsure' to the commitment question. CONCLUSION: Positive responses to commitment questions distributed as part of national, multifaceted interventions were consistently associated with increased uptake of targeted services.

An international comparison of spontaneous adverse event reports and potentially inappropriate medicine use associated with dabigatran.

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.

A cross-country comparison of rivaroxaban spontaneous adverse event reports and concomitant medicine use with the potential to increase the risk of harm.

BACKGROUND: Concerns with the safety profiles of the newer anticoagulants have been raised because of differences in treatment populations between pre-marketing studies (randomized controlled trials) and clinical practice. Little is known about the potential safety issues and the reporting in spontaneous adverse event databases associated with rivaroxaban. OBJECTIVES: To analyse spontaneous adverse event reports associated with the oral anticoagulant rivaroxaban from Australia, Canada and the USA; and to examine concomitant medicine use that may increase the risk of adverse events. METHODS: Spontaneous adverse event report databases from Australia, Canada and the USA were examined for all reports of adverse events associated with rivaroxaban and concomitant medicines from 1 August 2005 to 31 March 2013. Disproportionality analysis (the proportional reporting ratio [PRR] and reporting odds ratio [ROR]) was conducted for quantitative detection of signals, using the US database. RESULTS: There were 244 spontaneous adverse event reports associated with rivaroxaban from Australia, 536 from Canada and 1,638 from the USA. Reporting of haemorrhage (any type) was common, ranging from 30.7% for Australia to 37.5% for Canada. Gastrointestinal haemorrhage was the most commonly reported haemorrhage, accounting for 13.9% of Australian, 16.4% of Canadian and 11.1% of US adverse event reports. Positive signals were confirmed in the US data (haemorrhage [any type] PRR 11.93, χ (2) 4,414.78 and ROR 13.41, 95% confidence interval [CI] 12.13-14.81; gastrointestinal haemorrhage PRR 12.52, χ (2) 2,018.48 and ROR 13.15, 95% CI 11.36-15.21). Reporting of concomitant use of medicines with the potential to increase bleeding risk ranged from 63.7% in Australia to 89.2% in Canada. CONCLUSION: A large proportion of adverse event reports for rivaroxaban were associated with use of concomitant medicines, which may have increased the risk of adverse events-in particular, haemorrhage. Increased awareness of a patient's comorbidity and associated medicine use is needed when rivaroxaban is used in clinical practice.

Multiple anticholinergic medication use and risk of hospital admission for confusion or dementia.

OBJECTIVES: To identify the association between use of multiple anticholinergic medications and risk of hospitalization for confusion or dementia. DESIGN: Retrospective cohort study conducted over 2 years between July 2010 and June 2012, using administrative claims data from the Australian Department of Veterans' Affairs. SETTING: Australia. PARTICIPANTS: Australian veterans dispensed at least one moderately or highly anticholinergic medication in the year before study start. MEASUREMENTS: Cumulative anticholinergic use on each day of the study period was determined. The association between hospitalization for confusion or dementia and number of anticholinergic medications used at the time of admission was compared against times during which participants were not taking anticholinergic medications. Sensitivity analyses were undertaken limiting the outcome to admissions for acute confusion and excluding individuals taking antipsychotics. RESULTS: Adjusted results showed a significantly greater risk of hospitalization for confusion or dementia when individuals were taking two or more anticholinergic medications. The adjusted incident rate ratios (IRRs) were 2.58 (95% confidence interval (CI) = 1.91-3.48) for those taking two anticholinergics and 3.87 (95% CI = 1.83-8.21) for those taking three or more. Sensitivity analyses in which participants taking antipsychotic medications were excluded and the outcome was limited to acute confusion also found similar risks for those taking two (IRR 1.82, 95% CI = 1.18-2.80) and three or more (IRR = 3.98 95% CI = 1.50-10.58) anticholinergic medications. CONCLUSION: Taking more anticholinergic medications is associated with greater risk of hospitalization for confusion or dementia. Strategies to reduce anticholinergic medication burden are likely to translate into significant health benefits.

Association between use of multiple psychoactive medicines and hospitalization for falls: retrospective analysis of a large healthcare claim database.

BACKGROUND: Little is known about the impact of taking multiple psychoactive medicines on the risk of hospitalization for falls. OBJECTIVE: To identify the association between multiple psychoactive medicine use and hospitalization for falls. METHODS: A retrospective cohort study was conducted between July 2011 and June 2012 in the Australian veteran population who had been dispensed at least one psychoactive medicine within the previous year. Psychoactive medicines with sedative properties included antipsychotics, anxiolytics, hypnotics, antidepressants, opioids, anti-epileptics, anti-Parkinson medicines and medicines for migraine. The associations between falls and the number of psychoactive medicines used or the number of doses were analysed in comparison with falls that occurred when no psychoactive medicine was used. RESULTS: The adjusted results showed a significantly increased risk of falls when patients were on one or more psychoactive medicines or were receiving 0.1-0.9 defined daily dose (DDD) or more per day. The incident rate ratios (IRRs) were 1.22 (95% confidence interval [CI] 1.08-1.38) for those on one psychoactive medicine, 1.70 (95% CI 1.45-1.99) for those on two, 1.96 (95% CI 1.58-2.43) for those on three or four, and 3.15 (95% CI 1.90-5.23) for those on five or more. A similar result was observed when the data were analysed by dose, with the highest risk being found for those taking three or more DDD per day (adjusted IRR 4.26, 95% CI 2.75-6.58). CONCLUSION: Increased numbers or increased doses of psychoactive medicines are associated with an increased risk of hospitalization for falls in older adults. Strategies to reduce the psychoactive medicine burden are likely to translate into significant health benefits.

Risk of medication-associated initiation of oxybutynin in elderly men and women.

OBJECTIVES: To determine whether there is greater risk of initiation of oxybutynin to treat urinary incontinence (UI) after initiation of medicines reported to be associated with UI. DESIGN: Prescription sequence symmetry analysis (PSSA). SETTING: Administrative claims data from the Australian Government Department of Veterans' Affairs. PARTICIPANTS: Individuals who initiated oxybutynin and a medicine reported to be associated with UI in a 12-month period. MEASUREMENTS: Between January 1, 2001, and December 31, 2011, the distribution of incident dispensing of medicines reported to be associated with UI (prazosin, diuretics, calcium channel blockers (CCBs), angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), hormone replacement therapy (HRT), opioid analgesics, anticonvulsants, levodopa, antipsychotics, sedatives, selective serotonin reuptake inhibitors (SSRIs), venlafaxine, anticholinesterases) was assessed before and after incident dispensing of oxybutynin (to treat UI). Crude and adjusted sequence ratios (ASRs) with 95% confidence intervals (CIs) were calculated. RESULTS: Significant associations between initiation of CCBs, ACEIs, ARBs, and hypnotic-sedatives and subsequent initiation of oxybutynin were found. ASRs ranged from 1.28 (95% CI = 1.19-1.39) for ACEIs to 1.59 (95% CI = 1.29-1.96) for verapamil. In women, there was greater risk of initiation of oxybutynin after prazosin (ASR = 1.84, 95% CI = 1.29-2.63) and HRT (ASR = 1.54, 95% CI = 1.42-1.67) initiation. PSSA showed no significant association with initiation of opioids, anticonvulsants, levodopa, SSRIs, venlafaxine, or anticholinesterases and subsequent initiation of oxybutynin. CONCLUSION: This study highlights the potential for initiation of commonly used medicines to be associated with subsequent initiation of oxybutynin to treat UI. Greater awareness of the potential for medicines to contribute to UI is required.

Bridging evidence-practice gaps: improving use of medicines in elderly Australian veterans.

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.

Prevalence of preventable medication-related hospitalizations in Australia: an opportunity to reduce harm.

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.

Prevalence of potentially hazardous drug interactions amongst Australian veterans.

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.

Assessing overall duration of cardiovascular medicines in veterans with established cardiovascular disease.

BACKGROUND: This study aimed to determine persistence, adherence, and time without therapy with cardiovascular medicines over all episodes of use among veterans following hospitalization for ischemic heart disease. METHODS: Retrospective cohort study using Department of Veterans' Affairs database including 9635 veterans with a hospitalization for acute myocardial infarction, angina, or ischemic heart disease, and who had been dispensed cardiovascular medicines in the 3 months posthospitalization. The main outcome measures were duration of first treatment episode, duration of overall treatment episode, and adherence with recommended therapies: angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), lipid-lowering therapy, calcium channel blockers (CCBs), beta-blockers, and antiplatelet therapy. RESULTS: The median duration of overall treatment was 6.2 years [95% confidence interval (CI): 6.0-6.4] for lipid-lowering therapy, 5.4 years (95% CI: 5.1-5.5) for ACE inhibitors/ARBs, 5.0 years (95% CI: 4.8-5.1) for antiplatelets, 3.4 years (95% CI: 3.3-3.6) for beta-blockers, and 2.8 years (95% CI: 2.6-3.0) for CCBs. Adherence was 72% for CCBs, 75% for ACE inhibitors/ARBs, 84% for lipid-lowering therapy, and 84% for antiplatelets other than aspirin. The median time without therapy was 4.5 months or less for ACE inhibitors/ARBs, antiplatelets, and lipid-lowering therapy. CONCLUSION: Problems with medication adherence can relate to either persistence or compliance during treatment. This novel method provides a way to determine which of these factors is most problematic when considering chronic therapies. We found that Australian veterans with established cardiovascular disease are persistent with their cardiovascular therapy, with only small gaps in therapy.