A scoping review of therapeutic reasoning process research.

Therapeutic reasoning is when the purpose, task, or goal for engaging in reasoning is to determine the patient's management plan. As the field's understanding of the process of therapeutic reasoning is less well understood, we focused on studies that collected data on the process of therapeutic reasoning. To synthesize previous studies of therapeutic reasoning characteristics, methodological approaches, theoretical underpinnings, and results. We conducted a scoping review with systematic searching for English language articles with no date limits. Databases included MEDLINE, CINAHL Plus, Scopus, Embase, Proquest Dissertations and Theses Global, and ERIC. Search terms captured therapeutic reasoning in health professions education research. Initial search yielded 5450 articles. The title and abstract screening yielded 180 articles. After full-text review, 87 studies were included in this review. Articles were excluded if they were outside health professions education, did not collect data on the process of therapeutic reasoning, were not empirical studies, or not focused on therapeutic reasoning. We analyzed the included articles according to scoping questions using qualitative content analysis. 87 articles dated from 1987 to 2019 were included. Several study designs were employed including think-aloud protocol, interview and written documentation. More than half of the articles analyzed the data using qualitative coding. Authors often utilized several middle-range theories to explain therapeutic reasoning processes. The hypothetico-deductive model was most frequently mentioned. The included articles rarely built off the results from previous studies. Six key result categories were found: identifying themes, characterizing and testing previous local theory, exploring factors, developing new local theory, testing tools, and testing hypothesis. Despite the cast body of therapeutic reasoning research, individual study results remain isolated from previous studies. Our future recommendations include synthesizing pre-existing models, developing novel methodologies, and investigating other aspects of therapeutic reasoning.

A systematic review of opioid prevalence in Australian residential aged care facilities.

OBJECTIVE: To systematically review the prevalence of opioid prescribing, dispensing and administration in Australian residential aged care facilities (RACFs). METHODS: MEDLINE, Embase, CINAHL, AgeLine, Web of Science Core Collection, InformIT and International Pharmaceutical Abstracts (inception to September 2021) were searched for studies reporting opioid prevalence in Australian RACFs. Regular and as-required (i.e. pro re nata, PRN) opioid uses were considered. Screening, data extraction and quality assessment were performed independently by two review authors. RESULTS: Twenty-three studies (n = 286,141 residents) reported opioid prevalence, of which 16 provided overall regular or PRN prescribing, dispensing or administration data. Five studies reported 28%-34% of residents were prescribed regular opioids over assessment periods ranging from one week to one month. Five studies reported 11%-42% of residents were prescribed PRN opioids over assessment periods ranging from one week to 30 months. Three studies reported 27%-50% of residents were dispensed an opioid over 12 months. Five studies reported 21%-29% were administered both regular and PRN opioids over 24 hours. Two studies reported 22%-42% of residents were administered PRN opioids over 1 week to 12 months. Two studies reported 6%-13% of residents were using doses >100 mg oral morphine equivalents/day. CONCLUSIONS: Up to half of the residents were dispensed opioids over 12 months. The prevalence of opioid prescribing, dispensing and administration was highly variable, suggesting the potential value of opioid quality indicators and analgesic stewardship interventions to ensure opioid appropriateness.

Strategies to simplify complex medication regimens.

BACKGROUND: Older people use increasingly complex medication regimens. Complex regimens are challenging to administer, particularly for those with cognitive impairment, frailty, poor eyesight or limited dexterity. Complex regimens have been linked to non-adherence, medication errors and hospital admissions. OBJECTIVE: The aim of this article is to describe strategies to reduce the complexity of medication regimens in community and residential aged care settings. DISCUSSION: Medication regimen simplification is the process of reducing medication burden through strategies such as consolidating dosing times, standardising routes of administration, using long-acting rather than shorter-acting formulations, and switching to combination products in place of single-ingredient products. Obtaining a best possible medication history, ensuring appropriateness of current therapy, and deprescribing are important steps prior to implementing regimen simplification. Implementing such strategies should be based on a discussion and consideration of patient preferences, and include clinical judgement to limit the risk of unintended consequences for patients or carers.

Strategies to promote access to medications during the COVID-19 pandemic.

BACKGROUND: During the COVID-19 pandemic, vulnerable and older people with chronic and complex conditions have self-isolated in their homes, potentially limiting opportunities for consultations to have medications prescribed and dispensed. OBJECTIVE: The aim of this article is to describe initiatives to ensure ongoing access to medications during the COVID-19 pandemic. DISCUSSION: Cooperation between wholesalers and purchase limits in pharmacies have helped to ensure supply of essential medications. Therapeutic substitution by pharmacists is permitted for specific products authorised by the Therapeutic Goods Administration. Prescribers are permitted to issue digital image prescriptions, and implementation of electronic prescribing has been fast-tracked. Expanded continued dispensing arrangements introduced during the bushfire crises have been temporarily extended. Pharmacists are permitted to provide medication management reviews via telehealth. A Home Medicines Service has been introduced to facilitate delivery of medications to people who are vulnerable or elderly. Anticipatory prescribing and medication imprest systems are valuable for access to end-of-life medications within residential aged care.

Application of Healthcare 'Big Data' in CNS Drug Research: The Example of the Neurological and mental health Global Epidemiology Network (NeuroGEN).

Neurological and psychiatric (mental health) disorders have a large impact on health burden globally. Cognitive disorders (including dementia) and stroke are leading causes of disability. Mental health disorders, including depression, contribute up to one-third of total years lived with disability. The Neurological and mental health Global Epidemiology Network (NeuroGEN) is an international multi-database network that harnesses administrative and electronic medical records from Australia, Asia, Europe and North America. Using these databases NeuroGEN will investigate medication use and health outcomes in neurological and mental health disorders. A key objective of NeuroGEN is to facilitate high-quality observational studies to address evidence-practice gaps where randomized controlled trials do not provide sufficient information on medication benefits and risks that is specific to vulnerable population groups. International multi-database research facilitates comparisons across geographical areas and jurisdictions, increases statistical power to investigate small subpopulations or rare outcomes, permits early post-approval assessment of safety and effectiveness, and increases generalisability of results. Through bringing together international researchers in pharmacoepidemiology, NeuroGEN has the potential to be paradigm-changing for observational research to inform evidence-based prescribing. The first focus of NeuroGEN will be to address evidence-gaps in the treatment of chronic comorbidities in people with dementia.