Reducing opioid use for chronic non-cancer pain in primary care using an evidence-based, theory-informed, multistrategic, multistakeholder approach: a single-arm time series with segmented regression.

BACKGROUND: Many 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. METHOD: We 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. RESULTS: 13 968 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; p<0.001) as a result of the intervention, equating to 25 387 (95% CI 24 676, 26 131) patient-months of opioid use avoided during the 22-month follow-up. The targeted group had a significantly higher rate of incident patient psychologist claims compared with the historical comparison group (rate ratio: 1.37, 95% CI 1.16, 1.63; p<0.001), equating to an additional 690 (95% CI 289, 1167) patient-months of psychologist treatment during the 22-month follow-up. CONCLUSIONS: Our 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.

Impact of a patient-specific national programme aimed at increasing the use of emollient moisturisers to reduce the risk of skin tears: a longitudinal cohort study.

OBJECTIVES: To evaluate the impact of a patient-specific national programme targeting older Australians and health professionals that aimed to increase use of emollient moisturisers to reduce to the risk of skin tears. DESIGN: A prospective cohort intervention. PARTICIPANTS: The intervention targeted 52 778 Australian Government's Department of Veterans' Affairs patients aged over 64 years who had risk factors for wound development, and their general practitioners (GPs) (n=14 178). OUTCOME MEASURES: An interrupted time series model compared the rate of dispensing of emollients in the targeted cohort before and up to 23 months after the intervention. Commitment questions were included in self-report forms. RESULTS: In the first month after the intervention, the rate of claims increased 6.3-fold (95% CI: 5.2 to 7.6, p<0.001) to 10 emollient dispensings per 1000 patients in the first month after the intervention. Overall, the intervention resulted in 10 905 additional patient-months of treatment. The increased rate of dispensing among patients who committed to talking to their GP about using an emollient was six times higher (rate ratio: 6.2, 95% CI: 4.4 to 8.7) than comparison groups. CONCLUSIONS: The intervention had a sustained effect over 23 months. Veterans who responded positively to commitment questions had higher uptake of emollients than those who did not.

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.

Gathering tips from carers to support people with dementia: an adaptation of the TOP 5 program for community use.

AIM: Behavioral and psychological symptoms of dementia are often managed inappropriately with antipsychotic medicines. The TOP 5 program, which involves recording up to five relevant and meaningful tips that assist in personalizing care for the person with dementia, has been tested in the hospital setting and transitions of care in Australia, and has been found to be useful. Our study aimed to adapt the TOP 5 program as a strategy to support people with dementia in a primary care setting and to test the acceptability of our adapted TOP 5 program materials. METHODS: The adapted TOP 5 program materials were delivered as part of a larger intervention by the Australian Government Department of Veterans' Affair's Veterans' Medicines Advice & Therapeutic Education Services program to reduce inappropriate antipsychotic use in veterans with dementia. This study focuses on the acceptability of our adapted TOP 5 program materials for ascertaining carer or family members' advice about what actions might help to calm their relative when she or he is agitated. Educational materials relating to the resources for implementing the adapted TOP 5 program together with the one-page survey response to evaluate acceptability of our adapted TOP 5 program materials were mailed to 4827 general practitioners (GPs), 8381 accredited pharmacists, and 2510 Residential Aged Care Facilities. RESULTS: We received survey response forms from 350 (7%) GPs, 366 (4%) pharmacists, and 196 (8%) residential aged care facilities. Although the response rate was low, 90% of respondents in all groups indicated they were very likely or moderately likely to assist family members and carers of patients with dementia to identify their top tips to personalize care. GPs who found the information useful more frequently indicated that they were likely to assist family members and carers in identifying their top tips. Approximately one-third of respondents reported they had received positive feedback from families regarding the helpfulness of sharing their practical tips for care of their loved one. Pharmacists indicated having the tips would assist them when undertaking medicines reviews. CONCLUSIONS: Our findings suggest that the TOP 5 program, or an adaptation of the TOP 5 program, such as ours, has potential to improve the health and care of people with dementia and their carers by using patient centerd nonpharmacological approaches and avoiding the unnecessary use of antipsychotics for behavioral and psychological symptoms of dementia. Longer-term follow-up would help to establish whether the apparent benefits persist.

Prevalence of multiple antipsychotic use and associated adverse effects in Australians with mental illness.

AIM: This article analyzes the prevalence of use of concurrent multiple antipsychotics and high dosage treatment in people with mental illness, to assess the burden of antipsychotic drug-related side-effects associated with multiple use, and to identify strategies shown to reduce antipsychotic polypharmacy. METHODS: Literature reviewed was sourced from MEDLINE, Embase, CINAHL, InformIT, PsycINFO, International Pharmaceutical Abstracts, Cochrane Library database and Joanna Briggs Institute databases to identify Australian studies published between January 2000 and February 2015. Studies that reported prevalence of multiple antipsychotic use or addressed the issue of antipsychotic drug-related side-effects were included. Systematic reviews, randomized controlled trials, and observational pre-post studies of Australian and international interventions aiming to reduce multiple antipsychotic use in mental health settings were also identified. RESULTS: Nineteen studies reporting prevalence of multiple antipsychotic use were identified. The proportion of patients taking more than one antipsychotic ranged from 5 to 61%. Of the studies assessing dosages used, between one-third and one-half of all patients taking multiple antipsychotics received doses higher than recommended. Data from one national study reported that people taking multiple antipsychotics were more likely to experience at least one side-effect in comparison to consumers taking a single antipsychotic (90 verses 80%).International evidence of direct trials of conversion from treatment regimens involving multiple antipsychotics to those based on monotherapy show that between 50 and 75% of people with serious mental illness could be successfully converted to single-agent treatment, with up to 25% obtaining an improvement in health and the remaining 50% staying well managed. CONCLUSION: Use of multiple antipsychotics is common among Australian people with mental illness, despite guidelines recommending that only one antipsychotic should be used in most cases. People taking more than one antipsychotic at a time are more likely to experience side-effects, and to receive higher than recommended antipsychotic doses. Direct trials that aimed to reduce multiple antipsychotic use suggest it is possible to effectively reduce therapy in the majority of people without worsening outcomes. Simple educational programmes targeting health professionals have not been found to be effective; however, complex multifaceted programmes and quality improvement programmes have demonstrated effect.

Heparin dosing and therapeutic activated partial thromboplastin times (aPTT) in acute coronary syndrome (ACS).

This study assessed the current practices of heparin dosing and determined the extent of therapeutic activated partial thromboplastin times (aPTT) achieved, utilising a standard heparin nomogram in the coronary care unit and step-down cardiac ward of a health care facility in South Australia. The study also examined the effect of actual body weight (ABW), body mass index (BMI), smoking, concomitant intravenous glycerine trinitrate, age, gender and creatinine levels, individually, on the time taken to attain a therapeutic aPTT in acute coronary syndrome (ACS) patients receiving a heparin infusion. A retrospective correlational research design was utilised to include the collection of quantitative data from 66 men and women of all ages and background consecutively admitted into the coronary care unit and the step-down cardiac ward and receiving a continuous heparin infusion. The quantitative data included demographic details plus all information regarding treatment and results of heparin therapy from the patients' medical records. Descriptive analysis of the data revealed 32% of the participants attained a therapeutic level with the first aPTT taken and that, successively, 35% and 45% of the participants attained a therapeutic level with the second and third aPTT taken. The majority of participants were found to be outside of the therapeutic range at any one time during the study. A generalised linear model (log-binomial model) applied to the data revealed that increased ABW (p=0.002), creatinine levels (p=0.033) and, in particular, BMI (p=0.000) were significant risk factors that contributed to the failure of participants attaining a therapeutic aPTT level. Age (p=0.668), gender (p=0.623), smoking (p=0.993) and the use of concomitant intravenous glycerine trinitrate (p=0.897) did not have a significant effect on the time to reach a therapeutic aPTT. The results provide noteworthy information for the re-evaluation of the use of the standard heparin nomogram. A robust randomised clinical trial is required to further examine BMI as the best predictor for heparin requirements in ACS patients receiving a heparin infusion.