Professor Beata Bajorek

Aim:The aim of this review was to explore the status of key performance indicators (KPIs) in Australian hospital pharmacy practice. Data sources:For this narrative review, databases (MEDLINE, PubMed and EBSCO) were searched for relevant publications within the period from April 1980 to April 2014 using the following search terms: hospital pharmacy, key performance indicators, performance measures, clinical indicators and benchmarking. The inclusion criteria were as follows: full text papers (papers only available as abstracts were discarded) and English language. Reference lists of selected papers were also searched to identify additional literature. Results:While there are established competencies, standards and quality use of medicines (QUM) indicators for hospital pharmacy in Australia, there are no standardised KPIs relating to the performance and practice of hospital pharmacy. International research has demonstrated that KPIs are valuable tools for measuring pharmacy performance; the need for KPIs is highlighted in research from the UK, USA, Canada, New Zealand and Australia. Particular challenges associated with KPI implementation include: the need for relevance to all stakeholders; difficulties in measuring pharmacists¿ activities due to the inherent nature of their work; lack of resources for data collection; limited understanding of KPIs; and negative attitudes toward KPIs by some pharmacists. Conclusion:Before nationally standardised KPIs are introduced into Australian hospital pharmacy practice, attention must be paid to developing relevant measures through careful consultation with all relevant stakeholders, including pharmacists themselves. KPIs should provide relevant results, be easy to measure and highlight the value of hospital pharmacy services in a resource-friendly manner.

Background The Australian government¿s General Practitioner (GP) super clinics programme aims to provide well-integrated, multidisciplinary, patient-centred care for people with chronic disease. However, there is no research into the current role of pharmacists in this setting. Aims To explore the perspectives of GP super clinic staff on current and potential (future) pharmacist-led services provided in this setting. Methods Individual interviews (facilitated using a semi-structured interview guide and thematically analysed) were conducted with purposively sampled staff of a GP super clinic in a semirural location in the state of New South Wales, until theme saturation. Participating staff included (n=9): three GPs, one pharmacist, one nurse, one business manager, and three reception staff. Results Three themes emerged conveying perspectives on: working relationships between staff; a pharmacist¿s current role; and potential future roles for a pharmacist. All clinic staff actively engaged the pharmacist in their ¿team approach¿. Currently established roles for home medicines reviews (HMRs) and drug information were well supported, but needed to be expanded, for example, with formalised case conferences between GPs, pharmacists, and other staff. New roles needed be explored in auditing medication use, optimising medication records, specialised drug information, dispensing, and prescribing. Although GPs had differing views about opportunities for pharmacists¿ prescribing in this setting, they saw several benefits to this service, such as reducing the time pressure on GPs to enable more effective consultations. Conclusion Results suggest a pharmacist¿s services can potentially be better used within the multidisciplinary super clinic model of care to address current gaps within the semi-rural practice setting. Any future role for the pharmacist could be addressed as part of a formalised, strategic approach to creating an integrated healthcare team, with attention to funding and government legislation.

Clinical guidelines advocate stroke prevention therapy in atrial fibrillation (AF) patients, specifically anticoagulation. However, the decision to initiate treatment is based on the risk (bleeding) versus benefit (prevention of stroke) of therapy, which is often difficult to assess. This review identifies available risk assessment tools to facilitate the safe and optimal use of antithrombotic therapy for stroke prevention in AF. Using key databases and online clinical resources to search the literature (1992¿2012), 19 tools have been identified and published to date: 11 addressing stroke risk, 7 addressing bleeding risk and 1 integrating both risk assessments. The stroke risk assessment tools (e.g. CHADS2, CHA2DS2-VASc) share common risk factors: age, hypertension, previous cerebrovascular attack. The bleeding risk assessment tools (e.g. HEMORR2HAGES, HAS-BLED) share common risk factors: age, previous bleeding, renal and liver impairment. In terms of their development, six of the stroke risk assessment tools have been derived from clinical studies, whilst five are based on refinement of existing tools or expert consensus. Many have been evaluated by prospective application to data from real patient cohorts. Bleeding risk assessment tools have been derived from trials, or generated from patient data and then validated via further studies. One identified tool (i.e. Computerised Antithrombotic Risk Assessment Tool [CARAT]) integrates both stroke and bleeding, and specifically considers other key factors in decision-making regarding antithrombotic therapy, particularly those increasing the risk of medication misadventure with treatment (e.g. function, drug interactions, medication adherence). This highlights that whilst separate tools are available to assess stroke and bleeding risk, they do not estimate the relative risk versus benefit of treatment in an individual patient nor consider key medication safety aspects. More effort is needed to synthesize these separate risk assessments and integrate key medication safety issues, particularly since the introduction of new anticoagulants into practice. © 2013, SAGE Publications. All rights reserved.

Objective: To explore the potential for community pharmacist prescribing in terms of usefulness, pharmacists' confidence, and appropriateness, in the context of asthma management. Methods: Twenty community pharmacists were recruited using convenience sampling from a group of trained practitioners who had already delivered asthma services. These pharmacists were asked to complete a scenariobased questionnaire (9 scenarios) modelled on information from real patients. Pharmacist interventions were independently reviewed and rated on their appropriateness according to the Respiratory Therapeutic Guidelines (TG) by three expert researchers. Results: In seven of nine scenarios (78%), the most common prescribing intervention made by pharmacists agreed with TG recommendations. Although the prescribing intervention was appropriate in the majority of cases, the execution of such interventions was not in line with guidelines (i.e. dosage or frequency) in the majority of scenarios. Due to this, only 47% (76/162) of the interventions overall were considered appropriate. However, pharmacists were deemed to be often following common clinical practice for asthma prescribing. Therefore 81% (132/162) of prescribing interventions were consistent with clinical practice, which is often not guideline driven, indicating a need for specific training in prescribing according to guidelines. Pharmacists reported that they were confident in making prescribing interventions and that this would be very useful in their management of the patients in the scenarios. Conclusion: Community pharmacists may be able to prescribe asthma medications appropriately to help achieve good outcomes for their patients. However, further training in the guidelines for prescribing are required if pharmacists are to support asthma management in this way.

Method: Guidelines pertaining to the use of pharmacotherapy, focusing on conditions described in National Health Priority Areas, were identified using databases (Medline, Google Scholar) and organisation websites (Department of Health and Ageing, National Heart Foundation, National Health and Medical Research Council). Guidelines were reviewed and qualitatively analysed to identify any references or definitions of ¿elderly¿ persons.

Objectives The literature identifies many barriers to medicines use, including bio-psycho-social issues, but less is known regarding ethno-cultural barriers, which are important in culturally diverse nations. The aim of this study was to explore ethnic differences in attitudes to medicines and medicines-taking, focusing on the main constituents of the New Zealand (NZ) population: NZ European, Maori (the indigenous people of NZ), Pacific and Asian peoples. Methods A qualitative study involving a series of focus groups was conducted. Participants (>50 years old) taking medicines were recruited from various community-based groups. The focus group discussions were transcribed verbatim and analysed for key themes via manual inductive coding and constant comparison. Key findings Twenty focus groups (n = 100 participants) were conducted. Three key common themes emerged: (1) conception of a medicine; (2) self-management of medication; and (3) seeking further medicines information. In general, NZ European participants had a very narrow view of what a medicine is, were motivated to source medicines information independently and were very proactive in medicines management. At the other end of the spectrum, Pacific peoples expressed a broad view of what constitutes a medicine, were not motivated to source medicines information independently and were not proactive in medicines management, tending to instead rely on healthcare professionals for answers. The findings from the various ethnic groups highlight differences in attitudes to medicines per se and medicines-taking; these influences on medication-taking behaviour need to be considered in the provision of pharmaceutical care. Conclusion Ethnic differences in attitudes to medicines and medicines-taking are apparent, although there are some commonalities in terms of needs regarding support and advice around medicines' use. This will help inform the development of resources and communication tools to assist pharmacists in providing pharmaceutical care to diverse patient populations. © 2011 Royal Pharmaceutical Society.

Background: Effective management of warfarin therapy is often challenged by its complex pharmacology and preventable adverse events. One strategy to ensure safe warfarin use is provision of comprehensive warfarin education to patients. Aim: To review the provision of warfarin education to hospital patients prescribed warfarin and to describe patient characteristics that may impact on warfarin education. Method: A prospective study was undertaken at 2 large Australian metropolitan hospitals. Provision of warfarin education was identified by auditing the medication charts and clinical notes of hospitalised older patients (= 65 years). Patients were also interviewed to confirm whether they recalled receiving warfarin education during their hospital stay. Results: Data were collected for 96 patients with a mean age of 74 (SD 13) years. Most patients (78%) were admitted to medical wards, were taking warfarin for atrial fibrillation (56%), and had started warfarin prior to admission (54%). 36% of patients had provision of warfarin education documented in medication charts and clinical notes, and in most cases warfarin education was provided by a pharmacist. Of the 68 patients available for interview, only 47% recalled receiving warfarin education; in the majority of cases they cited pharmacists as providers of the education. Conclusion: There is a need to improve documentation and provision of warfarin education to hospital patients.

Objective: To review the challenges of warfarin education for older patients (aged 65 years or older) in terms of knowledge, access to warfarin education, and education resources. Methods: A quasi-systematic review of the literature was performed via electronic database searches (eg, Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, International Pharmaceutical Abstracts, Meditext, and Google Scholar) from 1990 to May 2011. Results: The 62 articles reviewed found that improved patient knowledge results in better anticoagulation control. The review also found that between 50% and 80% of older patients have inadequate knowledge about the basic aspects of warfarin therapy (eg, action, benefits and risks, interactions with other drugs or foods, international normalized ratio management). Demographic factors, such as advancing age, lower family income, and limited health literacy, were found to inversely affect patients' warfarin knowledge, and access to warfarin education and information resources were often suboptimal in different practice settings. Finally, a number of educational strategies and resources that could be readily incorporated to improve the effectiveness of current warfarin education programs were extracted from the review. Conclusion: This comprehensive review highlights that education about warfarin in older patients is currently suboptimal and may in part contribute to poor therapeutic outcomes. This review article also acknowledges the need to identify, target, and develop educational strategies and resources to further improve older patients' knowledge about their warfarin therapy. © SAGE Publications 2012.

Background: Warfarin is a high-risk medication where patient information may be critical to help ensure safe and effective treatment. Considering the time constraints of healthcare providers, the internet can be an important supplementary information resource for patients prescribed warfarin. The usefulness of internet-based patient information is often limited by challenges associated with finding valid and reliable health information. Given patients' increasing access of the internet for information, this study investigated the quality, suitability and readability of patient information about warfarin presented on the internet. Method: Previously validated tools were used to evaluate the quality, suitability and readability of patient information about warfarin on selected websites. Results: The initial search yielded 200 websites, of which 11 fit selection criteria, comprising seven non-commercial and four commercial websites. Regarding quality, most of the non-commercial sites (six out of seven) scored at least an 'adequate' score. With regard to suitability, 6 of the 11 websites (including two of the four commercial sites) attained an 'adequate' score. It was determined that information on 7 of the 11 sites (including two commercial sites) was written at reading grade levels beyond that considered representative of the adult patient population with poor literacy skills (e.g. school grade 8 or less). Conclusion: Despite the overall 'adequate' quality and suitability of the internet derived patient information about warfarin, the actual usability of such websites may be limited due to their poor readability grades, particularly in patients with low literacy skills.

Background: Medication-taking behavior, specifically non-adherence, is significantly associated with treatment outcome and is a major cause of relapse in the treatment of psychotic disorders. Non-adherence can be multifactorial; however, the rates and associated risk factors in an Ethiopian population have not yet been elucidated. The principal aim of this study was to evaluate adherence rates to antipsychotic medications, and secondarily to identify potential factors associated with non-adherence, among psychotic patients at tertiary care teaching hospital in Southwest Ethiopia.Methods: A cross-sectional study was conducted over a 2-month period in 2009 (January 15th to March 20th) at the Jimma University Specialized Hospital. Adherence was computed using both a compliant fill rate method and self-reporting via a structured patient interview (focusing on how often regular medication doses were missed altogether, and whether they missed taking their doses on time). Data were analyzed using SPSS for windows version 16.0, and chi-square and Pearsons r tests were used to determine the statistical significance of the association of variables with adherence.Result: Three hundred thirty six patients were included in the study. A total of 75.6% were diagnosed with schizophrenia, while the others were diagnosed with other psychotic disorders. Most (88.1%) patients were taking only antipsychotics, while the remainder took more than one medication. Based upon the compliant fill rate, 57.5% of prescription fills were considered compliant, but only 19.6% of participants had compliant fills for all of their prescriptions. In contrast, on the basis of patients self-report, 52.1% of patients reported that they had never missed a medication dose, 32.0% sometimes missed their daily doses, 22.0% only missed taking their dose at the specific scheduled time, and 5.9% missed both taking their dose at the specific scheduled time and sometimes missed their daily doses. The most common reasons provided for missing medication doses were: forgetfulness (36.2%); being busy (21.0%); and a lack of sufficient information about the medication (10.0%). Pill burden, medication side-effects, social drug use, and duration of maintenance therapy each had a statistically significant association with medication adherence (P = 0.05).Conclusion: The observed rate of antipsychotic medication adherence in this study was low, and depending upon the definition used to determine adherence, it is either consistent or low compared to previous reports, which highlights its pervasive and problematic nature. Adherence must therefore be considered when planning treatment strategies with antipsychotic medications, particularly in countries such as Ethiopia. © 2012 Alene et al.; licensee BioMed Central Ltd.

Objective: To explore healthcare professionals' views about the benefits and challenges of using information technology (IT) resources for educating patients about their warfarin therapy. Methods: A cross-sectional survey of both community and hospital-based healthcare professionals (e.g., doctors, pharmacists and nurses) involved using a purpose-designed questionnaire. The questionnaires were distributed using a multi-modal approach to maximise response rates. Results: Of the total 300 questionnaires distributed, 109 completed surveys were received (43.3% response rate). Over half (53.2%) of the healthcare participants were aged between 40-59 years, the majority (59.5%) of whom were female. Fifty nine (54.1%) participants reported having had no access to warfarin-specific IT-based patient education resources, and a further 19 (38.0%) of the participants who had IT-access reported that they never used such resources. According to the healthcare participants, the main challenges associated with educating their patients about warfarin therapy included: patient-related factors, such as older age, language barriers, cognitive impairments and/or ethnic backgrounds or healthcare professional factors, such as time constraints. The healthcare professionals reported that there were several aspects about warfarin therapy which they found difficult to educate their patients about which is why they identified computers and interactive touch screen kiosks as preferred IT devices to deliver warfarin education resources in general practices, hospital-based clinics and community pharmacies. At the same time, the healthcare professionals also identified a number of facilitators (e.g., to reinforce warfarin education, to offer reliable and easily comprehensible information) and barriers (e.g., time and costs of using IT resources, difficulty in operating the resources) that could impact on the effective implementation of these devices in educating patients about their warfarin therapy.Conclusion: The findings of the study suggest that there is a need for improving healthcare professionals' use of, and access to IT-based warfarin education resources for patients. The study findings also suggest addressing the concerns raised by the healthcare professionals when implementing such IT resources successfully to help educate patients about their warfarin therapy.

Background: The risk of medication misadventure is heightened in emergency settings. Identifying at-risk patients is integral to minimising medication-related adverse events. Aim: To pilot a medication misadventure risk assessment tool to identify at-risk patients most likely to benefit from targeted intervention by an emergency department pharmacist. Method: A prospective descriptive study was undertaken in an emergency medical unit over 2 weeks (June to July 2009). Patients were included if they were over 70 years of age, took 3 5 regular medications, had 3 3 comorbidities, and/or were newly started on warfarin or had been admitted to the emergency department as a result of a medication-related adverse event. Nurses were encouraged to use the medication misadventure risk assessment tool for all patients admitted to the emergency medical unit. The pharmacist provided targeted interventions to all patients who were identified as being at-risk by the nurses. The pharmacist also verified the accuracy of the risk assessments undertaken by the nurses using this tool. Main outcome measures were the sensitivity and specificity of the tool and the reliability of the nurses' risk assessment. Results: Nurses completed 115 medication risk assessments for 194 patients. The risk assessments were accurately completed in all but 10 patients. Of the 36 (31%) patients assessed as high risk, 18 required pharmacist intervention. Of the 79 patients assessed as low risk, 3 required pharmacist intervention. The tool was useful in identifying at-risk patients (specificity 78%, 95%CI 69-85; sensitivity 83%, 95%CI 60- 94). Conclusion: Nurses in the emergency department used the risk assessment tool to identify patients at risk of medication misadventure and facilitate targeted interventions by pharmacists.

Aim: To implement a pharmacist charting service in the preadmission clinic (PAC) and describe a preparatory process for the initiation of this service. Method: Stage 1: a proposal for a pharmacist charting service in the PAC was devised via an iterative process with an advisory panel. Stage 2: feedback on the proposal was obtained from key staff via a survey comprising 15 linear scale statements (0 = strongly disagree to 10 = strongly agree) and open-ended questions. Stage 3: baseline data were collected on existing PAC service outcomes, e.g. consultation times, accuracy of medication charts. Results: Stage 1: a service protocol was developed following positive feedback. Stage 2: most staff strongly agreed that a pharmacist charting service would improve the efficiency and workflow in the PAC (median 8; n = 19) and that PAC pharmacists were competent and skilled to chart medications (median 9). Pharmacists perceived that the proposed service would increase their workload (median 10), consultation times (median 9) and medicolegal responsibilities (median 7) while the opposite was reported by the doctors (median 2, 2, and 3, respectively). Stage 3: mean baseline consultation times for pharmacists and doctors were 18.6 and 25 minutes, respectively. Most (95%) of the 56 analysed medication charts were incomplete (at least 1 piece of information missing) while 41% had at least one or more inaccuracies. Conclusion: There are benefits of a pharmacist charting service. This is the first step toward exploring models for pharmacist prescribing.

Background: The emergence of antimicrobial resistance reinforces the need for antimicrobial stewardship to promote the appropriate and judicious use of antimicrobials. Aim: To quantify restricted antimicrobial use among intensive care unit (ICU) discharges to general wards, and to review appropriateness of antimicrobial use. Method: A prospective clinical audit was conducted over a 2- week period. Medical records for ICU discharges were reviewed, with relevant data extracted (patient characteristics, antimicrobial therapy prescribed, treatment instructions). Appropriateness of restricted antimicrobials used was gauged in accordance with hospital policies and the Therapeutic Guidelines: Antibiotic. Results: 98 patients were discharged from the ICU - 74 (76%) discharged to general wards were on antimicrobials, 15 discharged to general wards were not on antimicrobials and 9 discharged out of the hospital. Of these 74 patients, 31 (42%) were prescribed a total of 57 restricted antimicrobials; only 11 of these 31 (36%) patients had documented approval (from microbiology/infectious diseases teams) for use of restricted antimicrobials. 46 restricted antimicrobials (n = 57; 81%) were deemed clinically appropriate and the remaining 11 were prescribed outside guideline-recommended indications. Conclusion: While most restricted antimicrobials were prescribed according to national guidelines, in only one-third of patients were the restricted antimicrobials 'approved' for use according to hospital policies. Better clinical documentation on treatment plans and review processes for restricted antimicrobial use is needed during the transition from ICU to general wards.

Anticoagulant drugs maintain a high potential for adverse events due to their inherent risk of haemorrhage and/or complex pharmacology. In addition, compromising the safety of these agents is the context in which they are principally used; that is, in the long-term prevention of thromboembolic diseases in an older patient population. These challenges are especially pronounced in the prevention of stroke in older persons with atrial fibrillation (AF), where the need for thromboprophylaxis is paramount and in whom the arrhythmia is most prevalent, but where the target population is simultaneously at high risk of adverse drug events. Essentially, this translates to the use of high-risk therapies on an indefinite basis, in persons who have multiple comorbidities, use polypharmacy, and who may have age-related functional and cognitive decline, culminating in a higher potential for medication misadventure. For this reason, anticoagulants mandate extra pharmacovigilance, and therefore the aim of this review is to address some of the key safety considerations in the use of anticoagulant drugs (warfarin, dabigatran, rivaroxaban), spanning the initiation of therapy to its ongoing management. Using the Medication Management Pathway (MMP) as a framework, in this review we canvas and highlight specific developments in practical strategies to facilitate the safe use of anticoagulants (particularly warfarin) in ¿at-risk¿ elderly patients including: comprehensive risk/benefit assessment using novel risk stratification tools; focused medicines review services; therapeutic drug monitoring services delivered in the primary care setting; and practical education strategies and resources targeting the older patient population. Until newer alternative anticoagulants become viable options for widespread use, clinicians will necessarily need to rely on specific resources and interventions to facilitate the safe use of currently available anticoagulants (i.e. warfarin) in ¿at-risk¿ older people. © 2011, SAGE Publications. All rights reserved.

The short-comings of current anticoagulants have led to the development of newer, albeit more expensive, oral alternatives. Objective: To explore the potential impact the new anticoagulants dabigatran and rivaroxaban in the local hospital setting, in terms of utilisation and subsequent costing. Method: A preliminary costing analysis was performed based on a prospective 2-week clinical audit (29th June - 13th July 2009). Data regarding current anticoagulation management were extracted from the medical files of patients admitted to Ryde Hospital. To model potential costing implications of using the newer agents, the reported incidence of VTE/stroke and bleeding events were obtained from key clinical trials. Results: Data were collected for 67 patients treated with either warfarin (n=46) or enoxaparin (n=21) for prophylaxis of VTE/stroke. At least two-thirds of all patients were deemed suitable candidates for the use of newer oral anticoagulants (by current therapy: warfarin: 65.2% (AF), 34.8% (VTE); enoxaparin: 100%, (VTE)). The use of dabigatran in VTE/stroke prevention was found to be more cost-effective than warfarin and enoxaparin due to significantly lower costs of therapeutic monitoring and reduced administration costs. Rivaroxaban was more cost-effective than warfarin and enoxaparin for VTE/stroke prevention when supplier-rebates (33%) were factored into costing. Conclusion: This study highlights the potential cost-effectiveness of newer anticoagulants, dabigatran and rivaroxaban, compared to warfarin and enoxaparin. These agents may offer economic advantages, as well as clinical benefits, in the hospital-based management of anticoagulated patients.

Background: There are a paucity of data on the use of anti arrhythmics for a trial fibrillation (AF), particularly in view of new treatment guidelines recommending rate control over rhythm control. Aim: To investigate the use of anti-arrhythmics for AF in the local clinical setting. Method: A retrospective clinical audit of the medical records of 174 adult patients with primary or secondary AF was conducted at a large Sydney teaching hospital. Data were collected on patients' characteristics, medical history, factors affecting treatment choice and clinical outcomes. Results: For acute treatment of AF, 38 (22%) patients received rhythm control only, 30 (17%) received rate control only, and 42 (24%) received rate control plus rhythm control. For longterm management of AF, 24 (14%) patients received rhythm control only, 42 (24%) received rate control only, and 28 (16%) received rate control plus rhythm control. The number of patients who attained sinus rhythm was higher in those receiving rhythm control drugs versus rate control drugs (84% vs 31%; p < 0.05). A decrease was observed in the number of patients on digoxin (41% vs 6%; p < 0.01) and amiodarone (26% vs 6%; p < 0.001). Factors identified as influencing treatment choice were age, heart rate, AF characteristics and comorbidities. Conclusion: There has been a temporal change in the use of anti-arrhythmics for AF, reflecting changes to recommendations on the use of rhythm versus rate control drugs. These changes in prescribing patterns are reflective of current guidelines and evidence-based practice.

Background: Heavy physical exertion, emotional stress, heavy meals and respiratory infection transiently increase the risk of myocardial infarction, sudden death and stroke, however it remains uncertain how to use this information for disease prevention. Aims: We determined the feasibility of taking targeted medication for the hazard duration of a triggering activity to reduce risk. Methods: After a run-in training period over 1 month, 17 healthy subjects recorded for 1 month all episodes of physical and emotional stress, heavy meal and respiratory infection. For each episode, they were instructed to take either aspirin 100 mg and propranolol 10 mg (for physical exertion and emotional stress) or aspirin 100 mg alone (for respiratory infection and heavy meal) and record adherence with taking medication. Subjects performed exertion while wearing a heart rate monitor, once during the run-in period, and once 30 min after taking propranolol and aspirin. Results: Based on study diary subjects reliably documented triggers with 94% adherence. Designated medication was also reliably taken, with 88% adherence. Propranolol taken prior to exertion resulted in a lower peak heart rate (128 ± 38 versus 149 ± 21, p < 0.01) compared to similar exercise during the run-in period. Over two-thirds (71%) of subjects considered that it was feasible to continue taking medication in this manner. Conclusions: The study indicates that potential triggers of acute cardiovascular disease can be reliably identified, and it is feasible and acceptable to take targeted medication at the time of these triggers. These findings encourage further investigation of the potential role of this therapeutic strategy. © 2009 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand.

Aim: To determine the number of warfarinised hospital patients experiencing over-anticoagulation; to identify how overanticoagulation is managed and whether local guidelines are adhered to. Method: 2 prospective one-week clinical audits were conducted in 2005 (Audit 1) and 2008 (Audit 2). The medical notes, drug charts and anticoagulation charts of warfarinised patients admitted to hospital were reviewed. The following data were collected: medical histories, warfarin regimen, international non-nalised ratio results, clinical events and over-anticoagulation clinical management and treatment options. Results: Data were collected for 58 patients (Audit 1: n = 30; Audit 2: n = 28). At least one-third of all patients experienced over-anticoagulation (Audit 1: 53%; Audit 2: 36%). Haemorrhagic events occurred in 40% of patients in Audit 1 and 18% in Audit 2 (p = 0.06) - not all were associated with elevated international normalised ratios. Most cases of overanticoagulation were managed by withholding warfarin doses and one case (Audit 2) required Prothrombinex. Drug interactions were the most common risk factor (> 50% of patients) for over-anticoagulation in both audits. Problems with documentation were more prevalent in Audit 1 than in Audit 2. Conclusion: Over-anticoagulation is a common occurrence in warfarinised hospital patients. Hospital over-anticoagulation management practices need to be reviewed to ensure safe and efficacious anticoagulation.

Warfarin theraphy is underused in the target at-risk elderly population. Clinicians perceive that older patients are reluctant to use this theraphy, however the perspective of patients or their carers has yet to be explored. Objective: To explore in-depth the perspectives of elderly patients and/ or their carers regarding the use of warfarin therapy. Method: A qualitative study, using semi-structured group interviews was undertaken. The audio-taped discussions were transcribed verbatim, then thematically analysed to identify emergent themes. Group discussions were conducted at a major Sydney teaching hospital, over a 2-month period. Individuals aged 65 years or older (and/or their carers) who were using long-term (6 months) warfarin therapy were recruited by voluntary response to study flyers. Results: 17 patients and carers (mean age 77.2 SD=7.5 years) participated in one of two focus groups. Five core themes emerged regarding warfarin therapy: inadequate knowledge and understanding about it, patients/carers variable experience of information provision, cycle of reactions to being on it, issues in its practical management, and the spectrum of experiences with it. Overall, participants were very accepting of the therapy, describing a high level of compliance, despite initial fears and anxieties, and a relative lack of knowledge. Patients felt somewhat abandoned in their management of warfarin due to the lack of ongoing support services in the community, and inadequate information provision. Conclusions: Elderly patients and their carers appear to be quite accepting of warfarin therapy, in contrast to the perceptions of health care professionals. More effort is needed, however, in terms of information provision, particularly in the form of community-based services, to assist patients in the long-term management of warfarin.

Background: Managing warfarin therapy can be challenging and a multidisciplinary approach to achieve optimal outcomes can be beneficial. Internationally, extended roles for pharmacists have involved collaborative prescribing privileges. Aim: To explore the clinical utility and capacity of pharmacists to undertake prescribing functions in anticoagulation management in the hospital setting. Methods: Pharmacists were recruited from a large Sydney teaching hospital. A questionnaire was used to simulate a pharmacist prescribing function and to explore their opinion of the usefulness of prescribing and their confidence to undertake such roles. The appropriateness of pharmacists' prescribing decisions was evaluated. Results: Prescribing authority was generally considered useful for pharmacists in the management of warfarin therapy. Pharmacist prescribing in the inpatient setting was thought to enable enhanced pharmacovigilance and be useful when medical staff are unavailable. However, outpatient settings were considered more appropriate. Dependent or collaborative models of prescribing were considered more appropriate than independent models. Despite expressing confidence in their ability to prescribe, the majority of participants' responses (58%) were deemed clinically inappropriate. Lack of training and experience and opposition from the medical team were identified as potential barriers toward pharmacist prescribing. Conclusion: Extended prescribing roles for pharmacists in anticoagulation management may be useful, particularly in the outpatient setting. Training and experience is needed to ensure safe prescribing practices are maintained.

Aim: To explore Australian general practitioners' views on extending prescribing rights to pharmacists, the appropriateness of pharmacist prescribing models, and the influence of general practitioners' characteristics on their preference for a particular pharmacist prescribing model. Method: The study consisted of two parts. Part A was a scenario-based questionnaire using Likert-scale responses and Part B was a semi-structured interview. General practitioners were randomly recruited from two Sydney divisions of general practice. Data were analysed using descriptive statistics and qualitative responses were thematically analysed. Results: Completed questionnaires were received from 22/150 general practitioners (response rate 15%), with 10 general practitioners providing additional comments. 10/12 (83%) general practitioners participated in the interviews. Repeat prescribing and prescribing by referral were the most favoured models; 53% of general practitioners rated them as appropriate or somewhat appropriate models of pharmacist prescribing. 6 major themes emerged: focus on safety issues, lack of awareness of pharmacist training and capabilities, division of professional/clinical responsibility, conflict in definition of prescribing versus treating, interference with the general practitioner-patient relationship and remuneration. Conclusion: General practitioners favoured the dependent pharmacist prescribing approach, which is the most widespread practice overseas. The issues raised by the general practitioners need to be addressed before pharmacist prescribing can be pursued in Australia.

Background: Although the many factors that affect the initiation of lactation have been identified, the impact of medications on lactogenesis remains largely unknown. Aim: To explore the impact of medications used during pregnancy on time to lactogenesis after parturition. Method: Data were collected prospectively from women admitted to a metropolitan Sydney hospital for parturition. Information was obtained via a short interview with each patient, as well as from medical notes, drug charts and infant feeding charts. Results: The average time to lactogenesis was 68.9 hours (range 22.5-126). 39% of women experienced delayed lactogenesis. Observational results showed that the use of some medications during pregnancy may impact on the time to lactogenesis. Cigarette smoking during pregnancy and prolonged stage II vaginal delivery may also increase the time to lactogenesis. Conclusion: Several medications used during pregnancy may impact on time to lactogenesis but the biological plausibility is unknown.

Background: Despite numerous guidelines and consensus statements on venous thromboembolism (VTE) prophylaxis, there appears to be a large gap between evidence and practice. Aim: To identify the incidence of VTE, thromboprophylaxis practice, VTE risk factors, and bleeding complications in patients undergoing elective total hip or knee arthroplasty. Method: Patients who underwent elective total hip or knee arthroplasty from 1 January 2004 to 31 December 2005 were identified retrospectively from medical records at two hospitals. A clinical case audit was performed and data collected on the 3-month incidence of VTE, thromboprophylaxis practice, VTE risk factors and bleeding episodes. Results: VTE incidence was 13% (in-hospital incidence 9.3% and 3-month readmission incidence 3.3%) and was significantly higher at Hospital 1 for unilateral total knee arthroplasty (p= 0.02) and unilateral total hip arthroplasty (p = 0.02). At both hospitals the 3-month incidence of VTE was 16% post unilateral total knee arthroplasty compared to 7.7% post unilateral total hip arthroplasty (p = 0.06). 99% of patients received appropriate pharmacological prophylaxis and of these 87% received an appropriate dose. 17 patients (55%) that developed VTE had one or more risk factors. There were 23 cases (9.30%) of minor bleeding and 4 cases (1.6%) of major bleeding. Conclusion: VTE incidence was higher than that quoted in the literature, which may reflect high usage of pre-discharge deep vein thrombosis screening in the study population. There is a need to develop and disseminate management algorithms for elective total hip or knee arthroplasty in the local setting.

Background: Long-term warfarin therapy requires intensive laboratory monitoring of venous blood. Reliable and efficient point-of-care testing (POCT) of capillary blood offers an alternative to laboratory monitoring. Aim: To explore the perceptions of health professionals to POCT in warfarin management and to identify the models of monitoring warfarinised patients preferred by health professionals. Method: An exploratory descriptive study that purposively sampled health professionals (hospital pharmacists, specialists, nurses, general practitioners) involved in the management of anticoagulated patients and practising within an area health service. Health professionals were invited to participate in a group discussion on POCT and to then complete a brief survey ranking proposed monitoring models incorporating POCT. Results: 4 group discussions and/or individual interviews with 33 health professionals elucidated several themes, such as lack of knowledge or confidence in POCT, operator accreditation and careful patient selection. An acute post-acute care model and general practice surgery model incorporating POCT was preferred by health professionals in terms of perceived benefits to patients, cost-effectiveness and time efficiency. Conclusion: POCT will be a component in the monitoring and management of warfarinised patients in the future. A drawback to POCT is the perceived inaccuracy of the devices used. Operator training and maintenance of a controlled practice environment were suggested strategies to overcome variability.

Background: General practitioners integrate an array of social and environmental factors into their prescribing decisions. In teaching hospitals, despite the involvement of multiple practitioners in making and acting on prescribing decisions, little is known about the influence of roles, relationships, professional subcultures and underlying beliefs, on prescribing practices. Aim: To explore the social and cultural dynamics of prescribing in teaching hospitals. Method: Consultants, registrars, junior doctors, nurses and pharmacists from 2 large Sydney teaching hospitals were sampled purposively and invited to participate in a qualitative study involving semi-structured interviews. The interview topics explored included: attitudes about prescribing, roles and responsibilities, communication of decisions, influences on prescribing and factors contributing to prescribing errors. Interviews were transcribed verbatim and the content analysed thematically. Results: Participants included 8 consultants, 8 registrars, 9 junior doctors, 7 nurses and 11 pharmacists. 5 distinct sets of social and cultural influences on prescribing behaviours were identified. The dominant set of influences related to the structure of how prescribing took place and chief among these were the strong intra-professional relationships of medical teams. Other social and cultural influences related to how prescribing decisions were communicated, underlying assumptions within medical teams, knowledge acquisition and the hospital environment. Conclusion: Prescribing in teaching hospitals is shaped by a complex web of social and cultural dynamics. An appreciation of these influences may be vital to the success of strategies to improve use of medicines in teaching hospitals.

Background: Anticoagulation control is a strong predictor of Iclinical outcomes for patients on warfarin. Aim: To identify instances of excessive anticoagulation in hospitalised patients on warfarin and to determine the causes of international normalised ratios (INRs) of 5 and above and the management strategies used to correct it. Method: An observational descriptive study undertaken at a teaching hospital over a 3-month period. Data were reviewed prospectively and retrospectively to measure the percentage of time patients were maintained within their target INR range while in hospital and to identify cases of excessive anticoagulation. Patients were divided into a control group (INR < 5) and a high INR group (INR = 5). Possible causes of INRs of 5 and above and its management strategies were recorded. Results: Out of a total of 208 patients on warfarin identified in the geriatric, orthopaedic and cardiology wards, 144 patients met the study criteria. The mean percentage of time spent within, above and below the target INR range by the control group was 60%, 0% and 15%, and by the high INR group was 41%, 33% and 16%, respectively. In the high INR group, 26 possible causes of INRs of 5 and above were identified and the co-administration of roxithromycin and warfarin were implicated in 7 cases. Management strategies for INRs of 5 and above were compared between two stratified groups (INR 5-9 and INR = 9). The management strategies adopted included warfarin dose reduction (83%; 86%), temporary withholding of warfarin (100%; 100%), administration of vitamin K (58%; 100%), fresh frozen plasma (13%; 43%) and prothrombin complex concentrate (8%; 29%). The time to return to the upper limit of the target INR range was INR 5-9 (1.6 SD 1.5 days) and INR = 9 (0.5 SD 0.4 days). Conclusion: Anticoagulation control is difficult for hospital patients and drug interactions are an important contributing factor. The management strategies adopted to correct excessive anticoagulation followed the relevant guidelines.

Aim: To identify Australian pharmacists' awareness of their international colleagues' prescribing practices and explore their views about the feasibility and utility of pharmacist prescribing privileges within the scope of their current practice. Method: Members of the AusPharmList, Australian Association of Consultant Pharmacy and The Society of Hospital Pharmacists of Australia were invited by e-mail to participate in a community pharmacist, consultant pharmacist or hospital pharmacist electronic survey. These surveys were designed to elicit views concerning: dependent and independent prescribing; resource availability to support pharmacist prescribing; ability to justify prescribing decisions; and limitations of pharmacist prescribing. Results: Of the 268 surveys completed (response rate 6.4%), 45% of respondents were aware of their international colleagues' prescribing activities. 74% agreed that pharmacists should be granted dependent prescribing authority, while 52% agreed that pharmacists should be granted independent prescribing authority. The majority (88%) indicated they could identify their own limitations and 86% believed they could justify their prescribing decisions as dependent prescribers. 73% believed they would benefit from prescribing authority in their daily scope of practice. Conclusion: In 2004, awareness of international developments in pharmacist prescribing was not extensive among the respondents. However, many identified areas where they would benefit from dependent prescribing activities in their daily scope of practice.

Background: Warfarin has traditionally posed a challenge to clinicians because of its narrow therapeutic index. Extended roles for pharmacists may address some of the problems in warfarin management. International experience has involved anticoagulation clinics in which pharmacists have authority to engage in collaborative prescribing activities with physicians. Aim: To identify opportunities for pharmacist prescribing activities in warfarin management within the hospital setting. Method: Pharmacists from a Sydney teaching hospital were recruited. The first stage involved an audit of pharmacists' interventions in patients receiving warfarin. Stage two involved a focus group discussion to further explore these issues. Results: 9 pharmacists saw 41 warfarinised patients over the 5-day data collection period. Pharmacists saw reason to intervene in the warfarin therapy of 19 (46%) of these patients and a prescribing activity was involved in 16 (84%) of these interventions. Despite these ample opportunities to prescribe, pharmacists felt limited in their ability to use these opportunities. Lack of information about the patient, workloads, medicolegal responsibility, and the need for further training and experience, were cited as the main reasons pharmacists were hesitant to prescribe. It was also suggested that the outpatient setting may be more appropriate to trial a pharmacist prescribing role. Conclusion: There are ample opportunities for pharmacist prescribing in the area of warfarin management. However, practice change is needed before such a role can be taken up in the hospital setting.

Aim: To explore the views of a sample of Australian hospital pharmacists on prescribing privileges. Method: The study involved a questionnaire and a focus group discussion for hospital pharmacists and teacher practitioners. Participants could participate in either or both of these activities. Results: 15 pharmacists completed the questionnaire and 8 participated in the focus group discussion. Several models of pharmacist prescribing (discharge and specialist settings) were seen to be appropriate and useful to Australian practice. 93% of pharmacists noted that prescribing privileges would enable them to provide more efficient/improved pharmaceutical care; 64% that prescribing would result in reduced healthcare costs; and all noted physician opposition as a barrier. Pharmacists indicated that they already prescribed on an 'unofficial' basis. Training and accreditation beyond registration was deemed necessary by all pharmacists. Conclusion: Hospital discharge or specialist settings may be most appropriate to pilot pharmacist prescribing in Australia. Further research on a larger scale is needed to provide a base of evidence before this practice is pursued.

Background: The benefit of warfarin for stroke prevention in non-valvular atrial fibrillation has been demonstrated in various clinical trials. Warfarin has a narrow therapeutic window and carries a significant risk of bleeding. Ximelagatran is a new oral antithrombotic with predictable plasma concentrations and excellent bioavailability. Aim: To compare the costs and benefits of ximelagatran to that of warfarin and aspirin. Method: In a preliminary cost-effectiveness analysis, the costs and clinical consequences of warfarin, aspirin and ximelagatran were compared. The principal outcome was measured in the form of an incremental cost-effectiveness ratio. A decision analysis model was constructed to map the expected outcomes of three treatment alternatives. Sensitivity analysis tested the robustness of the data. Results: Warfarin appeared to be most cost effective in this clinical setting. The incremental cost-effectiveness ratio indicated that the use of ximelagatran in preference to warfarin would cost an additional $272 000/patient/year. Likewise the use of ximelagatran in preference to aspirin would cost an additional $13 000/patient/year. Conclusion: Ximelagatran appears to be cost effective in a small group of high-risk patients. This may have implications for the development of treatment guidelines in this clinical setting.

It is estimated that the best practice management of pain in Australia could result in savings (on medications, drug-related hospital admissions, utilisation of ancillary health services, social benefits such as those to the workforce) of approximately $4.8bn per annum.1,5 Pharmacy-based interventions have demonstrated cost savings and increased quality use of medicines, as well as healthcare practitioner satisfaction, in other healthcare priority areas (for example, asthma and diabetes). However, in Australia so far, no pharmacy-based interventions have been evaluated for the management of chronic pain, despite the pharmacist's accessibility and ideal placement to play a significant role in its management.

Aim: To investigate the use of long-term antiarrhythmic (rhythm-control [RHY] and rate-control [RAC]) therapy for the management of atrial fibrillation (AF) in elderly patients. Method: Data were collected retrospectively from the medical records of 255 patients with AF who were =65 years of age and were admitted to Royal North Shore Hospital in the period 1 July 1996 to 30 June 1997. Results: Overall, 192 (75%) patients were discharged on antiarrhythmic therapy for the long-term management of AF. Sixty-six patients (26%) received RHY only, 90 (35%) received RAC only, 36 (14%) were prescribed the combination of RHY + RAC therapy, and 63 (25%) received no therapy. Patients =80 years of age were equally likely to receive long-term antiarrhythmic therapy as those <80 years (74% versus 77%, p = 0.65), but a significantly lower proportion of them received RHY only than in those <80 years (17% versus 34%, p = 0.001). The preferred option in older patients was RAC only (42%). Cardiology patients were more likely to receive RHY ± RAC therapy (53%) than Aged Care (16%) or General Medicine patients (16%; p < 0.05). Logistic regression analysis indicated that old age and medical specialty were significant predictors for the choice of agent: patients =80 years were 2.2 times more likely to receive RAC only in preference to RHY only therapy than their younger counterparts (p = 0.044). Conclusion: Long-term rhythm-control therapy (e.g. amiodarone, sotalol) is potentially underutilised in AF patients =80 years of age. Reliance on the use of rate-controlling agents such as digoxin persists in clinical practice.

Background. Bone marrow transplant (BMT) recipi ents, who receive high-dose cyclophosphamide as part of conditioning therapy, are at considerable risk of developing haemorrhagic cystitis (HC). The role of prophylaxis of cyclophosphamide-induced HC is well- established in the literature, however, the literature is inconclusive with respect to the most effective form of prophylaxis. This study was undertaken to evaluate three methods of prophylaxis for HC used in BMT recipients in terms of the rate and severity of HC. The incidence and type of adverse effects attributed to each prophylactic regimen were also documented. Method. A retrospective cohort study was con ducted in four teaching hospitals. During the 5-week data collection period, the medical records of 354 adult BMT patients were reviewed. Routine prophy laxis for cyclophosphamide-induced HC was used in all four hospitals. Three methods of prophylaxis were identified; bladder irrigation, forced diuresis, and Mesna. Results. The incidence of HC (micro- and mac rohaematuria combined) was significantly higher in the hospital using bladder irrigation for prophylaxis than in the hospitals using Mesna or forced diuresis (P < 0.0001). The effect was more pronounced when the incidence of microhaematuria and macrohaema turia were compared separately. Patients receiving bladder irrigation for prophylaxis experienced an approximately threefold higher incidence of micro haematuria (35.4%) than patients receiving either Mesna or forced diuresis. The incidence of macroh aematuria in the bladder irrigation group was approx imately twice as high (21.1%) as in other methods. The difference in the incidence of HC between Mesna and forced diuresis was not statistically significant, with a reported incidence of microhaematuria of 9.6% and 8.9%, respectively, and for macrohaematuria of 13.2% and 8.9%, respectively. Logistic regression anal ysis was performed to examine the relationship be tween potential risk factors, methods of prophylaxis, and the incidence of HC. The final model included previous incidence of HC and graft failure during the current BMT. The most significant contributing factor was found to be the use of bladder irrigation for prophylaxis of HC (P = 0.001). Conclusions. The results of this study suggest that the use of Mesna or forced diuresis for prophy laxis may reduce the incidence of cyclophosphamide- induced HC by approximately 20% compared with the 40% incidence in unprotected patients reported in the literature. Bladder irrigation was associated with a higher incidence of HC (57%), particularly in terms of microhaematuria. The findings suggest that bladder irrigation is the least effective method of prophylaxis and is possibly even a detrimental one because of the bladder trauma it induces. Mesna and forced diuresis appear to be more effective in pre venting the incidence of cyclophosphamide-induced HC, although, there is no clear difference in efficacy between these two methods. © 1997 Appleton & Lange.