AimsTo ascertain and describe pharmacogenomic concepts included in the intended curriculum of accredited Australian medical schools.MethodsContent analysis of curriculum learning objectives of Australian medical schools was conducted, focusing on keywords and phrases pertaining to pharmacogenomic education. Learning objectives related to pharmacogenomics were categorized using (1) undergraduate medical genomic competencies per the Association of Professors in Human and Medical Genetics (2) Bloom's Taxonomy for cognitive and knowledge dimensions and (3) knowledge translation (enabling science, translation science and clinical implementation).ResultsThe curricula of 19 accredited medical schools in Australia were analyzed. Two-thirds (68%) contained genomic/pharmacogenomic education. Eight schools had content relating to undergraduate medical genomic competencies. Of those which had pharmacogenomic-related learning objectives, the majority (65%) were categorized in Bloom's Taxonomy's lower levels (Remember and Understand) and 15% were deemed to be at the level of 'Clinical Implementation.'ConclusionThe majority of Australian medical schools have incorporated pharmacogenomics in their current curriculum; however, learning objectives addressing application and clinical implementation are required. Doctors have a unique role to play in implementing pharmacogenomics into clinical practice. Comprehensiveness of course curricula across all learning domains would support uptake of pharmacogenomics into routine practice.

Background: Iron deficiency is the leading cause of anaemia worldwide and is increasingly treated with intravenous (IV) iron therapy. Staining from IV iron therapy is a rare but significant and preventable adverse event. To mitigate patient harm, a health-service-wide quality improvement project was implemented. This study aimed to determine the real-world impact of a quality improvement project on IV iron staining incidents and preventability. Methods: A retrospective chart audit was undertaken for all IV iron staining episodes reported in a directorate-wide clinical incident reporting database (RiskMan) between 2016 and 2022. Incidence rates of IV iron staining, preventability, and stain severity were compared pre- and post-implementation of a standardized IV iron procedure. Results: Over 7 years, 103 IV iron stains were identified, resulting in a staining rate of 0.31 stains per 100 infusions (pre 0.27% and post 0.34%, P = .25). Implementation of the standardized IV iron procedure resulted in improvements in pharmacist review of the medication order (61.8% versus 89.7%, P < .01), use of the statewide IV iron infusion consent form (27.3% versus 76.9%, P < .01), and appropriate cannula site (14.3% versus 52.5%, P < .01). Smaller stain sizes were associated with cessation of the infusion at identification of extravasation (312 cm(2) versus 35 cm(2)) (P = .04). Preventability was assigned to 86% of stains. Conclusion: The incidence rate of IV iron staining in a real-world clinical setting is 0.31%. There was increased compliance with several best practice principles and 86% of stains were preventable. Early identification and intervention of potential staining incidents results in smaller iron stains for patients. Quality improvement tools developed for this project can contribute to patient outcomes internationally.

BackgroundKnowledge of local antibiotic resistance data provided by antibiograms (cumulative-antimicrobial-susceptibility-tests) can assist prescribers to make appropriate empirical antibiotic choices.ObjectiveThis study explored the perceptions and knowledge of key stakeholders about the role of antibiograms in residential aged care facilities (RACF), and to understand barriers and enablers of antibiogram development and implementation in this setting.MethodSemi-structured interviews were conducted with aged-care health professionals (‘end-users’) and antibiogram content experts. This study was conducted in Queensland, Australia in 2023. Using qualitative techniques, framework thematic analysis was used to identify themes, which were mapped to the ‘Integrated Promoting Action on Research Implementation in Health Services’ framework constructs.ResultsTwenty interviews were conducted comprising of five ‘content-experts’ and fifteen ‘end-users’. Five themes were identified which indicated lack of knowledge about how to use antibiograms, and its availability. Potential insufficient data was the primary issue identified by content experts with regards to feasibility of annual antibiograms. Pragmatic solutions were offered, such as pooling pathology data from facilities in the same geographical location, extending antibiogram data to two-or three-yearly, or utilising local hospital antibiograms. Presenting antibiogram data in a mode and format suiting preferences of individual users would encourage uptake and improve usability. Antimicrobial stewardship (AMS) champions and pharmacists were highlighted as drivers of educating and promoting antibiogram use.ConclusionClinicians recognised the potential role of antibiograms in improving empirical antibiotic prescribing choices. Establishing their baseline knowledge provides an essential starting point for the education needs of this group. This study provides practical recommendations regarding the presentation of antibiograms to ensure appropriate use and uptake as an AMS tool in RACFs. Pragmatic solutions suggested to overcome challenges of antibiogram development for RACFs should be applied and evaluated to determine feasibility of RACF-specific antibiograms.

Increasing the contribution of pharmacists to primary care has been long discussed, particularly in the context of health workforce shortages and the push to better integrate all providers across primary care. This study examines the employment preferences of Australian pharmacy degree holders (PDHs) elicited through a discrete choice experiment (DCE), to better understand the drivers of current labour force choices. A labelled DCE was developed incorporating the six employment sectors: hospital pharmacy, community pharmacy, primary healthcare settings, pharmaceutical industry, government/academia, and non-pharmacy-related sector. Each alternative was described by five attributes using Herzberg's Two Factor Theory as a conceptual framework. They include motivators - role and career opportunities, and hygiene factors-flexible work schedule, geographic location, and salary. Unforced choice data were analysed using conditional logit and mixed logit models. Based on a sample of 678 PDHs in Australia, our findings indicated pharmaceutical industry is the least preferred sector, followed by non-pharmacy-related sector. Motivators in the form of role and career opportunities are the most important attributes in hospital pharmacy while hygiene factors - geographic location and salary significantly drive the choice of community pharmacy and primary care settings. We provided evidence of a willingness to adopt expanded roles in community pharmacy. This unique interpretation of the key drivers of employment preference in light of motivators and hygiene factors provides policy makers with important information when designing policies to attract and retain PDHs across employment sectors.

BACKGROUND:Antibiograms can optimize empirical antibiotic prescribing; however, they are not readily available for residential aged care facilities (RACFs) in Queensland, Australia. This study aimed to determine whether alternatively available data can be used to approximate resistance patterns for RACFs. METHODS:Annual RACF-specific antibiograms were compared with local hospital antibiograms accessed through pathology providers. Additionally, composite antibiograms, of geographically united RACF data, were compared with regional hospital and private pathology RACF antibiograms. Antibiotic susceptibility rates for commonly observed bacteria (Escherichia coli, Klebsiella pneumonia, Enterococcus faecalis, Pseudomonas aeruginosa, and Staphylococcus aureus) were compared among different antibiograms using Fisher exact test, with a P value ≤ 0.05 indicating the statistically significant difference. The concordance among the antibiograms was described by percentage similarity overall and for a subset of clinically relevant pathogen-antibiotic pairs. RESULTS:Composite RACF antibiogram was highly concordant (83%-100% similarity) to private pathology RACF data when compared for clinically relevant pathogen-antibiotic pairs. Mixed results were found when individual RACF-specific antibiograms were compared with local hospital all-ages and ≥ 65 years data (50%-100% and 67%-100% similarity, respectively). CONCLUSIONS:Private pathology RACF antibiograms can serve as a proxy indicator of resistance patterns for RACFs. Mixed findings were noted for comparisons with hospital data.

Background: Hospital pharmacy services support quality use of medicines and medication safety through clinical pharmacy activities such as medication reviews and patient education. These activities can be measured and monitored using evidence-based and standardised key performance indicators (KPIs), which highlight the value of pharmacy services. Standardisation of KPIs supports long-term benchmarking and inter- and intra-site comparisons to target key areas for improvement in clinical pharmacy services.Aim: To describe the type and frequency of clinical pharmacy activity across five hospitals within one metropolitan hospital district.Methods: Key Performance Indicator data were collected by pharmacists from five hospital sites at one metropolitan hospital district, in Queensland Australia. Data were collected over one week for the following clinical settings: inpatient, discharge, outpatient clinic, and the dispensary. Data were collected using a manual, paper-based data collection tool previously developed using a co-design process.Results: Across 11,215 inpatient encounters, hospital pharmacy services provided: best possible medication history (BPMH) within 24 h of admission: 69.5%; daily medication chart review: 57.2%; discharge education: 82.7%, discharge reconciliation: 88.2%; and provision of discharge medication record: 82.4%. Across 1,092 outpatient encounters, pharmacists documented BPMH for 33.3% of patients. Pharmacists identified a total of 5,009 drug-related problems (DRPs) across the data collection period, with the rate of identification highest in the outpatient clinic setting (64.8 per 100 patient reviews) followed by discharge (52.6 per 100 patient reviews) and then inpatient (48.1 per 100 patient reviews). Almost 20% of DRPs identified (n = 975) were high risk.Conclusion: Reporting and benchmarking clinical pharmacy activity through standardised KPIs supports opportunities to identify service improvements. Future research should focus on larger scale studies using routinely recorded data to monitor clinical pharmacy KPIs across all care settings.

Background Direct-to-consumer (DTC) electronic prescription services (EPS) are a novel addition to the Australian healthcare landscape. This study aimed to explore consumers’ perceptions on how this model of care supports the delivery of best-practice care. Method Focus groups participants were recruited through social media and included adults aged 18 years or older, Queensland (Australia) residents, and interested in DTC EPS. Focus groups were conducted via Zoom ® and repeated until data saturation. Inductive thematic analysis was undertaken to elicit consumer perception themes from focus group discussions and field notes. Results Three focus groups were conducted between July and August 2022 and included 13 participants of which two (15%) had previously used DTC EPS. Four major perception themes were induced: (a) Consumer responsibility. There is an assumed level of consumer health literacy leading to an unacceptable burden of responsibility on the patient; (b) System processes appear to be underdeveloped to support best-practice care; (c) Access to convenient and timely healthcare will be improved for many patients, however, out of pocket expenses may promote inequity; and (d) Service model improvements can address safety and quality concerns including integration of the model within existing national digital health platforms. Conclusion Participants believed that DTC EPS was a valuable addition to the Australian health care landscape increasing convenient and timely access to medicines for consumers. Participants were concerned that a heavy reliance on health literacy and underdeveloped system processes may lead to unsafe prescribing.

OBJECTIVE:Knowledge of local antibiotic resistance data, provided by antibiograms (a cumulative summary of in vitro-antimicrobial-susceptibility-test results), can aid prescribing of appropriate empirical antibiotics. This study aimed to explore the feasibility of antibiogram development for residential aged care facilities (RACFs). DESIGN:Retrospective observational study of culture and sensitivity data. SETTING:Nine RACFs in Queensland, Australia. METHOD:Available antimicrobial susceptibility results were collected retrospectively for all residents of recruited RACFs from January 1, 2020, to December 31, 2022. Data were managed and analyzed with WHONET software®, and antibiograms were developed in accordance with the CLSI-M39 guidelines. Antibiogram data beyond the standard 12-months and pooling of data from geographically similar RACFs were explored as options to improve feasibility and validity of the antibiograms. RESULTS:The most prevalent bacteria in the RACFs were Escherichia coli and Staphylococcus aureus. Due to the low number of positive cultures (less than 30) for individual RACFs, an annual antibiogram was not feasible. Extending the time-period to three years improved feasibility of antibiograms for E.coli in seven RACFs and S.aureus in five RACFs. Combining the data from closely located RACFs allowed for sufficient urinary and skin swab isolates to produce annual pooled antibiograms for all three years. CONCLUSION:Use of extended time period antibiograms can provide RACF specific urinary and skin/soft tissue resistance data without the necessity of private pathology provider input. However, pooled syndromic antibiograms can be made available on an annual basis, which may be the preferred option.

Background: Antimicrobial stewardship (AMS) guidelines advocate for the use of antibiograms (cumulative antimicrobial susceptibility test data) as a tool to guide empirical antibiotic prescribing and inform local treatment guidelines. The objective of this review is to evaluate the effectiveness of antibiograms as an intervention to optimize antimicrobial prescribing and patient outcomes. Methods: Embase, PubMed, CINAHL, and International Pharmacy Abstracts (IPA) databases were searched from inception until September 2022, to identify studies of antibiogram-related interventions in all health care settings. The National Institutes of Health Quality Assessment Tools were used to assess the methodological quality of the included studies. Results: Of the 37 included studies, the majority of studies were conducted in the United States (n = 25) and in hospital settings (n = 27). All interventions were multifaceted and in 26 (70%) studies, facility-specific antibiograms could be considered as an integral component of the interventions. A positive impact on antibiotic consumption trends (17 studies), appropriateness of prescribing (16 studies), and cost of treatment (6 studies) was found, with minimal evidence for improvement in mortality, hospitalization, and resistance profiles. Due to the heterogeneity in study designs and outcomes, a meta-analysis was not performed. Conclusions: AMS interventions including antibiograms may improve antibiotic use, appropriateness, and costs. Multifaceted interventions were often used, which precludes drawing conclusions about the effectiveness of antibiograms alone as an AMS tool.(c) 2023 The Author(s). Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

As team-based care continues to evolve, pharmacists have been included in general practice teams in many countries, to varying extents, to improve medication use and patient safety. However, evidence on interprofessional collaboration and team effectiveness of pharmacists in general practice is sparse. This study aimed to compare the extent of interprofessional collaboration and team effectiveness of general practice pharmacists in Australia with international sites (Canada and the UK), and identify the factors associated with interprofessional collaboration and team effectiveness. General practice pharmacists from Australia, Canada, and the UK were identified through professional organisations and networks, and invited to participate in an online survey, adapted from existing validated tools. The survey explored interprofessional collaboration through four sub-domains (professional interactions, relationship initiation, trust and role clarity, and commitment to collaboration) and team effectiveness of general practice pharmacists. Of the 101 respondents (26 from Australia, 44 from Canada and 31 from the UK), 79% were female and 78% were aged below 50 years. Interprofessional collaboration and team effectiveness appeared to be high and similar between countries. Total scores for collaboration of pharmacists were 86.1 ± 7.4 in Australia, 88.5 ± 7.5 in the UK, and 89.1 ± 7.3 in Canada (mean ± SD, where higher scores represent more advanced collaboration), while the team effectiveness scores of the pharmacists were 88.6 ± 14.6 in Canada, 91.8 ± 14.6 in Australia and 97.5 ± 14.0 in the UK. Pharmacists who had worked in general practice for a longer time showed advanced interprofessional collaboration while those who worked exclusively in general practice had higher scores for team effectiveness. Overall, general practice pharmacists in the three countries were highly collaborative with general practitioners. Long-term employment and longer work hours could enhance interprofessional collaboration and team effectiveness in general practice pharmacists by improving trust and working relationships over time.

BACKGROUND:Community pharmacists' active participation in research is essential to build a robust, translatable evidence base. Practice-based research networks (PBRNs) have been established to support collaborative research and knowledge translation in community pharmacies. However, PBRNs' effectiveness in supporting research engagement and knowledge translation remains unexplored. A new PBRN will be implemented in southeast Queensland, Australia. This realist evaluation seeks to explain whether, how, why, for whom, in what context and over what duration the PBRN supports community pharmacists to engage in research.OBJECTIVES:1. to generate transferable knowledge about the different circumstances in which-and the mechanisms by which-a PBRN influences research engagement outcomes for different community pharmacists, in the form of a program theory. 2. To use the program theory to develop evidence-informed recommendations for use by PBRN stakeholders.METHODS:A realist evaluation will be conducted in four iterative phases: (1) theory development, (2) hypothesis generation, (3) observations, and (4) theory refinement. A two-year multi-method study will be conducted, including interviews with pharmacists, surveys, participatory and observational data collection. The evidence will be used to confirm, refute, and/or refine the program theory. The evaluation will adhere to the Realist And Meta-Narrative Evidence Synthesis (RAMESES) publication and quality standards.CONCLUSIONS:The evaluation will contribute to the body of knowledge by generating a realist program theory to explain how, why, for whom, in what contexts, to what extent, in what respects, and over what duration the PBRN supports community pharmacists to engage in research. The findings will support the broader implementation of PBRNs and future network activities.

Pharmacists embedded in general practice can improve medicines optimisation and patient safety, but Australia has been slower to adopt and fund this model than other comparable countries. Over the last decade there have been various local programs integrating pharmacists in general practice across Australia. This article summarises the results of an evaluation in Canberra from 2016–2021. Pharmacists predominantly conducted clinical activities, including medication reviews and clinical audits. General practitioner (GP) acceptance and implementation of medication review recommendations was high (75%). General practice pharmacists were able to achieve positive clinical outcomes in asthma and smoking cessation. Surveys and interviews identified that the general practice pharmacist role was welcomed by patients, GPs, and other healthcare professionals. Patient satisfaction was very high, with patients supporting the expansion of this pharmacy service. Collaboration between the pharmacists and other healthcare professionals was high. Some pharmacists left employment in general practice after less than a year. Introducing a clear job description could be beneficial in retaining pharmacists, improving trust and working relationships, and enhancing collaboration. The majority of clinical activities conducted by the pharmacists had the potential to improve patient care and decrease healthcare costs. Apart from healthcare savings, benefit–cost ratios of income generated and costs reduced by pharmacists when compared to salaries suggested that pharmacists may be cost‐beneficial in some scenarios. Absence of funding for this model of care remains a barrier to wider adoption in Australia and needs addressing. This study was approved by the University of Canberra Human Research Ethics Committee (Project number: 15–235) and funded under the Primary Health Network Program (Grant number: 25097479).

BackgroundMany people experience withdrawal symptoms when they attempt to stop antidepressants. Withdrawal symptoms are readily misconstrued for relapse or ongoing need for medication, contributing to long-term use (> 12 months). Long-term antidepressant use is increasing internationally yet is not recommended for most people. Long-term use is associated with adverse effects including weight gain, sexual dysfunction, lethargy, emotional numbing and increased risk of falls and fractures. This study aims to determine the effectiveness of two multi-strategy interventions (RELEASE and RELEASE+) in supporting safe cessation of long-term antidepressants, estimate cost-effectiveness, and evaluate implementation strategies.MethodsDesign: 3-arm pragmatic cluster randomised controlled trial effectiveness-implementation hybrid type-1. Setting: primary care general practices in southeast Queensland, Australia. Population: adults 18 years or older taking antidepressants for longer than one year. Practices will be randomised on a 1.5:1:1 ratio of Usual care:RELEASE:RELEASE+. Intervention: RELEASE for patients includes evidence-based information and resources and invitation to medication review; RELEASE for GPs includes education, training and printable resources via practice management software. RELEASE + includes additional internet support for patients, and prescribing support including audit and feedback for GPs. Outcome measures: the primary outcome is antidepressant use at 12-months self-reported by patients. Cessation is defined as 0mg antidepressant maintained for at least 2 weeks. Secondary outcomes: at 6- and 12-months are health-related quality of life, antidepressant side effects, wellbeing, withdrawal symptoms, emotional numbing, beliefs about antidepressants, depressive symptoms, anxiety symptoms; and at 12-months 75% reduction in antidepressant dose; aggregated practice level antidepressant prescribing, and health service utilisation for costs. Sample size: 653 patients from 28 practices. A concurrent evaluation of implementation will be through mixed methods including interviews with up to 40 patients and primary care general practitioners, brief e-surveys, and study administrative data to assess implementation outcomes (adoption and fidelity).DiscussionThe RELEASE study will develop new knowledge applicable internationally on the effectiveness, cost-effectiveness, and implementation of two multi-strategy interventions in supporting safe cessation of long-term antidepressants to improve primary health care and outcomes for patients.Trial registration:ANZCTR, ACTRN12622001379707p. Registered 27 October 2022, https://www.anzctr.org.au/ACTRN12622001379707p.aspx

Background: Pharmacist and general practitioner (GP) collaborative models of care are continuing to evolve in the Australian primary care setting. The REMAIN HOME study investigated whether a pharmacist integrated into 14 different primary care teams in general practice (the "practice pharmacist model") reduces readmission to hospital for patients prescribed five or more long term medicines or high risk comorbidities. The aim of this paper is to describe the attitudes of GPs, patients, and practice pharmacists towards this model of pharmacist and GP collaboration.Methods: To explore the views and opinions about the model of care (pharmacist integration into general practice), participating GPs were invited to complete a survey that included the 13-item validated Attitudes Toward Collaboration Instrument for GPs (ATCI-GP) one month after the pharmacist had been integrated into the practice. Survey instruments were also created for patients and pharmacist participating in the intervention. These were deployed after the initial consultation and at the end of the intervention period respectively, to elicit each stakeholders' views and experiences of the service. Data were analysed using descriptive statistics.Results: In total, 48 GPs, 43/101 patients (43%) and 11/13 practice pharmacists (85%) completed the survey. The majority of GPs strongly agreed or agreed with all statements of the ATCI-GP, indicating support for the practice -integrated pharmacist model. Most patients agreed that there was a role for a pharmacist in their general practice (n = 28, 76%), and that they would like to see the pharmacist again (n = 34, 79%). Pharmacists indicated that they enjoyed the role (n = 11, 91%) and found the position professionally satisfying (n = 9, 82%). Most pharmacists agreed that co-location (inside the general practice itself, rather than in a co-located pharmacy) was beneficial (n = 8, 73%) and all pharmacists (100%) acknowledged the benefits of having access to patient medical records. Free text comments from GPs were enthusiastic overall, although some concerns about the financial viability of the model in the current setting were raised. The primary limitation of the study is the anonymous nature of the survey, meaning clustering of responses across the 14 sites could not be determined.Conclusions: A practice pharmacist model of care in the Australian primary care setting appears to be accepted by GPs, patients and practice pharmacists and provides promising evidence that this model of care is likely to be well accepted if implemented more broadly in the Australian healthcare setting, provided that it can be appropriately remunerated.

Introduction: Prescription opioid use and evidence of the harm caused by these medicines has increased over the past 20-30 years. Despite a number of system level interventions, the opioid crisis has not yet resolved in Australia or globally. Pharmacists are increasingly required to take a proactive, clinical role to fulfil their re-sponsibility for patient outcomes relating to both medication efficacy and safety.Aim: To evaluate the current health system guidelines available to pharmacists dispensing opioids and to examine the implications of this guidance on pharmacist responsibility.Methods: A scoping review was conducted by searching in CINAHL, MEDLINE, Embase, PubMed and Web of Science, in addition to the grey literature and referral from topic experts to collate a list of current health system guidelines relevant to pharmacists dispensing opioids. These guidelines were then examined through thematic analysis and the use of the "Appraisal of Guidelines Research & Evaluation-Health Systems" tool (AGREE-HS).Results: Ten health system guidelines were identified in the search. Identified guidelines were published in Australia, the United States, and the United Kingdom. Health system guidelines analysed in this study most commonly provide general practice statements that are not specific to opioid medicines. Current guidelines frequently recommend risk assessment, but less commonly provide implementable risk mitigation advice. Additionally, guidelines are of poor overall quality when analysed through metrics relating to their development and implementation.Conclusion: There are gaps in current health system guidelines which contribute to perceived barriers in phar-macy practice. Current health system guidance does not provide a clear account of the responsibilities of pharmacists when dispensing opioids. This study provides an argument for the development of implementable health system guidelines that support pharmacists in taking direct responsibility for patient outcomes when dispensing opioid medicines.

Empowering people living with dementia to be active partners in conversations about their medicines is imperative. Consumers, people living with dementia and their carers, have reported limited confidence to start conversations with their healthcare professional (HCP) about deprescribing, reducing or stopping, their medicines.1 Co-design is the process of co-producing an output by engaging end users throughout the entire project.2 To co-design impactful, usable, healthcare tools with real-world relevance, key stakeholders should be engaged in the research, not just as participants but as true partners. To our knowledge, deprescribing tools that are co-designed with consumers to meet their individual preferences and beliefs, are currently unavailable in the public domain.3 Form stakeholder group (SG) We conducted the following meetings to date: Future meetings include: We gathered input from SG members to select key elements to include and refined them to create a PRIME tool draft ready for further testing. Examples of key feedback that we incorporated included: Cultural and language differences were noted between the US and Australia. For example, in Australia the term “carers” is used and in the US “caregivers” is used. Additionally, the scope of practice of specific HCPs (e.g., nurse practitioners) may differ depending on the country and the healthcare setting. We are considering these differences as we finalise the PRIME tool. Overall, the discussion between SG members was rich. Some members had opposing views which created a range of possible options. For example, there was discussion about whether to create tailored versions of the PRIME tool for subgroups in the future (e.g., people living with dementia and carers separately; various healthcare settings). Conduct SG meetings Co-design the tool As a research team, we collated a list of potential key elements to include in the PRIME tool based on existing literature.1 During Meeting #2, SG members broke off into smaller groups using Zoom's break-out room function to discuss the key elements. Each group was assigned a research team member to facilitate the discussion. The SG members then discussed their feedback as a whole group, which we used to create the first draft of the PRIME tool. During Meeting #3, SG members provided feedback on wording and formatting of the tool. Meeting #4 focused on reviewing a guide to test the tool's usability and comprehensibility via interviews and focus groups with people living with dementia, carers and HCPs. Meetings #5 and #6 discussed interview findings and further revisions to the tool. We also elicited feedback from our SG to co-design the design of the pilot study in Meeting #6. Our pilot study aims to test the feasibility of implementing the PRIME tool in practice. The methods and findings from our alpha-testing (interviews, focus groups) and beta-testing (pilot study) will be published separately. Overall, SG members were engaged and enjoyed the co-design process of the PRIME tool. For example, one SG member stated, “It has been an absolute delight being a part of this design consultative group.” The SG members also reported that they believed the tool would address an unmet need for resources to encourage and enable consumers to engage in medicine reviews. There was consensus amongst SG members to include three sections: (a) Background: information about reviewing medicines and medicine-related harm; (b) Self-reflection: questions from the Revised Patients' Attitude Towards Deprescribing (rPATD) questionnaire for people with mild cognitive impairment and mild-to-moderate dementia (rPATDcog),7 which invites consumers to answer how willing they are to have one or more of their medicines deprescribed if recommended by a doctor; (c) Call-to-action: example phrases to empower consumers to start deprescribing conversations. To improve the content of the tool, our SG put forward several suggestions (Table 1), which we implemented to improve the PRIME tool's usability in practice. Identifying meeting times: People living with dementia may have limited times in the day when they have more energy (e.g., in the morning or the middle of the day).8 These times often clash with HCPs' schedules who may be busiest at those times. Given this, identifying convenient times to meet was challenging. Recommendation(s): We recommend gathering individuals' preferences to meet using a Doodle poll. We offered times that are early in the morning to accommodate both consumers' and HCPs' preferences. If members were unavailable to attend the meeting, we provided them the opportunity to meet separately at a different time. Incorporating cultural and language differences: We noticed cultural and language preference differences (Table 1). Recommendation(s): We recommend taking full advantage of incorporating the SG's diverse and rich feedback by using a framework for guidance. To achieve this, we used the Comparative Effectiveness Framework to ensure the tool's relevance to an international audience. Forging connections between a new group of people: Given that our SG had a mixture of HCPs and consumers, the potential for a “power imbalance” to exist was present. Recommendation(s): We recommend working as a research team to facilitate communication between the group to hear and include every member's voice. We also recommend orientating the members in the first meeting by facilitating introductions of SG members, explaining co-design concepts, familiarising members with the project and encouraging their feedback. We also recommend using break-out rooms with a small number of people3-6 to allow people to get comfortable with other members. These recommendations along with maintaining values such as respect and transparency translated into members' comfort to speak up even within the larger group. Engaging the SG: Maintaining interest and engagement of the SG over an extended period (1–2 years) of research is challenging. Recommendation(s): We recommend transparently providing SG members with an upfront timeline. We also recommend informing people, as soon as feasibly possible, when meetings would be. We aimed to have one meeting every 3–4 months to maintain engagement. We also recommend regular correspondence with SG members via email to provide updates and communicate potential delays in the progress of research plans. Considering SG members' capacity to be involved: Overtime, SG members might experience changes to their health or caring responsibilities, which impacts their involvement. Recommendation(s): We recommend employing a flexible approach by providing them the opportunity to end their involvement at any time. We also recommend collecting their feedback via practical avenues, such as e-mail correspondence. Fairly remunerating SG members: Limited guidance exists for researchers to achieve fair remuneration. Recommendation(s): We recommend checking local guidance regarding consumer renumeration. We were guided by South Australia health consumer guidelines and chose to remunerate both consumers and HCPs equally.9 We incorporated SG payment into our grant's budget to ensure the project's feasibility. Determining the size of the SG and managing the SG's diversity: It can be challenging to determine the ideal size of a SG, and appropriate diversity between SG members, for maximal knowledge exchange. Recommendation(s): We recommend leaning on similar co-design research to guide the size of your SG for effective engagement.6, 10 Taking this into consideration, we aimed to invite up to 12 members in total, the majority of whom are people with lived experiences with dementia and some HCPs. To bridge members' variability of health information and experiences, we recommend developing and using consumer-facing materials, such as PowerPoint presentations, to guide discussion. These strategies along with our SG members being respectful of other members' opinions, even when they differed from their own, enabled us to facilitate a rich discussion. Deciding the number of SG members and meetings needed: To ensure there is ample opportunity for all members to provide feedback, an adequate number of SG meetings is needed. This decision needs to be balanced against budget considerations and avoiding overburdening the SG. Recommendation(s): Based on previous similar research, we recommend holding between six to eight meetings whilst taking into consideration meeting research goals and budget targets. Previous research has shown that consumer engagement through the provision of health information can be a successful deprescribing strategy.11 Similarly, partnering with our SG enabled us to successfully co-design a deprescribing communication tool for people living with dementia and their carers. We will continue to work alongside our SG to complete our research program's next steps. These include feasibility and pilot testing the implementation of the PRIME tool in clinical practice followed by the pragmaticly embedding the PRIME tool in various healthcare settings. Once ready for use, we will widely disseminate the PRIME tool, in collaboration with partner organisations, so that it may reach all end-users who may benefit the most from its use. We would like to acknowledge Dementia Australia, Step Up for Dementia Research, and our stakeholder steering group members who supported this research. We would also like to acknowledge the US Deprescribing Network and the University of Washington's Plein Centre for Geriatric Pharmacy support towards this research. Open access publishing facilitated by The University of Queensland, as part of the Wiley - The University of Queensland agreement via the Council of Australian University Librarians. Dr Reeve receives honoraria for co-authoring a chapter on deprescribing in UpToDate and from the Society of Hospital Pharmacists of Australia (leading workshops on deprescribing).

Abstract Background: Pharmacists working in general practices provide medication reviews with suggestions to general practitioners to implement their recommendations to optimise medications. The next step is a model where the pharmacist takes on responsibility for implementing their recommendations. Aim: To explore the feasibility of an expanded model of collaborative pharmaceutical care in which the pharmacist has increased responsibility to manage patients with chronic diseaseMethod: This was a prospective cohort study (March to September 2018). A pharmacist developed a collaborative pharmaceutical care plan to identify drug related problems in patients with chronic disease in three general practices. The pharmacist consulted with the general practitioner discussing recommendations to manage drug related problems identified and recommendations the general practitioner was happy for the pharmacist to implement. The pharmacist implemented agreed recommendations and followed patients for six months. Outcome measures included number of recommendations implemented and drug related problems identified.Results: The pharmacist made 135 recommendations to optimise medicine use of which 126 (93.3%) were accepted by the general practitioner with 105 (83.3%) implemented by the 6-month follow up. The pharmacist was responsible for implementing 62 (49.3%) of the 126 accepted recommendations. The median number of drug related problems per patient reduced at six months compared to baseline (5 [IQR 3.3 – 7.0] vs. 2 [IQR 1.0 – 3.0]). Conclusion: The results confirm the feasibility of a pharmacist-general practitioner collaborative model within a general practice setting in Australia. The general practitioner accepted a high proportion of the pharmacist’s recommendations and almost half were implemented by the pharmacist.

Polypharmacy increases the risk of adverse drug events and drug–drug interactions, and contributes to falls, hospital admissions, morbidity and mortality. Veterans with post-traumatic stress disorder often have psychological and physical comorbidities, increasing the likelihood of general and psychotropic polypharmacy. This study investigates the prevalence of general and psychotropic polypharmacy in inpatient veterans with post-traumatic stress disorder, and illustrates potential risks associated with polypharmacy in this population. Medical records of 219 veterans admitted to a mental health facility for post-traumatic stress disorder management were retrospectively reviewed. Medication lists on admission were extracted and coded according to Anatomical Therapeutic Chemical Classification classes. The prevalence of general (five or more total medications), psychotropic (two or more N-code medications), and sedative (two or more medications with sedating effects) polypharmacy and Drug Burden Index were calculated. Class combinations were reported, and associations between demographic characteristics and polypharmacy were determined. Mean age was 62.5 (± 14.6) years. In addition to post-traumatic stress disorder, 90.9% had a diagnosis of at least one other psychiatric condition, and 96.8% had a diagnosis of at least one non-psychiatric medical condition. The prevalence of general polypharmacy was 76.7%, psychotropic polypharmacy was 79.9% and sedative polypharmacy was 75.3%. Drug Burden Index scores ranged from 0 to 8.2, with 66.2% of participants scoring ≥ 1. This cohort of inpatient veterans with post-traumatic stress disorder had a high prevalence of general, psychotropic and sedative polypharmacy, and were at high risk for drug-related adverse events. This highlights the importance of increasing awareness of polypharmacy and potentially inappropriate drug combinations, and the need for improved medication review by prescribers.

Background Pharmacists working in general practices provide medication reviews with recommendations to general practitioners (GPs) to optimise medications. We describe a model where the pharmacist is empowered with increased responsibility to implement agreed recommendations through collaborative prescribing. Aim To assess a collaborative pharmacist prescribing model incorporating increased pharmacist responsibility, for patients with chronic diseases in general practice. Method This was a pre-test-post-test quasi experimental pilot study using a pharmacist embedded in three Australian general practices. A pharmaceutical care plan was developed with patients and their GP to identify drug related problems (DRPs). The pharmacist discussed recommendations to manage DRPs with the GP and implemented recommendations agreed by the GP and patient over the six-month study period. Outcome measures included acceptance and implementation rate of recommendations made by the pharmacist. Results The pharmacist made 135 recommendations to optimise medicine use of which 126 (93.3%) were accepted by the GP. There were 105 (83.3%) implemented by the end of the study of which the pharmacist implemented 62 (49.3%). Conclusion Compared to other Australian studies using a general practice pharmacist model, this study suggested increased pharmacist responsibility through collaborative prescribing led to high acceptance and implementation rates of recommendations to manage DRPs.

Personalised medicine aims to move goldstandard care away from empiric prescribing for a typical patient towards tailored treatment for the patient as an individual.1 It is well known that the effect of a medicine on an individual can vary based on factors including sex, genetics and even hormones. Currently, the personalisation of medicines to adjust for factors such as these is limited by the doses and combinations that are commercially available. This inflexibility makes it difficult for clinicians to tailor the medication for individual needs. One technology that could revolutionise personalised medicine is a process called additive manufacturing. In this process, a threedimensional (3D) object is produced by fusing thin layers of materials on top of each other until the complete object is formed. This 3D printing method could be applied to medicines to include several drugs in a single tablet at entirely customisable doses set by the clinician, such as the proof of concept fiveinone polypill developed in 2015.2