Background Many countries have high opioid use among people with chronic non-cancer pain. Knowledge about effective interventions that could be implemented at scale is limited. We designed a national intervention that included audit and feedback, deprescribing guidance, information on catastrophising assessment, pain neuroscience education and a cognitive tool for use by patients with their healthcare providers. Method We used a single-arm time series with segmented regression to assess rates of people using opioids before (January 2015 to September 2017), at the time of (October 2017) and after the intervention (November 2017 to August 2019). We used a cohort with historical comparison group and log binomial regression to examine the rate of psychologist claims in opioid users not using psychologist services prior to the intervention. Results 13 968 patients using opioids, 8568 general practitioners, 8370 pharmacies and accredited pharmacists and 689 psychologists were targeted. The estimated difference in opioid use was −0.51 persons per 1000 persons per month (95% CI −0.69, –0.34; p<0.001) as a result of the intervention, equating to 25 387 (95% CI 24 676, 26 131) patient-months of opioid use avoided during the 22-month follow-up. The targeted group had a significantly higher rate of incident patient psychologist claims compared with the historical comparison group (rate ratio: 1.37, 95% CI 1.16, 1.63; p<0.001), equating to an additional 690 (95% CI 289, 1167) patient-months of psychologist treatment during the 22-month follow-up. Conclusions Our intervention addressed the cognitive, affective and sensory factors that contribute to pain and consequent opioid use, demonstrating it could be implemented at scale and was associated with a reduction in opioid use and increasing utilisation of psychologist services.

Tinnitus is among the top three most frequently accepted service-related conditions for Australian veterans. Veterans have described the effects of tinnitus as causing physical, emotional and social problems. In addition, many veterans with tinnitus, especially those with troublesome tinnitus, have other health conditions, such as hearing loss, insomnia, anxiety and depression. Research suggests tinnitus develops due to maladaptive neural changes in auditory and non-auditory pathways. This is thought to be due to actual or potential physical or psychological trauma. Hence, treatments focusing on physical and psychological factors, including emotional, attentional, behavioural and social aspects, obtain the best outcomes in reducing tinnitus-related distress. The most promising therapy to address these factors is cognitive behavioural therapy, particularly in a multidisciplinary setting, for which robust evidence exists.

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

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

BACKGROUND Poor recognition of medicine-induced dry mouth can have a number of adverse effects, including difficulties with speech, chewing and swallowing dry foods, gum disease, dental caries and oral candidosis. This study examined the prevalence of use of medicines that cause dry mouth and claims for dental services funded by the Department of Veterans' Affairs (DVA) in an Australian cohort. METHODS We used the DVA administrative health claims data to identify persons using medicines that can cause dry mouth at 1st of September 2016 and determine their DVA dental claims in the subsequent year. Results were stratified by gender, residence in community or residential aged cared facility, and number of medicines. RESULTS We identified 50,679 persons using medicines known to cause dry mouth. Of these, 72.6% were taking only one medicine that may cause dry mouth, and 21.6% were taking two. Less than half (46.2%) of all people taking at least one of these medicines had a dental claim in the following year. A smaller proportion of women (35.9%) made claims than men (56.9%), χ2 = 2248.77, p<.0001. CONCLUSIONS Targeted interventions raising awareness of the relationship between some medicines and dry mouth, and the importance of dental visits are warranted.

Older people might be embarrassed to talk about falling as they worry this may be judged as a loss of their ability to live independently. Ask older patients, at least yearly, if they ever feel unsteady on their feet or if they have fallen. Consider whether medicines may be contributing to feelings of unsteadiness or falling. Drugs such as benzodiazepines and selective serotonin reuptake inhibitors, particularly if taken together, are associated with a risk of falling and hip fracture. Review the patient's treatment regimen to see if there are drugs that are no longer required. Psychotropic drugs should usually be tapered gradually so that adverse effects can be minimised. Involve a range of health professionals to identify and manage the risk of falls. Help patients stay physically active, independent and socially connected.

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

BackgroundRenal function is an important prescribing consideration. On average, glomerular filtration rate declines by about 10 mL/min every 10 years after the age of 40. Renal impairment may cause medicines to accumulate or cause toxicity, especially if the medicine has a narrow therapeutic index.ObjectiveTo present an overview of prescribing considerations in the primary care setting for patients with chronic renal impairment.DiscussionSerum creatinine considered in isolation is not a reliable indicator of renal function. The estimated glomerular filtration rate provided in pathology reporting can alert prescribers to possible renal impairment and the need to consider dose adjustments. The Cockcroft-Gault equation should be used to adjust medicine doses. Renal function monitoring is recommended for patients using medicines that can impair renal function or cause nephrotoxicity (eg. NSAIDs, ACEIs, ARBs).

BACKGROUND:Older people with dementia may be particularly susceptible to cognitive impairment associated with anticholinergic and sedative medicines. This impairment may be misattributed to the disease process itself.OBJECTIVE:This review examines clinical considerations associated with using anticholinergic and sedative medicines in people with dementia or incipient cognitive impairment. It highlights issues associated with concomitant use of cholinesterase inhibitors and anticholinergic medicines, and pharmacotherapy of conditions that commonly occur in people with dementia.DISCUSSION:Use of medicines with anticholinergic or sedative properties may result in adverse events by increasing the overall anticholinergic or sedative load. Patients may benefit from clinicians reviewing the anticholinergic load of the current medicine regimen before the initiation of cholinesterase inhibitors or memantine. Reducing the number and dose of anticholinergic and sedative medicines may improve cognitive function and reduce the likelihood of adverse events.

BACKGROUND:Osteoporosis remains undertreated in Australian primary care, with as few as 30% of postmenopausal women with a fracture and 10% of men with osteoporosis receiving pharmacological treatment.OBJECTIVE:This article presents an overview of the pharmacological management of osteoporosis in older people in the general practice setting.DISCUSSION:Lifestyle factors and ensuring adequate calcium and vitamin D intake are important in preventing and treating osteoporosis. Pharmacological treatments are recommended for patients with a minimal trauma fracture, for those aged 70 years or over with a T-score of -3.0 or lower, or for those who are currently taking prolonged high dose corticosteroids and who have a T-score of -1.5 or lower. Bisphosphonates are recommended as first line therapy for established postmenopausal osteoporosis. Medicine selection is guided by patient gender, menopausal status, medical and fracture history, patient preference and eligibility for government subsidy.

Introduction: Obstructive Sleep Apnea (OSA) is a chronic disease with long term complications. OSA is a disease more prevalent in men and seen in higher prevalence amongst Veteran populations. Medical management of OSA includes CPAP to maintain airway patency. An additional program targeting factors contributing to OSA, comorbidities and lifestyle factors, including weight loss as a goal, could reduce excessive daytime sleepiness and improve other health outcomes. The intent of this pilot project was to evaluate the feasibility and acceptability of using the Flinders Program to BLOCKINtarget BLOCKINrisk BLOCKINfactors, BLOCKINas BLOCKINwell BLOCKINas BLOCKINmanage BLOCKINchronic BLOCKINdisease BLOCKINin patients with OSA Methods: Adelaide Institute for Sleep Health Physicians recruited patients with moderate to severe OSA (AHI≥30)At BLOCKINthe BLOCKINinitial BLOCKINappointment they were asked to complete baseline questionnaires (demographics, HADS, ESS, PACIC) and then they commenced the Flinders program with a trained clinician: this included jointly creating a care plan and identifying and setting goals with the intention of improving tenacity and motivation with OSA therapies as well as other problems and comorbidities. Referrals were provided to a commercial meal replacement program and health resources as required. Contact was maintained by a clinician to support behaviour change and participants attended two additional appointments BLOCKINat BLOCKINsix BLOCKINweeks BLOCKINand BLOCKINfour BLOCKINmonths BLOCKINlater.

Background: There is scant information on the types of musculoskeletal injuries, their causes and injury patterns that are sustained by Australian garrison soldiers (a permanent military post or place where troops are stationed). Rigorous physical training, manually emplacing weapon systems and daily military duties carried out by soldiers of the 16th Air Defence Regiment reflect the types of injuries observed in this study. It defines the injury patterns for trained soldiers and addresses those aspects of injury and mechanism of injury, forming the basis for further research targetted at injury prevention. Purpose: To identify the predominant musculoskeletal injuries sustained by soldiers of the 16th Air Defence Regiment and to explore the relationship between the type of injury and subunit as well as the relationship between type of injury and cause. This is important so that remedial measures can be engaged in an attempt to reduce the incidence of musculoskeletal injury to Australian soldiers, to maintain the regimental fighting strength and deployable status and to reduce the financial burden of rehabilitation and compensation borne by the Australian Defence Force and the Federal Government. Materials and Methods: All patients were trained serving soldiers of the 16th Air Defence Regiment and were referred by the Medical Officer for physiotherapy treatment. On conclusion of a course of treatment, a physiotherapy patient discharge summary (PM 528) was written and it is from these summaries that the demographic data for this study was extracted, which included the type of musculoskeletal injury (diagnosis), cause of that injury and the subunit that the soldier belonged to in the 16th Air Defence Regiment during the years 2008 to 2010. Tests of significance based on the chi-square test statistic were carried out at the 0.05 significance level using Minitab 16 statistical software. When the chi-square test of independence was significant, then the source of the dependence was investigated by analysis of standardised residuals for each cell. Results: Five predominant types or areas of injury sustained by Australian soldiers of the 16th Air Defence Regiment were identified to be neck, low back, ankle, patella and knee ligament. The frequency of low back injuries was found to be significantly higher than the other types of injury (chi-square goodness of fit test, p < 0.001, then analysis of standardised residuals with Bonferroni adjustment). There was insufficient evidence of a relationship between type of injury and subunit (chi-square test of independence, p = 0.33). Five predominant causes of musculoskeletal injury were identified to be biomechanical, work, running, sports and physical training. Evidence of a relationship between type of injury and cause was found to be statistically significant (chi-square test of independence, p < 0.001) in the cause ‘sports’, which is associated with a relatively higher frequency of ankle inversion injuries, and ‘running’, which is associated with a relatively higher frequency of patella-femoral joint injuries (p < 0.002). Conclusion: This is the first full review of data on musculoskeletal injuries sustained by Australian soldiers of the 16th Air Defence Regiment. Types of musculoskeletal injuries and causes were analysed and patterns of injury were identified. Measures can now be drawn up with the aim of injury prevention.