AIM:The TEN-SPIDERS framework provides a structured approach to calculating and reporting the proportion of days covered (PDC) in medication adherence research, but gaps remain in operationalizing this framework into statistical code. We aimed to develop an open-source tool to standardize PDC calculation against parameters of the TEN-SPIDERS reporting framework. METHODS:Phase 1 involved developing the Stata statistical tool to enable flexible adjustment of TEN-SPIDERS PDC parameters: threshold, eligibility, numerator, in-hospital stays, dose imputation, early refills and survival. The tool was developed to align with established data definitions, variable schemas and person-level record structures in linked Australian Pharmaceutical Benefits Scheme (PBS) datasets, with scope for interoperability across similar international systems. In Phase 2, PDC was estimated in a linked PBS dataset for survivors of myocardial infarction (37 919 statin users and 29 163 P2Y12 inhibitor users). The impact of different TEN-SPIDERS adjustments was evaluated against basic settings and a pre-existing Stata package (MedAdhere). RESULTS:The TEN-SPIDERS tool was developed to support reproducible PDC calculations. While computation time was similar to the pre-existing MedAdhere package (116.5 vs. 100.2 s), the TEN-SPIDERS tool had greater flexibility to incorporate adjustments for different medication-taking situations. A bivariate comparison between different settings of TEN-SPIDERS highlighted a strong correlation (Pearson's r: >.9) with MedAdhere, with additional adjustments reducing Pearson's correlation from .987 to .921. CONCLUSION:The TEN-SPIDERS tool provides a transparent, reproducible and efficient open-source method for medication adherence research within Australia, with potential applicability to similarly structured international datasets. Adoption of this tool will support global efforts for standardization in medication adherence research.

Background: Non-adherence to lipid-lowering therapy (LLT) affects up to half of patients and contributes substantially to preventable cardiovascular morbidity and mortality. Existing measures, such as the proportion of days covered, provide cross-sectional summaries but fail to capture the dynamic patterns of adherence over time. Although group-based trajectory modelling identifies distinct longitudinal adherence patterns, no approach currently predicts trajectory membership prospectively while incorporating patient-reported barriers. We developed BRIDGE, a barrier-informed Bayesian model to predict adherence trajectories and identify their underlying drivers. Methods: BRIDGE incorporates patient-reported barriers as structured prior information within a Bayesian framework for adherence-trajectory prediction. The model was designed not only to estimate which patients are likely to follow different adherence trajectories, but also to generate clinically interpretable probability estimates that help explain why those trajectories may arise and what modifiable factors may be most relevant for intervention. Results: BRIDGE achieved a macro AUROC of 0.809 (95% CI 0.806 to 0.813), comparable to random forest (0.815 (95% CI 0.812 to 0.819)) and XGBoost (0.821 (95% CI 0.818 to 0.824)), two widely used machine-learning benchmarks for structured clinical prediction. Calibration was superior to random forest (Brier score 0.530 vs 0.545; ), and performance was stable across six independent training runs (AUROC SD = 0.003). Incorporating barrier-informed priors improved accuracy by 3.5% and calibration by 5.5% compared to flat priors, showing that incorporation of patient-reported barriers added value beyond electronic medical record data alone. Four clinically distinct adherence trajectories were identified: gradual decline associated with treatment deprioritisation amid polypharmacy (10.4%), early discontinuation linked to asymptomatic risk dismissal (40.5%), rapid decline associated with intolerance (28.8%), and persistent adherence (20.2%). Counterfactual analysis identified trajectory-specific intervention levers. Conclusions: BRIDGE provides accurate and well-calibrated prediction of adherence trajectories while offering clinically actionable insights into their underlying drivers. By integrating patient-reported barriers with routine clinical data, the model supports targeted, mechanism-informed interventions at the point of prescribing to improve adherence to cardioprotective therapies. Funding MRFF CVD Mission Grant 2017451 ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Funding by MRFF CVD Mission Grant 2017451 ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethics approval was obtained under Monash University Human Research Ethics Committee (MUHREC) project number 40627. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data underlying this article will be shared on reasonable request to the corresponding author and subject to approval by stakeholders.

BACKGROUND:Acromial stress fractures can occur after reverse total shoulder arthroplasty (rTSA). We performed this study to assess the incidence, risk factors, characteristics, and outcome of acromial stress fractures and reactions after rTSA. METHODS:We determined the incidence of acromial stress fractures and reactions in a cohort of patients who underwent rTSA, and assessed risk factors using a case-control design. Each patient who developed an acromial stress fracture or reaction after rTSA (case) was matched by date of rTSA with 2 patients who did not develop acromial stress fractures/reactions after rTSA (control subjects); univariate and multivariable analyses were performed to identify risk factors. Characteristics of acromial stress fractures/reactions are described. Outcomes were compared between cases and control subjects. RESULTS:The incidence of acromial stress fracture/reaction after rTSA was 11% (24/220 rTSAs). Acromial stress fractures/reactions occurred at a median time of 5.5 months after rTSA (range: 20 days-118 months) and most were fractures (18/24, 75%). Using a multivariable analysis, we found 2 factors to be independently associated with the occurrence of an acromial stress fracture/reaction after rTSA: corticosteroids use (adjusted OR: 9.6, 95% confidence interval: 1.1-86.1, P = .04) and previous shoulder surgery (adjusted OR: 7.2, 95% confidence interval: 1.4-36.6, P = .02). In this cohort, in which the management was exclusively conservative, the occurrence of post-rTSA acromial stress fracture/reaction was associated with a significantly worse functional outcome at last follow-up visit, as compared with control subjects. This was illustrated by significantly lower American Shoulder and Elbow Surgeons Shoulder score, higher Shoulder Pain and Disability Index and Disabilities of the Arm, Shoulder and Hand scores, and worse forward elevation and internal rotation as compared with control patients who did not develop acromial stress fracture/reaction after rTSA. CONCLUSIONS:In our Australian cohort, acromial stress fractures/reactions were relatively common after rTSA, and independently associated with corticosteroids use and previous shoulder surgery. The occurrence of acromial stress fracture/reaction was associated with a significantly worse functional outcome, as compared with patients who do not develop this complication after rTSA.

INTRODUCTION:The absence of guidance on pharmacological management of urinary incontinence (UI) for individuals with dementia may lead to potentially avoidable medication-related harm. This systematic review aimed to evaluate efficacy and safety of medications for managing UI in people living with cognitive impairment, dementia, or in long-term care. METHODS:Four bibliometric databases were searched for randomized control trials (RCTs) from inception to March 2026. Risk of bias was assessed using the Joanna Briggs Institute critical appraisal tool for RCTs. Efficacy, adverse events (ADEs), and cognitive effects were synthesized. RESULTS:Nine RCTs (N = 310 participants) were included (all had possible risk of bias). Efficacy of oral anticholinergics ranged from no significant effects to 17% greater reduction in UI symptoms compared with placebo, while oral estrogen demonstrated no significant effects compared with placebo. Dry mouth was the most common ADE for oral anticholinergics (n = 61/194 participants in intervention vs. 26/194 in control across 4 trials). Oral anticholinergic effects on cognition (reported in three trials) ranged from no significant effects to statistically significant short-term declines in attention/alertness compared with placebo. CONCLUSIONS:UI medications for people with cognitive impairment or dementia should be prescribed cautiously, with consideration of possible benefits and harms. PROSPERO:https://www.crd.york.ac.uk/PROSPERO/view/CRD420251270946.

Psychotropic medication use remains highly prevalent in dementia despite guidelines recommending against routine use. The Evidence-based Medication knowledge Brokers in Residential Aged CarE (EMBRACE) trial evaluated the effectiveness and cost of using knowledge brokers to implement Australia’s Clinical Practice Guidelines for the Appropriate Use of Psychotropic Medications for People Living with Dementia and in Residential Aged Care. This 12-month helix-counterbalanced randomised controlled trial conducted between October 2023 and September 2024 evaluated three residential aged care facility (RACF)-level implementation strategies for antipsychotics, benzodiazepines and antidepressants. The strategies were: passive distribution of the Guideline (Level 1), quarterly pharmacist-led staff education (Level 2), and tailored implementation led by an onsite knowledge broker pharmacist (Level 3). Nineteen RACFs across four Australian states participated. The primary outcome was a composite measure of overall Guideline non-concordance for antipsychotics, benzodiazepines and antidepressants, comparing the Level 3 intervention with Level 1 and Level 2 at 6-months. Secondary outcomes included overall non-concordance at 3-, 9- and 12-months, and non-concordance with specific Guideline recommendations at all time points. Linear mixed models were used to analyse the primary and secondary outcomes. A cost consequence analysis was also conducted. Differences in overall non-concordance between intervention levels at 6 months (primary outcome) were not observed (Level 3 versus Level 2: −0.02 [95

INTRODUCTION:High-risk medications are medications associated with significant patient harm or death if misused or used in error. This study aimed to develop a national consensus high-risk medication list for use in Australian residential aged care. METHODS:A 3-round modified Delphi study involving Australian healthcare professionals was conducted. In Round 1, participants indicated their level of agreement, on a 9-point Likert scale, whether 60 medications/medication classes were considered high-risk and should be included in a high-risk medication list for Australian residential aged care. Round 2 included medications/medication classes that did not reach consensus and new medications identified by participants. Consensus was defined as 70% or more of participants responding at 7 or higher on the Likert scale. In Round 3, participants were asked to prioritise medications/medication classes that reached consensus in Round 1 or 2. RESULTS:In total, 42 participants completed Round 1, and 35 (83%) completed all three rounds. Participants included pharmacists (n = 21), prescribers (n = 15), nurses (n = 5) and a paramedic (n = 1), with representation from all Australian states and mainland territories. Overall, 26 medications reached consensus (21 in Round 1, five in Round 2) and were categorised into 15 medications/medication classes for prioritisation in Round 3. The final prioritisation list was opioids, insulin, benzodiazepines, anticoagulants, z-drugs, antipsychotics, lithium, sulfonylureas with high risk of hypoglycaemia, chemotherapeutic agents, methotrexate, digoxin, narrow therapeutic range antiepileptics, tricyclic antidepressants, immunosuppressants for transplant and sedating antihistamines. DISCUSSION:This is the first, national consensus list of high-risk medications developed specifically for Australian residential aged care. It can be used to implement targeted strategies to minimise medication-related harm.

BACKGROUND:Knowledge brokers act as intermediaries to bridge evidence-to-practice gaps. Limited evidence describes how the knowledge broker role in health settings evolves over time. This study aimed to (a) examine the evolution of knowledge broker activities over a 12-month implementation trial and (b) identify enablers necessary to strengthen and support the role. METHODS:This longitudinal multi-method study is nested within the 12-month Evidence-based Medication knowledge Brokers in Residential Aged CarE (EMBRACE) trial. The EMBRACE intervention involved knowledge brokers working in 19 residential aged care facilities (RACFs) to support implementation of Australia's Clinical Practice Guidelines for the Appropriate Use of Psychotropic Medications in People Living with Dementia in Residential Aged Care. Seventy-six knowledge broker local action plans, representing 19 RACFs at four time points, were analysed to characterise core knowledge broker functions and the frequency of planned quality improvement activities targeting seven pre-defined sub-indicators of psychotropic appropriateness. The Consolidated Framework for Implementation Research informed thematic analysis of 76 separate quarterly written reflections and 28 semistructured interviews with knowledge brokers. RESULTS:The number and breadth of knowledge broker activities increased over time. At baseline, six RACF local action plans included activities targeted towards at least one sub-indicator, increasing to all 19 local action plans from the 3-month timepoint onwards. Knowledge brokers enacted overlapping functions as knowledge managers, linkage agents and capacity builders, although the timing and extent of role progression varied across RACFs and individuals. Evolution of activities was shaped by individual (clinical leaders, implementation facilitators, peer support) organisational (culture, governance pathways, digital integration) and outer setting factors (COVID-19 disruptions, national policy directives). CONCLUSION:The knowledge broker role fundamentally evolved from assessing local context and establishing foundational rapport to driving systemic change. Effective translation of guidelines into practice requires future implementation programmes to support this role with a strong organisational culture, robust infrastructure and strategic alignment with RACFs and national priorities.

BACKGROUND:Australia recently became the first country to reschedule methylenedioxymethamphetamine (MDMA) to permit authorized prescribing for post-traumatic stress disorder (PTSD) outside of clinical trials. This study explored the direct experience of Australian clinicians, researchers, and patients regarding the use of MDMA-assisted psychotherapy (MDMA-AP) for PTSD to inform guideline development. METHODS:In-depth semi-structured interviews were conducted with clinicians, researchers, and patients who had direct experience with the use of MDMA-AP or PTSD. Interviews were transcribed verbatim and coded. Themes were developed using both inductive and deductive approaches (guided by the World Health Organization Guide to Good Prescribing framework). RESULTS:Twenty-one interviews were conducted with clinicians (mental health-focused general practitioners, psychiatrists, psychologists, therapists), researchers (health economist, pharmacologist, social worker, trial researcher), and patients. Eleven themes emerged: (1) role of MDMA-AP in relation to established PTSD therapies; (2) importance of expectation management and shared decision-making; (3) perceived therapeutic benefits of MDMA-AP; (4) importance of comprehensive baseline screening (medical, psychological, financial, and social support); (5) variable patient values and preferences; (6) desire for flexible treatment protocols; (7) importance of comprehensive and ongoing consent; (8) duty of care in establishing strong therapeutic alliance; (9) patient need for information about process and logistics; (10) treatment monitoring and discontinuation; and (11) importance of post-treatment continuity of care. CONCLUSION:Australians with direct experience of the use of MDMA-AP or PTSD highlight the importance of expectation management, comprehensive screening, consent, safeguard measures, therapeutic alliance, integration of care, and training of healthcare providers. As MDMA-AP becomes implemented into clinical practice, there is scope to incorporate these insights into a national guideline.

BACKGROUND:Statins, renin-angiotensin system inhibitors (RASIs) and beta-blockers are guideline-recommended cardiovascular medications post-myocardial infarction (MI) for secondary prevention, but evidence for people with dementia is scarce. OBJECTIVE:To evaluate the association between post-MI cardiovascular medication use and the risk of cardiovascular outcomes and mortality, focusing on people with dementia. DESIGN:Large retrospective cohort study using data from Australia, Finland, Taiwan, the UK and the USA. SUBJECTS:People with and without dementia. METHODS:Seven exposure groups were assigned using one or combinations of the three guideline-recommended medication classes-(i) statin, RASI and beta-blocker, (ii) statin and beta-blocker, (iii) statin and RASI, (iv) RASI and beta-blocker, (v) statin only, (vi) beta-blocker only and (vii) RASI only, based on medication records during a 60-day landmark period post-MI. Recurrent MI, major adverse cardiovascular event (MACE) and all-cause mortality were evaluated as outcomes. Jurisdiction-specific results were pooled together using meta-analyses. RESULTS:A total of 28 122 people with dementia and 260 360 people without dementia were included. Among people with dementia, using any single or two medications carried a similar risk of recurrent MI and MACE as using all three guideline-recommended medications, except that using RASI and a beta-blocker without a statin was associated with a lower risk of recurrent MI (HR 0.85; 95% CI, 0.75-0.96). Using a statin and RASI without beta-blockers resulted in similar all-cause mortality to using all three (HR 1.16; 95% CI, 0.97-1.39), while all the remaining single- or dual-medication regimens were associated with higher risks of all-cause mortality. CONCLUSIONS:For people with dementia, using one or two guideline-recommended medications appeared sufficient to protect against recurrent MI and MACE. Beta-blockers may not provide additional survival benefits over statins and RASIs.

BACKGROUND:Telehealth can increase access to medical and allied health services in residential aged care facilities (RACFs). OBJECTIVES:This study investigated the feasibility of a telehealth collaborative care model involving on-site nurse practitioner and off-site clinical pharmacist to simplify complex medication regimens in RACFs. METHODS:This was a pragmatic, nonrandomized pilot and feasibility study in three Western Australian RACFs. A nurse practitioner and an off-site clinical pharmacist applied a validated five-step regimen simplification tool. The nurse practitioner identified residents who may benefit and had a desire to simplify their regimen. The nurse practitioner and pharmacist then conducted video case conferences to discuss simplification opportunities. The nurse practitioner decided which simplification opportunities to implement in consultation with residents and general medical practitioners (GPs). The primary outcome was feasibility (recruitment and retention, protocol adherence, and stakeholder acceptability). Secondary outcomes included change in the number of medication administration times per day, medication and behavioral incidents, falls and fractures, and hospitalization at 4 months. RESULTS:Telehealth collaborative care was delivered according to the protocol, with one or more simplification opportunities identified for 18 of 21 residents. The most frequent simplification opportunities involved changing a dose time or formulation. The intervention was well received by the interviewed stakeholders. At the 4-month follow-up, 47% of residents had at least one simplification recommendation implemented and one-third had a reduced number of regular daily medication administration times. Compared to the previous quarter, there was a non-significant decline in medication incidents (24%-18% of residents), behavioral incidents (48%-35%), and falls and fractures (48%-41%). No hospitalizations were reported among residents who completed follow-up. CONCLUSIONS:This nurse practitioner-pharmacist telehealth intervention was feasible and acceptable. Further adequately powered trials to detect clinical outcomes are warranted. IMPLICATIONS FOR NURSING MANAGEMENT:Nursing managers should actively support telehealth-enabled interdisciplinary collaboration that promotes nurse practitioner leadership and fosters partnerships with pharmacists and GPs to advance medication regimen simplification and optimize medication management processes. Such initiatives may enhance the efficiency of medication administration, improve care coordination, and strengthen medication safety within aged care environments.

BACKGROUND:Antipsychotic use in people living with dementia has been linked to serious adverse outcomes. Guidelines recommend limiting antipsychotic treatment to short-term use (<12 weeks), followed by tapering and cessation. However, antipsychotic treatment in routine practice often exceeds the recommended duration. The effect of discontinuing antipsychotics on reducing adverse outcomes in practice remains unclear. We aimed to use linked primary and secondary care data in England to investigate whether tapering or abrupt discontinuation of antipsychotics, versus continuation, affected the risk of stroke, death, fracture, delirium, and pneumonia in people living with dementia. METHODS:Using UK primary care data from the Clinical Practice Research Datalink, linked with hospital and mortality data from Jan 1, 1998, to March 31, 2021, we emulated two sets of target trials, one after 12 weeks of antipsychotic treatment and another after 24 weeks of antipsychotic treatment, to compare continuing treatment versus tapering treatment and continuing treatment versus abrupt discontinuation of treatment. Patients aged 65 years and older at incident dementia diagnosis with antipsychotic treatment duration of at least 12 weeks were included. Study outcomes were incidence of fracture, stroke, hospitalisation for delirium, hospitalisation for pneumonia, and all-cause mortality within 24 months. A negative control outcome of skin conditions was included to measure potential unmeasured confounding. A clone-censor-weight approach was used with a 6-month grace period allowed for discontinuing antipsychotics. Weighted pooled logistic regression models were used to estimate 24-month absolute risk differences (ARDs). FINDINGS:134 549 eligible patients had a new antipsychotic treatment after dementia diagnosis, of whom 24 822 (18·4%) had a treatment period of at least 12 weeks and 16 795 (12·5%) had a treatment period of at least 24 weeks and met the eligibility criteria. The mean age was 83·57 (SD 7·07) in the 12-week trial and 83·65 (SD 7·02) in the 24-week trial; 16 725 (67·4%) of 24 822 patients were female and 8097 were male in the 12-week trial and 11 523 (68·6%) of 16 795 patients were female and 5272 were male in the 24-week trial. Compared with continuation after 12 weeks of treatment, estimated risks of delirium and fracture under the tapering strategy corresponded to 24-month ARDs of -2·46% (95% CI -4·10 to -1·27) and -2·80% (-4·14 to -1·29), respectively. Estimated risks for stroke, pneumonia, and all-cause mortality were similar between strategies. No difference in risk was observed for the negative control outcome. Similar results were found after 24 weeks of treatment and in sensitivity analyses. INTERPRETATION:Irrespective of method, antipsychotic discontinuation decreased the risk of delirium and fracture. Antipsychotics can be discontinued safely when treatment duration has exceeded guideline recommendations without increasing the risk of death, stroke, or pneumonia in those living with dementia. FUNDING:PharmAlliance Research Clusters for Doctoral Training.

Background: Polypharmacy and potentially inappropriate medications (PIM) are common in older adults, but prevalence among people with a prognosis of six months or less is poorly characterised. We aimed to estimate prevalence of polypharmacy, PIMs, and potential prescribing omissions (PPOs) in older adults approaching end of life. Methods: A systematic search of PubMed, Embase, CINAHL Plus, PsycINFO, Web of Science, and Scopus from inception to April 30, 2026, for studies reporting polypharmacy (≥5 medications) or PIMs in adults aged ≥65 years with life-limiting illnesses (≤6 months prognosis) was performed. Two reviewers independently screened records, extracted data, and assessed risk of bias using the Joanna Briggs Institute checklist or Newcastle-Ottawa Scale. Pooled prevalence was calculated using random-effects models. Heterogeneity was explored by setting, region, and assessment tool. The review was registered with PROSPERO (CRD42023454636). Findings: We included 18 studies with 499,853 participants (52·3% female). The pooled prevalence of polypharmacy (≥5 medications) was 76·0% (95% CI 65·0–87·0). Excessive polypharmacy (≥10 medications) was 34·0% (95% CI 9·0–58·0%). The pooled prevalence of PIMs was 54·0% (95% CI 40·0–68·0). PIM prevalence remained above 50% until the final week of life, with preventive medications (statins, antithrombotics, PPIs) often continued until death. Only two studies assessed PPOs, reporting prevalences of 30·0% (absent prophylactic laxatives with opioids) and 76·6% (absent strong opioids for moderate-severe cancer pain), precluding pooled analysis. Interpretation: Three-quarters of people with a prognosis of six months or less have polypharmacy, and half use PIMs. The persistent use of preventive medications warrants urgent need for coordinated, evidence-based deprescribing protocols in this vulnerable population

OBJECTIVES:To systematically examine the prevalence of, and factors associated with, benzodiazepine, Z-drug and melatonin use in Australian residential aged care facilities (RACFs). METHODS:MEDLINE, Embase, CINAHL, PsycINFO, Scopus and International Pharmaceutical Abstracts were searched from January 2000 to February 2025 for studies reporting benzodiazepine, Z-drug and/or melatonin prevalence in Australian RACFs. Overall, regular and pro re nata (PRN) medication use was considered. Screening, data extraction and quality assessment were performed independently by two authors. The primary outcome was overall prevalence (regular and PRN) of benzodiazepines, Z-drugs and/or melatonin. Secondary outcomes included regular prevalence, PRN prevalence and medication class prevalence. RESULTS:Fifty-two studies (n = 658,585 residents) were included. Overall prevalence of benzodiazepines and/or Z-drugs was 33% (95% confidence interval [CI]: 30.4%-34.7%, 30 studies) when assessed over periods from point prevalence to one-year prevalence. Prevalence was highest when assessed using prescribing (35%) rather than dispensing (32%) or administration (28%) data. Findings were similar when limited to studies published in the last 10 years (31%), studies of 100 or more residents (32%) and when excluding studies conducted in subsets of residents (33%). Benzodiazepine prevalence (35% [95% CI: 32.5%-36.9%], 24 studies) was higher than Z-drug prevalence (0.4% [95% CI: 0.1%-1.1%], three studies). No published studies reported melatonin prevalence, and unpublished regular prevalence ranged 1%-9% (four studies). CONCLUSIONS:One in three Australian residents in RACFs use benzodiazepines and/or Z-drugs. Targeted interventions are needed to ensure their use is consistent with evidence-based practice and residents' clinical needs.

Objectives Hospital discharge to a long-term care facility (LTCF) often represents an opportunity to reassess care goals, treatment intensity, and medication use. We examined changes in glucose-lowering medication (GLM) dispensing following first hospital discharge to LTCFs and whether these changes differed by resident frailty status. Design Retrospective cohort study. Setting and Participants Adults aged ≥65 with type 2 diabetes (T2D) newly discharged to LTCFs in Victoria, Australia, from 2012 and 2018. Methods Using linked hospital and medication dispensing data, we compared age- and sex-adjusted prevalence of GLM use in the 90-day period prehospitalization and 90-day period postdischarge to LTCF using Poisson regression. Multivariable adjusted relative risks (aRRs) were estimated using generalized estimating equations. Results Among 19,704 individuals discharged to an LTCF (78.7% frail, 45.9% aged ≥85 years, 54.6% female), overall GLM use declined from 59.7% (95% CI 58.4-61.0) to 54.8% (95% CI 53.6-56.1) in frail residents, and 59.3% (95% CI 56.9-61.9) to 56.2% (95% CI 53.8-58.7) in robust residents. Changes in age- and sex-adjusted GLM prevalence among frail and robust residents were mainly attributable to decreased use of metformin and sulfonylureas and increased use of insulin. In multivariable-adjusted analyses, frailty was associated with lower likelihood of dispensing metformin monotherapy within 90 days postdischarge (aRR 0.91, 95% CI 0.85-0.97) and metformin plus sulfonylurea at 90 days (aRR 0.89, 95% CI 0.79-0.99). There were no statistically significant differences in aRRs for combination therapy with ≥2 GLMs. In sensitivity analyses, frailty was associated with greater likelihood of no GLM dispensing within 6 months (aRR 1.04, 95% CI 1.02-1.07), but not within 90 days postdischarge (aRR 1.02, 95% CI 1.00-1.05). Conclusions and Implications There are potential missed opportunities to reassess GLM regimens in the 90-day period postdischarge to LTCFs. Resident frailty status did not appear to be associated with meaningful T2D treatment deintensification. Further initiatives may be needed to promote postdischarge medication reviews to optimize diabetes care in this vulnerable population.

This study compared the number and cumulative dose of antibiotic dispensings among new users of sodium–glucose cotransporter‐2 (SGLT2) inhibitors and dipeptidyl peptidase‐4 (DPP4) inhibitors following hospital discharge in individuals with type 2 diabetes. A retrospective cohort study was conducted using data from public and private hospitals in Victoria, Australia. Antibiotic dispensings were assessed over 12 months among new users of these medicines. Negative binomial regression with inverse probability of treatment weighting was applied to estimate weighted incidence rate ratios and confidence intervals for the total number of antibiotic dispensings and cumulative defined daily doses, stratified by antibiotic class. A total of 58.3% of SGLT2 inhibitor users (9,162 individuals) and 61.4% of DPP4 inhibitor users (16,589 individuals) received antibiotics. Initiators of SGLT2 inhibitors had a lower number of overall antibiotic dispensings compared with initiators of DPP4 inhibitors (weighted incidence rate ratio 0.88, 95% confidence interval 0.85 to 0.90), a pattern that was consistent across antibiotic classes. SGLT2 inhibitor initiators also had lower cumulative defined daily doses overall (weighted incidence rate ratio 0.89, 95% confidence interval 0.86 to 0.93), with significantly lower doses for penicillins, sulphonamides, and quinolones. These findings suggest that the initiation of SGLT2 inhibitors was associated with lower antibiotic use in terms of both the number of dispensings and cumulative dose, indicating potentially lower rates of infections among individuals with type 2 diabetes.

Background:People with diabetes are at increased risk of infections. Emerging evidence suggests sodium-glucose cotransporter 2 (SGLT2) inhibitors have pleiotropic effects that may protect against certain infections. We systematically reviewed real-world evidence on the association between SGLT2 inhibitors and infections among adults with Type 2 diabetes. Methods:We searched Medline, Embase, Scopus, and Google Scholar from January 1, 2012 to March 18, 2024 for observational studies conducted in adults with Type 2 diabetes published in English. The exposure was SGLT2 inhibitors, and comparators were nonusers or users of other glucose-lowering medications. Studies reporting outcome estimates for specific non-genitourinary infections were included. The study was prospectively registered with PROSPERO (CRD42023492265). Results:From 6827 records, 28 studies were included in qualitative synthesis and 14 in meta-analyses. There was no association with COVID-19-related mortality in seven studies (OR 0.91; 95% CI: 0.57-1.46) or COVID-19-related hospitalisation in three studies (OR 0.90; 95% CI: 0.67-1.20). A reduced risk of pneumonia was observed in three studies (HR: 0.61; 95% CI: 0.57-0.66), a reduced risk of pneumonia-related mortality in two studies (HR: 0.49; 95% CI: 0.35-0.67), and a reduced risk of sepsis in three studies (HR: 0.45; 95% CI: 0.30-0.68). Conclusion:Real-world evidence suggests SGLT2 inhibitors are associated with lower risk of pneumonia, pneumonia-related mortality and sepsis. Given the high burden of infection in this population, these associations deserve further research.

OBJECTIVE:All Australian residential care facilities are recommended to have access to a medication advisory committee (MAC) to provide governance of medication management. The objective was to explore the structure and function of Australian MACs. METHODS:A national 43-item survey of MACs was conducted from November 2023 to January 2024. The survey was adapted from the Australian Government Department of Health and Aged Care Audit Tool and Checklist for a Medication Advisory Committee (Audit Tool). All MAC representatives were recruited using a comprehensive and purposive strategy including the Department of Health and Aged Care newsletter, professional organisations, social media and professional contacts. Outcomes included self-reported MAC structure and function across four key roles as per the Audit Tool, including policy development, risk management, education and quality improvement. RESULTS:Responses were received from 120 MACs covering 642 residential care facilities (24% of Australian residential care facilities) in all Australian states and mainland territories. The MACs provided oversight to a median (IQR) 116 (61-196) beds/residents and a median (IQR) 1 (1-4) facilities. Over half (58%) of MACs were multidisciplinary (nursing, pharmacist and prescriber representation). More than half of MACs reported performing all functions listed in the Audit Tool relating to policy development (59%) and risk management (53%). Only 41% and 28% of MACs reported they performed all functions in the Audit Tool related to education and quality improvement, respectively. CONCLUSION:There is extensive heterogeneity in the structure and function of MACs with scope for MACs to become more multidisciplinary, identify staff training needs and proactively lead quality improvement.