Protocol for a feasibility study of an Indigenous Medication Review Service (IMeRSe) in Australia

Medication-related problems identified by community pharmacists: a descriptive case study of two Australian populations

BACKGROUND

Medication-related problems (MRPs) contribute significantly to preventable patient harm and global healthcare expenditure. Vulnerable populations, including Indigenous Australians (please note that the use of the term 'Indigenous' in this paper includes all Aboriginal and Torres Strait Islander people and acknowledges their rich traditions and heterogenous cultures.) and people living with severe and persistent mental illness (SPMI), may be at increased risk of MRPs. Pharmacist-led medication reviews can identify MRPs for targeted action.

OBJECTIVE

To characterize MRPs identified and recommendations made by community pharmacists during medication reviews conducted with Indigenous Australians and people living with SPMI.

METHODS

Participants were recruited through two Australian trials testing the feasibility and/or effectiveness of novel community pharmacist-led interventions, the Indigenous Medication Review Service (IMeRSe) feasibility study (June 2018-July 2019) and Bridging the Gap between Physical and Mental Illness in Community Pharmacy (PharMIbridge) randomized controlled trial (September 2020-December 2021). Trained community pharmacists conducted medication reviews responsive to the cultural and health needs of participants. MRPs, MRP severity and pharmacist recommendations were documented and classified using an established classification system (DOCUMENT). MRP severity was assessed by pharmacists and an independent assessor. Data were analysed descriptively, and paired t-tests were used to compare severity ratings.

RESULTS

Pharmacists identified 795 MRPs with 411 participants across both trials (n = 255 IMeRSe, n = 156 PharMIbridge). Non-adherence to medication was the most common (n = 157, 25.1%) and second-most common (n = 25, 14.7%) MRP in IMeRSe and PharMIbridge, respectively. Undertreatment was the second-most common MRP in the sample of Indigenous Australians (n = 139, 22.2%), and reports of toxicity/adverse reactions were most common in people living with SPMI (n = 41, 24.1%). A change in pharmacotherapy was the most frequent recommendation made by pharmacists (40.2% and 55.0% in IMeRSe and PharMIbridge, respectively). Severity ratings varied, with the majority being 'Mild' or 'Moderate' in both groups. Significant differences were found in the severity rating assigned by trial pharmacists and the independent assessor.

CONCLUSIONS

Community pharmacists identified a range of MRPs experienced by two at-risk populations, most commonly non-adherence and toxicity or adverse reactions, when conducting medication reviews and proposed diverse strategies to manage these, frequently recommending a change in pharmacotherapy. These findings highlight the opportunity for more targeted approaches to identifying and managing MRPs in primary care and tailored community pharmacist-led interventions may be of value in this space.

TRAIL REGISTRATION

Australian and New Zealand Clinical Trial Registry records (IMeRSe ACTRN12618000188235 registered 06/02/2018 & PharMIbridge ACTRN12620000577910 registered 18/05/2020).

Activating pharmacists to reduce the frequency of medication-related problems (ACTMed): a stepped wedge cluster randomised trial

BACKGROUND

Medicines are the most frequent health care intervention type; their safe use provides significant benefits, but inappropriate use can cause harm. Systemic primary care approaches can manage serious medication-related problems in a timely manner.

OBJECTIVES

ACTMed (ACTivating primary care for MEDicine safety) uses information technology and financial incentives to encourage pharmacists to work more closely with general practitioners to reduce the risk of harm, improve patients' experience of care, streamline workflows, and increase the efficiency of medical care.

METHODS AND ANALYSIS

The stepped wedge cluster randomised trial in 42 Queensland primary care practices will assess the effectiveness of the ACTMed intervention. The primary outcome will be the proportion of people at risk of serious medication-related problems - patients with atrial fibrillation, heart failure, cardiovascular disease, type 2 diabetes, or asthma or chronic obstructive pulmonary disease - who experience such problems. We will also estimate the cost per averted serious medication-related problem and the cost per averted potentially preventable medication-related hospitalisation.

ETHICS APPROVAL

The University of Queensland Human Research Ethics Committee approved the pilot (2021/HE002189) and trial phases of the ACTMed study (2022/HE002136). Access to Patron data was granted by the Patron Data Governance Committee (PAT052ACTMed). Access to linked hospitalisations and deaths data are subject to Public Health Act approval (pending).

DISSEMINATION OF FINDINGS

A comprehensive dissemination plan will be co-developed by the researchers, the ACTMed steering committee and consumer advisory group, project partners, and trial site representatives. Aboriginal and Torres Strait Islander communities will be supported in leading community-level dissemination.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (pilot: ACTRN12622000595718; 21 April 2022; full trial: ACTRN12622000574741; 14 April 2022).

How pharmacist-led health services are tailored to minoritized populations, their acceptability and effectiveness: A scoping literature review

BACKGROUND

Worldwide, minoritized populations experience inequitable health risks and outcomes. The importance of offering tailored services to meet the specific needs of target populations should be addressed during service development. Within healthcare systems, pharmacists play a crucial role in supporting patients to manage their medicines and health conditions.

OBJECTIVES

This scoping review aims to identify, collate and analyse literature describing pharmacist-led services tailored for minoritized populations in order to strengthen the knowledge base and support for achieving health equity.

METHODS

A scoping review was guided by the PRISMA-ScR checklist and the five-stage process outlined by Arksey and O'Malley. Medline, EMBASE, Scopus, CINAHL Plus, International Pharmaceutical Abstracts, and Google Scholar databases, plus grey literature were searched to identify relevant studies published up to October 2022. Texts were included if they reported on a pharmacist-led health service tailored to meet the needs of a minoritized population. The review protocol was registered with the Open Science Framework (https://doi.org/10.17605/OSF.IO/E8B7D).

RESULTS

Of the 566 records initially identified, 16 full-text articles were assessed for eligibility and 9 articles describing 6 unique services met the criteria and were included in the review. Three services were non-health-condition-specific, 2 targeted type two diabetes and 1 focussed on opioid dependency disorders. Service acceptability was consistently explored, and all services ensured that pharmacists' views were considered. However, only 4 consulted with the people from the group that the service targeted. Where reported, the effectiveness was not comprehensively evaluated.

CONCLUSION

There is limited literature in this area and a critical need for more evidence on the effectiveness of pharmacist-led services for minoritized populations. We need a better understanding of how pharmacists contribute to health equity pathways and how to expand this. Doing so will inform future services and contribute towards achieving equitable health outcomes.

Building practice-informed indigenous health curricula: A systematic review of pharmacy services for indigenous peoples

BACKGROUND

An increased need is recognized to improve Indigenous cultural safety curriculum. This review aimed to inform curriculum development by identifying and categorizing challenges and opportunities that underlie existing practices. This entails policies, pharmacy services, and health workers' perspectives associated with pharmacy services for Indigenous peoples of Australia, Canada, New Zealand, and the United States.

METHODS

Four academic databases were screened including PubMed, Embase, CINAHL, and Web of Science. This search was complemented by grey literature database searches. Thematic analysis by NVivo, version 12 (QSR International) was utilized to analyze qualitative data, and a narrative strategy guided common theme consolidation. This approach was prefaced and supplemented using Endnote X9 (Clarivate) and SUMARI 2019 (JBI) and according to the Joanna Briggs Institute's guidelines. An Indigenous Curriculum Advisory Committee at the University of British Columbia Pharmaceutical Sciences was queried for suggestions, potential cross-cultural interpretation, and guidance for explicit content in the context of pharmacy service delivery in Indigenous communities.

RESULTS

Fourteen studies were included and classified into three categories: (1) Indigenous patients', pharmacists', and health care providers' perspectives, (2) policies and practices, (3) pharmacy-based programs. Thematic analysis portrayed several themes with overlapping presentation of challenges and opportunities. It is important to utilize evidence-based strategies for improving the effectiveness of culturally-safe pharmacy services for Indigenous populations and for optimizing education and practice-informed curriculum development.

IMPLICATIONS

This information can inform pharmacists, educators, and faculty members in understanding and delivering optimal care and education engaging Indigenous insights and perspectives at systems and curricular levels.

Development and feasibility testing of a training programme for community pharmacists to deliver a culturally responsive medication review intervention

Background

Cultural differences between health professionals and Indigenous peoples contribute to health inequalities, and effective cross-cultural communication and person-centred healthcare are critical remedial elements. Community pharmacists can play a significant role by reducing medication-related problems through medication reviews, yet barriers to access include cultural and linguistic challenges. The Indigenous Medication Review Service (IMeRSe) aimed to address these barriers via a culturally responsive intervention. The aim of this paper is to present the cross-cultural training framework developed as a component of this intervention and the feasibility evaluation of the first stage of the training framework.

Methods

A training framework was developed, emphasising pharmacists’ skills and confidence in effective cross-cultural communication and relationship-building with Indigenous Australians (Please note that the use of the term ‘Indigenous’ in this manuscript includes all Aboriginal and Torres Strait Islander people and acknowledges their rich traditions and heterogenous cultures) across three stages: (1) online and workshop-based, covering Indigenous history and health, cross-cultural communication and a holistic, strengths-based approach to intervention delivery; (2) orientation to local Aboriginal Health Services, community and cultural protocols; and (3) ongoing mentoring. The feasibility evaluation of the first stage included the following: self-reported levels of cultural capability, cultural confidence and skills, motivators and barriers to working with Indigenous Australians, assessed pre- and post-training. Participants completed self-administered questionnaires including a 22-item validated Cultural Capability Measurement Tool. Paired t tests assessed change in mean scores of Likert scale data.

Results

Stage 1 development resulted in an 8.5-h standardised cross-cultural training programme tested with 39 pharmacists working across urban and rural/remote Australia. Thirty-six pharmacists completed the feasibility evaluation (75.7% female, all non-Indigenous, 75.7% never attended prior cross-cultural training). Participants reported overall acceptability with training; the majority perceived it added value to their practice. Improved cultural capability post-training was reflected in increased scores for 21/22 items, nine reaching statistical significance. There were significant improvements for all 26 confidence and skills statements, and selected motivational and barrier statements, particularly participants role in improving Indigenous health outcomes and cross-cultural communication.

Conclusions

This study provides preliminary evidence that the training programme was feasible to deliver and prepared pharmacists to deliver a culturally responsive medication review intervention. The online knowledge-based modules and face-to-face workshops provide a standardised framework for larger-scale implementation of the intervention training.

Trial registration

Australia and New Zealand Clinical Trials Registry ACTRN12618000188235.Prospectively registered 22 January 2018.

Home medicines reviews: a national survey of Australian accredited pharmacists' health service time investment

Background

In Australia, polypharmacy and medication-related problems are prevalent in the community. Therefore, medicines safety initiatives such as the Home Medicines Review (HMR) service are critical to health care provision. While the evidence continues to expand around HMR service, little is known of accredited pharmacists' experiences of HMR time investment.

Objective

This study aimed to explore accredited pharmacists' experiences of HMR practice regarding time investment in the study's defined HMR Stages: 1 (initial paper-based assessment and review), 2 (in-home patient-accredited pharmacist consultation), and 3 (HMR report collation, generation, completion, and provision to the patient's General Practitioner, including any liaison time).

Methods

An electronic survey was developed and piloted by a panel of reviewers. Convenience sampling was used to distribute the final anonymous survey nationally via professional pharmacy organisations. Data were analyzed for frequency distributions and a chi-square test of independence was performed to evaluate any association between demographic variables relating to HMR time investment.

Results

There was a total of 255 survey respondents, representing approximately 10% of national accredited pharmacist membership. The majority were experienced accredited pharmacists who had completed >100 HMRs (73%), were female (71%), and aged >40 years (60%). Regarding time investment for a typical instance of HMR, most spent: <30 minutes performing Stage 1 (46.7%), and 30-60 minutes performing Stage 2 (70.2%). In Stage 3, 40.0% invested 1-2 hours, and 27.1% invested 2-3 hours in HMR report collation and completion. Quantitative analysis revealed statistically significant (p=0.03) gender findings where females performed longer patient consultations than males (Stage 2). More HMR career experience resulted in statistically significant (p=0.01) less time performing Stage 1 (initial paper-based assessment and review); with a trend to less time performing Stage 3 (HMR report writing).

Conclusions

Accredited pharmacists invest significant time in performing comprehensive HMRs, especially during in-home patient consultations and during HMR report collation and completion. Their significant HMR time investment as medicines experts provides insight for program and workforce considerations and warrants further research to better understand their work processes for optimizing medicines use and improving health.

Provision of home medicines reviews in Australia: linking population need with service provision and available pharmacist workforce

Objective Identifying and quantifying the health needs of a population are the basis of evidence-based health policy and workforce planning. The motivation for undertaking the present study was to evaluate whether the current level of medication review services corresponds to population need, as proxied by the rate of polypharmacy, and to undertake a preliminary analysis of the sufficiency of the current workforce. This paper: (1) estimates the age- and sex-standardised rates of polypharmacy as a proxy for population need for home medicines review; (2) compares the rate of polypharmacy with current service provision of home medicines reviews; and (3) links the estimated need for services with the current number and location of pharmacist providers. Methods Age- and sex-adjusted polypharmacy rates, by state, were estimated from the National Health Survey of Australia (2017-18), service levels were estimated from national-level administrative claims data (2017-18) and the current workforce was estimated from the Australian Association of Consultant Pharmacists (2018). The current level of service provision was compared to the estimated population need for services, alongside the size of the pharmacy workforce required if need was met. Results The adjusted rate of polypharmacy in Australia, using the strictest definition of ≥10 medications and ≥3 current chronic illnesses, was 1389 per 100000 population. The illustrative needs-based analysis suggests that there may be a disconnect between the current level of service provision and population health needs. Conclusion Given that polypharmacy is a risk factor for medication-related problems, and that medication review is one of the few targeted strategies currently available to address medication-related problems in the population, service provision may be inadequate. Policy options to improve service provision could include interventions to increase workforce productivity and relaxing the current eligibility criteria for review, especially in rural and remote areas. What is known about the topic? Polypharmacy is a risk factor for medication-related problems, which can cause increased morbidity and mortality in the population. What does this paper add? This paper provides representative, population-based rates of polypharmacy in Australia and uses these rates in a needs-based analysis of service provision and workforce adequacy to provide home medicines review services. What are the implications for practitioners? Several policy options are available for consideration, including interventions to increase workforce productivity and relaxation of the current eligibility criteria for medicines review, especially in rural and remote areas.

Adaptation of potentially preventable medication-related hospitalisation indicators for Indigenous populations in Australia using a modified Delphi technique

OBJECTIVES

One of the outcomes of a medication review service is to identify and manage medication-related problems (MRPs). The most serious MRPs may result in hospitalisation, which could be preventable if appropriate processes of care were adopted. The aim of this study was to update and adapt a previously published set of clinical indicators for use in assessing the effectiveness of a medication review service tailored to meet the needs of Indigenous people, who experience some of the worst health outcomes of all Australians.

DESIGN

A modified Delphi technique was used to: (i) identify additional indicators for consideration, (ii) assess whether the original indicators were relevant in the context of Indigenous health and (iii) reach consensus on a final set of indicators. Three rounds of rating were used via an anonymous online survey, with 70% agreement required for indicator inclusion.

SETTING

The indicators were designed for use in Indigenous primary care in Australia.

PARTICIPANTS

Thirteen panellists participated including medical specialists, general practice doctors, pharmacists and epidemiologists experienced in working with Indigenous patients.

RESULTS

Panellists rated 101 indicators (45 from the original set and 57 newly identified). Of these, 41 were accepted unchanged, seven were rejected and the remainder were either modified before acceptance or merged with other indicators. A final set of 81 indicators was agreed. Conclusions This study provides a set of clinical indicators to be used as a primary outcome measure for medication review services for Indigenous people in Australia and as a prompt for pharmacists and doctors conducting medication reviews.

TRIAL REGISTRATION NUMBER

The trial registration for the Indigenous Medication Review Service feasibility study is ACTRN12618000188235.