Do dose administration aids support medication adherence for Aboriginal and Torres Strait Islander peoples? An exploration of patients' perspectives, experiences and use on the North Coast of New South Wales.

INTRODUCTION: Management of medication regimens and improvement of medication-taking behaviours may require various levels of support, education, engagement and barrier reduction from health services and or pharmacists. The use of dose administration aids (DAAs) may improve medication management for some people, and therefore may facilitate positive health benefits. This Australian study was informed by a literature review that found there was a dearth of data about Aboriginal and Torres Strait Islander peoples' use of DAAs. This study therefore aimed to understand the experiences of Aboriginal and Torres Strait Islander people living on the North Coast of New South Wales with DAAs and if the provision of DAAs supported medication-taking behaviours. METHODS: A mixed-methods approach that included data collected from a questionnaire and a series of focus groups was used in this study. Analysis was completed at three stages throughout the study. RESULTS: A total of 30 Aboriginal participants participated in the study. Participants lived in the area ranging from Tweed Heads to Port Macquarie. Twenty-six participants completed the questionnaire and 20 participated in the focus groups; 16 completed both. Participants felt they were managing their medications well. The study noted that, despite this assessment, 45% of focus group participants (9/20) missed taking medications regularly for various reasons. The medication regimens of participants were varied and potentially complex; for example, some participants were taking up to 23 individual doses of oral medications and insulin injections daily as a part of these regimens. Participants described their use of DAAs and how they supported their medication-taking both functionally and financially. Most participants reported that DAAs helped them manage their medications. The weekly or fortnightly provision of DAAs provided regular opportunities for pharmacists to interact with patients and/or their caregivers, supporting improved therapeutic relationships and possibly better health outcomes. CONCLUSION: DAAs were an important tool for improving medication management for most study participants. DAAs provided affordable and appropriate in-home support for patients to follow prescribed medication regimens. For the participants from this small study who used DAAs and viewed them as an important tool for managing medications, removal of financial subsidies that assist the provision of DAAs to Aboriginal and Torres Strait Islander peoples would have a negative effect on their ability to access them. This in turn may affect their medication-taking behaviours, potentially negatively affecting their long-term health outcomes. Further study regarding the Aboriginal and Torres Strait Islander patient experience of the use of DAAs over a longer period tracking medication adherence, and for a larger cohort of Aboriginal and Torres Strait Islander people, would be beneficial to understanding experience of use of DAAs on a wider scale.

Enablers and barriers to non-dispensing pharmacist integration into the primary health care teams of Aboriginal community-controlled health services.

BACKGROUND: The primary health care management of chronic disease affecting Aboriginal and Torres Strait Islander peoples requires healthcare quality and equity demands to be met, and systems that foster better team-based care. Non-dispensing pharmacists (NDPs) integrated within primary healthcare settings can enhance the quality of patient care, although factors that enable or challenge integration within these settings need to be better understood. OBJECTIVES: To investigate enabling factors and barriers influencing integration of NDPs within Aboriginal community-controlled health services delivering primary health care. This was achieved through qualitative evaluation of the Integrating Pharmacists within Aboriginal Community Controlled Health Services (IPAC) Trial exploring the perceptions of NDPs, community pharmacists, healthcare staff, managers, and Aboriginal and Torres Strait Islander patients of these services. METHODS: NDPs were employed across twenty urban, rural, and remote services in three Australian states and provided pre-defined medication-related roles to adult Aboriginal and Torres Strait Islander patients. Perceptions were elicited from online surveys, interviews, and focus groups. Transcripts were thematically analyzed using the constant comparison method to identify, compare, and refine emerging themes. RESULTS: One hundred and four participants informed the findings, including 24 NDPs, 13 general practitioners, 12 service managers, 10 community pharmacists, 17 health service staff, and 17 patients. Enablers of integration included: personal (previous experience with Aboriginal and Torres Strait Islander peoples, cultural awareness, skills, individual attributes); health service-related (induction programs, Aboriginal Health Worker support, team-building initiatives); and community-related factors (engaged community elders, leaders, cultural mentors, community pharmacy champions). Barriers to NDP integration included a lack of systems supports for patients and staff to adapt to NDP roles, health service factors, travel requirements, a lack of community linkages, and time and budget constraints. CONCLUSIONS: NDP integration within primary health care services has potential to enhance medication-related services to Aboriginal and Torres Strait Islander peoples if enabling factors are supported and health systems and adequate resources facilitate the integration of pharmacists within these settings.

The benefits and challenges of a rural community-based work-ready placement program for allied health students.

INTRODUCTION: Rural and remote Australia has a shortage of allied health clinicians. The provision of quality rural placement experiences for allied health students has been a significant strategy to address these health workforce shortages. Service learning rural placements are providing allied health services in small rural towns where previously allied health services were limited or did not exist. Published literature has little detailed description of the origin or nature of particular placement programs. METHODS: An increase in Commonwealth funding for rural allied health clinical placements led to the development of an innovative service learning placement model in northern New South Wales, the Rural Community-Based Work-Ready Placement Program. During this placement, students were paired for 4-10 full-time weeks in a preschool, school or aged care facility. The program's fundamental properties included cultural and social equity education, providing continuous service throughout the year, and quality improvement initiatives in placement sites. The program was underpinned by an interdisciplinary approach that included interdisciplinary placements, interdisciplinary supervision and a structured interdisciplinary education program. RESULTS: The program required investment in stakeholder engagement and in the alignment of universities' requirements for student learning outcomes and the sites' specific needs. Clinical supervisors had to adapt to supervising students from various disciplines and universities across several sites, towns and services. The program provided students with opportunities to work autonomously, problem-solve and to initiate and implement quality improvement projects at each site. CONCLUSION: Careful selection of students, adequate preparation and management of students' expectations were important contributors to the success of the program. Providing a continuous service is an ongoing logistical challenge.

Medication reviews are useful, but the model needs to be changed: Perspectives of Aboriginal Health Service health professionals on Home Medicines Reviews.

BACKGROUND: The Australian Home Medicines Review (HMR) program consists of a pharmacist reviewing a patient's medicines at his or her home and reporting findings to the patient's general practitioner (GP) to assist optimisation of medicine management. Previous research has shown that the complex HMR program rules impede access to the HMR program by Aboriginal and Torres Strait Islander clients. This study explores the attitudes and perceptions of health professional employees working within Aboriginal Health Services (AHSs) towards the HMR program. The goal was to identify how the HMR program might better address the needs of Aboriginal and Torres Strait Islander people. METHODS: Thirty-one semi-structured interviews were conducted with health professionals at 11 diverse AHSs. Fourteen Aboriginal Health Workers (AHWs), five nurses, one manager and 11 GPs were interviewed. Interviews were recorded, de-identified and transcribed verbatim. Transcripts were coded and analysed for themes that recurred throughout the interviews. RESULTS: This study identified a number of barriers to provision of HMRs specific to Aboriginal and Torres Strait Islander clients. These included paternalistic attitudes of health professionals to clients, heightened protection of the GP-client relationship, lack of AHS-pharmacist relationships, need for more culturally responsive pharmacists and the lack of recognition of the AHS's role in implementation of culturally effective HMRs. Changes to the HMR model, which make it more effective and culturally appropriate for Aboriginal and Torres Strait Islander people, were recommended. Improved relationships between GPs and pharmacists, between pharmacists and AHSs, and between pharmacists and Aboriginal and Torres Strait Islander clients were identified as key to increasing HMRs for Aboriginal and Torres Strait Islander people. CONCLUSIONS: Aboriginal Health Services are well-placed to be the promoters, organisers, facilitators and implementers of health programs, such as HMR, for Aboriginal and Torres Strait Islander clients. Embedding a pharmacist within an AHS addresses many of the barriers to HMRs. It ensures pharmacists are culturally mentored and that they build strong relationships with health professionals and clients. The HMR program rules need to be changed significantly if medication review is to be an effective tool for improving medication safety and adherence for Aboriginal and Torres Strait Islander people.

Exploration of Aboriginal and Torres Strait Islander perspectives of Home Medicines Review.

INTRODUCTION: In Australia, Home Medicines Review (HMR) has been found to be an important tool to raise awareness of medication safety, reduce adverse events and improve medication adherence. Aboriginal and Torres Strait Islander people are 'underserviced' by the HMR program and are the most likely of all Australians to miss out on HMRs despite their high burden of chronic disease and high rates of hospitalisation due to medication misadventure. The goal of this study was to explore Aboriginal and Torres Strait Islander perspectives of the Home Medicines Review program and their suggestions for an 'improved' or more readily accessible model of service. METHODS: Eighteen semi-structured focus groups were conducted with 102 Aboriginal and Torres Strait Islander patients at 11 Aboriginal Health Services (AHSs). Participants who were multiple medication users and understood English were recruited to the study by AHS staff. Seven focus groups were conducted for people who had already used the HMR program (User, n=23) and 11 focus groups were conducted for people who had not had an HMR (Non User, n=79). Focus groups were recorded, de-identified and transcribed. Transcripts were coded and analysed for themes. Focus groups continued and concepts were explored until no new findings were being generated and thus saturation of data occurred. RESULTS: Focus group participants who had not had an HMR had little or no awareness of the HMR program. All the participants felt that lack of awareness and promotion of the HMR program were contributing factors to the low uptake of the HMR program by Aboriginal and Torres Strait Islander people. Most participants felt that an HMR would assist them to better understand their medicines, would empower them to seek information about medicines, would improve relationships with health professionals and would increase the likelihood of medication adherence. Most of the User participants reported that the HMR interview had been very useful for learning more about their medicines. However, many reported that they found the process confusing and confronting. The majority of participants felt HMRs for Aboriginal and Torres Strait Islander patients should be organised by AHS staff, with patients being offered a choice of location for the HMR interview. Participants identified that Aboriginal Health Workers should play a key role in communication, knowledge translation, referral and follow-up. CONCLUSIONS: Current HMR rules impede rather than facilitate HMRs for Aboriginal and Torres Strait Islander people. Tailoring and remodelling of the HMR program is needed to increase the awareness, accessibility, acceptability and effectiveness of the HMR program for Aboriginal and Torres Strait Islander people.

Attitudes of pharmacists to provision of Home Medicines Review for Indigenous Australians.

BACKGROUND: Home Medicines Reviews could improve the quality use of medicines and medicines adherence among Aboriginal people. Despite high level of chronic disease very few Home Medicines Review are currently being conducted for Aboriginal and Torres Strait Islander people. OBJECTIVE: The aim of this research was to explore the barriers and facilitators from the pharmacists' perspective for the provision of Home Medicines Review to Aboriginal people attending Aboriginal Health Services. SETTING: A cross sectional survey was used to gather demographic, qualitative and quantitative data from 945 Australian pharmacists accredited to undertake Home Medicines Review. METHOD: The survey consisted of 39 items which included both closed, open ended and Likert scale questions. Data was extracted from the online survey tool and analysed. Descriptive statistics were used to explore the quantitative data while qualitative data was thematically analysed and coded for emergent themes. MAIN OUTCOME MEASURE: Number of Home Medicines Review conducted for Aboriginal and Torres Strait Islander patients. RESULTS: A total of 187 accredited pharmacists responded to the survey. They reported that barriers to Home Medicines Review to Aboriginal patients may include lack of understanding of cultural issues by pharmacists; lack of awareness of Home Medicines Review program by Aboriginal Health Service staff; difficulties in implementation of Home Medicine Review processes; burdensome program rules; the lack of patient-pharmacist relationship, and the lack of pharmacist-Aboriginal Health Service relationship. CONCLUSION: Changes to the medication review processes and rules are needed to improve the accessibility of the Home Medicine Review program for Aboriginal and Torres Strait Islander people. Improved relationships between pharmacists and Aboriginal health service staff, would increase the likelihood of more Home Medicines Reviews being conducted with Aboriginal and Torres Strait Islander patients.

Postoperative delirium in Parkinson's disease patients following deep brain stimulation surgery.

Deep brain stimulation (DBS) surgery is an effective treatment for patients with advanced Parkinson's disease. Delirium in hospitalized Parkinson's disease patients is common and often leads to prolonged hospital stays. This study reports on the incidence and etiology of postoperative delirium following DBS surgery. Patients (n=59) with advanced Parkinson's disease underwent bilateral (n=56) or unilateral (n=3) DBS electrode implant surgery, followed 1 week later with surgical placement of DBS generators. The development of delirium during either hospital stay was evaluated retrospectively from the hospital chart. Potential causes of delirium were evaluated, including history of delirium, opiate equivalents, medication administration delays and missed doses during hospitalization, and Parkinson's disease duration. Delirium following implantation of DBS electrodes was common (22% of patients). It was less commonly associated with generator placement (10%). A history of delirium, age, and disease duration were positive predictors of delirium. Opiate equivalent doses were negatively correlated with delirium. Missed Parkinson's medication doses (53% of patients) and delayed administration (81% of patients) were common, and had a slight relation with delirium. Delirium was not related to complexity of medication regimen or use of dementia medications. Despite the presence of delirium most patients still only required a single night in the hospital post-surgery (67%). Prolonged hospital stay was due not only to delirium but also severe off states and other medical issues. Recognition and expectant management of delirium is best accomplished in a multidisciplinary setting, including the patient's family and nursing, pharmacy and neurological surgery staff.

They've given me that many tablets, I'm bushed. I don't know where I'm going: Aboriginal and Torres Strait Islander peoples' experiences with medicines.

OBJECTIVE: To explore Aboriginal and Torres Strait Islander patients' experiences with medicines and the barriers and facilitators to their effective use of medicines. DESIGN: A descriptive, qualitative study, using 18 semi-structured focus groups with 101 Aboriginal and Torres Strait participants. Groups were conducted at 11 Aboriginal health services. These were recorded, transcribed and a thematic analysis was performed. SETTINGS AND PARTICIPANTS: Participants were Aboriginal and Torres Strait Islander patients, taking multiple medicines, who attended Aboriginal health services (AHSs) and who spoke English. AHSs varied in governance, size and service delivery models as well as their locations which were across urban, regional, rural and remote settings. RESULTS: Major themes identified were consistent across all settings and patients. These were confusion over medicines, perceived lack of advice from health professionals to patients about medicines and challenges in having effective interactions with medical practitioners and pharmacists. Participants wanted more information about medicine, indications for medicine, how they should be used, potential side effects, drug interactions and duration of therapy. They also reported an absence of appropriate medication labelling and written information. CONCLUSION: Many Aboriginal and Torres Strait Islander patients take multiple medicines and often find managing their medicines difficult and worrying. These patients require more comprehensive information, verbal and written, and more effective communications from doctors and pharmacists about medication indications, mechanisms, side effects, drug interactions and duration of treatment. Pharmacists have an opportunity to play a greater role in improving understanding of medicines and treatment choices.

A pharmacist's contribution to an ambulatory neurology clinic.

OBJECTIVE: Identify and categorize recommendations made by a consultant pharmacist in a neurology clinic, and document patient satisfaction with consultations provided by the pharmacist. DESIGN: Prospective, case series. SETTING: Ambulatory neurology clinic located in eastern Washington state. PATIENTS: Participants were referred to the consultant pharmacist by the neurologist or neurology nurse practitioner or self-referral. The pharmacist saw 56 patients, for a total of 66 encounters. INTERVENTIONS: A medication review was completed, and the patient and pharmacist met for consultation, assessment, and patient counseling. The pharmacist made pharmacotherapeutic recommendations and referrals to other health care providers. Printed surveys were distributed to patients regarding their satisfaction with the pharmacy consultation. MAIN OUTCOME MEASURE(S): The number and types of recommendations made by the pharmacist. Patient satisfaction with the pharmacist and pharmacy consultation, reported in a written survey provided after the consultation. RESULTS: The pharmacist spent an average of 38 minutes with each patient. A total of 192 pharmacotherapeutic recommendations were made: 55 (29%) to discontinue a medication, 46 (24%) to add a medication, 45 (23%) to change a dose, 39 (20%) therapeutic substitutions, and 7 (4%) for therapeutic monitoring. Survey respondents indicated they were very satisfied (97%), and all (100%) had a better understanding of how to take their medications after meeting with the pharmacist. CONCLUSION: Pharmacist involvement in a neurology clinic increases patient-pharmacist contact time and patient understanding regarding medications. The pharmacist offers numerous recommendations to health care providers, potentially improving the patient's pharmacotherapy.