"Quality Use of Medicines" (QUM) policy is firmly entrenched and widely supported in the Australian healthcare system. It aims to achieve judicious, appropriate, safe and efficacious use of medications through a collaborative approach where all stakeholders in medication care participate as partners. Despite significant progress in the area of pharmaceutical drug use, iatrogenic disease remains prevalent in our community. Older people, especially those living in aged care facilities, are considered to be at high risk of experiencing iatrogenic outcomes from medications and have therefore been targeted in various QUM initiatives.
Australia is not alone in endeavouring to improve QUM in residential care. The USA has seen the emergence of a new pharmaceutical discipline - consultant pharmacy - with specific responsibility for improving medication care in nursing homes. Although consultant pharmacy activities are a legal requirement in US nursing homes, evidence that they are effective in improving patient outcomes is lacking. Improved patient outcomes are the primary goal of "Pharmaceutical Care". Pharmaceutical care is a philosophy, also originating from the USA, which is analogous to QUM in its intent and collaborative approach.
Commonly used health-related outcome measures in pharmaceutical research include: mortality, morbidity, perceived health status and satisfaction with care. Quality of life assessments, which include health/functional status and subjective measures such as satisfaction, are also frequently employed as outcome measures. The appropriateness and usefulness of these measures may be limited when applied in an older population, particularly one that is inherently infirm and ephemeral, such as the nursing home population.
It has been suggested that suboptimal medication use in aged care facilities exists because QUM, or multidisciplinaiy pharmaceutical care, is not being practised. The Quality Medication Care Project was initiated to investigate the impacts of implementing the principles of QUM/Pharmaceutical care in nursing homes. The Study found that an intervention loosely based on the US Consultant Pharmacy model, lead to improved survival for NH residents without detrimental effect on other health-related outcomes such as hospitalisation rates, adverse events and ability to undertake activities of daily living.
The Quality Medication Care Project also revealed several unexpected findings relating to the general practitioners that provide medical care to nursing home residents. Apart from establishing that little is known about the nature and role of doctors that care for nursing home residents, it suggested that this group of doctors has negative views about aspects of QUM such as a partnership approach to care.
A subsequent study, the General Practitioners and Quality of Care in Nursing Homes Study, was conceived in order to further explore the relationships between general practitioners and nursing homes and how this might relate to the quality of care provided to residents. In this study, the concept mapping technique was employed to conceptualise "high quality medical care".
A concept map depicting eight elements of high quality medical care was developed. The map was derived from seventy-one statements about high quality medical care. Triangulation of results lead to development of a final list of seventy-six quality indicators for medical care in nursing homes. These could be grouped into five domains, or key quality areas: Knowledge; Nursing Home Practice; Nursing Home Policy; Professional Interaction and Continuity of Care.
Triangulation of qualitative and quantitative data across both major research projects facilitated comprehensive discussion about the key quality areas in nursing home care. This enabled development of a series of potential strategies to improve pharmaceutical care in aged care facilities. Subsequent to the conduct of this research, some of these recommendations have been implemented.