More than a decade ago the Australian Commonwealth Government commenced development of a National Medicines Policy. In response to concerns about the use of medications, one of the four arms of this policy is Quality Use of Medicines (QUM). The key elements of this policy are: 1) judicious selection of management options; taking account of whether drugs are needed and the non-drug options when appropriate, 2) appropriate choice of medicines and dosage regimen and 3) safe and effective use of medications. A large number of strategies have been utilised as means of achieving QUM, ranging from the production of therapeutic guidelines to medication management and review programs.
The principal objective of this thesis was to examine the impact of two different approaches to achieving QUM on patient health outcomes in two different practice settings. The two strategies were drug use evaluation (DUE) and integrated care.
This thesis is divided into two parts. In Part One, a DUE study was undertaken to evaluate the use of opioid analgesics by patients attending the Royal Brisbane Hospital Multidisciplinary Pain Centre (MPC). The aim of the DUE was to provide a quality improvement audit of prescribing practices for referring general practitioners (GP) and the staff of the MPC. A major component of the audit was the development of a 10-point scoring system based on the World Health Organization (WHO) analgesic ladder, as a means of facilitating a comparison of analgesic prescribing on admission to the centre (GP prescribing) and at the time of discharge (MPC staff prescribing). A conversion table was also devised to standardize opioid analgesic doses to an oral morphine equivalent.
The results of Part One showed that a significant decrease in the total daily oral morphine equivalent being taken by patients and a reduction in prescribing scores could be made following admission to the Pain Centre. This result demonstrates the need for GP education in all aspects of opioid analgesic use for the relief of chronic pain. The methodology developed during the study (prescribing score tool and conversion table) provides a tool for the evaluation of education interventions designed to change prescribing patterns of GPs.
Part Two of this thesis focused on integrated care as a means of optimising QUM and patient health outcomes. This was achieved through the development of a model of care, which facilitated an extension of the role of community pharmacists in QUM and disease state management. The study focused on community pharmacists in rural and remote areas integrating the care of patients with complex needs. This was achieved in conjunction with the patient's GP and other members of the health care team.
This model of care had particular relevance in rural and remote Queensland where access to health services is limited due to both the lack of health care providers and the tyranny of distance. The study involved the randomisation of study patients from three sites in rural and remote Queensland (Blackall, Biloela and Stanthorpe), into either an active (care planning) or control (usual care) group. For the active patients, the pharmacists coordinated health services and delivered pharmaceutical care, based on a care plan developed collaboratively with the GP These care plans included both medication reviews and disease state management programs. Assessment of the project was based on both qualitative and quantitative outcome measurements.
The results of the study showed that patients receiving care integration through their community pharmacist demonstrated a significantly higher quality of life than those patients who received their usual care. Quality of life was assessed by the SF-36 health status questionnaire and through the calculation of Quality Adjusted Life Years. A cost analysis also demonstrated a total cost saving (Medicare services -t- medications) per active patient when compared to the controls.
The results of both Part One and Two of this thesis demonstrated the potential gains to be made through the implementation of QUM interventions in a variety of settings. Part Two is of particular importance, as the model of care integration by community pharmacists offers an alternate form of health service delivery in rural and remote Australia. Both parts of the thesis resulted in the development of new methodology to further enhance the strategies available to address the continuing quest to improve QUM in Australia.