The taking of medications is an expected approach to the treatment of illness and disease in our society but at the same time concern is often expressed about the things that can go wrong in the way medications are used. Older people, and particularly those in residential care, are at greater risk of adverse outcomes from medication use. The Australian "Quality Use Of Medicines" (QUM) policy has driven initiatives to improve the way that medications are used so that people taking medications have a better outcome. The policy aimed to achieve judicious, appropriate, safe and effective use of medicines through a collaborative approach to care that included all stakeholders. Residential aged care was a specific setting identified as a target for QUM improvement to change the risk-benefit balance in residential aged care (so that the beneficial outcomes of medication therapy outweigh the adverse outcomes).
Poor QUM in residential aged care has been a major concern in the United States since the early 1970s. As a result, a new pharmacy service emerged, known as 'consultant pharmacy'. The uptake of this service was assured by legislation that mandated medication review by pharmacists in US nursing homes. The central questions addressed by this dissertation are "Would this type of service work in Australian nursing homes in the absence of mandation?" and "If so, how is this best done?". This work follows the change that occurred as an Australian residential aged care clinical pharmacy service evolved through two 'efficacy' studies to the implementation stage as a national program in which the effectiveness of the service was examined.
In the first study, a service model was developed to address the situation in Australian nursing homes. The service model included relationship building, nurse education and medication review and was largely nurse-focussed, supporting the finding that an individual nursing home exerted considerable influence over drug use in that home. The model then was tested in a randomised controlled trial. Overall, there was an 11- 15% reduction in drug use in the intervention group compared to controls (mainly in drug classes significantly influenced by nursing home factors) without significant mortality or morbidity changes.
The second study examined the impact of the model adapted for the less controlled environment of aged care hostels (which have lower levels of skilled staff and a more heterogenous resident mix). The model retained its core elements but evolved to more firmly adopt a continuous quality improvement (CQI) framework and direct contact between general practitioners and clinical pharmacists. Overall drug use was not reduced however the impact of the service was demonstrated by changes in drug use patterns, the attainment of needs and adoption of medication review recommendations. The differential impact of intervention was linked to organisational factors in each hostel.
The final study was an evaluation of the nationally funded program of accredited pharmacist - conducted medication reviews in nursing homes over its first year of operation. Nursing staff, accredited pharmacists and visiting general practitioners were surveyed to obtain information about the medication review service processes, drug use and health outcome. As expected change in drug use and outcome was not observed. Triangulation of survey results showed general support for medication review by accredited pharmacists. Nursing homes indicated strong support, however, the views of general practitioners were polarised. Disaffected general practitioners raised process issues, identified in the research study but not implemented in the national program, which require further program development. Communication, teamwork, equity of remuneration, perceived threats to role boundaries, education and training of practitioners were identified as areas for service improvement. Case conferencing overcame some of the problems and was successfully used as an alternative QUM strategy in a substudy.
This work describes the ground-breaking studies which enabled Australian community pharmacists to be paid for a cognitive (knowledge-based) service unconnected to the supply of medication for the first time. However, there is room for improvements in the program as first implemented that address, in particular structural, organisational and attitudinal issues.