| Recommendations
Most of the
following recommendations correspond to a section and a table
with data in this report, both of which are cited. The national
and state bodies of pharmacy referred to in the recommendations
to implement the recommendations are listed in the glossary (Section
7).
Methodology
Recommendation 1: Australia's
community pharmacies were stratified in a national survey for
the first time according to the PhARIA zones 1 to 6 (Section 1.4)
. Approximately 81% of Australia's community pharmacies are in
PhARIA zone 1 which skewed the sampling process and required much
larger samples than planned , much more work and higher costs
than budgeted to overcome the difficulties (Section 1.4.1.1) .
Systems other than the PhARIA system should be carefully evaluated
for stratification purposes in future national surveys of community
pharmacies . Other available systems of stratification such as
SEIFA should be compared with the PhARIA for stratification.
Recommendation
2: It was found many pharmacies in the lists of registered
pharmacies provided by state pharmacy authorities were invalid
because they were no longer operating, were not community pharmacies,
were duplicated, or had operated for a fraction of the whole year
(Section 1.4.2) . During the 12 months ending 30 June 2002 it
was found just 4447 approved pharmacies operated for the full
12 months (Section 1.4.7) . This total is much smaller than the
total number of 4824 pharmacies in the pool from which the samples
were drawn and smaller than previously reported national totals
of pharmacies which caused unnecessary difficulties for calculating
the national estimates.
In order to make accurate national estimates the months of operation
of pharmacies in the subject year should be included in future
questionnaires to accurately ascertain the number of full time
equivalents of community pharmacies operating during the survey
period.
Recommendation
3: For a number of the questions the results were skewed
requiring various statistical and other methods of adjustment
(Section 1.4.7) . With respect to analysis by Pharia zone the
results obtained in this survey provide reference values for a
range of questions.
If the PhARIA system is applied to future national surveys using
a similar questionnaire, then
a) the two separate best estimates should first be calculated
for the results of pharmacies PhARIAS 1 and PhARIAS 2-6 so that
the corresponding future questions reflect the ranges of results
around the respective best estimate; and
b) that separate pilot surveys of Pharia 1 and Pharias 2-6 pharmacies
be conducted with questionnaires reflecting 'regular' ranges of
estimates around the respective best estimate means in a) above.
Recommendation 4:
Many questions in the questionnaire contained the terms "number
of clients" or "number of patients" in relation
to prescription-related activities (Section 1.4.7) . These terms
need to be standardised to "number of dispensing occasions"
which requires a number of key parameters.
To facilitate more accurate national estimates of the activities
occurring in Australia's community pharmacies the national bodies
of pharmacy should arrange to obtain from the Drug Utilisation
Sub-Committee in the Department of Health and Ageing (a) the mean
number of items dispensed per dispensing occasion, (b) the percentage
of repeats per dispensing occasion and (c) the percentage of prescription
items dispensed for non-ambulatory .
Database results
Recommendation
5: Pharmacy respondents reported they spent a minimum
of 6.8 hours per month on continuing pharmacy education activities
which appears to be at least twice the level reported by pharmacists
in Northern Ireland and England (Section 3.1, A). It was difficult
to compare continuing pharmacy education activities from statistics
reported by interstate and overseas bodies of pharmacy. This will
expedite more accurate time-series, interstate and international
comparisons. Refer Section 3.1, Table D-A1.
National and State pharmacy bodies in Australia should cooperate
to standardise and report continuing pharmacy education activities
by the hours per month spent in these with appropriate weighting
of the activities by representative samples of pharmacists. These
bodies should verify the higher levels of continuing pharmacy
education activities reported by Australian pharmacies compared
to UK pharmacists because of the important implications for the
remuneration of pharmacy services .
Recommendation 6: There was
no relationship evident between the prevalence of enhanced pharmacy
services reported by community pharmacies and the recognised official
priorities in health (Section 3.1, B). Refer Table D-B7-1.
National and State bodies of pharmacy and university departments
of pharmacy should emphasise the teaching of enhanced pharmacy
services by reference to Australia's national health priorities
(Section B).
Recommendation
7: The marked variations in the prevalence of enhanced
pharmacy services reported by community pharmacies with trained
staff may reflect interstate differences in the training programs
available for enhanced pharmacy services (Section 3.1, B). Refer
Table D-B7-1.
National and State bodies of pharmacy should cooperate to produce
and offer standard pharmacy training programs for enhanced pharmacy
services should be adopted nationally.
Recommendation
8: There was no relationship evident between fees charged
by pharmacies for enhanced pharmacy services and the availability
of trained staff for these services (Section 3.1, B). Refer Table
D-B7-1.
National and State bodies of pharmacy should plan the systematic
evaluation of enhanced pharmacy services to determine the basis
for and level of their remuneration by pharmacies with trained
staff.
Recommendation
9: Wound care is an outstanding example of an enhanced
pharmacy service which is practiced by trained staff in a comparatively
high percentage of Australia's pharmacies and is growing at a
high rate (Section 3.1, B). Refer Table D-B7-1.
National and State bodies of pharmacy should assess the training
programs and promotional methods used for the remarkably successful
adoption of wound care services in pharmacies for their application
to other enhanced pharmacy services which rank highly in Australia's
national health priorities.
Recommendation 10: Many enhanced pharmacy services
were reported from low percentages of pharmacies in PhARIA zones
5 and 6 where many under-privileged aborigines reside (Section
3.1, B). Refer Table D-B7-1.
National and State bodies of pharmacy should produce suitable
intensive training programs for enhanced pharmacy services to
be implemented and/or made more accessible to pharmacists working
in pharmacies in PhARIA zones 5 and 6.
Recommendation
11: Pharmacies reported the serious barriers to performing
enhanced pharmacy services were "lack of time", "shortage
of pharmacists" and "no extra remuneration" (Section
3.1, C). Pharmacies rejected that enhanced pharmacy services were
not part of their work.
National and State bodies of pharmacy should investigate and produce
intensive structured training programs for specific enhanced pharmacy
services most likely to be remunerated in the future to help to
overcome the reported barriers to their adoption by pharmacies
. Refer Table D-C8.
Recommendation
12: The facilitators reported by pharmacies for performing
enhanced pharmacy services were "dedicated study time",
"accreditation", "closed counselling areas"
and "access to patient notes" (Section 3.1, C). Refer
Table D-C9.
National bodies of pharmacy should promote remunerated, accredited
programs for enhanced pharmacy services and closed counselling
areas and access to clients' clinical histories for the higher
adoption and competent performance by community pharmacies of
enhanced pharmacy services in order to respond to those facilitating
factors for these services reported by pharmacies .
Recommendation
13: High percentages of Australia's community pharmacies
reported the weekly provision of dose administration aids and
supervised dosing without charging (Section 3.1, D). Refer to
Tables D-D11A and D-D11c.
National bodies of pharmacy should organise and publicise the
cost-effectiveness evaluations of the provision of dose administration
aids and supervised dosing by pharmacies in order to establish
acceptable remuneration for these services. University departments
of pharmacy should emphasise the benefits and procedures of dose
administration aids and supervised dosing in the routine teaching
of pharmacy practice.
Recommendation
14: Approximately 40% of Australia's pharmacies declined
dispensing prescription drugs for at least one patient weekly
because of inappropriate drug, dose or suspected interaction or
contraindication, or for prescription defects (Section 3.1, D).
Another 30.7% of pharmacies declined dispensing prescription drugs
for at least one patient weekly for suspected adverse drug effects.
Overall, 1.25% of patients dispensed 216 million prescription
items yearly were reported to have had their prescribed medications
declined for the above reasons. Refer to Table D-D12.
These reported rates of intervening in the dispensing of prescribed
medicines in pharmacies should be verified by direct observation
in a representative sample of pharmacies and submitted to pertinent
agencies by national bodies of pharmacy as they provide strong
evidence for the vigilance by pharmacies in preventing the inappropriate
prescribing and adverse effects of prescription medicines , and
detecting legally defective prescriptions over-the-counter medicines.
Recommendation
15: Community pharmacies reported counselling in the
past 12 months a minimum of 3.17 million patients with low or
poor English speaking ability about their prescription medicines
(Section 3.1, D). Refer to Table D-D13a.
National bodies of pharmacy should verify the extent and evaluate
the provision of counselling to patients with poor English speaking
ability for prescription-related activities so that community
pharmacies are adequately remunerated for providing this service.
Recommendation
16: Low percentages of Australia's community pharmacies
reported the use of clinical testing and the application of laboratory
results to the assessment of the effects of prescribed drugs in
patients (Section 3.1, D). Refer Table D-D13c.
National bodies of pharmacy should investigate and produce software
programs for interpreting laboratory results in routine pharmacy
practice to enhance the evaluation of effects of prescribed medications
.
Recommendation
17: Relatively low percentages of community pharmacies
reported performing primary care multidisciplinary care plans,
case conferences or case health assessments compared to the percentage
performing home medicine reviews (HMRs) or medication management
reviews in residential age care facilities (Section 3.1, E). Refer
Table D-E14d.
National bodies of pharmacy should consider programs for enhancing
the ability of accredited pharmacists top participate in primary
care medication review processes to enhance their wider adoption
by community pharmacies.
Recommendation
18: Pharmacies reported that the rate of self-medication
activities for the management of minor ailments for clients was
exceeded by the provision of primary health care activities including
issuing over the counter medications, verbal and printed information
and referral to GPs and other health workers (Section 3.1, F).
This ratio of self-medication to primary care activities appears
to differ to that evident in pharmacies in other developed countries
and has strong implications for the control of pharmacist-only
and pharmacy medicines and the education and training of student
and graduate pharmacists and pharmacy staff. Refer Table D-F15a.
National bodies of pharmacy need to verify by direct observation
the ratio of self-medication and primary health care activities
occurring in a representative sample of community pharmacies .
Recommendation
19: Pharmacies reported estimated yearly totals of
36.97 million self-medication and 41.23 million primary health
care activities (Section 3.1, F). These statistics far exceeded
those reported for pharmacies by the 2001 National Health Survey
.These services do not currently attract remuneration for pharmacies.
Refer Table D-F15a.
National bodies of pharmacy need to verify the statistics and
organise cost-effectiveness evaluations of self-medication and
primary health care activities in Australia's pharmacies in order
to accurately represent the magnitude of the national contribution
to health care by pharmacies , the potential costs savings to
Australia's health system and the possible remuneration of community
pharmacy services .
Recommendation
20: Pharmacies reported an estimated 4.19 million clients
yearly with ailments were referred to GPs compared with 1.77 million
referred to other health workers (Section 3.1, F). Refer Table
D-F15a.
National bodies of pharmacy should verify the high rates of referrals
of clients with ailments by pharmacies to general practitioners
and organise the evaluation of referral forms in pharmacies in
order to lay the basis for remunerating referrals by pharmacies.
Recommendation
21: Pharmacies reported an estimated 10.26 million
clients yearly with ailments were provided with printed information
(Section 3.1, F). Printed information is a widespread form of
conveying health information and needs to be evaluated singly
and in combination with other methods in order to quantify the
impact on specific health outcomes. Refer to Table D-F15a.
National bodies of pharmacy should plan the cost-effectiveness
evaluation of printed information provided in pharmacies for clients
with ailments.
Recommendation
22: Pharmacies reported an estimated total of 0.86
million clients yearly were suspected of misuse of dependence-producing
over-the-counter medicines of whom 0.63 million were refused supply
of these medicines (Section F). Refer to Table D-F15b.
The high rates of intervening in the supply of over-the-counter
reported by pharmacies should be verified and submitted to pertinent
agencies by national bodies of pharmacy as they provide strong
evidence for the vigilance by pharmacies in preventing the misuse
of over-the-counter medicines.
Recommendation
23: 16% of Australia's pharmacies reported not having
vaccine refrigerators which comply with pharmacy standards (Section
3.1, G). Refer to Table D-G16.
National bodies of pharmacy should ascertain the standards of
vaccine refrigerators used in pharmacies nationwide for their
compliance with recognised standards. Refer
Recommendation
24: Pharmacies reported that they initiated non-prescribed
medicines for preventive purposes in more than 5.8 million undiagnosed
clients over 12 months (Section 3.1, G). Refer to Table D-G17.
National bodies of pharmacy should obtain further statistics on
and plan a cost-effectiveness evaluation of pharmacies in providing
non-medically prescribed medicines for preventative purposes.
Recommendation
25: Clinical testing for screening undiagnosed patients
were reported to occur in pharmacies which engaged nurses at rates
of 2- to 20-fold those of pharmacies which did not engage nurses
(Section 3.1, G). Refer to Table D-G19.
National bodies of pharmacy should identify those pharmacies which
engage nurses to provide screening activities of undiagnosed patients
in order to compare with these activities with those pharmacies
which do not engage nurses.
Recommendation
26: Up to 60% of Australia's pharmacies reported providing
harm reduction activities daily including methadone dosing, needle
supply and issuing benzodiazepines and other drugs according to
patient contracts with prescribers (Section 3.1, H). Studies have
shown that the provision of these services by pharmacies in Australia
and other developed countries are widespread and efficient . Refer
to Table D-H19a.
National bodies of pharmacy should examine the systematic and
appropriate remuneration of pharmacies active in prescriber contracts
, supervised dosing and other harm reduction services.
Recommendation
27: Pharmacies reported detecting a minimum estimated
13,519 patients with forged prescriptions and 23,391 'doctor shoppers'
in the previous 12 months (Section 3.1, H). These appear to be
the highest rates of detecting forgery and 'doctor shoppers' of
prescribed opioids and psychostimulants ever reported by pharmacies.
Refer to Table D-H19b.
National bodies of pharmacy should verify the above rates of detection
of fraudulent prescriptions for Schedule 8 drugs as they suggest
high vigilance in pharmaciess in dispensing these agents or/and
extraordinarily high rates of Schedule 8 prescription fraud in
Australia.
Recommendation
28: Australia has very high rates of the consumption
of prescribed opioids and psychostimulants compared with other
developed countries and the results of their fraudulent obtention
and misuse (Section 3.1, H) suggest current legislation is defective
in facilitating the online access by pharmacies to the medication
histories of these patients and taking effective actions to stem
the misuse of prescribed Schedule 8 agents.
National and State bodies of pharmacy should immediately press
for legislation requiring patients prescribed Schedule 8 drugs
to be limited to one medical and one pharmacy provider of these
agents and permit medication histories to be accessed online and
discussed by these providers prior to dispensing of these drugs.
Recommendation
29: Pharmacies reported they referred more than 40,000
clients per 30 days to complementary therapists (Section 3.1,
I). Refer to Table D-I20.
The Pharmaceutical Society of Australia should include guidelines
in the Australian Pharmaceutical Formulary and Handbook for the
referral of clients to complementary therapists.
Recommendation
30: Pharmacies reported that they referred approximately
15,000 clients per 30 days to aromatherapy, homeopathy and iridology
practitioners (Section 3.1, I). Refer to Table D-I20.
Pharmacy Boards in each jurisdiction, the Council of Pharmacy
Registering Authorities, the Pharmaceutical Society of Australia
and University departments of pharmacy should assess and where
necessary act decisively on the questionable referral of clients
to complementary practitioners.
Recommendation
31: High percentages of Australia's pharmacies reported
the daily use of a wide variety of information, facilities and
resources for patient care (Section 3.1, J). Refer to Table D-J21.
National bodies of pharmacy should formulate standard methods
for comparing the frequency of use and the cost-effectiveness
of outcomes of information resources in pharmacies applied routinely
in practice to patient care.
Recommendation
32: Just 7.8% of Australia's pharmacies reported daily
or higher use of web-based drug information facilities (Section
3.1, J). Refer to Table D-J21.
The Pharmaceutical Society of Australia and University departments
of pharmacy should review their teaching and training programs
for pharmacy students and practitioners to ensure the convey the
superior benefits of web-based facilities compared with other
forms of drug information facilities in patient care.
Recommendation
33: 89.2% of Australia's pharmacies reported Pentium
processors but only 4.2% reported having broadband facilities
in their dispensary computers (Section 3.1, K). The technological
requirements for dispensary computers are changing rapidly in
relation to pharmacies participating in the MediConnect system
planned to be introduced in 2005. Refer to Table D-K22a
National bodies of pharmacy should ensure the results of ongoing
MediConnect trials in pharmacies are well so pharmacies can rationally
plan to install the correct computer facilities and enhancements
.
Recommendation
34: More than 10% of pharmacies reported they had web
sites which offered medication-related activities (Section 3.1,
K). Refer to Table D-K22b.
The Pharmaceutical Society of Australia and pertinent bodies of
pharmacy should organise an evaluation of existing websites against
standards in the Australian Pharmaceutical Formulary and Handbook
and other appropriate standards .
Recommendation
35: 34.3% and 24.4% of pharmacies reported they expected
respectively internet sales of over-the-counter and prescription
medicines would depress their sales of these medicines by 2004
(Section 3.1, L). Joint actions have been taken in 2003 by national
bodies of pharmacy in the USA and Canada on the basis of safeguarding
consumers from preventable adverse effects of drugs obtained through
the internet. Refer to Table D-L24.
National bodies of pharmacy should review actions taken in North
America to curtail the internet sale of prescription medicines
by pharmacies and other sources.
Recommendation
36: 93.1% and 75.7% of pharmacies agree respectively
the telephone is the best form of technology for liaising with
doctors and patients about health care (Section 3.1, L). Telephone
counselling has proven for two decades to be the most cost-efficient
technology in improving the care of patients with chronic disorders.
Refer to Table D-L24.
National bodies of pharmacy should plan controlled studies of
telephone counselling by community pharmacies in for example patients
discharged with treated mental disorders who are known to have
high rates of relapse and readmission into hospitals.
Recommendation
37: The most common settings of pharmacies were city,
suburban or town shopping strips (41.4%) , followed isolated shops
(23.5%) and 18.7% in neighbourhood, 6.3% in medical and 4.8% in
regional shopping centres (Section 3.1, M). The locations and
hours of opening of pharmacies are important for assessing changing
patterns in the location of pharmacies and accessibility to pharmacy
services by consumers but it is difficult to ascertain these factors
because of the lack of standard definitions and the lack of information
on the hours of opening and pharmacy settings. Refer to Tables
D-M25b and D-M25c.
The Pharmacy Guild of Australia and other national bodies of pharmacy
should agree on standard definitions for the locations of pharmacies
and appropriate methods of weighting access to these locations
by the public .
Recommendation
38: The retail, storeroom and dispensary section were
the largest in area and enclosed counselling and forward pharmacy
sections the smallest (Section 3.1,M) . These data are the first
known national data on the internal arrangement of pharmacies
and have important ramifications on the performance of certain
services ( Sections 3.1 C, F and H). Refer to Table D-M26.
The Pharmacy Guild of Australia and other national bodies of pharmacy
should agree on standard definitions for the analysis of sections
in pharmacies and perform surveys of representative samples of
pharmacies in order to monitor the trends in the internal structures
of pharmacies.
Recommendation
39: Owners and managers reported they spent up to 30.9
of their 41.7 hours per week in dispensaries and 21% of Australia's
pharmacies reported having non-pharmacist retail managers (Sections
3.1,M) . These are important indicators of the involvement by
pharmacists in patient care activities. Refer Tables D-M29b, D-M32a
and D-M32b)
The Pharmacy Guild of Australia and other national bodies of pharmacy
should agree on standard definitions for the analysis of staff
in pharmacies and perform surveys of representative samples of
pharmacies in order to monitor the trends in the internal structures
of pharmacy staff.
Recommendation
40: The national survey of British pharmacies found
statistically strong relationships between pharmacists rather
than pharmacies and the performance of specialist or extended
pharmacy services whereas these Australian results pointed more
to certain pharmacy characteristics significantly related to the
performance of enhanced and other specialist services in pharmacies
(Section 4 ). These results have strong implications for national
policies on the development of professional services in pharmacies
but they require hypothesis testing with the application of logistic
regression analyses to define these relationships. Refer to Table
D4.1.
The Pharmacy Guild of Australia and other national bodies of pharmacy
should engage further logistic regression analysis be conducted
to ascertain the relationship between pharmacy factors including
area, group membership and the implementation of enhanced pharmacy
and other specialist services on a national basis.
Recommendation
41: Statistically significant relationships were found
between certain pharmacy characteristics and barriers and facilitators
to taking on enhanced pharmacy services which is the first time
such relationships have been analysed and reported (Sections 5.1
and 5.2) . The statistical analyses were limited t-test and chi-squared
tests . Refer to Tables D5.1 and D5.2.
The Pharmacy
Guild of Australia and other national bodies of pharmacy should
engage further logistic regression analysis be conducted to continue
the statistical analysis to define the pharmacy variables and
ascertain the associations between pharmacist variables and the
performance of enhanced pharmacy services.
Pharia comparisons between pharmacies in Pharia zones and services
were limited and standardisation is required before deciding policy
in certain areas.
Recommendation
42: Statistically significant relationships were found
between pharmacy characteristics inferring statistically strong
relationships between larger, busier pharmacies and the use communication
technologies (Section 5.3) . Refer to Table D5.3.
The Pharmacy Guild of Australia and other national bodies of pharmacy
should engage further logistic regression analysis be conducted
to continue the statistical analysis to define the pharmacy variables
such as Pharia zone, related to the use or impact of technologies
on the performance of specified patient care activities and the
impact on the sales of prescribed and over-the counter medicines.
Recommendation 43: The effect
of the location of pharmacies in certain PhARIA zones especially
remote rural pharmacies in PhARIA zones 1 and 2 were referred
to in Sections 3 A to M and tested statistically (Sections 4 and
5). Refer Tables 5.1,5.2 and 5.3.
The national bodies of pharmacy should engage statistical analysis
in order to standardise the data for pharmacies in the rural and
remote Pharia zones and extend the statistically analyses to test
relationships between Pharia location and services provided.
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