Integrating pharmacists into Aboriginal Community Controlled Health Services (IPAC project): Protocol for an interventional, non-randomised study to improve chronic disease outcomes
Introduction
Aboriginal and Torres Strait Islander peoples’ in Australian communities face many barriers accessing medicines including financial and geographic constraints, failed patient-clinician interactions, poor healthcare delivery systems and complex therapeutic medication regimens.1,2 The physical settings of community pharmacies and informational continuity challenges with Aboriginal health services that limit the sharing of patient information, have made it difficult for some Aboriginal and Torres Strait Islander people to have productive relationships with pharmacists.3,4 While Australian initiatives under the 6th Community Pharmacy Agreement (6CPA), the section 100 program for remote area Aboriginal health services, and the Closing the Gap (CTG) Pharmaceutical Benefits Scheme (PBS) Co-payment Measure have removed some of the financial barriers to accessing medicines,5 the 2013-14 PBS per person expenditure for Indigenous Australians was only 33% of the expenditure for non-Indigenous Australians.5 There is still considerable need to improve medicines access, as well as the quality use of medicines for populations that are medically underserved. Medication adherence, in general for anyone with chronic disease is poor, resulting in disease-related complications, higher levels of hospitalisation, and increased morbidity and mortality,6 whilst the economic costs of non-adherence are very high.7
Innovative and culturally appropriate models of care to enhance the quality use of medicines for Aboriginal and Torres Strait Islander peoples are necessary. One model is to better integrate pharmacists within primary health care services. The National Health Service in the UK have invested heavily in such an initiative,8 whilst New Zealand, Canada and the USA already have pharmacists providing clinical services within general practice settings.9 In Australia, the concept has received endorsement from leading medical organizations such as the Australian Medical Association,10 general practice groups,11 and pharmacists.12,13 Currently, registered pharmacists provide only limited clinical pharmacy services to Indigenous Australians due to several barriers.14,15 These include prohibitive Home Medication Review (HMR) business rules including processes that are not always possible nor culturally acceptable.15,16 Many Aboriginal health services provide few HMR referrals due to issues with the cultural responsiveness of pharmacists, and lack of pharmacist relationships with ACCHSs.16,17 Yet, when medication reviews are delivered in culturally appropriate settings (such as in Aboriginal health services) there is great potential to increase patients’ medication knowledge, medication adherence and to improve chronic disease management.16
Public inquiries,18 pharmacists,19 and independent statutory bodies such as the Australian Productivity Commission,20 have recommended exploring better ways to utilise the full scope of pharmacist roles within collaborative clinical models. Co-location of pharmacists within general practice has enabled greater communication, collaboration and relationship building among health professionals.12,21 Pharmacist integration within primary health care services can also improve clinical health outcomes and quality prescribing. Pharmacists that are fully integrated offer improved outcomes especially when providing holistic services to patients on multiple medications and co-morbidities.22 Integrated pharmacists can also significantly reduce medicine errors as shown in UK general practices.23 An economic analysis found that the integration of pharmacists in Australian general practice has the potential to be cost-effective through broader heath savings at a federal, state and consumer level.24
Despite the substantial interest in health reform, the impact of pharmacists on patient health outcomes when working within their scope of practice and integrated within Aboriginal health settings has never been evaluated. In order to investigate the potential gains in health outcomes arising from integrated models of care within Aboriginal health settings, the Integrating Pharmacists within Aboriginal Community Controlled Health Services (ACCHSs) to improve Chronic Disease Management (IPAC) Project was developed. The project is funded by the Australian Government Department of Health, under the Pharmacy Trials Program (Tranche 2) funding as part of the Sixth Community Pharmacy Agreement (6CPA) that seeks to improve clinical outcomes for patients utilizing the full scope of pharmacists role in delivering primary health care services. This Program is also supporting a study of the feasibility of a 6-step medication review service to be delivered by community pharmacy with pharmacists trained to work with clients of Aboriginal health services.25
The IPAC project will determine if including a non-dispensing registered pharmacist as part of the primary health care (PHC) team within ACCHSs (the intervention) leads to improvements in the quality of the care received by Aboriginal and Torres Strait Islander peoples with chronic diseases. The project will target adult patients with chronic diseases to optimise the pharmacological management of their condition given that coronary heart disease and diabetes contribute 22% and 12% respectively of the mortality gap with other Australians.26 ACCHSs provide comprehensive culturally appropriate primary health care to predominantly Aboriginal and Torres Strait Islander clients and form the vast majority of Aboriginal health services in Australia. They share a community governance model of care employing local Aboriginal and Torres Strait Islander staff, governed by elected Aboriginal and Torres Strait Islander leaders. Although funded largely by the Australian Government, they are independent not-for-profit agencies established by Aboriginal leaders from 1971 in response to significant unmet health needs.27
The IPAC Project makes two clinical claims. Firstly, Aboriginal and/or Torres Strait Islander adult patients with chronic disease who are managed by this model of care, receiving pharmacist services integrated within ACCHSs, will experience superior quality of care outcomes compared to usual care. Secondly, services provided by pharmacists within ACCHSs is likely to lead to superior health care service utilization (towards equity) by patients with chronic disease compared to usual care. This paper describes the development and planned evaluation of the intervention within a community-based participatory research model and complies with the SPIRIT 2013 guidelines for clinical trial protocols (Supplementary File A).28
Section snippets
Study design
The IPAC project is a pragmatic, non-randomized, prospective, pre and post quasi-experimental study (Trial Registration Number and Register: ACTRN12618002002268). The intervention is the integration of a registered pharmacist within the ACCHS primary healthcare team for a 15-month period. Up to 22 ACCHS sites will be recruited for the project across three jurisdictions: Victoria, Queensland and the Northern Territory to ensure a sampling frame that best informs external validity of the outcomes
Discussion
Healthcare reform depends on ways to improve productivity and ensure the triple aim of: clinically effective healthcare, improved patient experience, and cost-effectiveness (‘better health, better health care, and better value’).60 This project aims to evaluate a new integrated care model where Australian pharmacists work collaboratively with healthcare staff and patients to improve the quality use of medicines within primary health care settings that target Aboriginal peoples and Torres Strait
Funding body
The project is funded by the Australian Government Department of Health, under the Pharmacy Trials Program (Tranche 2) funding as part of the Sixth Community Pharmacy Agreement (6CPA). The project funder had no role in study design, data collection, management of the project, analysis and interpretation, writing of the report, or the decision to submit the report for publication. The project funder has a role in approving reports for publication.
CRediT authorship contribution statement
Sophia Couzos: Conceptualization, Methodology, Formal analysis, Investigation, Writing - original draft, Visualization, Supervision, Funding acquisition. Deborah Smith: Methodology, Formal analysis, Investigation, Writing - review & editing, Visualization, Project administration. Mike Stephens: Conceptualization, Methodology, Writing - review & editing, Supervision, Funding acquisition. Robyn Preston: Methodology, Formal analysis, Investigation, Writing - review & editing. Delia Hendrie:
Declaration of competing interest
None.
Acknowledgments
The IPAC Operational Team wishes to acknowledge Ms Dawn Casey, Deputy Chief Executive Officer for NACCHO in her role as Chair of the Project Reference Group and member of the IPAC Steering Committee, and the NACCHO Affiliates for their assistance in this project and their staff: Dr Nadia Lusis, Dr Elizabeth Moore, and Mr Roderick Wright in the early stages of project design. The team also acknowledges Ms Priscilla Page for her assistance with planning the qualitative analysis, Mr Mitch Russell
References (62)
- et al.
The degree of integration of non-dispensing pharmacists in primary care practice and the impact on health outcomes: a systematic review
Res Soc Adm Pharm
(2018) - et al.
A pragmatic–explanatory continuum indicator summary (PRECIS): a tool to help trial designers
J Clin Epidemiol
(2009) - et al.
For the Chronic Kidney Disease Prognosis Consortium and Chronic Kidney Disease Epidemiology Collaboration. Change in albuminuria and subsequent risk of end-stage kidney disease: an individual participant-level consortium meta-analysis of observational studies
Lancet Diabetes Endocrinol
(2019) - et al.
Sampling and recruitment methodology for a national eye health survey of Indigenous Australians
Aust N Z J Public Health
(2010) - et al.
Cardiovascular disease risk profiles
Am Heart J
(1991 Jan) - et al.
Psychometric properties of the four-item morisky green levine medication adherence scale among atherosclerosis risk in communities (ARIC) study participants
Value Health
(2016) - et al.
Potentially suboptimal prescribing of medicines for older Aboriginal Australians in remote areas
Med J Aust
(2019) - et al.
Systematic review of adherence in Indigenous Australians: an opportunity to improve chronic condition management
BMC Health Serv Res
(2017 Dec 27) - et al.
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
Aust J Rural Health
(2013) - et al.
Better medication management for Indigenous Australians: findings from the field
Aust J Prim Health
(2005)
Aboriginal and Torres Strait Islander Health Performance Framework 2017 Report
Adherence to Long Term Therapies; Evidence for Action
Economic impact of medication non-adherence by disease groups: a systematic review
BMJ Open
Clinical pharmacists in general practice: an initial evaluation of activity in one English primary care organization
Int J Pharm Pract
Integrating family medicine and pharmacy to advance primary care therapeutics
Clin Pharmacol Ther
Pharmacists Working within General Practice – the Way Ahead
General Practice Supports Pharmacists as Part of GP-Led Teams
Integration of pharmacists into general practice clinics in Australia: the views of general practitioners and pharmacists
Int J Pharm Pract
Integrating a pharmacist into the general practice environment: opinions of pharmacist's, general practitioner's, health care consumer's, and practice manager's
BMC Health Serv Res
Are rural and remote HMRs viable?
Aust Pharm
Home Medicines Review Program. Qualitative Research Project
Medication reviews are useful, but the model needs to be changed: perspectives of Aboriginal Health Service health professionals on Home Medicines Reviews
BMC Health Serv Res
Attitudes of pharmacists to provision of home medicines review for indigenous Australians
Int J Clin Pharm
Inquiry into the Establishment of a Pharmacy Council and Transfer of Pharmacy Ownership in Queensland. Report No. 12, 56th Parliament Health, Communities, Disability Services and Domestic and Family Violence Prevention Committee
Pharmacists in 2023: For Patients, for Our Profession, for Australia's Health System
Shifting the Dial: 5 Year Productivity Review, Report No. 84, Canberra
Shifts in expectations: evaluating physicians' perceptions as pharmacists become integrated into family practice
J Interprofessional Care
A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomized, controlled trial and cost-effectiveness analysis
Lancet
Analysis of Non-dispensing Pharmacists in General Practice Clinics
Protocol for a feasibility study of an indigenous medication review service (IMeRSe) in Australia
BMJ Open
Contribution of Chronic Disease to the Gap in Adult Mortality between Aboriginal and Torres Strait Islander and Other Australians. Cat. No. IHW 48
Cited by (7)
Enablers and barriers to non-dispensing pharmacist integration into the primary health care teams of Aboriginal community-controlled health services
2022, Research in Social and Administrative PharmacyCitation Excerpt :This project aimed to determine if integrated NDPs lead to improvements in the quality of care received by Aboriginal and Torres Strait Islander peoples with chronic disease.21 Quality of care outcome measures included clinical endpoints, prescribing quality, medication adherence, Home Medicines Review (HMR)22 and other service utilization, and patient self-assessed health status that have been explained elsewhere.21 Factors that influence the extent and ease of NDP integration within these health services form a vital context for understanding expectations in quality of care improvements.
The use of medication adherence guidelines in medication taking behaviour research
2022, Research in Social and Administrative PharmacyGuidelines and standards in medication adherence research
2022, Contemporary Research Methods in Pharmacy and Health ServicesStakeholder role in setting curriculum priorities for expanding pharmacy scope of practice
2023, Pharmacy EducationExpanded practice in rural community pharmacy in Australia: pharmacists’ perspectives
2021, Journal of Pharmacy Practice and ResearchIntegration of non-dispensing pharmacists into primary healthcare services: An umbrella review and narrative synthesis of the effect on patient outcomes
2021, Australian Journal of General Practice