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Third Community Pharmacy Agreement Research & Development Grants Program Pharmacy Cardiovascular Health Care Model Final Report to the Pharmacy Guild of Australia This research is funded by the Australian Government Department of Health and Ageing through the Third Community Pharmacy Agreement Research and Development Program “Community pharmacists are well placed to help patients who have cardiovascular disease or who are at risk of this.” Petty D. Drugs and professional interactions: the modern day pharmacist. Heart 2003; 89 (Suppl 2): 31-2 Chief Researcher: Professor Gregory Peterson Lead investigators: Jeff Hughes Dr Kay Stewart Professor Roger Nation Professor Shane Scott Assoc Prof Karen Farris
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Third Community Pharmacy Agreement Research & Development Grants Program

Pharmacy Cardiovascular Health Care Model

Final Report to the Pharmacy Guild of Australia

This research is funded by the Australian Government Department of Health and Ageing through the Third Community Pharmacy Agreement Research and Development Program

“Community pharmacists are well placed to help patients who have

cardiovascular disease or who are at risk of this.”

Petty D. Drugs and professional interactions: the modern day pharmacist. Heart 2003; 89 (Suppl 2): 31-2

Chief Researcher:

Professor Gregory Peterson

Lead investigators:

Jeff Hughes Dr Kay Stewart Professor Roger Nation Professor Shane Scott Assoc Prof Karen Farris

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Co-investigators:

Dr Shane Jackson Kim Fitzmaurice Peter Gee Luke Bereznicki

Project Manager:

Michael Ryan

Contact person for correspondenceProfessor Gregory Peterson Unit for Medication Outcomes Research and Education School of Pharmacy University of Tasmania Locked Bag 83 Hobart Tas 7001 Phone: 61-3-62262197 Fax: 61-3-62267627

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Table of Contents

Table of Contents .................................................................................................................................................. 3

Index to Figures ..................................................................................................................................................... 6

Index to Tables ...................................................................................................................................................... 9

Abstract ................................................................................................................................................................ 16

Executive Summary ............................................................................................................................................ 16

Acknowledgements.............................................................................................................................................. 30

1.Introduction ...................................................................................................................................................... 31

1.1 Overview of possible roles for community pharmacy .......................................................................... 33

2. Methodology and results................................................................................................................................. 36

2.1 Systematic literature review ................................................................................................................ 36

2.1.1 MEDLINE search terms and criteria ............................................................................................... 38

2.1.2 International Pharmaceutical Abstracts (IPA) search terms and criteria ......................................... 38

2.1.3 Cochrane search terms and criteria ................................................................................................. 39

2.1.4 EMBASE search terms and criteria ................................................................................................. 39

2.1.5 INFORMIT search terms and criteria ............................................................................................. 40

2.1.6 Kinetica search terms and criteria ................................................................................................... 40

2.1.7 Community Pharmacy Research Database (CPRD) search terms and criteria ................................ 41

2.1.8 Summary of database searching ...................................................................................................... 42

2.2 Evaluating quality of research papers ................................................................................................. 45

2.2.1 Overall assessment of evidence ....................................................................................................... 50

2.2.2 Results of the Systematic Review ................................................................................................... 51

2.3 Public survey ....................................................................................................................................... 54

2.3.1 Public Survey Methods ................................................................................................................... 54

2.3.2 Results of the public survey ............................................................................................................ 55

2.3.3 Summary of the results of the public survey ................................................................................... 78

2.4 Survey of peak representative organisations ....................................................................................... 80

2.4.1 National Heart Foundation .............................................................................................................. 82

2.4.2 National Stroke Foundation ............................................................................................................ 85

2.5 Canvassing of Australian community pharmacists and pharmacy organisations to report on their own

CVD activities ................................................................................................................................................... 87

2.5.1 General Public (education, posters etc) ........................................................................................... 88

2.5.2 High-risk groups (screening/ referral) ............................................................................................. 89

2.5.3 Management of existing CVD ......................................................................................................... 89

2.5.4 Summary of self-reported CVD activities: ...................................................................................... 93

3. Developing the Pharmacy Cardiovascular Health Care Model .................................................................. 94

3.1 Draft National Chronic Disease Strategy .......................................................................................... 104

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3.2 Draft National Service Improvement Framework for Heart, Stroke and Vascular Disease .............. 107

3.3 Potential roles for community pharmacists for the ‘General Community’ group ............................. 124

3.4 Potential roles for community pharmacists for the ‘At-Risk’ group .................................................. 125

3.5 Potential roles for community pharmacists for the ‘confirmed CVD’ group .................................... 126

3.6 Additional overarching guidelines .................................................................................................... 128

3.6.1 Education of Pharmacists ............................................................................................................. 128

3.6.2 Relevant Professional Practice Standards ................................................................................. 128

3.6.2 Blood Handling Procedures ...................................................................................................... 130

3.6.3 Ethics and Privacy Guidelines ...................................................................................................... 137

Health Information and the Privacy Act 1988 ................................................................................................ 139

A short guide for the private health sector - December 2001 ......................................................................... 139

4.The Tentative Model ...................................................................................................................................... 145

5. Elements of the Pharmacy Cardiovascular Health Care Model: Public/preventive health promotion 147

5.1 ................................................................................................................................................................... 147

Guiding principles and existing framework .................................................................................................... 147

5.2 Health promotion to prevent development and progression of CVD ................................................. 148

5.2.1 The SNAP Framework .............................................................................................................. 153

5.3 Improving community awareness of their risk factors ....................................................................... 169

5.4 Promote awareness of the early symptoms of acute cardiovascular events ...................................... 171

5.4.1 Chest pain ................................................................................................................................. 171

5.4.2 Stroke ........................................................................................................................................ 181

6.Elements of the Pharmacy Cardiovascular Health Care Model: Continuum of care .............................. 183

6.1 Guiding principles and existing framework ....................................................................................... 183

6.2 Transfer of medication related information and follow-up of patients post-discharge ..................... 184

7. Elements of the Pharmacy Cardiovascular Health Care Model: High-risk patients .............................. 192

7.1 Guiding principles and existing framework ....................................................................................... 192

7.2 Pharmacy-based risk factor screening and referral for assessment .................................................. 193

8. Elements of the Pharmacy Cardiovascular Health Care Model: Compliance with therapy .................. 212

8.1 Guiding principles and existing framework ....................................................................................... 212

8.2 Promoting patient compliance with drugs, diet and exercise ............................................................ 212

8.2.1 Hyperlipidaemia ............................................................................................................................ 216

8.2.2 Hypertension ................................................................................................................................. 225

8.3 Practical strategies to promote compliance in cardiovascular disease ............................................ 226

9.Elements of the Pharmacy Cardiovascular Health Care Model: Medication management and reviews233

9.1 Guiding principles and existing framework ....................................................................................... 233

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9.2 Promoting evidence-based pharmacotherapy of CVD ...................................................................... 234

9.2.1 Heart failure .................................................................................................................................. 245

9.2.2 Atrial fibrillation ........................................................................................................................... 249

9.2.3 Hypertension ................................................................................................................................. 250

9.2.4 Hyperlipidaemia ............................................................................................................................ 252

9.3 Monitoring and educating patients .................................................................................................... 257

9.3.1 Patient education, including participation in cardiac rehabilitation programs .......................... 258

9.3.2 High-risk drugs requiring ongoing monitoring ......................................................................... 261

9.4 Use of information and communications technology solutions to promote QUM in CVD ................ 284

10.Assessment of Opinion on the Model .......................................................................................................... 291

10.1 Input from stakeholders using a modified Delphi Process ................................................................ 291

10.1.1 National Heart Foundation........................................................................................................ 294

10.1.2 The Royal Australian College of General Practitioners ............................................................ 298

10.1.3 National Stroke Foundation ..................................................................................................... 298

10.1.4 Heart Support ........................................................................................................................... 303

11. Conclusions .................................................................................................................................................. 307

12. Recommendations ....................................................................................................................................... 298

13. References .................................................................................................................................................... 315

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Index of Figures

Figure 1 Framework for the potential roles of community pharmacists in alleviating the societal

burden of cardiovascular disease ....................................................................................... 34

Figure 2 “ABC” format to summarise the key principles of an evidence-based approach to the

prevention of CVD. ........................................................................................................... 35

Figure 3 Approach to the conduct of the systematic literature review of pharmacy programs in

cardiovascular disease........................................................................................................ 37

Figure 4 Example screen shot of the comprehensive electronic database of relevant literature ...... 44

Figure 5 Approach to the development of the National Pharmacy Cardiovascular Health Model .. 94

Figure 6 Stages of CVD risk ............................................................................................................ 95

Figure 7 Continuum of chronic disease prevention and care ........................................................... 98

Figure 8 Continuum of chronic disease prevention and care ........................................................ 101

Figure 9 From Pharmacy News, 13 May 2004 .............................................................................. 113

Figure 10 From Pharmacy News, 21 July 2005 ............................................................................... 113

Figure 11 From Pharmacy News, 27 May 2004 .......................................................................... 114

Figure 12 Staged approach to developing the pharmacist-physician collaborative working

relationship ................................................................................................................... 120

Figure 13 Stages of CVD (normal health, elevated risk for CVD, and diagnosed CVD) .............. 122

Figure 14 Possible roles for community pharmacists within the stages of CVD ............................ 123

Figure 15 Lifestyle interventions and drug treatments shown to reduce the risk of cardiovascular

morbidity and/or mortality ............................................................................................... 150

Figure 16 Lifestyle guidelines for preventing cardiovascular events .............................................. 151

Figure 17 Risk factor assessment, targets and monitoring intervals for the prevention of vascular

disease41 ........................................................................................................................... 152

Figure 18 Five step model (5As) for detection, assessment and management of risk factors within

the SNAP Framework ................................................................................................... 154

Figure 19 The National Heart Foundation of Australia’s Heartmoves program. ............................ 159

Figure 20 Excerpt from the patient decision aid “Making Choices: Life Changes to Lower Your Risk

of Heart Disease and Stroke”, developed by the Ottawa Health Research Institute

(http://decisionaid.ohri.ca/decaids.html). ......................................................................... 160

Figure 21 Example of materials for consumers available from the National Heart Foundation of

Australia’s website. .......................................................................................................... 162

Figure 22 Information leaflets for patients with CVD available from the National Heart Foundation

of Australia’s website. ..................................................................................................... 163

Figure 23 Example of general material on prevention of CVD for consumers available from the

National Heart Foundation of Australia’s website. .......................................................... 164

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Figure 24 Educational material available for order through the National Heart Foundation of

Australia’s Heartline ........................................................................................................ 166

Figure 25 Pharmacy Self Care card on exercise and CVD .............................................................. 167

Figure 26 Pharmacy Self Care card on hypertension ....................................................................... 168

Figure 27 Example of educational material on prompt presentation for chest ................................ 179

Figure 28 Excerpt from ‘Heart Attack, available in 10 languages from the National Heart Foundation

of Australia’s website. ..................................................................................................... 180

Figure 29 Excerpt from ‘Transient Ischaemic Attack’, available from the Stroke Foundation’s

website. ............................................................................................................................ 181

Figure 30 Example of an educational poster suitable for display in community pharmacy (from the

Stroke Foundation’s website). ......................................................................................... 182

Figure 31 Deficits in the delivery of care at the hospital-community interface ............................... 184

Figure 32 Pharmacy-based Heart Assessment and Referral Methodology: a program to tackle

coronary heart disease in the Australian community (Pharmacy Guild of

Australia/Government, Third Community Pharmacy Agreement Research and

Development Grants Program. Project ............................................................................ 195

Figure 33 Predictors of poor patient compliance ............................................................................. 216

Figure 34 Discontinuation rates with lipid-lowering drug therapy (from Simons et al.226). Dispensing

data six to seven months after initial supply. Values are numbers (percentages) ............ 218

Figure 35 Treatment persistence with antihypertensive medications. Data from Jones et al.256 ..... 226

Figure 36 General strategies to improve compliance with medication ............................................ 227

Figure 37 General approach to enhancing patient compliance with lipid-lowering drug therapy ... 228

Figure 38 Multiple strategies that can improve medication compliance in CVD ............................ 231

Figure 39 Clinical aid outlining appropriate therapy for patients in different CVD risk categories 235

Figure 40 Therapeutic guidelines for preventing cardiovascular events in patients with CVD ...... 237

Figure 41 National Prescribing Service guidelines on drug use in CVD ......................................... 239

Figure 42 Example of media coverage of a published study of management of CHF by members of

the Project Team .............................................................................................................. 247

Figure 43 Underuse of beta-blockers and the pharmacist ................................................................ 256

Figure 44 Suggest content of cardiac rehabilitation programs ........................................................ 260

Figure 45 Pharmacist checklist for patient counselling on warfarin ................................................ 264

Figure 46 One page guide to warfarin treatment ............................................................................. 265

Figure 47 New anticoagulants or better use of existing therapy? .................................................... 267

Figure 48 Need for close monitoring of amiodarone therapy .......................................................... 283

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Figure 49 Decision support box to promote the appropriate use of low-dose aspirin (from

PROMISe2). The pharmacy dispense screen has links to print-friendly secondary

windows providing further information for the pharmacist and an information leaflet for

the patient ......................................................................................................................... 285

Figure 50 Screen shot of automated intervention alert for Low-dose aspirin (from PROMISe2) ... 286

Figure 51 Patient handout for aspirin automatic intervention prompt ............................................. 287

Figure 52 Pharmacist information sheet for aspirin automatic intervention prompt ....................... 288

Figure 53 Example of an intervention from the PROMISe2 study relating to the aspirin alert within

the dispensing software .................................................................................................... 289

Figure 54 Effect of aspirin intervention prompt on the overall intervention rate in different phases of

the PROMISe2 study ....................................................................................................... 289

Figure 55 The response from the National Heart Foundation, providing feedback on the draft Model

......................................................................................................................................... 298

Figure 56 The response from the National Stroke Foundation, providing feedback on the draft Model

......................................................................................................................................... 302

Figure 57 The response from Heart Support, providing feedback on the draft Model .................... 306

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Index of Tables

Table 1 INFORMIT search terms and criteria ................................................................................ 40

Table 2 CPRD search terms and criteria ........................................................................................ 41

Table 3 Source of papers for literature review ............................................................................... 42

Table 4 Information extracted from clinical papers ....................................................................... 45

Table 5 NHMRC levels of evidence classification ........................................................................ 46

Table 6 Checklist for appraising the quality of studies of interventions ........................................ 47

Table 7 Quality of Non-randomised controlled trials (NHMRC) .................................................. 48

Table 8 Definitions of types of outcomes (NHMRC) .................................................................... 49

Table 9 Body of evidence assessment matrix (NHMRC) .............................................................. 50

Table 10 Summary of papers examined, by CVD focus and evidence grade .................................. 52

Table 11 Location of residents completing survey ........................................................................... 56

Table 12 Categories of patients based on future risk of a cardiovascular event .............................. 96

Table 13 Common obstacles to inter-professional collaboration ................................................... 118

Table 14 Collaboration Between Community Pharmacists and Family Physicians: Lessons Learned

from the Seniors Medication Assessment Research Trial ............................................... 119

Table 15 Strategies to Achieve Stage 1: Increasing Pharmacists’ Recognition among Doctors .... 121

Table 16 Strategies to Achieve Stage 2: Relationship Exploration and Trial ................................ 121

Table 17 Strategies to Achieve Stage 3: Expanding the Professional Relationship ....................... 121

Table 18 Common causes of chest pain ......................................................................................... 175

Table 19 Differentiating features with the major causes of chest pain ........................................... 176

Table 20 Counselling Plan for High-Risk Patients ......................................................................... 178

Table 21 Summary of subject details from Pharmacy-based Heart Assessment and Referral

Methodology: a program to tackle coronary heart disease in the Australian community 196

Table 22 Main unit costs for pharmacy-based cardiovascular risk profiling ................................. 198

Table 23 Summary table of benefits, costs and cost-effectiveness of a ......................................... 200

Table 24 Individuals at increased risk of CVD .............................................................................. 205

Table 25 Some roles for the pharmacist in the care of the patient with dyslipidaemia (modified from

Luxford) ........................................................................................................................... 224

Table 26 Examples of conditions which may be under-diagnosed and/or under-treated in the elderly

......................................................................................................................................... 243

Table 27 Some roles of the pharmacist in patients with dyslipidaemia (modified from Luxford) . 253

Table 28 Patient partnership in medicine taking ............................................................................ 258

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Table 29 Specific aims of cardiac rehabilitation programs ............................................................ 259

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AbstractCardiovascular health is a National Health Priority Area. Cardiovascular disease is the largest

cause of premature death and death overall in Australia, and its health and economic burden

exceeds that of any other disease. Australia has one of the highest incidences of

cardiovascular disease in the Asia-Pacific region. Cardiovascular disease accounts for

approximately 40% of deaths among Australians. These issues are expected to become more

acute over the next decades with the growing number of elderly Australians, among whom

cardiovascular disease is most common. Cardiovascular disease will affect one in four

Australians by 2051. Total financial costs of cardiovascular disease are more than $14 billion

per annum (1.7% of GDP). Direct health system costs of cardiovascular disease were

estimated at $7.6 billion in 2004 (11% of total health spending).

The proximal causes of the cardiovascular disease epidemics are well known. The major

risk factors - inappropriate diet and physical inactivity (as expressed through unfavourable

lipid concentrations, high body mass index, and raised blood pressure), together with tobacco

use - explain at least 75% of new cases of cardiovascular disease. In the absence of these risk

factors, cardiovascular disease is a rare cause of death. The optimum levels of cardiovascular

disease risk factors are known; unfortunately, only about 5% of the adult population of

developed countries is at low risk with optimum risk factor levels.

It is essential that pharmacists join other health professionals in national programs to

tackle the leading cause of morbidity and mortality in Australia. It would seem that

pharmacists, being the most readily accessible health professional in the community setting,

could fulfil a useful role in the prevention, detection, and management of cardiovascular

disease.

Considerable information on the status of cardiovascular disease in Australia (e.g.

statistics, health care delivery programs, government and professional group policies) was

collected. The Project Team then performed a systematic review of published studies

describing community pharmacy-based cardiovascular disease programs. This included an

assessment of the quality of the published randomised controlled studies. The systematic

review was developed within the following three major sub-areas.

Health promotion to prevent development and progression of cardiovascular disease in

the general population.

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Screening for cardiovascular risk factors and recommending referral for medical

assessment and management when appropriate (high-risk individuals).

Improving therapeutic outcomes in cardiovascular disease – e.g. promoting evidence-

based guidelines in the pharmacotherapy of cardiovascular disease, monitoring and

promoting compliance with prescribed drug therapy (patients with existing

cardiovascular disease).

Information was also collected on community pharmacy cardiovascular disease

programs that have operated or are currently operating in Australia and abroad, to identify

opportunities for them to be adopted or expanded in Australia.

A national public survey was performed to assist in developing the Pharmacy

Cardiovascular Health Care Model. The intention was to assess the public’s perceptions of

pharmacists’ involvement and role in cardiovascular disease prevention and management.

Peak national organisations were also canvassed for views on pharmacy’s role in

cardiovascular disease.

The results of the systematic review and public survey, along with the collective

learnings from previous studies in Australia and overseas by the Project Team members, were

subsequently used in the development of a Pharmacy Cardiovascular Health Care Model. This

model builds on existing health service and health promotion priorities, and promotes

partnership and collaboration across the health care system. As far as possible, the model has

been developed to be consistent with the goals of the ‘National Strategy for Heart, Stroke and

Vascular Health in Australia’, and the draft versions of the ‘National Chronic Disease

Strategy’ and the ‘National Service Improvement Framework for Heart, Stroke and Vascular

Disease’. Feedback was provided by the Expert Advisory Group and key stakeholder

organisations.

The Pharmacy Cardiovascular Health Care Model is based on the following priority

areas.

Public/preventive health promotion including:

- health promotion to prevent development and progression of cardiovascular disease;

- improving awareness of risk factors;

- improving awareness of symptoms and early warning signs of acute episodes.

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Continuum of care including:

- transfer of medication-related information between hospital and community;

- follow-up of patients post-discharge to identify and remedy any drug-related

problems.

High-risk patients including:

- referral for screening and risk-assessment (must be based on absolute risk

assessment);

- pharmacy-based risk factor screening and referral (may be a role).

Compliance with therapy including:

- promoting patient compliance with drugs, diet, exercise.

Medication management and reviews including:

- promoting evidence-based drug therapy of cardiovascular disease and preventing

drug-related problems;

- monitoring and educating patients e.g. through Home Medicines Review scheme.

The model supports the role of the pharmacy profession in promoting the dissemination

and uptake of best preventive and treatment practices for heart, stroke and vascular diseases;

enhances the role of consumers in maintaining and managing their own health; and improves

the management of heart, stroke and vascular diseases across the continuum of care.

The model will require improved clinical performance by pharmacists, greater

collaboration with other health professionals, and improved use of information and

communications technology. In related projects, the research team has demonstrated that

electronic communication of medication histories between hospital and community improves

the pharmaceutical care of elderly patients with cardiovascular disease, while in a randomised

controlled trial it has been demonstrated that a computer-based educational alert and

reminder, related to the use of low-dose aspirin in high-risk diabetic patients, within pharmacy

dispensing software significantly increases intervention rates by pharmacists.

The Project Team has also made the following recommendations.

1. The Pharmacy Guild of Australia and other relevant organisations (e.g.

Pharmaceutical Society of Australia) progress the proposed framework, as detailed in

this Project, prior to a wider implementation.

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2. The Pharmacy Guild of Australia and the Pharmaceutical Society of Australia form

closer links with the key national organisations related to cardiovascular disease,

especially the National Heart Foundation of Australia and the National Stroke

Foundation, as well as the National Prescribing Service.

3. There be an ongoing improvement in communication between community pharmacists

and general practitioners and their respective organisations, and reinforcement of the

fact that the Pharmacy Cardiovascular Health Care Model and related programs are

intended to assist in improving the health of Australians and not as a threat to the

medical profession.

4. Comprehensive training packages for pharmacists and pharmacy assistants on

cardiovascular disease prevention and management be developed and disseminated.

5. There be increased promotion of the Home Medicines Review scheme in patients with

cardiovascular disease, particularly in collaboration with the National Heart

Foundation of Australia and the National Prescribing Service, as a key component of

the Pharmacy Cardiovascular Health Care Model.

6. Pharmacy-based cardiovascular disease screening programs be specifically targeted at

those individuals likely to be at elevated risk of cardiovascular disease and incorporate

absolute risk assessment and close liaison with general practitioners. Further, only

pharmacists with appropriate training and demonstrated competence should perform

cardiovascular disease risk factor assessments. More research needs to be conducted

on the clinical and economic outcomes of community pharmacy cardiovascular

disease screening programs before they are widely implemented.

7. There be further development of information technology-based strategies (e.g.

prompts within dispensing software) to encourage pharmacists to intervene and

investigate possible instances of under-use of important cardiovascular agents, such as

aspirin and -blockers. The vast pool of electronic data at community pharmacists’

fingertips must be utilised to greater effect.

8. The role of accredited pharmacists in improving the management of therapy with

warfarin be further developed and evaluated, given the promising results to date. This

includes the need for further research to be conducted on the impact of pharmacist-

conducted INR monitoring on patient care and outcomes. Subsequently, the profession

should develop training courses and an accreditation process for consultant

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pharmacists to perform monitoring of warfarin therapy, in collaboration with general

practitioners.

The Pharmacy Cardiovascular Health Care Model has the potential to encourage the

adoption and maintenance of healthy lifestyle behaviours, improve the detection and

management of cardiovascular disease and make a significant impact on current health care

practices and expenditure in Australia. The model will also improve the quality use of

medicines by consumers and enhance the practice of community pharmacy in Australia.

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Executive Summary Cardiovascular diseases (predominantly ischemic heart disease and stroke) are the leading

causes of death worldwide, accounting for about one-third or 17 million of global deaths

annually. That figure is expected to increase to 25 million by 2025, unless major prevention

efforts can halt the rise. Cardiovascular disease (CVD) places a heavy burden on Australians

and cardiovascular health is recognised as a National Health Priority Area.

It is essential that pharmacists join other health professionals in national programs to

tackle the leading cause of morbidity and mortality in Australia. For instance, it would seem

that pharmacists, being the most readily accessible health professional in the community

setting, could fulfil a useful role in the detection, counselling, and referral of members of the

public at risk of CVD.

1. Framework development

Firstly, a framework for the potential roles of community pharmacists in alleviating the

societal burden of CVD was constructed and this is shown below. Key possible activities

include the following.

Health promotion to prevent development and progression of CVD (general

population).

Screening for cardiovascular risk factors and recommending referral for medical

assessment and management when appropriate (high-risk individuals).

Improving therapeutic outcomes in CVD – e.g. promoting evidence-based guidelines

in the pharmacotherapy of CVD, monitoring and promoting compliance with

prescribed drug therapy (patients with existing CVD).

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Framework for the potential roles of community pharmacists in alleviating

the societal burden of cardiovascular disease

Considerable information on the status of CVD in Australia (e.g. statistics, health care

delivery programs, government and professional group policies) was collected by the Project

Team.

2. Systematic literature review

The Project Team then performed a systematic review of published studies describing

community pharmacy-based CVD programs. This included an assessment of the quality of the

Monitoring and promoting adherence to prescribed drug therapy

Screening for cardiovascular risk factors and recommending referral for medical assessment and management when appropriate

Health promotion to help prevent development of cardiovascular disease

Promoting evidence-based guidelines in the pharmacotherapy of cardiovascular disease

Health promotion to slow progression of

cardiovascular disease

Monitoring response to pharmacotherapy of cardiovascular disease (e.g. clinical control,

adverse drug reactions)

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published randomised controlled studies. The systematic review was developed within the

following three major sub-areas.

health promotion to prevent development and progression of CVD;

screening for cardiovascular risk factors and recommending referral for medical

assessment and management when appropriate; and

improving therapeutic outcomes in CVD – e.g. promoting evidence-based guidelines

in the pharmacotherapy of CVD, monitoring and promoting compliance with

prescribed drug therapy.

Literature searching across each of these areas within multiple databases (including

MEDLINE, International Pharmaceutical Abstracts, EMBASE and the Cochrane Library) was

performed simultaneously and independently by two researchers, each of whom had been

trained in systematic review and meta-analysis methodology by the Australasian Cochrane

Centre. The quality of the studies was assessed - noting for example, randomisation and

adequate allocation concealment or blinding. The figure below sets out the approach to the

conduct of the systematic literature review of pharmacy programs in CVD. The final product

was an electronic, searchable database of relevant articles, including an assessment of the

quality of publications. A copy of the database has been submitted with this report.

A relatively small proportion of the sourced literature was suitable for systematic

review. A total of 132 papers were deemed relevant and eligible for systematic review. In

general, the quality of these studies was poor, with only a small amount of high quality

randomised controlled trials evaluating the effect of community pharmacy’s involvement in

CVD prevention and management. The most evidence for community pharmacist

involvement in the management of CVD was related to hypertension and hyperlipidaemia.

However, a number of these studies were of poor methodological quality or were conducted

in hospital outpatient clinic or managed care settings, making the results difficult to

extrapolate to community pharmacy practice in Australia.

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Approach to the conduct of the systematic literature review of pharmacy

programs in cardiovascular disease

Information was also collected on community pharmacy CVD programs that have

operated or are currently operating in Australia. This information was sought from State

Branches of the Pharmacy Guild of Australia and Pharmaceutical Society of Australia,

Schools of Pharmacy and Divisions of General Practice. There was very little information

forthcoming on community pharmacy involvement in CVD programs. Most details came

from outpatient cardiac rehabilitation programs, and these pharmacist services were generally

Areas of focus

Health promotion to prevent development and progression of CVD

Screening for cardiovascular risk factors and recommending referral

Improving therapeutic outcomes in CVD

Electronic and manual literature review of each major area

independently by 2 researchers

Review and collate articles of potential interest

Database entry

Systematic review

Review and collate articles of potential interest

Database entry

Systematic review

Other information via Web

resources and direct

consultation with AIHW,

NHF etc.

Reconciliation of database entries

Overall review of published studies, and meta-analyses

where appropriate

Preparation of report

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funded by the pharmacist’s usual employee i.e. hospital pharmacy, or contracted by the

outpatient clinic concerned.

Two postings to AusPharmList were used to canvass experiences of Australian

community pharmacists, although the feedback from this source was also minimal.

While there is good evidence that community pharmacists are well placed to help

patients who have, or who are at risk, of CVD, there is very little information available on

these types of activities. Unfortunately, as has been noted many times previously, the

pharmacy profession as a whole does not generally document or publish its actual activities to

enable the public, other health professionals and governments to appreciate the extent of

pharmacy practice in Australia.

At present, the role of community pharmacists in the prevention and management of

CVD in this country and overseas can be essentially described in the same manner as the

results of the 2000 Cochrane Database Systematic Review of pharmacists’ role expansion -

there are relatively few studies, with doubtful generalisability as they have poorly defined

interventions, cost assessments and patient outcome data. More rigorous research is needed.

The pharmacy profession in Australia needs to urgently produce high quality studies of

community pharmacists’ expanded role in CVD.

3. Public survey

A national survey was performed to assist in developing the Pharmacy Cardiovascular Health

Care Model. The intention was to assess the public’s perceptions of pharmacists’ involvement

and role in CVD prevention and management.

A computer-assisted telephone interview (CATI) survey of 505 households was

conducted across Australia. The survey was administered to metropolitan, rural and remote

residents (Australian consumers over the age of 29 years) via a 15-minute telephone

interview. People aged over 29 years were targeted as they represent a higher rate of

community pharmacy use and are more likely to benefit from CVD

detection/prevention/treatment programs. The sample was screened to include only those

who had visited a pharmacy in the previous month, and a quota of 50% with CVD.

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Respondents’ ages ranged from 30 to 90 years (mean 57 years of age); 58% of

respondents were female and 42% male. Fifty percent of respondents were in full time or part

time work, with 30% pensioners and 10% in home duties. The targeted equal sample split of

CVD:non CVD was achieved (251:254). It was found that there was little difference between

the responses from each state. Regional (n = 189) and metropolitan (n = 316) respondents

were picked up in the random sampling.

The data came from a good cross-section of the adult population (i.e. metropolitan and

country, female and male, incidence of hypertension and diabetes). There was a high level of

satisfaction with the quality of service provided by regularly visited pharmacies, although

there appeared to be a lack of awareness amongst consumers as to the skills and capabilities

of pharmacists and of services available through pharmacies.

Consumers indicated that providing advice on how to take medicines properly was the

major activity in which pharmacists were most capable. The majority of respondents also

agreed or strongly agreed that pharmacists are capable of providing screening or testing for

hypertension and diabetes, and providing advice on lifestyle changes (weight loss, smoking,

alcohol intake etc.) and information about cardiovascular diseases and their management.

The majority of respondents agreed or strongly agreed that pharmacists are capable of:

providing screening or testing for raised blood pressure.

providing screening or testing for diabetes

providing advice on lifestyle changes (weight loss, smoking, alcohol intake

etc).

supplying medicines for cardiovascular diseases

providing advice on over-the-counter and herbal medicines to be avoided by

patients with a cardiovascular disease.

providing information about cardiovascular diseases and their management.

providing advice on how to take medicines properly. This is the activity that

most respondents see as the one in which pharmacists are most capable.

A minority of respondents agreed or strongly agreed that pharmacists are capable of:

providing screening or testing for raised cholesterol

diagnosing cardiovascular diseases

prescribing drug treatment for cardiovascular diseases.

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In regard to pharmacists’ capability in checking or monitoring the outcomes of drug

treatment, respondents were evenly divided with 40% either agreeing or strongly agreeing and

41% either disagreeing or strongly disagreeing and the balance neither agreeing nor

disagreeing. Although doctors were seen as the most likely provider of diagnostic and

screening services, respondents said that they would be likely or very likely to use a

pharmacist (after doctors) for services such as to:

prescribe medicines

obtain prescription medicines,

seek advice on over-the-counter and herbal medicines to be avoided by patients

with cardiovascular diseases from a doctor,

seek information on cardiovascular diseases and their management

seek advice on how to take medicines properly

monitor the outcome of their drug treatment

In summary, there appeared to be a gap in the perception of what consumers believe

pharmacists can do and are capable of doing, and what the pharmacy profession believes it

can do and currently does. Clearly the profession as a whole needs to undertake a program of

self-promotion to educate consumers of the potential role that pharmacists can have in their

lives.

4. Survey of peak representative organisations

Peak national organisations (National Heart Foundation of Australia and National Stroke

Foundation) were canvassed to determine their views on pharmacy involvement in CVD and

health promotion activities, relevant to their particular organisation’s constituency. The

intention was to use the outcomes to guide the development of an overarching model that

depicts the three stages of CVD where community pharmacists could intervene. The website

of each body was also used to find information on the perceived role of the pharmacy

profession.

The National Heart Foundation of Australia replied that it would take into account

pharmacy involvement in cardiovascular areas with the evidence provided by the present

project. The Foundation believed all activities that could be provided by pharmacies, such as

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heath advice, screening and monitoring with consequent referral, should be evidence-based

and occur within an appropriate accredited environment by trained practitioners. It also

suggested these activities should be supported by government policy and also should include

links to others in health care practice, such as general practitioners.

The Heart Foundation considered the core role of the pharmacist as one of medication

advice in the areas of side effects, drug interactions and compliance. It suggested pharmacy

health promotion advice should be given using other organisations’ resources and also links to

national programmes.

The Heart Foundation’s web site has health professional resources (for doctors), such as

lipid and hypertension management guidelines. General resources do not mention the

pharmacy as a source of information or having any role in cardiac disease management in

health promotion or screening.

The National Stroke Foundation considers pharmacies as outlets for information,

education for public health campaigns while working in partnerships to keep people safe. It

also sees the pharmacy profession working on the development of best evidence guidelines

for medication use in stroke prevention. The organisation had no opinion on the role of

pharmacy in anticoagulation but does see a role in hypertension and smoking cessation. The

role in hypertension is one of screening to increase the identification of those with

hypertension and consequent referral.

Pharmacies are seen as information sources using the ‘Strokesafe’ resources developed

by the foundation and actively encouraging individuals in lifestyle change to reduce the risk

of stroke. Generally, the pharmacy profession is not seen to have a role outside the pharmacy

itself except working on the evidence guides on medication.

There is a large unmet need in Australia to perform scientifically rigorous trials of the

management of CVD by community pharmacists in collaboration with general practitioners.

As noted by the National Heart Foundation of Australia, the potential role of the pharmacy

profession is considerable but needs to be evidence-based, and one that liaises with other

health professionals involved in patient care.

There is also a clear need for the professional pharmacy organisations to work

collaboratively with the key stakeholder organisations associated with CVD.

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5. Developing the Pharmacy Cardiovascular Health Care Model

The systematic literature review, public survey and canvassing of pharmacists and key

organisations were all conducted to inform the development of a Pharmacy Cardiovascular

Health Care Model. This Model was to build on existing health service and health promotion

plans in CVD, and promote partnership and collaboration across the health care system. It was

to be consistent with the goals of pre-existing national strategies, rather than re-defining what

the national priorities should be.

Approach to the development of the National Pharmacy Cardiovascular

Health Model

A guiding principle was that any model should be built around existing health service

and health promotion plans in CVD, and encourages partnership and collaboration across the

health care system. The model should be consistent with the goals of pre-existing national

strategies. The National Strategy for Heart, Stroke and Vascular Health in Australia presented

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a useful starting point, depicting what are essentially the major three stages of CVD (normal

health, elevated risk for CVD, and diagnosed CVD).

Stages of CVD (normal health, elevated risk for CVD, and diagnosed CVD)

The results of the systematic literature review and public survey, along with the advice

from peak organisations and the collective learnings from previous studies in Australia and

overseas by the Project Team members, were subsequently used in the development of a

Pharmacy Cardiovascular Health Care Model. The sources of guidance (systematic literature

review, environmental scan and public survey, along with input from the Expert Advisory

Group and key stakeholder groups) were reasonably consistent in that the focus should be on

high-risk patients, particularly with regard to improving the quality use of medicines (QUM).

The expanded involvement of pharmacists in improving compliance with medication, alone,

would have major implications for the prevention of cardiovascular events and health

resources savings nationally.

The Model lists potential priority areas in CVD where community pharmacy could play

a useful role.

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PPublic/preventive health promotion

Health promotion to prevent development and progression of cardiovascular diseaseImproving community awareness of risk factors Improving awareness of symptoms and early warning signs of acute episodes

CContinuum of care

Transfer of medication-related information between hospital and community

Follow-up of patients post-discharge to identify and remedy any drug-related problems

HHigh-risk patients

Referral for screening and risk-assessment

Pharmacy-based risk factor screening and referral

CCompliance with therapy

Promoting patient compliance with drugs, diet and exercise

MMedication management and reviews

Promoting evidence based drug therapy of cardiovascular disease and preventing drug-related problems

Monitoring and educating patients e.g. through the Home Medicines Review scheme

Each of these proposed elements is discussed in the report. This discussion includes the

following.

The relevant National Chronic Disease Strategy key points.

National Service Improvement Framework for Heart Stroke and Vascular

Disease critical intervention points.

Evidence for the proposed element.

Strategy for improvement.

Examples of supporting resources.

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Opinions were subsequently canvassed on the draft Model. Although the feedback

obtained was relatively limited, it was supportive of the Model.

The Model will require improved clinical performance by pharmacists, greater

collaboration with other health professionals and improved use of information and

communications technology. Pharmacists need to practise their skills and acquire additional

training to be able to perform these expanded roles effectively. Only those with the requisite

skills will be able to achieve the desired outcomes including having a positive influence on

the quality of medication use in CVD.

Greater cooperation between pharmacy organisations and the peak bodies associated

with CVD would facilitate the acceptance and implementation of pharmacy-based services

targeting CVD. Again, as noted by the National Heart Foundation of Australia, “Clearly the

relationship between pharmacy and the National Heart Foundation of Australia is a key one

that can support a potential change in pharmacy practice, a change endorsed by the peak body

representing this health priority”. One example of where support would be of assistance

would be in the greater promotion of the Home Medicines Review scheme, which represents a

unique opportunity in Australia to optimise drug use in CVD and improved medication safety

following hospitalisation of patients with CVD. The National Heart Foundation of Australia’s

endorsement of this scheme and its promotion to the medical profession and the public would

help achieve this goal. A Home Medicines Review for all patients discharged from hospital

with an acute cardiovascular event would be an ideal mechanism, in the right environment, to

provide education in regard to medicines and more general aspects of the secondary

prevention of CVD.

Similarly, greater collaboration between the pharmacy organisations and the National

Prescribing Service is critical for the profession and for society in improving QUM generally.

One area where pharmacists are likely to have a major positive influence is in the

screening and /or monitoring of patients with CVD when directed at improving the outcome

of drug therapy (e.g. blood pressure monitoring; INR monitoring with warfarin). Given the

increasing usage of warfarin for chronic atrial fibrillation, coupled with the availability of

accurate, portable and relatively inexpensive monitoring devices, there is an opportunity to

improving the management of therapy with warfarin by developing the role of the pharmacists

in the area. The Project’s research has clearly shown that education and INR monitoring of

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patients by appropriately trained pharmacists improves clinical outcomes and, when

implemented in a collaborative model, is welcomed by patients and general practitioners. This

should be a role developed by accredited pharmacists who have completed advanced training

in anticoagulation management.

The Project Team has made the following recommendations.

1. The Pharmacy Guild of Australia and other relevant organisations (e.g.

Pharmaceutical Society of Australia) progress the proposed framework, as detailed in

this Project, prior to a wider implementation.

2. The Pharmacy Guild of Australia and the Pharmaceutical Society of Australia form

closer links with the key national organisations related to CVD, especially the

National Heart Foundation of Australia and the National Stroke Foundation, as well as

the National Prescribing Service.

3. There be an ongoing improvement in communication between community pharmacists

and general practitioners and their respective organisations, and reinforcement of the

fact that the Pharmacy Cardiovascular Health Care Model and related programs are

intended to assist in improving the health of Australians and not as a threat to the

medical profession.

4. Comprehensive training packages for pharmacists and pharmacy assistants on CVD

prevention and management be developed and disseminated.

5. There be increased promotion of the Home Medicines Review scheme in patients with

CVD, particularly in collaboration with the National Heart Foundation of Australia

and the National Prescribing Service, as a key component of the Pharmacy

Cardiovascular Health Care Model.

6. Pharmacy-based CVD screening programs be specifically targeted at those individuals

likely to be at elevated risk of CVD and incorporate absolute risk assessment and close

liaison with general practitioners. Further, only pharmacists with appropriate training

and demonstrated competence should perform CVD risk factor assessments. More

research needs to be conducted on the clinical and economic outcomes of community

pharmacy CVD screening programs before they are widely implemented.

7. There be further development of information technology-based strategies (e.g.

prompts within dispensing software) to encourage pharmacists to intervene and

investigate possible instances of under-use of important cardiovascular agents, such as

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aspirin and -blockers. The vast pool of electronic data at community pharmacists’

fingertips must be utilised to greater effect.

8. The role of accredited pharmacists in improving the management of therapy with

warfarin be further developed and evaluated, given the promising results to date. This

includes the need for further research to be conducted on the impact of pharmacist-

conducted INR monitoring on patient care and outcomes. Subsequently, the profession

should develop training courses and an accreditation process for consultant

pharmacists to perform monitoring of warfarin therapy, in collaboration with general

practitioners.

The Pharmacy Cardiovascular Health Care Model has the potential to encourage the

adoption and maintenance of healthy lifestyle behaviours, improve the detection and

management of CVD and make a significant impact on current health care practices and

expenditure in Australia. The model will also improve the quality use of medicines by

consumers and enhance the practice of community pharmacy in Australia.

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Acknowledgements

The Project Team thanks the following for valuable assistance with various aspects of the

project:

The funding body (Australian Government Department of Health and Ageing,

through the Third Community Pharmacy Agreement Research and Development

Program) and the Pharmacy Guild of Australia;

Dr Simone Jones and the members of the Expert Advisory Group;

All stakeholders who provided input;

Mr Ian DeBoos, DeBoos Associates;

Mr James Reeve, Mr Peter Tenni and Dr Omar Hasan; and

Mr Rod Unmack, Mr Keith Gordjin and Mr Brett O’Halloran, PCA/NU

Systems.

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1. Introduction Cardiovascular diseases (predominantly ischemic heart disease and stroke) are the leading

causes of death worldwide, accounting for about one-third or 17 million of global deaths

annually. That figure is expected to increase to 25 million by 2025, unless major prevention

efforts can halt the rise.1

Cardiovascular disease (CVD) places a heavy burden on Australians.2-5 It remains the

major public health problem in Australia and the leading cause of mortality and disability.

Every 10 minutes one Australian dies from CVD, accounting for 38% of all

deaths.

CVD causes 22% of the burden of disease in Australia.

Compared to other diseases, CVD is the largest health cost item.

Total financial costs of CVD are more than $14 billion per annum – 1.7% of

GDP.

Direct health system costs of CVD are estimated at $7.6 billion in 2004 (11% of

total health spending).

Cardiovascular disease will affect one in four Australians by 2051.2

The proximal causes of the CVD epidemics are well known. The major risk factors -

inappropriate diet and physical inactivity (as expressed through unfavourable lipid

concentrations, high body mass index, and raised blood pressure), together with tobacco use -

explain at least 75% of new cases of CVD.3 In the absence of these risk factors, CVD is a

rare cause of death. The optimum levels of CVD risk factors are known; unfortunately, only

about 5% of the adult population of developed countries are at low risk with optimum risk

factor levels.3

The prevention of CVD in Australia, as in many other countries, is far from optimal.

For instance, based on findings in the AusDiab study in 1999-2000,4 only 14% of patients

with hypertension are treated and adequately controlled, and 33% are treated but not

controlled. Similar figures have been reported in Canada and the United States.5, 6

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National Heart Foundation of Australia. The shifting burden of cardiovascular

disease. Report prepared by Access Economics, 2005.2

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1.1 OVERVIEW OF POSSIBLE ROLES FOR COMMUNITY PHARMACY

A framework for the potential roles of community pharmacists in alleviating the societal

burden of CVD is shown in Figure 1. Key possible activities include the following.

Health promotion to prevent development and progression of cardiovascular disease

(general population).

Screening for cardiovascular risk factors and recommending referral for medical

assessment and management when appropriate (high-risk individuals).

Improving therapeutic outcomes in cardiovascular disease – e.g. promoting evidence-

based guidelines in the pharmacotherapy of cardiovascular disease, monitoring and

promoting compliance with prescribed drug therapy (patients with existing CVD).

It is essential that pharmacists join other health professionals in national programs to

tackle the leading cause of morbidity and mortality in Australia. For instance, it would seem

that pharmacists, being the most readily accessible health professional in the community

setting, could fulfil a useful role in the detection, counselling, and referral of members of the

public at risk of cardiovascular disease.

Community pharmacists are well placed to help patients who have cardiovascular

disease or who are at risk of this. They have an opportunity to identify at-risk patients,

based on their knowledge of the families, what drug treatments are being taken, and

information provided by patients. They can identify under treated patients at the point

of dispensing and feed relevant information back to the surgery. Public health is

another important aspect of the community pharmacist’s work and involves provision

of education and advice on lifestyle and diet. Pharmacists are also involved in smoking

cessation services, and are able to support patients by providing structured advice and

smoking cessation products. Some pharmacies participate in screening services for

example, measuring cholesterol and blood pressure. This can be useful provided that

screening is undertaken in the context of global risk assessment and that services are

discussed with local GPs to secure agreement on such matters as when patients should

be referred for medical advice.7

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Figure 1 Framework for the potential roles of community

pharmacists in alleviating the societal burden of

cardiovascular disease

Acknowledging that there is a significant treatment gap in the secondary prevention of

CVD in practice, Gluckman et al.8 have recently developed an “ABC” format to summarise

the key principles of an evidence-based approach to the secondary prevention of CVD (Figure

2). This format is useful not only in the development of hospital clinical pathways, but also in

the community-based management of individuals with vascular disease and/or type 2 diabetes

mellitus. It also has application in identifying potential roles of community pharmacy in the

management of CVD.

Monitoring and promoting adherence to prescribed drug therapy

Screening for cardiovascular risk factors and recommending referral for medical assessment and management when appropriate

Health promotion to help prevent development of cardiovascular disease

Promoting evidence-based guidelines in the pharmacotherapy of cardiovascular disease

Health promotion to slow progression of

cardiovascular disease

Monitoring response to pharmacotherapy of cardiovascular disease (e.g. clinical control,

adverse drug reactions)

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Figure 2 “ABC” format to summarise the key principles of an

evidence-based approach to the prevention of CVD.8

These frameworks provide a useful indication of some of the key current issues in CVD

where community pharmacists could make a significant contribution.

High levels of lifestyle-related cardiovascular risk factors in society (e.g.

cigarette smoking, obesity and inactivity).

Under-detection of hypertension, hyperlipidaemia and diabetes mellitus.

Under-use of agents according to evidence-based guidelines: including

antiplatelet agents; warfarin (in non-valvular atrial fibrillation); angiotensin-

converting enzyme inhibitors, spironolactone and -blockers (in heart failure).

Under-dosing of agents according to evidence-based guidelines (e.g.

angiotensin-converting enzyme inhibitors in heart failure).

Poor therapeutic outcomes: blood pressure and lipid control, anticoagulation.

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2. Methodology and results

2.1 SYSTEMATIC LITERATURE REVIEW

The Project Team undertook a systematic review of published studies describing community

pharmacy-based cardiovascular disease programs. As proposed, a systematic review was

chosen as the preferred method of literature review. It is superior to a conventional literature

review, as it includes an assessment of the quality of the published studies and the

performance of statistical meta-analyses where appropriate.

The systematic review was developed within the following three major sub-areas.

health promotion to prevent development and progression of cardiovascular disease;

screening for cardiovascular risk factors and recommending referral for medical

assessment and management when appropriate; and

improving therapeutic outcomes in cardiovascular disease – e.g. promoting evidence-

based guidelines in the pharmacotherapy of cardiovascular disease, monitoring and

promoting compliance with prescribed drug therapy.

Literature searching across each of these areas was performed simultaneously and

independently by two researchers, each of whom had been trained in systematic review and

meta-analysis methodology by the Australasian Cochrane Centre. The quality of the studies

was assessed - noting for example, randomisation and adequate allocation concealment or

blinding. Figure 3 sets out the approach to the conduct of the systematic literature review of

pharmacy programs in cardiovascular disease.

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Figure 3 Approach to the conduct of the systematic literature

review of pharmacy programs in cardiovascular disease

Areas of focus

Health promotion to prevent development and progression of CVD

Screening for cardiovascular risk factors and recommending referral

Improving therapeutic outcomes in CVD

Electronic and manual literature review of each major area

independently by 2 researchers

Review and collate articles of potential interest

Database entry

Systematic review

Review and collate articles of potential interest

Database entry

Systematic review

Other information via Web

resources and direct

consultation with AIHW,

NHF etc.

Reconciliation of database entries

Overall review of published studies, and meta-analyses

where appropriate

Preparation of report

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The team members used the following databases and search terms:

2.1.1 MEDLINE search terms and criteria

((Pharmacy[MH] OR Pharmaceutical Services[MH] OR Pharmacists[MH] OR Pharmacies[MH])

AND (Monitoring, Physiologic[MH] OR Primary Prevention[MH] OR Mass Screening[MH] OR

Disease Management[MH] OR Health Promotion[MH] OR "health education"[mh]) AND

(Cardiovascular System[MH] OR Coronary Arteriosclerosis[MH] OR hypertension[MH] OR Heart

Failure, Congestive[MH] OR Hyperlipidaemia[MH] OR lipids[MH] OR Cholesterol[MH] OR Drug

therapy[MH] OR Patient Compliance[MH] OR smoking cessation[MH] OR Diabetes Mellitus[MH]

OR Drug Therapy[MH] OR Exercise[MH] OR Body weight[MH] OR diet[MH])) AND English

[Lang] AND "adult"[MeSH Terms] AND "humans"[MeSH Terms]

Limiting to English language and years 1990 – 2005 resulted in 191 papers.

2.1.2 International Pharmaceutical Abstracts (IPA) search terms and criteria

Criteria 1: (pharmacy or pharmaceutical services or pharmacists or pharmacies).mp. [mp=title,

subject heading word, registry word, abstract, trade name/generic name] which resulted in 64,215

papers;

Criteria 2: (monitoring physiologic or primary prevention or mass screening or disease

management or health promotion or health education).mp. [mp=title, subject heading word, registry

word, abstract, trade name/generic name] which resulted in 3,213 papers;

Criteria 3: (cardiovascular system or coronary atherosclerosis or hypertension or heart failure,

congestive or hyperlipidaemia or lipids or cholesterol or drug therapy or patient compliance or

smoking cessation or diabetes mellitus or exercise or body weight or diet).mp. [mp=title, subject

heading word, registry word, abstract, trade name/generic name] which resulted in 30,483 papers;

Criteria 4: The combination of criteria 1, 2 and 3 resulted in 410 papers;

Limiting Criteria 4 to English language and human and years 1990 – 2005, resulted in 130 papers.

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2.1.3 Cochrane search terms and criteria

Search ID 1: cardiovascular system or coronary atherosclerosis or hypertension or heart failure,

congestive or hyperlipidaemia or lipids or cholesterol or drug therapy or patient compliance or

smoking cessation or diabetes mellitus or exercise or body weight or diet in Keywords in all products

produced 165,769 hits;

Search ID 2: monitoring physiologic or primary prevention or mass screening or disease

management or health promotion or health education in Keywords in all products produced 8917 hits;

Search ID 3: pharmacy or pharmaceutical services or pharmacists or pharmacies in Keywords in all

products produced 617 hits;

Search ID 4: combining search IDs 1 and 2 and 3 from 1990 to 2005 produced 49 hits.

2.1.4 EMBASE search terms and criteria

Search ID 1: pharmacy or pharmaceutical services or pharmacists or pharmacies).ab,ot,sh,hw,ti.

produced 25,905 citations;

Search ID 2: monitoring physiologic or primary prevention or mass screening or disease

management or health promotion or health education).ab,ot,sh,hw,ti. produced 49,425 citations;

Search ID 3: (cardiovascular system or coronary atherosclerosis or hypertension or heart failure,

congestive or hyperlipidaemia or lipids or cholesterol or drug therapy or patient compliance or

smoking cessation or diabetes mellitus or exercise or body weight or diet).ab,ot,sh,hw,ti. produced

626,136 citations;

Search ID 4: combining search criteria 1 and 2 and 3 produced 245 citations;

Search ID 5: limiting search criteria 4 to – human and English and year 1990 to 2005 produced 219

citations.

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2.1.5 INFORMIT search terms and criteria

Informit incorporates and searches the following databases; AMI, APAFT, APAIS, APAIS-

HEALTH, DRUG, MEDITEXT, ATSIhealth, H&S Health and Society database, RURAL –

Rural and Remote Health Database.

Table 1 INFORMIT search terms and criteria

Set Search terms Records

#4 #1 AND #2 AND #3 131

#3 hypertension or coronary arteriosclerosis or cardiovascular

system or lipids or heart failure or hyperlipidemia or

patient compliance or drug therapy or cholesterol or

exercise or body weight or smoking cessation or diet or

53202

#2 monitoring physiologic or primary prevention or mass

screening or disease management or health promotion or

health education

22716

#1 pharmacy or pharmacist or pharmacies or pharmaceutical

services

15831

Total number of papers found 131

Number of papers deemed relevant 34

Excluding duplicates left 22 relevant papers

2.1.6 Kinetica search terms and criteria

Command search using the same search terms as above (Informit).

Search terms were used as subject headings and subject keywords. No relevant papers were

found on this site.

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2.1.7 Community Pharmacy Research Database (CPRD) search terms and criteria

The recently established Community Pharmacy Research Database

(http://www.communitypharmacyresearch.org) was also reviewed. This database was

searched by relevant disease state/condition. Paper titles were assessed for relevance; 19 were

relevant but already recorded in our database.

Table 2 CPRD search terms and criteria

Search term Number of papers Number of relevant papers

Coronary artery disease 8 3

Cardiovascular disease 3 1

Coronary heart disease 4 0

Dyslipidaemia 13 2

Heart arrhythmia 1 0

Heart disease 1 0

Heart failure 8 2

Hypertension 17 10

Obesity 2 1

Tobacco/nicotine addiction 5 0

TOTALS 62 19

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2.1.8 Summary of database searching

Table 3 Source of papers for literature review

Database Total

papers

Deemed not

relevant (*)

Rele

vant

New Duplicated Excluded Added for

quality review

MEDLINE 191 140 51 51 0 0 51

IPA – Ovid 130 80 50 48 2 0 48

Cochrane 49 31 18 4 13 1 not in

English

3

EMBASE 219 185 34 29 5 3 not in

English

26

Journals@Ovid 20 12 8 8 4 4 4

Total 132

(*) The search terms used for the bibliographic databases were thoroughly researched and refined over

a period of time, and tailored to each specific database wherever possible. The terms were kept

generally broad to reduce the possibility of missing papers. The downside of this process is that it is

inevitable that extraneous articles would be identified. To eliminate theses extraneous articles, the title

and abstract of every identified paper was printed out for review by two independent researchers.

Papers were excluded according to the following criteria.

o A diabetes focus. If the paper primarily described a diabetes monitoring program it was

excluded. This does not mean that all papers that referred to blood sugar monitoring or

screening were excluded, as any screening program that incorporated BP, TC, HDL, and BSL

monitoring etc. were still included.

o Hospital or outpatient clinic setting.

o Activities clearly not transferable to the community setting were cause for exclusion.

o Anonymous articles that were clearly ‘news-clippings’ and referred to a published study. In

this case, the published article was identified and located during manual searching.

Any papers that were not unanimously supported by both reviewers were discussed at length to reach

consensus.

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Appendices 2 and 3 sets out the citation details of the 132 articles referred to the ‘quality

review processes.

Each of the two researchers performing the systematic review abstracted pertinent data

from every article and entered this into a Microsoft Access database according to a pre-

defined format. The resulting databases were then compared in the presence of a third

researcher, and any significant discrepancies resolved. The final product is an electronic,

searchable database of relevant articles, including an assessment of the quality of

publications. A copy of the database has been submitted with this report. An example

screenshot of the database is shown below (Figure 4).

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Figure 4 Example screen shot of the comprehensive electronic

database of relevant literature

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The following information was extracted from each of the published papers and entered

into the database.

Table 4 Information extracted from clinical papers

Publication details

Country and evidence grading

Time frame

Setting and participants

Study design

Intervention

Outcome measures

Key findings

Limitations

2.2 EVALUATING QUALITY OF RESEARCH PAPERS

The two reviewers had attended Cochrane courses and had read publications by the NHMRC

on reviewing the evidence in practice9-11. The reviewers classified each study according to

the following NHMRC levels of evidence classification (Table 5)9, 11. The definitions for

each of these types of trials are defined by the NHMRC.

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Table 5 NHMRC levels of evidence classification

Level Intervention

I A systematic review of level II studies

II A randomised controlled trial

II-1 A pseudo randomised controlled trial (i.e. alternate allocation or some other method)

III-2 A comparative study with concurrent controls:

Non-randomised, experimental trial

Cohort study

Case-control study

Interrupted time series with a control group

III-3 A comparative study without concurrent controls:

Historical control study

Two or more single arm study

Interrupted time series without a parallel control group

IV Case series with either post-test or pre-test/post-test outcomes

For randomised controlled trials the following NHMRC criteria (Table 6) were used by

the reviewers. All randomised controlled trials were given a quality mark according to each of

the criteria for each of the four categories. Discrepancies were resolved through consensus of

the two reviewers and if this could not be clarified a third reviewer resolved the outcome.

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Table 6 Checklist for appraising the quality of studies of

interventions

Method of treatment assignment

a. Correct, blinded randomisation method described OR randomised, double-blind method

stated AND group similarity documented

b. Blinding and randomisation stated but method not described OR suspect technique (eg

allocation by drawing from an envelope)

c. Randomisation claimed but not described and investigator not blinded

d. Randomisation not mentioned

Control of selection bias after treatment assignment

a. Intention to treat analysis AND full follow-up

b. Intention to treat analysis AND <15% loss to follow-up

c. Analysis by treatment received only OR no mention of withdrawals

d. Analysis by treatment received AND no mention of withdrawals OR more than 15%

withdrawals/loss-to-follow-up/post-randomisation

Blinding

a. Blinding of outcome assessor AND patient and care giver

b. Blinding of outcome assessor OR patient and care giver

c. Blinding not done

Outcome assessment (if blinding was not possible)

a. All patients had standardised assessment

b. No standardised assessment OR not mentioned

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Studies of interventions that were not randomised controlled trials, but were systematic

reviews, controlled-cohort or case control studies were classified according to NHMRC

criteria, as outlined below in Table 7. Papers were rated according to their adequate fulfilment

of the quality criteria used.

Table 7 Quality of non-randomised controlled trials (NHMRC)

Cohort studies

1. How were subjects selected for the ‘new intervention’?

2. How were subjects selected for the comparison or control group?

3. Does the study adequately control for demographic characteristics, clinical features and other

potential confounding variables in the design or analysis?

4. Was the measurement of outcomes unbiased (i.e. blinded to treatment group and comparable

across groups)?

5. Was follow-up long enough for outcomes to occur?

6. Was follow up complete and were exclusions from the analysis?

Case-control studies

1. How were cases defined and selected?

2. How were controls defined and selected?

3. Does the study adequately control for demographic characteristics and important potential

confounders in the design or analysis?

4. Was measurement of exposure to the factor of interest (eg the new intervention) adequate and

kept blinded to case/control status?

5. Were all selected subjects included in the analysis?

Systematic reviews

1. Was an adequate search strategy used?

2. Were the inclusion criteria appropriate and applied in an unbiased way?

3. Was a quality assessment of included studies undertaken?

4. Were the characteristics and results of the individual studies appropriately summarised?

5. Were the methods for pooling the data appropriate?

6. Were sources of heterogeneity explored?

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The definitions of the types of outcomes used in the trial were also classified according

to the following NHMRC criteria.

Table 8 Definitions of types of outcomes (NHMRC)

Surrogate

A laboratory measurement or a physical sign used as a substitute for clinically meaningful endpoint

that measures directly how a patient feels, functions or survives. Changes induced by a therapy on a

surrogate endpoint should be expected to reflect changes in a clinically meaningful endpoint.

Clinical

Outcomes that tend to be defined on the basis of the disease being studied; for example, survival in

cancer, occurrence of vertebral fractures in treatments for osteoporosis, ulcer healing, walking distance

or microbiological ‘cure’ in the treatment of infections.

Patient-relevant

Outcomes that matter to the patient and their carers. They need to be outcomes that patients can

experience and that they care about (eg quality of life, return to normal function). Patient-relevant

outcomes may also be clinical outcomes or surrogate outcomes that are good predictors (in a causal

sense) of outcomes that matter to the patient and their carers.

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2.2.1 Overall assessment of evidence

The NHMRC has developed a process for assessing the overall body of evidence and

formulating recommendations that should assist guideline developers and help to ensure that

different guidelines are consistent in their development of evidence-based recommendations.

Table 9 Body of evidence assessment matrix (NHMRC)

Component A B C D

Excellent Good Satisfactory Poor

Volume of

evidence

Several level I or II

studies with low risk

of bias

one or two level II

studies with low risk of

bias or a SR/multiple

level III studies with

low risk of bias

level III studies

with low risk of

bias, or level I or II

studies with

moderate risk of

bias

level IV studies, or

level I to III studies

with high risk of bias

Consistency all studies consistent most studies consistent

and inconsistency may

be explained

some inconsistency

reflecting genuine

uncertainty around

clinical question

evidence is

inconsistent

Clinical impact very large substantial moderate slight or restricted

Generalisability population/s studies

in body of evidence

are the same as the

target population for

the guideline

population/s studies in

the body of evidence

are similar to the target

population for the

guideline

population/s

studies in body of

evidence different

to target population

for guideline but is

clinically sensible

to apply this

evidence to target

population

population/s studies

in body of evidence

different to target

population and hard

to judge whether it is

sensible to generalise

to target population

Applicability directly applicable to

Australian

healthcare context

applicable to Australian

healthcare context with

few caveats

probably applicable

to Australian

healthcare context

with some caveats

not applicable to

Australian healthcare

context

The overall grade of recommendation reflects the strength of the evidence supporting it.

It is based on a summation of the grading of individual components of the body of evidence

assessment. A recommendation cannot be graded A or B unless the volume and consistency

of evidence components are both graded either A or B. A standardised form has been used to

assess the body of evidence for each clinical question requiring a recommendation in this

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guideline. NHMRC grades of recommendation are provided to assist users of the clinical

practice guideline in making clinical judgements and indicate the strength of the

recommendation. Grade A and B recommendations are generally based on a body of

evidence which can be trusted to guide clinical practice, whereas Grade C and D

recommendations must be applied carefully to individual clinical and organisational

circumstances and should be followed with care.

As the studies found were not of sufficient structure, quality and number (within CVD

categories) to which meta-analyses could be applied, no meta-analysis was performed across

studies within the major health conditions.

2.2.2 Results of the Systematic Review

A total of 132 papers were deemed relevant and eligible for systematic review (see Table 10

and Appendices 2 and 3; Appendix 2 has the results grouped by study type, as per Table 10,

and Appendix 3 has the results grouped by cardiovascular condition/topic).

A relatively small proportion of the sourced literature was suitable for systematic review.

In general, the quality of these studies was poor, with only a small amount of high quality

randomised controlled trials evaluating the effect of community pharmacy’s involvement in

CVD prevention and management. Despite appearances at first glance, almost all the

published reports had major limitations, as outlined in Appendices 2 and 3. One study stands

out in terms of methodological quality - the landmark SCRIP study (Study of Cardiovascular

Risk Intervention by Pharmacists), a randomised controlled trial conducted in 54 community

pharmacies in Canada to determine the effect of a program of community pharmacist

intervention on the process of cholesterol risk management in patients at high risk for

cardiovascular events.12, 13

The most evidence for community pharmacist involvement in the management of CVD

was related to hypertension and hyperlipidaemia. However, a number of these studies were of

poor methodological quality or were conducted in hospital outpatient clinic or managed care

settings, making the results difficult to extrapolate to community pharmacy practice in

Australia.

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Table 10 Summary of papers examined, by CVD focus and evidence grade

Disease States E1 E2 E3-1 E3-2 E3-3 E4 Total

A

systematic

review of

level II

studies

A

randomised

controlled

trial

A pseudo

randomised

controlled trial

(i.e. alternate

allocation or

some other

method)

A

comparative

study with

concurrent

controls:

A

comparative

study

without

concurrent

controls

Case series

with either

post-test or

pre-test/post-

test outcomes

Anticoagulation 1 1 1 3 6

Cardiovascular Disease

(Ischaemic) 7 2 6 15

Cholesterol Management 9 1 5 3 11 29

Compliance 6 1 4 2 13

Diabetes Management 1 2 1 3 7

Heart Failure 4 4

Hypertension 10 1 5 1 7 24

IDDM 1 1

Lipids 7 2 6 2 11 28

Obesity/Weight management 1 1 2 4

Smoking cessation 1 1 4 6

TOTAL 1 47 5 26 8 50 137

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Note that if a paper was coded with more than one disease state, it will have more than one entry in this table

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2.3 PUBLIC SURVEY

A national survey was performed to assist in developing the Pharmacy Cardiovascular Health

Care Model. The intention was to assess the public’s perceptions of pharmacists’ involvement

and role in CVD prevention and management. The Project Team believes that any

development of models and services for the involvement of community pharmacists in CVD

prevention and management needs to be cognisant of the public’s wishes and expectations.

One of the important steps that must be undertaken in developing the Pharmacy

Cardiovascular Health Care Model is an assessment the public’s perceptions of how

pharmacists can assist them with their cardiovascular health, and how these perceptions might

have to be modified through education and marketing. It is clearly pointless to develop a

comprehensive model of service delivery, but has no demand for the service. For instance:

“..although pharmacists and other allied health care providers may be capable of

practising as primary care providers, the public’s expectations of the pharmacist’s role

may not be consistent with a new, primary care role, and therefore there may be some

reluctance to transferring the responsibility of chronic care from a physician to another

health care professionals.”14

2.3.1 Public Survey Methods

A computer-assisted telephone interview (CATI) survey of 505 households was

conducted across Australia. CATI is a telephone monitoring system designed to provide

high-quality data and is an efficient means of monitoring self-reported aspects of population

health, particularly in regional areas where the expense of conducting face-to-face is

prohibitive and has previously prevented adequate representation.15

The survey was administered to metropolitan, rural and remote residents (Australian

consumers over the age of 29 years) via a 15-minute telephone interview. People aged over

29 years were targeted as they represent a higher rate of community pharmacy use and are

more likely to benefit from cardiovascular disease detection/prevention/treatment programs.

Households were randomly selected from the Electronic White Pages (EWP). At least six

call-backs were made to a selected telephone number, at different times of the day and

evening, in an attempt to interview the selected household. Replacement interviews were not

permitted. Respondents who were employed as doctors, nurses or pharmacists, or who lived

in the same household as any one of these health professionals were excluded. This was to

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maintain the focus on consumers of cardiovascular disease services without introducing the

bias or perspective of those who work closely with the management of the condition. Only 52

calls were terminated for this reason (0.6%).

The telephone survey involved 8,874 calls to achieve the 500 completed interviews. The

sample was drawn from the population in all states of Australia. A target sample size of 500

was chosen because in the worst case i.e. where an answer to a question produces a 50:50

response, a sample this size would give a sampling error of 4.4%, with a 95% confidence

level - which is acceptable given the objective.

The sample was screened to include:

those over 30 years of age;

only those who had visited a pharmacy in the previous month (based on the

assumption that every Australian visits a pharmacy about 14 times a year - paper

presented at the 17th National Rural Health Conference);

a quota of 50% with cardiovascular disease (with the assumption that the

incidence of cardiovascular disease is estimated to be 18% of the population -

3.67 million out of 20 million)

a quota of 50% without cardiovascular disease (this included those with family

members with cardiovascular disease).

The sample was split into 50:50 cardiovascular/non cardiovascular, as the use of a

sample of 500 with the incidence of cardiovascular disease at 18%, random sampling would

amount to about 100 respondents with cardiovascular disease. As this is an important group

to the study it was felt it was better to increase this strata to ensure that an adequate number

was sampled for statistical analysis. The questionnaire was designed to be a maximum of 25

minutes long (as consumers are reluctant to participate in anything longer).

2.3.2 Results of the public survey

Respondents’ ages ranged from 30 to 90 years (mean 57 years of age); 58% of

respondents were female and 42% male. Fifty percent of respondents were in full time or part

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time work, with 30% pensioners and 10% in home duties. The targeted equal sample split of

CVD:non CVD was achieved (251:254). It was found that there was little difference between

the responses from each state. Regional (n = 189) and metropolitan (n = 316) respondents

were picked up in the random sampling.

Table 11 Location of residents completing survey

Location Number of successful

phone calls

Sydney 108

Melbourne 90

ACT 8

Hobart 5

Perth 33

Adelaide 34

NT 4

Brisbane 38

Rest of Victoria 38

Rest of NSW 63

Rest of Tasmania 10

Rest of WA 15

Rest of SA 11

Rest of QLD 48

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In response to questions:

i. The majority of respondents (69%) had ongoing conditions/illnesses that required them to take regular medications.

ii. The most frequently reported condition affecting respondents was hypertension (33%), followed by dyslipidaemia (17%) and diabetes (9%).

iii. 85% of respondents used a preferred pharmacy which they used regularly.

iv. The majority of respondents (97%) were either satisfied or very satisfied with quality of service provided by the pharmacies they had visited in the previous 6 months.

v. To the question regarding the features of the respondent’s preferred pharmacy which attracted them to it (multiple answers were allowed and features were unprompted), convenient location (53%) followed by quality of service (21%) and knowledge of the pharmacy staff (12%) were the most common responses.

vi. The majority of respondents (52%) either agreed or strongly agreed that pharmacists are capable (i.e. having the skills and the ‘cultural authority’) to provide screening or testing for raised blood pressure.

vii. The majority of respondents (51%) either agreed or strongly agreed that pharmacists are capable of providing screening or testing for diabetes.

viii. A minority (38%) of respondents either agreed or strongly agreed that pharmacists are capable of providing screening or testing for raised cholesterol, with 50% either disagreeing or neither agreeing nor disagreeing.

ix. The minority 10%) of respondents either agreed or strongly agreed that pharmacists are capable of diagnosing cardiovascular diseases.

x. The majority of respondents (76%) either agreed or strongly agreed that pharmacists are capable of providing advice on lifestyle changes (weight loss, smoking, alcohol intake etc).

xi. The minority (19%) of respondents either agreed or strongly agreed that pharmacists are capable of prescribing drug treatment for cardiovascular diseases.

xii. The majority of respondents (77%) either agreed or strongly agreed that pharmacists are capable of supplying medicines for cardiovascular diseases.

xiii. The majority of respondents (70%) either agreed or strongly agreed that pharmacists are capable of providing advice on over-the-counter and herbal medicines to be avoided by patients with a cardiovascular disease.

xiv. The majority of respondents (64%) either agreed or strongly agreed that pharmacists are capable of providing information about cardiovascular diseases and their management.

xv. The majority of respondents (92%) either agreed or strongly agreed that pharmacists are capable of providing advice on how to take medicines properly. This is the activity that most respondents see as the one in which pharmacists are most capable.

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xvi. In regard to pharmacists’ capability in checking or monitoring the outcomes of drug treatment, respondents were evenly divided - with 40% either agreeing or strongly agreeing and 41% either disagreeing or strongly disagreeing and the balance neither agreeing nor disagreeing.

xvii. The majority (97%) would likely or very likely use a blood pressure testing or screening service if provided by doctors, with nurses being the second most preferred provider with 73%, and pharmacists third of the five professions offered as choice, with 58%.

xviii. The majority (98%) would likely or very likely use a testing or screening service for diabetes if provided by doctors, with nurses being the second most preferred provider with 63%, and pharmacists third of the five professions offered as choice, with 60%.

xix. All respondents (100%) would likely or very likely use a testing or screening service for raised cholesterol if provided by doctors, with nurses being the second most preferred provider with 58%, and pharmacists third of the five professions offered as choice, with 52%.

xx. All respondents (100%) would likely or very likely use a diagnostic service for cardiovascular diseases if provided by doctors, with nurses being the second most preferred provider with 47%, and pharmacists third of the five professions offered as choice, with 31%.

xxi. The majority (91%) would likely or very likely seek advice on lifestyle changes if provided by doctors, with nurses being the second most preferred provider with 53%, and pharmacists fourth (50%) behind dieticians with 61%.

xxii. Almost all respondents (99%) would likely or very likely use doctors to prescribe medicines, with 42% likely or very likely use a pharmacist, with 31% indicating using a nurse.

xxiii. The majority (90%) would likely or very likely use a doctor to obtain prescription medicines, with only 69% a pharmacist, and 27% a nurse.

xxiv. The majority (92%) would likely or very likely seek advice on over-the-counter and herbal medicines to be avoided by patients with cardiovascular diseases from a doctor, 65% from a pharmacist and 43% a nurse, with dieticians and naturopaths almost equal at 32%.

xxv. The majority (94%) would likely or very likely seek information on cardiovascular diseases and their management from a doctor, 50% from a pharmacist and 44% from a nurse.

xxvi. The majority (98%) would likely or very likely seek advice on how to take medicines properly from a doctor, 90% from a pharmacist and 61% from a nurse.

xxvii. The majority (99%) would likely or very likely use a doctor to monitor the outcome of their drug treatment, with 51% a pharmacist and 47% a nurse.

xxviii. The response was almost identical (mean ranging from 7.2 to 7.9 out of max of 10, and medium 8) to the question (with each issue asked individually) how concerning to you is it ‘that hypertension affects 25% of Australians’, ‘20% of deaths are caused by a heart attack’, ‘that more than 10% of Australians over 60 have heart failure, causing reduced life expectancy’, ‘that the most common form of abnormal heart rhythm affects over 2% of

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Australians over 45 years’, and ‘that around 50% of adult Australians have raised cholesterol, putting them at risk of heart attack and stroke’.

xxix. The majority of respondents in almost all cases did not know if the pharmacy they visit offers blood pressure monitoring, blood sugar screening or cholesterol monitoring. More said ‘no’ than ’yes’ about whether these services are offered by the pharmacy they visit.

xxx. Most respondents (69%) had at some time sought help in regard to weight control.

xxxi. Most respondents (17%) had sought weight control help from a doctor, with Weight Watchers® (13%) and dieticians (9%) second and third most often used, respectively. Pharmacists had been used in this way by only 2% of respondents.

xxxii. In regard to how often would a respondent do 20 or more minutes of exercise in one session, 50% of respondents exercised more than 2-3 times per week, with 11% saying they never exercised to this extent.

xxxiii. The majority (65%) of respondents had never sought help in regard to exercise.

xxxiv. Of those who had sought help in regard to exercise, most had done so from a gym or sports instructor (24%), with pharmacists being consulted by only 1 of the 202 respondents who answered in the positive.

xxxv. 20% of respondents smoke tobacco (with most smoking between 11 and 20 cigarettes a day), and 47% say they had never smoked.

xxxvi. Most current smokers (39%) had never sought assistance to stop smoking.

xxxvii. Most who had sought assistance to stop smoking had done so from a doctor (8%) with pharmacists the second most often cited source of help at 4%.

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A more detailed breakdown of the survey results is shown below. Unless otherwise specified

Ntotal = 505.

2. How often do you visit a pharmacy? (Unprompted)

Number Percentage

Weekly 81 16%

Fortnightly 121 24%

Monthly 303 60%

The majority of respondents (60%) had visited a pharmacy within the previous month; the balance within a

lesser period of time.

3. How would you describe your general satisfaction with the quality of the service provided by the

pharmacies you have visited in the last 6 months?

Number Percentage

Dissatisfied 5 1%

Neither Satisfied nor dissatisfied 12 2.4%

Satisfied 148 29.3%

Very Satisfied 340 67.3%

The majority of respondents (97%) were either satisfied or very satisfied with quality of service provided by the

pharmacies they had visited in the previous 6 months.

4. Do you have any ongoing conditions/illnesses that

require you to take regular medications?

Number Percentage

YES 349 69.1%

NO 156 30.9%

The majority of respondents (69%) had ongoing conditions/illnesses that required them to take regular

medications.

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5. Does your illness(es) include any of the following?

(Multiple response)

Illness No Yes

Hypertension Number 181 168

Percentage 35.8% 33.3%

Angina Number 324 25

Percentage 64.2% 5%

Myocardial Infarction Number 321 28

Percentage 63.6% 5.5%

Heart failure Number 330 19

Percentage 65.3% 3.8%

Cardiac arrhythmia Number 318 31

Percentage 63% 6.1%

Dyslipidaemia Number 255 94

Percentage 50.5% 18.6%

Transient ischaemic attacks Number 345 4

Percentage 68.3% 0.8%

Cerebrovascular accident Number 338 11

Percentage 66.9% 2.2%

Diabetes Number 305 44

Percentage 60.4% 8.7%

Renal failure Number 338 11

Percentage 66.9% 2.2%

The most frequently reported condition affecting respondents was hypertension (33%), followed by

dyslipidaemia (17%) and diabetes(9%).

6. Do you have a regular (preferred) pharmacy?

Number Percentage

YES 428 84.8%

NO 77 15.2%

85% of respondents had a preferred pharmacy which they used regularly.

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7. If yes, what are the features of that pharmacy which attract you to it?

(Multiple answer & unprompted)

Number of

responders

Percentage of

responders

Convenient location 265 61.9%

Friendly Staff 177 41.4%

Professional advice 62 14.5%

Professional services provided 46 10.7%

Quality of the service 108 25.2%

Product prices 34 7.9%

Other 23 5.4%

Knowledge of the pharmacy

staff

60 14.0%

Opening hours 9 2.1%

Range of products 9 2.1%

Discounts/Loyalty scheme 12 2.8%

The features (multiple answers were allowed and features were unprompted) of the respondent’s preferred

pharmacy which attracted them to it were its convenient location (61.9%) followed by friendly staff (41.4%) and

quality of service (25.2%). Professional advice (14.5%) and knowledge of the staff (14.0%) also rated quite

highly.

8. Pharmacists are capable of providing screening or testing for raised Blood Pressure.

Number Percentage

Strongly disagree 32 6.3%

Disagree 104 20.6%

Neither Agree or Disagree 106 21%

Agree 187 37%

Strongly Agree 76 15%

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The majority of respondents (52%) either agreed or strongly agreed that pharmacists are capable (i.e. having the

skills and the ‘cultural authority’) to provide screening or testing for raised blood pressure.

9. Pharmacists are capable of testing or screening for diabetes?

Number Percentage

Strongly disagree 38 7.5%

Disagree 89 17.6%

Neither Agree or Disagree 122 24.2%

Agree 182 36%

Strongly Agree 74 14.7%

The majority of respondents (51%) either agreed or strongly agreed that pharmacists are capable of providing

screening or testing for diabetes.

10. Pharmacists are capable of testing for raised cholesterol?

Number Percentage

Strongly disagree 62 12.3%

Disagree 133 26.3%

Neither Agree or Disagree 120 23.8%

Agree 146 28.9%

Strongly Agree 44 8.7%

A minority (38%) of respondents either agreed or strongly agreed that pharmacists are capable of providing

screening or testing for raised cholesterol with 50% either disagreeing or neither agreeing nor disagreeing.

11. Pharmacists are capable of diagnosing cardiovascular diseases?

Number Percentage

Strongly disagree 134 26.5%

Disagree 226 44.8%

Neither Agree or Disagree 95 18.8%

Agree 38 7.5%

Strongly Agree 12 2.4%

The majority (72%) of respondents either disagreed or strongly disagreed that pharmacists are capable of

diagnosing cardiovascular diseases with only 10% either agreeing or strongly agreeing.

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12. Pharmacists are capable of providing advice on lifestyle changes (weight loss, smoking, alcohol intake etc)?

Number Percentage

Strongly disagree 11 2.2%

Disagree 56 11.1%

Neither Agree or Disagree 56 11.1%

Agree 273 54.1%

Strongly Agree 109 21.6%

The majority of respondents (76%) either agreed or strongly agreed that pharmacists are capable of providing

advice on lifestyle changes (weight loss, smoking, alcohol intake etc).

13. Pharmacists would be capable of prescribing drug treatment for cardiovascular diseases?

Number Percentage

Strongly disagree 132 26.1%

Disagree 202 40%

Neither Agree or Disagree 77 15.2%

Agree 64 12.7%

Strongly Agree 30 5.9%

The majority (66%) of respondents either disagreed or strongly disagreed that pharmacists are capable of

prescribing drug treatment for cardiovascular diseases with only 19% either agreeing or strongly agreeing.

14. Pharmacists are capable of supplying medicines for cardiovascular diseases?

Number Percentage

Strongly disagree 18 3.6%

Disagree 61 12.1%

Neither Agree or Disagree 41 8.1%

Agree 220 43.6%

Strongly Agree 165 32.7%

The majority of respondents (77%) either agreed or strongly agreed that pharmacists are capable of supplying

medicines for cardiovascular diseases.

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15. Pharmacists are capable of providing advice on over-the-counter and herbal medicines to be avoided by patients

with a cardiovascular disease?

Number Percentage

Strongly disagree 16 3.2%

Disagree 50 9.9%

Neither Agree or Disagree 83 16.4%

Agree 243 48.1%

Strongly Agree 113 22.4%

The majority of respondents (70%) either agreed or strongly agreed that pharmacists are capable of providing

advice on over-the-counter and herbal medicines to be avoided by patients with a cardiovascular disease.

16. Pharmacists are capable of providing information about cardiovascular diseases and their management?

Number Percentage

Strongly disagree 17 3.4%

Disagree 84 16.6%

Neither Agree or Disagree 81 16%

Agree 241 47.7%

Strongly Agree 82 16.2%

The majority of respondents (64%) either agreed or strongly agreed that pharmacists are capable of providing

information about cardiovascular diseases and their management.

17. Pharmacists are capable of providing advice on how to take medicines properly

Number Percentage

Strongly disagree 2 0.4%

Disagree 10 2%

Neither Agree or Disagree 11 2.2%

Agree 220 43.6%

Strongly Agree 262 51.9%

The majority of respondents (92%) either agreed or strongly agreed that pharmacists are capable of providing

advice on how to take medicines properly. This is the activity that most respondents see as the one in which

pharmacists are most capable.

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18. Pharmacists are capable of checking or monitoring the outcomes of drug treatment?

Number Percentage

Strongly disagree 60 11.9%

Disagree 144 28.5%

Neither Agree or Disagree 103 20.4%

Agree 149 29.5%

Strongly Agree 49 9.7%

In regard to pharmacists’ capability in checking or monitoring the outcomes of drug treatment, respondents were

evenly divided with 40% either agreeing or strongly agreeing and 41% either disagreeing or strongly disagreeing

and the balance neither agreeing nor disagreeing.

19. How likely is it that you would use a blood pressure testing or screening service if provided by the following

professions?

V Unlikely Unlikely

Neither

Unlikely nor

Unlikely

Likely V. Likely

Pharmacist Number 57 107 45 213 83

Percentage 11.3% 21.2% 8.9% 42.2% 16.4%

DoctorNumber 3 6 5 132 359

Percentage 0.6% 1.2% 1% 26.1% 71.1%

Nurse Number 30 71 36 232 136

Percentage 5.9% 14.1% 7.1% 45.9% 26.9%

Dietician Number 123 199 57 104 22

Percentage 24.4% 39.4% 11.3% 20.6% 4.4%

NaturopathNumber 135 205 47 74 26

Percentage 26.7% 40.6% 9.3% 14.7% 5.1%

The majority (97%) would likely or very likely use a blood pressure testing or screening service if provided by

doctors, with nurses being the second most preferred provider with 73%, and pharmacists third of the five

professions offered as a choice, with 58%.

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20. How likely is it that you would use a testing or screening service for diabetes if provided by the following

professions?

V Unlikely Unlikely

Neither

Unlikely nor

Unlikely

Likely V. Likely

Pharmacist Number 62 101 41 221 80

Percentage 12.3% 20% 8.1% 43.8% 15.8%

DoctorNumber 3 3 6 126 367

Percentage 0.6% 0.6% 1.2% 25% 72.7%

Nurse Number 43 103 41 209 109

Percentage 8.5% 20.4% 8.1% 41.4% 21.6%

Dietician Number 117 188 54 111 35

Percentage 23.2% 37.2% 10.7% 22% 6.9%

NaturopathNumber 140 201 49 74 23

Percentage 27.7% 39.8% 9.7% 14.7% 4.6%

The majority (98%) would likely or very likely use a testing or screening service for diabetes if provided by

doctors, with nurses being the second most preferred provider with 63%, and pharmacists third of the five

professions offered as a choice, with 60%.

21. How likely is it that you would use a testing or screening service for raised cholesterol if provided by the following

professions?

V Unlikely Unlikely

Neither

Unlikely nor

Unlikely

Likely V. Likely

Pharmacist Number 76 119 50 188 72

Percentage 15% 23.6% 9.9% 37.2% 14.3%

DoctorNumber 6 6 5 131 357

Percentage 1.2% 1.2% 1% 25.9% 70.7%

Nurse Number 53 98 58 198 98

Percentage 10.5% 19.4% 11.5% 39.2% 19.4%

Dietician Number 129 181 62 104 29

Percentage 25.5% 35.8% 12.3% 20.6% 5.7%

NaturopathNumber 164 188 51 66 18

Percentage 32.5% 37.2% 10.1% 13.1% 3.6%

All respondents (100%) would likely or very likely use a testing or screening service for raised cholesterol if

provided by doctors, with nurses being the second most preferred provider with 58%, and pharmacists third of

the five professions offered as a choice, with 52%.

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22. How likely is it that you would use a diagnostic service for cardiovascular diseases if provided by the following

professions?

V Unlikely Unlikely

Neither

Unlikely nor

Unlikely

Likely V. Likely

Pharmacist Number 119 168 61 127 30

Percentage 23.6% 33.3% 12.1% 25.1% 5.9%

DoctorNumber 4 1 5 119 376

Percentage 0.8% 0.2% 1% 23.6% 74.5%

Nurse Number 79 134 55 178 59

Percentage 15.6% 26.5% 10.9% 35.2% 11.7%

Dietician Number 169 210 45 65 16

Percentage 33.5% 41.6% 8.9% 12.9% 3.2%

NaturopathNumber 184 195 44 51 13

Percentage 36.4% 38.6% 8.7% 10.1% 2.6%

All respondents (100%) would likely or very likely use a diagnostic service for cardiovascular diseases if

provided by doctors, with nurses being the second most preferred provider with 47%, and pharmacists third of

the five professions offered as a choice, with 31%.

23. How likely is it that you would seek advice on lifestyle changes from the following professions?

V Unlikely Unlikely

Neither

Unlikely nor

Unlikely

Likely V. Likely

Pharmacist Number 49 133 70 192 61

Percentage 9.7% 26.3% 13.9% 38% 12.1%

DoctorNumber 10 17 18 168 292

Percentage 2% 3.4% 3.6% 33.3% 57.8%

Nurse Number 56 120 61 188 80

Percentage 11.1% 23.8% 12.1% 37.2% 15.8%

Dietician Number 55 97 44 203 103

Percentage 10.9% 19.2% 8.7% 40.2% 21%

NaturopathNumber 114 146 45 129 53

Percentage 22.6% 28.9% 8.9% 25.5% 10.5%

The majority (91%) would likely or very likely seek advice on lifestyle changes if provided by doctors, with

nurses being the second most preferred provider with 53%, and pharmacists fourth (50%) behind dieticians with

61%.

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24. How likely is it that you would use the following professions to prescribe medicines?

V Unlikely Unlikely

Neither

Unlikely nor

Unlikely

Likely V. Likely

Pharmacist Number 99 144 51 159 52

Percentage 19.6% 28.5% 10.1% 31.5% 10.3%

DoctorNumber 2 5 111 387

Percentage 0.4% 1% 22% 76.6%

Nurse Number 108 180 60 122 35

Percentage 21.4% 35.6% 11.9% 24.2% 6.9%

Dietician Number 159 209 51 74 12

Percentage 31.5% 41.4% 10.1% 14.7% 2.4%

NaturopathNumber 162 185 44 78 18

Percentage 32.1% 36.6% 8.7% 15.4% 3.6%

Almost all respondents (99%) would likely or very likely use doctors to prescribe medicines, with 42% likely or

very likely use a pharmacist, with 31% indicating using a nurse.

25. How likely is it that you would use the following professions to obtain prescription medicines?

V Unlikely Unlikely

Neither

Unlikely nor

Unlikely

Likely V. Likely

Pharmacist Number 52 72 27 126 228

Percentage 10.3% 14.3% 5.3% 25% 45.1%

DoctorNumber 13 32 10 129 321

Percentage 2.6% 6.3% 2% 25.5% 63.6%

Nurse Number 128 194 50 96 37

Percentage 25.3% 38.4% 9.9% 19% 7.3%

Dietician Number 166 228 47 51 13

Percentage 32.9% 45.1% 9.3% 10.1% 2.6%

NaturopathNumber 170 205 30 65 17

Percentage 33.7% 40.6% 5.9% 12.9% 3.4%

The majority (90%) would likely or very likely use a doctor to obtain prescription medicines, with only 69% a

pharmacist, and 27% a nurse.

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26. How likely is it that you would seek advice on over-the-counter and herbal medicines to be avoided by patients

with cardiovascular diseases?

V Unlikely Unlikely

Neither

Unlikely nor

Unlikely

Likely V. Likely

Pharmacist Number 47 76 54 206 122

Percentage 9.3% 15% 10.7% 40.8% 24.2%

DoctorNumber 9 19 14 151 312

Percentage 1.8% 3.8% 2.8% 29.9% 61.8%

Nurse Number 67 161 60 164 53

Percentage 13.3% 31.9% 11.9% 32.5% 10.5%

Dietician Number 98 179 66 141 21

Percentage 19.4% 35.4% 13.1% 27.9% 4.2%

NaturopathNumber 119 161 58 113 37

Percentage 23.6% 31.9% 11.5% 22.4% 7.3%

The majority (92%) would likely or very likely seek advice on over-the-counter and herbal medicines to be

avoided by patients with cardiovascular diseases from a doctor, 65% from a pharmacist and 43% a nurse, with

dieticians and naturopaths almost equal at 32%.

27. How likely is it that you would seek information on cardiovascular diseases and their management from the

following professions?

V Unlikely Unlikely

Neither

Unlikely nor

Unlikely

Likely V. Likely

Pharmacist Number 59 126 66 199 55

Percentage 11.7% 25% 13.1% 39.4% 10.9%

DoctorNumber 4 4 127 370

Percentage 0.8% 0.8% 25.1% 73.3%

Nurse Number 58 161 63 182 41

Percentage 11.5% 31.9% 12.5% 36% 8.1%

Dietician Number 108 184 59 131 23

Percentage 21.4% 36.4% 11.7% 25.9% 4.6%

NaturopathNumber 146 203 53 65 20

Percentage 28.9% 40.2% 10.5% 12.9% 4%

The majority (94%) would likely or very likely seek information on cardiovascular diseases and their

management from a doctor, 50% from a pharmacist and 44% from a nurse.

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28. How likely is it that you would seek advice on how to take medicines properly from the following professions?

V Unlikely Unlikely

Neither

Unlikely nor

Unlikely

Likely V. Likely

Pharmacist Number 13 26 14 232 220

Percentage 2.6% 5.1% 2.8% 45.9% 43.6%

DoctorNumber 3 9 127 366

Percentage 0.6% 1.8% 25.1% 72.5%

Nurse Number 39 105 52 206 103

Percentage 7.7% 20.8% 10.3% 40.8% 20.4%

Dietician Number 119 219 53 94 20

Percentage 23.6% 43.4% 10.5% 18.6% 4%

NaturopathNumber 142 195 47 83 20

Percentage 28.1% 38.6% 9.3% 16.4% 4%

The majority (98%) would likely or very likely seek advice on how to take medicines properly from a doctor,

90% from a pharmacist and 61% from a nurse.

The following question is about checking or monitoring the outcomes of drug treatment

29. How likely is it that you would use the following professions to monitor the outcome of your drug treatment?

V Unlikely Unlikely

Neither

Unlikely nor

Unlikely

Likely V. Likely

Pharmacist Number 57 131 57 189 71

Percentage 11.3% 25.9% 11.3% 37.4% 14.1%

DoctorNumber 3 5 125 372

Percentage 0.6% 1% 24.8% 73.7%

Nurse Number 60 152 59 166 68

Percentage 11.9% 30.1% 11.7% 32.9% 13.5%

Dietician Number 132 217 59 82 15

Percentage 26.1% 43% 11.7% 16.2% 3%

NaturopathNumber 146 201 43 76 21

Percentage 28.9% 39.8% 8.5% 15% 4.2%

The majority (99%) would likely or very likely use a doctor to monitor the outcome of their drug treatment, with

51% a pharmacist and 47% a nurse.

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Disease State Concerns

If all of the following statements are true, how concerning is each to you (rating from 0 to 10, when 0 =

unconcerned and 10 = very concerned)?

30. Raised blood pressure (Hypertension) affects about 1 in 4 Australian adults

0 1 2 3 4 5 6 7 8 9 10

Unconcerned Very concerned

Mean 7.5 Median 8

31. Approximately 1 in 5 deaths in Australia is caused by a heart attack

0 1 2 3 4 5 6 7 8 9 10

Unconcerned Very concerned

Mean 7.9 Median 8

32. More than 10% of Australians over the age of 60 years have heart failure, causing reduced life

expectancy

0 1 2 3 4 5 6 7 8 9 10

Unconcerned Very concerned

Mean 7.6 Median 8

33. The commonest form of abnormal heart rhythm atrial fibrillation affects over 2% of the Australians

over 45 years putting them at increased risk of stroke.

0 1 2 3 4 5 6 7 8 9 10

Unconcerned Very concerned

Mean 7.2 Median 8

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34. Around 50% of adult Australians have raised cholesterol, putting them at increased risk of heart attack

and stroke.

0 1 2 3 4 5 6 7 8 9 10

Unconcerned Very concerned

Mean 7.6 Median 8

The response was almost identical (mean ranging from 7.2 to 7.9 out of max of 10, and medium 8) to the

question (with each issue asked individually) how concerning to you is it ‘that hypertension affects 25% of

Australians’, ‘20% of deaths are caused by a heart attack’, ‘that more than 10% of Australians over 60 have heart

failure, causing reduced life expectancy’, ‘that the most common form of abnormal heart rhythm affects over 2%

of Australians over 45 years’, and ‘that around 50% of adult Australians have raised cholesterol, putting them at

risk of heart attack and stroke’.

Does any pharmacy that you visit offer any of the following services?

Yes No Don’t Know

Blood Pressure monitoring Number 139 177 169

Percentage 27.5% 35% 33.5%

Blood sugar testing Number 126 169 190

Percentage 25% 33.5% 37.6%

Cholesterol monitoring Number 91 189 205

Percentage 18% 37.4% 40.6%

The majority of respondents in almost all cases did not know if the pharmacy they visit offers blood pressure

monitoring, blood sugar screening or cholesterol monitoring. More said ‘no’ than ’yes’ about whether these

services are offered by the pharmacy they visit.

Cardiovascular Risk Factors

37. Have your every sought help on weight control? Yes No (To Question 39)

Number Percentage

YES 349 69.1%

NO 156 30.9%

Most respondents (69%) had at some time sought help in regard to weight control.

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38. If Yes, from who?

(Unprompted and multiple answers)

Number Percentage

Doctor 96 16.2%

Pharmacist 11 2.2%

Nurse 3 0.6%

Dietician 43 8.5%

Naturopath 6 1.2%

Friend/Relative 12 2.4%

Weight Watchers or similar 65 12.9%

Other 7 1.4%

Most respondents (17%) had had weight control help from a doctor, with Weight Watchers® (13%) and

dieticians (9%) second and third most often used, respectively. Pharmacists had been used in this way by only

2% of respondents.

39. How often would you do 20 or more minutes of exercise in one session?

(Select one only)

Number Percentage

More than once a day 35 6.9%

Daily 151 29.9%

4-6 times a week 96 19%

2-3 times a week 102 20.2%

Weekly 29 5.7%

Fortnightly 8 1.6%

Monthly 6 1.2%

Occasionally 23 4.6%

Never 55 10.9%

In regard to how often would a respondent do 20 or more minutes of exercise in one session, 50% of respondents

exercised more than 2-3 times per week, with 11% saying they never exercised to this extent.

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40. Have your every sought help on exercise?

Number Percent

Yes 177 35

No 328 65

The majority (65%) of respondents had never sought help in regard to exercise.

41. If Yes, from who?

Unprompted and multiple answers)

Number Percentage

Doctor 31 6.1

Pharmacist 1 0.2

Nurse 4 0.8

Dietician 4 0.8

Physiotherapist 27 5.3

Gym/sports instructor 120 23.8

Friend/Relative 9 1.8

Other 6 1.2

Of those who had sought help in regard to exercise, most had done so from a gym or sports instructor (24%) with

pharmacists being consulted by only 1 of the 202 respondents who answered in the positive.

42. Have you ever smoked tobacco products?

Number Percent

Never 239 47.3

Past Smoker 167 33.1

Current smoker 99 19.6

20% of respondents smoked tobacco (with most smoking between 11 and 20 cigarettes a day), and 47% said they

had never smoked.

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43. How many cigarettes do you normally smoke per day?

Unprompted (Current smokers only)

< 1 10

1-10 29

11-20 35

21-30 20

31-40 4

> 40 - (1 refusal)

44. Have you ever sought assistance to stop smoking?

Number Percent

YES 70 13.9%

NO 196 38.8%

Most current smokers (39%) had never sought assistance to stop smoking.

45. If YES, from who?

Unprompted

Number Percentage

Doctor 39 7.7

Pharmacist 20 4

Nurse 1 0.2

QUIT line 10 2

Friend/Relative 1 0.2

Acupuncture/Hypnotherapy 9 1.8

Other 6 1.2

Most who had sought assistance to stop smoking had done so from a doctor (8%) with pharmacists the second

most often cited source of help at 4%.

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Demographic Information

46. Gender

Male Female

Number 213 292

Percent 42.2% 57.8%

47. Work Status

Number Percentage

Unemployed 13 2.6

Pensioner 152 30.1

Retired 34 6.7

Student 1 0.2

Home duties 51 10.1

Part Time 88 17.4

Full Time 166 32.9

Age mean: 56.8 years (SD 14.2) Range: 30-90 years

BMI mean: 26.1 (SD 4.7) Range: 15.6 – 50.8

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2.3.3 Summary of the results of the public survey

1. The data seems to have come from a good cross-section of the adult population (i.e.

metropolitan and country, female and male, incidence of hypertension and diabetes).

2. There is a high level of satisfaction with the quality of service provided by regularly

visited pharmacies;

3. There appears to be a lack of awareness amongst consumers as to the skills and

capabilities of pharmacists and of services available through pharmacies.

4. The majority of respondents agree or strongly agree that pharmacists are capable of:

providing screening or testing for raised blood pressure.

providing screening or testing for diabetes

providing advice on lifestyle changes (weight loss, smoking, alcohol intake

etc).

supplying medicines for cardiovascular diseases

providing advice on over-the-counter and herbal medicines to be avoided by

patients with a cardiovascular disease.

providing information about cardiovascular diseases and their management.

providing advice on how to take medicines properly. This is the activity that

most respondents see as the one in which pharmacists are most capable.

5. A minority of respondents agree or strongly agree that pharmacists are capable of:

providing screening or testing for raised cholesterol

diagnosing cardiovascular diseases

prescribing drug treatment for cardiovascular diseases.

6. In regard to pharmacists’ capability in checking or monitoring the outcomes of drug

treatment, respondents were evenly divided with 40% either agreeing or strongly

agreeing and 41% either disagreeing or strongly disagreeing and the balance neither

agreeing nor disagreeing

7. Although doctors were seen as the most likely provider of diagnostic and screening

services, respondents said that they would be likely or very likely to use a pharmacist

(after doctors) for services such as to:

prescribe medicines

obtain prescription medicines,

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seek advice on over-the-counter and herbal medicines to be avoided by patients

with cardiovascular diseases from a doctor,

seek information on cardiovascular diseases and their management

seek advice on how to take medicines properly

monitor the outcome of their drug treatment

There appears to be a gap in the perception of what consumers believe pharmacists can

do and are capable of doing, and what the pharmacy profession believes it can do and

currently does. Clearly the profession as a whole needs to undertake a program of self-

promotion to educate consumers of the potential role pharmacists can have in their lives. This

will clearly have to be incorporated in to the development of any proposed Model.

Despite this gap, consumers are still overwhelmingly satisfied with the current service

they receive, which may be why the profession does not seem to push itself outside the

comfort zone to expand its activities. In this climate of constant threat from the supermarket

fraternity, expanding the clinical role of pharmacists can provide a clear point of difference.

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2.4 SURVEY OF PEAK REPRESENTATIVE ORGANISATIONS

Peak national organisations (National Heart Foundation of Australia and National Stroke

Foundation) were canvassed to determine their views on pharmacy involvement in CVD and

health promotion activities, relevant to their particular organisation’s constituency. The

intention was to use the outcomes to guide the development of an overarching model that

depicts the three stages of CVD where community pharmacists could intervene.

The survey questions that were used, along with an explanatory covering letter, are

shown below. The website of each body was also used to find information on the perceived

role of the pharmacy profession.

Pharmacy/Organisation Expectations

Organisation:

Spokesperson and position:

What does your organisation consider is the role of pharmacy?

What does your organisation consider is the role of pharmacy in relation to patients with heart disease?

What does your organisation perceive is the role of pharmacy in health promotion?

What sort of general health advice should pharmacists offer?

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Are there any potential roles for pharmacy in relation to your organisation’s constituents that are not

undertaken now?

Does your organisation think pharmacies should conduct the following activities or provide the

following services of screening, monitoring and consequent referral? (please place ‘x’ in the relevant

cell).

Yes No N/A No

opinion

Specific Comments

Anticoagulation

Arthritis

Asthma

Bone Density Testing

Depression

Falls prevention

Heart Health

Hyperlipidaemia/Cholesterol

Hypertension

Immunisation

Nutrition

Osteoporosis

Pain management

Smoking Cessation

Weight Management

Wellness Activities

Wound Care

Any other comments?

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2.4.1 National Heart Foundation

The vision of the of the National Heart Foundation is for Australians to have the best

cardiovascular health in the world and the mission is to reduce the suffering, disability and

death from heart, stroke and blood vessel disease in Australia. The Foundation is an

independent Australia-wide, non-profit health organisation and works to achieve its aim by:

promoting and conducting research to gain and apply knowledge about heart, stroke

and blood vessel disease, and its prevention and treatment; and

promoting and influencing behaviour which improves heart and blood vessel health by

conducting education and other programs directed at health professionals, those with

heart disease, and the Australian community at large.

The website of the National Heart Foundation does not mention the role of the

pharmacy profession except as a supply for blood pressure monitors, but instruction on these

monitors is by a ‘trained professional (doctor, nurse, technician)’.

The health professional resources are for doctors as lipid and hypertension management

guidelines. General resources do not mention the pharmacy as a source of information or

having any role in cardiac disease management in health promotion or screening.

The National Heart Foundation of Australia replied that it would take into account pharmacy

involvement in cardiovascular areas with the evidence provided by the present project. The

Foundation believed all activities, that could be provided by pharmacies, such as heath advice,

screening and monitoring with consequent referral, should be evidence-based and occur

within an appropriate accredited environment by trained practitioners. It also suggested these

activities should be supported by government policy and also should include links to others in

health care practice, such as general practitioners.

The Heart Foundation considered the core role of the pharmacist as one of medication

advice in the areas of side effects, drug interactions and compliance. It suggested pharmacy

health promotion advice should be given using other organisations’ resources and also links to

national programmes. It hoped that the nature of general health advice to be offered by

pharmacies will be determined by the Pharmacy Cardiovascular Health Care Model. The

Foundation suggested the pharmacy profession may have a possible role in targeting high risk

individuals using, for example, the Heart Foundation ‘response to chest pain’ messages.

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The Heart Foundation did have specific comments with regard to the health promotion

and screening activities suggested by the survey in addition to its previous comments:

‘Although there may be a potential role for pharmacy in areas such as lipid and blood

pressure measurement, the Heart Foundation does not currently have a formal position

in this area.

Further consideration by the Heart Foundation on these issues could be informed by the

evidence-based literature review to be reported on in the Pharmacy Cardiovascular

Health Care Model report.

The Heart Foundation believes that the identification and management of

cardiovascular risk factors should not occur in isolation from each other and should be

part of a broader system of assessment and management of absolute risk of

cardiovascular disease, which should largely be coordinated at the general practice

level.’

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The role of pharmacy in services of screening, monitoring and consequent referral,

as perceived by the National Heart Foundation of Australia

Yes No N/A No opinion

Specific Comments

Anticoagulation As above

Arthritis X

Asthma X

Bone Density Testing X

Depression General comment- The link between depression as a risk factor for coronary heart disease (CHD) and the increased risk of depression occurring in people with CHD is now recognised

Falls prevention X

Heart Health Pharmacy can act as an outlet for heart health advice using consumer materials provided by others (e.g. provision of NHFA consumer materials and/or referral to Heartline)

Hyperlipidaemia/Cholesterol See general comments above and footnote1

below

Hypertension See general comments above

Quality control relating to blood pressure measurement protocols and equipment is important.

Immunisation X

Nutrition Pharmacy could act as an outlet for nutrition advice using quality consumer materials (e.g. provision of NHFA materials).

Osteoporosis X

Pain management X

Smoking Cessation It is our understanding that Dr Andrew Gilbert (SA) has done significant work in this area and may be worth consulting.

Weight Management Pharmacy could act as an outlet for advice on healthy weight using quality consumer materials (e.g. provision of NHFA materials).

Wellness Activities X

Wound Care X

Footnote:

1 The following excerpt from NHFA/CSANZ Lipid Management Guidelines 2001 (MJA 5 November 2001 Vol 175. Supplement) is provided for information: ‘Lipid levels should be measured by laboratories or practices accredited by the National Association of Testing Authorities, as this indicates satisfactory compliance with the many facets of good

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practice that are required to ensure confidence in the reliability of these measurements. It is unusual for the operators of near-to-patient devices, such as those that provide on-the-spot cholesterol results, to have undertaken these.’’

“Clearly the relationship between pharmacy and the National Heart Foundation of

Australia is a key one that can support a potential change in pharmacy practice, a

change endorsed by the peak body representing this health priority. The potential

role of the pharmacy profession is considerable but needs to be evidence-based, and

one that liaises with other health professionals involved in patient care.”

2.4.2 National Stroke Foundation

According to the 2003 Annual Report the National Stroke Foundation lists its activities as:

Promoting and conducting research into the incidence, causes and treatment of stroke.

Working with all stakeholders to develop and implement policy on the prevention and

management of stroke.

Educating the public about the risk factors and signs of stroke and promoting healthy

lifestyles.

Encouraging the development of comprehensive and co-ordinated services for all

stroke survivors and their families.

The Foundation, as stated by Dr. Erin Lalor, Chief Executive Officer, considers

pharmacies as outlets for information, education for public health campaigns while working in

partnerships to keep people safe. It also sees the pharmacy profession working on the

development of best evidence guidelines for medication use in stroke prevention.

This organisation has no opinion on the role of pharmacy in anticoagulation but does see

a role in hypertension and smoking cessation. The role in hypertension is one of screening to

increase the identification of those with hypertension and consequent referral.

Pharmacies are seen as information sources using the ‘Strokesafe’ resources developed

by this foundation and actively encouraging individuals in lifestyle change to reduce the risk

of stroke. Generally, the pharmacy profession is not seen to have a role outside the pharmacy

itself except working on the evidence guides on medication.

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The role of pharmacy in services of screening, monitoring and consequent referral,

as perceived by the National Stroke Foundation

Yes No N/A No

opinion

Specific Comments

Anticoagulation x

Arthritis x

Asthma x

Bone Density Testing x

Depression x

Falls prevention x

Heart Health x

Hyperlipidaemia/Cholesterol x

Hypertension x Screening through pharmacy with appropriate referral could increase identification of those in the community with HT

Immunisation x

Nutrition x

Osteoporosis x

Pain management x

Smoking Cessation x

Weight Management x

Wellness Activities x

Wound Care x

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2.5 CANVASSING OF AUSTRALIAN COMMUNITY PHARMACISTS AND PHARMACY

ORGANISATIONS TO REPORT ON THEIR OWN CVD ACTIVITIES

Information was sought on community pharmacy involvement in CVD programs that have

operated or are currently operating in Australia and abroad, to identify opportunities for them

to be adopted or expanded in Australia.

Two postings to AusPharmList were used to canvass experiences of Australian

community pharmacists, although the feedback from this source was minimal. The content of

the posting is shown below.

Is your pharmacy running any community based programs to help detect or support improved outcomes for cardiovascular patients? Help us devise the plan of attack for the future. If you don’t tell us all the great work you are doing no one will know!!!! Even a walking group etc is of interest. Also of interest is your opinion on the improved/potential utilisation of pharmacists in cardiovascular care. What do you perceive is the role of community pharmacy in cardiovascular health promotion and disease management? What sort of activities would you most likely think appropriate for cardiovascular disease management programs in community pharmacy? In which areas do you think community pharmacist should be more involved in relation to cardiovascular co-ordinated care?

This project aims to identify the structures and programs that currently operate in the community, through outpatient, community pharmacy, health clinics and general practice, to enhance outcomes for CVD. We would assume that most programs are based on the National Heart Foundation of Australia and Australian Cardiac Rehabilitation Association Guidelines. We would appreciate having access to as many details of the structure of your currently running programs as possible (education information, medication education etc) for evaluation purposes. Of particular interest is the involvement of pharmacists and any remuneration available or areas which you feel pharmacists would be well utilised in your programs. Any source of feedback would be appreciated.

A number of groups were also directly contacted to attempt to identify the structures and

programs that exist. Contacting target groups was attempted by email and follow-up

telephone calls to determine any feedback or non-receipt. A summary showing the groups

contacted is below.

It appears that community pharmacies generally do not inform any central pharmacy

organisations of their activities in this regard. Feedback on activities in community

pharmacies relied heavily on word of mouth and direct response to one of the contact

measures used.

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Groups approached

S – sent details

Y – confirmed circulated (NY for not circulated for reason)

R – responded to us

C – contacted by us

Vic Tas SA WA QLD NSW ACT

PSA State Branches Y Y S

NY

S S Y S

Guild State Branches Y Y Y Y Y Y

R

S

ACRA

Rehab groups

Y

Directory

Y

Directory

S No

contact

S S S

Divisions of General

Practice

R R S R S R S

Hospitals Y Y Y Y S Y Y

Schools of Pharmacy Y Y Y Y RS Y

ECG R R R R R R R

AusPharmList

Postings 19/04/05

and 11/05/05

Rural Pharmacy

Groups

S

Guild information circulated by National Office PSA circulated by State Branches DGP, hospitals and Schools of Pharmacy were individually contacted ACRA contacts cross over with hospital contacts

Information received was matched to the major three stages of CVD (normal health,

elevated risk for CVD, and diagnosed CVD). Remuneration for the pharmacist was noted.

2.5.1 General Public (education, posters etc)

Nothing reported.

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2.5.2 High-risk groups (screening/ referral)

Joanne Martin Health Promotion Officer West Vic Division of General Practice “I am the Health Promotion Officer for our Division and we have a Risk Factor approach to CVD, with a focus on Physical Inactivity and Nutrition. We have a service where GPs identify patients who would benefit from physical activity mentoring and refer the patient to a PA professional who coaches them for 12 months to make sustainable changes to their levels of physical activity. The PA professionals are locally based and all have certificate 4 fitness as an additional qualification to their predominant profession which include – dieticians, physiotherapists or community health nurses. I have attached a patient pathway for your information and would be happy to discuss this model further if it is of interest.”

Geetpal Sandhu, BPharm, Pharmacy graduate Lynne Emmerton*, PhD MPS, Senior Lecturer School of Pharmacy The University of Queensland Screening and Monitoring Services in Community Pharmacies: A Pilot Project Australian Pharmacist 2004; 23(12): 854-9. Large national studies are needed to examine experiences and socio- demographics of pharmacists specialising in disease detection and monitoring services and further test this classification.

2.5.3 Management of existing CVD

Outpatient

Cardiac rehabilitation support groups range in length from 1-6 sessions.

Pharmacist involvement is generally by Hospital Pharmacist as part of their duties.

Session by the Pharmacist usually ½-1 hour, covering general principles of medication (brands, missed doses, preventive therapy), rest of the session on CVD specific drugs (mostly anti-platelets, statins, antihypertensives).

“Heart Smart” Zehava Samuel Clinical Pharmacist (Cardiac & ICU) Slade Pharmacy (Epworth Hospital, Melbourne) “I try to focus on side effects and explain the mechanism/rationale for each drug group in simple terms. There is opportunity for patients to ask questions at any time.”

Julie Parker Latrobe Community Health Service, Vic. “I run a phase 3 cardiac rehab program. We organize a ‘pharmacy update, Q & A time’ once or twice a year utilizing the pharmacist who works with home Medicine Review program as it is a free service. We have no funding to pay guest speakers. Community pharmacists could certainly help us with most of our CHC programs by actively encouraging their clients to participate. As they have a fair idea of the health problems their clients are experiencing e.g.

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arthritis, falls, osteoporosis, asthma, incontinence etc they could actively refer them to our range of education, support, self management, consultation services.”

Fiona Ellem Assistant Director of Pharmacy Gold Coast Hospital andLecturer School of Pharmacy, Griffith University, Qld. “I have been involved with the 'Heart Support Group' on the Gold Coast since 1996. This is a multidisciplinary 6 week course that was originally funded by the Heart Foundation and 'managed' as a joint effort between the Gold Coast (Public) Hospital and Allamanda and Pindara Private Hospitals. Several years ago the private hospitals elected to pull out of the joint program and establish their own programs (I think because private insurers started rebating patients for attendance at such a course, so the private hospitals decided to start charging patients for attendance!)

The Heart Foundation funding to our area also declined, and so the program is now funded jointly with HF and with some drug company sponsorship, but all the speakers speak voluntarily.”

Ruth Emmerton Cardiac Rehabilitation Coordinator Mersey Cardiology

Manya Angley Uni SA “There is a heart failure program at the Royal Adelaide Hospital here that employ a heart failure nurse (no direct involvement of pharmacists). Will send through further details. We are about to start a continuity of care (CC) project which will recruit a lot of cardiac patients but does not target them specifically. This project will improve communication between health professional across the interfaces of care and facilitate an HMR to be conducted post discharge.”

Lynn O’Neill Nurse Unit Manager Cardiac Rehabilitation Unit Caulfield General Medical Centre “I am a cardiac rehab co-ordinator and our program is run at a hospital. We utilise the services of the hospital pharmacist to conduct two education sessions. Medication Management for coronary artery disease patients. Medication management of heart failure patients. As they are hospital staff, this is part of their role and they do not get paid by the program as such.”

Jenny Howe Program Manager Cardiac Rehabilitation St John of God Hospital Bendigo “What I think our clients need is to understand the simple action of the medication groups used frequently in CV disease in plain language…….These may all seem simple but the

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patients really respond to the opportunity to discuss with the pharmacist these issues and their own particular question. I hope this supports your research.”

Community

Pharmacy

Ian Heslop Senior Lecturer - Pharmacy School of Pharmacy & Molecular Sciences James Cook University Townsville, Qld. “we are currently in the process of developing a PhD project examining the development of a collaborative treatment model for Heart Failure in North Queensland which with involve ourselves, medical staff and community pharmacists from North Queensland and staff at the University of Sydney. As the project is very much in the development stages we can't give details but just wanted to highlight the project for consideration in any national developments.”

Jessica-Anne Panaguiton Clinical Pharmacist The Queen Elizabeth Hospital & Health Service, SA. “I am aware of many community pharmacies already being involved in BP & lipid monitoring with the aid of community health nurses and this process should continue. It may also be useful to tap into cardiac rehabilitation services of the local hospital(s) that serve the community to find out what recommendations/information they are providing to the patients to enable the community pharmacist to reinforce this with the patient well into the future after the cardiac rehabilitation sessions have ended.”

Justin Turner Hayborough Pharmacy “I am not currently involved in providing a CVD programme, however I am interested in getting one started…. I have been a hospital pharmacist for the last 5 years (until we opened this) and have worked in many CCU units both in SA and in the UK, hence I want to get more involved. There is a community cardiac rehab group that has been started by the local hospital (who imports a pharmacist from the city for a day as per their contract!) but apart from that group, there doesn't appear to be much on offer down here.”

Suzanna Nisbet-Smith, BSc(Hons) AMusA Lynne Emmerton*, PhD MPS, Senior Lecturer School of Pharmacy The University of Queensland “Responses from the three groups were largely supportive of pharmacists’ involvement. There was some concern, mostly from clients, about pharmacists’ ability to provide advice, thus highlighting the need for specialist training. Despite these issues, the potential for role development was highlighted in these findings, particularly in light of the increasing prevalence of lifestyle-related disease.”

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Divisions of General Practice

Helen Brown BPharm MPS MACP AACPA NPS & HMR Facilitator Rockingham Kwinana Division of General Practice, Qld “I am about to start involving pharmacies in education of patients with particular disease states - one of them being HF and/or history of MI. The plan is to place a consultant pharmacist into a pharmacy for a period of 2-3 hours. The pharmacy will make appointments for their patients who fit a certain criteria, to come in and speak with the pharmacist (one-on-one) about their HF.”

Brigitte Cusack HMR Facilitator South Eastern Sydney Division of General Practice, NSW “Heartlink Program (a community outreach to patients living at home with cardiovascular disease, in particular heart failure patients, who have been past patients of Prince of Wales Hospital)……. It seems to work well for both JB and myself- as we feel it is important that the specialists, the GPs, the pharmacies, the accredited pharmacists and the patients are all receiving the same information on heart failure. I'd like to mention that even before the patient has left POWH cardiac ward, the cardiac ward pharmacist sends the current list of medications to the pharmacy where the patient usually gets their medications dispensed so that when the patient leaves the hospital, the pharmacy knows what the patient needs to be taking.”

Emma Stringfellow Population Health Project Officer Canning Division of General Practice, WA “I coordinate a community based cardiac rehabilitation. We utilise a pharmacist for our medications presentation which is one session out of seven delivered to the group. The pharmacist is always very well received and we get excellent feedback. He is contracted to deliver the sessions and is also encouraged to discuss the home medications review.”

Graham Sweet, Quality Use of Medicines Facilitator (NPS/HMR), Dandenong District Division of General Practice, Vic. “Hi. I am the pharmacist running the QUM program for the DDDGP. This year we have delivered the NPS programs on drug use in hypertension, antiplatelet drugs used to prevent CV events and the use of warfarin in AF. We have just stared delivering the drug use in heart failure module (associated with the promotion of echocardiography in diagnosis) and will shortly be delivering an update on diabetes. These programs are being delivered to GPs. With NPS permission and in association with Bill Horsfall we also deliver these programs to a group of AACPA pharmacists at the VCP. The division is the lead agency in a HARP project to manage CV and diabetes in association with local hospitals. The division also has a project officer involved in CV exercise programs. The divisions are in an ideal position to subcontract ongoing pharmacy CE via their HMR program officers who could work with the NPS programs. Unfortunately and shortsightedly (cash constraints?) the NPS does not make pharmacist CE a core function of its facilitators however it is not discouraged and can be undertaken by the facilitator if they wish (as can nurse education).”

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Jenny Gowan PhD HMR Facilitator Northern & North East Valley Divisions of General Practice, Vic.

o There was a project completed now that hit the headlines re Medication Reviews for patients with CCF - they were not HMRs, but it got the front page of Aust Dr weekly. The project was run out of Northern Hospital. Peter Stuchbery, Pharmacy Dept should be able to help- Prof Bruce Jackson (now at Monash) was the main researcher.

o HMR project- many of these involve CV intervention - a model which is working. Specifically utilised via community pharmacy

o RMMR project via Aged Care homes. o Many pharmacies in our area measure BP - and provide a written GP referral - very

few do cholesterol due to pathology requirements. o Obesity programs - individual counselling using Xenical materials. o NPS is active in this area - case studies visits etc - and audits of GP patients.

2.5.4 Summary of self-reported CVD activities:

There is very little information available on community pharmacy involvement in

CVD programs.

Most details come from outpatient cardiac rehabilitation programs.

Generally all pharmacist services are funded by the pharmacist’s usual employee i.e.

hospital pharmacy, or contracted by the outpatient clinic concerned.

“Cardiac rehabilitation provides patients and their families with a program of education, information, physical activity and support. The World Health Organisation and the National Heart Foundation of Australia, recommend that, unless contraindicated, all patients who have had a heart attack, heart surgery, coronary angioplasty or other heart or blood vessel disease, are routinely offered the opportunity to be referred to, and participate in, a cardiac rehabilitation and prevention program that is appropriate to individual needs. Cardiac rehabilitation should be an integral component of the long-term, comprehensive care of cardiac patients. Cardiac rehabilitation programs or services should be available to all patients with cardiovascular disease. Rehabilitation services should be provided by any trained health professional caring for cardiac patients, since no sophisticated equipment or facilities are required. Both patients and their families should participate.” 16 17

Cardiac rehabilitation programs are an essential component of the ongoing care of

people presenting with acute coronary syndrome, with attendance linked with improved

survival, compliance with medications and risk factor status.16 The impact of these programs

is limited, however, by their poor attendance, especially among elderly female patients, and

people from lower socio-economic backgrounds. There is an opportunity for greater

community and accredited consultant pharmacist involvement in these programs to improve

uptake by patients (discussed further in Chapter 9).

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3. Developing the Pharmacy Cardiovascular Health Care Model

The systematic literature review, public survey and canvassing of pharmacists and key

organisations were all conducted to inform the development of a Pharmacy Cardiovascular

Health Care Model. This Model was to build on existing health service and health promotion

plans in CVD, and promote partnership and collaboration across the health care system

(Figure 5). This approach is consistent with the Project’s aim of developing models and

pharmacy services that are consistent with the goals of pre-existing national strategies (e.g.

Guidelines for preventing cardiovascular events in people with coronary heart disease.

National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand,

2004),18 rather than re-defining what the national priorities should be. In effect, the Project

will be demonstrating how community pharmacists can contribute to meet the goals of

irrefutable national strategies for CVD.

Figure 5 Approach to the development of the National Pharmacy

Cardiovascular Health Model

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As far as possible, the model was to be developed to be consistent with the goals of the

‘National Strategy for Heart, Stroke and Vascular Health in Australia’.19 This strategy aims

to:

support the dissemination and uptake of best preventive practices for heart, stroke and

vascular diseases;

enhance the role of consumers in maintaining and managing their own health;

improve care and management of heart, stroke and vascular diseases across the

continuum of care, and optimise the outcomes by identifying and promoting proven

interventions; and

progressively reduce the inequalities in health outcomes associated with heart, stroke

and vascular disease, particularly through a focus on preventive and management

practices for Aboriginal and Torres Strait Islander peoples.

The National Strategy for Heart, Stroke and Vascular Health in Australia19 presents a

useful model (Figure 6), depicting what are essentially the major three stages of CVD (normal

health, elevated risk for CVD, and diagnosed CVD).

Figure 6 Stages of CVD risk

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Table 12 Categories of patients based on future risk of a

cardiovascular event 20

High-risk patients are those with:

Clinically evident coronary heart disease (prior acute myocardial infarction, angina, or history of a revascularisation procedure) Clinically evident vascular disease (cerebrovascular or peripheral vascular disease) Diabetes Renal disease A risk of a future vascular event 2%–3% per year, based on an aggregate of unfavourable risk characteristics*

Low-risk patients are those with:

A risk of a future vascular event < 2%–3% per year*

* Determined using a calculation of the 5-year risk of any cardiovascular event and death, from a validated absolute-risk calculator, such as the Framingham Heart Study Prediction Score Sheets

The depiction in Figure 6 was used as a guide in the development of the Pharmacy

Cardiovascular Health Care Model, by focussing attention on the three general aspects where

the pharmacy profession could have an impact on the societal impact of CVD in Australia.

Health promotion to prevent development and progression of CVD (general

population).

Screening for CVD risk factors and recommending referral for medical assessment

and management when appropriate (high-risk individuals).

Improving therapeutic outcomes in CVD – e.g. promoting evidence-based guidelines

in the pharmacotherapy of cardiovascular disease, monitoring and promoting

compliance with prescribed drug therapy (patients with existing CVD).

Hence, the key issues that need to be addressed by the model are:

What is the role of pharmacists in the prevention of CVD?

What is the role of pharmacists in the detection of CVD?

What is the role of pharmacists in improving therapeutic outcomes in patients with

CVD?

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Key recently released policy documents are the draft versions of the National Chronic

Disease Strategy21 and the National Service Improvement Framework for Heart, Stroke

and Vascular Disease.22 The National Chronic Disease Strategy aims to provide an

overarching framework of national direction for improving chronic disease prevention and

care across Australia. The Strategy aims to strengthen Australia’s capacity to meet the

challenges arising from increasing prevalence of chronic disease, and improve health

outcomes and reduce the impact of chronic disease on individuals, families, communities, and

society. Improved outcomes will be achieved through enhanced effort and more consistent

and integrated, evidence-based, practical and effective (including cost-effective), consumer-

focussed approaches for improving the prevention, detection and management of chronic

disease.

The National Chronic Disease Strategy focuses on the directions to be taken by the

health system, recognising that the health sector must achieve significant and sustainable

change, as well as take a leadership role in advocating, engaging and partnering with other

sectors to influence the social and environmental factors that determine the current and future

burden of chronic disease. The primary objectives of the National Chronic Disease Strategy

are to:

prevent and/or delay the onset of chronic disease for individuals and population groups;

reduce the progression and complications of chronic disease;

maximise the wellbeing and quality of life of individuals living with chronic disease

and their families and carers;

reduce avoidable hospital admissions and health care procedures;

implement best practice in the prevention, detection and management of chronic

disease; and

enhance the capacity of the health workforce to meet population demand for chronic

disease prevention and care into the future.

Underlying these objectives is the theme of strengthening activity across the continuum

of chronic disease prevention and care (Figure 7).

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Figure 7 Continuum of chronic disease prevention and care22

In essence, the National Chronic Disease Strategy espouses a patient-centred approach,

including self-management. The focus is on:

addressing the poor integration between health services (particularly hospital and

community sectors) and between different health professionals; and

refocussing health care delivery to adopt a more patient-centred approach, which

encourages self-management of chronic disease.

Key directions identified within the Strategy that appear to be most relevant to

community pharmacy and the development of a Pharmacy Cardiovascular Health Care Model

are:

Key direction 5: Promote exclusive breast feeding for the first six months of life.

Key direction 6: Promote healthy eating and physical activity for pre-school and

school-aged children.

Key direction 8: Develop consistent health messages addressing the common

behavioural risk factors for chronic disease - tobacco smoking, physical inactivity,

poor diet and nutrition, and risky and high risk alcohol use.

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Key direction 9: Ensure health promotion is effectively targeted and delivered through

appropriate settings and formats.

Key direction 11: Encourage all health services to identify opportunities to promote

health and identify and address risk factors for chronic disease.

Key direction 13: Encourage primary care to engage in early intervention, through

appropriate opportunistic screening, use of approaches such as the SNAP Framework

to identify and address the risk factors for chronic disease, and support for self-

management.

Key direction 14: Improve screening and early detection opportunities and uptake for

high-risk population groups, such as older Australians and Aboriginal and Torres

Strait Islander peoples.

Key direction 16: Investigate emerging evidence for early detection and treatment, and

implementation mechanisms including evidence-based guidelines for effective

practice.

Key direction 17: Improve the public’s awareness and understanding of the risk

factors for chronic disease and opportunities for early detection, particularly among

high-risk population groups.

Key direction 21: Consider a range of mechanisms to better support multi-disciplinary

care planning, co-ordination and review.

Key direction 24: Improve access for all Australians to the range of services needed

for chronic disease prevention and care.

Key direction 25: Encourage the implementation of the National Service Improvement

Frameworks.

Key direction 26: Promote the development of standard procedures for referral, pre-

admission, discharge, and other transfer arrangements between services and sectors.

Key direction 27: Implement strategies to promote multi-disciplinary care planning for

people with complex care needs, which incorporates patient participation and self-

management principles and maximises the capacity of primary care to co-ordinate

care.

Key direction 31: Support appropriate use of medicines to maximise health

outcomes and quality of life.

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Key direction 32: Implement measures that improve access to medications for

Aboriginal and Torres Strait Islander peoples.

Key direction 33: Promote the inclusion of the core competencies for chronic disease

prevention and care in the education, training and accreditation of the health

workforce.

Key direction 34: Encourage health care entry points to identify opportunities to

actively promote self-management.

Key direction 35: Develop education and training strategies for health care providers

to gain knowledge and skills to support self-management, so that self-management

becomes part of routine clinical practice.

Key direction 36: Ensure that self-management is incorporated into clinical practice

through its inclusion in multi-disciplinary care planning with the patient and their

family and carers.

The National Chronic Disease Strategy acknowledges that collaboration between

specialist and primary care, including pharmacists, is fundamental to the quality use of

medicines.20 Health professionals also need to be skilled in behavioural interventions and

other evidence-based approaches to encourage people to use medicines optimally. The quality

use of medicines is an essential component of integrated care incorporating self-management.

The National Service Improvement Frameworks concentrate on service improvement

for specific diseases.22 These are high level guides informing all parts of the health system

about the most effective care for the diseases of cancer; asthma; diabetes; heart, stroke and

vascular disease; and osteoarthritis, rheumatoid arthritis and osteoporosis. Together, these

diseases represent the major burden of chronic disease in Australia.

The National Service Improvement Framework for Heart, Stroke and Vascular Disease

is intended to complement the National Chronic Disease Strategy and forms part of a national

approach for improving health services for chronic disease prevention and care. The National

Chronic Disease Strategy is an “umbrella” strategy supporting a consistent and effective

approach for all non communicable chronic diseases.

The National Service Improvement Framework for Heart, Stroke and Vascular Disease

is intended to outline the best practice evidence for integrated heart, stroke and vascular

services for people across the “patient journey” and continuum of care (Figure 8). Five

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phases of the “patient journey” - reducing risk, finding disease early, managing acute

conditions, long term care and care in the advanced stages - are addressed.

Figure 8 Continuum of chronic disease prevention and care22

The Framework identifies ‘critical intervention points’. These are points along the

continuum of care where significant health gains and service improvements can be made. The

critical intervention points that appear to be most relevant to community pharmacy and the

development of a Pharmacy Cardiovascular Health Care Model are:

REDUCE RISK

1. Adopt National, State/Territory and local plans to further reduce rates of smoking using evidence based public health strategies and government actions.

2. Adopt National, State/Territory and local plans to promote awareness of Heart, Stroke And Vascular Disease risk factors, healthy eating and active living including healthy weight in collaboration with other national health priorities and policies

5. Establish and encourage the development of systems and tools enable absolute risk estimation in people without overt cardiovascular disease (including early detection and management of high blood pressure

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and dyslipidaemia)

DETECT HEART, STROKE AND VASCULAR DISEASE EARLY

7. Promote awareness among people of the early symptoms of heart, stroke and vascular disease and associated conditions, and emergency response where appropriate.

8. Develop systems which include absolute risk measurements in prescribing and treatment algorithms and which help people to understand their individual risk.

9. Improve detection systems so that all people with transient ischaemic attacks, suspected rheumatic heart disease chronic kidney disease are referred appropriately and assessed promptly and effectively

BEST LONG-TERM CARE AND SUPPORT

24. Develop and implement strategies to support a multi-disciplinary team approach which promotes continuity of care

28. Implement policies to encourage the safe and quality use of medicines.

The Frameworks document is relatively light in terms of self-management, when viewed

against the National Chronic Disease Strategy (“Achieve person-centered care and optimise

self-management”). There is mention of self-monitoring blood pressure, but relatively little

else. The document is also clearly more ‘medico-centric’ and less patient-focused than the

National Chronic Disease Strategy. Other comments on the draft versions of the National

Chronic Disease Strategy and National Service Improvement Framework for Heart, Stroke

and Vascular Disease are shown from page 90.

There are many areas where community pharmacists could make an important

contribution, particularly in relation to the critical intervention points listed above, but none of

this is mentioned in the National Service Improvement Framework for Heart, Stroke and

Vascular Disease. In particular, the Government’s HMR Scheme is intended to improve the

quality use of medicines across the continuum of care and is an ideal strategy for patients with

cardiovascular events after discharge from hospital. For instance, the Framework discusses

the issue of medication management in heart failure.

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“For people with heart failure, medication and treatment issues are paramount in the early stages. People with heart failure often have problems adhering to their medication and other treatment requirements. Poor compliance and physician error with medication plans frequently leads to re-hospitalisation.”22

This is the ideal environment for the performance of HMRs. There is coverage of the

Enhanced Primary Care (EPC) Medicare items in the Framework, but no mention of HMRs.

The provision of medicines information is mentioned, but without referring to pharmacists.

There is also much discussion of promoting the cessation of tobacco use, but again without

reference to the established role of community pharmacy.

There are several references in the Framework document to nurses coordinating care and

specialist ‘nurse led’ secondary prevention clinics, based on overseas studies. This is to be

welcomed, but it also needs to be acknowledged that the evidence base is similarly strong for

other health professionals e.g. pharmacists. For instance, the SCRIP study (Study of

Cardiovascular Risk Intervention by Pharmacists)12 has had a number of published studies.

As previously mentioned, however, the development of the Pharmacy Cardiovascular

Health Care Model must be mindful of how (i) the public perceives pharmacists can assist

them with their cardiovascular health, and (ii) what other health care professionals perceive

the pharmacist’s role to be, and how these perceptions might have to be modified through

education and marketing. It is clearly pointless to develop a comprehensive model of service

delivery, but have no demand for the service.

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3.1 DRAFT NATIONAL CHRONIC DISEASE STRATEGY

Proforma for Comments

Question Comments Page

Number

Is the intent and purpose of the

National Chronic Disease Strategy

clearly articulated?

Yes, excellent.

Is the format and language clear

and concise? Do any terms need

explanation?

Yes, excellent.

Is there anything that you consider

significant that should be included

in the text of the document?

Do you agree broadly with the

focus and balance of the Key

Directions?

Yes.

Is there anything significant that

should be included in the Key

Directions?

In your local area of expertise, can

you identify:

factors which will support

the implementation of the

key directions and/or

barriers to implementing

the key directions?

Inadequate funding of health care professionals to enable delivery of key directions. The present models of funding are geared towards limited-time attention to medical problems once they have developed, without consideration of preventive health strategies and promoting self-management of chronic disease. Reluctance/refusal of the medical profession (driven by the AMA) to involve other health professionals in the management of chronic disease. This document clearly indicates in several places that primary care involves a number of other professionals, apart from GPs. Someone now has to convince the medical profession and AMA of this.

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Can you identify two or three

priorities where you consider

significant improvements can be

made within the next few years?

Poor integration between health services (particularly hospital and community sectors) and between different health professionals.Refocussing health care delivery to adopt a more patient-centred approach, which encourages self-management of chronic disease. Achieving consistency between different arms of Federal Government in approaching funding of health care delivery; in particular, convincing Treasury that focussing solely on containing costs can adversely influence the quality of health care and increase long-term costs.

Do you have any other comments

you would like to make?

This sounds like a great initiative:

In New South Wales, Integrated

Primary Health Care Services are

being set up, with 15 proposed

over the next three years. These

services will be GP-led and

provide better multi-disciplinary

chronic disease management by

locating GPs, nurses and allied

health with community health

services with co-ordinated access

to medical specialists. Funding will

be accessed through MBS, state

community health resources

allocated separate to Australian

Health Care Agreement funds, and

private contributions where

appropriate.

“Primary care, including general practice,

community health, Aboriginal health

workers, and community pharmacy, is

generally understood to be the main entry

point into the health system. Many

initiatives have, therefore, concentrated on

building the capacity of primary care, for

example through the use of Enhanced

Primary Care MBS items.”

Page 23

Page 24

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There needs to be greater support for building capacity in other areas e.g. community health, Aboriginal health

workers, and community pharmacy

(not just MBS items)

Workforce issues:

“The capacity of the health workforce to provide multi-disciplinary and

integrated care must be a focus through consideration of funding and structural arrangements. The

development of regional primary health care networks will need to be progressed, as well as better support

for the role of primary care in the prevention, detection and management

of chronic disease.”

Again, this should not just focus on GPs

and the MBS. For instance, there are very

limited funding opportunities for pharmacists for professional

services…certainly little scope via the PBS.

Page 33

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3.2 DRAFT NATIONAL SERVICE IMPROVEMENT FRAMEWORK FOR HEART,

STROKE AND VASCULAR DISEASE

Proforma for Comments

Comment Chapter /

page

number

Is the intent and the

purpose of the national

service improvement

framework clearly

articulated?

Yes.

Do you agree that the

framework is person-

centred? If not, what

needs to change?

Yes. It should be noted, however, that this document is

clearly more medico-centric and less patient-focussed

than the document (The National Chronic Disease

Strategy) which is stated as providing the “umbrella

strategy providing a consistent and effective approach for

all non communicable chronic diseases.”

The document is light in terms of self-management, when

viewed against the National Chronic Disease Strategy

(“Achieve person-centred care and optimise self-

management”). There is mention of self-monitoring blood

pressure, but relatively little else.

Is the language clear and

concise with limited use

of technical clinical terms

or jargon? (This does not

include in the ‘Rationale

for optimal services’

section of each chapter of

the framework).

It is noted that “This document has been designed so that

each chapter may be read as a separate unit for easier

reference. As a result, some information that is relevant to

more than one chapter is duplicated. Every effort has

been made to minimise this duplication.”

However, the format is excessively repetitive, especially

with regard to discussion of the cardiovascular risk

factors. A different presentation format should be

considered, which eliminates the duplication to a greater

extent.

Do you have any other

concerns with any of the

language used?

No.

Is the evidence base

clear, as outlined in the

Rationale for optimal

Yes, although some evidence is not covered e.g. point of

care testing; involvement of pharmacists.

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services?

Comment Chapter /

page

number

Do you agree broadly

that the critical

intervention points

represent areas where

there are:

currently suboptimal services; and

opportunities for significant gains to be made in terms of reducing mortality and suffering, increasing the quality of life etc.

Poor integration between health services (particularly hospital and community sectors) and between different health professionals. Refocussing health care delivery to adopt a more patient-centred approach, which encourages self-management of chronic disease.

Is there anything that you

consider significant and

should be included?

There are many areas where community pharmacists

could make an important contribution, but none of this is

mentioned. In particular, the Government’s HMR Scheme

is intended to improve the quality use of medicines across

the continuum of care and is an ideal strategy for patients

with cardiovascular events after discharge from hospital.

Are the links between

what is known about sub-

optimal services and the

critical intervention

points clear?

Yes.

In your local area of

expertise, will you be

able to work with others

in the health sector to

address the critical

intervention points?

Yes, although there are several key impediments.

Reluctance/refusal of the medical profession (driven by the AMA) to involve other health professionals in the management of chronic disease. This and the umbrella document clearly indicate in several places that primary care involves a number of other professionals, apart from GPs. Someone now has to convince the medical profession and AMA of this. Inadequate funding of health care professionals (especially those not covered by the MBS) to enable delivery of key directions. The present models of funding are geared towards limited-time attention to medical problems once they have developed, without consideration of preventive health strategies and promoting self-management of chronic disease. Poor integration between health services (particularly hospital and community sectors) and

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between different health professionals, which in part is obviously what these documents are attempting to address.

Are there any other

comments you wish to

make?

This document as stated is intended as a guide and is

more about principles, but it does seem to be light in

terms of implementation.

“Establish and encourage the development of systems and tools

enable absolute risk estimation in people without overt

cardiovascular disease (including early detection and

management of high blood pressure and dyslipidaemia)”

This needs to therefore include point of care screening

(when shown to be as accurate and reliable as pathology

testing) by GPs and other health professionals. Current

arrangements seem to unnecessarily protect pathology

providers, despite proven performance of many POC

devices. Also, where appropriate training and quality

assurance procedures are in place, absolute risk

assessment could be performed by pharmacists and other

non-medical health professionals.

“Promote awareness among people of the early symptoms of heart, stroke and vascular disease and associated conditions, and emergency response where appropriate.”

Community pharmacies would seem to be one ideal site

to locate awareness programs.

Promoting cessation of tobacco use

Also an important role for community pharmacy.

Re warfarin use in AF

What is needed here is better education and systems to

support the safe use of warfarin (e.g. point of care INR

testing by GPs, pharmacists, patients).

Page 22.

Critical

Intervention

Point 5.

Page 22.

Critical

Intervention

Point 7.

Page 34.

Page 44.

Page 52.

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Heart failure

For people with heart failure, medication and treatment

issues are paramount in the early stages. People with

heart failure often have problems adhering to their

medication and other treatment requirements. Poor

compliance and physician error with medication plans

frequently leads to re-hospitalisation.

Important role again for HMRs.

There are several mentions in the document to nurses

coordinating care and specialist ‘nurse led’ secondary

prevention clinics, based on overseas studies. This is to be

welcomed, but it also needs to be acknowledged that the

evidence base is similarly strong for other health

professionals e.g. pharmacists.

For instance, the SCRIP study (Study of Cardiovascular Risk Intervention by Pharmacists) was a randomised controlled trial conducted in 54 community pharmacies in Canada to determine the effect of a program of community pharmacist intervention on the process of cholesterol risk management in patients at high risk for cardiovascular events. There have been a number of published studies out of this work, including the following.

Tsuyuki RT, Johnson JA, Teo KK, et al. Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP): a randomized trial design of the effect of a community pharmacist intervention program on serum cholesterol risk. Ann Pharmacother 1999; 33: 910-9.

Tsuyuki RT, Johnson JA, Teo KK, et al. A randomized trial of the effect of community pharmacist intervention on cholesterol risk management: the Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP). Arch Intern Med 2002; 162: 1149-55.

Patients randomised to pharmacist intervention received education and a brochure on risk factors, point-of-care cholesterol measurement, referral to their physician, and regular follow-up for 16 weeks. Pharmacists faxed a simple form to the primary care physician identifying risk factors and any suggestions. Usual care patients received the same brochure and general advice only, with minimal follow-up. The primary end point was a composite of performance of a fasting cholesterol panel by the physician or addition or increase in dose of cholesterol-lowering medication. The external monitoring committee recommended early study termination owing to benefit. The primary end point was reached in 57% of intervention patients vs. 31% in usual care (odds ratio, 3.0; 95% confidence interval, 2.2-4.1; P<0.001). It was concluded that a community-based intervention program improved the process of cholesterol management in high-risk patients. The program demonstrated the value of community pharmacists working in collaboration with patients and physicians.

Page 67.

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Provision of medicines information

No mention of pharmacists?

Supportive Infrastructure: The Enhanced Primary Care

(EPC) items

What about HMRs???

Page 77.

Page 78.

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There is very little available information on what roles that the public perceives as being

appropriate and useful for community pharmacists. General public surveys in Australia have

consistently demonstrated pharmacists to be highly trusted professionals,23 yet reports of

public perception of what pharmacists actually do are sometimes far less flattering (Figure

9),24 although a recent unpublished survey commissioned by Australian Doctor and Pfizer

seemed to indicate support for community pharmacists taking on more clinical roles (Figure

10). Our own phone survey of consumers indicated that they are generally very satisfied with

the level and range of services they currently receive, and are generally unaware of the

potential for increased scope of services. Even the Federal Health Minister has appeared to be

lukewarm regarding any expansion of pharmacists’ professional activities (Figure 11). Such

perceptions present potentially significant barriers to community pharmacists expanding their

role into patient care, and need to be accommodated in the development of the Pharmacy

Cardiovascular Health Model.

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Figure 9 From Pharmacy News, 13 May 2004

Figure 10 From Pharmacy News, 21 July 2005

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Figure 11 From Pharmacy News, 27 May 2004

There is also very little available information on what roles that Australian doctors

perceive as being appropriate and useful for community pharmacists, although the Australian

Medical Association has been adamant that pharmacists should restrict themselves to

dispensing medication. Unfortunately our own attempts to obtain current opinions from peak

medical representative bodies (Divisions of GP and the AMA) were fruitless. The American

College of Physicians – American Society of Internal Medicine (ACP-ASIM) Position Paper

entitled “Pharmacist scope of Practice” acknowledged pharmacists’ push for a greater role in

patient care and the legislative support for this within America.25 Whilst support was given to

pharmacist involvement in immunisation, provision of patient education and therapeutic

substitution policies, the ACP-ASIM opposed independent pharmacist prescription privileges

and initiation of therapy. Other examples exist as to medical practitioners’ negative opinions

as to the roles that pharmacists may fill in the future 26-29 This is despite the broad acceptance

that patient care must be multidisciplinary. This is illustrated by Carlson who wrote: “The

‘new provider’ team, which includes nurses and, more recently, pharmacists, are collaborating

with physicians to provide disease management and drug therapy management services.”30

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Beney et al. concluded from their systematic review that pharmacists should continue

their role in providing patient counselling on drug therapy and education of physicians about

drug therapy.31 Pharmacists’ involvement in the provision of advice and medication control

is well received by physicians, however medication prescribing and adjustment of ongoing

pharmacotherapy are less so.26, 27, 29 Begley et al. suggested that community pharmacy-based

monitoring services, such as cholesterol and blood pressure testing, were not widely

supported by medical and nursing practitioners.27 They suggest that this may be because of a

fear that those “one-off” interventions might actually result in harm to the patient.

Many doctors have an incorrect or outdated perception of the training and skills of

pharmacy graduates. As determined recently by Smith et al.32 in a large survey of Californian

doctors, the medical profession simply do not know what to expect of pharmacists. Not

surprisingly, recent medical graduates were more supportive of pharmacists being directly

involved in patient care, as has been shown before.33 It was concluded that it appears that

pharmacists need to improve their credibility with doctors by accepting greater personal

responsibility for patients’ drug therapy outcomes.

Doctors often expect pharmacists to tell them, rather than patients, about suspected

problems.34 They are generally reluctant to support pharmacists giving patients direct advice

about prescription drugs, including information about possible adverse effects or

complications. Doctors wish to remain the primary caregiver for medications and want all

recommendations regarding prescription medications to be directed to them for review before

being implemented (Table 13, Table 14). Some doctors express concern that pharmacists

focus more on the potential harms rather than the likely benefits of taking a medication, and,

thereby, may create compliance problems.34

“Although pharmacists may not be aiming to dismantle the boundaries between their occupation and medicine, at the micro-level some doctors perceived some of their activities as a threat and responded by trying to reinforce the existing division of labour between pharmacy and medicine. As with nurses, physiotherapists and acupuncturists, GPs were happy to delegate tasks to pharmacists that they found difficult or mundane. However, ultimately the pharmacists were very dependent on their referral. Thus, by giving up some tasks to the pharmacists (monitoring of adherence for example) the doctors were not giving up control. Rather, they were delegating jobs perceived as low status. The GPs’ resistance to the clinical aspect of some of the extended roles for pharmacists may well be rooted in the fact that clinical identity is particularly important to doctors’ identity because of their lengthy training and the centrality of the concept of clinical autonomy. Thus, doctors might react defensively to an apparent challenge to their professional competence - in so doing they maintain a sense of control and reinforce their professional identity.”35

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There are many possible areas where the pharmacy profession could become more

involved in preventing, detecting and managing CVD. These are shown later in Figure 14.

However, a number of barriers could prevent the successful uptake of many of these

activities. These potential barriers include the following;

Resistance from the medical profession.

Acceptance by the public (“cultural authority”).

Need for extensive training and accreditation of pharmacists.

Lack of pharmacists’ time.

Little probability of achieving remuneration for activities.

The range of activities offered within community pharmacy could vary between

locations e.g. activities including CVD risk screening might be more appropriate for

community pharmacies in rural and remote regions, where access to medical and pathology

services is more limited.

It becomes essentially a matter of prioritising the possible activities, and determining

what is feasible given the constraints and pressures on pharmacists, and acceptance of

pharmacists’ professional activities. When designing the model, the research team was

guided by feedback from the National Heart Foundation of Australia and the EAG, indicating

that the initial emphasis to achieve “quick returns” should be on people with diagnosed CVD

- ensuring the quality use of medicines (QUM) and promoting compliance with therapy. This

is also consistent with the results from our public survey, which suggested that the focus of

pharmacy activity should be on medicines and providing information to consumers. As will

be discussed later, this should not be viewed as a minor role. In particular, improving

compliance with drug therapy in CVD would reap significant societal benefits.

It is interesting that Unal et al. recently investigated whether population based primary

prevention (risk factor reduction in apparently healthy people) might be more powerful than

current government initiatives favouring risk factor reduction in patients with CVD

(secondary prevention).36 They concluded that compared with secondary prevention, primary

prevention achieved a four-fold larger reduction in deaths. Tobacco control and healthier diets

were nominated as priority areas.

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An initial focus on improving medication outcomes in patients with existing CVD

would facilitate implementing processes that are streamlined and can be easily implemented

in community pharmacy practice e.g. by building on existing systems (e.g. HMRs).

The initial focus on QUM and a gradual move into other activities, as appropriate,

would also be consistent with the collaborative model (“Model for Pharmacist-Physician

Collaborative Working Relationship”) developed during recent years by Doucette and

colleagues (see Figure 12 ).37-40 The model is based on a staged approach to developing

collaborative working relationships among pharmacists and doctors. The progressive stages of

the model are: Stage 0 - Professional Awareness; Stage 1 - Professional Recognition; Stage 2

- Exploration and Trial; Stage 3 - Professional Relationship Expansion; and Stage 4 -

Commitment to the Collaborative Working Relationship. Interactions among pharmacists and

doctors are viewed as exchanges. At Stage 0, exchange is minimal and interactions are of a

discrete nature. Examples of discrete interactions among pharmacists and doctors include

pharmacists telephoning for prescription refill requests, alerting doctors to possible adverse

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drug reactions, or discussing a drug therapy or PBS problem identified during the dispensing

process. Such interactions tend to be of short duration and conducted without much thought to

developing a relationship or identifying new strategies to improve the patient care process.

During Stage 1, the efforts to establish a relationship are mostly unilateral and the

pharmacist is the primary instigator. For example, as pharmacists develop new services, they

may call on doctors to ask for referrals to their practice. At this stage, pharmacists see the

relationship as necessary for the success of their new clinical service, whereas doctors may

not see the value of the service or the need to establish a direct working relationship with the

pharmacist. As the relationship progresses through the stages, efforts to maintain it become

more bilateral. Once practitioners reach Stage 4, commitment to the collaborative working

relationship has been achieved, all those involved have an interest in sustaining the

relationship, communication is bilateral, and mutual trust and respect have been established.

In essence, the recommended approach is one of establishing rapport, credibility and a

sound relationship with the medical profession first and then gradually developing more roles

as the relationship strengthens and becomes more durable.

Table 13 Common obstacles to inter-professional collaboration38

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Table 14 Collaboration Between Community Pharmacists and

Family Physicians: Lessons Learned from the Seniors

Medication Assessment Research Trial34

Physicians and pharmacists viewed the expanded role pharmacist (ERP) role differently.

Physicians did not want pharmacists directly advising patients on medications other than over-the-

counter (OTC) products and expressed concern that pharmacists must respect physicians' relationship

with patients. Physicians saw quality control, help with OTC and herbal products, detection of

potential interactions, and help with adherence as appropriate pharmacist roles. Pharmacists saw

advancing the profession, being more equal partners, and advising physicians on the best medication

regimens as major aspects of their role.

Impact of the intervention was perceived as modest but helpful. Patients were very accepting of

ERPs. Physicians reported some new learning that could be generalized to other patients; some

potential and actual medication interactions were spotted, particularly between OTC and prescribed

medications; and some patient adherence problems were identified. Many times, physicians were

already making good decisions; sometimes, ERPs recommended strategies that had already been tried

and had failed. Few ERP recommendations were seen by either professional as having a major impact

on health outcomes.

Pharmacists need to practice their skills and acquire additional training. Pharmacists found the

ERP role challenging initially and acknowledged that to perform ERP roles effectively, they needed

more opportunities to practice some skills and acquire new ones.

Development of trusting relationships is important to effective collaboration between physicians

and ERPs. Working together over an extended period builds trust. With time, less contact is required

for physicians and ERPs to work together effectively.

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Figure 12 Staged approach to developing the pharmacist-physician

collaborative working relationship38

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Table 15 Strategies to Achieve Stage 1: Increasing Pharmacists’

Recognition among Doctors38

1. Communicate with targeted doctors to inform them of your interest in collaborating. 2. Identify pharmacy services that can complement the doctor’s practice while also meeting

patients’ needs. 3. Discuss ideas with doctors to judge their interest. 4. Refine ideas to meet the needs of doctors with whom the potential for establishing a

collaborative working relationship exists.

5. Schedule another face-to-face meeting with the goal of starting to build a collaborative working relationship.

Table 16 Strategies to Achieve Stage 2: Relationship Exploration

and Trial38

1. Make only high-quality, high-priority recommendations to doctors. 2. Get doctors’ feedback about recommendations. 3. Document the outcomes of recommendations.

4. Discuss with the doctor the best way to communicate recommendations (e.g., telephone call, fax, progress note, or a combination of these).

Table 17 Strategies to Achieve Stage 3: Expanding the Professional

Relationship38

1. Communicate to referring doctors the patient outcomes that have resulted from pharmacy care interventions.

2. Be consistent in the provision of care to patients. 3. Continue to make high-quality clinical interventions. 4. Have periodic face-to-face meetings with doctors to establish and enhance personal and

professional relationships.

5. Identify any conflicts due to pharmacy care interventions and discuss strategies to resolve them.

Strategies to achieve Stage 4 are similar, with an emphasis on the consistency of providing high-quality patient care.

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“Previous work suggests that doctors’ resistance to changes in pharmacy practice is open to change over time. For example, one study has shown that although doctors were initially sceptical about increased use of OTC medicines, over a period of a few years there was an overall increase in GP approval for the provision of a range of medications by community pharmacists. It might well be that through co-operative experience doctors would become more amenable to pharmacists engaging in more clinical activities in the future.”35

A guiding principle of the Project Team is that any model should be built around

existing health service and health promotion plans in CVD, and encourages partnership and

collaboration across the health care system. The model should be consistent with the goals of

pre-existing national strategies. The National Strategy for Heart, Stroke and Vascular Health

in Australia presented a useful starting point, depicting what are essentially the major three

stages of CVD (normal health, elevated risk for CVD, and diagnosed CVD).19

Figure 13 Stages of CVD (normal health, elevated risk for CVD, and

diagnosed CVD)19

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Figure 14 Possible roles for community pharmacists within the

stages of CVD

Some of the activities are already undertaken to differing degrees in this country, but

could become more commonplace. Others are not currently feasible in Australia but have

been implemented overseas. These activities could be considered later as future

improvements to the recommended model.

General Community

Community talks and lectures

Provision of education materials

Uptake of specialty health promotion weeks

Promoting or organising exercise groups

SNAP (smoking, nutrition, alcohol and physical activity) counselling

At-Risk Individuals

Identification of at-risk individuals

Targeted screening and referral if necessary

Identification of need for preventive therapy e.g., low-dose aspirin, statins

Medication advice to promote compliance and quality use of medicines

Defibrillator in pharmacies in

large shopping centres

Confirmed CVD

Medication advice to promote compliance and quality use of medicines

Monitoring of existing drug therapy, including BP and BSL monitoring in the pharmacy

Promoting adherence to evidence-based therapeutic guidelines

Adverse events monitoring

Drug-related problem detection

Referral for further testing

Home visits for monitoring purposes

Promotion of self-monitoring and education to enable this to occur

Home Medicines Reviews and medication plans

Co-ordination of allied health professionals

Prescribing ongoing therapy and

repeats

NB. Where not explicitly stated, all strategies recommended in a lower category apply to higher risk

groups (e.g. promotion of smoking cessation in patients with existing CVD)

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3.3 POTENTIAL ROLES FOR COMMUNITY PHARMACISTS FOR THE ‘GENERAL

COMMUNITY’ GROUP

Community talks and lectures

There is potential in the community for pharmacists to use their extensive health

knowledge to educate members of the public in relation to health issues. This can be achieved via radio broadcasts or talks to community groups, including sporting clubs, schools, volunteer groups, nursing homes etc.

Provision of educational materials

This is an activity that is currently undertaken by community pharmacists to

differing degrees. Many resources are available, and the public would benefit from a more co-ordinated distribution of these materials, perhaps tying in with ‘specialty weeks’ (see below). An extensive range of educational materials is

available through the National Heart Foundation of Australia, Stroke Foundation etc.

Uptake and promotion of specialty weeks

Many of the large health organisations arrange specialty weeks to raise the profile of their cause and organisation. Materials are usually provided to assist the

promotion of these awareness weeks and community pharmacy could more fully embrace this concept, and take the opportunity to help raise public awareness. For example:

World no tobacco day Talk to your pharmacist week Get active Diabetes week

Promoting/organising or conducting walking/exercise groups

A community pharmacy is a logical meeting place for like-minded, health

conscious people, and those who wish to improve their health status. This can be utilised to co-ordinate group exercise activities. Some pharmacies have conducted walking groups. Joining a group and committing to a regular activity has been

found in many circumstances to improve participation levels, and longevity.

SNAP Framework

A population health guide to behavioural risk factors in general practice. The RACGP SNAP Framework for General Practitioners is a set of recommended guidelines to help GPs tackle the most important behavioural risk factors that

affect the health of the Australian community - Smoking, Nutrition, Alcohol and

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Physical activity. As mentioned in the Framework’s documentation, these

concepts could also be adapted by other health professionals, including community pharmacists, to ensure a co-ordinated, structured approach to reducing the significant effect of the modifiable risk factors in the Australian population.

Smoking

assessment at every opportunity of smoking status establishing position on ‘stages of change’ model re-enforcement of benefits of quitting behaviour modification support NRT (nicotine replacement therapy) advice referral to QUIT

Nutrition

assessment of diet advice on appropriate diet referral to dietician as necessary

Alcohol

assessment of current consumption advice regarding ‘safe’ alcohol intake referral to GP or drug and alcohol centre as necessary

Physical Activity

assessment of current level advice regarding appropriate level referral to physical therapist as required

3.4 POTENTIAL ROLES FOR COMMUNITY PHARMACISTS FOR THE ‘AT-RISK’

GROUP

Identification of at-risk individuals for referral

Pharmacists often come into contact with otherwise healthy people, and could take the opportunity to screen for CVD risk factors. This identification process may take many forms, for example:

via OTC purchases (repeated antacid purchases for ‘indigestion’ which is perhaps angina) via dispensing history (e.g. diabetic patients) via population screening of people known to be at elevated risk of CVD due to their age, gender, family history, comorbidities, weight etc.

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Targeted screening and referral to GP if necessary

Examples of screening activities undertaken in community pharmacies include

cholesterol, BP and BSL measurement. Targeted opportunistic screening, with appropriate quality assurance procedures in place, could identify people at increased risk CVD when early intervention is possible. It is recognised that the

focus should be on absolute risk assessment for CVD, utilising the New Zealand or other risk calculators.

Identification of need for preventive therapy e.g., low-dose aspirin, statins

Pharmacists could identify patients who might benefit from therapies including low-dose aspirin (e.g. patients with type 2 diabetes), for referral to their GP.

Simvastatin 10mg is available from pharmacists in the United Kingdom, so initiation of statin therapy is possible. Clearly, this is not possible currently in Australia. It may or may not prove to be beneficial and cost-effective, but will

need to be considered for future models.

Defibrillator in pharmacies in large shopping centres

St John Ambulance has embarked on a program to make public access to automated defibrillators widely available throughout the country.

Deployment of defibrillators in pharmacies in large shopping centres and training of pharmacists might represent a useful model to improve rapid access to this life-

saving technology.

3.5 POTENTIAL ROLES FOR COMMUNITY PHARMACISTS FOR THE ‘CONFIRMED

CVD’ GROUP

Medication advice to promote compliance and quality use of medicines

Ensuring patients are receiving the appropriate medication for their condition and then ensuring they continue to take it as prescribed is probably one of the simplest ways community pharmacists could improve the health of patients with CVD.

Many studies have shown that long-term compliance rates are low, and marginally improving these rates would improve outcomes.

Monitoring of existing therapy

Ensuring treated CVD patients are at target levels for BP, cholesterol etc. In-pharmacy screening can be undertaken to assess achievement of targets and

promote compliance.

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Promoting adherence to evidence-based therapeutic guidelines

Evidence-based management Guidelines exist for most cardiovascular conditions.

Community pharmacists should familiarise themselves with the current guidelines and could help ensure that patients are receiving the most appropriate treatments.

Adverse events monitoring and Drug Related Problem (DRP) detection

The community pharmacy is often the first port of call for patients with medication queries. Community pharmacists should be vigilant to potential DRPs

and act to rectify and report them as a matter of course, in collaboration with the patient and GP.

Referral for further testing

If non-compliance is detected, referral to the patient’s GP should be provided. Similarly, many cardiovascular medications (e.g. statins, amiodarone, digoxin,

warfarin) require ongoing testing and monitoring, and the community pharmacist’s role should be to ensure this happens at the appropriate intervals.

Home visits for monitoring purposes

Blood pressure, INR, BSL and cholesterol monitoring equipment is portable and reliable enough now that pharmacists could conduct monitoring programs in the

home, and a number of successful programs have appeared in the literature.

Promotion of ‘self-monitoring’ and education to enable this to occur

Many of the monitors available now are very straight forward to use, and patients could be taught how to use the equipment and interpret the results. This is a role that community pharmacists could undertake, and it would assist reducing the

burden on GP time, and improve concordance.

HMRs and medication plans

The use of Home Medication Reviews is growing in the community, and their value has been demonstrated. They can be particularly useful following the hospital discharge of patients with CVD.

Prescribing ongoing drug therapy

This is not possible in Australia currently but it is common in other countries,

including the United States. This is an activity that would need to be considered for future models.

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3.6 ADDITIONAL OVERARCHING GUIDELINES

3.6.1 Education of Pharmacists

PriMeD Pharmacy is an online professional education service designed specifically for

pharmacists, and is a recognised educational activity under the Pharmaceutical Society of

Australia (PSA)’s CPD&PI program. It is available online but a subscription is required.

This subscription is subsidised for PSA members.

PriMeD Pharmacy contains a comprehensive range of topics including Heart Health and

Weight Management which are of particular interest to the creation of a CVD Model for

pharmacy. It also provides links to relevant and up to date clinical papers. It is reasonable to

recommend this standardised source of information, which is well-supported and recognised

within the profession.

3.6.2 Relevant Professional Practice Standards41

Health promotion in community pharmacies

The pharmacist actively promotes health in the community and provides information of health

conditions and their management.

Health promotion is the process of enabling people to take greater control of their health to

improve it. It seeks to influence public policy, mobilise community action and involvement,

and create equity of access to services and facilities making them available in places where

people work, live and play.

The pharmacist is a resource for individuals and community groups for health

education information.

The pharmacist provides health education to consumers at individual and community

level.

The pharmacist actively participates in developing health promotion skills of

individuals engaged in relevant activities.

The pharmacist works in partnership with health organisations, community groups and

other health professionals to promote health.

The pharmacist has a record of health educations and promotion activities provided.

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Smoking Cessation Service

The pharmacist provides a smoking cessation service following established procedures to

optimise therapeutic outcomes and quality of life for the consumer and to contribute to the

reduction of harm associated with tobacco use.

The National Tobacco strategy 1999-2002-3 highlights the need for a comprehensive and

multi-variate approach and national collaborative effort to improve the health f all Australians

by eliminating or reducing their exposure to tobacco in all its forms.

Evidence shows that pharmacists and their staff can play an effective role in smoking

cessation, especially when augmenting advice from doctors and health workers. The

professional responsibility and duty of care of pharmacists to protect the health of patients call

for an active role by pharmacists in the provision of smoking cessation services.

Screening and monitoring of clinical indicators in community pharmacy.

Blood pressure measurements are taken accurately, and a responsible and accountable

explanation of results, their significance, and a written report provided to the patient.

Blood glucose measurements are taken accurately, and a responsible and accountable

explanation of results, their significance, and a written report provided to the patient.

Blood cholesterol measurements are taken accurately, and a responsible and accountable

explanation of results, their significance, and a written report provided to the patient.

Pharmacists offering clinical measurement services have an obligation to be aware of

new products and evolving changes in clinical practice that may impact on the service

they provide.

The availability of the service should be communicated in a professional and

responsible manner.

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Testing is offered as a screening and monitoring purpose and not for diagnostic

purposes.

Written consent must be obtained from each patient prior to measurement, and a

record of this consent must be kept.

Where results are not within the desired range patients should be counselled and

advised of the desirability of a medical consultation.

The pharmacist must ensure that the explanation of the results and their significance is

based on contemporary knowledge of the management of the relevant condition and

the risk factors for cardiovascular disease.

A written record of each test performed shall be maintained in the pharmacy. This

will include the name and contact details of the patient and usual doctor, as well as the

date, test results and name of the person performing the test

All clinical indicators measuring equipment must undergo systematic maintenance and

calibration procedures according to manufacturer’s specifications.

Only personnel who have been trained in the correct use of the equipment shall

perform clinical indicator testing. Generally, manufacturers of such equipment will

provide training to ensure the correct use, maintenance and calibration of the

equipment.

Privacy and confidentiality shall be preserved at all times.

3.6.2 Blood Handling Procedures

As well as the procedures and guidelines outlined above, additional measures need to be taken

when blood handling is involved.

Each state of Australia has its own workplace Health and Safety Act, and this should be

consulted when establishing guidelines for blood handling procedures.

To reduce the amount of work required for each pharmacy to design its own ‘Blood

Handling Policy’ a modified version of the University of Tasmania’s policy is provided in

abbreviated form to provide a baseline starting point. This document was created in reference

to the Workplace Health and Safety Act 1995.

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OVERVIEW

An institution needs to be committed to continuously improving the management and standards of Occupational Health and Safety. This extends to the prevention and management of occupational exposures to blood and body fluids contaminated with blood, including needlestick/sharps injuries, which have a potential to carry the human immunodeficiency virus (HIV), Hepatitis B (HBV), Hepatitis C (HCV) and/or other blood borne infections.

DEFINITIONS

Accountable Person: An individual, who assumes responsibility for the health or welfare of any other person in a workplace by providing instruction, direction, assistance, advice or service, is deemed an accountable person in accordance with the Workplace Health and Safety Regulations 1998. All management and supervisory staff are therefore considered “accountable persons”.

Affected Person: The employee exposed to blood or body fluid.

Exposure: Contact with blood or body fluids possibly contaminated with blood. Exposure can be categorised in the following manner:

Doubtful parenteral exposure

o Intradermal (‘superficial’) injury with a needle considered not to be contaminated with blood or body fluid

o A superficial wound not associated with visible bleeding produced by an instrument considered not to be contaminated with blood or body fluid.

o Prior wound or skin lesion contaminated with a body fluid other than blood and with no trace of blood, eg. Urine.

Non-parenteral exposure

o Intact skin visibly contaminated with blood or body fluid.

o Possible parenteral exposure

o Intradermal ('superficial') injury with a needle contaminated with blood or body fluid.

o A wound not associated with visible bleeding produced by an instrument contaminated with blood or body fluid.

o Prior (not fresh) wound or skin lesion contaminated with blood or body fluid.

o Mucous membrane or conjunctival contact with blood.

Definite parenteral exposure

o Skin penetrating injury with a needle contaminated with blood or body fluid.

o Injection of blood/body fluid not included under 'Massive Exposure'.

o Laceration or similar wound which causes bleeding and is produced by an instrument that is visibly contaminated with blood or body fluid.

o In laboratory settings, any direct inoculation with human immunodeficiency virus (HIV) tissue or material likely to contain HIV, hepatitis B virus (HBV) or hepatitis C virus (HCV) not included above.

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Massive Exposure

o Transfusion of blood.

o Injection of large volume of blood/body fluids (>1ml)

o Parenteral exposure to laboratory specimens containing high titre of virus.

Hepatitis: Hepatitis A, B and C are all viruses that attack the liver with each form of the virus having different levels of seriousness to health, Hepatitis B being a common cause of liver cancer and cirrhosis of the liver.

HIV/AIDS: Refers to the Human Immunodeficiency Virus (HIV) which gradually impairs the immune system of an infected person and eventually weakens a person's defences against disease. HIV is the putative causative agent for Acquired Immune-Deficiency Syndrome (AIDS).

Mucous Membrane: The lining of the mouth, nose and respiratory tract, the conjunctival membrane covering the eye, the gastrointestinal tract and the urinogenital tract.

Source Individual: The person whose blood or body fluid was inoculated or splashed onto the affected person. The source individual may sometimes not be identifiable, for example, when an affected person has been injured by a needle/instrument and it is not know on whom it was used.

RESPONSIBILITIES

Accountable Persons:

Accountable Persons need to ensure that employees in their control who are at risk of exposure to blood and body fluids are appropriately trained in correct handling procedures, are aware of the associated risks, are supplied with all protective equipment and are provided with any vaccinations required. In the event of an occupational exposure, ensure that procedures outlined in this document are followed and that in the case of an infected person confidentiality is maintained.

Employees:

Whilst undertaking any activity associated with blood and body fluids, employees are required to do so in a manner which does not adversely affect their own health and safety, or that of others, by following this Policy and Procedure. Employees must report all incidents arising from exposure to blood and body fluids and adopt work practices to minimise such incidents.

In particular, employees who know they have HIV/AIDS or Hepatitis, are required to exercise their duty of care towards others to minimise the risk of transmitting infection.

GENERAL PREVENTATIVE MEASURES

for minimising risk of infection from exposure to blood and body fluids are:

o ensuring that people considered to be at risk eg. employees directly involved in patient care,

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employees handling blood and body fluids are immunized

o ensuring that hands are washed after contact with blood and body fluids, especially before eating or drinking.

o ensuring that gloves are worn when handling blood or body fluids, which substantially reduces the risk of hands being contaminated. However, gloves contaminated with blood or body fluids should be discarded between treating persons, as the wearing of gloves does not prevent cross-infection. Hands should be thoroughly washed after discarding gloves.

o ensuring that waterproof aprons/gowns are worn when clothing is likely to be soiled with blood or body fluid

o ensuring that masks and/or protective eye wear is worn in situations where ocular and/or mucous membrane exposure to splashed or sprayed blood or body fluid is likely, eg. cleaning soiled equipment.

o ensuring that employees with cuts or abrasions on exposed parts of the body cover these with waterproof dressings.

o ensuring that needles and disposable sharp instruments used on any treated person are discarded directly into a container for the disposal of sharps which complies with Australian Standards.

PROCEDURE FOR DEALING WITH EXPOSURES

Affected Person

o If skin is penetrated, wash the area well with soap and water (alcohol based hand rinses or foams, 60-90 per cent alcohol by weight should be used when water is not available).

o If blood gets on the skin, irrespective of whether there are cuts or abrasions, wash well with soap and water.

o If the eyes are contaminated, rinse the area gently but thoroughly with water or normal saline, while the eyes are open; and

o If blood or body fluid gets in the mouth, spit it out and then rinse the mouth with water several times.

o Ensure the safe disposal of the needle or sharp (if applicable).

Then report IMMEDIATELY to your Accountable Person. Complete an Accident/Incident Report form which must include:

o date and time of exposure;

o how the incident occurred; and

o name of the source individual (if known).

Regardless of the status of the source individual, the affected person should immediately be evaluated and the risk assessed, preferably by a physician or trained health care worker with experience in the management of these situations. Prophylaxis should be offered on the basis of the risk of infection associated with the injury/exposure.

Accountable Persons

If an employee has suffered a possible parenteral, definite parenteral or massive exposure it is important that you make sure that immediate steps are taken to reduce the risk to the employee of contracting a serious illness.

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o Ensure that the employee has thoroughly washed the exposed area and the needle or sharp has been disposed of safely (if applicable).

o Arrange for blood to be taken from the employee as soon as possible by referring the person to a General Practitioner or the Accident/Emergency (Casualty) Department of the nearest Public Hospital.

o Find out whether a known source individual is involved in the incident and if so, organise for blood to be taken from the source individual which needs to be tested for:

o HIV antibody;

o Hepatitis B surface antigen (HbsAg); and

o Hepatitis C antibody (Anti-HCV).

o The source blood should be collected and processed immediately after the incident. (Remember, informed consent with appropriate counselling is required).

o When the source individual is known to be positive for either HIV antibody, HbsAG or antiHCV, ensure that a physician with experience in the management of these infections has been contacted.

o Ensure that an Accident/Incident Report Form has been completed and includes:

o The date and time of the incident;

o How the incident happened; and

o Nature of exposure, eg. Whether the affected person had been stabbed by a syringe or other sharp, or been splashed in the eye, or other mucosal contact has occurred.

o Source information if known

o Reassure the employee that only a small proportion of accidental exposure to blood or body fluid results in infection.

o Provide support and advise the employee that counselling can be arranged.

o Investigate the circumstances of the accident and take measures to prevent recurrence. This may include changes to work practices, changes to equipment, and/or training.

Note: It is most important that confidentiality of employee and source individuals be

maintained.

MEDICAL MANAGEMENT INFORMATION

Affected Person

The affected person should be examined IMMEDIATELY to confirm the nature of exposure and counselled about the possibility of transmission of blood borne disease.

If the accident involved non-parenteral or doubtful parenteral exposure then no further testing or examinations are required apart from the possibility of further counselling. This should be determined according to the individual circumstances.

If the accident involved massive, definite or possible parenteral exposure then the following should occur:

o immediate steps to identify status of the source individual;

o blood should be taken from the affected person (the types of tests undertaken will depend

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upon the status of the sources); and

o arrangements should be made for follow-up assessments of the affected person when the status of the source individual is confirmed.

Source individual

In the case of massive, definite or possible parenteral exposure then the source individual should be investigated.

If the status of the source individual is unknown at the time of the accident, then tests should be undertaken to ascertain the source’s infection status for HIV, HBV and HCV. Blood samples may already be in the laboratory and available for immediate testing.

The following tests should be undertaken on the source:

o HIV antibody

o HBsAg; and

o Anti-HCV

Blood tests for HIV and HBV should be undertaken urgently so that prophylactic treatments can be given to achieve best outcomes.

The source individual (if accessible) should be appropriately counselled and informed consent should be obtained prior to undertaking the tests.

SHARPS DISPOSAL GUIDELINES – modified from the University of Tasmania “Sharps Disposal Policy and Procedures”

Sharps:

Sharps are defined in the "National Guidelines for the Management of Clinical and Related Wastes" published by the National Health and Medical Research Council as "objects or devices having acute rigid corners, edges, points or protuberances capable of cutting or penetrating the skin". Hypodermic needles, pasteur pipettes, scalpel blades and broken glass all fit this definition.

PROCEDURE: DISPOSAL OF SHARPS

All sharps have the potential to cause injury through cuts or puncture wounds. In addition, many sharps are contaminated with blood or body fluids, microbiological materials, toxic chemicals or radioactive substances, posing a risk of infection or illness if they penetrate the skin. It is therefore essential to follow safe procedures when using and disposing of sharps in order to protect staff and students from sharps injuries.

The following sharps disposal procedures shall be adhered to:

1. Pharmacies which use sharps must have a designated container suitable for the safe storage of used sharps. Suitable containers are rigid and impervious, with a tightly fitting lid and they must be clearly labelled as sharps containers. They must be discarded when full.

2. All sharps are to be placed in the sharps container immediately after use. If the container is full then users must not try to force further sharps inside as this may lead to an injury.

3. To avoid needlestick injuries, used needles must not be recapped, bent or otherwise manipulated unless an approved needle containment device is being used.

4. Containers of used sharps contaminated with biological, infectious or radioactive material must be

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labelled accordingly

5. When a sharps container is full the lid must be securely closed and the container disposed of properly. Sharps containers must not be placed into the general rubbish stream, but disposed of in an approved manner. Local Councils are generally the best point of contact to establish what the approved manner of disposal of sharps containers is in your local area.

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3.6.3 Ethics and Privacy Guidelines

Prior to undertaking clinical research involving human subjects, ethics approval must be

obtained from the relevant committee. In general, these bodies assess ethics applications for

the following reasons.

o Ensure the information that is dispersed to the participants contains all the risks,

benefits and actual tests and tasks that they will have to undergo if they participate

within the research, indicated clearly and in everyday language that the ordinary

person can understand.

o Ensure that specific features of the various participant groups are protected against

prejudice and have been considered appropriately.

o Ensure that there is adequate indemnity for the patients

o Ensure that there are adequate mechanisms for reporting of serious adverse events that

occur to patients

These same principles should be considered before undertaking clinical screening in the

community pharmacy setting. Ethics approval as such is not required, but the issues should

be considered and addressed to ensure informed consent is supplied by the patient.

All pharmacists are covered by a professional code of conduct written by the

Pharmaceutical Society of Australia.42 The relevant principle is shown below.

Principle THREE

A pharmacist must respect the confidentiality of information acquired in the course of

professional practice relating to clients and their families. Such information shall not be

disclosed to anyone without the consent of the client. Exceptions may arise where the

health of the client or others is at risk, where information is sought by an officer of a

statutory authority empowered under legislation, where a court order requires the release

of confidential information, or the information is released to those assuming responsibility

for the patient (e.g. next of kin, parent, relative, guardian or anyone with powers of

attorney).

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Obligations

3.1 The pharmacist must exercise discretion and restrict access to information relating to clients and their families to those who, in the pharmacist's judgment, need the information to discharge their responsibilities to the client or, in extraordinary circumstances, the public.

3.2 The pharmacist must ensure that anyone who has access to information relating to client and their families

a. is aware of the need to respect its confidential nature, and b. does not disclose such information but refers the matter to the

pharmacist.

3.3 Where exceptional circumstances necessitate disclosure of information relating to clients and/or their families the content should be limited to the minimum necessary for the purpose of the disclosure.

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HEALTH INFORMATION AND THE PRIVACY ACT 1988

A SHORT GUIDE FOR THE PRIVATE HEALTH SECTOR - DECEMBER 2001

This Guide provides a brief introduction to the Commonwealth privacy law covering the private health

sector. For private sector health service providers, the amended Privacy Act 1988 takes effect from 21

December 2001. This Guide does not describe the law in detail.

PRIVACY AND HEALTH CARE

Access to quality health care is an important priority for all Australians.

It is also important that individuals' privacy is respected during the provision of health care and treatment services. Being reassured about privacy gives consumers the confidence to access the health services they need.

People have different views about their privacy, including when and why it is important. Their views may depend on the sensitivity of the information or their circumstances and beliefs.

At times, health service providers need to share information with each other to ensure that a person receives good quality health care. The Privacy Amendment (Private Sector) Act 2000, which amends the Privacy Act 1988, allows the sharing of information with others, where necessary, while outlining the privacy issues and safeguards to consider in these circumstances.

Importantly, the legislation gives a person choice about how their health information is handled.

Open communication between health service providers and health consumers regarding the handling of health information is central to properly addressing privacy issues.

PROTECTING HEALTH INFORMATION

In today's health environment, the privacy protection of health information is important for both electronic health records and paper-based records.

When deciding how best to protect a person's health information, health service providers may need to consider:

Who should be allowed to see hospital medical records, records kept in a pharmacy, or computerised records in a medical practice? When and how is it appropriate for one health service to transfer information to another? What safeguards must apply when information is used for health research? Is the person's consent needed for handling health information in each situation?

This is where the privacy legislation can help.

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<< Good privacy - good health care>>

THE PRIVACY AMENDMENT (PRIVATE SECTOR) ACT 2000

The Privacy Amendment (Private Sector) Act 2000 amends the Commonwealth Privacy Act 1988 ('the Privacy Act') to establish minimum privacy standards for the Australian private sector, including for all private sector organisations that both provide health services and hold health information. The legislation applies from 21 December 2001.

The Privacy Act creates a single, nationally consistent framework for protecting privacy. It complements existing codes of practice and ethics in the health sector.

The Commonwealth legislation prevails over State or Territory privacy legislation, to the extent that these laws are inconsistent.

WHAT IS A 'HEALTH SERVICE'?

The Privacy Act stipulates providing a 'health service' includes any activity that involves:

assessing, recording, maintaining or improving a person's health; or diagnosing or treating a person's illness or disability; or dispensing a prescription drug or medicinal preparation by a pharmacist.

The Privacy Act applies to all private sector organisations that deliver these types of services, including all small health services that hold health information.

The types of health services covered include traditional health service providers such as private hospitals and day surgeries, medical practitioners, pharmacists, and allied health professionals, as well as complementary therapists, gyms, weight loss clinics and many others.

<< All private sector health service providers that hold health information are covered>>

WHAT TYPE OF INFORMATION IS PROTECTED?

The Privacy Act protects 'personal information' about individuals - that is, any information recorded about a person where their identity is known or could reasonably be worked out.

Personal information includes a person's name, address, Medicare number and any health information (including opinion) about the person. Sometimes, details about a person's medical history or other contextual information can identify them, even if no name is attached to the record. This is still 'personal information'.

The Privacy Act does not cover de-identified statistical data, where individuals cannot reasonably be re-identified.

'Health information' is a particular kind of 'personal information' and attracts additional privacy protection because of its greater sensitivity.

'Health information' includes information about a person's health, disability, use of health services, or other personal information collected from someone when delivering a health service.

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THE NATIONAL PRIVACY PRINCIPLES (NPPS)

Ten NPPs form the core of the private sector provisions of the Privacy Act. These principles set the minimum standards for privacy that organisations must meet.

The principles cover the whole information handling lifecycle - from the collection of health information, to its storage and maintenance, as well as its use and disclosure.

The principles, as they might apply in the health sector, are summarised below. For more details see the Privacy Commissioner's Guidelines on Privacy in the Private Health Sector.

NPP 1 - Collection and NPP 10 - Sensitive Information

These principles apply to the collection of health information. In general, they require a health service provider to:

collect only the information necessary to deliver the health service; collect lawfully, fairly and not intrusively; and obtain a person's consent to collect health information about them.

Providers also need to ensure that consumers are informed about why their health information is being

collected, who is collecting it, how it will be used, to whom it may be given and that they can access it

if they wish.

<< Health service providers can collect health information only with consent>>

NPP 2 - Use and Disclosure

This principle sets out how providers can use and disclose health information.

'Use' refers to the handling of information within an organisation.

'Disclosure' is the transfer of information to a third party outside the organisation.

A health service provider may use or disclose health information:

for the main reason it was collected (the primary purpose); or for directly-related secondary purposes, if the consumer would reasonably expect these; or if the consumer gives consent to the proposed use or disclosure; or if one of the other provisions under this principle applies.

The key is to make sure that there is alignment between the expectations of the health service provider and those of the consumer about what will be done with the health information.

<< Promote a common understanding about privacy of health information >>

NPP 3 - Data Quality

Health service providers are required to take reasonable steps to keep health information up to-date, accurate and complete.

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<< Health service providers should maintain data quality and integrity >>

NPP 4 - Data Security

This principle requires that health service providers take reasonable steps to protect and secure health information from loss, misuse and unauthorised access. Information that is no longer needed should be destroyed.

As health information may be needed for future care of the individual or for public health reasons, the priority should be to secure the data properly.

<< Health service providers should protect information against security risks >>

NPP 5 - Openness

Health service providers need to be open about how they handle health information.

A provider must develop a document for consumers which clearly explains how their organisation handles health information. The document must be made available to anyone who asks for it.

<< Fewer surprises about handling health information leads to fewer privacy complaints >>

NPP 6 - Access & Correction

Consumers have a general right of access to their own health records.

Access can only be denied in certain circumstances - for instance where access can pose a serious risk to a person's life or health.

Also, consumers can ask for information about them to be corrected, if it is inaccurate, incomplete or out-of-date. The provider will need to take reasonable steps to correct the information.

<< Consumers have a general right of access to their own health records>>

NPP 7 - Identifiers

There are restrictions on how Commonwealth government identifiers, such as the Medicare number or the Veterans Affairs number, can be adopted, used or disclosed.

At present, a health service provider is not permitted to adopt these identifiers for their own record keeping systems. These identifiers may only be used or disclosed for the reasons they were issued or if other provisions under this principle apply.

NPP 8 - Anonymity

Where lawful and practicable, consumers must be given the option to use health services without identifying themselves.

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NPP 9 - Transborder data flows

If health information needs to be transferred out of Australia, this may occur if laws (or a scheme) with similar privacy protection to these principles bind the recipient.

Otherwise, health information should only be transferred with the consumer's consent, or if other provisions under this principle apply.

COMPLAINTS

Complaints about alleged breaches of privacy can be made to the Privacy Commissioner. The Commissioner can investigate, conciliate and, if necessary, make determinations about complaints. However, the Commissioner will not investigate, unless the complainant has first complained formally to the health service provider concerned.

GUIDELINES ON PRIVACY IN THE PRIVATE HEALTH SECTOR

For more assistance on how the privacy legislation applies to health service providers, see the Privacy Commissioner's Guidelines on Privacy in the Private Health Sector and Information Sheets (especially Information Sheet 9 2001 Handling Health Information for Research and Management).

These Guidelines and the Privacy Act 1988 are available on the Office's web site at www.privacy.gov.au.

Health service providers are also encouraged to contact their professional body or association for further information on privacy in their profession.

FOR FURTHER INFORMATION CONTACT:

Office of the Privacy Commissioner

1300 363 992 (Hotline)[email protected]

SOME PRIVACY ISSUES FOR PHARMACISTS

Collecting health information, dispensing medication and discussing symptoms in a public space

When a pharmacist collects health information from a patient in a place where they may be overheard, this should be done in a manner sensitive to the surroundings - as some individuals may be particularly concerned about discussing health issues in an open area. In some circumstances, the pharmacist may wish to take additional steps to protect privacy, such as taking the patient to one side.

Change of business circumstances and pharmacies

When a pharmacy's business circumstances change, some privacy-related steps may be needed. If the new arrangements lead to delivering services in the same way as before, but under new ownership, patients should be advised of the change, perhaps via a notice in the pharmacy or in a local newspaper.

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If the new arrangements change the way services are delivered, including the way health records are used and disclosed, then the consent of patients will usually be needed.

This might occur, for instance, if a pharmacy becomes newly co-located with other clinical services and shared record handling is introduced, or where a large corporation buys a pharmacy, and the corporation wants to transfer health information within the organisation.

Access to health records

From 21 December, patients have a general right of access to their own health records and can ask for a copy. Patients also have a right to seek the correction of information held about them, if this is shown to be inaccurate, incomplete or not up-to-date.

Children's privacy

The Privacy Act does not set an age limit at which a child or young person can exercise their own privacy rights - this occurs when the individual becomes competent to make such decisions. Where a child or young person is competent they should make their own decisions; if they are not competent to do so, a pharmacist may discuss their health record with a parent.

If a parent seeks information about their child, but the child explicitly asks that certain health information not be disclosed to that parent, the pharmacist may consider it appropriate to keep such information confidential.

Providing personal information to others - the collection of medication by friends, neighbours or

relatives

A patient's consent to the disclosure of their personal information can be expressed or implied. In many instances, implied consent may reasonably be inferred from the actions of the patient. Depending on the circumstances, it may be inferred that a patient has consented to someone else collecting medication on their behalf (and thereby receiving some of their personal information), if they have given a friend or relative their prescription for that reason.

Complaints

Complaints about alleged breaches of privacy can be made to the Federal Privacy Commissioner. The Commissioner can investigate, conciliate and, if necessary, make determinations about complaints.

Need more information...?

Other resources include:

a privacy booklet 'Guidelines on Privacy in the Private Health Sector', and a range of Information Sheets.


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