NATIONAL PHARMACY DATABASE PROJECT

CG Berbatis, VB Sunderland, CR Mills and M Bulsara

June 2003

School of Pharmacy Curtin University of Technology of Western Australia

GPO Box U1987 Perth WA 6845

C Berbatis and V B Sunderland School of Pharmacy Curtin University of Technology of Western Australia GPO Box U1987 Perth Western Australia 6845

This project was funded under the Third Community Pharmacy Agreement Research and Development Grants Program for the project titled “Reference data base of Australia’s community pharmacies: Analysis of national

survey”. First published in June 2003 Reference database of Australia’s community pharmacies. Copyright School of Pharmacy, Curtin University of Technology of Western Australia GPO Box U1987 Perth W Australia 6845. ISBN: 1 74067 2747. All rights reserved. This publication may be reproduced with appropriate citation and the prior informing of the copyright owners and the authors of this report

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Table of Contents Acknowledgements …………...……………………..………………………………………… 3 Executive summary …………...……………………..………………………………………… 4 Recommendations …………...……………………..………………………………………… 9 Contact details …………...……………………..………………………………………… 16 1. Introduction …………….……………..………………………………………… 17 1.1 Terms of Reference ………………..………..………………………………………… 17 1.2 Origins of the National Pharmacy Database Project ….………………..……… 17 1.3 Review of pharmacy surveys overseas and in Australia ………..…..……… 18 1.4 Methodology …………………….…..…………………………………………… 19 1.4.1Sample and stratification with PhARIA system ……….…………..……… 19 1.4.1.1 Difficulties with the PhARIA system for stratification ….……..………… 20 1.4.2 Participation rate ……………..…….………………………………………… 20 1.4.3 Response rate ……………..…….………………………………………… 21 1.4.4 Questionnaire ……………..…….………………………………………… 22 1.4.5 Implementation and administration of survey …….……………………… 22 1.4.6 Analysis ……………..…….………………………………………………... 23 1.4.7 National estimates …..…….………………………………………………... 24 2. Database (Term of Reference 1, disk attached) …..………………………………..... 25 2.1 Pharmacy activities, facilities, services, PhARIA and estimates …………....... 25 2.2 Pharmacy characteristics and facility/service provision ……………………..... 25 2.3 Pharmacy characteristics and barriers …..………………………………........... 26 3. (Terms of Reference 1, 2 and 5) Discussion by section ……………………........... 27 3.1 Section A Respondent pharmacist details ……………………………….............. 28 3.2 Section B Enhanced pharmacy services paid or unpaid …………………………. 33 3.3 Section C Barriers to and facilitators of enhanced pharmacy services ………. 37 3.4 Section D Prescription-related activities ............………………………………..... 39 3.5 Section E Medication review processes ............………………………………..... 47 3.6 Section F Primary health care, pharmacy and pharmacist-only medicines ……. 51 3.7 Section G Preventive services ……………...........……………………………….... 54 3.8 Section H Harm minimisation or reduction ...........………………………………... 59 3.9 Section I Complementary therapies and herbal medicines …………………….. 63 3.10 Section J Information facilities and programs ....………………………………... 66 3.11 Section K Technologies and health communications ………………………….... 68 3.12 Section L Opinion on the use of technical facilities ………………………….... 72 3.13 Section M Pharmacy and staff …………………………....………………………. 75 4. Pharmacy characteristics, facility/service provision (Term Reference 3) …………….. 83 5. Pharmacy characteristics and barriers (Term of Reference 4) 86 5.1 Barriers to extended services .…….……..…..………………….………. 86 5.2 Facilitators of extended services ………..………………..………………… 88 5.3 Opinions on technical facilities .…………….…………………..………………… 90 6. Glossary and definitions ……………………………..……………..……………………….. 92 7. Technical notes ………………………….…………..……………..………………………… 93 8. References …………………………………………………………………………………….. 94 9. Appendices ………………………….…………..……………..……………………………… 106

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Acknowledgements We are indebted to the 1131 respondent pharmacists, the following for their investment of experience and expertise, many others for their valued contribution and our partners. National advisory panel A.Prof C Alderman Director Pharmacy, Daw Park VA Hospital, SA; delegate of SHPA Mr R Brennan Registrar Pharmaceutical Council of WA; delegate of COPRA Mr W Kelly Deputy CEO ; delegate of Pharmaceutical Society of Australia Mr T Logan Pharmacy Guild of Australia; Chairman and delegate of QCPP Dr M Ortiz Researcher, RTI Health, N Carolina, USA ; delegate of APMA Dr P Passmore Research and Community pharmacist, South Perth, WA Prof K Raymond LaTrobe University, Ballarat; delegate of CHAPANZ Dr M Tatchell Director Health Economics; delegate of Pharmacy Guild of Australia, International specialist and research pharmacists Dr S Anderson School of Tropical Health and Hygiene, London, England Mrs A Burns American Pharmacists Association, Washington DC, USA A Prof L MacKeigan Faculty of Pharmacy, University of Toronto, Canada Prof J McElnay School of Pharmacy, Queen’s University, Belfast, N Ireland Mrs G Norheim American Pharmacists Association, Washington DC,USA Dr C A Pedersen College of Pharmacy, Ohio State University, Columbus, USA Mrs K Roberts Area pharmacy specialist - drug misuse, Glasgow, Scotland Dr A Ruston Greenwich University, England A Prof J Sheridan University of Auckland, New Zealand Dr J.W.F.van Mijl Quality Institute for Pharmaceutical Care, Kampen, The Netherlands Specialist and other pharmacists in Australia Prof M Garlepp School of Pharmacy, Curtin University of Technology of W Australia Mr J Gibson Research and Practicing Pharmacist, Nedlands, W Australia Mr P Hannan Webstercare, Mortlake, NSW, Australia Mr A Lloyd Pharmacy Consultant, Melbourne Victoria Mr R Manning Chief Pharmacist, Tiwi Islands, NT, Australia Mr P Muhlheisen Turning Point Alcohol and Drug Centre, Fitzroy, Victoria Debbie Rigby Consultant Pharmacy, Pharmaceutical Society Australia (Q) Mr A Saunders Health Communication Network, Melbourne, Victoria Mr K Sclavos Chairman QCPP 2001, Pharmacy Guild of Australia (Queensland) Ms H Stark Formerly ACNielsen Consult, Sydney, Australia Mr G Stevens Webstercare, Mortlake, NSW, Australia Focus group and pilot test pharmacists Mr F Grapsas Kardinya Park Shopping Centre Pharmacy, W Australia Mr G Lowe 7 Day Pharmacy, Leeming Shopping Centre, Leeming, W Australia Mr D Manuel Amcal Pharmacy, Tuart Hill, W Australia Mr P Rees Amcal Chemist, Westfield Shopping Centre, Innaloo, W Australia Mr M Rollings Pharmacity Chemist Supermart , Perth, W Australia Mr L Souness Guardian Pharmacy, East Victoria Park (medical centre), W Australia Mrs M Bou-Samra Pharmacy Guild of Australia, Queensland Mr R Cox Terry White Chemists, Buranda, Queensland Mrs S Forrester Soul Pattinson, Palmerston, NT Ms R Guastella Mount Hospital Pharmacy, Perth Ms S Holzberger School of Pharmacy, University of Queensland Mr B Horsfall PSA, Victoria Ms A Hudson Bob Willis Chemist, NSW Ms J Kagi Boulevard Pharmacy, Mt Newman, W Australia

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Ms A Legg Riverview Pharmacy, NSW Mr K O’Connor Wishart Pharmacy, Queensland Mr B Moffatt Manley, NSW Mr S McCahon Amcal Chemist, Kalgoorlie, W Australia Mrs L Rushton Mayne Pharmacy, Blacktown, NSW Ms H Stark Seaforth Pharmacy, NSW Others who assisted exceptionally Mr G Bridge QCPP, Pharmacy Guild of Australia, Barton, ACT Australia Mr A Daniels Australian Pharmacist, Deakin, ACT, Australia Mr P Dragovic Danica Graphic Design studio, Bayswater, W Australia Mrs C D’Costa WPO-Receptionist, School of Pharmacy, Curtin University Mrs D D’Souza Administrative Co-ordinator, School of Pharmacy, Curtin University Mr M Eton Australian Journal of Pharmacy, Sydney, NSW, Australia Ms J Gilson RN National Pharmacies, Adelaide, South Australia Ms V Graham Survey Research Centre, University of Western Australia Mr B Langham Sign Multimedia, Perth, Western Australia Dr A Rossouw Survey Research Centre, University of Western Australia This project was funded by the Commonwealth Department of Health and Ageing as part of the Third Community Pharmacy Agreement. The Pharmacy Guild of Australia as managers of the Third Community Pharmacy Agreement Research and Development Grants (CPA R&D Grants) Program.

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Executive Summary Background Up to 2002 there was no database of the nature and frequency of general or specialist health-related activities performed in Australia’s community pharmacies. Without such a database accurate time-series comparisons of changes occurring in pharmacy practice could not be made. Pharmacy practice could not be compared with that in other countries. Pharmacy’s activities could not be measured against Australia’s health priorities. Those making plans or policies for undergraduate or continuing pharmacy education or training were doing so with limited data on the pattern and trends of activities in pharmacy practice. National professional bodies had little idea of the relative utility of the various drug information resources, the incursion of the internet in pharmacy or even the utilisation of the telephone in pharmacists’ day-to-day communication. These same bodies and state boards wishing to make submissions on legislative changes to government agencies or Parliamentarians had little reliable data on the duty of care activities pharmacists do but do not actually report. Negotiators in the pharmacy-government agreements were often data-poor on fundamental statistics of the settings of and areas within pharmacies, the characteristics of pharmacy owners and staff, the composition of national pharmacy sales, let alone the high prevalence of dose administration aids (DAAs) and the nil fees for DAAs or supervised dosing in pharmacies. Students or outside parties had no single reference to the range and frequency of the health-related activities involved in contemporary pharmacy practice in this country. The construction of a database of community pharmacy practice in Australia together with data from other sources may partly overcome some of these deficiencies particularly if it is updated regularly like Australia’s five-yearly national health surveys. The ‘National Pharmacy Database Project (the ‘project’) officially commenced in January 2002. The national survey of community pharmacies was conducted from 12 July to 9 September. The resulting frequency data were compiled and summarised from September to November 2002. The results were analysed from January to April 2003. The report was completed during May and June 2003. Aims The terms of reference or aims of the project were :

1. To construct a national database of the most important types and rates of pharmacy characteristics including facilities, health-related general and specialised including preventive services in Australia’s community pharmacies for Australian and overseas reference or comparisons;

2. To make comparisons between pharmacies in the different PhARIA zones; 3. To test relationships between pharmacy characteristics and facility/service provision; 4. To test relationships between pharmacy characteristics and barriers to facility/service

provision; and 5. To make national estimates of a range of pharmacy services and facilities.

Method The sample of pharmacies was adequate to meet statistically defined margins of error with prevalence rates of pharmacy services or facilities down to 1%. The PhARIA (i.e. the physical and professional remoteness of pharmacies within Australia) was used to stratify to ensure adequate numbers of rural and remote pharmacies. To overcome the skewness due to the large bulk of pharmacies in Pharia 1, a 20% random of pharmacies in Pharia 1 and a total sampling of all pharmacies in Pharias 2 to 6 was done. A questionnaire was developed with most of the 33 questions and 240 items of data requiring numerical data with which statistical estimates could be made adding a crucial quantitative value. The questions reflected a balance of the core general and special activities growing in Australia’s pharmacy practice . These were largely based on demographics trends, changes made to national health policies since 1997 often arising from results produced by pharmacy researchers, the occurring in this country and an inexorable evolution in pharmacy practice proceeding overseas and in Australia. The questionnaire was designed by a professional graphics artist and reflected the

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contemporary requirements by the pre-eminent survey methodologist, Professor Don A Dillman. The implementation of the survey closely followed Dillman’s mixed mode survey guidelines and was conducted and analysed independently by the University of Western Australia’s Survey Research Centre and its Biostatistician. A 91% participation and over 81% response rates were achieved hence non-respondent bias was minimal. A website was constructed which for the first time in Australian pharmacy research posted results for the participant pharmacies to observe whether they worked furthest north in the Tiwi Islands on the coast of the Great Australian Bight to the south-west. Results The following table summarise the key findings in the following sections A to M following and the Sections 4 and 5 which analysed statistically the strength of relationships between pharmacy variables and the activities in community pharmacies. Details may be found in the attached database.

Table 1. Key findings from the database : for Term of Reference 1,2.3 - Section Title Key Findings

A. Respondent pharmacist details.

• Respondents were mainly male with one-third aged greater than 50 years.

• Pharmacies outside Pharia 1 have fewer female, and also older and less qualified staff.

• Each respondent group reported much higher continuing professional education (CPE) hours than their counterparts in Great Britain.

B. Enhanced pharmacy services. • All 24 nominated enhanced

pharmacy services were represented to some degree in Australia’s community pharmacy.

• Enhanced services with trained staff were evident at high levels for asthma, diabetes, harm reduction, herbal medicines, hypertension, smoking cessation and wound care.

• Attention should be given to the promotion of weight reduction services as has already occurred for wound care.

Many of these enhanced services were provided with trained staff at no charge.

C. Barriers and facilitators of enhanced pharmacy services.

Greatest barriers were: • lack of time (90.3%), shortage of

pharmacists (78.3%), no extra remuneration (63.3%) and cannot find locums (63.2%).

Greatest facilitators were: • dedicated study time (77.9%)

accreditation (75.6%), closed counselling areas (72.8%) and access to patient notes (70.6%).

• The combined resistance and uncertainty were “appointment systems” and “clinical testing area.”

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D. Prescription related activities in community pharmacies.

• Dose administration aids were issued to 9.19 million patients annually.

• Supervised administration of individual doses included a range of analgesics, benzodiazepines, methadone, buprenorphine and psychotropic agents and occurred in community pharmacies for 25,904 patients each week.

• Community pharmacists declined to dispense 1.075 million prescriptions annually due to dosages, interactions, adverse effects or other problems.

• Counselling occurred in private locations in the pharmacy on 14.42 million occasions annually.

• CMI computerised formation was provided on 6.76 million occasions and other written or printed drug information to 8.61 million patients annually.

• 3.71 million patients annually required special counselling owing to poor English language.

• compliance interventions by community pharmacists were recorded on 14.42 million occasions annually.

E. Medication review process • 53.7% of community pharmacies

provided medicines to aged care facilities and 50.8% were approved for domiciliary medication management reviews.

• At least 4,600 patients received one of a range of medication reviews by community pharmacists each month.

• Most of these reviews were carried out by a contracted consultant pharmacist.

F. Primary health care including

pharmacy and pharmacist only medicines

• 78.2 million consultations occurred annually in community pharmacies regarding health and medications.

• At least 4.19 million patients annually were referred to GPs and 1.77 million to other health workers.

• Misuse of S 2 and S 3 medicines was suspected in 0.863 million patients and supply refused on 0.631 million occasions annually.

• Computerised or Self-Care printed information was provided to patients on 10.26 million occasions annually.

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G. Preventive services implemented in this pharmacy

• 82% of Australia’s community pharmacies had a dedicated vaccine refrigerator.

• Primary prevention actions initiated by community pharmacists were annually: 1.452 million nicotine treatments, 0.687 million low-dose aspirin , 0.739 million iron for anaemia, 0.576 million folic acid in pregnancy, 0.869 million calcium for osteoporosis.

• 385,288 screening tests were conducted annually in pharmacies for undiagnosed chronic conditions and 25,081 pregnancy tests were performed.

H. Harm minimisation services

and detected S4 and S8 forgeries and doctor shopping in Australia’s pharmacies

• More than 40% of pharmacies are active in each of methadone or buprenorphine dosing and needle exchange.

• 18.8% are active in benzodiazepine or other prescriber contracts.

• 13,519 clients with forged prescriptions and 23,391 patients were identified as “doctor shoppers” annually.

I. Complementary therapies

including herbal medicines • Community pharmacies refer 44,044

clients monthly to complementary practitioners

• Highest referrals were for naturopathy and homeopathy.

J. Information facilities and

programs • The following information sources

were used with a daily frequency in pharmacies in Australia: CMI Computerised 23202 CD ROMs (APP/MIMS) 20212 PSA Self Care 11867 MIMS or APP books 10709 AMH 6126 APF 4969

K. Technologies and health information and communication

• 89.2% pharmacies had a computer with a Pentium processor and 39.8% used the internet and 40.8% email regularly.

• On average each pharmacy contacted doctors 3.73 times daily, patients or their carers 1.95 times and other health workers 0.68 times daily by telephone.

L. Opinion on the use of technical facilities

• Telephone was strongly agreed to be the best mode of communicating with doctors, patients and carers.

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• There was some concern that

privacy legislation restricted telephone communication.

• There is a greater concern that internet sales will depress OTC prescriptions by 2004.

M. Pharmacy and staff • The majority of pharmacies are

located in a shopping strip and are open on average 6.18 days and 55.5 hours per week.

• 50.5% of pharmacies are members of a wide range of “groups”.

• 54.1% of pharmacies responding were QCPP accredited.

• 57.2% have one owner and 9.6% have 3 or more owners and 39.5% owners are aged over 50 years.

• The majority of proprietors work hours was spent in the dispensary.

Pharia . Pharmacies in Pharia zones 5 and 6 consistently ranked low in the provision of a range of services but these results need to be standardised for customer flow and other variables. Relationships with enhanced (specialised) pharmacy services - Term of Reference 4 Of the pharmacy variables tested the provision of enhanced and certain other services by pharmacies was consistently and significantly related to the individual characteristics of turnover, pharmacy size and group membership. But regression analysis is required to control for effect modification and confounding variables.

Relationships with barriers and facilitators of pharmacy services - Term of Reference 5 For the provision of enhanced pharmacy services Pharia zone location was significantly related individually to a number of barriers including shortage of time, shortage of pharmacists, availability of locums, remuneration and opportunity to meet local GPs. But regression analysis is required to control for effect modification and confounding variables. For the provision of enhanced pharmacy services QCPP status was significantly related individually to facilitators including access to patient notes, clinical testing area, appointment system, and accreditation for these services. . But regression analysis is required to control for effect modification and confounding variables.

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Recommendations The following recommendations refer to a section and a table in the report with related evidence. The national and state bodies of pharmacy recommended to implement the recommendations are listed in the glossary (Section 7). METHODOLOGY Recommendation 1: Australia’s community pharmacies were stratified in a national survey for the first time according to the PhARIA zones 1 to 6 (Section 1.4) . Approximately 81% of Australia’s community pharmacies are in PhARIA zone 1 which skewed the sampling process and required much larger samples than planned , much more work and higher costs than budgeted were required to overcome the difficulties (Section 1.4.1.1) . Systems other than the PhARIA system should be carefully evaluated for stratification purposes in future national surveys of community pharmacies. For example, the Socio-Economic Indexes for Areas (SEIFA) system should be compared with the PhARIA for stratification. Recommendation 2: It was found many pharmacies in the lists of registered pharmacies provided by state pharmacy authorities were invalid because they were no longer operating, were not community pharmacies, were duplicated, or had operated for a fraction of the whole year (Section 1.4.2) . During the 12 months ending 30 June 2002 it was found just 4447 approved pharmacies operated for the full 12 months (Section 1.4.7) . This total is much smaller than the total number of 4824 pharmacies in the pool from which the samples were drawn and smaller than previously reported national totals of pharmacies. This caused unnecessary difficulties for calculating the national estimates. In order to make accurate national estimates the months of operation of pharmacies in the subject year should be included in future questionnaires to accurately ascertain the number of full time equivalents of community pharmacies operating during the survey period. Recommendation 3: For a number of the questions the results were skewed requiring various statistical adjustments (Section 1.4.7) . With respect to analysis by Pharia zone the results obtained in this survey provide reference values for a range of questions. If the PhARIA system is applied to future national surveys using a similar questionnaire, then a) the two separate best estimates should first be calculated for the results of pharmacies in PhARIAS 1 and PhARIAS 2-6 so that the corresponding future questions reflect the ranges of results around the respective best estimate; and b) that separate pilot surveys of Pharia 1 and Pharias 2-6 pharmacies be conducted with questionnaires reflecting ‘regular’ ranges of estimates around the respective best estimate means in a) above. Recommendation 4: Many questions in the questionnaire contained the terms “number of clients” or “number of patients” in relation to prescription-related activities (Section 1.4.7) . These terms need to be standardised to “number of dispensing occasions” . This requires a number of key parameters. To facilitate more accurate national estimates of the activities occurring in Australia’s community pharmacies the national bodies of pharmacy should arrange to obtain from the Drug Utilisation Sub-Committee in the Department of Health and Ageing (a) the mean number of items dispensed per dispensing occasion, (b) the percentage of repeats per dispensing occasion and (c) the percentage of prescription items dispensed for institutionalised non-ambulatory patients. DATABASE RESULTS Recommendation 5: Pharmacy respondents reported they spent a minimum of 6.8 hours per month on continuing pharmacy education activities which appears to be at least twice the level reported by pharmacists in Northern Ireland and England (Section 3.1, A). It was difficult to compare continuing pharmacy education activities from statistics reported by interstate and

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overseas bodies of pharmacy. Standardising these activities would expedite more accurate time-series, interstate and international comparisons . Refer Section 3.1, Table D-A1. National and State pharmacy bodies in Australia should cooperate to standardise and report continuing pharmacy education activities by the hours per month spent in these with appropriate weighting of the activities by representative samples of pharmacists. These bodies should verify the higher levels of continuing pharmacy education activities reported by Australian pharmacy respondents compared to UK pharmacists because of the important implications for the remuneration of pharmacy services . Recommendation 6: The levels of enhanced pharmacy services reported by community pharmacies do not reflect Australia’s official priorities in health (Section 3.1, B). Refer Table D-B7-1. National and State bodies of pharmacy and university departments of pharmacy should emphasise the teaching of enhanced pharmacy services by reference to Australia’s national health priorities (Section B). Recommendation 7: The marked differences in the enhanced pharmacy services reported by community pharmacies with trained staff may reflect interstate differences in the training programs available for enhanced pharmacy services (Section 3.1, B). Refer Table D-B7-1. National and State bodies of pharmacy should cooperate to produce and adopt nationally standard pharmacy training programs for enhanced pharmacy services. Recommendation 8: There was no obvious relationship between fees charged by pharmacies for enhanced pharmacy services and the availability of trained staff for these services (Section 3.1, B). Refer Table D-B7-1. National and State bodies of pharmacy should plan the systematic evaluation of enhanced pharmacy services to determine the basis for and level of their remuneration by pharmacies with trained staff. Recommendation 9: Wound care is an outstanding example of an enhanced pharmacy service which is practiced by trained staff in a comparatively high percentage of Australia’s pharmacies and is growing at a high rate (Section 3.1, B). Refer Table D-B7-1. National and State bodies of pharmacy should assess the training programs and promotional methods used for the remarkably successful adoption of wound care services in pharmacies for their application to other enhanced pharmacy services which emphasise Australia’s national health priorities. Recommendation 10: Many enhanced pharmacy services were reported from low percentages of pharmacies in PhARIA zones 5 and 6 where many under-privileged Indigenous Australians reside (Section 3.1, B). Refer Table D-B7-1. National and State bodies of pharmacy should produce suitable intensive training programs for enhanced pharmacy services to be implemented and/or made more accessible to pharmacists working in pharmacies in PhARIA zones 5 and 6. Recommendation 11: Pharmacies reported the serious barriers to performing enhanced pharmacy services were “lack of time”, “shortage of pharmacists” and “no extra remuneration” (Section 3.1, C). Pharmacies agreed that enhanced pharmacy services were part of their work. Refer to Table D-C8. National and State bodies of pharmacy should investigate and produce intensive structured training programs for specific enhanced pharmacy services most likely to be remunerated in order to overcome the reported barriers to their adoption by pharmacies . Recommendation 12: The facilitators reported by pharmacies for performing enhanced pharmacy services were “dedicated study time”, “accreditation”, “closed counselling areas” and “access to patient notes” (Section 3.1, C). Refer Table D-C9. National bodies of pharmacy should promote remunerated, accredited programs for enhanced pharmacy services and closed counselling areas and access to clients’ clinical histories for increasing the adoption and competent performance by community pharmacies

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of enhanced pharmacy services in order to respond to those factors pharmacies reported as likely to facilitate their implementation of these services. Recommendation 13: High percentages of Australia’s community pharmacies reported the weekly provision of dose administration aids and supervised dosing without charging (Section 3.1, D). Refer to Tables D-D11A and D—D11c. National bodies of pharmacy should organise and publicise the cost-effectiveness evaluations of the provision of dose administration aids and supervised dosing by pharmacies in order to establish acceptable remuneration for these services. University departments of pharmacy should emphasise the benefits and procedures of dose administration aids and supervised dosing in the routine teaching of pharmacy practice. Recommendation 14: Approximately 40% of Australia’s pharmacies declined dispensing prescription drugs for at least one patient weekly because of inappropriate drug, dose or suspected interaction or contraindication, or for prescription defects (Section 3.1, D). Another 30.7% of pharmacies declined dispensing prescription drugs for at least one patient weekly for suspected adverse drug effects. Overall, 1.25% of patients dispensed 216 million prescription items yearly were reported to have had their prescribed medications declined for the above reasons. Refer to Table D-D12. The reported rates of pharmacies intervening in the dispensing of prescribed medicines should be verified by direct observation in a representative sample of pharmacies and submitted to pertinent agencies by national bodies of pharmacy because they provide strong evidence for the vigilance by pharmacies in preventing the inappropriate prescribing and adverse effects of prescription medicines and detecting legally defective prescriptions. Recommendation 15: Community pharmacies reported counselling in the past 12 months a minimum of 3.17 million patients with low or poor English speaking ability about their prescription medicines (Section 3.1, D). Refer to Table D-D13a. National bodies of pharmacy should verify the extent and evaluate the provision of counselling to patients with poor English speaking ability for prescription-related activities so that community pharmacies are adequately remunerated for providing this service. Recommendation 16: Low percentages of Australia’s community pharmacies reported the use of clinical testing and the application of laboratory results to the assessment of the effects of prescribed drugs in patients (Section 3.1, D). Refer to Table D-D13c. National bodies of pharmacy should investigate and produce software programs for interpreting laboratory results in routine pharmacy practice to enhance the evaluation of effects of prescribed medications . Recommendation 17: Relatively low percentages of community pharmacies reported performing primary care multidisciplinary care plans, case conferences or case health assessments compared to the percentage performing home medicine reviews (HMRs) or medication management reviews in residential age care facilities (Section 3.1, E). Refer Table D-E14d. National bodies of pharmacy should consider programs for enhancing the ability of accredited pharmacists to participate in primary care medication review processes to enhance their wider adoption by community pharmacies. Recommendation 18: Pharmacies reported that the rate of self-medication activities for the management of minor ailments for clients was less than the provision of primary health care activities including issuing over the counter medications, verbal and printed information and referral to GPs and other health workers (Section 3.1, F). This ratio of self-medication to primary care activities appears to be less than found in pharmacies in other developed countries. This has strong implications for the control of pharmacist-only and pharmacy medicines and the education and training of student and graduate pharmacists and pharmacy staff. Refer Table D-F15a. National bodies of pharmacy need to verify by direct observation the ratio of self-medication and primary health care activities occurring in a representative sample of community

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pharmacies in order to compare with results from pharmacies in other countries and to make time-series comparisons in Australia . Recommendation 19: Pharmacies reported estimated yearly totals of 36.97 million self-medication and 41.23 million primary health care activities (Section 3.1, F). These statistics far exceeded those reported for pharmacies by the 2001 National Health Survey .These services do not currently attract remuneration for pharmacies. Refer to Table D-F15a. National bodies of pharmacy need to verify the statistics and organise cost-effectiveness evaluations of self-medication and primary health care activities in Australia’s pharmacies in order to accurately represent the magnitude of the national contribution to health care by pharmacies , the potential costs savings to Australia’s health system and the possible remuneration of community pharmacy services . Recommendation 20: Pharmacies reported an estimated 4.19 million clients yearly with ailments were referred to GPs compared with 1.77 million referred to other health workers (Section 3.1, F). Refer to Table D-F15a. National bodies of pharmacy should verify the high rates of referrals of clients with health ailments by pharmacies to general practitioners and organise the evaluation of referral forms in pharmacies in order to quantify and lay the basis for remunerating referrals by pharmacies. Recommendation 21: Pharmacies reported an estimated 10.26 million clients yearly with health ailments were provided with printed information (Section 3.1, F). Printed information is a widespread form of conveying health information and needs to be evaluated singly and in combination with other methods in order to quantify their impact on specific health outcomes. Refer to Table D-F15a. National bodies of pharmacy should plan the cost-effectiveness evaluation of printed information provided in pharmacies for clients with health ailments. Recommendation 22: Pharmacies reported an estimated total of 0.86 million clients yearly were suspected of misuse of dependence-producing over-the-counter medicines of whom 0.63 million were refused supply of these medicines (Section F). Refer to Table D-F15b. The high rates of intervening in the supply of over-the-counter reported by pharmacies should be verified and submitted to pertinent agencies by national bodies of pharmacy because they provide strong evidence for the vigilance by pharmacies in preventing the misuse of over-the-counter medicines. Recommendation 23: 82% of Australia’s pharmacies reported having vaccine refrigerators which comply with pharmacy standards (Section 3.1, G). Refer to Table D-G16. National bodies of pharmacy should ascertain the standards of vaccine refrigerators used in pharmacies nationwide for their compliance with recognised standards. Recommendation 24: Pharmacies reported that they initiated non-prescribed medicines for preventive purposes in more than 5.8 million undiagnosed clients over 12 months (Section 3.1, G). Refer to Table D-G17. National bodies of pharmacy should obtain further statistics on and plan a cost-effectiveness evaluation of pharmacies in providing non-medically prescribed medicines for preventative purposes. Recommendation 25: Clinical testing for screening undiagnosed patients were reported to occur in pharmacies which engaged nurses at rates of 2- to 20-fold those of pharmacies which did not engage nurses (Section 3.1, G). Refer to Table D-G19. National bodies of pharmacy should identify those pharmacies which engage nurses to provide screening activities to undiagnosed patients and organise economic evaluations of these in order to compare the performance of these activities with those pharmacies which do not engage nurses. Recommendation 26: Up to 60% of Australia’s pharmacies reported providing harm reduction activities daily including methadone or buprernorphine dosing, needle supply and issuing benzodiazepines and other drugs according to patient contracts with prescribers (Section 3.1,

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H). Australia’s pharmacies rank high internationally in the provision of these services and studies have found these services are widespread, less costly and more or equally effective compared with other providers. Refer to Table D-H19a. National bodies of pharmacy should examine the systematic and appropriate remuneration of pharmacies active in supervised dosing, prescriber contracts and other harm reduction services. Recommendation 27: Pharmacies reported detecting a minimum estimated 13,519 patients with forged prescriptions and 23,391 ‘doctor shoppers’ in the previous 12 months (Section 3.1, H). These appear to be the highest rates of detecting forgery and ‘doctor shoppers’ of prescribed opioids and psychostimulants ever reported by pharmacies. Refer to Table D-H19b. National bodies of pharmacy should verify the above rates of detection of fraudulent prescriptions for Schedule 8 drugs as they suggest high vigilance in pharmacies in dispensing these agents or/and very high rates of Schedule 8 prescription fraud in Australia. Recommendation 28: Australia has very high rates of the consumption of prescribed opioids and psychostimulants compared with other developed countries. Reports of illegal or deceptive procuration, diversion and misuse of these agents imply existing legislation is defective in allowing pharmacists prevent these malpractices (Section 3.1, H) . Limiting the source of these agents to a single medical and pharmacy provider and facilitating the online access by pharmacies to the medication histories of these patients before dispensing are the most effective actions for pharmacists to stem the misuse of prescribed Schedule 8 agents. National and State bodies of pharmacy should immediately press for legislation requiring patients prescribed Schedule 8 drugs to be limited to one medical and one pharmacy provider of these agents and permit medication histories to be accessed online and discussed by these providers prior to dispensing of these drugs. Recommendation 29: Pharmacies reported they referred more than 40,000 clients per 30 days to complementary therapists (Section 3.1, I). Refer to Table D-I20. The Pharmaceutical Society of Australia should include guidelines in the Australian Pharmaceutical Formulary and Handbook for the referral of clients to complementary therapists. Recommendation 30: Pharmacies reported that they referred approximately 15,000 clients per 30 days to aromatherapy, homeopathy and iridology practitioners (Section 3.1, I). Refer to Table D-I20. Pharmacy Boards in each jurisdiction, the Council of Pharmacy Registering Authorities, the Pharmaceutical Society of Australia and University departments of pharmacy should identify and where necessary act decisively on the referral of clients to questionable complementary practitioners. Recommendation 31: High percentages of Australia’s pharmacies reported the daily use of a wide variety of information, facilities and resources for patient care (Section 3.1, J). Refer to Table D-J21. National bodies of pharmacy should formulate standard methods for comparing the frequency of use and the cost-effectiveness of outcomes of information resources in pharmacies applied routinely in practice to patient care. Recommendation 32: Just 7.8% of Australia’s pharmacies reported daily or higher use of web-based drug information facilities (Section 3.1, J). Refer to Table D-J21. The Pharmaceutical Society of Australia and University departments of pharmacy should review their teaching and training programs for pharmacy students and practitioners to ensure the convey the superior benefits of web-based facilities compared with other forms of drug information facilities in patient care. Recommendation 33: 89.2% of Australia’s pharmacies reported Pentium processors but just 4.2% reported having broadband facilities in their dispensary computers (Section 3.1, K). The technological requirements for dispensary computers are changing rapidly in relation to

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pharmacies participating in the MediConnect system planned to be introduced in 2005. Refer to Table D-K22a National bodies of pharmacy should ensure the results of ongoing MediConnect trials in pharmacies are appropriately promoted so pharmacies can rationally plan to install the correct computer facilities and enhancements in readiness for participating in the MediConnect system. Recommendation 34: More than 10% of pharmacies reported they had web sites which offered medication-related activities (Section 3.1, K). Refer to Table D-K22b. The Pharmaceutical Society of Australia and pertinent bodies of pharmacy should organise an evaluation of existing pharmacy websites against the Australian Pharmaceutical Formulary and Handbook and other appropriate standards . Recommendation 35: 34.3% and 24.4% of pharmacies reported they expected respectively internet sales of over-the-counter and prescription medicines would depress their sales of these medicines by 2004 Joint actions have been taken in 2003 by national bodies of pharmacy in the USA and Canada on the basis of safeguarding consumers from preventable adverse effects of drugs obtained through the internet(Section 3.1, L). Refer to Table D-L24. National bodies of pharmacy should review actions taken in North America to curtail the internet sale of prescription medicines by pharmacies and other sources. Recommendation 36: 93.1% and 75.7% of pharmacies agree respectively the telephone is the best form of technology for liaising with doctors and patients about health care (Section 3.1, L). Telephone counselling has proven for two decades to be the most cost-efficient technology in improving the care of patients with chronic disorders. Refer to Table D-L24. National bodies of pharmacy should plan controlled studies of telephone counselling by community pharmacies in for example patients discharged with treated mental disorders who are known to have high rates of relapse and readmission into hospitals. Recommendation 37: The most common settings of pharmacies were city, suburban or town shopping strips (41.4%) , followed isolated shops (23.5%) and 18.7% in neighbourhood, 6.3% in medical and 4.8% in regional shopping centres (Section 3.1, M). The locations and hours of opening of pharmacies are important for assessing changing patterns in the location of pharmacies and accessibility to pharmacy services by consumers but it is difficult to ascertain these factors because of the lack of standard definitions and the lack of information on the hours of opening and pharmacy settings. Refer to Tables D-M25b and D-M25c. The Pharmacy Guild of Australia and other national bodies of pharmacy should agree on standard definitions for the locations of pharmacies and appropriate methods of weighting access to these locations by the public . Recommendation 38: The retail, storeroom and dispensary section were the largest in area and enclosed counselling and forward pharmacy sections the smallest (Section 3.1,M) . These data are the first known national data on the internal arrangement of pharmacies and have important ramifications on the performance of certain services ( Sections 3.1 C, F and H). Refer to Table D-M26. The Pharmacy Guild of Australia and other national bodies of pharmacy should agree on standard definitions for the analysis of sections in pharmacies and perform surveys of representative samples of pharmacies in order to monitor the trends in the internal structures of pharmacies. Recommendation 39: Owners and managers reported they spent up to 30.9 of their 41.7 hours per week in dispensaries and 21% of Australia’s pharmacies reported having non-pharmacist retail managers (Sections 3.1,M) . These are important indicators of the involvement by pharmacists in patient care activities. Refer Tables D-M29b, D-M32a and D-M32b) The Pharmacy Guild of Australia and other national bodies of pharmacy should agree on standard definitions for the analysis of staff in pharmacies and perform surveys of representative samples of pharmacies in order to monitor the trends in the internal structures of pharmacy staff.

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RELATIONSHIPS OF PHARMACY CHARACTERISTICS AND PHARMACY SERVICES (Terms of reference 4 and 5) Recommendation 40: The national survey of British pharmacies found statistically significant relationships between pharmacists rather than pharmacies and the performance of specialist or extended pharmacy services whereas these Australian results pointed more to certain pharmacy characteristics significantly related to the performance of enhanced and other specialist services in pharmacies (Section 4 ). These results have strong implications for national policies on the development of professional services in pharmacies but they require hypothesis testing with the application of logistic regression analyses to define these relationships. Refer to Table D4.1. The Pharmacy Guild of Australia and other national bodies of pharmacy should commision further multivariate analysis ( ie regression analysis) to ascertain the relationship between pharmacy factors including area, group membership and the implementation of enhanced pharmacy and other specialist services on a national basis. Recommendation 41 : Statistically significant relationships were found between certain pharmacy characteristics and barriers and facilitators to taking on enhanced pharmacy services which is the first time such relationships have been analysed and reported (Sections 5.1 and 5.2) . But the statistical analyses were limited to t-test and chi-squared tests . Refer to Tables D5.1 and D5.2. The Pharmacy Guild of Australia and other national bodies of pharmacy should engage further multivatiate analysis (ie. regression analysis) to ascertain associations between pharmacist variables and barriers to the provision of enhanced pharmacy services. Recommendation 42 : Statistically significant relationships were found between pharmacy characteristics inferring statistically strong relationships between larger, busier pharmacies and the use communication technologies (Section 5.3) . But the statistical analyses were limited to t-test and chi-squared tests . Refer to Table D5.3. The Pharmacy Guild of Australia and other national bodies of pharmacy should engage further logistic regression analysis be conducted to continue the statistical analysis to define the pharmacy variables such as Pharia zone, related to the use or impact of technologies on the performance of specified patient care activities and the impact on the sales of prescribed and over-the counter medicines. Recommendation 43 : The effect of the location of pharmacies in certain PhARIA zones especially remote rural pharmacies in PhARIA zones 5 and 6 were referred to in Sections 3 A to M and tested statistically (Sections 4 and 5). But the statistical analyses were limited to t-test and chi-squared tests . Refer to Tables 5.1, 5.2 and 5.3. The national bodies of pharmacy should commission further statistical analysis in order to standardise the data for pharmacies in the rural and remote Pharia zones and extend the statistical analyses to test relationships between Pharia location and services provided.

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Contact details Con Berbatis Lecturer School of Pharmacy Curtin University of Technology GPO Box U1987 Perth Western Australia 6845 Email: berbatis@git.com.au Ph: +61 8 9271 7180

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1 Introduction The following sections serve as the background to the National Pharmacy Database Project (the project) which commenced officially in January 2002 and concluded in June2003. 1. 1 Terms of reference The terms of reference and aims of the ‘National Pharmacy Database Project (the ‘project’) were:

1. To construct a national database of the most important types and rates of pharmacy characteristics including facilities, health-related general and specialised including preventive services in Australia’s community pharmacies for Australian and overseas reference or comparisons;

2. To make comparisons between pharmacies in the different PhARIA zones; 3. To test relationships between pharmacy characteristics and facility/service provision; 4. To test relationships between pharmacy characteristics and barriers to facility/service

provision; and 5. To make national estimates of a range of pharmacy services and facilities.

The project officially commenced in January 2002 and the national survey of community pharmacies was conducted from 12 July to 9 September. The resulting frequency data were compiled and summarised from September to November 2002. The results were analysed from January to April 2003. The report was completed during May and June 2003. The terms of reference are fulfilled in this report as follows. Term 1: Full copies of the database for the project are enclosed in disk and printed forms and summarised in Section 2. Terms 2 and 5 are included in each of the discussions in Section 3. Terms 3 and 4 are included in Section 4. 1. 2 Origins of the National Pharmacy Database Project Since 1970, pharmacy departments in Australia’s teaching hospitals have led pharmacy practice in this country but community pharmacy is now moving quickly to redress the imbalance. There is however, a paucity of data on the prevalence, incidence, frequency, and distribution of established and new services in community pharmacy practice. These data are needed by our administrators and educators in revising existing programs and devising new policies. In 2001, a project entitled ‘A reference database of Australia’s community pharmacies: analysis of national survey’ was funded under the Third Community Pharmacy Agreement Research and Development Grants Program. The study commenced in January 2002 and was finalised in June 20031. The design of this national survey was guided by Australia’s legal requirements2,3, guidelines and references for the design and implementation of surveys4-8, and the findings of previous studies9-18. This project operated under necessary approvals from the Commonwealth Government Statistical Clearing House2, the Pharmacy Guild of Australia, Curtin University Human Research and Ethics Committee and was overseen by a national panel consisting of delegates of national bodies and experienced researchers. A national survey of a 15% sample of community pharmacies was conducted in stratified groups (zones 1 to 6 of PhARIA 2001)19. Both random sampling and stratification reduce bias20-22. Stratification is a sampling tool that divides a large population such as Australia’s nearly 5000 community pharmacies into specified groups. This allows more accurate estimates of the prevalence and distribution of variables such as pharmacy services, hence facilitating comparison of services between zones. This is crucial for policy makers in the allocation of services and for administrators who are planning education or training programs. A sample is required because of limited funding and time. A 15% sample, or approximately 750 pharmacies, was statistically calculated to meet defined margins of error with prevalence rates of pharmacy services or facilities down to 1%, a 75% response rate, and confidence interval of 95% for pharmacy services23. To achieve a high response rate (i.e. at least 75%) a series of survey techniques were used 4,

24-28. These comprised (1) wide publicity in pharmacy newsletters and journals to create respondent awareness and engender study participation, (2) a prioritised letter from the

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university investigators introducing the study and requesting participation from the sample of pharmacies, (3) the construction of a national survey website to reinforce awareness, to clarify difficulties encountered in responding to the questionnaire and to provide feedback of results, (4) telephone contact to ensure the introductory letter had been received, obtain consent for the pharmacy to participate and to identify the pharmacist who would be responding on behalf of the pharmacy, (5) three consecutive mailings of the questionnaires at regular intervals starting on the 14 July (one initial and two follow up to non-respondents) and (6) follow-up reminder calls / faxes. The response rate was further enhanced by (7) the careful construction and design of the questionnaire according to set guidelines and (8) by offering incentives (i.e. accreditation points and a cash payment) 2,41 . 1.3 Review of pharmacy surveys overseas and in Australia The design and conduct of the survey was guided by Australian legal requirements2,3, guidelines and references for the design and implementation of surveys41 -8 and the finding of previous studies 9-18. These studies are outlined below.

The Netherlands In 1998 the Board of Pharmaceutical Practice of the International Pharmaceutical Federation (FIP) sponsored a series of systematic national surveys of pharmacy practice conducted by the Quality Institute for Pharmaceutical Care in Kempen, the Netherlands 9, 23. Using a social pharmacy approach, whereby the prevalence of activities performed by community-based pharmacy practices was surveyed, this group developed the Pharm Value model with a questionnaire for community pharmacies and another for the coordinating research centre 9,23. These questionnaires were used in a survey of community pharmacies in Northern Ireland. The PharmValue questionnaires and results were assessed for their application in this study and were found to be unsuitable as their content was not pertinent to the Australian context.

United Kingdom In 1996 the Royal Pharmaceutical Society of Great Britain produced a national database. Results were collated from responses to a 67-question survey, and were completed by 7% of British community pharmacies10. The interpretation of the results was compromised by the small sample and low response rate 23. In 2001, a national data set was produced by a consortium of national pharmacy bodies, which was led by the Royal Pharmaceutical Society of Great Britain11. The survey focused on pharmacy services and pharmacy related characteristics. Overall, four mailings of the survey were conducted and achieved a response rate of 58% 11. The investigators found statistically significant relationships between certain services and community pharmacy characteristics. The methodology and questionnaire were relevant and applied to our Australian study.

United States of America From 1992 to 1994, the Scope of Practice Project was conducted by national pharmacy bodies and coordinated by the American Pharmaceutical Association 12,23. This survey was conducted in community, hospital and mixed practice sites and achieved a response rate of 28% of licensed pharmacists and 29% of pharmacy technicians. Demographic data, responses relating to practice performance and activities in need of development/ enhancement were compared with the results of a national study completed in 1978. The analysis showed pharmacists spent more time on patient pharmaceutical care and less on medication purchasing and control; whereas technicians’ time was mainly confined to dispensary related activities. A revised classification resulted, with expanded and more defined pharmacy activities. This was made more relevant to educational requirements and subsequent surveys 11,29,30. In 1998, the American Society of Health-System Pharmacists began national surveys of hospital pharmacy practice13. The methodology, implementation and response rates reported in these national surveys support the sampling, selection and survey modes that were applied

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in our Australian survey23. The questionnaire was relevant and utilised in developing the Australian project.

Malta In 1997, 184 community pharmacies were surveyed (n.b. response rate and other details were omitted). Data was obtained on the range and rate of health-related activities performed within the pharmacy, the time spent on each activity, and pharmacy staff and premises 14. The design of this study was a resource used in designing the survey instrument used in our Australia survey, but the questionnaire was of limited value.

Australia A review of national and jurisdictional surveys of community pharmacies conducted in Australia since 1970, by government agencies, national and state pharmacy bodies and university researchers summarised the activities of community pharmacists in prescription-related, primary health care, health promotion, and other services 31. The methodologies were examined and applied to pertinent parts of the Australian survey. In 1992, community pharmacies within Western Australia were surveyed, using a structured questionnaire to document the scope and nature of pharmaceutical services provided for the elderly. This study achieved a response rate of 42% 15. Investigators found high levels of first-aid assistance, health information provision and incontinence counselling, but low levels of monitoring (e.g. blood glucose levels) and advice (e.g. therapeutic drug levels or blood cholesterol levels). Few respondent pharmacists reported having evaluated the effectiveness (9%) or the efficiency (4%) of services provided 15, 23. The results of this study provided insight into the range of activities performed, but the low response rate limits generalising them. The Pharmacy Guild of Australia’s 1999-2000 annual financial survey was based on a sample of 353 Guild member pharmacies. It comprised a small random sample of 193 plus 160 ‘consecutive year respondents’ 16. The findings from this study emphasised the benefit of stratification but generalising the results needs to be validated and hence the need to use consistent sampling methodology23. In Australia other studies , of the demand and supply of pharmacists and the pharmacy labour force 17,18, achieved high response rates demonstrating the importance of survey timing and the involvement of pharmacy boards . 1.4 Methodology From January to June 2002 ethics and other approvals were obtained, the national pool of registered community pharmacies compiled, stratified samples selected, participating pharmacies resolved and the questionnaire prepared, tested and professionally produced and printed . These activities occurred in consultation with many researchers and pharmacists and approved by the national panel for the project (refer Acknowledgements). 1.4.1 Sample and stratification with PhARIA system Calculations of sample size were based on the confidence interval for a binomial parameter4. A 15% sample, or approximately 750 pharmacies (refer to table A) was calculated to meet statistically defined margins of error with prevalence rates of pharmacy services down to 1%, a 75% response rate and confidence interval of 95% for pharmacy services 23. The Pharmacy Guild, State and Territory Boards of Pharmacy and Health Departments in each state provided the pool of registered pharmacies in each of Australia’s jurisdictions. In order to minimise sampling bias arising from location and to ensure including the relatively low percentages of remote and rural pharmacies stratification 22,32 was needed . The PhARIA (i.e. the physical and professional remoteness of pharmacies within Australia) system was selected 19. This system was produced by the Health Insurance Commission (HIC) with a university group in 2000. It was based on the ARIA system for stratifying medical practices principally based on a remoteness index or distance from other medical practices 23. PhARIA was utilised for determining additional remuneration of rural and remote pharmacies. It had

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not been used for stratification before this project. On the basis of PhARIA classification the pharmacies were stratified into one of six groups by a statistician, these being:

PhARIA 1: Highly accessible PhARIA 2: Accessible (group 1) PhARIA 3: Accessible (group 2) PhARIA 4: Moderately accessible PhARIA 5: Remote PhARIA 6: Very remote

Due to 81% of the total of community pharmacies (Table 1.1) being in PhARIA 1, a random sample of 20% of the total PhARIA 1 sample was drawn and used in this study. Due to the small number of pharmacies in PhARIA 2 to 6 the entire original sample was used. Furthermore, because of the very small number of pharmacies in PhARIA 5 and 6 this group was merged to form one “remote” group. Overall, this gave a total of 1641 possible participants (Table 1.1).

Table 1.1 Sample by PhARIA Minimum response required Original sample PhARIA Pharmacy

numbers* Freq % Freq % 1 3927 340 45.3 744 45.3 2 321 147 19.6 321 19.6 3 313 143 19.1 313 19.1 4 123 56 7.5 123 7.5

5 and 6 140 64 8.5 140 8.5 Total 4824 750 100 1641 100 * Actual pharmacy numbers at time of survey that could be matched to a PhARIA.

1.4.1.1 Difficulties with PhARIA system for stratification Difficulties arose due to the large numbers of pharmacies in PhARIA 1 as compared to PhARIA 2 to 6. The skewness resulted in the need for a random sample of just PhARIA 1, and a census sample and survey of all pharmacies in PhARIA 2 to 6 (i.e. all pharmacies were surveyed). This resulted in project costs being higher than anticipated. During sample preparation it was also found that a number of pharmacies (n=50), did not have a matching PhARIA for their postcode. These pharmacies were omitted. This resulted in a reduction in the pool of pharmacies and possibly some selection bias. Other standard stratification systems based on electoral divisions (which have similar population numbers), socio-economic features (SEIFA) or other factors need to be considered 34,35,36. The process of selecting an alternative system should consider characteristics of the alternative systems and the result of stratification in relation to numbers of pharmacies in each stratified sample to ensure skewness is minimised, the purposes of the survey, previous applications of and reports of experiences with the system and assess the suitability of the system to the samples and identifiers of the pharmacies chosen (e.g. matching postcodes). 1.4.2 Participation rate The participation rate refers to the number of pharmacies which were eligible and consented to participate in the study as a proportion of the total valid sample. Of the original sample of 1641 possible pharmacies, 1391 agreed to participate in this study, 141 refused, 42 were not contactable and 67 were screened out as the phone number no longer belonged to a pharmacy or was a duplicate number. The participation rate of pharmacies was therefore 90.8% or 1391 / [1641-42-67] (Figure 1.1 and Table 1.2). Some bias on the basis of refusal to participate may have occurred as when the non-participants who provided information and respondents were compared significant differences were found according to pharmacy description (PhARIA 1 and 2-6), staff numbers (PhARIA 2-6 only), ownership (PhARIA 1 only) and setting (PhARIA 1 and 2-6). Due to the very high participation rate however the bias is small.

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1.4.3 Response rate Response rate refers to the number of pharmacies which returned their questionnaire as a proportion of those which consented to participate in the study. In total, questionnaires were mailed to 1391 participant pharmacies, of which 1131 were completed and returned (Figure 1.1). Data from questionnaires received after 9 September 2002 were not included in the study. The overall response rate for this study is therefore 81.3% (i.e. 1131/1391). Response rates by PhARIA are detailed (Table 1.2). Some bias on the basis of refusal to respond may have occurred as when the non-respondents which provided information and respondents were compared significant differences were found according to pharmacy description (PhARIA 1 and 2-6), and setting (PhARIA 1 only). Due to the very high response rate the effect of this bias is however small.

Figure 1.1 Overall participation and response

Original Sample

(n=1641 pharmacies)

Participant Pharmacies (n=1391)

Non-participants & Invalid sample

141 refused to participate 42 not contactable 67 duplicate number or no longer a pharmacy

Respondent Pharmacies Non-respondent Pharmacies

(n=1131) (n=260)

PhARIA 1: n=482 PhARIA 2: n=240 PhARIA 3: n=226 PhARIA 4: n=91 PhARIA 5&6: n=92

Table 1.2. Participant rate and response rate by PhARIA

Participants Response

PhARIA Freq % Freq % 1 611 43.9 482 42.6 2 278 20.0 240 21.2 3 276 19.8 226 20.0 4 110 7.9 91 8.0

5 and 6 116 8.3 92 8.1 Total 1391 100 1131 100

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1.4.4 Questionnaire The questionnaire consisted of 10 pages, 13 sections and 33 questions which were divided into 231 sub-questions ( Table 1.3). Authoritative guidelines and reported international surveys were reviewed in developing the questionnaire ( Sections 1.2 and 1.3). Due attention was given to the inclusion of questions relating to Australia’s health priorities and quality use of medicines. The survey instrument was constructed in consultation with a wide range of specialist pharmacists , professionally designed by a graphics consultant, tested, approved by the national panel and independent ethics and national committees and printed by a professional printer in the period from February to July 2002. Specifically, from May to July 2002 the questions (wording and code frames) were examined and tested by academic, administrative, specialist and practicing pharmacists throughout the country (across PhARIA zones 1 to 6). A focus group of pharmacists was conducted to gain practical feedback on the questionnaire. On the basis of their comments various changes were made to the wording of questions. The national panel also commented on the questionnaire and methodology. A website was developed to enhance participation and provide feedback.

Table 1.3 Sections comprising the national pharmacy questionnaire 2002

Section Question % Questionnaire

A Respondent pharmacist details 1 to 6 10 B Enhanced pharmacy services paid or unpaid 7 6 C Barriers to and facilitators of enhanced pharmacy services 8 and 9 6 D Prescription related activities in this pharmacy 10a to 13c 18 E Medication review processes 14a to 14f 10 F Primary health care including pharmacy (S2) and

pharmacist only (S3) medicines 15a and 15b 4

G Preventive services implemented in this pharmacy 16 to 18 6 H Harm minimisation or harm reduction activities 19a and 19b 4 I Complementary therapies including herbal medicines 20 3 J Information facilities and programs 21 3 K Technologies and health communications 22a to 23 6 L Opinion on the use of technical facilities 24 4 M Pharmacy and staff 25a to 33b 20

Items within the questionnaire were derived from a number of different sources such as a) overseas, national and regional questionnaires, b) contributions from specialist pharmacists or pharmacy consultants throughout Australia, c) a review of a range of contemporary Australian and overseas literature, d) observations in a range of pharmacies and e) advice and contributions from specialists in the field of epidemiology and survey research methods 2-

18. On average the survey took approximately 1hour to complete (i.e. time spent reading the instructions, answering questions and obtaining information). 1.4.5 Implementation and administration of survey From March to June 2002 articles were published in the major national pharmacy journals and circulated through newsletters produced by the Pharmacy Guild of Australia to all pharmacies to create a national awareness of the project and the need for cooperation and a high response rate. In June 2002 the School of Pharmacy sent an individualised letter to the 1641 pharmacies explaining the survey , requesting that one owner or manager pharmacist be selected to be the respondent for the pharmacy and introducing the Survey Research Centre (SRC) in the School of Population Health, University of Western Australia which would implement the survey. Soon after these pharmacies were telephoned by trained SRC interviewers and asked to participate in this study, of which 1391 agreed (Figure 1.1) . The pharmacies which agreed to participate in the study were asked to provide the name and contact information of a pharmacist respondent.

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The 1391 pharmacies were first mailed the questionnaire on the 12th July 2002, with two subsequent mail outs at approximately 20 day intervals to non-respondents in July and August to increase response rates. This was followed by a “follow-up” phone call to the remaining non-respondents in early September. The cut off date for questionnaires to be returned was the 9th of September. Questionnaires that were completed and returned by respondent pharmacies, were data entered into a Computer Assisted Data Entry (CADE) system by trained clerks. The data entered into the CADE system was validated using double entry verification. Data entry error levels were found to be within acceptable levels (i.e. <0.005). The effects of non-differential information bias would therefore be minimal. 1.4.6 Analysis Data were extracted from the CADE system and exported to SPSS (Version 11) for analysis. An experienced biostatistician advised on statistical methods, questionnaire results and analysis. Frequencies and percentage of response were generated for each question, followed by cross tabulations by PhARIA where relevant (refer to the technical notes for formula). If responses were continuous and numerical (e.g. q11d), descriptive statistics were generated (i.e. mean, standard deviation, median, minimum and maximum scores) 21,36. Where responses related to grouped variables (e.g. q19a), descriptive estimates were calculated (i.e. estimate mean, standard deviation, standard error, upper and lower confidence interval) 36,37.

Relationships between pharmacy characteristics (i.e. PhARIA, state, setting-q25b, days open- q25c, total area of premises- q26, group membership-q27, QCPP status-q28, existence of a retail manager-q29b, number of owners-q30a, total number of customers per week-q31 and turnover-q33a) and service provision (q7, q11c, q12, q13a, q13b, q13c, q14d, q17, q18, q19a, q19b, q20, q23) were then tested. Service variables were first combined (within questions) and an overall binary service variable created (e.g. “No service provided” vs. “1 or more services provided”). If “characteristic” questions were categorical (i.e. PhARIA, state, setting, group membership, QCPP status, existence of a retail manager, number of owners, total number of customers per week and turnover), subsections were combined to create new pharmacy characteristic variables. Characteristic questions were combined on the basis of respondent numbers, study results and experimenter knowledge of pharmacy characteristic trends within Australia. This resulted in the following 11 pharmacy characteristic variables: PhARIA (“PhARIA 1” vs. “PhARIA 2-6”); State (“ACT & NSW”, “NT & WA”, “QLD”, “SA”, “TAS” and “VIC”); setting (“urban retail” vs. “other”); group membership (“not in a banner group” vs. “in a banner group”); QCPP status (“QCPP accredited” vs. “not QCPP accredited”); retail manager (“yes” vs. “no”); number of owners (“1 owner” vs. “2 or more”); customers per week (“0 to 1400” vs. “1401 to 5001+”) and turnover (“<$1M to $2M” vs. “$2M to >$8M”). To test if significant relationships existed between individual pharmacy characteristics and provision of service, separate Pearson chi-square tests were conducted (n.b. where expected cases were less then five, Fisher’s exact test was calculated). If questions on ‘characteristics of pharmacies ‘ were numeric (i.e. days open, total area of premises) then significance testing was conducted using t-tests 21. To test relationships between pharmacy characteristics (i.e. PhARIA, state, setting-q25b, days open- q25c, total area of premises- q26, group membership-q27, QCPP status-q28, existence of a retail manager-q29b, number of owners-q30a, total number of customers per week-q31 and turnover-q33a) and barriers to provision of service (q8, q9 and q24) binary agreement variables (within sub-questions) were created (i.e. “strongly disagree, disagree and neutral” vs. “agree and strongly agree”). Characteristic variables were created as described above. To test if significant relationships existed between individual pharmacy characteristics and barriers to provision of service, separate Pearson chi-square tests were conducted (n.b. where expected cases were less then five, Fisher’s exact test was calculated). If characteristic questions were numeric (i.e. days open, total area of premises) then significance testing was conducted using t-tests 21.

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1.4.7 National estimates As stated above, frequencies and percentage of response were generated for each question. If responses were continuous and numerical, descriptive statistics were generated (i.e. mean, standard deviation, median, minimum and maximum scores) 21,36. Where responses related to grouped variables or ranges (i.e. 11 to 50 per month), descriptive estimates were calculated (i.e. estimate mean, standard deviation, standard error, upper and lower confidence interval) 36,37. Descriptive estimates were calculated (refer to the Technical Notes for formula) for relevant questions using the midpoint for the range (except in the case of the last range in which the lowest score was used). It should be noted that this method of calculation may have resulted in over estimation of the true figure, especially for questions with ranges of unequal and increasing size. The Lower Confidence Interval (LCI) for the mean was therefore used consistently to correct for overestimation as discussed above. In some cases it was evident the LCI inadequately adjusted for this source of overestimation. The numbers of frequency data in the ranges on either side of the range in which the midpoint fell, were calculated in certain cases to moderate these data in order to calculate alternative best estimates and corresponding confidence intervals . The terms ‘number of clients’ or ‘number of patients’ included in Questions 10b, 11a, 11c, 12,13a, 13b, 13c, 19a, 19b and 21 relate to prescriptions dispensed. The results need to be carefully reviewed because each client or patient actually refers to a dispensing occasion in community pharmacies and not just a prescription item dispensed. A dispensing occasion refers to each case of prescriptions presented in a pharmacy for one patient. There are no published statistics in Australia of the number of dispensing occasions and little data on parameters for calculating this figure. These deficiencies need to be remedied by Australia’s bodies of pharmacy because they affect many areas of decision making. For the purpose of assessing the results in relation to dispensing occasions for the above questions this report adopted the following parameters : a) the adopted mean for prescription items dispensed per occasion was 2.5 and b) the adopted number of items dispensed for patients domiciled, in aged care facilities and in other situations inhibiting direct pharmacist communication was 15 million. If just original prescriptions are considered c) the adopted percentage for repeat prescriptions to subtract was 65%. Appropriate other parameters need to be considered for the results for questions 15a, 15b, 17 and 20. For the total 216,581,000 prescription items dispensed in 2002 therefore, the estimate of ‘dispensing occasions ‘ was (100-65) x 216,581,000 / 2.5 - 15,000.000) or 25.071 million dispensing occasions. The national totals in the results for each of the above questions therefore need to be revised according to the occasions dispensed and not the estimated total of prescriptions dispensed. To calculate national estimates the overall percentage of pharmacies that positively responded to a question was multiplied by the corresponding actual number of pharmacies within PhARIA 1 and PhARIA 2 to 6 (Table 1.1), therefore giving an estimate of total pharmacies. To calculate the number of services/facilities the lower confidence interval (LCI) mean estimate was multiplied by the appropriate number of pharmacies. In certain instances, where skewness to the left or to ranges with smaller numbers was pronounced , appropriate recalculations of the best estimates were made. For estimates relating to facilities or services daily, weekly or 30 day estimates the 4824 pharmacies in Table 1.1 was used and for estimates occurring in pharmacies over a period of 12 months the total of 4,447 pharmacies was applied being the number of PBS-approved pharmacies which had operated for the full 12 months ending 30 June 2002. That is, the LCI x 4447 was the multiple commonly used for yearly estimates. These numbers resulted therefore in the most conservative national annual estimate of services or facilities.

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2. Database (Term of reference 1, disk attached) Term of Reference 1 requires a database based on the results of the survey. These are reported in the following three parts and included in the attached disk and printed copy. In total the database comprises 288 pages and 810 tables. Due to the word limits for this report a copy of the database is in the attached disk and hard copy. To assist the reader in their understanding of the results, separate discussion tables designated Table D - A, B, C, etc. according to the corresponding section and question number (Table 2.1) in the results were created and reported in Section 3 of this report. 2.1 Pharmacy activities, facilities, services, PhARIA and estimates Part 1 in the attached database contains response frequencies, percentage response, cross tabulation by PhARIA, descriptive/estimate statistics of pharmacy activities, facilities and services according to the sections in the questionnaire (Table 2.1). These are detailed in Section 3 of this report

Table 2.1 Pharmacy activities, facilities, services, PhARIA and estimates

Section Question Source (number of tables) A 1 to 6 Table 1.1 to 6.2 (26 tables) B 7 Tables 7.1.1 to 7.28.2 (56 tables) C 8 and 9 Tables 8.1.1 to 9.7.2 (38 tables) D 10a to 13c Tables 10a.1 to 13c.2.2 (73 tables) E 14a to 14f Tables 14a.1 to 14f (14 tables) F 15a and 15b Tables 15a.1.1 to 15b.2.2 (16 tables) G 16 to 18 Tables 16 to 18.7.2 (29 tables) H 19a and 19b Tables 9a.1.1 to 19b.2.2 (16 tables) I 20 Tables 20.1.1 to 20.12.2 (24 tables) J 21 Tables 21.1.1 to 21.11.2 (22 tables) K 22a to 23 Tables 22a.1 to 23.4 (16 tables) L 24 Tables 24.1 to 24.7 (7 tables) M 25a to 33b Tables 25a.1 to 33b (29 tables)

2.2 Pharmacy characteristics and facilities / service provision Part 3 contains cross tabulations and chi-square tests performed in order to find individual relationships between pharmacy characteristics and service provision (Table 2.2). These are detailed in Section 4a of this report:

Table 2.2 Pharmacy characteristics and facility/service provision

Section Question Source (number of tables) 7 Table 34.1 to 34.12 (12 tables) 11c Table 35.1 to 35.12 (12 tables) 12 Table 36.1 to 36.12 (12 tables) 13a Table 37.1 to 37.12 (12 tables) 13b Table 38.1 to 38.12 (12 tables) 13c Table 39.1 to 39.12 (12 tables) 14d Table 40.1 to 40.12 (12 tables) 17 Table 41.1 to 41.12 (12 tables) 18 Table 42.1 to 42.12 (12 tables) 19a Table 43.1 to 43.12 (12 tables) 19b Table 44.1 to 44.12 (12 tables) 20 Table 45.1 to 45.12 (12 tables)

Pharmacy characteristics and

facility/service provision

23 Table 46.1 to 46.12 (12 tables)

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2.3 Pharmacy characteristics and barriers Part 4 contains cross tabulations and chi-square tests performed in order to assess the relationships between pharmacy characteristics and barriers to enhanced pharmacy services. From the low level of invalid or non-response within this study it could be inferred that respondents had a high level of comprehension for a majority of the questions (Table 2.3). These are detailed in Section 4b of this report.

Table 2.3 Pharmacy characteristics and barriers Section Question Source (number of tables)

8 Table 47.1 to 57.12 (132 tables) 9 Table 58.1 to 63.12 (72 tables)

Pharmacy characteristics and

barriers 24 Table 64.1 to 70.12 (84 tables) 2.4 Pharmacy characteristics and opinion on the use of technical facilities Part 4 contains also cross tabulations and chi-square tests performed in order to seek relationships between pharmacy characteristics and barriers to enhanced pharmacy services. From the low level of invalid or non-response within this study it could be inferred that respondents had a high level of comprehension for a majority of the questions (Table 2.4). These are detailed in Section 4c of this report. Table 2.4 Pharmacy characteristics and opinion on the use of technical facilities

Section Question Source (number of tables) 24 Table 47.1 to 57.12 (132 tables) Table 58.1 to 63.12 (72 tables)

Opinion on the use of technical facilities

Table 64.1 to 70.12 (84 tables)

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3. Terms of reference 1, 2 and 5 : characteristics of , facilities and services and national estimates in Australia’s community pharmacies by PhARIA zone

Terms of reference 1 (characteristics, facilities and services in Australia’s community pharmacies), 2 (comparisons between pharmacies in Pharia zones) and 5 (national estimates) are reported below by each section in order in the questionnaire. The questionnaire is appended in this report but may be conveniently viewed in the website constructed for this project: www.curtin.edu.au/curtin/dept/pharmacy/survey/index.html The discussion for each section in the questionnaire is in a standardised format under the same subheadings so readers can logically follow the results from the database and to satisfy the terms of reference relating to national and international comparisons of the data. The standard subheadings are the title, aims of the data, pertinent question numbers in the questionnaire , statistical sources from the database, methodology related to the questions and national estimates, findings in summary tables based on results in the database, results by PhARIA, national estimates, reviews of the pertinent Australian and overseas literature , interpretations and references.

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3.1 Section A. Respondent pharmacist details Questions: 1 to 6 Statistical sources: Tables 1.1 to 6.2 (26 tables); Aims To compare the demographics and other features of the respondents and owners (Section M) in Australia’s community pharmacies. To compare features of respondents and owners with pertinent data from international surveys of community pharmacists. Background In Australia, an approved community pharmacy is defined as a pharmacy operating from premises in respect of which a pharmacists is approved to supply pharmaceutical benefits. 38 Beforehand pharmacies need to be registered by jurisdictional pharmacy boards hence not all registered pharmacies may be approved pharmacies. In this survey the pool of pharmacies was drawn from pharmacies registered with the relevant State or Territory (jurisdictional) authorities which rarely involves any not approved to supply medicines listed in the national Schedule of Pharmaceutical Benefits and remunerated by the Health Insurance Commission (HIC). National surveys of the pharmacy workforce are carried out regularly and comparisons are made with features of those reported since 2000. The respondents in this national survey were owners, partners, managers or pharmacists-in-charge of Australia’s community pharmacies. That is those pharmacists who determine and implement the practices in Australia’s pharmacies. Other terms used in this and other questions are based on those published in the reference publication Australian Pharmaceutical Formulary and Handbook. 38 Discussion of methods The questions 1-6 pertaining to the demographics and other characteristics of respondents in Section A were drawn from recent surveys of the Australian pharmacy workforce and other data on the continuing professional development from the literature and from national and State pharmacy administrators. Questions 1-6 were completed after consultation with the national panel, visits to pharmacies across all Pharia zones in the large States and direct or telephone discussions with their key staff. The question was tested in a focus group of pharmacists from a variety of pharmacies in Pharia zones 1 and 2 and a nationwide sample of practicing and specialist pharmacists in Pharia zones 1 to 6. The questions were framed in order to be comparable to but appropriately expand on reported regional or national surveys of Australia’s community pharmacies, from a state survey of pharmaceutical care services in the USA 39 ,a national survey of pharmacies in the UK 40 and from exchanges with leaders in pharmacy practice, teaching, research and administration in Australia and internationally. Findings The demographics and pharmacy details of the respondents (Tables 1-6) compared with owners (Section M) showed more respondents were females, they were younger, more held university degrees and spent more time in continuing pharmacy education (Table A-D1). Respondents comprised 73.3% owners or partners. The hours per month spent on CPE by respondents (73% owners and partners) were: in the last 12 months, we can be 95% confident that respondent pharmacists spent between 6.78 and 7.46 hrs per month on CPE with a best estimate of 7.12 hours per month. In comparison, the hours per month spent on CPE by owners were (Q30b): 5.63hrs per month (95% CI 5.39, 5.87hrs). The composition of CPE in order of time spent was: 1. journal/personal reading, 2. CPE courses/lectures, 3. questionnaires in professional journals, 4 conferences and 5.online CPE.

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Table D-A1.Comparison of respondents and owners in Australia’s community pharmacies 2002.

Features Respondents owners females 31.7% 23.7%

51+ years 32.6% 39.5% Pre-1970 registration 20.4% NA

Diploma 15.3% 18.2% CPE >10hours/month 20.1% 13.1%

Owners/partners 73.3% 100% PhARIA zones There were marginally less male respondents ( 66% and 64%) from PhARIAs 1 and 2 and 5 and 6 than from PhARIAs 3 and 4 (73% and 76%) . Just 27% of respondents from PhARIA 1 were 51 years or over compared to 30-41% in the others. Just 16% of respondents from PhARIA 1 were first registered before 1970 compared to 20-32% in the others. Initial graduates from NSW and Victoria was 55% in PhARIA 1 and 36% in PhARIAs 5&6. Those with diplomas as their highest qualification (non-baccalaureates) was 11% in PhARIA 1 and rising to 25% of respondents in PhARIAs 5&6. Less respondents (51%) in PhARIA 1 spent five hours or less monthly on continuing pharmacy education (CPE) than those for example in PhARIA 4 (62%) and 55% in PhARIAs 5&6. The higher commitment to CPE in PhARIA 1 respondents was reflected variously across CPE forms . For example 55.8% of respondents in PhARIA 1 increasing to 82.6% in PhARIAs 5&6 reported under 20% of their CPE time or ‘no response’ to CPE of a participatory nature such as courses and lectures. There was little difference in PhARIAs in the less participatory forms of CPE such as ‘journals/personal reading’ and ‘online’ where 22.2% in PhARIA 1 and 22.8% in PhARIAs 5&6 and 88.6% in PhARIA 1 and 89.1% in PhARIAs 5&6 reported respectively under 20% of their CPE time or ‘no response’ . There are clearly challenges to national pharmacy bodies in identifying and overcoming barriers to CPE forms of a non-participatory nature throughout he country. Australia Three national work force surveys of Australia’s community pharmacists have been published since 2000 41,42,43,44. The ‘Pharmacy labour force 1998’ reported results of a census survey (national response 83.8%) of Australia’s pharmacy workforce undertaken in 1996 with the assistance of State pharmacy boards (AIHW,2000). It is the last available report in a series of three-yearly national labour force surveys of pharmacy conducted in 1996 and 1999 41 and portrays the most detailed picture of community pharmacists of any report. In 1996 the total 11,126 community pharmacists comprised 6,617 males and 4,509 females of whom 5301 and 2176 were fulltime. The fulltime pharmacists comprised 42.9% males and 8.6% females aged 45 years and over (51 years and over in 2002) . Part-time pharmacists comprised 36.1% males and 29.2% females aged 45 years and over. Part-time pharmacists were higher ( 33.7 -33.9%) in cities and metropolitan centres than in remote areas (15.9-6.7%). The average age of females and males was 41.4 and 49.4 years respectively and females comprised 60.6% of all community pharmacists aged less than 30 years (36 years in 2002). Weekly hours worked ranged from 38.4 hours weekly in cities and metropolitan centres to 47.6 hours in remote areas. In the week before the 1996 census 57.9% worked 40 hours and over weekly. Community pharmacies were located in non-mall shopping centres (71.5%), mall complexes (22%) and in medical centres ( 6.2%). Community pharmacists became qualified as follows : 25.6% in 1960-69, 21.0% in 1970-79 and 23.0% in 1980-89 . 41 The AIHW reported the total 4958 community pharmacies in 1999 reflected a national decline in numbers; 182.77 million prescriptions were dispensed through the Pharmaceutical Benefits Scheme (PBS) in 1998 -a 16.5% rise since 1993; community pharmacies employed in 1996 11,126 people equating to 80.4% of the total pharmacy workforce. 41 The 1996 results from community pharmacists were compared with our 2002 results (Table A-D2). Even with the time differences the respondents comprised less females, were older and more partners and owners. The initial qualification in pharmacy was obtained in NSW and Victoria by 50.4% of respondents compared with 54.6% of the total pharmacy graduates from universities in NSW and Victoria (HIC,2002). These data suggest relatively more opportunities in non-community pharmacy employment in NSW and Victoria than in other States.

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Table D-A2.Comparison of respondents in 2002 and community pharmacists in 1996

(AIHW,2000)

Features 2002 respondents 1996 community pharmacists

Females 31.7% 40.5% 51+ years 32.6% 54.5% (46+)

Pre-1970 registration 20.4% 43.5% NSW or Vic. location 52.9% 61.2% Baccalaureate (Uni) 83.3% NA

CPD >10hours/month 20.1% NA Owners/partners 73.3% 46.6%

The ‘Study of the demand and supply of pharmacists, 1995-2010’ reported responses from 518 respondents (52.7% ) of an unspecified sample survey of State registrants 43. The results are not comparable with either the 1996 labour force census41 or the results from this 2002 survey. The ‘Study of the demand and supply of pharmacists, 2000-2010’ reported responses from 666 respondents (60.4%) of an unspecified sample survey of State registrants 44. The results are not comparable with either the 1996 labour force census 41 or the results from this 2002 survey. Totals of prescriptions dispensed by Australia’s community pharmacies and part or wholly remunerated by government payers ( PBS and RPBS and HIC ) were provided by Australia’s Drug Utilization Sub-Committee. In 1999 a total of 191.404 million ( 44.72 million private and under concession) and in 2000 200.345 million ( 45.02 million private and under concession) were dispensed . The totals include ‘private’ and ‘under concession’ (dispensing fee below PBS price) are obtained from surveys organised by the Pharmacy Guild of Australia. The categories of prescriptions dispensed in Australia’s community pharmacies are recorded in Table A-D3.

Table D-A3. Total prescription numbers dispensed in community pharmacies by category in

Australia in 2001 (Source : Drug Utilisation Sub-Committee drug utilisation database, December 2002 ) PBS=Pharmaceutical Benefits Scheme; RPBS = Repatriation PBS (Veterans’ Affairs)

Source Patient category Prescriptions

PBS/RPBS Concession safety net 28 115 148 PBS/RPBS Concession non Safety net 98 976 103 PBS/RPBS Doctors’ bag 466 168 PBS/RPBS General non Safety net 18 645 735 PBS/RPBS General Safety net 4 779 598 PBS/RPBS ostomy 10 299 PBS/RPBS Repatriation (VA) Safety Net 2 005 239 PBS/RPBS Repatriation non Safety Net 11 479 076

Survey private 14 397 429 Survey Under concession 31 602 613 Total all 210,477,000

In order to enable validation of the figures on CPE commitment by owner and non-owner pharmacists, enquiries from national and State bodies of pharmacy proved unsuccessful. International The results from Australia’s community pharmacies in this survey are often compared with data from the USA, UK, Canada , New Zealand and the Netherlands, so a summary of key national features are made for reference (Table A-D4).

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Table D-A4. Key features in Australia and other comparison countries 45

Population

(million) Population growth p.a.

Population over 65 years

Doctors per 1000

GDP per head : Purchasing power parity (USA=100)

Australia 19.1 1.1% 12.3% 2.5 73.2 Canada 30.8 0.93% 12.6% 2.1 79.7

Netherlands 15.9 0.52% 13.6% 3.1 75.8 New Zealand 3.8 0.94% 11.7% 2.3 54.3

UK 59.4 0.27% 15.8% 1.8 69.1 USA 283.2 1.05% 12.3% 2.7 100

In the USA national pharmacy bodies 46, government agencies 47 and research groups 48-51 have since 1999 reported the results of national surveys or projections on many aspects of the US community pharmacist workforce. By 2000 nearly three billion prescriptions were filled in US community pharmacies 46 similar per capita to the 200.345 million dispensed in 2000 by Australia’s community pharmacies (Tables D-A3 and D-A4). Third party billing of prescriptions account for 75% of US prescriptions 46 compared with 78% of Australia’s third party prescriptions (eg PBS,RPBS) dispensed in Australia’s community pharmacies (Table D-A3). In both the USA and Australia improved clinical pharmacy education, a large and better trained pharmacy technician force and modern electronic technology with automation have grown to meet the challenges of expanded pharmacist roles, surging prescription volumes and pharmacist shortages 46. Australia, New Zealand and the USA have from 64 to 70 practising pharmacists per 100,000 population 42,47.A survey of US community pharmacists conducted in 2000 found their time was apportioned 56% to dispensing, 19% to consultation ( eg counselling) , 16% to business management and 9% to drug management including prescription review and monitoring 49,51. Based on a US labour force model estimates of increased total and younger female pharmacists per 100,000 were made 47,50. Mapping of health providers and populations in rural areas by postcode (ZIP code) found localised shortfalls of health providers suggesting pharmacists may substitute by providing more primary health care services in these locations 48. In the UK surveys of working pharmacists in 1997 and 1998 found trends from permanent to locum work, to reduced hours of work and to dissatisfaction with community pharmacy work, all of which add to the shortage of available pharmacists 52. In Great Britain continuing pharmacy education (CPE) is included in the action phase of a voluntary four-phase model of continuing professional development or CPD commencing with (1) reflection, (2) planning, (3) action and concluding with (4) evaluation introduced in 200253,54. CPD requires minimally 30 hours annually of CPE. Of 427 respondent pharmacists (25.6%) in a Northern Ireland survey54 under 1 % did 0 hours pa, approximately 90% did up to 39 hours pa and about 15% over 40 hours pa. It was found recent graduates (post-1990) , females , those working in city, town and chain pharmacies most strongly favoured CPD while pharmacists were apprehensive to over 30 hours mandatory CPE 54 . Two surveys of mid-England pharmacists found a mean of 26.4 hours yearly (range 0-90 hours pa) with 43% achieving 30 hours pa 55. All UK surveys found poor understanding of CPD. The nursing, dental and medical councils in the UK are at stages of legislating mandatory CPD56. Interpretations From national surveys published since 2000 Australia’s fulltime community pharmacists comprise mainly males who are older and part-time community pharmacists who are mainly females under 36 years. Respondents were mainly owners, partners and managers who were male, graduates from NSW and Victoria, with one-third aged 50 years or more who spent more than 60 hours annually on CPE or more than double the commitment reported by community pharmacists in Great Britain. The term CPE needs to be standardised for comparisons to be valid. Pharmacies outside of PhARIA 1 have older, fewer female and less qualified pharmacists, owners and managers with a lower participation in CPE than those in PhARIA 1 pharmacies. CPE commitment was 18% higher in respondents than owners (7.12 Versus 5.63 hours CPE per month) . Each of these was much higher than either CPE hours reported by pharmacists

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in Northern Ireland or England or the minimum of 2.5 hours monthly required under Great Britain’s 2002 pharmacy CPD requirements. Australia’s national bodies should further develop electronic, more accessible, practical and efficient forms of CPE for pharmacists residing in rural and remote areas of Australia. National and State bodies of pharmacy in Australia need to consider standardise CPE commitment in hours monthly by owner and non-owner pharmacists for international and time-series comparisons. National estimates These were based on percentages reported by respondents and included demographics, qualifications, position held in pharmacy and CPE activities.

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3.2 Section B Enhanced pharmacy services (EPS) Question: 7 Statistical sources Tables 7.1 to 7.28.2 ( 56 tables) Aim To quantify the prevalence of trained staff, payment and planned growth of ‘enhanced pharmacy services’ in Australia’s community pharmacies. Background Enhanced pharmacy services refer to those offered in community pharmacies requiring additional or special skills, knowledge and/ or facilities and are provided to sub-groups with special needs. They exclude services covered in the prescription-related (Sections D and E), and OTC-related (Section F) and certain other activities in other sections of the questionnaire. In Australia, many of these services such as wound management, hospital discharge (or community liaison), cytotoxic drugs preparation and compounding are recognised, defined and described for implementation in community pharmacies. 57 While community pharmacies worldwide routinely provide the safe, effective and rational use of medically prescribed , pharmacy- and self-selected medicines to all people 58, there is a growing diversity of additional services which are being developed and remunerated in developed countries. The main ones are included in Question 7. Discussion of methods Question 7 was compiled after consultation with the national panel, visits to pharmacies across all Pharia zones in the large States and direct or telephone discussions with their key staff , direct or telephone discussions with leaders of pharmacy bodies and pharmacy groups and reference to a range of pharmacy business, practice and research journals published in Australia and internationally. The question was tested in a focus group of pharmacists from a variety of pharmacies in Pharia zones 1 and 2 and a nationwide sample of practicing and specialist pharmacists in Pharia zones 1 to 6. The 28 services itemised in Question 7 were drawn chiefly from defined activities in Australia’s pharmacies 57, reports in Australian pharmacy journals, questionnaires from a State survey of pharmaceutical care services in the USA 59, a national survey of pharmacies in the UK 60 and from exchanges with leaders in pharmacy practice , teaching, research and administration in Australia and internationally. Findings Asthma, diabetes , community education, harm reduction with methadone, geriatric care, herbal medicines/nutritional supplement counselling, hypertension, skin care management, smoking cessation and weight reduction were the services reported to be provided by over 25% of Australia’s community pharmacies. Of these, trained staff were reported in over 14% of pharmacies for herbal medicines/nutritional supplement counselling, smoking cessation, harm reduction, asthma , diabetes and wound care . 2% or more of Australia’s community pharmacies planned to introduce enhanced pharmacy services by July-September 2003 in the following order . Diabetes (8.1%) , asthma (5.9%), naturopathy (4.7%), structured community education (3.8%) , smoking cessation (3.8%), herbal medicines (3.6%), hypertension (3.5%), hyperlipidaemia (3.4%) , geriatric care (3.0%) , osteoporosis (2.8%) , community clinics with nurses (2.7%), wound care (2.7%) and weight reduction (2.1%). 7.5% or more of pharmacies in the following order reported accredited or trained staff for herbal medicines (23.2%), smoking cessation (19%), diabetes (17.2%), asthma (14.9%), harm reduction (14.6%), wound care (14.3%), hypertension (13.3%) , skin care management (11.1%) , geriatric care (9.2%), weight reduction (8.7%) , body piercing ( 7.5%) and structured community education (7.5%). Only in the cases of harm reduction and body piercing were higher percentages receiving fees . 6% or more of pharmacies in the following order received payment for harm reduction (31%), body piecing (13%), specialised compounding (6.4%) and osteoporosis (6.3%) services. Much lower percentages of pharmacies had trained or accredited staff for all but osteoporosis services.

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Only 13.1% of pharmacies reported other unlisted enhanced services including baby nurse, massage, child care, chiropodist , compression stockings , constipation management , and a range of other services. Many of these were reported in other sections in the questionnaire. Pharia zone Higher percentages of the enhanced services were reported consistently in Pharias 1 , 2 , 3 and 4 . The only services which occurred in significantly higher percentages in pharmacies in Pharias 4, 5 and 6 were aboriginal health services and herbal medicines. This needs closer study because smoking and obesity which are risk factors for cardiovascular and other major chronic disorders are higher in indigenous and rural populations than in people living in areas served by pharmacies in Pharias 1,2 and 3. Furthermore, the rates of other priority disorders are also higher in people served by pharmacies in Pharias 4, 5 and 6 implying many enhanced services relating to priority disorders should be equally represented in them. Australia These results are the first known national quantitative data on the range of enhanced services provided in Australia’s community pharmacies. The evaluation and future remuneration of enhanced services are being explored in Australia currently. These include services which improve patient concordance, monitoring of effectiveness of therapy, educating patients on the better management of their diseases, specialisation in diabetes, weight loss and asthma, medication reviews in ‘at risk’ recently discharge patients from hospitals 61,62. Australia’s national health priority areas (NHPAs) are based on the World Health Organisation’s initiatives and adopted in July 1999. They have been widely promoted and have been successful according to an independent review 63. These international and national health priorities form essential references for the introduction of enhanced pharmacy health services if pharmacies are to fulfil the health needs of the public. In Australia for example the health priorities in 2003 are asthma, cancer, cardiovascular health, diabetes, injury prevention, mental health and arthritis and musculoskeletal disorders 64. Probably the most serious unmanaged risk factor is overweight and obesity which predisposes to type 2 diabetes, cardiovascular disease, osteoarthritis and cancer, all of which are which are health priorities in this country. Overweight was evident in 6.5 million Australians in 2001 and is increasing in adults regardless of gender or level of education 65. In comparison, wound care a condition of much lower frequency than overweight, ranked fifth in both trained staff and the percentage of pharmacies offering the service with or without payment. Its high acceptance in community pharmacy practice demonstrates the successful organised promotion of a pharmacy service which should be examined for applying to other under-represented health priority services 66,67 .The 4.8% of pharmacies with community clinics and nurses is probably an artificially low rate as it was found subsequently many pharmacies engage nurses without necessarily having a community clinic. The role of nurses has in the past decade expanded rapidly from government and private hospitals into rural, remote , aged care and domiciliary settings in primary health care 68 . Their ability to overcome hurdles opens the way to a range of services such as vaccination and clinical testing in community pharmacies which may be under-represented in pharmacies 69,70. More active roles in asthma and related activities have been advocated for pharmacies in rural areas for almost a decade 71. International The World Health Organisation’s international health priorities designated for 2002-2005 are malaria, tuberculosis, HIV/AIDS, cancer, cardiovascular disease and diabetes, tobacco, maternal health, food safety, mental health and safe blood 72. Community pharmacies worldwide routinely provide the safe, effective and rational use of medically prescribed , pharmacy- and self-selected medicines to all people 58 . Differences in national health and social systems , consumer needs 73,74 and health priorities 75 are shaping pharmacy practice in Australia 76-79 and other countries 58,80. As a result many services performed by pharmacists and non-pharmacists have evolved in community pharmacies to cater for the special needs of various subgroups in local populations. The effectiveness of these services is being continuously analysed to identify those that are the most viable for pharmacies 81-84. Cognitive pharmacy services, pharmaceutical care and disease management are terms which connote distinct pharmacy services which are capable of remuneration 61,85,86. In the USA the growth of ‘specialty drug’ pharmacies has focused on

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drugs for patients with chronic, life-threatening conditions , requiring infusion, injection, or other non-oral method of administration requiring a health professional, with special conditions of storage and transport and entailing extensive patient education, clinical monitoring , follow up and support with total costs for each drug exceeding $USD 10,000 yearly 87. Table D-B7-1 . Enhanced pharmacy services offered in Australia’s community pharmacies by

trained staff, fees charged and planning in 12 months (total respondents = 1131; missing = respondents did not tick any of the five possible boxes in the item row/1131)

Enhanced pharmacy

service Missing cases

Does not offer

Enhanced service with trained staff

No charge

Payment In 12 months

Aboriginal health 14.2% 81.2% 0.5% 2.4% 1.7% 1.2% anticoagulation 16.5% 74.1% 2.0% 8.1% <0.1% 0.8% Asthma 11.3% 43.4% 14.9% 38.3% 0.4% 5.9% Body piercing 13.9% 69.6% 7.5% 1.4% 13.0% 0.8% Chemotherapy preparation 15.5% 82.0% 1.1% 1.6% 1.1% 0.4% Community education 15.2% 58.3% 7.5% 21.6% 1.3% 3.8% Community clinic + nurses 15.2% 70.6% 4.8% 10.7% 0.8% 2.7% Diabetes 10.1% 41.7% 17.2% 38.1% 1.6% 8.1% Discharge for hospital patients

14.9% 70.1% 3.4% 11.2% 2.3% 1.9%

Drug level monitoring 15.6% 79.1% 1.9% 3.8% 1.1 0.5% Geriatric care 14.5% 56.9% 9.2% 9.2% 7.3 3.0% Harm reduction and methadone

10.4% 49.2% 14.6% 6.2% 31.5% 1.5%

Herbal medicines / nutritional supplement counselling

10.3% 34.0% 23.2% 45.1% 3.1% 3.6%

Hyperlipidaemia 14.8% 67.3% 4.5% 14.0% 1.5% 3.4% Hypertension 11.8% 44.7% 13.3% 36.2% 3.5% 3.4% Naturopathy 14.4% 62.5% 9.9% 15.2% 3.0% 4.7% Nutritional support including parenteral/enteral nutrition

15.4% 74.3% 3.3% 8.6% 0.9% 0.4%

Osteoporosis 14.1% 62.5% 6.6% 14% 6.3% 2.8% Ostomy counselling 16.0% 81.9% 0.4% 2.0% 0 0.4% Paediatric pharmacy 14.8% 66.6% 5.0% 16.2% 0.3% 1.2% Pain management 13.7% 65.6% 4.9% 18.4% 0.4% 1.3% Psychiatric pharmacy 15.6% 76.5% 1.7% 6.7% 0.5% 0.4% Skin care management 13.8% 52.9% 11.1% 28.5% 1.2% 1.3% Smoking cessation 8.9% 36.1% 19.0% 46.8% 1.5% 3.8% Specialised compounding 16.1% 66.4% 5.4% 8.7% 6.4% 1.3% Weight reduction 12.8% 56.9% 8.7% 25.5% 1.6% 2.1% Wound care 11.8% 45.8% 14.3% 35.5% 1.3% 2.7% other 86.9% 3.5% 4.2% 3.4% 5.5% 0.8%

Interpretations Australia’s community pharmacies have reported providing an impressive diversity of enhanced pharmacy services. Few other services were provided which were not included in this or other sections of the questionnaire. There are wide disparities between the high prevalence of certain risk factors and disorders in Australia and the rates of provision of pertinent enhanced pharmacy services by Australia’s community pharmacies. For example, obesity in Australian adults now exceeds 20% of the population and is growing at rates exceeding 5% per annum. Despite this, only 8.7% of pharmacies reported staff trained in weight reduction, just 1.6% charged for the service and only 2.1% of pharmacies planned to

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introduce the service by September 2003. Most of the enhanced pharmacy services occurred at higher rates in pharmacies in Pharias 1,2 and 3 but aboriginal health services and herbal medicines occurred more frequently in pharmacies in Pharias 4, 5 and 6. The disparities between the high rates of smoking , substance abuse and obesity which are risk factors for cardiovascular and other major chronic disorders are higher in indigenous and rural populations than in people living in other areas. The rates of other priority disorders are also higher in people served implying many enhanced services relating to priority disorders should be equally represented in them. These large disparities in Australia need to be addressed by our national pharmacy bodies. One step would be to evaluate these mismatches between rates of risk factors or health disorders in each Pharia zone and compare the provision of services reported by pharmacies in corresponding zones. Another approach is to provide incentives for pharmacies to introduce and increase the utilisation of devices for screening of risk factors for these health disorders high proportions of which (eg. obesity and type 2 diabetes) remain under-diagnosed and/or unmanaged. National estimates Percentage of Australia’s community pharmacies offering each service, with trained staff, charging of fees and plan to introduce in the 12 months to July 2002 are reported for the first time . These national reported percentages and future growth of the services may be compared with Australia’s national health priorities in order for national bodies of pharmacy to determine existing deficiencies and appropriate evaluation, educational or training initiatives.

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3.3 Section C Barriers and facilitators of enhanced pharmacy services

Questions : 8,9 Statistical sources : Tables 8.1.1 to 8.12.2 (24 tables); and Tables 9.1 to 9.7.2 (14 tables) Aims : To measure the factors which act as the main barriers to and the main facilitators of introducing or expanding the enhanced pharmacy services in Question 7. Background The concept of identifying barriers to and facilitators of health interventions, or novel disease management, or preventive practices was introduced during the 1980s in the USA . In Australia, little pharmacy research has been undertaken in this area. Discussion of methods Questions were compiled after consultation with the national panel, visits to pharmacies across all Pharia zones in some States and direct or telephone discussions with their key staff, direct or telephone discussions with leaders of pharmacy bodies and pharmacy groups and reference to a range of pharmacy business, practice and research journals published in Australia and internationally. Questions were compiled with particular reference to the national survey of pharmacies conducted in Great Britain in 2000 88 and the barriers were derived from surveys in Northern Ireland89 and the USA 90 . The questions were tested in a focus group of pharmacists from a variety of pharmacies in Pharia zones 1 and 2 and a nationwide sample of practicing and specialist pharmacists in Pharia zones 1 to 6. Findings The greatest barriers (Table D-C8) to the introduction of enhanced services in order of declining priority were ‘lack of time’ (90.3%) , ‘shortage of pharmacists’ (78.3%) , ‘no extra remuneration’ ( 63.3%), ‘cannot find locums’ (63.2%), ‘customers won’t pay’ (56.3%) and ‘cannot meet with local GPs and health workers’ ( 50.5%). The barriers most strongly rejected for EPS were ‘not felt to be part of pharmacy job’ ( 71.5%) and ‘ may impair their relations with local GPs’ ( 52.5%). The facilitators (Table D-C9) most strongly supported for EPS were ‘ dedicated study time’ (77.9%), ‘accreditation’ (75.6%), ‘closed counselling areas’ (72.8%) and ‘access to patient notes’ (70.6%) . The highest combined resistance and uncertainty were ‘appointment systems’ and ‘clinical testing area’ (Table D-C9). Only 5.0% of all pharmacies offered other barriers and just 5.4% other facilitators . Thus those factors listed in Questions 8 and 9 appeared to be comprehensive. Pharia zone Pharmacies (> 80%) in Pharias 2-6 strongly identified ‘shortage of pharmacists’ and ‘unable to find locums’ as the major barriers to introducing enhanced pharmacy services . Pharmacies in Pharias 4, 5 and 6 ( < 37%) were less concerned with ‘meeting with GPs’ or ‘GPs not recognising their skills’ in comparison with pharmacies in other Pharias . Pharmacies in Pharia 1 to 4 supported ‘access to patient notes’ , ‘closed counselling area’ and ‘accreditation’ as the most important facilitators for the introduction of enhanced pharmacy services compared to pharmacies in Pharias 4,5 and 6. Australia No studies were found from Australian sources . International Lack of time is reported as the main barrier to providing enhanced services in British pharmacies 88 and to pharmaceutical care in Northern Ireland 89 and the USA 90 , while lack of resources in pharmacies was found to be the main barrier to pharmaceutical care in Danish pharmacies 91. Further training was found to be the main facilitator in two studies88,91 and external promotion of these services and changes in the operation in pharmacies were also

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found to be important. Differences in study design and the object of the barriers and facilitators in the studies limit the comparison between other studies and this national survey.

Table D-C8. Barriers to enhanced services reported by Australia’s community pharmacies in

2002

Barrier Strongly disagree - disagree

unsure Strongly agree- agree

No response

Time shortage 7.3% 1.4% 90.3% 1.0% Pharmacist shortage 11.8% 7.5% 78.3% 2.4% Customers won’t pay 16.1% 24.8% 56.3% 2.8% Cannot find locums 19.1% 13.9% 63.2% 3.8%

Lack knowledge/skills 44.2% 14.6% 38.5% 2.7% Lack confidence 49.3% 16.4% 31.4% 2.9%

Not part of pharmacy job 71.5% 14.7% 11.3% 2.5% No extra remuneration 20.7% 14.1% 63.3% 1.9%

Impair relations with local GPs 52.5% 26.2% 20.1% 1.2%0 Cannot meet with GPs or health workers 31.4% 16.3% 50.5% 1.8%

GP’s don’t recognise EHS skills 29.7% 25.0% 43.5% 1.7% Other 0.5% 0.4% 4.1% 95.0%

Table D-C9.Facilitators for enhanced pharmacy services for Australia’s community pharmacies in 2002

Facilitator Strong-

disagree unsure agree-

strong Missing

Access to patient notes 11.5% 14.9% 70.6% 2.6% Closed counselling area 15.8% 9.5% 72.8% 1.9%

Clinical testing area 14.3% 17.5% 65.4% 2.7% Appointment systems 16.2% 20.3% 60.6% 2.8%

Accreditation 10.8% 11.4% 75.6% 2.2% Study time 8.4% 11.8% 77.9% 1.9%

other 0.3% 0.3% 4.8% 94.6%

Interpretations The results show agreement on barriers and facilitators in Australia’s pharmacies and identify factors that, if addressed, may facilitate the increased provision of enhanced pharmacy services. The major barriers were lack of time and shortage of pharmacists. The major facilitators were dedicated study time, accreditation, closed counselling areas and access to patient notes. National estimates Pharmacies which selected barriers to, or the facilitators of, enhanced pharmacy services are grouped as percentages of those who agree or strongly agree, who are unsure, or who disagree or strongly disagree. The major barriers were lack of time and shortage of pharmacists. The major facilitators were dedicated study time, accreditation, closed counselling areas and access to patient notes.

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3.4 Section D Prescription related activities in community pharmacies

Questions : 10a - 13c Statistical sources : Tables 10a to 13c-2.2 (73 tables) Aims To quantify the number, nature, external dispensing, supervised dosing, reasons for declining, counselling type and monitoring activities of prescriptions dispensed by Australia’s community pharmacies Background In Australia, guidelines for dispensing practice, providing medicines information and the terms prescription, dispensing , counselling , consumer medicine information (CMI) , dose administration aids and mail order dispensing, are defined for pharmacists 92. For example CMI is brand-specific manufacturer-produced written information about drug products which conforms with special provisions set out in Therapeutic Goods Regulations. All prescription and pharmacy-only medicines will have CMI by December 2002 92. Dose administration aids (DAAs) are compartmentalised boxes or blister-pack devices used to aid the administration of solid, oral medications and mail order dispensing refers to the process where a pharmacist receives and dispenses a prescription and the medication is delivered by mail 92 . Limited data have been reported on the utilisation or occurrence of these prescription-related activities for the existing or new types of medication review services or devices performed in Australia’s community pharmacies. Discussion of methods Questions were compiled after consultation with the national panel, visits to pharmacies across all Pharia zones in some States and direct or telephone discussions with their key staff, direct or telephone discussions with leaders of pharmacy bodies and pharmacy groups and reference to a range of pharmacy business, practice and research journals published in Australia and internationally. For example, Questions 11a and 11b were produced with the advice from a pharmacist specialising in DAAs in Australia. The questions were tested in a focus group of pharmacists from a variety of pharmacies in Pharia zones 1 and 2 and a nationwide sample of practicing and specialist pharmacists in Pharia zones 1 to 6. The standard equation (LCI x 4447) for national 12 months estimates was applied (Section 1.4.7) in Table D-D10a. For the national estimates in Tables D-D10b d ,D-D11a, D-D11c, D-D11e, D-D12, D-D13a, D-D13b and D-D13c. For the national estimates per day or seven days, the LCI was multiplied by the total of 4824 pharmacies (Table 1.1) . The number of items dispensed per prescription / patient needs to be ascertained in order to standardise the rates of DAAs issued (Table D-D11a) , prescription activities (Table D-D13 a), counselling in written , verbal, or other forms (Table D13b), compliance activities (Table D-D13c) and assessing drug effects ( Table D-D13c). In the absence of available data and for the purposes of standardising the following national estimates, we adopted a mean of 2.5 items per prescription form or per patient with prescription forms on each occasion of dispensing. This equates to 85.8 million occasions of dispensing per annum. Furthermore, for many of the standardised results in the following tables, the numerator of 85.8 million needs to be regarded carefully because an unknown proportion of prescription medicines are dispensed for external patients in residences, private hospitals, aged care and other facilities. If this total of prescriptions for external patients for example constituted approximately 20% of the total then the standardised figures need to be increased accordingly. Findings The conservative national estimate of 214.516 million prescriptions (Table D-D10a) was found to be close to the national total prescriptions dispensed in 2001 and 2002 as estimated by the Drug Utilisation Subcommittee or DUSC (Table D-D10). The DUSC total is based on prescriptions remunerated by the Health Insurance Commission and two ‘survey’ figures estimated from data provided by a national sample of pharmacies organised by the Pharmacy

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Guild of Australia. The DUSC total excludes S100 prescriptions which are not remunerated by the HIC. For accurate adjustments, the total of full time pharmacy equivalents and less conservative estimates of the mean may need to be applied. The results for national estimates in seven days of mail, distance and delivery prescriptions dispensed are the first known figures (Table D-D10b-d). The results for national estimates in seven days of DAAs provided to patients in the different types of aged care and community settings are the first known to be reported (Table D-D11a). DAAs are used for more than one patient weekly in 78.1% of Australia’s community pharmacies. There are approximately 3300 residential aged care facilities in Australia . Many pharmacies provide services and DAAs to a number of facilities. Nursing home patients are immobile whereas many hostel patients are mobile often resulting in patients in the one hostel having their medications dispensed by more than one pharmacy. The 29.5% and 40.3% of pharmacies who respectively provided more than one patient weekly with DAAs in nursing homes and hostels may reflect the differences in patient mobility with hostel patients possibly obtaining DAAs from different sources (Table D-D11a). DAAs were issued to an overall estimated total of 9.19 million patients in 12 months or a rate or 10.71 DAAs per 100 prescriptions/ dispensing occasions per annum, or alternatively 189,719 patients weekly overall in all settings receive DAAs (Table D-D11a) . If these totals are validated by detailed studies then they reflect the emergence of a major activity in pharmacy practice. The fee charged for DAAs varies by patient setting. High proportions of pharmacies do not charge for providing DAAs (Table D-D11b). This is an issue which needs to be examined in detail particularly if controlled studies demonstrate the cost-effectiveness of DAAs 93.

Table D-D10. Total prescriptions (millions) by category : Australia 1999-2002 (DUSC, 2003)

1999 2000 2001 2002 PBS/RPBS concession/ safety net 114.589 120.54 127.091 137.875 PBS/RPBS doctors 0.520 0.480 0.466 0.441 PBS/RPBS general 19.543 21.81 23.426 20.017 PBS/RPBS ostomy 0.107 0.011 0.001 0.0012 PBS/RPBS Repat 11.562 12.483 13.484 14.617 Survey private 12.404 13.286 14.397 16.014 Survey under-co-payment 32.319 31.736 31.603 27.616 Total 191.044 200.346 210.477 216.581

Table D-D10a. Total prescriptions dispensed in Australia’s community pharmacies in 2002 Prescriptions weekly Monthly Prescriptions yearly Percentage of pharmacies

0 to 300 0-1300 0-15600 6.8 301 to 800 1301-3467 15601-41600 39.7 801 to 1200 3468-5200 41601-62400 27.1 1201 to 2000 5201-8667 62401-104000 19.5 2001 to 3000 8668-13000 100401-156000 4.7 3000 or more 13001- 156001 - 0.5 No response No response No response 1.7

Total Total 214,515,809 Total

Table D-D10b-d. Australia’s community pharmacies by number of patients with mail, distance and delivery prescriptions per typical seven days

Type of

prescription % active

pharmacies Estimated number per

seven days (LCI) National estimate of

patients per seven days Mail 14 0.32 1,543

Distance 42.5 2.92 14,086 Delivery 91.3 9.52 45,924

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Table D-D11a. Australia’s community pharmacies by patients in aged care and community settings issued with dose administration aids per typical seven days

Aged or

community Setting % active

pharmacies Estimate for seven days

(LCI)

National estimate for seven days

National estimate per annum

(million) Nursing home 29.5 12.44 60,010 2.877 Hostel 40.3 13.26 63,966 3.066 Community 80.6 13.62 65,702 3.150 Remote clinics 2.8 0.42 2,026 0.097

Table D-D11b. Australia’s pharmacies which charged fees by DAA per patient-week and unit pack for patients in aged care settings

Best estimate of mean Pharmacies with nil charge (%) Nursing $2.75 50.7 Hostel $3.00 47.7 Community $3.30 38.6 Remote NA 55.5

The percentage of pharmacies where supervising dosing of patients with a range of drugs takes place more than once weekly and the total cases of supervised dosing occurring nationally in Australia’s pharmacies show the emergence of an important pharmacy practice activity in this country. It appears up to 50% of Australia’s community pharmacies perform supervised dosing of at least one of the five categories of drugs included in the survey each week. It was reported that 31% of Australia’s pharmacies in May 2000 were approved to participate in methadone maintenance programs involving the supervised dosing of methadone liquid 94. In comparison the total of 46.7% of pharmacies in this study reported supervised dosing of methadone and/ or buprenorphine more than once weekly implies a marked increase in participation rates by pharmacies in opioid replacement programs since May 2000. At least 80% of the pharmacies do not appear to charge for supervised dosing therefore the reported fees for supervised dosing were estimated from data from pharmacies which reported charging (Table D-D11d ).

Table D-D11c. Australia’s community pharmacies by drugs and patients with supervised dosing per typical seven days in pharmacy

Drugs % active pharmacies

(>0 per week) % pharmacies (>1 per week)

Pharmacy per seven days

(LCI)

National estimate per seven days

Analgesics 21.4 17.3 0.82 3,956 Benzodiazepines 35.9 26.9 1.09 5,258 Buprenorphine 12.5 11.1 0.56 2,701 Methadone 38.1 35.6 2.48 11,963 Other psychotropics 12.6 9.6 0.42 2,026 Other agents 5.0 3.8 NA NA

Table D- D11. Australia’s community pharmacies by reported fees charged per supervised drug ( mean for fees was skewed hence estimates for active charging pharmacies reported)

Analgesics Benzodiazepines Buprenorphine Methadone Other agents Estimated mean fee ($)

1.50 1.50 4.30 4.00 1.00

% invalids, nil and invalid charges

97.5% 96.7% 89.9% 58.5%; fee subsidised in ACT

0

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An estimated conservative total of 1.075 million patients were declined prescriptions in pharmacies during the previous 12 months for inappropriate drug/s or doses, suspected adverse effects or prescription defects (Table D-D12) . Of these, an estimated 59.5% or 0.64 million patients during 12 months were declined for reasons of inappropriate drug/s or dose, or suspected adverse effects .In total, a rate of 12.5 per 1,000 patients were declined their prescriptions . The rates of pharmacies declining prescriptions at least once weekly for each of these reasons were 40.9%, 30.7% and 39.3% equating to estimated weekly numbers nationally of 7574, 5789 and 9069 in each category totalling 22,432 prescriptions declined weekly in Australia’s pharmacies (Table D-D12) .

Table D-D12. Australia’s community pharmacies by patients in past seven days with

prescriptions declined

Prescriptions declined for following reason

% active pharmacies (>1 weekly)

Each pharmacy per seven days

(LCI)

National estimate per seven days

National estimate pa

(million)

Declined per 1000 Patients*

Drug, dose, interaction, contraindication

40.9 1.57 7,574 0.363 4.2

Adverse effect 30.7 1.20 5,789 0.277 3.2 Prescription problem 39.3 1.88 9,069 0.435 5.1

* each patient with 2.5 prescribed drugs dispensed An estimated total of 14.19 million patients with prescriptions or approximately 18 per 100 were provided with computerised or written counselling in the 12 months prior . This was in addition to the verbal counselling , labelling and other forms of standard activities along with DAAs provided in pharmacies during the 12 months period (D-D13a ) . CMIs were provided in a computerised form by 74.2% of pharmacies to one or more patients daily, with the majority providing in excess of 5 patients daily with CMIs. In addition, an estimated 3.17 million non-or-poor English speaking patients or 3.7% of the estimated 85.8 millions patients with prescriptions received counselling. Written information produced by computer programmes other than CMIs were provided by 51.2% of pharmacies to one or more patients daily. Other written or printed drug information were provided by 51.8% of pharmacies to one or more patients daily . Table D-D13a. Australia’s community pharmacies by counselling category per typical day

Counselling type % pharmacies

( >1 daily) Pharmacy daily (LCI)

National estimate daily

National estimate per annum (mill)

Per 100 Patients#

Poor English 34.6 2.22 10,709 3.17 3.7 CMI computerised information 74.2 4.73 22,818 6.76 7.9 Other computer information 51.2 2.98 14,376 4.26 5.0 Written or printed information 51.8 3.04 14,665 4.35 5.1 Closed area 19.0 1.43 6,898 2.04 2.4 Unenclosed area 67.8 8.59 41,438 12.28 14.3 Forward pharmacy 7.0 0.07* 338 0.10 0.1 MAS (health insurance) 2.5 0.16 772 0.23 0.3 Other 1.9 NA NA NA NA

*>31/day; #* each patient with 2.5 prescribed drugs dispensed

An estimated total of 16.8 per 100 patients prescriptions were counselled in unenclosed , enclosed or forward pharmacy areas . Only 19% of pharmacies provided counselling in a closed counselling area one or more times with the majority of these counselling five or more times daily and 67.8% of pharmacies counselled in a private unenclosed area with the majority of these doing so 15 or more times daily. Counselling in forward pharmacy areas occurred 31 times or more daily in 0.07% (approximately 34) of Australia’s pharmacies. The percentage responses to this item need to be reconciled with the percentages of pharmacies reported to have forward pharmacy areas in Question 26. Pooling the data for counselling in the three identified areas, the mean value indicates 25,087,361 patients (dispensing

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occasions) were counselled per annum in private in community pharmacies. Just 2.5% of pharmacies in Australia are paid for counselling one or more patients daily with prescription medicines through the MAS or other health insurance schemes suggesting this form of payment to pharmacies is in its infancy in Australia. Verbal questioning for monitoring compliance occurs one or more times daily in 82.7% of pharmacies with the LCI mean 19.22 patients daily (Table D-D13b). Monitoring compliance through repeat prescriptions occurs in at least one patient daily in 85% of pharmacies with the LCI mean 26.51 patients daily. A total 26.9% of pharmacies monitor compliance by repeats in 41 or more patients daily and 16% in more than 80 patients daily. Monitoring by repeat prescriptions is the most frequent (and convenient) form of monitoring prescription drugs in Australia’s pharmacies. Dose administration aids (DAAs) have emerged as devices for enhancing compliance with 60.5% of pharmacies reporting use of DAAs for monitoring compliance in more that one patient daily. The results show more than the LCI mean 16.69 patients per day have their drugs monitored by DAAs and 14.5% of pharmacies now monitor compliance with DAAs in 41 or more patients daily and 5.5% in more than 81 patients daily using DAAs. This result is consistent with the high rate of almost 80% of pharmacies which now package prescription medicines for community based patients with DAAs one or more times weekly (refer to Table D-D11a).

Table D-D13b. Australia’s community pharmacies by patients and monitoring for compliance

activities in typical seven days

Method of monitoring compliance

% active pharmacies

(>1 daily)

Estimate for typical seven days

(LCI)

National estimate per seven days

National estimate pa

(mill)

Per 100 Patients*

questions 82.7% 19.22 92,717 4.44 5.2 Repeats 85.0% 26.51 127,884 6.12 7.1 DAAs 70.6% 16.69 80,512 3.86 4.5 Other 1.5% NA NA NA NA

* each patient with 2.5 prescribed drugs dispensed Most pharmacies monitor patient responses to therapy by questioning patients or their carers The use of methods other than verbal assessment to monitor the effects of prescribed therapy in patients( Table D-D13c) show 45.4% of pharmacies monitor drug effects with the use of clinical testing devices such as weight scales, blood pressure and glucose meters more than once daily with 18.3% using devices for 6 or more patients daily in a typical period of 7 days. Adverse effects in patient files are used for 6.4 patients per 1000 of whom half or 3.2 per 1000 were reported to have had their prescriptions declined for adverse effects (Table D-D12). The application of clinical testing devices for clinical monitoring in diagnosed and managed patients, complement the pharmacies with clinical testing devices reported for the purpose of screening clients who are neither diagnosed or receiving treatment (Table D-G18).

Table D-D13c. Australia’s community pharmacies by methods for assessing drug effects in

past seven days

Method for assessing drug

effects

% pharmacies >1 daily

Estimate in typical 7 days (LCI)

National estimate per seven days

National estimate per annum (mill)

Per 1000 Patients*

Clinical testing 45.4 2.45 11,819 0.57 6.6 Laboratory results 5.6 0.22 1,061 0.05 0.6 Adverse effects in patient files

55.1 2.38 11,481 0.55 6.4

Other 1.5 NA NA NA NA * each patient with 2.5 prescribed drugs dispensed

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Only 5.7% of pharmacies reported using laboratory results for monitoring the effects of drugs in one or more patients weekly. These results are presumably made available by doctors to be used by pharmacists accredited to conduct DMMRs or other forms of medication reviews and are available to the pharmacist for assessing patients’ therapies. Adverse effects to drugs now have a legal importance as well as being an important aspect of patient care. The recording of adverse drug reactions is necessary to prevent adverse effects from worsening or recurring with repeat dosing of offending drugs. 55.2% of pharmacies now record adverse effects in patient files with 11.2% recording these in 6 or more patients weekly. Pharia zone Most ( 60% or more) pharmacies in all Pharia zones provided DAAs to 50 or less patients weekly in nursing homes, hostels , community settings or remote health clinics. Supervised dosing occurred one or more times weekly in 15-18% of pharmacies in all Pharia zones for analgesics, 16-30% for benzodiazepines, 4-13% for buprenorphine, 27-46% for methadone and 8-12% for other psychotropic agents with pharmacies in Pharias 5 and 6 being consistently lowest. Between 24-40% of pharmacies in all zones declined prescriptions for one or more patients per week for inappropriate doses and drugs, suspected adverse effects and for defects in prescriptions. Six or more non-poor English speaking patients with prescriptions per day were counselled from 1-5% of pharmacies in Pharia zones 2 to 6 and in 18% of pharmacies in Pharia 1. Six or patients with prescriptions daily received CMI computerised in 19-28% of pharmacies in Pharias 1-6, other computer produced information in 9-16% of pharmacies in Pharias 1-6, other written or printed information in 7-14% of pharmacies with pharmacies in Pharias 5 and 6 providing the least in each category. Six or patients with prescriptions daily were counselled or administered medicines in closed counselling areas in 5-9% of pharmacies in Pharia zones 1 to 6 , unenclosed private counselling areas 39-43% of pharmacies in Pharia zones 1 to 6, in forward pharmacy areas in 12-25% of pharmacies in Pharia zones 1 to 6, counselling paid by MAS or other health insurance in 1-2% of pharmacies in Pharia zones 1 to 6. Compliance was monitored by questions in one or more patients daily with prescriptions in 73-89% of pharmacies, by repeats in 76-90% of pharmacies, by DAAs in 58-80% of pharmacies, in Pharia zones 1 to 6. Therapeutic and adverse effects were monitored with clinical testing devices in one or more patients with prescriptions weekly in 2-7% of pharmacies, with laboratory test results in 2-7% of pharmacies and adverse reactions recorded in files in 47 to 59% of pharmacies in Pharia zones 1-6. The percentage of pharmacies was consistently lowest in Pharia zones 5 and 6. Australia Totals of prescriptions dispensed by Australia’s pharmacies are estimated by the Drug Utilisation Subcommittee (DUSC) from a combination of the number of prescriptions remunerated by the Health Insurance Commission and data on prescriptions submitted by regular surveys of pharmacies conducted since 1999 by the Pharmacy Guild of Australia. Totals of dispensed prescriptions have grown from an estimated 190 million in 1999 to 216 million by 31 December 2002 in Australia ( Table D-D10). From 1999 to 2001 general prescriptions grew by 20%, Veterans Affairs by 17% , private by 14% and concession prescriptions by 11% (Table D-D10). The use of DAAs in medication management is supported by literature and survey evidence collated by Australian researchers 93. The rate of supervised dosing in pharmacies has grown substantially from just those involved in Australia’s methadone maintenance programs94 to a higher percentage regularly supervising dosing the wide range of drugs reported in this national survey (Table D-D11). A national survey of Australian GPs found an estimated 7.0% of 104, 700 GP-patient encounters involved non-English background patients95. Little data exist on the rates of prescription or medication errors, adverse drug reactions or doctor-pharmacist communications in patients in primary health care 96. Medication management is improved by collaboration between doctors and pharmacists which is enhanced by communication and good inter-professional relationships 97. Pharmaceutical company produced CMIs were introduced in Australia in 1993 as brand-specific, written information about prescription and pharmacist-only medications in either a one-page package insert or computer-generated printout. A focus group study found CMIs were long, too technical and the font size too small and pharmacists were advised to use CMIs as a counselling tool and

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tailor their advice to optimise the use of medicines 98. Face-to-face counselling with the patient is the most acceptable way legally to clarify patients’ concerns and to avoid serious dispensing errors 99. International 74% of Great Britain’s pharmacies dispensed up to 5000 prescriptions in an average month100 compared with 73.6% of Australia’s pharmacies which reported dispensing up to 1200 prescriptions in a typical seven days or up to 5,142 monthly (Table D-D10a). In the USA an estimated three billion prescriptions or approximately 11.1 per capita were filled by pharmacies in 2000 10 which is close to Australia’s estimated 10.5 per capita (Tables D-D10 and D-D10a). UK pharmacists are under-reporting adverse drug reactions to national authorities 101. In order to improve adherence with long-term medicines DAAs, appointment reminders and counselling both patients and their carers were effective while clear verbal and written instructions achieved adherence with medicines in the short-term (< two weeks)102-104. Adverse drug events to prescribed medicines were found in 25% of 600 primary care “not ill” patients older than 18 years of which 1.7 of 3.6 (47%) per 100 patients had preventable serious adverse effects105. Activities to prevent adverse drug effects included better patient-doctor communication, educational materials, translation services , web sites for patients for drug information and allow email contact with prescribers, e -prescribing to dispensing pharmacies to facilitate more counselling time and better access by patients to pharmacists who should more actively question patients about drug effects105,106. The above contemporary activities are reflected in the following results (Tables D-D10-13 and D-DK22b and 23). One US study found 34.7% of a sample of pharmacies counselled one or more patients daily with poor or little English comprehension 107. A study of dispensing errors reported to the Institute for Safe Medication Practices in the USA concluded face-to-face counselling is required for all new prescriptions, all prescriptions for warfarin and methotrexate because of the number of fatalities resulting from errors and from asking patients to repeat back important information108. A study which observed 747 clients presenting NHS prescriptions in 30 English pharmacies from September 2001 to January 2002 found 103 (13.8%) received unsolicited counselling and another 30 (4%) were counselled only after prompting the pharmacist and six pharmacies gave no advice during the study period and the percentage of patients receiving advice ranged from 0 to 66.7%109. Just 10.7 % of those using prescription collection services received advice compared with 20.2% of those directly presenting prescriptions109. The type of pharmacy resulted in different frequencies of advice with just 7.7% of those in supermarket pharmacies and 27.3% of clients in a small chain of English pharmacies receiving advice 109. Much higher rates of changes to prescribed doses and drugs and drug discontinuations were achieved by pharmacists working closely with medical practices110. A study of 141 pharmacies in Holland compared characteristics of “prescriptions that were modified” with a sample of “nonmodified prescriptions” found at least 30% of pharmacies each corrected 2.8 prescription medicines daily because of clinical consequences which was extrapolated to 4400 prescriptions nationally a day of which 71.8% involved a clarification with the prescriber 111. This rate compares with Australia’s reported 22,432 estimated patients in pharmacies who had declined prescriptions in seven days of whom 40.4% involved a prescription defect (Table D-D12) . Precise comparisons between the above results is not possible . Studies therefore need to be designed to quantify the rate and nature and combinations of counselling methods actually occurring in Australia’s pharmacies and to compare verbal and non-verbal methods in terms of prescription interventions in pharmacies and outcomes for patients. The use of clinical testing devices in pharmacies according to Australian standards 112 may help to overcome the barrier to de-scheduling of Schedule 4 agents to S3 status. In the USA the 1951 Durham-Humphrey Amendment to the Food, Drug and Cosmetic Act requires orally administered drugs to have “….their effects monitored by a health professional..” to enable medically prescribed drugs to be eligible to be deregulated to over-the-counter drugs 113 . That is, if potent but relatively safe orally administered S4 drugs such as the statins (HMgCoaReductase inhibitors) have their effects monitored they may be eligible for over-the-counter status. This is being fought for by manufacturers in the USA 113. If clinical testing for monitoring purposes therefore became widely and frequently performed in community pharmacies, then the case for widening the range of S3 and pharmacy medicines avail;able in pharmacies would be strengthened.

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In the USA studies of fatal or serious medical errors show prescription errors outnumber all other types (eg in surgery, diagnoses) 114.The Institute for Safe Medication Practices was set up after 1990 to be a centralised collection of information on medication errors in the USA which are analysed, reported , with methods recommended to reduce errors and to evaluate the effectiveness of these methods which include computerised prescribing, prohibiting hand written prescriptions and clearly identifying high-alert drugs115. In Australia, continuous quality improvement (CQI) refers to monitoring and assessing clinical practice to identify opportunities for improvement and change to reduce risk.The PSA has reported CQI guidelines to be adopted in prescription related activities and other aspects of pharmacy practice 96. Interpretations Australia’s community pharmacies have reported a wide range of data supporting the nature and frequency of the services provided with prescription drugs. The high widespread provision of DAAs by most pharmacies often at no charge needs to be assessed for the implications for improved medication use and addition to the associated PBS dispensing fee. Similarly, the less widespread practice of supervised dosing for a growing range of drugs needs to be assess also for the implications for improved medication use and addition to the associated PBS dispensing fee. The medication care activities in Australia’s community pharmacies are corroborated by the 7.4 per 1000 clients reported to have prescriptions declined for therapeutic reasons and 5.1 per 1000 for other prescription defects. Counselling for 14.7% of clients in unenclosed and 2.4% in enclosed and another 0.1% in forward pharmacy areas. Counselling for non-poor English speaking occurs in 3.7% of clients. Monitoring for compliance occurs with questions in 5.2%, checking repeats in 7.1%) and with DAAs in 4.5% of patients with prescriptions. Effects of therapy are assessed by clinical testing in 6.6 per 1000 patients, laboratory results in 0.6 per 1000 patients and with files for adverse effects in 6.4 per 1000 patients with prescribed medications . The results suggest that pharmacies which hold files on adverse effects for patients may be contributing substantially to the 3.2 per 1000 patients declined prescriptions for suspected adverse effects. The rates of verbal counselling and the combinations of counselling aids either with verbal counselling or individually need to be ascertained by studies specifically for this purpose. Similar percentages of pharmacies in all Pharia zones performed these various prescription related activities with the percentage consistently lowest in Pharia zones 5 and 6.

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3.5 Section E Medication review processes Questions: 14a - 14f Statistical sources: Tables 14a- 14f (14 tables). Aims To quantify the nature and rates of medication services provided to patients outside to pharmacies Background In Australia a simple medication review is carried out at the time a medicine is dispensed without the benefit of specific clinical information 116 . Comprehensive medication review refers to a systematic evaluation of a resident’s/patient’s complete medical treatment regimen in the context of other clinical information and the resident’s/patient’s health status. It is a process which is conducted with the resident/patient in collaboration with other members of the health care team and involves communication of, and follow-up on findings and recommendations. It facilitates application, by pharmacists, of special skills and knowledge to support and assist other health professionals and contribute to the care of residents/patients by ensuring quality use of medicines 116 . The quality use of medicines 116 constitutes use that is judicious (only when necessary with non-medicinal alternatives considered), appropriate (taking into account medical conditions, risks and benefits, duration and cost), safe (minimising misuse, including over and under use), and efficacious ( achieves the goals of therapy and delivers actual benefits to health outcomes). Pharmacy services to residential care facilities includes (i) dispensing, supply and distribution of medications; (ii) provision of information and advice about drugs, with the primary objective being the promotion of quality use of medicines ; and (iii) pharmacists responding to residents’ medication-related needs to help them achieve desired health outcomes. A domiciliary medication management review (DMMR) service is a consumer-focused, structured and collaborative health care service provided in the community setting, to optimise quality use of medicines and consumer understanding. It involves the consumer, their general practitioner, pharmacist and other relevant members of the health care team, such as community nurses or carers116 . Discussion of methods Questions were compiled after consultation with the national panel, visits to pharmacies across all Pharia zones in some States and direct or telephone discussions with their key staff, direct or telephone discussions with leaders of pharmacy bodies and pharmacy groups and reference to a range of pharmacy business, practice and research journals published in Australia and internationally. Questions were compiled with the assistance of researchers in the panel and interstate and overseas experienced in these activities. The questions were tested in a focus group of pharmacists from a variety of pharmacies in Pharia zones 1 and 2 and a nationwide sample of practicing and specialist pharmacists in Pharia zones 1 to 6. For national estimates of monthly rates in Table 14d yearly rates were based on the most conservative estimate or the LCI (lowest Confidence Interval), excluding pharmacies with ‘no response’ or ‘none at all’ and multiplying by the 4447 pharmacies operating for the full 12 months. Some of the following results can be reconciled with recently published data 117. Findings The following results pertain to pharmacies reporting in July to September 2002. The numbers of providers of the various medication reviews being approved were increasing rapidly hence the following estimates need to be considered in the context of this rapid growth. A total 53.7% or 2590 pharmacies reported supplying medicines to aged care facilities ( Table D-E14a). An estimated total of 145,182 beds by type of aged care facility were supplied in the 12 months prior ( Table D-E14b). Numbers of private beds in public hospitals are supplied by hospital pharmacies. A total 50.8% or an estimated 2450 pharmacies were approved for DMMRs ( Table D-E14c). The estimated beds or cases by medication review or supply process are recorded in Table D-E14d. The frequency distributions of DMMRs , medication reviews in aged care facilities and S100 supply of medicines reflect activities in progress for some years whereas the frequency distributions for the other review processes signify activities in their infancy (Tables 14d.1-7, Database) . Both

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S100 and enhanced primary care case health assessment received 1% or less pharmacies responding which is at or below the lowest percentage for reliable estimates to be made (refer Section 1.4 methodology). The S100 scheme for supplying Aborigines in remote areas of Australia with medicines at a reduced rate and the medicines are generally provided through a local Aboriginal health service. A total 56% or an estimated 2701 pharmacies reported having access to an AACP-accredited pharmacist (Table D-E14e). The reported position of the AACP-accredited pharmacist in pharmacies is recorded in Table D-E14f. Table D-E14a. Australia’s community pharmacies by those supplying medicines to aged care

facilities in July-September 2002

Status Percentage Estimated total# Yes 53.7 2590 No 45.7 2205

No response 0.6 29 # 4824 pharmacies by % responded

Table D-E14b Australia’s community pharmacies by beds supplied and type of aged care

facility in 2002

Type of facility Mean sd Median * Valid response Estimated total #

Total beds 1999-00

(AIHW,2002) Nursing homes 35.9 85.7 16.0 47.8% 76,311

Hostels 26.0 44.5 15.0 50.1% 57,927 Private hospitals 10.3 41.0 0.0 23.8% 10,901 25,246

other 9.3 28.5 0.0 10.4% 43 Total 145,182

*Results skewed therefore median calculated # 4447 x by % responded by mean

Table D-E14c Pharmacies by HIC approval for Domiciliary Medication Management Reviews in July-September 2002

Approved Percentage Estimated total#

Yes 50.8% 2450 No 43.6% 2103

Don’t know 2.6% 125 No response 3.1% 150

# 4824 pharmacies by % responded by mean

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Table D-E14d Australia’s community pharmacies and patients by medication review (MR)

process monthly during 2002

Review Process Percentage pharmacies

involved (≥ 0 per month)

Percentage pharmacies active

(≥ 1 per month)

Beds or cases monthly

(LCI )

Total beds or cases monthly#

Home medicine reviews or DMMrs

24.5 16.5 1.30 1416

Medication management reviews in aged care

facilities

19.7 16.4 3.37 2952

Enhanced primary care multidisciplinary care plan

10.9 5.8 0.43 207

Enhanced primary care case conference

3.7 1.6 0.06 10

Enhanced primary care Case health assessment

2.6 0.8 0.03 3.5

S100 for aborigines 2.1 1.0 0.14 13 Other medication reviews 0.6 NA

# 4447 x by % involved (≥ 1 per month) x LCI

Table D-E14e . Pharmacies by access to Australian Association of Consultant Pharmacy accredited pharmacist in July-September 2002

Access to AACP pharmacists Percentage Total#

Yes 56.0 2701 No 35.2 1698

Don’t know or no response 8.5 410 Total pharmacies with access 56.0 2701

# 4824 by percentage

Table D-E14f. Position held with AACP-accredited pharmacist in Australia’s community pharmacies with access in July-September 2002

Position in pharmacy % Estimate#

Proprietor 15.3 413 Manager 2.2 59

Employee full-time 2.5 68 Employee part-time 4.6 124

Consulted or contracted 26.9 727 Other and no response 48.5 1310

Total with AACP-accredited pharmacists 51.5 1442 # 0.56 x 4824 = 2701 by percentage

Pharia zone Only 31% pharmacies in Pharia zone 1 supply medicines to aged care facilities or private hospitals compared higher percentages up to 84% of pharmacies in Pharia zone 4 whereas 56% of pharmacies in Pharia zone1 and 55% in Pharia zone 2 are registered with the HIC as DMMR providers . Australia Studies concluded before 2000 in three States of Australia demonstrated the benefits of comprehensive medication review by pharmacists in aged care facilities and residences118-121. Pharmacies were able from 1997 to engage and be remunerated for pharmacists accredited by the Australian Association of Consultant Pharmacy or the Society of Hospital Pharmacists of Australia to perform comprehensive medication reviews in residential aged care facilities

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and since 1 October 2001 to perform Domiciliary Medication Management Reviews 117 . The subsequent development and promotion of programs with pharmacists accredited to perform comprehensive medication reviews specifically for patients in residential aged care facilities and in homes have occurred widely in community pharmacy practice 122-124. In July to August 2002, 50.8% of Australia’s community pharmacies were HIC-registered DMMR providers (Table D-F14c).This had risen to 68% by January 2003 117 reflecting a 33.3% increase in six months . This trend suggests more than 90% of pharmacies will be DMMR providers in 2004. The actual number of 2450 DMMR pharmacy providers of DMMRs in July and 2760 in August 2002 is consistent with the estimated total of 2540 (Table D-E14a) . The actual total 146,332 operating residential aged care facilities is close to the estimated total of 145,182 beds supplied medicines by Australia’s community pharmacies (Table D-E14b). The estimated total of 1416 DMMRs performed monthly (Table D-E14c) compares with the mean 1220 DMMRs claimed monthly by Australia’s GPs in 2002 and 1433, 1416 and 1424 DMMRs claimed in June, July and August 2002 117. The reported rate of over 1400 DMMRs estimated to be supplied medicines monthly (Table D-F14d) in June-September 2002 (survey period) is higher than the corresponding GP Item 900 item at that time 117. The difference may be due to differences in the periods compared, non-HIC remuneration, statistical variation in Confidence Intervals or other factors . The other rates in Table D-F14d need also to be reconciled against the relevant HIC or GP Item Numbers. The access to AACP-accredited pharmacists is in accord with their numbers and distribution compared with numbers of approved pharmacies with DMMRs (Tables D-F14c, D-F14d and D-F14e). The rates for the other forms of medication reviews reported and remunerated (Table D14d) need to be reconciled against actual HIC remuneration data. Australian researchers have reported other steps which need to be taken to improve medication use in nursing homes117. International In the UK the studies of pharmacists’ medication activities in nursing homes or aged care facilities were limited to the supply of drugs, providing drug information and identification of drug interactions 125. Research in the USA confirms the high rates of inappropriate prescribing ranging from 21.3% in domiciled and up to 40% of institutionalised patients126 . National estimates The national estimates for DMMR providers, total beds supplied by pharmacies and DMMRs provided monthly by pharmacies are consistent with official statistics. The other estimates need to be reconciled. Interpretations The rates of comprehensive home medication reviews are consistent with official data. The rates for other forms of reviews reported in residential aged care facilities and other forms of medication review processes (Table D-E14d) need to be reconciled against actual HIC remuneration data. The rates of DMMR provider pharmacies is higher in Pharia zone 1 than percentages of pharmacies in Pharia zones 2-6. In comparison the rates of pharmacies supplying medicines to aged care facilities is much lower in Pharia zone than by pharmacies in Pharia zones 2-6.

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3.6 Section F Primary health care including pharmacy and pharmacist-only medicines

Questions: 15a and 15b. Statistical sources: Tables 15a 1.1- 15a.6.2 (12 tables); Tables 15b.1.1 -15b.2.2 ( 4 tables) Aim To quantify primary health care, self-medication and associated activities in pharmacies and the frequency of detecting misuse and refusal of supply of over-the-counter medicines (S2 and S3). Background Australia has standards and guidelines for pharmacists assisting self-medication by consumers, providing consumer medicine information, general practitioners’ and pharmacists’ inter-professional communication and the provision of pharmacist only and pharmacy medicines in community pharmacy 127. Self care actions are taken by individuals to manage their health without paying for services provided by a health worker 128. Primary health care in developed countries is provided by health workers including doctors and pharmacists who form the first level of contact with health systems 129. Self-medication, the most frequent form of health care, refers to patients taking responsibility for the management of minor illnesses using products they have selected without the assistance of a health worker 128. Community pharmacists have been documented as active primary health care providers in Great Britain and Australia since the 19th century 129,130 . In the USA, the Indian Health Service pharmacists have, since the 1980s, routinely offered primary health care in reservations 131. Medical bodies in the USA however oppose “…independent pharmacist prescription privileges and initiation of drug therapy…” 132 . For drug deregulation (switching in the USA) from medical prescription (Schedule 4 or S4 in Australia) to pharmacist-prescribing (P status in the UK, or Schedule 3 or S3 in Australia) and non-medical- non-pharmacist agents, the criteria are stricter in the USA than in the UK or Australia 133,134. Limited pharmacist and nurse prescribing has commenced in the UK 135-137 . In Australia the S3 (pharmacist-only) status is under challenge and if Australia’s pharmacists are to retain S3 drugs then they must exercise duty of care to ensure proper use and minimise harm from adverse effects, misuse or abuse of these drugs 138. The American Pharmaceutical Association has published a monograph on pharmacists “assuring appropriate OTC medication use” 139. Discussion of methods Questions were compiled after consultation with the national panel, visits to pharmacies across all Pharia zones in some States and direct or telephone discussions with staff, direct or telephone discussions with leaders of pharmacy bodies and pharmacy groups and reference to a range of pharmacy business, practice and research journals published in Australia and internationally. Additionally, self-medication and other non-prescription health activities were recorded by trained independent observers in four pharmacies before finalising Question 15a. A focus group from pharmacies in Pharia zones 1 and 2 and a nationwide sample of practicing and specialist pharmacists in Pharia zones 1 to 6 tested the questions. The national estimates of these activities are recorded in Tables D-F15a and D-F15b. Findings The main results are summarised in Tables D-F15a,D-F15b and D-F15c. The conservative daily estimates per pharmacy are 25.87 self-medication clients and 28.85 clients for heath requests resulted in national estimates of 36.97 and 41.23 million consultations for a total 78.2 millions per annum in Australia’s pharmacies (Table D-F15a). Printed information including computerised CMIs and Self Care cards (c. 1.5 million annually) were issued to a total 12.493 million clients. The estimated 4.19 million (adjusted) referrals to doctors by pharmacies approximates nearly 5% of the total yearly GP consultations in Australia 140 and compares with 1.77 million referrals to other health workers and the total of 0.666 million referred annually to complementary health workers (Table D-I20a).

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An estimated 0.863 million clients annually were suspected of misusing a range of dependence-producing S2 and S3 medicines (pharmacist-only and pharmacy over-the-counter medicines) and an estimated 0.631million (73.1%) clients (Table D-F15a) were refused supply in Australia’s pharmacies. The 73.1% refusal is the most decisive of available actions. Table D-F15a. Australia’s community pharmacies by primary health care and self medication

activities per typical working day

Health care actions OTCs only

Persons daily per pharmacy

(LCI)

Per week per pharmacy*

Total in pharmacies per week 1

(millions )

Total in pharmacies pa

(millions )# Self-medication (named S2 or S3) 25.87 159.9 0.771 36.97 Primary care (received assistance) 28.85 178.3 0.860 41.23 Printed information including computerised CMIs and Self Care

7.18 44.4 0.214 10.26

Referred to GPs 5.93 a

2.93 36.6 18.11

0.177 0.087

8.47 4.19

Referred to other health workers 2.74 b

1.24 16.9 7.7

0.082 0.037

3.92 1.77

* 6.18 x LCI . 1. 6.18 x 4824 x LCI. # 4447 x 6.18 x 52 x LCI. a = adjusted to 2.93 due to skewness of results ; b= adjusted to 1.24 due to skewness of results .

Table D-F15b. Number of clients with suspected misuse of over-the-counter medicines (S2

and S3) in last seven days

Misuse of OTCs Per week per pharmacy Yearly per pharmacy*

Total in pharmacies (million pa)

Suspected 3.73 194.0 0.863 Refused supply 2.73 142.0 0. 631

* LCIx52 #LCI x 52 x 4447

Table D-F15c. Australia’s community pharmacies by health consultations in past two weeks by Australians

(Sources: National Health Surveys 1983-4, 1995 and 2001; Berbatis, 1986) 141-143

Consultations 1983-4 1995 2001 Thousands per two weeks 395.0 424.5 789.5

Millions per annum 10.27 11.04 20.53

Pharia zones The rates of self-medication are consistently less than health care or information provision overall and in each Pharia zone. The ratio of health requests : self-medication is higher in Pharia zones 2 to 6 than in 1 reflecting perhaps the more pronounced effects of direct-to-consumer advertising of pharmaceuticals and marketing by pharmacy banner groups in urban than rural areas144 . Australia The ratio of 25.87: 28.85 (Table D-F15a) or 90:100 of self-medication : primary health serves as a reference for measuring trends in self-medication resulting from changes in S3 legislation or direct to consumer advertising in Australia 145. The estimated total 1.63 million cases of self-medication and health assistance weekly reported by pharmacies exceeds by 4-fold the rate recalled by household consumers in the National Health Survey 2001 (Table D-F15c). If verified, the reported rates raise pharmacies to second place in health consultations after doctors and above dentists in Australia142. These reported rates are well below those recorded by trained independent observers in four pharmacies during the preparation of the questionnaire. The PSA reported between 1.5 and 2.0 million Self Care cards are procured

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yearly by Australia’s pharmacies which implies over eight million computerised CMIs are given yearly by pharmacies to consumers to accompany non-prescribed pharmacy medicines (Table D-F15a). The need for vigilance in pharmacies for misuse of S2 and S3 medicines in the case of a possible pseudoephedrine-associated death was reported in 1996 and the consequent need for pharmacies to retain these medicines was made by a prominent pharmacist-solicitor 146. International National guidelines for pharmacists in the USA assuring the appropriate use of OTC (over the counter) medication use have been published by the American Pharmaceutical Association 139,147. In the USA the misuse of self-selected products with pseudoephedrine, dextromethorphan and antihistamine off the shelves without pharmacist intervention has been reported in large numbers from Missouri, California, Minnesota, New Jersey and Illinois 148,149 . Reports of misuse of cough and cold products to US Poisons centres rose to 13,393 in 2000 from 9,889 in 1999 148 . Direct to consumer advertising results in increased self-medication but less likelihood of effectiveness 144,150. The continued promotion of outdated medicines occurs often in non-pharmacy outlets150. Options to refusing supply are pharmacist counselling, referral to doctors, increased communication between pharmacies to better identify strangers or ‘pharmacy shoppers’ and a contract between pharmacy and consumer to regulate supply as part of a ‘harm minimisation approach’ 148,150,151 . In the UK a textbook entitled ‘Minor illness or major disease?’ 152 includes action plans for a range of common disorders encountered in community pharmacies. This book is complemented by current treatment guidelines with over the counter and pharmacist-only medicines for the common encountered disorders 153. Surveys of OTC misuse in the UK have found opioids in males, antihistamines, sympathomimetics and laxatives in females are the most frequently misused over-the-counter drugs 151,154. Most community pharmacists deal with suspected misuse by refusing sales150,154 . The rate of 3.73 cases of suspected misuse per week reported here (Table D-F15b) is much higher than the 1.66 cases weekly of misuse and abuse of over-the-counter drugs reported by community pharmacies in Northern Ireland154 . Interpretation A total annual 92.2 million non-prescription health care cases comprising 36.97 million cases of self-medication and 41.23 million advice or pharmacy-selected medication and health assistance are estimated to occur annually in Australia’s pharmacies . Of these, 13.6% resulted in CMI or printed information including approximately 1.5 million Self Care cards. Pharmacies in Pharia 1 have higher self-medication rates relative to primary care than Pharias 2-6. The rates are four-fold those reported in Australia’s ABS national health surveys. An estimated 0.863 million cases of OTC misuse were suspected with 73% refused supply which is over twice the rate reported in overseas studies. Rising misuse of dependence-producing OTCs in the USA reported by police and poisons centres may result in legislation for firmer control in US outlets.

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3.7 Section G Preventive services implemented in this Pharmacy

Questions: 16-18 Statistical sources: 16 - 18.7.2 (28 tables) Aims To quantify a facility (vaccine refrigerator), OTC agents and screening tests used or issued for preventive purposes in Australia’s pharmacies. Background Australia has reference values for laboratory tests and information on immunisation and protocol for cold chain management in community pharmacies155. The history and rationale of pharmacists’ involvement in preventive, health promotion or public health activities in Australia have been reviewed156. Australia has standards and guidelines for pharmacists assisting self-medication by consumers, providing consumer medicine information, general practitioners’ and pharmacists’ inter-professional communication and the provision of pharmacist only and pharmacy medicines in community pharmacy 156,157. The revised RACGP (2002) guidelines identify by level and strength of evidence the preventive activities recommended for general medical practice in Australia158. These are generally applicable to preventive activities in Australia’s community pharmacies but the RACGP (2002) omits guidelines for the primary prevention of cardiovascular disease in at-risk people and the secondary prevention of acute myocardial infarction158. Other evidence-based evaluations of pharmacy services were also taken into account159-162. The trend in Australia towards approved agents used for primary and secondary prevention (ie chemopreventive agents) is reflected by cardiovascular agents and vaccines indicated for preventive purposes comprising 32.6% of Australia’s Pharmaceutical Benefits Scheme (PBS) expenditure in 2001-02, up from 29.1% in 2000-01. Discussion of methods Questions were compiled after consultation with the national panel, visits to pharmacies across all Pharia zones in some States and direct or telephone discussions with staff, direct or telephone discussions with leaders of pharmacy bodies and pharmacy groups and reference to a range of pharmacy business, practice and research journals published in Australia and internationally. A focus group from pharmacies in Pharia zones 1 and 2 and a nationwide sample of practicing and specialist pharmacists in Pharia zones 1 to 6 tested the questions. The national estimates of these activities are recorded in Tables D-G17 and 18. Findings In July-September 2002 ,82% or an estimated 3,956 community pharmacies in Australia (Table D-G16) had vaccine refrigerators (2-8oC). The percentages of pharmacies which reported providing over the counter agents for primary preventive purposes and annual total numbers of preventive OTC agents initiated by Australia’s community pharmacies weekly and annually are estimated (Table D-G17). The annual total numbers of screening tests performed in Australia’s community pharmacies weekly and annually are estimated (Table D-G18) from the results in the database (Tables 18.1.1 to 18.7.1) .Similar percentages of screening services in US pharmacies have been reported by a nationwide survey of pharmacy customers in the USA (Table D-G18) 163 . Australia’s community pharmacies in 2002 reported similar percentages to those reported in US pharmacies 163 and higher percentages ever performing screening services (Table D-G18) than those reported from Great Britain’s 2000 national survey of pharmacies164. The percentages reported by British pharmacies were blood glucose by 5%, 11% tested blood pressure and 3% tested blood cholesterol 164 . Data on clinical testing performed in 2002 were obtained also from a group of pharmacies which engaged nurses to provide this service every two to four weeks in urban pharmacies and monthly to a distant pharmacy (Table D-G19).

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Table D -G16. Vaccine refrigerators in Australia’s pharmacies Response % pharmacies Total *

yes 82.0 3956 no 15.9 767

No response 2.1 101 * % x 4824

Table D -G17. Total pharmacist-initiated OTC medicines for primary prevention in Australia’s

pharmacies

Preventive OTC Pharmacy week (LCI)

National per week (LCI)*

National per 12 months (million) #

Population potential

Nicotine therapy 6.28 30,295 1.452 c. 1.2 million smokers Aspirin ( ≤ 100mg daily) 2.97 14,327 0.687 c. 3million

Iron for anaemias 3.20 15,437 0. 740 c. 1 million Folic acid in pregnancy 2.49 12,012 0. 576 c. 250,000 born yearly

Calcium 3.76 18,138 0. 869 c. 1.0 million Daily multivitamins 6.51 31,404 1.505 c. 0.5 million

* LCI x 4824 ; # LCI x 52 x 4447

Table D G-18. Numbers of screening tests provided by Australia’s pharmacies for undiagnosed patients in a typical 30 days and 12 months

Screening test 30 days

(LCI) national

(LCI)* National in 12

months# % pharmacies

≥ 1 test/ month % pharmacies

in USA 9 Anthropometric

(weight, etc) 0.27 1,303 14,408 6.7% NA

Cholesterol 0.23 1,110 12,273 4.9% 17% Glucose 1.48 7,140 78,979 21.6% 13%

Blood pressure 4.84 23,348 258,282 51.1% 55% Bone density 0.40 1,930 21,346 8.3% 11% Pregnancy 0.47 2,267 25,081 8.2% NA

* LCI x 4824 ; # LCI x 12 x 4447

Table D-G19. Screening tests provided in all Australia’s community pharmacies 12 months by all pharmacies and a sample of 30 pharmacies with nurses in 2002.

Tests pa / pharmacy in 2002

Tests pa/ pharmacy in pharmacy group with nurse in 2002

Blood pressure 58.1 160.2 Blood glucose 17.8 86.7

Blood cholesterol 4.2 103.4 anthropometric 3.2 7.97

Pharia zone For OTC agents issued for preventive purposes one or more times in seven days for undiagnosed clients the pharmacies in Pharia zones 4, 5 and 6 ranked lowest for nicotine therapies with 76% and 77% respectively . For low dose aspirin the highest (41%) were pharmacies in Pharia 1 and the lowest (27%) in Pharias 5& 6. For iron supplementation, the highest (60%) were pharmacies in Pharia 1 and the lowest (47%) in Pharias 5 and 6. For folate, the highest (60%) were pharmacies in Pharia 1 and the lowest (46%) in Pharias 3, 5& 6. For calcium products, the highest (64%) were pharmacies in Pharia 1 and the lowest (48%) in Pharias 5 and 6. For daily multivitamins, the highest (84%) were pharmacies in Pharia 1 and the lowest ( 69%) in Pharia 3. For rates of clinical testing just 4% of pharmacies in Pharia zone 4 provided anthropometric testing more than once monthly. Just 3% of pharmacies in Pharia zones 4, 5 and 6 provided

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cholesterol testing more than once monthly. Just 12% of pharmacies in Pharia zones 5 and 6 provided cholesterol testing more than once monthly. Just 36% of pharmacies in Pharia zones 5 and 6 provided blood pressure testing more than once monthly. Just 6% of pharmacies in Pharia zones 5 and 6 provided bone density testing more than once monthly. Just 3% of pharmacies in PhARIA zone 4 provided pregnancy testing more than once monthly. The above data need to be standardised for the total number of clientele in order to enable complete comparisons. Australia The prevalence of vaccine refrigerators, rates of OTC agents issued and screening tests performed reflect the extent and level of prevention (mainly primary preventive) activities offered by Australia’s community pharmacies. The evidence-based reports above were used in selecting the agents and tests in Questions 16 to 18 together with advice from pharmacy practitioners nationwide. In particular OTC preventive agents such as mini-dose aspirin, folate and calcium are recommended in the RACGP (2002) guidelines as is smoking cessation for which nicotine replacement agents are an effective treatment 158 . Low dose aspirin (75-150 mg) daily was included because it is recommended for the prevention of stroke and where transient ischaemic attacks are due to arterial disease 158,165,166 . Its use is well established for the secondary prevention of serious vascular events including myocardial infarction, transient ischaemic attacks and stable or unstable angina165,166. For primary prevention low dose aspirin is warranted in those with a raised cardiovascular risk score 165,167 but should be an adjunct and not replace the management of existing cardiovascular risk factors 166 .

Antioxidant vitamins are no longer warranted for the prevention of cardiovascular, cancer or other morbidities 168,169 and are not recommended by the RACGP (2002)158. Daily multivitamins for nutritional deficiency were included because their low cost and greater likelihood of benefit than harm at doses not exceeding recommended daily allowances appear vindicated for the prevention of nutritional deficiency especially in certain subgroups . These include women who may become pregnant, for elderly who tend to consume Vitamin B12 poorly and are often deficient in vitamin E , persons who regularly consume one or two alcoholic drinks per day, vegans who require supplemental vitamin B12 and for indigent people who may be unable to afford adequate intakes of fruit and vegetables170 . Multivitamin products were included also because of the evidence for preventing infections in vulnerable populations including diabetics171. The RACGP guidelines (2002) recommend 5.0mg folate daily for high risk pregnant females and 0. 5mg daily routinely in pregnant women to prevent neural tube defects in offspring158. Fluoride is recommended routinely for preventing dental caries in at-risk people158. Calcium is indicated for preventing osteoporosis172. Iron for preventing anaemias was included because the estimated prevalence of iron deficiency in the USA is 7% in toddlers (1-2 years) and 9%-16% in females aged 12-49 years and is much higher among those in ethnic minorities 173 . These rates also appear true in Australia’s aborigines 174. The latter two agents need to be reviewed for their inclusion in future surveys. At least one million Australians have undetected and untreated risk factors such as raised blood pressure, total cholesterol, blood glucose or low bone density who could be screened by Point of Care Testing in community pharmacies 175,176 . Another estimated two million Australians have poorly managed obesity and tobacco smoking who may be better managed with organised interventions in pharmacies. There are legal and practical barriers to clinical testing in Australia’s community pharmacies 176,177. University teaching of undergraduate and graduate pharmacists have been introduced by university departments of pharmacy 178. State surveys of testing in Western Australia’s pharmacies were reported in 1997 for a range of tests179. Glucose and microalbuminuria found most were done in shopping centre pharmacies 180. Clinical testing for the screening of blood total cholesterol and glucose performed and supervised by pharmacists in two Western Australian shopping centre malls found good acceptability by 76 subjects who were willing to pay up to $10 per test 181. A study of clinical testing in nine Upper Hunter Valley (NSW) pharmacies including two with a nurse found 75% of 389 subjects had at least one test result that was outside the reference range. Results included 53% with raised blood pressure and total cholesterol above 5.0mmol/L and 32% who had never had cholesterol measured before182. They referred 28% of subjects of whom 58% visited GPs with 11 prescribed medications involving eight on lipid lowering agents and three on antihypertensives. The nurse delivered service cost just 60% of the pharmacist service.

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Both capital and operating costs of the nurse service could be lowered. It was strongly recommended the nurse-pharmacist model be further evaluated 182. The national survey revealed a group of 30 pharmacies which had engaged nurses since 1990 to perform screening tests. The group provided results performed in 2002 by category (Table D-G19). These show much higher rates when compared with the results of all pharmacies with respect to blood glucose and blood cholesterol each of which requires skin penetration. Skin penetration is one of the barriers to pharmacies introducing clinical testing 176,177 In Australia, the sales of personal and health products including OTC agents and vitamins are monitored through wholesale and manufacturers data by IMS Health Australia (manufacturer and pharmaceutical wholesaler) and AC Nielsen (warehouse, manufacturers and suppliers). Retail data from pharmacies are reported by the Australian Bureau of Statistics and by Aztec Information Systems from a national sample of 330 pharmacies stratified into States 183. These are reported yearly in categories of products and therapeutic groups of OTC agents183,184. The annual sales figures may potentially be converted to units and reconciled against the OTCs reported here (Table D-G17). In the monthly pharmacy retail turnovers, the months of July and August when the survey was conducted, are amongst the highest monthly national sales in pharmacies each year 183 . International No reports were found from Australian or overseas sources on the initiation or issue of OTC agents for primary preventive activities in community pharmacies. The preventive effects of OTC agents especially vitamins need to be carefully considered by pharmacy bodies in Australia. For instance a five year randomised double blind study found 600 mg vitamin E, 250 mg vitamin C and 20 mg β-carotene taken daily by high risk individuals was safe but did not lower mortality or incidence of any type of vascular disease, cancer or other major outcome168. Of 710 respondents in a national survey of 1,000 households in the USA held in 2001, 55% reported that their pharmacies screened for hypertension, 17 % for cholesterol, 13% for blood glucose and 11% for osteoporosis 163. Approximately one-third reported their pharmacies offered immunisation. Evaluative studies reported from the USA and Canada have shown the effectiveness and acceptance in community pharmacies of testing for the screening and management of blood pressure, blood cholesterol, blood glucose and bone density 162,185-189. In the UK local health authorities coordinate primary health care activities with sharing of resources between doctors, pharmacists and other health care workers. In a two year study in an English medical centre 449 patients were divided into three defined cardiovascular risk groups, screened, then treated by doctors and advised on medication compliance, managing their lifestyle risk factors and monitored by a pharmacist trained in clinical testing190. The pharmacist advised on medication changes and measured or recorded body mass index, smoking, blood glucose, blood pressure and hypercholesterolaemia. Significant reductions in individual and overall risk factors occurred over two years 190 . Of 40 patients who had diastolic blood pressure > 100mm Hg, 18 were originally receiving antihypertensive agents . Of these 11 received medication changes during the study. Of another 20, 13 were started on antihypertensives and nine were controlled without medications 190. Interpretations 82% of Australia’s pharmacies reported compliant vaccine refrigerators in 2002. Pharmacies in Pharia zones 5 and 6 consistently reported the lowest percentages to issue OTC agents for preventive purposes and to perform screening tests. These results imply that rural and remote pharmacies have smaller rates of clients, where screening was less uneconomical or desirable, the pharmacists had less knowledge and skills about these preventive activities or less pharmacies are located in large shopping centres where the rates of screening are higher 179 . The high numbers who screen for blood pressure was five fold higher than was reported by British pharmacies but similar to rates of screening blood pressure, blood cholesterol, blood glucose and osteoporosis by pharmacy clients in the USA. This may be due to higher levels of awareness, knowledge and/or skills of screening in Australia’s community pharmacies compared to British pharmacies and similar levels to US pharmacies. The higher rate of blood pressure than blood glucose or blood cholesterol screening may be

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due to a combination of legal or practical barriers to skin penetration or ignorance or resistance by clients or their carers. The numbers of Australians with raised levels of either blood pressure, blood glucose or blood cholesterol exceed one million in each category. The low rates of anthropometric screening in pharmacies is difficult to explain given the 20% of Australians with obesity, the grave consequences on health of obesity and the low cost, non-invasive nature and ease of measurement. The much higher rates of screening found in one group of pharmacies which employed nurses for this task compared with pharmacies overall, together with the lower costs of clinical testing involving nurses in pharmacies, reinforce the need to evaluate clinical testing first in those pharmacy groups with nurses.

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3.8 Section H Harm minimisation services and detected S4 and S8 forgeries and doctor shopping in Australia’s pharmacies.

Questions: 19a and 19b Statistical sources: Tables 19a.1.1- 19a.6.2 (12 tables); Tables 19b.1.1-19b.2.2 (4 tables) Aims To quantify the harm reduction and detection of forgeries and doctor shopping for S8 and S4 drugs of dependence occurring in Australia’s pharmacies. Background Standards for the pharmacist management of licit opioids in Australia are set down in State and national regulations and guidelines 191,192,193 . In Australia, harm minimisation in the 1980s referred mainly to methadone and needle syringe programs but by 1999 the term ‘harm reduction’ had broadened to efforts which reduced the adverse health, social and economic consequences of illicit drugs without necessarily reducing their consumption 194. In Australia, methadone and needle syringe programs first appeared in Australia’s community and hospital pharmacies around 1970 in the form of providing methadone for treating illicit heroin addiction195 . Harm reduction in pharmacies in Australia now encompasses a range of activities including participating in needle syringe programs and programs involving methadone and other therapies or activities for treating drug or agent dependence, providing information for reducing harms from the misuse of drugs or agents of dependence, issuing condoms for the purpose of preventing sexually transmitted diseases in drug or agent misusers and measures taken to identify and prevent drug or agent misuse in individuals195,196 . The UK’s National Addiction Centre was the first to conduct systematic national research of harm reduction activities performed in community pharmacies from the late 1980s197-199. In Australia the first comprehensive surveys and cost analyses of methadone programs involving community pharmacies were first performed in 1996 by Victoria ‘s Turning Point group 200,201. In 1999 and 2000, Curtin University pharmacy researchers (WA) managed a series of studies in five of Australia’s jurisdictions which reported high client acceptability of pharmacies in community methadone programs, characteristics of participating pharmacists and pharmacies, retention of clients in methadone programs, costs in public and private clinics and factors affecting the prevention and treatment of drug misuse 202. Reviews of international and UK data corroborated the large and effective roles played by community pharmacies in the prevention and management of drug misuse 199,203. Discussion of methods Questions were compiled with the assistance of pharmacists experienced in harm reduction activities in pharmacy. The questions were tested in a focus group of pharmacists from a variety of pharmacies in Pharia zones 1 and 2 and a nationwide sample of practicing and specialist pharmacists in Pharia zones 1 to 6. The ‘harm reduction’ activities listed in Question 19a items excluded the sale of condoms and the provision of information; these were largely disregarded by respondents in the ‘other’ activities. Detected forged prescriptions and identifying doctor shoppers in Australia’s pharmacies related to medically prescribed dependence-producing and Schedule 8 agents (opioids and psychostimulants) . Findings The prevalence of 34.6% and 10.8% of Australia’s pharmacies involved in methadone and buprenorphine dosing (Table D-H19a) are consistent with the rates reported in the results for Questions 7 and 11c. The prevalence of methadone and buprenorphine dosing in 2002 reflect a marked increase from the 31% of Australia’s pharmacies in May 2000 registered to provide methadone for opioid-dependent patients 202 . Methadone dispensing occurred more frequently compared to needle supply in a similar number of pharmacies nationwide (Table D-

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H19a) . Benzodiazepine contracts or arrangements with prescribers for other drugs of dependence193,202 is practiced in 45.5% of Australia’s pharmacies with 18.8% active at least once daily (Table D-H19a).

Table D-H19a. Pharmacies and harm reduction activities: daily clients and percentage pharmacies ever involved in July-September 2002

Activity Number daily per

pharmacy (LCI) National daily total * % of pharmacies

active ≥ 1 daily Methadone dosing 2.16 10,420 34.6%

Buprenorphine dosing 0.49 2,364 10.8% Naltrexone dispensing 0.05 300 0.5%

needle supply or exchange

1.91 9,214 33.9%

benzodiazepine or other prescriber contracts

0.70 3,377 18.8%

* LCIx4824

The estimates of forgeries detected in pharmacies are above those estimated from reports of forgeries by pharmacists in Victoria 204 and estimates of 0.04% forgeries in the USA equating per capita to 8,800 forgeries pa in Australia. The results imply awareness of forgeries by pharmacists and/or higher rates of forged prescriptions of prescriptions for S8 and other dependence-producing S4 drugs. The HIC reported 8179 doctor shoppers who received 1,047,582 prescriptions in the 12 months to 30 June 2000205. This project terminated on 30 June 2002. Pharmacies reported detecting an estimated 7332 clients with forgeries which equates to an estimated 12,687 doctor shoppers in the six months to 30 June 2002 (Table D-H19b). These figures may include the multiple detection of the same doctor shoppers in pharmacies, less strict criteria than the HIC’s applied by pharmacies, many more actual doctor shoppers exist than reported by the HIC because doctor shopping with private or other prescriptions for these agents were not accounted for by the HIC, or an overestimate in the LCI.

Table D-H19b. Numbers of clients with prescription forgeries of S8 and S4 dependence

drugs and doctor shoppers detected from 1 January to 30 June 2002 in Australia’s community pharmacies 2002

Number per

pharmacy (LCI) Total six months per

pharmacy* Total 12 months per pharmacy#

% of pharmacies detected ≥ 1

over six months Forgeries 1.52 7,332 13,519 34.3% Doctor shopping 2.63 12,687 23,391 49.1%

* LCI x 4824 # LCI x 2 x4447

Pharia zone The percentage of pharmacies providing each harm reduction service once or more daily was consistently lowest in Pharia zones 5 and 6. The percentage of pharmacies detecting doctor shopping or forged prescriptions was lowest in Pharia zones 4, 5 and 6. Australia The relatively high rates of methadone and buprenorphine dispensing (Table D-H19a) reflect the continued success of community pharmacies in primary care-based methadone maintenance treatment (MMT) programs in Australia . A national evaluation reported pharmacists are well regarded by MMT clients, the price of methadone dosing in pharmacies is lower or competitive with private clinics and the retention of patients in MMT programs with methadone pharmacies is higher than in hospital-based methadone programs202. Australia’s high world ranking in the per capita consumption of oral morphine, pethidine, methadone liquid and psychostimulants is associated with 2-5 fold differences between states and territories and concurrent high rates of misuse reported in serial surveys from

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jurisdictions with higher consumption 206-209. Pharmacists are required by statute to be alert to forged prescriptions and exercise reasonable care in assessing prescriptions 210 . Many pharmacists in Australia are unaware of the extent of forgery nor of their legal and ethical responsibilities204 . The rising rates of misuse of licit drugs such as morphine, pethidine , Panadeine Forte and benzodiazepines have been attributed to the persisting nationwide shortage of illicit heroin 211,212. The misuse of Schedule 8 drugs in Australia is partly reflected in the numbers of stolen doctors’ prescription pads throughout the country , reports of forged prescriptions, from 0.5-1% of doctors in NSW and Victoria self-administering opioids, excessive prescribing and dispensing by doctors and pharmacies, the numbers of doctor shoppers (excessive visits to doctors or excessive prescriptions for drugs of dependence ) , pharmacy break-ins for S8 agents , diversion or sale by recipients of the drugs to others , the improper administration by injection or other routes and the morbidity or mortality related to misuse. Doctor shoppers in Australia obtained Schedule 8 drugs and other drugs of dependence 204,205,211,212 These many examples reflect a state of drug misuse in Australia requiring high vigilance and preparedness to intervene by pharmacists but they are currently limited principally because they lack the access to S8 medication histories of patients when they dispense these agents. A survey of forged prescriptions undertaken in Victoria from 1999- 2000 included reports of forgeries received from pharmacies by Victoria’s Department of Human Services’ Drugs and Poisons Unit 204. In 1997 they comprised 155 pharmacies with 73 alterations to genuine prescriptions, 99 forged on stolen stationery, involving 146 names and 191 different drugs sought. In 1998 they comprised 112 pharmacies, 76 and 51 types of forgeries, 121 names and 124 different drugs. From 1 January to 15 March 1999 (74 days) the figures were 38 pharmacies, 15 alterations with 28 on stolen stationery, 41 names and 38 different drugs. The survey used for estimating rates of forgery was based on 261 responses from 739 randomly selected pharmacists in the first round and in the second round 56 responses from 300 of the 478 non-respondents. These made a total of 317/739 ( 42.9%) responses or 35.3% ( 261/739) plus 56/300 (18.7%) or 54% based on adding the responses to each mailing denominator204: 59% of respondents reported between 2-10 per year and 74% reported 1 or more yearly (pages 39, 60.The Department received concurrently just 13 reports per month thus being “..a major underestimate.. “ of the number occurring (page 60) 204 . The national estimates of reported detected forgeries and doctor shopping (Table D-H19B) now serve as references for assessing community pharmacists’ performance in this area. A variety of methods have been implemented in Australia since 1997 to minimise or prevent and treat drug dependence. The privacy release of information to prescribers by patients that allows doctors access to drug histories before prescribing is common in methadone programs193 . Agreements or undertakings by patients with prescribers to limit their source of drugs to one prescriber occur in parts of Australia 193 and to one doctor and dispenser in the Australian Capital Territory 202. Developments are progressing nationally to facilitate access to patients’ drug histories and for prescribers and dispensers to communicate online through the MediConnect system formerly known as the Better Medication Management System which has some similarities with British Columbia’s Pharmnet system 213-216. The technical requirements for pharmacies to participate in MediConnect system are specified by the Department of Health and Ageing. The introduction of these different approaches to prevent prescription drug misuse probably reflect a more serious licit drug misuse problem in Australia than elsewhere resulting from a national prescribing system designed to provide high access without adequate resources to monitor or manage abuse of the system , the lack of information or authority to enable prescribers or dispensers to identify or intervene to prevent or treat drug misuse. A change to the legislation for Schedule 8 drugs has been proposed to overcome existing hurdles and to suitably enable pharmacists to intervene to prevent misuse 217. The continuing heroin shortage and the more efficient and effective systems developed to manage opioid dependence and treating heroin overdoses have resulted in falling heroin overdose fatalities201. This decline may lead to lower demand for methadone and other maintenance treatments for opioid dependence. The harm reduction activities in community pharmacies may modify from treating or minimising the harms of the misuse of illicit agents and drugs such as heroin to preventive misuse of licit dependence-producing agents and

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drugs including nicotine, alcohol, benzodiazepines, morphine, oxycodone and dexamphetamine 217 . International The terms “ gatekeepers to controlled substances” in the USA218 and “prescriptions custodian” in Australia 210,219 are synonymous in depicting the key role for pharmacists in properly managing the issuing of prescribed S8 agents. In the USA, the pharmacists’ responsibilities for managing opioids in prescriptions or combined with non-narcotic analgesics have focused on State regulations and programs for controlling opioids for their proper use in pain management and activities for preventing their diversion 216. In the UK the pharmacists’ broader recognised role in the detection of licit opioid misuse and the management of drug misuse and opioid dependence are recognised and well documented 216 . The most infamous example of the misuse of licit opioids has been the deaths of more than 100 females in England caused by injections into the victims of dispensed diamorphine by a doctor from 1987 to 1998. Researchers found ‘mortality monitoring’ of deaths to be a poor indicator of drug misuse217. The failure of mortality monitoring to efficiently identify the potential misuse of licit opioids indicates the need for other methods to detect and prevent the diversion and misuse of S8 agents.

Table D-H19c. International comparison of harm reduction services 222,223

Australia 2002 England and Wales 1998 (EMCDDA,2000)

Scotland 2001 (Matheson et al, 2002)

Dispensing opioid dependence therapies

40-55% 50% 81%

Selling injecting equipment and needle exchange

51.3% 34.5% selling/ 19% exchange a

11% selling/19% exchange b

a,b = percentages for needles sales and exchange retrieved by Dr J Sheridan (June,2003)

Interpretations Australia’s pharmacies rank high internationally in providing harm reduction activities. Harm reduction including methadone dosing is now amongst the most widely practiced and cost-effective of the specialised services in community pharmacy in this country. The estimated rates of detected doctor shoppers and forged prescriptions for S8 drugs and drugs of dependence are the first known reports in the world. The rates suggest pharmacists’ high vigilance in this area. The possibly high rates of forgeries compared to other countries may reflect Australia’s high per capita consumption of S8 drugs and concurrent high misuse. Australia’s very high consumption of S8 agents and high levels of their misuse in this country, the rate of detecting doctor shoppers along with the trend to licit opioids and other prescribed agents emphasises the need for access to patient drug histories by pharmacists when dispensing S8 agents. The need for access to online drug histories before prescribing and dispensing is reinforced by the failure of mortality monitoring of opioid overdose deaths to locate and assist to prevent licit opioid misuse reported in England. The requirement to restrict patients to one medical and pharmacy source for S8 drugs is urgent given the likely delays in implementing access to patients’ drug histories through the MediConnect system. State and national bodies of pharmacy should press for appropriate legislative changes to S8 regulations in order to enable pharmacists to take a more effective role in detecting and preventing the misuse of S8 and other dependence-producing agents.

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3.9 Section I Complementary therapies including herbal medicines

Question: 20 Statistical sources: Tables 20.1.1 to 20.12.2 (24 tables) Aims To quantify the rates of referral by Australia’s community pharmacies to complementary medicine practitioners or services Background Complementary and alternative medicines and services (CAMS) refers to diagnostic, treatment and preventive techniques or agents which complement mainstream medicine224. In Australia, complementary medicines include a variety of materials as described in the Complementary Medicines Schedule (Schedule 14) of the Therapeutics Goods Regulations225. They include techniques 226-230 and herbal medicines 225 and non-medically prescribed vitamins, minerals and trace elements 231. Their use has increased markedly since 1990 in the USA and Australia. For example, estimates from sample surveys of population usage of CAMS products and services vary from $AUD 2.3 billion in 2000 to industry figures of approximately $1.5 billion in 2000-2001227,232. CAMS products are regulated in Australia as therapeutic goods231 but the evidence supporting the effectiveness of CAMS products or services by either consumer ratings233 or controlled trials224 is inconsistent and inadequately recorded for use by pharmacists. For instance, iridology and negative ion therapy are regarded as unproven or unprofessional 234-236, or spurious in the case of questionable products such as gingko or “smart pill” for improving intellectual performance237. In addition many herbal medicines have adverse effects and interactions 224,225,238. Discussion of methods In Australia the legal definition of complementary medicines includes herbal products and an authoritative summary of therapeutics information are published for pharmacists225. Complementary use in Australia does not necessarily require the same evidence of efficacy as required for regulated therapeutic medicines225. Questions were compiled with the assistance of a pharmacist experienced on complementary medicines and services. The questions were tested in a focus group of pharmacists from a variety of pharmacies in Pharia zones 1 and 2 and a nationwide sample of practicing and specialist pharmacists in Pharia zones 1 to 6. The items in Question 20 were based partly on a questionnaire used in an earlier survey of Australian general practitioners 226.

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Table D-I20. Australia’s community pharmacies by clients referred to or provided complementary practitioners July-September,2002

Complementary

activity Clients referred per

pharmacy in 30 days ( LCI )

Total clients referred nationally

30 days*

Pharmacies ≥1/30 days

% (total) acupuncture 0.24 1158 7.0% aromatherapy 1.28 6175 22.1% Chiropractic 0.76 3666 19.5% Homeopathy 1.41 6802 19.8% Hypnosis 0.04 193 1.5% Iridology 0.62 2991 8.7% Meditation 0.34 1640 7.8% naturopathy 3.07 14810 33.0% reflexology 0.08 386 2.5% massage 1.23 5934 23.9% Spiritual healing 0.06 289 1.8% other NA NA 2.3% Total 44,044 GP referrals (Q15)

* LCI x 4824 Findings The estimated referrals total 44,044 per month for Australia’s 5,000 pharmacies (Table DI-20). Further study is required into those pharmacies which have a relationship with or provide the services on site, in adjacent premises or elsewhere. The rate of the ‘complementary’ referrals by pharmacies represent les than 10% of clients referred annually to GPs. If each ‘complementary’ referral generated a $25 cost to consumers then these total $1.101 million monthly. The highest referrals including naturopathy (14810 monthly), homeopathy (6802), aromatherapy (6175), massage ( 5934) and iridology ( 1991) need to be further investigated for professional and economic implications. Pharia zone Clients were referred for naturopathy more frequently by pharmacies in Pharia zones 1 and 2. Clients were referred less frequently for acupuncture, homeopathy or iridology by pharmacies in Pharia zones 5 and 6. Australia Annual sales in 2000-2001 of complementary health care products including vitamins, minerals and nutritional supplements and herbal aromatherapy and homeopathic products totalled $AUD 940 million retail. Industry estimates of total complementary products and practitioner services in 2000-01 was $AUD 1.5 billion, a fall of $100 million from 1999-2000239 following the introduction of the GST 240 . This total is much less than the estimated total expenditure in 2000 in Australia of $AUD2.3 billion comprising $AU1,671 million for complementary agents and $AU616 million for complementary practitioners estimated from a large telephone survey of a representative population in South Australia 228. Of industry’s estimated total $1.5 billion on CAMS, $940 million were spent on CAMS products of which 36% were sold in pharmacies equating to $338 million in 2000-01 232. Sales of CAMS products in Australia is likely to drop in 2003-04 especially in health food stores with pharmacies and supermarket increasing their shares of sales of CAMS products following the recall in April and May 2003 by Australia’s Therapeutic Goods Administration of over 1,300 CAMS products 241-244 . Herbal medicines and vitamins comprise 4% of pharmacy sales or $AUD 368 million annually in Australia (Database Tables 33a and 33b) which is consistent with industry estimates and survey results with pharmacy constituting approximately 20% of national total sales228. In the UK 76% of pharmacies sell herbal medicine products and 50% of sales occur in pharmacies245 . Only 6% of UK consumers use professional advice to purchase these products whereas 30.9% do so mainly from doctors in Australia 228,245.

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Australians are concerned with safety, accurate information and fair advertising of complementary agents 228. In the USA the inclusion of CAM in formal medical education is advocated 230. Most of the complementary therapies listed in Table D-I20 were surveyed in July 1997 in a random sample of 764 of Victoria’s general medical practitioners. The 488 respondents (64%) were a representative sample by age, gender and geographical distribution226. Respondents rated their knowledge of effectiveness, safety and medical versus non-medical providers of these therapies. Most (93%) had referred at least once and 8% at least a few times a year for complementary therapies. Just under half referred at least a few times a year for acupuncture, meditation, hypnosis and chiropractic. Only 29% would encourage chiropractic in contrast to two-thirds for the former three. Herbal medicines, naturopathy, vitamin and mineral therapy, osteopathy and homeopathy were accepted by a minority of doctors 226. Australia’s health survey conducted in 2001 by the Australian Bureau of Statistics found Australians reported 389,900 visits to chiropractors and 29,800 visits to naturopaths in two weeks 246. When these ABS data are compared with the rates referred by pharmacies (Table DI-20 ) they suggest pharmacies generate less than 1% of visits to these CAMS practitioners. International The total estimated cost for complementary products and practitioners in the USA for 2000 was $US34 billion USA 228,247. Australia ranked third internationally in 2000 in prevalence of use after Germany and Canada224. A telephone survey of 187 participating (of 248) pharmacies in Johannessburg found 64.7% consulted for alternative medicines for conditions of a minor nature and more frequently in those located in shopping centres in middle-higher income areas. Pharmacists and other staff consulted for CAMS products but ‘alternative healers’ existed in less than 10% of pharmacies overall and located chiefly in middle-higher income areas248. Nurses were employed in pharmacies which ran a comprehensive alternative medicine practice associated with a health clinic. Interpretations Overall the reputable literature suggest CAMS products and services need to be reviewed by state pharmacy boards and national professional bodies and require firm guidelines for their issuing or referral in Australia’s community pharmacies. The annual retail sales of CAMS products and services adopted for Australia was the industry estimate of $1.5billion. The total annual referral of CAMS services reported by Australia’s pharmacies is less than 10% of annual referrals to general practitioners but is still sizable. The efficacy, safety, recall and public requirements need to be reviewed in relation to the appropriate use of CAMS products. This is crucial with the recall in April and May 2003 of over 1300 mainly CAMS products by Australia’s Therapeutic Goods Administration and likely higher proportion of sales of CAMS products in pharmacies after May 2003.

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3.10 Section J Information facilities and programs Question: 21 Statistical sources: Tables 21.1.1 to 21.11.2 (22 tables) Aims To quantify the resources used to provide information to clients in Australia’s community pharmacies. Background In Australia, drug information in pharmacy refers to the provision of written and/or verbal information or advice about drugs and drug therapy in response to a request from other health care providers, organisations, committees, patients or members of the public249. This may relate to a specific patient or consist of general information promoting the safe or effective use of medications. The purpose of drug information is to optimise patient outcomes by supporting the quality use of medicines249. Relevant pharmacy standards and guidelines for providing consumer medicines information (CMI), assisting self-medication, communicating with other professionals and providing pharmacist-only and pharmacy medicines exist for Australia’s community pharmacies249 . Discussion of methods Questions were compiled with the assistance of pharmacists experienced in information services. The questions were tested in a focus group of pharmacists from a variety of pharmacies in Pharia zones 1 and 2 and a nationwide sample of practicing and specialist pharmacists in Pharia zones 1 to 6. Question 21 focuses on the patient-specific use of information resources being the purpose of drug information services in Australia’s pharmacies1. The use of the term ‘patients’ in the question may have lowered the rates reported compared with the more general term ‘clients’ . Findings The percentage of pharmacies using the information resources one or more times daily for patients were in order CMI computerised information in 71.7% of pharmacies , 66.1% used CDROM versions of MIMS and APP and the book versions (49.1%) and 46.4% used PSA Self Care and 32% or less pharmacies used the other listed resources (Table D-J21). The best estimates of daily use in pharmacies (LCI) were 4.81 for CMI computerised, 4.19 for CDROMS (MIMS, APP) , 2.46 for PSA Self Care , 2.22 for MIMS or APP books, 1.27 for Australian Medicine Handbook, 1.03 for APFH and less than one daily for the other resources (Table D-J21). CMI computerised information was received nationally by an estimated 23203 patients daily (Table D-J21) or by an estimated 6.874 million patients in the 12 months up to July-August 2002 (LCI x 6.18 x 52 x 4447). This compares with the estimated total of 6.76 million issued nationally by pharmacies for prescription-related purposes ( Table D-D13a). The results in this section need to be reconciled with pertinent results in Section D and F. Pharia zone CMI computerised and CD ROMs were used highest daily in 76% and 68% of Pharia 1 pharmacies. MIMS and APP books were most used daily in 52% of Pharia 1 pharmacies and least used daily in 43% of Pharia 5&6 pharmacies. PSA Self Care cards are used daily in 52% of Pharia 3 pharmacies compared to 44% of Pharia 1 pharmacies. Therapeutic Guidelines were used highest daily in 24% of Pharia 4 pharmacies compared to 20% in Pharia 1 pharmacies. Web-based was used highest daily in 9% of Pharia 1 pharmacies and least daily in 6% of Pharia 2 pharmacies.

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Australia No other comparable results on information provision by community pharmacies in Australia could be found. From 1 November 2002 pharmacists were remunerated at 10 cents per claimable PBS or RPBS prescription for providing approved Consumer Medicine Information (CMI) so the data in Table D-21 reported in July and August 2002 indicate a rate of pharmacies providing CMI before remuneration was introduced 250. Table D-J21. Australia’s community pharmacies by use of information facilities for patients per

day in July-September 2002

Information usage Per pharmacy per day (LCI)

Total pharmacies per day nationally*

Percentage pharmacies

used ≥ 1 daily AusDI book 0.36 1737 12.0%

AMH 1.27 6126 32.0% APF 1.03 4969 26.5%

CDROMs (MIMS,APP) 4.19 20212 66.1% CMI computerised 4.81 23203 71.3%

Martindale 0.90 4342 25.1% MIMS or APP books 2.22 10709 49.1%

PSA Self Care 2.46 11867 46.4% Therapeutic Guidelines 0.79 3881 20.1%

Web-based drug information

0.32 1544 7.8%

Other NA NA 4.3% * LCI x 4824

International Pharmacists in the USA and United Kingdom have a range of information resources, specialised information and internet sources for community pharmacies available. These are published in their respective countries by the American Pharmaceutical Association 251 and the Royal Pharmaceutical Society of Great Britain252. No other comparable results on information provision by community pharmacies in overseas countries were found. The latest evaluation of six studies and reports of drug information services found poor evidence of the clinical or economic impacts on patient outcomes 253. National estimates The national estimates of each type of drug information resource used in pharmacies directly for patient use are based on the Lowest confidence interval derived from the Statistical sources above and the 4824 pharmacies at the time of this survey. Interpretations Computerised CMI, CD ROMS of MIMS, APF, and PSA Self Care cards were in order of those surveyed the most frequently consulted information resource for patients in Australia’s pharmacies. Web-based drug information was the resource least consulted daily but is available and has been used in 34.3% of pharmacies which implies a potential for much higher daily use. Pharmacies in Pharia 1 ranked first or high in daily use of most information facilities. The rate of use of CMI serves as a reference before the introduction in November 2002 of remunerating for CMI provision for certain categories of PBS and RPBS prescriptions.

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3.11 Section K Technologies and health information and communication

Questions: 22a, 22b, 23 Statistical sources: Tables 22 a. 1-6 (6 tables); Tables 22 b. 1-5 (5 tables); Tables 23.1-23.5 (5 tables) Aim To report the percentage of pharmacies with pharmacy dispensary computer facilities required for involvement in the MediConnect system and the percentage with websites and their specified purposes and the rates of inter-professional communication by telephone, fax or email. Background Official standards exist for internet pharmacy and the content of pharmacy websites in Australia 254 . Websites with a range of pharmacy and health information have been compiled for reference by Australia’s pharmacies 254 . Broadband services (eg ADSL, cable, satellite) expedite high-speed and ‘always-on’ connections to the web. By December 2001 three million Australians including over 300,000 with ADSL were estimated to be using the internet mainly for email but also for online transactions such as shopping, banking and pharmacy services255. Australia in January 2002 ranked internationally third per capita in computers and eighth in internet users 256. Telephone communication between professionals and patients has been long known as a means to improve patients’ health indicators257. But there is little published research on the utilization of information technologies in pharmacy in Australia or other countries258 even though experts view internet-based business-to-consumer model as the most successful model for pharmacy in the future 259 . Discussion of methods Questions were compiled with the assistance of a pharmacist experienced in surveys of information technology. The questions were tested in a focus group of pharmacists from a variety of pharmacies in Pharia zones 1 and 2 and a nationwide sample of practicing and specialist pharmacists in Pharia zones 1 to 6. The items in Table D-K22a and Table D-K22b were taken from official requirements254 and the Health Insurance Commission specifications for pharmacies to participate in the MediConnect system 260 formerly known as BMMS 261,262. The standards for inter-professional communications for pharmacies in Australia 254 and requirements for pharmacies in overseas reports 254 were listed in the items in Table D-K 23. The results were reviewed by pharmacists with current experience in the above areas and whose views are reflected in the findings and interpretations below. Findings Dispensary computers with Pentium processors were present in 89.2% of pharmacies which was a key requirement at the time of the survey for the MediConnect system . This is an electronic health system designed to improve the quality and safety in the management of medications by giving participating doctors and pharmacists access to more complete information about the medication history and medicines people are using 254,263. But changes to the MediConnect system and ongoing trials have not clearly defined the nature of the software or hardware required. Dispensary computers were used regularly for internet, e-mail and pharmacy website activities in under 50% of pharmacies (Table D-K22a) while broadband access was present in just 4.2% of pharmacies. Overall, regular internet use in 2002 occurred in 39.8% of Australia’s pharmacies. For inter-professional communication with doctors initiated in pharmacies by telephone, Fax or email for prescription medication reasons, doctors were contacted daily by pharmacies 3.73 times, patients or their carers 1.95 times and other health workers or sources 0.68 times for patient health information (Table D-K23). These results equate to each pharmacy in Australia communicating yearly about patients’ prescription medicines with these facilities on at least 1,199 occasions with doctors, at least 627 occasions yearly with patients or their

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carers and at least 219 times yearly with other health workers . Australia’s pharmacies initiate at least once daily one or more of these communications (Table D-K23). That is, at least 8.117 million communications with technical facilities were initiated by pharmacies with doctors and patients or their carers yearly. This total equates to a rate of approximately 3.75 communications per 100 prescription items initiated in pharmacies with telephone, fax or email (this is based on 216 million prescriptions dispensed yearly in 2002 in Australia’s pharmacies in Table D-A3). Excluded from the results and estimates are communications initiated by doctors or patients for prescription medicines and 0.68 times daily initiated with other health workers or source for other patient information, other forms of communications including mail or face-to-face contacts for prescription medicines and the communications for prescription medicines in pharmacies , or in aged care, domiciliary or other places outside pharmacies . Included are multiple communications for a single item or for a single prescription. These totals and rates need to be considered with the prescription-related communications with patients or carers reported for Questions 11 to 14. Table D-K22a. Percentage Australia’s pharmacies with dispensary computer features for

MediConnect system (www.mediconnect.gov.au ) in 2002

Computer feature Yes % No / no response % Pentium processor 89.2 10.8

Regular internet use 39.8 60.2 Regular email use 40.8 59.2 Pharmacy website 11.1 88.9 ADSL (broad band) 4.2 95.8

Other activities 1.1 98.9 Table D-K22b. Percentage of Australia’s pharmacies with following website activities in 2002

Website activity Yes % No / no response %

Offers medications 2.4 97.6 Other products online 3.5 96.5

Home delivery 4.2 95.8 Health information 9.7 90.3

Other 1.0 99.0

Table D-K23. Inter-professional communication activities in pharmacies in a typical day for health reasons in 2002

Phone, fax or email contacts Daily per pharmacy

(LCI mean estimate ) % of pharmacies ≥ 1 daily in 2002

% of pharmacies > 0 daily in 2002

Doctor- clarify/correct prescription 2.40 69.7 99.1 Doctor - drug, dose, contra- indication or

adverse effect 1.33 40.5 97.1

Patient or carer - for compliance 1.17 31.3 83.9 Patient or carer - effects of therapy 0.78 17.3 70.1 Health worker - for patient health 0.68 19.1 70.7

Pharia zone Differences in computer facilities or website activities in pharmacies between Pharia zones were not analysed. Australia Professional practice standards exist for internet pharmacy and pharmacy websites in Australia 254 . A national survey by ACNielsen in 2001 found 91% of respondent pharmacists had internet access either at home or at work, 67% have Internet access at work, 30% reported regular internet access at work and 17% used the internet for customer education;

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46% reported using e-mails in their day to day practice and 28% had a website for the pharmacy 264,265. The ACNielsen surveyed pharmacists and not pharmacies and the representativeness of the respondents is not available to make comparisons with these data 265. The ACNielsen results show higher internet access and higher email use at work than these results (Tables D-K22a,22b,23) but this may suggest for respondent bias to heavier users of internet and possibly respondent pharmacists who worked in the same pharmacies with internet facilities . Internet resources for health information for pharmacies254 and pharmacy applications have been reported 255. The specific technical requirements 261,262 and difficulties for Australian pharmacies’ participation in MediConnect system have been reported 13,14 . The pharmacy requirements for the MediConnect system will be revised as the results of an ongoing trial in a sample of pharmacies are obtained. There are presently no clear specifications of final speed or type of connection that will be required to retrieve the MediConnect messages in a timely manner. It has been found 65% of pharmacies in the trial are running on “…DOS based software which is not MediConnect-compatible” hence requiring them to upgrade to Windows-based software which will also need upgrades of hardware. The additions of communication extras such as security, messaging and encryption standards required by MediConnect will add extra demands on existing computers . Mediconnect and increased usage of the internet (especially ‘always on’ broadband) will require further upgrades of the existing systems to handle security and virus protection. MediConnct will require broadband in pharmacy but with a managed service including firewall, antivirus and firewall ( P Naismith, May 28, 2003). One of the MediConnect functions may be like the Pharmanet system in British Columbia in potentially providing access to patient drug histories with online communication between dispensers and prescribers allowing pre-dispensing interventions, subject to patient consent for entering all drugs and access to doctors and pharmacists 267. But the observations of visiting pharmacists to Vancouver and the lack of published results from the Canadian system have created concerns about its application in Australia. The results on the pharmacy web sites do not indicate whether they are active or in the hands of an external party and are effectively dormant ( B Callaghan May 29, 2003). Computer use amongst Australia’s GPs has increased from under 10% in 1998 to approximately 78% in May 2001 the majority of whom use them to generate prescriptions 266. The practice standards, systems and establishment of office computers for Australia’s GPs have been reported 268-270. The changes required in GPs’ computer practice to enable them to be incorporated in the MediConnect system HealthConnect system to improve patient outcomes have been reported 266,267 . International Telephone communications with patients is an efficient medium for improving their compliance. The American Pharmacists Association has published guidelines for telephone communications between pharmacists and doctors for improving patient care271. The rationale and technical requirements for community pharmacies in the USA becoming internet-based and establishing websites to better serve the health needs of people have been reviewed and are equally applicable to Australia’s pharmacies 256,259 . A national survey of pharmacy internet use in the USA found 10% of respondents communicated by e-mail with patients of whom half did so at least once weekly. More than 20% of respondents emailed other health professionals with about half at least once weekly. Large US pharmacy groups are routinely using e-mail to remind patients about repeat prescriptions 256. The future use of the internet in a wide variety of activities such as e-prescribing where doctors email prescriptions direct to the patient’s pharmacy, telepharmacy for homebound patients or those living in rural and remote areas and in disease management clinics where pharmacists interpret online laboratory results and email suggested prescribing amendments to prescribers are being assessed 259,272 . A review of electronic or e-prescribing in USA medical practices found it to be most cost-effective for larger practices273 but by 2002 less than 5% of prescriptions in the US were processed entirely electronically 274. In Australia e-prescribing is viewed as a method of retaining clients which has implications for efficient medication reviews and better monitoring of medication effects in clients. By 2003, approximately 60% of the 50,000 US pharmacies will commence using an “ electronic prescribing gateway” which is expected to be gradually accepted by US prescribers as the privacy, logistics and other difficulties are overcome 275. References to internet sources for USA community pharmacies

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are produced by the American Pharmaceutical Association 276 . A publication comprising 11 chapters contributed by six pharmacists specialised in a variety of the internet, e-pharmacy and performing prescription- and health-related activities has been published by the American Pharmaceutical Association 277. References on internet sources are produced for British pharmacy by the Royal Pharmaceutical Society of Great Britain 278. But there is little quantitative data on the use of information technologies in pharmacies 258. Interpretations Dispensary computers in Australia’s pharmacies had high compliance with the technical requirements of the MediConnect system in July-September 2002 but a current trial in pharmacies and subsequent changes to the system will require broad band access (ADSL in urban areas) and replacing the prevailing DOS by Windows software. Adapting British Columbia’s Pharmanet system as a model system which facilitates full medication histories in pharmacies is uncertain. In 2002, approximately 40% of Australia’s pharmacies reported regular email and internet use and 11.1% had websites which were active in health-related and other areas . The foreseeable broadband and Windows software requirements for the future MediConnect system planned for 2005 should be readily adopted by pharmacies. Pharmacy websites need to be assessed against existing internet pharmacy standards. The estimated rates per 100 prescriptions at which pharmacies reported initiating communications about prescribed medicines with prescribers or patients by telephone, Fax or email at the rate approximated rates were found to be consistent with estimates for counselling, monitoring for compliance and for assessing effects of drug therapy in Tables D-D13a,13b and 13c.

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3.12 Section L Opinion on the use of technical facilities Question: 24 Statistical sources: Tables 24.1-24.7 (7tables) Aims To test pharmacy attitudes on the relative effectiveness of telephone, fax or email communication with prescribers and patients or carers, privacy restraints on such communication and the deleterious impact of growing internet use on the sales of prescription and non-prescription sales in pharmacies. Background Telephones have been known for more than two decades to be an efficient and convenient mode of health communication between health professionals and between professionals and patients279. With the wide uptake by pharmacies of the facsimile and email since 1980 and their increased use there are no known comparisons of the effectiveness or rates of use of the three modes in community pharmacies. The email and facsimile have the advantage of recording communications. Australia had 52 telephone lines and 12 internet users per 100 people in January 2002 280 which suggest the email will not seriously challenge the telephone as the main mode of communication with patients for some years. But the rapid penetration of the internet amongst health professionals since 1995 , its convenience and directness along with early results of its relative effectiveness in communication with health professionals281, suggest email mode may eventually challenge telephones as the main mode of communication between health professionals and with their clients in places where there has been a high uptake of internet facilities. On the other hand , the limitations and disadvantages on internet use are emerging. These include interference by unsolicited emails dubbed spam, email messages written abruptly often had errors which could be misunderstood by doctors or patients, emails were recorded so errors will persist and privacy is threatened and the internet promotions and sale of prescription medicines have caused problems in Australia and other countries282-284 . Discussion of methods In Australia, standards and guidelines exist for internet pharmacy285. Questions were compiled with the assistance of pharmacists experienced in surveys of information technology. The questions were tested in a focus group of pharmacists from a variety of pharmacies in Pharia zones 1 and 2 and a nationwide sample of practicing and specialist pharmacists in Pharia zones 1 to 6.

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Table D-L24. Rating of impact of technologies on doctor, patient and pharmacies

Strong

Disagree -Disagree

Unsure Agree- Strong Agree

No response

Telephone best with doctors or other health workers

3.3% 3% 93.1% 0.6%

Telephone best with patients or carers 15.2 8.3 75.7 0.8% Privacy laws restrict communications 47.3 24.2 27.5 1.0%

Fax will replace telephones 77.3 15.9 5.8 1.1% Email will replace telephones 73.8 18.4 6.6 1.1%

Internet will depress prescriptions by 2004 44.4 30.2 24.4 1.0% Internet will depress OTCs and other health

products by 2004 34.4 30.2 34.3 1.1%

Findings Respondents agreed or strongly agreed (93.1% and 75.7%) the telephone is the best mode of communicating with doctors or other health workers and with patients or their carers (Table D-L 24). The acceptability of the telephone is consistent with respondents disagreeing it will be replaced by Fax or e-mail (77.3% and 73.8%). More respondents (47.3%) agreed or strongly agreed than disagreed or strongly disagreed (27.5%) that privacy legislation restricted their telephone communications. More disagreed or strongly disagreed (44.4%) than agreed or strongly agreed ( 24.4%) that internet sales will depress their numbers of prescriptions by by 2004 . Respondents were equally divided that the internet will depress OTCs and other health products in their pharmacies by 2004 (Table D-L 24). Pharia zone No analysis was required. Australia In an ACNielsen survey of pharmacists in Australia in 2001, 75% of respondents were concerned with the impact of internet-based pharmacy on their dispensary business, 74% had customers ask questions about medical information from the internet and another main concern was the security of clients’ health records 283 . Evidence from aged care facilities and community settings in Australia are consistent that medication outcomes are improved by systematic communication between pharmacists, doctors and their clients286. International The cost-effectiveness of telephone communication in disease care management continue to be reported . A recently published randomised trial of 613 community patients with acute depression found two telephone follow-up calls significantly improved patient outcomes with lower recurrence and fewer symptoms of major depression at modest cost287 . The practice of selling drugs by pharmacies in Canada over the internet to patients in the USA has resulted in lowered prescription sales in the USA 288 . National pharmacy bodies in both countries agreed patient safety may jeopardised without face-to-face communication and medication histories are excluded by the practice which were both necessary for proper medication management and patient safety 284. Websites in the USA widely promote cheaper medicines and Internet-based discount pharmacies 288. There are many websites promoting the sale, packaging, billing and shipping of prescription drugs and payment by 285,289,290 credit card. These websites pose similar problems in Australia as do the Canadian internet pharmacies to pharmacies and patients in the USA 285. Interpretations Telephone communication by pharmacies with doctors, other health workers and patients or their carers is regarded as superior to fax or email communication. The telephone is unlikely to be displaced by either fax or email as the preferred mode of communication in pharmacies with doctors, other health workers and patients or their carers in the foreseeable future. There

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is higher acceptance that internet sales will depress by 2004 the sales of OTCs and health products than of prescription-only medicines. Privacy legislation is regarded as restricting communication between pharmacies and doctors or patients and suggest national bodies of pharmacy need to clarify for pharmacists the impact of privacy legislation on communicating with patients, carers and doctors. The practice of internet promotion and sales of prescription-only and other medicines by Canadian pharmacies to consumers in the USA and the resulting action by US and Canadian pharmacy authorities needs to studied by Australia’s pharmacy bodies for appropriate action in this country.

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3.13 Section M Pharmacy and staff Questions: 25a - 33b Statistical sources: Tables 25a, b and c, 26,27,28,29 a and b, 30a, b:1-4, 31.1-3 ,32 1-10,

33a 1-2, 33b (29 tables). Aims To quantify characteristics of Australia’s pharmacies relative to their location, size, group membership, commercial activities, ownership and staff. Background In Australia, pharmacies and pharmacists are required to first be registered by state bodies and to renew registration annually to practice. Pharmacies require approvals or accreditation by national government agencies in order to dispense prescriptions listed in the Schedule of Pharmaceutical Benefits or to participate in national programs such as medication review processes itemised in Section E. These are remunerated by the Health Insurance Commission. The Pharmacy Guild of Australia manages the Quality Care Pharmacy Program (QCPP). National sample surveys of pharmacies are conducted regularly by government agencies such as the Australian Bureau of Statistics and national pharmacy bodies such as the Pharmacy Guild of Australia or the Pharmaceutical Society of Australia. Regional or state surveys are often performed by state boards for their or other purposes. Surveys are frequently performed by university research groups or on behalf of national health research bodies such as labour force studies conducted by the Australian Institute of Health and Welfare 291. Discussion of methods In Australia the term community pharmacy is defined and standards exist for pharmacy design and layout 292. Questions were compiled after consultation with the national panel, visits to pharmacies across all Pharia zones and direct or telephone discussions with their key staff, direct or telephone discussions with leaders of pharmacy bodies and pharmacy groups and reference to a range of pharmacy business, practice and research journals published in Australia and internationally. Questions were compiled with the assistance of researchers in the panel, interstate and overseas experienced in conducting regional or national pharmacy surveys in Australia and other countries The questions were tested in a focus group of pharmacist owners or managers from a variety of pharmacies in Pharia zones 1 and 2 and a nationwide sample of practicing owners or managers and specialist pharmacists in Pharia zones 1 to 6. Findings The jurisdictional locations of respondents by locations of pharmacies in Great Britain were 38% in inner city or town centres, 11% on housing estates and 17% in a village293. The only directly comparable category in Australia appears to be group 1 with 41.4% of all pharmacies ( Table D-M25b). Most regional (over 30,000 sq m) shopping centres usually constitute town or city centres so these would make a total 46.2% (groups 1 and 2, Table D 25b). Most of Australia’s community pharmacies (64.9%) are located in urban or town shopping strips and regional or neighbourhood shopping centres (Table D-M25b). The highest number of pharmacies open six days a week (median) but a large number of pharmacies open seven days results in a mean of 6.16 days (Table D-M25c). The high percentages of ‘invalid’ responses for areas in pharmacies (Table D-M26) reflect the small percentages of certain pharmacy areas and large areas due to square feet or miscalculated areas. Most counselling seems to occur in the schedule area which requires investigation because of lack of privacy and the small size of this section of the pharmacy. A total of 50.5% of the pharmacies were reported to be members of groups (Table D-M27a) which is similar to membership reported in May 2003 294 and compares with 48.7% of pharmacies with PBS approval numbers which operated for the full 12 months reflecting a small over-representation of pharmacies in groups among the respondents.

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Respondents in the Pharmacy Guild-managed Quality Care Pharmacy Program or QCPP comprised 54.1% (Table D-M28) compared with 48.7% actually QCPP-accredited in October 2002 295. This apparent 5.4% over-representation of QCPP pharmacies was due mainly to the incentive of 3 CPI offered to accredited QCPP pharmacies who responded. This possible respondent bias may have affected a range of other results where QCPP-related factors are important. The characteristics of pharmacy in relation to the role of non-pharmacists and support for health-related in comparison with other services needs to be studied. The 53.8% of sole proprietors, their older age and less CPE involvement than other pharmacy staff are notable (Tables D-M29a, D-M30b-4 ). With 39.5 % of owners over 50 years of age, succession planning emerges as an issue because 57.2% off pharmacies have one owner and a minority of the partners are under 40 years of age. (Table D-M29a, D-M30b-1) Females are under-represented as owners (23.7%). A large majority of owners have university degrees. A surprisingly high 19.1% have a diploma indicating they graduated before 1966 and pharmacists of more than 60 years of age (Table D-M30b -3). Postgraduate degrees amongst owners comprise 2.4% and 1.1% of first and second owners respectively. The continuing education done by community pharmacy owners in hours per month(Table D-M30c). The big majority of owners are male and do under six hours monthly of continuing education (Table D-M30b-4). The best estimate of customers per pharmacy per week from the respondents’ reports is 1393.5 (CI 95% 1333.62 and 1453.08) which equates to a minimum 6.367 million customers weekly and 331.16 million per annum in Australia’s pharmacies pa. The majority of hours served in the dispensary by proprietors reflects the slow acceptance of face to face patient counselling and the continuing resistance to dispensary assistants who would relieve them of the technical activities and release pharmacists to the important function of counselling.(Table D-M32a) The relatively high dispensary commitments apparent in Table D-M32a are repeated in Table D-M32b. In contrast, the presence of a non-pharmacist retail manager in 21% of pharmacies (Table D-M29b) is signifies pharmacists focusing on health-related activities. The results in Table D-M32c suggest the under-utilisation of the dispensary assistants who work an average of just 32 hours per week. Ideally, dispensary assistants should be engaged for no less than 38 hours per week to free pharmacists from clerical and low grade technical activities to the more important patient counselling, patient care and medication review activities. The minimum estimated annual turnover per pharmacy is (best estimate of mean $1.84 million; 95% CI 1.76m and $1.91m). Overall 32.5% of pharmacies reported annual turnovers of $2million or more with 32% of those in Pharia 1, 41% of pharmacies in Pharia 2 and least were 15% of pharmacies in Pharias 5&6 with annual turnovers of $2million or more. Pharia zone By Pharia 36% of pharmacies in Pharia 1 had more than 1401 customers per week with Pharia 2 pharmacies having 41% , pharmacies in other Pharia zones having less with those in Pharia 5&6 having least with 21% with more than 1401 customers per week (Table D31). Australia The neighbourhood shopping centres ( 10- 100 shops or 2,000-30,000 sq m lettable area ) contain 18.7% of Australia’s community pharmacies (Table D-M25b) and are partly comparable with 17% of British pharmacies in villages(Table D-M27b)293. The 6.3% of Australia’s pharmacies situated in medical centres (Table D-M25b) is unlikely to change even though up to 2000, pharmacies could be located in medical centres if they were not within 2km of another pharmacy. This has been relaxed to 1.5km and is supported by a national competition policy review and the Australian Medical Association but is difficult to change due to inconvenience and cost 296 . A survey in 1999 of 81methadone pharmacies in Australia found 5% in NSW , 4% in WA, 15% in SA and 19% in the ACT reported closed dispensing or dosing booths and 70% overall having standing dose areas 297 . A national total of 2165 pharmacies in banner groups equates to 48.7% of the 4,447 pharmacies with PBS approval numbers which operated for the full 12 months to 30 June 2002 or at the time the questionnaires were mailed294. After moderate growth to 2000, membership of banner groups has slowed from 2156 in 2000294,298. Pharmacy groups based

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on commercial or promotional features have the majority of Australia’s pharmacies including Australia’s largest pharmacies hence pharmacy groups probably account for a disproportionately large majority of total national pharmacy sales or turnover. Australia’s pharmacy groups compete mainly on commercial grounds. Certain groups offer expanded pharmacy services such as screening by clinical testing for undiagnosed disorders such as hypertension and raised blood glucose which represents a health-related service offering an opportunity to compete 299 . The Pharmacy Guild collects but doesn’t publish customer numbers and the figure of 74,000 (Table D-M31) is higher than the usually cited 60,000. The turnover figure of $1.84m for 2002 (Table D-M33a) is in line with Pharmacy Guild estimates of $1.74m annual average turnover for 2000-01 (the last finalised year). The 64.5% for prescriptions as a percentage of total sales is lower than the Guild’s 2000-01 estimated 67.2% with later indications from monthly turnover monitor survey that it would have been even higher in 2002. The Guild applies weightings derived from PBS data received from the Department of Health & Ageing (originating from HIC) and based on PBS data for 2000-01 showing script volumes (subsidised scripts only - those paid wholly by the patients are excluded) for each of the 4,447 approval numbers which operated for the whole 12 month period 302 .

Table D-M25 a. Australia’s pharmacies by jurisdiction: respondents and registered pharmacies (May 2003)

Code Jurisdiction % by jurisdiction Actual (2003) 0-999 ACT 1.1 1.2

1000-1999 NT 0.1 0.6 2000-2999 NSW 32.0 34.8

3000-3999 Victoria 20.9 23.0

4000-4999 Queensland 20.1 19.9 5000-5999 SA 9.2 8.1

6000-6999 WA 10.5 9.7

7000-7999 Tasmania 4.5 2.7

No response 1.7 0

Total 100 100 (5032)

Table D-M25b. Australia’s pharmacies by setting

Location Percentage City, suburb or town shopping strip 41.4%

Regional shopping centre 4.8 Neighbourhood shopping centre 18.7

Isolated shops 23.5 Medical centre 6.3

Hospital 0.9 Other 1.9

Missing 2.7%

Table D-M25c. Australia’s pharmacies open by hours per day and days per weekly in 2002

78

Total days per week Total hours per week

Mean 6.18 55.5 Median 6.0 52.0

Standard deviation 0.70 14.4 missing 3.7% 2.7%

Table D-M26. Australia’s pharmacies in 2002: areas of sections in pharmacy

Mean Median SD invalid

Dispensary area 20.9 20.0 11.6 8.9% Schedule area 11.8 10.0 12.5 9.8%

Forward pharmacy 1.4 0.0 6.6 9.7% Unenclosed counselling area 3.1 2.0 3.5 9.7%

Enclosed counselling/dosing area 1.2 0.0 2.7 10.3 Retail 114.1 90.0 87.6 9.1

Storeroom, office, other 28.5 20.0 35.1 8.9 Other 3.4 0.0 11.7 11.4

Total area of premises 187.2 160.0 118.3 9.1

Table D-M27a. Australia’s community pharmacies by membership of groups in 2002

Group Percentage Pharmabroker (total 4950)

Not in a group 48.4% 42.2 Amcal 9.5 8.0

Chem Mart 6.5 4.6 Friendly 2.2 1.2

Guardian 6.3 5.4 Soul Pattinson 4.7 4.6 Other groups 21.3 34.0

Missing 1.1 NA

Table D-M 27b. Great Britain’s community pharmacies in 2000 by group and percentage 301

Pharmacy type Percentage of British pharmacies Non-pharmacy controlled corporate supermarkets and discount

stores (eg Tesco, Sainsbury’s, Safeway, Asda ) 4.1%

Pharmacy-controlled chains or groups (eg Lloydspharmacy, Boots, Moss)

35.5%

Others : pharmacist- controlled single or small groups 60.4%

Table D-M28. Australia’s community pharmacies by QCPP status July-September 2002

QCPP status Percentage

79

Not yet registered 9.8% Partly completed accreditation 27.9 Completed but not accredited 5.2

QCCP accredited 44.1 Re-accredited 10.0

other 1.8 Missing 1.2

Table D-M29a. Australia’s community pharmacies by management of pharmacy

Current management Percentage Owner 53.8%

Partnership 23.3% Manager 18.7%

Other 1.2% Missing 3.1%

Table D-M29b. Australia’s community pharmacies with non-pharmacist retail manager

Yes No Missing

21.0% 77.9% 1.1%

Table D-M30a. Australia’s community pharmacies by number of owners in 2002

Number of owners Percentage

1 57.2 2 23.9 3 7.5

4 or more 2.1 Invalid 0.5

Table D-M30b1. Australia’s community pharmacy owners by cumulative age

Age Cumulative percentage

21-30 7.7 31-40 22.5 41-50 30.3 51-60 24.4 61+ 15.1

Table D-M30b2. Australia’s community pharmacy owners by cumulative gender and CPE commitment

80

Gender Cumulative percentage Male 76.3

Female 23.7

Table D-M30b3. Australia’s community pharmacy owners in 2002 by cumulative highest pharmacy qualification

Highest qualification Percentage

Diploma 18.2 Bachelor 74.9 Masters 1.9

PhD 0.8 Other 4.2

Table D-M30b4. Australia’s community pharmacy owners by cumulative CPE hours monthly

in 2002

Hours monthly Percentage 0 7.5

1-5 58.2 6-10 21.2 11-20 9.7

Over 20 3.4

Table D-M32-1 Australia’s community pharmacies by customers per week in 2002

Customers weekly Percentage of pharmacies 0-700 21.8

701-1400 39.3 1401-2100 18.8 2101-3500 11.0 3501-5000 3.4

5001 0r more 1.1 No response 4.6

Table D-M32a. Hours in dispensary and patient care by proprietors

Dispensary-Prescriptions Patient care-Counselling Mean Median Mean Median 1 30.93 SD 14.5 18.8 10.8 SD 10.0 9.00 2 18.8 SD 14.7 18.00 8.2 SD 9.0 5.00 3 15.9 SD 16.1 10.00 8.8 SD 11.5 4.00 4 2.7 SD 5.9 - 0.33 SD 0.71 -

Table D-M32b. Dispensary and patient care by manager, consultant and other pharmacists

Dispensary-Prescriptions Patient care-Counselling Mean Median Mean Median

Manager 30.93 SD 14.5 18.8 11.2 SD 10.6 8.0

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Consultant 18.8 SD 14.7 18.00 9.3 SD 16.3 5.0 Other

pharmacists 15.9 SD16.1 10.00 10.3 SD 14.2 5.0

Table D-M32c. Hours by dispensary assistant or technician

Dispensary Prescriptions Mean Median

30.93 SD 14.5 30.8

Table D-M33a. Australia’s community pharmacies by total annual turnovers in 2002.

Annual sales ($AUD million) Percentage of total <$1m 20.9

$1-1.5m 25.6 $1.5-2m 19.0 $2-3m 18.9 $3-4m 8.6 $4-6m 4.1 $6-8m 0.7 $8m+ 0.2

No response 2.0

Table D-M33b Australia’s community pharmacies by categories of sales annually

Mean percentage of total Annual sales ( $ billion) Prescriptions 64.5 5.934 S2 and S3s 13.7 1.260

Herbals, vitamins 5.0 0.460 Medical aids 2.2 0.202 Other sales 15.4 1.417

Total 9.273

International The Nevada Board of Pharmacy recommended after reviewing a death related to a prescription dispensing error that “…the pharmacy be remodelled to better facilitate the confidential counselling of patients…whose interests should be paramount for all health professionals, including pharmacists… ” 300. This has implications for the design of pharmacies in relation to enclosed counselling areas. In Great Britain’s survey of pharmacies 37% reported being not in a group, 29% in groups of up to 20 pharmacies and 38% were in groups with more than 21 pharmacies293. The percentage in groups of more than 21 pharmacies is similar to a later classification of Great Britain’s pharmacies showing 39.6% are in large groups (Table D-M27b) 301. In Australia, there appear to be less pharmacies in large banner groups compared to Great Britain. Interpretations The respondent pharmacies differed variously from published figures in location, setting, group membership and QCPP membership. Data received for areas of sections in pharmacies, operation, non-pharmacist retail manager and details of owners and pharmacy staff are not able to be compared in the absence of unavailable data. Customer numbers, turnover and other data need be carefully validated but the reported data are in line with

82

reported data. Increasing numbers of owners seems to be associated with more time spent on patient care and counselling

83

4. Provision of services and pharmacy characteristics (Term of Reference 3) Questions: 7, 12, 13c,14d, 17, 18,19a, 19b, 20, 23, by 25b,25c,26,27,28,29b,30a,31,33a, Pharia and state. Statistical sources: Volume 2 (Database). Table s34.1 -34.12: q7 (12 tables); Tables 35.1 -35.12 :q7 (12 tables); Tables 36.1 -36.12 :q7 (12 tables); Tables 37.1-37.12 :q7 (12 tables); Tables 38.1-38.12 (12 tables); Tables 39.1-39.12 q13c; (12 tables) Tables 40.1-40.12 q 14d (12 tables) ; Tables 41.1-41.12 q17 ( 12 tables) ; Tables 42.1-42.12 q18 (12 tables); Tables 43.1- 43.12 q19a (12 tables); Tables 44.1-44.12 q19b (12 tables); Tables 45.1-45.12 (q20 12 tables); Tables 46.1-46.12 q23 (12 tables) . Total of 156 tables. Aim To test and identify individual relationships which are statistically significant between the provision of selected services against specified characteristics of community pharmacies in Section M as reported by respondents. Background Relationships between implementing important pharmacy services and selected pharmacy variables have not been previously reported for Australia’s pharmacies. The relationships found to be statistically significant are intended to provide reference data for national pharmacy bodies in making policy decisions. Discussion of methods The statistical analysis is limited to simple analysis involving hypothesis tests such as t-test and chi-squared test between the pharmacy service and a single pharmacy variable. Future comparisons will require more detailed analysis (e.g. logistic regression) to control for statistical interactions and confounding variables 303. Findings Statistically significant relationships were found between the tested pharmacy variables in Section M and the individual services recorded in Table D-4.1. For example for a pharmacy performing any enhanced pharmacy service (Question 7), it was significantly related to the State, setting, days open per week, area of premises, group membership, customers per week and turnover. An association between EPS and state was found, with the prevalence of providing one or more EPS being the highest in “ACT and NSW”. A significantly higher proportion of those in urban retail settings compared to other settings provided one or more EPS. Those who provided one or more EPS were open for significantly more hours and had larger premises. A significantly higher proportion of those in a banner group provided one or more EPS as compared to those not in a banner group. A significantly higher proportion of those with “1401 to 5001+” customers per week provided one or more EPS as compared to those with “0 to 1400” customers per week. A significantly higher proportion of those with an annual turnover of between “2M to >8M” provided one or more EPS as compared to those with an annual turnover between “<1M to 2M”. Each of these individual relationships are described in the database. For all significant relationships recorded in Table 4.1 refer to the corresponding table in the database for a description of the association. Pharia zone This was not required. Australia No reported analyses of the barriers to enhanced pharmacy services and pharmacy characteristics have been found. National estimates These were not required.

84

Table 4.1. General, specialised and enhanced pharmacy services by pharmacy characteristics

“√” represents significant individual association found between service and characteristic

EPS Q7

Supervised dosing Q11c

Declined prescription

drugs Q12

Counselling Q13a

Monitoring com

pliance Q13b

Monitoring drug effects

Q13c

Medication Review

Processes Q14d

Pharmacist

initiated agent Q17

PhARIA √ State √ √

Setting √ √ √ √ Days open per

week √ √ √ √

Area of premises

√ √ √ √ √

Group membership

√ √ √ √ √

QCPP status √ √ Retail manager

Number of owners

√ √

Customers per week

√ √ √ √ √

Turnover √ √ √ √ √

Table 4.1 General , specialised and enhanced pharmacy services by pharmacy characteristics (cont).

Tests Q18

Harm

minim

isation or reduction

Q19a

Fraud Q19b

Complem

entary therapies

Q20

Comm

unication activities

Q23

PhARIA √ √ State √ √ √

Setting √ √ Days open per

week √ √ √ √

Area of premises

√ √ √ √

Group membership

√ √ √ √

QCPP status √ √ √ Retail manager √ √

Number of owners

√ √ √ √

Customers per week

√ √ √ √

Turnover √ √ √ √

85

International Results from the national survey in 2000 of British pharmacies were statistically analysed for relationships between 39 ‘extended role’ activities from a list of general (eg medication reviews, compliance assistance) and specialised pharmacy services ( eg needle exchange, screening ) with 12 ‘business related’ characteristics (eg location, staffing levels, opening hours, private consultation area), 10 ‘pharmacist related’ characteristics (eg position of respondent, continuing education workshops, age and gender) and two ‘ inter-related’ characteristics (eg Health Authority accreditation, pharmacists working for Heath and Social services) 304. Chi-square statistical tests were performed on the provision of the services and individual pharmacy characteristics. Many individual relationships (significant) were found but the most consistently related significance with general and specialised services were found between the pharmacist related and inter-related characteristics. For example general services such as GP referral for minor ailments, medication reviews and domiciliary and residential/nursing home visits were significantly associated with the highest number ( two) of inter-related characteristics which are analogous to Australia’s pharmacies having DMMR approvals, access to AACP accredited pharmacists and QCCP accreditation. Involvement in general and specialised pharmacy services was stronger related with a higher number of pharmacist than business related characteristics 304. Specialised services such as stoma care and prescribing reviews were related to higher numbers of dispensed prescriptions. Business related characteristics (eg turnover, group membership) were significantly related to stoma care and other specialised or ‘extended’ activities. Statistically significant associations were found between pharmacy group number and domiciliary visits, dedicated counselling area, PACT analysis, prescribing reviews and formulary development; between private consultation area and involvement in compliance assessment, stoma care, PACT analysis, prescribing reviews and formulary development; autonomy and involvement in domiciliary visits, medication reviews, stoma care, designated counselling area and formulary development304. In summary, Health Authority accreditation, postgraduate qualification and pharmacy position (owner or staff) were associated with a wider range of activities 304. Many of the pharmacy characteristics and pharmacy services tested were not applicable to Australia’s pharmacies. Interpretations The relationships in Table 4.1 suggest more services are provided by characteristics related to higher turnover as examples. But the interpretation and the limitations on these relationships require detailed hypothesis testing with the use of logistic regression.

86

5. Barriers / facilitators to service provision by pharmacy characteristics Section 5.1. Barriers to enhanced pharmacy services and pharmacy

characteristics (Term of reference 4) Questions: Question 8 by PhARIA, state, 25b, 25c, 26, 27, 28, 29b, 30a, 31, 33a. Statistical sources (Database) Question 8 (barriers). Tables 47.1-47.12 q8a (12); 48.1-48.12 q 8b (12); 49.1-49.12 q8c (12); 50.1 -50.12 q 8d(12); 51.1-51.12 q8e (12); 52.1-52.12 q8f (12); 53.1 - 53.12 q8g (12); 54.1.-54.12 q8h (12 tables); 55.1-55.12 q8i (12 tables) ; 56.1-56.12 q8j (12 tables); 57.1 - 57.12 q8k (12 tables). Total of 132 Tables. Aim To identify those selected pharmacy variables in Section M which are found to have individual associations with the barriers listed in Question 8 to enhanced pharmacy services (in Question 7). Background Relationships between implementing important pharmacy services and selected pharmacy variables in Section M. The relationships found to be statistically significant are intended to provide reference data for national pharmacy bodies in making policy decisions. Discussion of methods A simple analysis involving hypothesis tests such as t-test and chi-squared test between the pharmacy service and a single pharmacy variable was performed. Future work will require more detailed analysis (e.g. logistic regression) to control for statistical interactions and confounding variables303. Findings Statistically significant relationships were found between the pharmacy characteristics in Section M and individual barriers as listed in question 8. Table D-5.1 summarises the significant and non-significant individual relationships. For example, a shortage of time for pharmacists as a barrier to EPS (question 8) was found to be individually associated (significant) with PhARIA, setting and group membership. For all significant relationships recorded in Table 5.1 refer to the corresponding table in the database for a description of the association. Pharia zone This was not required. Australia No reported analyses of the barriers to enhanced pharmacy services and pharmacy characteristics have been found. International Results from the national survey of British pharmacies were statistically analysed for relationships between 39 ‘extended role’ activities (eg general pharmacy services, specialised pharmacy services) and a sample of 12 ‘business related’ characteristics (eg location, staffing levels, opening hours, private consultation area), 10 ‘pharmacist related’ characteristics (eg position of respondent, continuing education workshops, age and gender) and two ‘ inter-related’ characteristics (eg Health Authority accreditation, pharmacists working for Heath and Social services) 304. National estimates These were not required.

87

Interpretations The following relationships are taken from Table 4.1 as examples of interpretation and the limitations on them hence requiring detailed hypothesis testing with the use of logistic regression. Table D5.1. Barriers to enhanced pharmacy services and specified pharmacy characteristics :

statistically significant relationships “√” represents significant individual association found between barriers / facilitators to service and characteristic

Shortage of tim

e Q8a

Shortage of pharm

acists Q8b

Customers

won’t pay Q8c

Locum

Q8d

Knowledge and skills Q8e

Confidence Q8f

Job Q8g

Remuneration Q8h

PhARIA √ √ √ √ √ State Setting √ Days open per week

√

Area of premises

√

Group membership

√ √

QCPP status √ Retail manager Number of owners

Customers per week

√ √

Turnover Table D5.1 - Barriers to enhanced pharmacy services and specified pharmacy characteristics

: statistically significant relationships (Cont) Relationship

with GP Q8i

Opportunity to m

eet local GP

Q8j

Recognition of

pharmacist

skill Q8k

PhARIA √ State √ √ Setting Days open per week

Area of premises

√

Group membership

√

QCPP status Retail manager Number of owners

Customers per week

√

Turnover

88

Section 5.2. Facilitators to enhanced pharmacy services and pharmacy characteristics (Term of reference 4)

Questions: Question 9 by PhARIA, state, 25b, 25c, 26, 27, 28, 29b, 30a, 31, 33a. Statistical sources Question 9 (facilitators) . Table 58.1- 58.12 q9a (12 tables) ; 59.1-59.12 q9b (12 tables) ; 60.1-60.12 q9c (12 tables); 61.1-61.12 q9d (12 tables ); 62.1-62.12 q9e (12 tables ); 63.1-63.12 25c (12 tables); 64.1-64.12 q24a (12 tables); 65.1-65.12 q24b (12 tables); 66.1-66.12 q24c (12 tables); 67.1-67.12 q24d (12 tables); 68.1-68.12 q24e (12 tables); 69.1-69.12 q24f ( 12 tables); 70.1-70.12 q24g (12 tables). Total of 132 tables. Aim To identify those selected pharmacy variables in Section M which are found to have statistically significant associations with the facilitators listed in Question 9 to enhanced pharmacy services (in Question 7) . Background Implementing enhanced pharmacy services are influenced by facilitators identified by respondents to Question 9. Selected pharmacy variables in Section M are suspected to have statistically significant relationships which can assist national pharmacy bodies in making policy decisions for increasing the adoption of enhanced pharmacy services in Australia’s pharmacies. Discussion of methods The statistical analysis is limited to simple descriptive analysis involving hypothesis tests such as t-test and chi-squared test between the pharmacy service and a single pharmacy variable 303. Detailed hypothesis testing ( eg by the use of logistic regression) is however necessary to control for possibly confounding variables. Findings Statistically significant relationships were found between pharmacy characteristics in Section M and facilitators of EPS as recorded in Table 5.2. For example access to detailed patient notes to facilitate EPS was found to be individually associated with days open per week, group membership and QCPP status. For all significant relationships recorded in Table 5.2 refer to the corresponding table in the database for a description of the association. Pharia zone This was not required. Australia No reported analyses of the facilitators to enhanced pharmacy services and pharmacy characteristics have been found. International Ruston (2001) has performed limited analyses of the provision of enhanced pharmacy services and pharmacy characteristics304. Interpretations The following relationships are taken from Table 5.2 as examples of interpretation and the limitations on them hence requiring detailed hypothesis testing with the use of logistic regression.

89

Table 5.2. Facilitators of enhanced pharmacy services and specified pharmacy characteristics : statistically significant relationships

Patient notes Q9a

Closed counsellin

g area Q9b

Clinical testing are

Q9c

Appointme

nt system

Q9d

Accreditation

Q9e

Study time

Q9f

PhARIA State √ √ Setting Days open per week

√ √

Area of premises

√

Group membership

√ √ √ √

QCPP status √ √ √ √ Retail manager √ √ Number of owners

√

Customers per week

Turnover

90

Section 5.3 Opinions on the use of technical facilities and pharmacy relationships. The following section was not required under the terms of reference. Questions Question 24, by Pharia, state, 25b, 25c ,26,27,28,29b,30a,31,33a. Statistical sources The following may be found in the attached Data Base. Tables 64.1q24a-70.12q24g (84 tables). Aim To identify those selected pharmacy variables in Section M which are found to have statistically significant associations with the agreement or disagreement with statements relating to impact of communication technologies and communications listed in Question 24. Background The telephone has been the facility most used in pharmacies for many years to communicate for medication or health-related reasons with patients, their carers , doctors and other health workers. With the installation of facsimile, email and internet facilities over the past decade and the enactment of national privacy legislation in December 2001, certain pharmacy variables in Section M are suspected to have statistically significant relationships which may assist national pharmacy bodies in making policy decisions for enhancing the performance of pharmacy services in Australia’s pharmacies in relation to communication technologies and patient care or health-related activities . Discussion of methods The statistical analysis is limited to simple descriptive analysis involving hypothesis tests such as t-test and chi-squared test between the pharmacy service and a single pharmacy variable. Detailed hypothesis testing ( eg by the use of logistic regression) is however necessary to control for possibly confounding variables. The methods described earlier were applied to this analysis 303. Findings Statistically significant relationships were found between pharmacy characteristics in Section M and the use or impact of communication technologies on the pharmacies health related activities during 2002, as recorded in Table 5.3. For example telephone being the first widely used method to communicate with community patients or carers was found to be individually associated with days open per week and number of customers per week. For all significant relationships recorded in Table 5.3 refer to the corresponding table in the above statistical sources in the database for a description of the association. Pharia zone This was not required. Australia No reported associations between pharmacy characteristics and existing or future communication technologies and communications have been reported. International No reported associations between pharmacy characteristics and existing or future communication technologies and communications have been reported from the survey of British pharmacies or other surveys of pharmacies. National estimates These were not required.

91

Interpretations For all significant relationships reported in Table 5.3 refer to the corresponding table in the above statistical sources in the database for a description of the association. There are limitations on the interpretations hence requiring detailed hypothesis testing with the use of logistic regression are necessary. Table 5.3. Opinions on the use of technical facilities for health communication purposes and

pharmacy characteristics : statistically significant relationships

Telephone with GP & other health workers

Q24a

Telephone with patients or carer Q24b

Privacy legislation restricts telephone com

munication

Q24c

Fax replace phone to com

municate with GP, health

workers or patients Q24d

Email replace phone to

comm

unicate with GP, health workers or patients

Q24e

Internet sales of prescription m

edicines depress medicines

dispensed Q24f

Internet sales of all medicines

depress sale of non prescribed m

edicines Q24g

PhARIA √ State Setting √ Days open per week

√

Area of premises

√

Group membership

√ √ √

QCPP status Retail manager √ Number of owners

√

Customers per week

√ √

Turnover √ √

92

6. Glossary and definitions AACP Australian Association of Consultant Pharmacy APAC Australian Pharmaceutical Advisory Council ACT Australian Capital Territory, Australia CPE Continuing Pharmacy Education CMI Consumer Medicine Information COPRA Council of Pharmacy Registering Authorities (replaces APRA) CHAPANZ Committee of heads of pharmacy in Australia and New Zealand CMI Consumer Medicine Information DAA Dose administration aids DMMR Domiciliary Medication Management Reviews HMR Home Medicine Reviews HIC Health Insurance Commission NSW New South Wales, Australia NT Northern Territory, Australia PhARIA Pharmacy Access Remoteness Index of Australia PBS Pharmaceutical Benefits Scheme PGA Pharmaceutical Guild of Australia PSA Pharmaceutical Society of Australia QCPP Quality Care Pharmacy Program QLD Queensland, Australia SA South Australia, Australia TAS Tasmania, Australia WA Western Australia, Australia Pharmaceutical Care The responsible provision of medicine therapy for the purpose

of achieving definite outcomes that improve a patient’s quality of life.

Screening Detection of unrecognised disease or condition by using reliable tests, examinations or other procedures that can be readily applied.

93

7. Technical Notes n Mean: 1 ∑ xi ni

i=1

n Variance: 1 [ (∑ xi

2) – nx-2] (n-1) i=1

Standard deviation: √Variance

n Mean estimate: 1 ∑ fixi

ni i=1

Where xi = midpoint (except last column where lowest score used), fi= frequency of score and n = number of valid scores.

n n Variance estimate: 1 [ (∑fixi

2) – (∑fixi)2 /n ] (n-1) i=1 i=1

Where xi = midpoint (except last column where lowest score used), fi= frequency of score and n = number of valid scores.

Standard deviation estimate: √Variance estimate

94

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202.Berbatis CG, Sunderland VB. The role of community pharmacy in methadone maintenance treatment. Final report. Barton (ACT): Australian Association of Consultant Pharmacy, 2000.

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206.Berbatis CG, Sunderland VB, Bulsara M. Licit psychostimulant consumption in Australia, 1984-2000: international and jurisdictional comparison. Med J Aust 2002; 177 : 539-543.

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209.Topp L, Degenhardt L, Day C, Collins L. Contemplating drug monitoring systems in the light of Australia’s “heroin shortage”. Drug Alcohol Rev 2003; 22:3-6.

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212.M Dobbin. Temazepam injecting in Victoria. Melbourne : Public Health Division, Department of Human Services, Victoria ; 2001.

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229.Vickers A, Zollman C. The manipulative therapies : osteopathy and chiropractic. Br Med J 1999; 319: 1176-1179.

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235.Pharmaceutical Council of WA. Iridology in pharmacies. Rescript (Pharmaceutical Society of Western Australia) September 1999:5.

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237.Moynihan R. It’s only natural : how Blackmores is being too clever by half. The Australian Financial Review 2000; 8 April :26-27.

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(ACT): Pharmaceutical Society of Australia, 2002 : 306-322, 436-440, 561-565. 255.Fox BI, Felkey BG. Is your pharmacy practice web-enabled? Aust J Pharm 2002; 83: 49-

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8. Appendix

1. Approvals in 2002. 2. Publicity in 2002. 3. Questionnaire :refer http://www.curtin.edu.au/curtin/dept/pharmacy/survey/index.html

107

108

109

110

111

112

113

114

115

116

117

Informed Consent I consent to the collection and use of the data in the enclosed form on the understanding it will be de-identified, processed and analysed in groups and held confidential according to National Health and Medical Research Council (NH&MRC, 2001) requirements and the project has been approved by the Human Research Ethics Committee of the Curtin University of Technology.

Signed:

Name (print): Date:

Australia’scommunitypharmacies

2002

Pharmacy (print):

SurveySurveyofof

This national survey of pharmacies is being conducted by Curtin University's School of Pharmacy under the Third Community Pharmacy Agreement Research and Development (R&D) Grants Program. The survey is supported by the Pharmacy Boards, Pharmacy Guild, the Pharmaceutical Society of Australia, University departments of pharmacy and other national pharmacy bodies.

The main purpose of the survey is to quantify the paid or unpaid health related activities occurring in Australia's pharmacies so our national bodies are in a stronger position to negotiate to increase your remuneration for a wider range of pharmacy services.

Questionnaires are the most efficient method of gathering data on pharmacies but the responses need to be complete and accurate so that the statistics are reliable. These results will allow the University statistician to quantify national numbers of pharmacy facilities and services for the first time in Australia.

The respondent pharmacist manager or owner may need to consult with other pharmacists or non-pharmacist staff who work at other times or in different areas in the pharmacy. Please keep the enclosed $10 for participating. Each accredited Quality Care Pharmacy Program (QCPP) pharmacy will receive 3 CQI points as part of the annual 8-CQI point QCPP re-accreditation for completing this questionnaire. T h e U n i v e r s i t y ' s I n t e r n e t H o m e P a g e http://www.curtin.edu.au/curtin/dept/pharmacy/survey/index.html will post the questionnaire and the results of the survey as they become available.

Queries may be directed to Con Berbatis, School of Pharmacy, Phone: (08) 9271 7180 (all hours), Fax: (08) 9266 2769 Email: berbatis@git.com.au

Thank you for participating in this important study.

/ /2002

This survey has Pharmacy Guild of Australia rating A1 (No.479)

Commonwealth Government Statistical Clearing House Approval No.01189-01Please provide an estimate of the time taken to complete this form.Include: The time actually spent reading the instructions, working on the question and obtaining the information; The time spent by all employees in collecting and providing this information.

hrs mins

PRIORITY

National Survey - Third Pharmacy Government Agreement

SECTION A

Respondent pharmacist details

1 Gender. Please tick

2 Age. Please tick

3

4

Please tick ( ) your highest qualification in pharmacy?

Male

Female

1

2

21-30

31-40

41-50

51-60

61+

1

2

3

4

5

Please tick ( ) where you obtained your initial qualification in pharmacy?

5a

5b Please tick ( ) the average number of hours you spent each month onContinuing Pharmacy Education activities in the last 12 months?

5c Please tick ( ) the percentage of your involvement in the following forms of Continuing Pharmacy Education (CPE).

6 Please tick ( ) which one of the following best describes your position in this pharmacy?

1

2

Sole proprietorPartner proprietorSalaried managerPharmacist in chargeLocum pharmacistConsultant pharmacistEmployee pharmacist

3

4

5

6

7

page 1

In which year did you first obtain Australian registration as a pharmacist (any category) in any State or Territory?

% CPE time involvement 0 - 20% 21 - 40% 41 - 60% 61- 80% 81 - 100%1 2 3 4 5

ConferencesCourse/lectures (seminars)Journals/ personal readingOnlineQuestionnaires in professional journals Other (specify)

NSWVICQLDSAWATASACTNTOther country

1

2

3

4

5

6

7

8

9

None1 to 5 hours6 to 10 hours11 to 20 hoursMore than 20 hours

1

2

3

4

5

DiplomaB PharmM PharmPhDOther (specify)

1

2

3

4

Enhanced pharmacy services paid or unpaidSECTION B

SECTION B

page 2

7

Barriers to and facilitators of enhanced pharmacy services

SECTION B

SECTION C

8

Please tick ( ) the following categories of enhanced pharmacy services over and above routine practice that this pharmacy offers or plans to offer.

Stronglydisagree

Disagree Unsure Agree Stronglyagree1 2 3 4 5

Barriers to enhanced pharmacy services in this pharmacy

Shortage of time for pharmacistShortage of pharmacistsCustomers won't payUnable to get locum cover for emergenciesLack of appropriate knowledge/skills by pharmacists Lack of confidence by pharmacy staffIt is not felt by pharmacists to be part of their jobThere is no extra remuneration for itWould impair working relationships with local general medical practitioners (GP's)Lack of opportunity to meet with local GP's or other health workersGP's do not recognise pharmacists' skills in enhanced pharmacy servicesOther (specify)

Plans in 12 months

Does not offerCategory of enhanced pharmacy serviceSpecially trained or

accredited pharmacist or non-pharmacist

Offers nowOffers at no charge

Receives payment for

Aboriginal health servicesAnticoagulationAsthmaBody piercingChemotherapy preparationCommunity education, structuredCommunity clinic services with nurseDiabetesDischarge services for hospital patientsDrug level monitoring/kinetic dosingGeriatric careHarm reduction including methadoneHerbal medicines/nutritional supplement counsellingHyperlipidaemiaHypertensionNaturopathyNutritional support (e.g. parental/enteral nutrition)OsteoporosisOstomy counsellingPaediatric pharmacyPain managementPsychiatric pharmacySkin care managementSmoking cessationSpecialised compoundingWeight reductionWound careOther (specify)

Please tick ( ) the extent to which you agree or disagree that the following are barriers to this pharmacy implementing the enhanced pharmacy services listed in Question 7.

2 3 4 51

page 3

9

10a

Prescription related activities in this pharmacySECTION

BSECTION

D

10b

Prescriptions per week 0 to 300 301 to 800 801 to 1,200 1,201 to 2,000 2,001 to 3,000 3,000 or more Total

1 2 3 4 5 6

Please tick ( )the extent to which you disagree or agree that the following will facilitate this pharmacy implementing the enhanced pharmacy services listed in Question 7.

Stronglydisagree

Disagree Unsure AgreeStrongly

agree1 2 3 4 5Facilitators of enhanced pharmacy services

Access to detailed patient notesDesignated closed counselling areaDesignated clinical testing areaAppointment systemsAccreditation for specific activityDedicated study time for pharmacistsOther (specify)

Please tick ( ) the average number of prescription items dispensed in this pharmacy in a typical period of seven days.

Please tick ( ) the average number of patients in the following categories who were dispensed prescribed drugs in a typical period of seven days in this pharmacy.

10c

Please tick ( ) the average number of patients in a typical period of seven days in the following settings who receive from this pharmacy prescription items packaged in dose administration aids or DAAs (e.g. Webster-type, Dosette-type).

11a

Please record the fee charged for each DAA per patient-week or per unit pack to patients in the following settings. If no fee is charged please record zero (0).

11b

Aged care or community setting

Nursing homeHostel Community based patientsRemote health clinics (specify)

Fee per patient-week ($) Fee per unit pack ($)

1 2 3 4 5 6

Less than 1per week

21 to 50per week

51 to 100per week

101 to 250per week

251 or moreper week

Nursing homeHostel Community based patientsRemote health clinics (specify)

None atall

None atall 1 2 3 4 5 6

1 to 5per week

6 to 10per week

11 to 20per week

21 or moreper week

Less than 1per week

Please record the transport fee ($) charged by this pharmacy for the following categories and units of dispensing.

If no transport fee is charged please record zero (0).

please record zero (0).Category of dispensing

Mail orderDistance Community deliveries(specify)

Transport fee per prescription

$

Transport fee per patient

$

Category of dispensing

Mail orderDistance Deliveries

1 to 20per week 7

Aged care orcommunity setting

page 4

13c Please tick ( ) the estimated number of patients who received the following monitoring activities for the therapeutic and adverse effects of their prescribed medications in this pharmacy during a typical period of seven days.

Less than 1per week

1 to 5per week

6 to 10per week

11 or moreper week1 2 3 4 5

Monitoring therapeutic and adverse effects

Clinical testing in pharmacy with devices such as weight scales, glucose meters, blood pressure meters, peak flow metersLaboratory test results to monitor medication effectsAdverse reactions recorded in patient file (e.g. drug allergies)Other (specify)

None atall

13b Please tick ( ) the estimated number of patients who received the following monitoring activities for compliance with their prescribed medications in this pharmacy during a typical period of seven days.

None atall

Less than 1per week

11 to 40per week

41 to 80per week

81 or moreper week1 2 3 4 5 6

Monitoring compliance

Monitor compliance by appropriate questions Monitor compliance by frequency of repeatsMonitor with DAAs (e.g. Webster-type, Dosette-type)Other (specify)

1 to 10per week

11c Please tick ( ) the number of individual (different) patients who receive the following drugs by supervised dosing in this pharmacy during a typical period of seven days.

Drug groups dosed in pharmacies

Analgesics (specify)

Benzodiazepines (specify)

BuprenorphineMethadoneOther psychotropic agents(specify)Other agents (specify)

Less than 1per week1 2 3 4 5

6 to 10per week

11 to 20per week

21 or moreper week

Noneper week

1to 5per week 6

Please record the fee charged per supervised dosing of each of the following prescription drugs in this pharmacy. If no fee is charged please record zero (0).

11d

13a Please tick ( ) the estimated number of patients with prescription medications who fall into of the following counselling categories in this pharmacy during a typical working day. Forward pharmacy refers to a seated counselling area with dispensary computer.

Verbal or written counselling

Non-or-poor-English speaking patientsCMI computerisedOther computer produced informationOther written or printed drug information Counselled or administered medicines in closed counselling areaCounselled or administered medicines in private unenclosed areaCounselled or administered medicines in a forward pharmacy areaMedication Assistance Service (MAS) or activity paid by health insuranceOther (specify)

1 2 3 4 5 6

Less than 1per day

1 to 5per day

6 to 10per day

11 to 30per day

31 or moreper day

None atall

Prescription related activities in this pharmacy(continued)

SECTION B

SECTION D

Dosing fee ($)

Analgesics Benzodiazepines Buprenorphine Methadone Other agents (specify)

12 Please tick ( ) the number of patients in the past seven days who were declined prescription drugs for the following reasons.

1 2 3 4 5 6

Less than 1per week

1 to 5per week

6 to 10per week

11 to 20per week

21 or moreper week

None atall

Inappropriate drug or dose, suspectedinteraction, or contraindication Suspected adverse effect Duplication, prescription defects

Reason for declining prescribed drugs

1 2 3 4 5

14a

page 5

SECTION E

Medication review processes

Please tick ( ) if this pharmacy supplies medicines to patients in residential aged care facilities (eg. nursing homes, hostels) or private hospitals?

1 Yes No

2

14b Please record the number of beds in the following locations supplied with medicines by this pharmacy.

Type of external facility Beds supplied

Nursing homesHostelsPrivate hospitalsOther (specify)

14c

14d

14e

Please tick ( ) which of the following positions the AACP accredited pharmacist occupies in this pharmacy14f

AACP accredited pharmacistProprietorManagerEmployee pharmacist full-timeEmployee pharmacist part-timeConsultant or contracted pharmacist Other (specify) __________________

Access to AACP accredited pharmacist YesNoDon't know

Please tick ( ) if this pharmacy has access to an Australian Association of Consultant Pharmacy (AACP) accredited pharmacist.

HMR (DMMR) approval by HICYesNoDon't know

Please tick ( ) if this pharmacy is registered with the HIC as an approved Home Medicine Reviews (HMRs) or DMMRs Service Provider. DMMR refers to Domiciliary Medication Management Review, a term interchanged with HMR.

Please tick ( ) the number of patients in a typical month in 2002 involved in the following medication review processes in which this pharmacy participated.

Medication review processes reimbursedHome Medicine Reviews (HMRs) or DMMRsMedication Management Review in residential aged care facilitiesEnhanced Primary Care (EPC) Multidisciplinary Care PlanEnhanced Primary Care (EPC) Case ConferenceEnhanced Primary Care (EPC) Case Health AssessmentSection 100 medicine access scheme for aboriginesOther form of medication review (specify)

Less than 1 per month

None atall

11 to 50 per month

51 to 100 per month 1 2 3 4

101 to 200 per month

201 or moreper month 75 6

1 to 10 per month

15a

page 6

SECTION F

Primary health care including pharmacy (S2) and pharmacist-only (S3) medicines

Pharmacy's control of these medicines or products is contentious. To ensure the reliability of the data recorded in 15A please refer to POS printouts and consider conducting sample surveys. Prescription medicines are excluded here.

Please tick ( ) the average number of clients who received the following services in a typical working day in this pharmacy.

15b Please tick ( ) the estimated number of clients in this pharmacy suspected in the last seven days of misusing S2 or S3 medicines (e.g. codeine liquids, compound codeine analgesics, diphenhydramine, pseudoephedrine).

Less than 1 per week

1 to 5per week

6 to 10 per week

11 to 20 per week

21 or more per week

Suspected S2 or S3 medicine misuse

Suspected misuse of S2 or S3Refused supply of S2 or S3

1 Yes No

2

16

SECTION G

Preventive services implemented in this pharmacy

Please tick( ) if this pharmacy has a vaccine refrigerator which complies with pharmacy standards (constantly between 2 C and 8 C)?

17

18 Please tick ( ) the estimated average number of each of the following tests provided to screen undiagnosed patients during a typical period of 30 days in this pharmacy.

Less than 1per month

1 to 2 per month

3 to 10 per month

11 to 20 per month

21 or more per month

Clinical testing to screen undiagnosed patients

Anthropometric tests (e.g. body weight, height and waist circumference)Blood cholesterol testing Blood glucose testing Blood pressure testing Bone density testing Pregnancy testing Other (specify)

None atall

Please tick ( ) the estimated number of clients in the last seven days who received one of the following agents initiated in this pharmacy by a pharmacist and not prescribed by a doctor.

None atall

Less than 1per week

1 to 2 per week

3 to 10 per week

11 to 20 per week

21 to 50 per week

Over 51 per week

1 2 3 4 5

1 2 3 4 5 6 7

1 2 3 4 5 6

Primary health care activities in this pharmacy (excludes prescription medicines)Total who asked for S2s and S3s by name (i.e. self medication)Total who received assistance with symptoms, health problems, or questionsClients issued computerised CMIs, printed information (e.g. Self Care card) Clients referred to GP with ailmentsClients referred to other health practitionersOther (specify)

Less than 1 per day

1 to 10per day

11 to 30 per day

31 to 50 per day

51 to 80 per day

81 or more per day1 2 3 4 5 6

Preventive activities with non-prescribed medicines Nicotine replacement therapiesAspirin (100mg or less per day) for the primary or secondary prevention of coronary heart diseaseIron supplementation to prevent anaemias in femalesFolic acid in early pregnancy to prevent neural-tube defects in offspringCalcium products to prevent osteoporosisDaily multivitamins to prevent suspected nutritional deficiencyOther (specify)

19a

page 7

SECTION H

Harm minimisation or harm reduction activities

Please tick ( ) the estimated average number of clients provided with each of the following harm minimisation or harm reduction activities during a typical working day.

None atall

Less than 1per day

1 to 5 per day

6 to 10 per day

11 to 20 per day

21 or more per dayHarm minimisation or reduction activity

Methadone dosingBuprenorphine dosingNaltrexone dispensed Needle exchange or supplyBenzodiazepine contracts or prescriber arrangements to prevent diversion and misuse of drugs of dependenceOther harm minimisation activity (specify)

19b Please tick ( ) the estimated number of clients detected in this pharmacy from 1 January to 30 June 2002 for prescription fraud including forgery of prescriptions for medicines such as morphine C-R, dexamphetamine, methadone, oxycodone, temazepam, benzodiazepines, compound codeine products. ‘Doctor Shoppers’ refers to people who in one year obtain more PBS prescriptions than appears to be clinically necessary or who see 15 or more general practitioners.

SECTION I

Complementary therapies includingherbal medicines

Please tick ( ) the estimated average number of clients referred to or provided with the following complementary therapies by this pharmacy in a typical period of 30 days.

20

SECTION J

Information facilities and programs

Prescription fraud Forgeries detected January to June 2002Doctor Shopping detected Jan to June 2002

None at all 1 to 6 6 to 12 13 to 30 31 or moreLess than 1

Complementary therapy referred or provided Acupuncture Aromatherapy Chiropractic Homeopathy Hypnosis Iridology Meditation Naturopathy Reflexology Massage Spiritual healing Other (specify)

None at allLess than 1per month

1 to 5per month

6 to 10per month

11 to 30per month

31 or moreper month

1 2 3 4 5 6

1 2 3 4 5 6

1 2 3 4 5 6

21 Please tick ( ) the estimated number of patients who receive services with reference to one of the following information resources in this pharmacy in a typical working day.

Less than 1per day

1 to 2 per day

3 to 10 per day

11 to 20 per day

21 or more per day

Information resource or programNone at

all 1 2 3 4 5 6

Australian Pharmaceutical Formulary (APF)CD ROM's (eg. MIMS, APP Guide)CMI computerisedMartindaleMIMS or APP Guide booksPharmacy Self CareTherapeutic GuidelinesWeb-based drug informationOther (specify)

Australian Medicines HandbookAusDI book

22a

page 8

SECTION K

Technologies and health communications

Please tick ( )the following features associated with the dispensary computer and its use in this pharmacy.

Dispensary computer featureComputer with Pentium processorRegular internet useRegular e-mail usePharmacy website ADSL broad band access (always on fast connection)Other (specify)

22b If this pharmacy has a website, please tick ( ) the medication-related activities currently provided by this pharmacy’s website.

Website activityOffers medications onlineOffers other products onlineOffers home delivery servicesOffers other health informationOther (specify)

23 Please tick ( ) the estimated average number of each of the following activities initiated in this pharmacy during a typical working day.

Less than 1 per dayNone at all

1 to 2 per day

3 to 10per day

11 to 20 per day

20 or more per day

24

SECTION L Opinion on the use of technical facilities

Technologies and this pharmacy

Telephone is the best method to communicate with community doctors or other health workersTelephone is the best method to communicate with community patients or their carers Privacy legislation restricts telephone communication by this pharmacy with community doctors, patients and carers Fax will replace telephones in this pharmacy as the best method to communicate with community doctors, health workers or patients E-mail will replace telephones in this pharmacy as the best method to communicate with community doctors, patients or carersInternet sales of prescription medicines will depress the number of medicines dispensed in this pharmacy within 24 monthsInternet sales of all medicines will depress the sale of non-prescribed medicines or other health products in this pharmacy within 24 months

Stronglydisagree Disagree Unsure Agree

Stronglyagree

Please tick ( ) the extent to which you agree or disagree with the following statements on the use or impact of communication technologies on this pharmacy's health related activities during 2002.

1 2 3 4 5 6

Telephone, fax or email contactwith prescriber, client, or carer Contacted prescriber to clarify or correct prescribed medicationContacted prescriber regarding appropria-teness of prescribed drug or dose, patient contraindication, or adverse effects Contacted patient or carer to reinforce or monitor complianceContacted patient or carer to assess effects of therapyContacted other health worker or source for patient health information

1 2 3 4 5

page 9

SECTION M

Pharmacy and staff

25a Location of this pharmacy by postcode

Please tick ( ) which one of the following best describes the setting of this pharmacy? 25bCity, suburb or town centre strip

2Regional shopping centre (over 100 shops or over 30,000m )2Neighbourhood shopping centre (under 30,000m )

Isolated (1-9 shops together)Medical centreHospitalOther (specify)

1

2

3

4

5

6

Please record the total hours and days this pharmacy is open.25cTotal hours per week Total days per week

Please record or estimate as accurately as possible the area of each of the following sections in this pharmacy. If a certain area is not applicable then please enter a value of '0’ (zero).

26

Dispensary areaSchedule area (for S2s and S3s) Forward pharmacy area (seated counselling area with dispensary computer)Private un-enclosed counselling/dosing areaClosed counselling/dosing areaRetail areaStoreroom, office, etcOther (specify)Total area of premises

4

1

2

3

5

6

7

8

9

2m 2m 2m

2m 2m 2m 2m 2m 2m

27 Please tick ( ) which one of the following describes this pharmacy's group membership.

Not in a groupAmcalChem MartFriendly SocietiesGuardianSoul PattinsonOther group (specify)

1

2

3

4

5

6

28 Please tick ( ) the QCPP status of this pharmacy. QCPP refers to Quality Care Pharmacy Program.

Not yet registered for QCPPPartially completed QCPP accreditationCompleted but not yet accreditedQCPP accreditedRe-accreditedOther (specify)

1

2

3

4

5

29a Please tick ( ) the method of operation of this pharmacy.

Owner operatedPartner operatedManager operatedOther (specify)

1

2

3

29b Please tick ( ) if this pharmacy has a non-pharmacist retail manager.

Yes No

page 10

30a Number of proprietors / owners of this pharmacy.

30b Please complete the following details for each proprietor/owner of this pharmacy.

st nd rd th1 2 3 4 Proprietor / OwnerAge - enter number:1=21-30, 2=31-40, 3=41-50, 4=51-60, 5=61+Gender - enter number: 1-Male, 2-FemaleHighest pharmacy academic qualification - enter number:1-Diploma, 2-Bachelor, 3-Masters, 4-PhD, 5-Other (specify)Continuing pharmacy education-average hours per month - enter number (estimate if necessary) :1=zero hours; 2=one to five hours; 3=six to 10 hours; 4=11 to 20 hours; 5= over 20 hours.

Please tick ( ) the total number of customers per week. Please include patients in hospitals and aged care facilities serviced by this pharmacy.

31

0-700 701-1,400 1,401-2,100 2,101-3,500 3,501-5,000 5,001 or more

32 Please record the number of current staff or contractors working in this pharmacy and their hours worked in a typical period of seven days. Exclude administration and other work done after hours.

Pharmacy staff

Proprietor 1Proprietor 2Proprietor 3Proprietor 4Pharmacist managerConsultant pharmacistOther pharmacist staffNon-pharmacist manager (retail)Dispensary assistant / Pharmacy technicianNon-pharmacist clerical or administrationOther non-pharmacist staffComplementary or other health practitioners (Please specify)Total

Full timePart time

and casualsTotal hoursper week

Hours in dispensary

Clinical, patient care or counselling

33a

33b

Total turnover

(total pharmacy and other income) <$1m $1-1.5m $1.5-$2m $2-3m $3-4m $4-6m $6-8m >$8m

Please tick ( ) the estimated annual turnover of this pharmacy.

Please complete details of sales/turnover per year for each of the following categories. If not known for any category, then please estimate.

Total prescription sales (incl. Safety Net and private prescriptions)S2 and S3 medicinesHerbal products and vitamins sales Medical aids and medical appliances / equipment (home health care)Other pharmacy sales

______% tumover______% tumover______% tumover______% turnover______% tumover

THE END - THANK YOU

Please place the checked and completed questionnaire in the enclosed stamped envelope addressed to the Survey Research Centre, School of Population Health, University of Western Australia 6009

SECTION M

Pharmacy and staff (continued)

1 3 42 5

21 3 4 5 6 7 8

Australia’s community pharmacies2002

SurveySurveyofof

This questionnaire was developed by Con Berbatis with the assistance of the National Panel, pharmacy colleagues in practice, teaching, and research overseas and throughout Australia.

It was designed to be a tool for quantifying community pharmacists’ health related activities in Australia. Community pharmacists completed the questionnaire within 50 minutes in the testing phase.

We believe the graphics and layout in the final questionnaire will facilitate less time for respondent pharmacists.