Medicines information services in a resource-limited setting.

INTRODUCTION: In resource-limited settings, it is particularly important to explore the priorities for, as well as barriers to, development of health services. There has been limited development of medicines information (MI) services in Vietnam despite national guidelines. OBJECTIVES: To explore the current status of MI services for healthcare professionals and patients in Vietnamese hospitals. METHODS: In 2018, all hospitals which were under the direct administration of the Ministry of Health and all 63 Provincial Health Bureaus were invited to participate (n = 1359). All national, provincial and district hospitals, as well as private hospitals and hospitals from other Ministries in Vietnam, were included. An online questionnaire about MI facilities, workforce, and activities was used. RESULTS: There were 560 eligible responses from pharmacists in hospitals. The most common MI service was pharmacovigilance (provided in 91% of hospitals), and the least common was providing MI for clinical case management (30%), nurse training (31%), and MI provision to patients (27%). Multivariate logistic regression analysis showed that the number of pharmacists and the geographical-economical area where hospitals were based had the strongest impact on the likelihood of offering more MI services in hospitals. While the type of hospital (traditional medicine vs. other hospitals) had some impact, hospital size, level, and specialization of hospital (general vs. specialized) did not have a significant impact on the provision of MI services. CONCLUSION: The differences in workforce and location may contribute to differences in MI practices between hospitals. These findings are relevant for the implementation of a national MI strategy in Vietnam and other developing countries.

"I have nine specialists. They need to swap notes!" Australian patients' perspectives of medication-related problems following discharge from hospital.

BACKGROUND: Research has shown that patients are most susceptible to medication-related problems (MRPs) when transitioning from hospital to home. Currently, the literature in this area focuses on interventions, which are mainly orientated around the perspective of the health-care professional and do not take into account patient perspectives and experiences. OBJECTIVE: To capture the experiences and perceptions of Australian patients regarding MRPs following discharge from hospital. DESIGN: A cross-sectional study was conducted using a questionnaire collecting quantitative and qualitative data. Thematic analysis was conducted of the qualitative data. SETTING AND PARTICIPANTS: Survey participants were recruited through The Digital Edge, an online market research company. Five hundred and six participants completed the survey. RESULTS: A total of 174 participants self-reported MRPs. Two concepts and seven subthemes emerged from the analysis. The first concept was types of MRPs and patient experiences. Three themes were identified: unwanted effects from medicines, confusion about medicines and unrecognized medicines. The second concept was patient engagement in medication management, of which four themes emerged: informing patients, patient engagement, communication amongst health-care professionals and conflicting advice. DISCUSSION AND CONCLUSION: This study provides an important insight into patients' experiences and perceptions of MRPs following discharge from hospital. Future direction for practice and research should look into implementing patient-centred care at the time of hospital discharge to ensure the provision of clear and consistent information, and developing ways to support and empower patients to ensure a smooth transition post-discharge from hospital.

Consumer perspectives of medication-related problems following discharge from hospital in Australia: a quantitative study.

OBJECTIVE: The aim of this study was to investigate the consumer's perspectives and experiences regarding medication related problems (MRPs) following discharge from hospital. DESIGN: A cross-sectional study was conducted using an online 80-question survey. SETTING: Survey participants were recruited through an online market research company. PARTICIPANTS: Five hundred and six participants completed the survey. Participants were included if they were aged 50 years or older, taking 5 or more prescription medicines, had been admitted to hospital with a minimum stay of 24 h, admitted to hospital within the last 4 months and discharged from hospital within the last 1 month. MAIN OUTCOME MEASURES: The survey comprised questions measuring: health literacy, health status, medication safety (measured by reported MRPs), missed dose(s), role of health professionals, health services and cost, and socio-demographic status. Descriptive and univariate statistics and logistic regression analysis was performed to examine the predictors of experiencing MRPs. RESULTS: Four main risk factors of MRPs emerged as significant: health literacy (P < 0.05), health status (P < 0.05), consumer engagement (P < 0.05) and cost of medicines (P = 0.001). Participants reporting a lack of perceived control over their medicines (OR 6.3; 95% CI: 3.4-11.8) or those who played less of a role in follow-up discussions with their healthcare professionals (OR 7.6; 95% CI: 1.3-45.7) were more likely to experience a self-reported MRP. CONCLUSIONS: This study provides insight into consumers' experiences and perceptions of self-reported MRPs following hospital discharge. Results highlight novel findings demonstrating the importance of consumer engagement in developing processes to ensure medication safety on patient discharge.

Strategies to improve adherence to medications for cardiovascular diseases in socioeconomically disadvantaged populations: a systematic review.

Medication non-adherence poses a major barrier to reducing cardiovascular disease (CVD) burden globally, and is increasingly recognised as a socioeconomically determined problem. Strategies promoting CVD medication adherence appear of moderate effectiveness and cost-effectiveness. Potentially, 'one-size-fits-all' measures are ill-equipped to address heterogeneous adherence behaviour between social groups. This review aims to determine the effects of strategies to improve adherence to CVD-related medications in socioeconomically disadvantaged groups. Randomised/quasi-randomised controlled trials (1996-June 2012, English), testing strategies to increase adherence to CVD-related medications prescribed to adult patients who may experience health inequity (place of residence, occupation, education, or socioeconomic position) were reviewed. 772 abstracts were screened, 111 full-text articles retrieved, and 16 full-text articles reporting on 14 studies, involving 7739 patients (age range 41-66 years), were included. Methodological and clinical heterogeneity precluded quantitative data synthesis. Studies were thematically grouped by targeted outcomes; underlying interventions and policies were classified using Michie et al.'s Behaviour Change Wheel. Contrasting with patient or physician/practice strategies, those simultaneously directed at patients and physicians/practices resulted in statistically significant improvements in relative adherence (16-169%). Comparative cost and cost-effectiveness analyses from three studies did not find cost-saving or cost-effective strategies. Unlike much current evidence in general populations, promising evidence exists about what strategies improve adherence in disadvantaged groups. These strategies were generally complex: simultaneously targeting patients and physicians; addressing social, financial, and treatment-related adherence barriers; and supported by broader guidelines, regulatory and communication-based policies. Given their complexity and potential resource implications, comprehensive process evaluations and cost and cost-effectiveness evidence are urgently needed.

Understanding rational non-adherence to medications. A discrete choice experiment in a community sample in Australia.

BACKGROUND: In spite of the potential impact upon population health and expenditure, interventions promoting medication adherence have been found to be of moderate effectiveness and cost effectiveness. Understanding the relative influence of factors affecting patient medication adherence decisions and the characteristics of individuals associated with variation in adherence will lead to a better understanding of how future interventions should be designed and targeted. This study aims to explore medication-taking decisions that may underpin intentional medication non-adherence behaviour amongst a community sample and the relative importance of medication specific factors and patient background characteristics contributing to those decisions. METHODS: A discrete choice experiment conducted through a web-enabled online survey was used to estimate the relative importance of eight medication factors (immediate and long-term medication harms and benefits, cost, regimen, symptom severity, alcohol restrictions) on the preference to continue taking a medication. To reflect more closely what usually occurs in practice, non-disease specific medication and health terms were used to mimic decisions across multiple medications and conditions.161 general community participants, matching the national Australian census data (age, gender) were recruited through an online panel provider (participation rate: 10%) in 2010. RESULTS: Six of the eight factors (i.e. immediate and long-term medication harms and benefits, cost, and regimen) had a significant influence on medication choice. Patient background characteristics did not improve the model. Respondents with private health insurance appeared less sensitive to cost then those without private health insurance. In general, health outcomes, framed as a side-effect, were found to have a greater influence over adherence than outcomes framed as therapeutic benefits. CONCLUSIONS: Medication-taking decisions are the subject of rational choices, influenced by the attributes of treatments and potentially amenable to intervention through education, strategic pricing and the altering of dosing characteristics. Understanding individual treatment preferences is thus an important step to improving adherence support provision in practice. Re-framing future interventions and policies to support rational and informed individual patient choices, is the way forward to realising the full potential health and economic benefits from the efficacious use of medications.

Setting priorities for high-cost medications in public hospitals in Australia: should the public be involved?

AIM: To explore healthcare decision makers' perceptions about public involvement in setting priorities for high-cost medications (HCMs) in public hospitals in Australia. METHODS: In-depth, semi-structured interviews were conducted with 24 decision-makers (executive directors of hospitals, area health service managers, directors of hospital pharmacy departments and senior medical doctors) in a Sydney Area Health Service. Interviews were digitally recorded, transcribed verbatim, thematically content analysed and coded. RESULTS: The majority of participants perceived that the 'rationing debate' needs to happen in Australia. The community at large should be encouraged to understand that healthcare resources are limited and choices need to be made. The perspectives of the public, according to participants, were considered diverse (tax payers, patients, consumers). Owing to the complexities of the healthcare system, their involvement of the public in decision-making regarding access to HCMs in public hospitals was considered limited. For participants, the role of the public was likely to be at the macro level, deciding how much they were prepared to spend on healthcare. CONCLUSION: The role of the public in setting priorities for HCMs in public hospitals was perceived by these healthcare decision makers as limited. However since rationing is unavoidable, there should be an explicit debate about the principles and issues concerned.

Challenges in chronic illness management: a qualitative study of Australian pharmacists' perspectives.

OBJECTIVE: To explore pharmacists' views on managing patients with chronic illness; to understand the incentives and barriers they perceive and the solutions they propose to overcome these barriers. SETTING: Hospital pharmacists, with experience in managing people with chronic illnesses, working in western Sydney, Australia, were interviewed during June and July 2008. METHOD: A qualitative study involving group and individual interviews using a semi-structured interview guide. RESULTS: Hospital pharmacists identified lack of communication between different healthcare providers and with patients as a contributing factor to lack of continuity of care and this was perceived as a major barrier in managing patients with chronic illnesses. Pharmacists were also concerned about the effects of medication costs, and poor patient knowledge regarding their disease and medications, and the effects on adherence. Suggested solutions included taking a teamwork approach in the management of chronic illness and providing more information to patients to improve adherence. CONCLUSION: The identified incentives and barriers have provided valuable information on what pharmacists face in managing patients with chronic illness. Most of the solutions suggested by them have been tested and proven unsuccessful. Develop successful health policy to address the identified barriers remains a challenge.

The Pharmaceutical Benefits Scheme and implications for paediatric prescribing.

AIMS: To evaluate the impact of the Pharmaceutical Benefits Advisory Committee (PBAC) decisions on access to medicines listed on the Pharmaceutical Benefits Scheme (PBS) for children. METHODS: We analysed all public summary documents from PBAC meetings from July 2005 to November 2006 and compared these with the Therapeutic Goods Administration (TGA) recommendations for children for the same medicine. Main outcome measures stratified by age, the total number of medicines for specific indications (accepted and rejected) by therapeutic class; estimated cost to the PBS per annum for each medicine recommended for listing; comparison of TGA-approved product information and PBS listing for recommended medicines. RESULTS: Of the 102 medicines for specific indications considered by the PBAC, 7% (7/102) of submissions were for new paediatric indications. Most submissions (60%, 61/102) did not specify age for the PBS recommendation and were for conditions which only affect adults. Listings which specifically included children were more likely to have a positive PBAC recommendation. Of the six recommended medicines for children, four were estimated to cost between $10-30 million per year. There was fair concordance between PBS- and TGA-approved product information for age (kappa 0.21) but in 46%, PBAC recommendations were for age-unrestricted listing compared with adults-only use in the TGA-approved product information. CONCLUSION: Access to new subsidised medicines for children in Australia lags behind adults because most applications to the PBAC for new medicines are for conditions which only affect adults. PBS processes facilitate access for children to new medicines by avoiding age restrictions.

Funding and access to high cost medicines in public hospitals in Australia: decision-makers' perspectives.

AIM: To investigate the perceptions, concerns and attitudes of decision-makers regarding access to high cost medicines (HCMs) in public hospitals. METHODS: In-depth semi-structured interviews were conducted with 24 decisions-makers (executive directors of hospitals, area health service managers, directors of hospital pharmacy departments and senior medical doctors) in a Sydney Area Health Service. The interviews were digitally recorded and transcribed and analysed using a modified grounded theory approach. RESULTS: Decision-makers perceived health care system funding models as obstacles to equity of access to HCMs. They were concerned that there were inequities in decisions for individual patients according to public or private sector status. A major concern for respondents was the lack of consistency in decision-making about funding for HCMs. Respondents described that besides safety, efficacy, effectiveness and cost, ethical principles should be borne in mind when deciding whether a HCM should be available in a public hospital. Most wanted a consistent, transparent, accountable, evidence-based decision-making process. CONCLUSIONS: The results of this study suggest that decision-makers were concerned about the equity of access to HCMs in public hospitals and wanted an explicit, systematic process to allocate resources to HCMs.

Public views on priority setting for high cost medications in public hospitals in Australia.

OBJECTIVE: To gather information about views of members of the general public about access to High Cost Medications (HCMs) in public hospitals. METHODS: A structured questionnaire was administered to members of the general public. Individuals were approached in train stations, shopping centres and different venues in the Sydney metropolitan area. People were eligible to answer the survey if they were: over 18 years of age, Australian permanent residents and able to complete the questionnaire in English. RESULTS: Two hundred people completed the survey. Of these 56% were females, 47% were married, 84% spoke English at home, 88% were working either full-time or part-time, 61% had a university degree, 27% had a household annual income greater than 100,000 dollars and 68% had private health insurance. Participants considered factors such as treatment outcomes, quality of life and current health status when determining who should have access to HCMs. Participants wanted resources to be allocated to provide the 'greatest benefit to the greatest number of people'. Almost half the respondents did not want direct involvement in decision-making, however, 38% did. CONCLUSIONS: The results offered support for indirect involvement through the development of a process to involve community members in discussion on policy on the provision of treatment and services within health-care institutions and specifically, to seek the views of members of the public on the provision of HCMs and expensive services within public hospitals.

Priority setting for high cost medications (HCMs) in public hospitals in Australia: a case study.

Health care providers (HCPs) are increasingly aware of pressures on funding for health care services, including high cost medicines (HCMs). Allocating resources to innovative and expensive medications is particularly challenging and the decision-making processes and criteria used to allocate resources to HCMs have not been widely described in the literature. This case study aimed to describe the operations of the first reported High Cost Drug Sub-Committee (HCD-SC) in a public hospital in Australia. In addition the study also evaluated the decision-making process using Daniel and Sabin's ethical framework of "accountability for reasonableness". Some lessons emerged from the description of the operations of the HCD-SC. Decisions were not solely based on effectiveness and cost. Additional factors such as "clinical need" and the lack of an alternative treatment were involved in decisions about access to HCMs. Members of the HCD-SC also considered it was important to have consistency in the way decisions were being made. The findings from this study provide an evidence base for developing strategies to improve this hospital's decision-making process regarding access to HCMs.

Provision of pharmaceuticals in Australian hospitals: equity of access?

In Australia, medicines are funded under a complex set of financial arrangements. Currently there are dual funding arrangements in public and private hospitals that can lead to differences in patient access to medications. There are considerable concerns about the consequences of the fragmentation and "lack of cohesion of the system". Some decision-makers consider there are inequities because of the funding models in place. What follows is a description of this system.

Tailoring access to high cost, genetically targeted drugs.

Assessment of real cost effectiveness, with data linked to individual health outcomes while protecting patient privacy, is an essential challenge we need to meet.

Frequency and characteristics of hospital admissions associated with drug-related problems in paediatrics.

AIM: To determine the frequency of paediatric hospital admissions associated with drug-related problems (DRPs) at two Australian hospitals. METHODS: The investigator and ward pharmacists prospectively screened eligible patients. A multidisciplinary panel reviewed data and established causality, preventability and clinical significance classifications. RESULTS: Over 22 weeks of data collection, a total of 11,564 patients were admitted, 2933 met eligibility criteria. Of those eligible, 127 [4.3%, 95% confidence interval (CI) 3.6, 5.0] were judged to have hospital admissions associated with DRPs. Direct costs associated with DRPs identified totalled pounds 100,707. Of the 81 cases assessed for preventability, 46.9% were deemed preventable. CONCLUSIONS: This research has provided information on the nature and characteristics of paediatric DRPs associated with hospital admissions.