Knowledge and attitudes to prescription charges in New Zealand and England.

BACKGROUND: Prescription charge regimes vary between countries but there is little research on how much people know about these or support values underlying them. OBJECTIVE: To explore, in New Zealand (NZ) and England, the public's knowledge of, and attitudes to, charges and whether knowledge and attitudes varied by demographic characteristics or by values about entitlement to public goods. METHOD: A questionnaire was developed and administered to people over 18 recruited in public places in NZ and England. RESULTS: 451 people in NZ and 300 people in England participated. Less than half in each country knew the current prescription charge. In each country 62% of people were unaware of arrangements to protect people from excessive annual charges. Support for free or lower cost medicines for children, people over 65, people on low incomes, people on benefits, and people with chronic health problems was higher in England than in NZ. Support varied by participants' demographic characteristics and, in the case of people on low incomes and people on benefits, by values about universal entitlements. DISCUSSION: Gaps in knowledge, particularly about mechanisms to protect people from high costs, are concerning and may lead to people paying excessive charges. There was consensus about the elderly, children and the chronically ill being "deserving" of lower prescription charges, but people who did not believe in universal access to public goods appeared to see people on low incomes or benefits as less "deserving". In general, public views resembled those underlying the prescription charge regime in their country.

The destination of Pacific Island health professional graduates from a New Zealand university.

BACKGROUND: There is a shortage of health professionals in Pacific Island states and territories, and a need in New Zealand for Pacific health professionals to serve Pacific communities. METHODS: A cross-sectional postal survey was conducted to investigate retention of Pacific graduates. All graduates of Pacific ethnicity or nationality from the University of Otago in the years 1994 to 2004 in medicine, dentistry, pharmacy, physiotherapy and medical laboratory science were included. RESULTS: The response rate was 59% (75 out of 128). Only 7% of respondents were working in the Pacific Islands (12% of non-residents and 4% of New Zealand residents), though the proportion in the whole cohort could be up to 20%. One third intended to work in Pacific communities in New Zealand or the Pacific Islands in the future. Factors that would favour such an intention were an adequate income, job availability, and good working conditions. CONCLUSIONS: Retention of graduates in the Pacific Islands is poor and measures to improve retention are needed.

Community pharmacists' perceptions of services that benefit older people in New Zealand.

BACKGROUND: There is limited information in New Zealand about community pharmacists' perceptions of services that benefit older people. OBJECTIVES: To explore the perceptions of community pharmacists' of services that benefit older people; the benefits perceived; and the experiences of pharmacists providing such services. SETTING: Community pharmacies in New Zealand. METHODS: A cross-sectional purpose-developed survey was carried out of all community pharmacies in New Zealand. This was followed by twenty qualitative telephone interviews of pharmacists identified as providing at least one specialized service. Interviews were recorded, transcribed verbatim, and coded for themes using constant comparison. MAIN OUTCOME MEASURES: Community pharmacists' opinions and perceptions in the cross-sectional survey and qualitative interviews. RESULTS: Responses were received from pharmacists in 403/905 evaluable pharmacies. All pharmacies provided some baseline services (advice, dispensing of prescriptions, medicines disposal) and 90% provided home deliveries of medicines. Adherence to medicines was supported by compliance packaging (96%), medication review (Medicines Use Review, MUR) (28%), and repeat prescription reminders (27%). Thirty-five percent provided screening (e.g. cholesterol, blood pressure), and 32% provided medicines education to community groups. Compliance packaging and home delivery were thought the services most beneficial for older people, and should help people adhere to their medicines. The 20 pharmacists interviewed by telephone provided 20 different specialized services (median 2, range 1-4). These included MUR, services to residential homes, visiting educators/special clinics, INR monitoring, services to hospices, and flu vaccination. Benefits perceived included improvements in adherence, patient safety, and patient-knowledge of medicines, and convenient access to services. "Patient need" was a frequent driver of services, and common facilitators for services were having appropriate training/skills, co-operation with health professionals, peer or expert support, sufficient time and funding. A lack of these facilitators were considered barriers as were resistance from general practitioners or the general public, or high set-up costs. CONCLUSION: Community pharmacists in New Zealand perceived they provide a range of services of potential benefit to older people for managing their medicines. Establishing new services requires cooperation from other health professionals, peer support, training, funding and time. Further research into patients' outcomes from new and established services is needed.

Medicine-taking practices in community-dwelling people aged > or =75 years in New Zealand.

BACKGROUND: older people experience more chronic medical conditions than younger people, take more prescription medicines and are more likely to suffer from cognitive or memory problems. Older people are more susceptible to the adverse effects of medicines, which may reduce their quality of life or lead to hospitalisation or death. OBJECTIVE: this study aims to identify medicine-taking practices amongst community-dwelling people aged > or =75 years in New Zealand. METHODS: this study was carried out in an urban setting in Dunedin (population 120,000), New Zealand. Interviews of a random sample of people from the electoral roll using a structured questionnaire were conducted. Subjects were community-dwelling people aged > or =75 years taking one or more prescription medicines. From a random sample of 810 people extracted from the electoral roll intended to recruit 300 participants, 524 people met the study criteria and were invited to participate. People living in a rest home or hospital, not contactable by telephone, or now deceased, were excluded. Responses were analysed, medicines categorised by the Anatomical Therapeutic Chemical classification and adherence classed as high, medium and low using a modified four-item Morisky Medication Adherence Scale. Univariate and multivariate linear and logistic regression was applied to combinations of variables. RESULTS: in total, 316 interviews were undertaken; a 61% response rate. Participants were 75-79 (35%), 80-84 (40%) and >85 years (25%); New Zealand European/European (84%), 'New Zealanders' (14%) or Maori (2%); and 141 (45%) lived alone. Almost half (49%) regularly saw a specialist and a third (34%) had been admitted to hospital in the past 12 months. Participants used a median of seven prescription medicines (range 1-19) and one non-prescription medicine (0-14). The majority (58%) believed medicines are effective and had systems/routines (92%) for remembering to take them. Doses tended to be missed following a change in routine, e.g. holiday. Men were more likely to report 'trouble remembering' than women (odds ratio = 1.86, 95% confidence interval 1.10-3.14; P = 0.020). Seventy-five percent of people had high or medium adherence scores and 25%, low scores. Common problems were reading and understanding labels (9 and 4%, respectively) and leaflets (12%, 6%), and difficulty swallowing solid dose forms (14%). Only 6% had problems paying for their medicines. Around 17% wanted to know more about their medicines, and some people were confused about their medicines following hospital discharge. CONCLUSION: overall, community-dwelling people aged > or =75 years in this study appeared to manage their medicines well and found them affordable. Nevertheless, there is a need to improve labelling, leaflets and education on medicines, particularly at hospital discharge.

"It's just routine." A qualitative study of medicine-taking amongst older people in New Zealand.

AIM: To explore how New Zealanders aged 65 years and older manage their medicines in their own homes, and determine the problems and concerns they might have with taking them. SETTING: Urban setting, Dunedin (population 120,000), New Zealand. METHODS: Twenty in-depth semi-structured interviews were undertaken of community-dwelling people 65 years and older. Sixty people, from a random sample of 80 from the electoral roll, met the recruitment criteria and were invited to participate. The first ten men and ten women agreeing to participate were interviewed. Interviews were taped and transcribed verbatim. Transcriptions were thematically coded and analysed using grounded theory and constant comparison. MAIN OUTCOME MEASURES: Emerging themes were explored under the topics: accessing medicines, remembering to take medicines, following instructions, practical problems, adverse effects, concerns about medicines, and beliefs about medicines. RESULTS: Ten of thirteen men and 10/20 women contacted (61%) agreed to participate. The men were aged 71, 67-82 years (median, range) and women 77, 69-87 years. They were using 140 prescription medicines (median 7, range 3-16) and 34 non-prescription medicines (1, 0-6); mainly for the nervous system (28%), or the cardiovascular system (22%). Participants felt that they had good access to medicines, could afford them, managed them well, and had systems and routines to help them remember to take them. Occasional doses were missed following a change in routine. Practical problems were found such as difficulty swallowing or halving tablets. Three-quarters of participants had experienced adverse effects during their lives. These were managed by dose or drug changes or by taking practical measures. People were worried about adverse effects occurring whether or not they had experienced them previously. Beliefs about medicines were mainly positive, although some people disliked taking them. CONCLUSION: The people 65 years and over in this study felt that they could access, afford and manage their medicines well. Although many participants had experienced adverse effects, their beliefs about medicines were mainly positive. Practical problems and concerns should be routinely inquired about and addressed, and prescribing and monitoring optimised to minimise adverse effects, in order to assist older people take their medicines.

"Price management" and its impact on hospital pharmaceutical expenditure and the availability of medicines in New Zealand hospitals.

OBJECTIVES: In 2002, the Pharmaceutical Management Agency (PHARMAC) began negotiating new price contracts for 90% of hospital pharmaceuticals on behalf of all New Zealand (NZ) public hospitals ("price management"[PM]). The present study was undertaken to examine the impact of 3 years of PM on hospital pharmaceutical expenditure, and the impact of the new contracts on the availability of medicines. METHODS: Annual savings for 29 major public hospitals (financial years 2003/4 to 2005/6) were calculated from the data from 11 hospitals and data from PHARMAC. Inpatient and total hospital pharmaceutical expenditure (IPE, THPE) (2000/1 to 2005/6) were calculated from the data from 23 hospitals. Hospital pharmaceutical expenditure (2000/1 to 2005/6) was compared with community pharmaceutical expenditure (CPE) in NZ, and with THPE in the UK, Canada, Norway, and Sweden. Surveys were undertaken (2004, 2005) to examine any changes in medicine availability resulting from the new contracts. RESULTS: Annual savings were NZ$7.84 million (m) to NZ$13.45m (2003/4 to 2005/6). Growth in IPE slowed for all hospitals in 2003 to 2004. Mean growth was higher for IPE and THPE than for CPE (8.8%, 9.7% vs. 1.9%). Mean growth in THPE appeared slightly lower in NZ (9.6%) and Norway (7.3%) than in the UK 14%, Sweden 12.5%, or Canada 10.2%. Some availability problems occurred with new contract items ("out-of-stocks"; products perceived as inferior). Problems were usually resolved in weeks, but some took more than a year. CONCLUSION: PM was moderately successful saving NZ$8m to NZ$13m (6-8%) in 2003/4 to 2005/6 and slowing growth in IPE in 2003/4. Further research should examine whether the favorable economic effects can be sustained while unfavorable effects are minimized.

Use of centrally developed pharmacoeconomic assessments for local formulary decisions.

PURPOSE: The distribution, content, timeliness, use, and influence of pharmacoeconomic assessments (PEAs) of drugs in New Zealand public hospitals were examined. METHODS: In April 2005, a questionnaire-based, cross-sectional survey was sent to chief pharmacists at all 29 New Zealand hospitals employing a pharmacist. The questionnaire asked pharmacists about the use and influence of PEAs in their hospitals' formulary decision-making process. Answers were given using a scale of 1 to 6, with 1 being the most positive response. RESULTS: Of the 29 surveys mailed, 24 (83%) were completed. Data on 12 PEAs were analyzed. Assessments were seen and summaries read in most hospitals (median, 77% and 65%, respectively). Full documents were read in fewer hospitals (35%). In general, the PEAs were considered moderately easy to understand, provided a concise summary, and contained adequate detail of the methodology. Of the 24 respondent hospitals, 21 had assessment processes for new medicines; hence, a total of 252 hospital evaluations of Pharmaceutical Management Agency (PHARMAC)-assessed drugs were possible. A total of 132 possible evaluations (52%) were undertaken. More evaluations (106 [42%]) took place before PHARMAC's PEAs were distributed and fewer (26 [10%]) after distribution. Where used, the PEAs appeared to have a modest effect on hospital decisions. CONCLUSION: The provision of 12 PEAS by PHARMAC to hospitals in New Zealand had only a modest influence on their formulary decision-making process, mostly due to the lack of timeliness of the PEAs. The timely delivery of centrally developed PEAs may be essential to generating a greater effect on the formulary decisions at a wider level.

Managing prices for hospital pharmaceuticals: a successful strategy for New Zealand?

OBJECTIVES: In 2002, as part of a National Hospital Pharmaceutical Strategy, the New Zealand (NZ) government agency PHARMAC commenced a 3-year period of negotiating prices for 90% of hospital pharmaceuticals on behalf of all NZ public hospitals. The present study was undertaken to determine the effects of this first year of "pooled procurement." METHODS: Using price changes and volume data for each of their top 150 pharmaceutical items, chief pharmacists at 11 public hospitals calculated projected cost savings for the financial year July 2003 to June 2004. Researchers calculated total projected savings for all 11 hospitals, and for three types of hospitals. Estimates of projected savings were made for all 29 major public hospitals by using savings per bed and savings per bed-day. A sensitivity analysis was undertaken. Items showing savings were categorized by using the Anatomical Therapeutic Chemical classification system. RESULTS: For the 11 hospitals, the top 150 items comprised 612 different items. Projected savings for 2003 to 2004 were NZ dollar 2,652,814, NZ dollar 658,984, and NZ dollar 127,952 for tertiary, secondary, and rural/special hospitals, respectively. Percentage savings as a median (range) of the total top 150 expenditure were: tertiary 5.28% (3.09-16.05%), secondary 7.41% (4.67-12.85%), and rural/special 9.55% (6.27-10.09%). For all 29 hospitals, estimated projected savings were NZ dollar 5,234,919 (NZ dollar 3,304,606-NZ dollar 8,044,482) by savings per bed, and NZ dollar 5,255,781 (NZ dollar 2,936,850-NZ dollar 8,693,239) by savings per bed-day. The main contributors to savings were: agents for infections, the nervous system, musculoskeletal system, and blood/blood-forming organs. CONCLUSION: The first year of pooled procurement under the National Hospital Pharmaceutical Strategy (2002-2003) has resulted in moderate savings. For all 29 major public hospitals, savings of around NZ dollar 5.2 million (dollar 2.9 million-dollar 8.7 million) or 3.7% were projected for 2003 to 2004. Longer-term effects, however, on patient outcomes and availability of pharmaceuticals, as well as on pharmaceutical expenditure, have yet to be evaluated.

Purchasing restricted medicines in New Zealand pharmacies: results from a "mystery shopper" study.

OBJECTIVE: New Zealand has a class of drugs (Restricted Medicines) which are available over the counter in pharmacies, but must be sold by qualified pharmacists. Patient names must be recorded for each sale. Many restricted medicines have recently been reclassified from prescription only, with the expectation that pharmacists provide professional input into their sale. The study described here explored whether pharmacists do fulfill this expectation. METHOD: In late 1999, 12 mystery shoppers made 360 visits to 180 pharmacies around New Zealand. Shoppers were of different ages, genders, ethnic and socio-economic backgrounds. Two kinds of products were purchased: diclofenac 25 mg, which was requested for "back pain" and vaginal anti-fungals requested for "thrush". MAIN OUTCOME MEASURE: The main outcome measure described here is whether the shoppers received specified items of counselling. These included questions about the shopper's health status, contraindications to medicine use, advice about the use of the product and the health problem presented. Other outcome measures are whether sales of restricted medicines were carried out by pharmacists or other staff, and whether sales were recorded. RESULTS: In spite of the requirement that pharmacists sell restricted medicines, shoppers often found it difficult to distinguish pharmacists from other pharmacy staff. Shoppers were able to confirm that a pharmacist was definitely involved in only 46% of visits. In 8.8% of the diclofenac visits, and 10.8% of the visits for vaginal anti-fungals, no counselling was provided. The vaginal anti-fungal visits tended to be more product-focussed than the diclofenac visits. When they purchased diclofenac, most pharmacists asked shoppers if they had, or had had, stomach problems (74.6%) or asthma (65.4%). A minority asked about the symptoms of the vaginal fungal infection which the female shoppers presented with. While most pharmacies recorded patient names, many did so in a way which compromised patient confidentiality. CONCLUSION: Pharmacies varied widely in the amount of counselling they provided to people purchasing restricted medicines.