A national mailed survey exploring weight management services across Australian community pharmacies.

This study investigated pharmacists' and pharmacy assistants' current weight management recommendations to consumers across Australian community pharmacies using a mailed questionnaire. Two questionnaires were developed, one for pharmacists and one for pharmacy assistants, each divided into five sections. One pharmacist and pharmacy assistant questionnaire were mailed in November 2011 to a systematic sample of 3000 pharmacies across Australia for one pharmacist and pharmacy assistant each to complete. A total of 537 pharmacist and 403 pharmacy assistant responses, from 880 different pharmacies, were received. Overall 94.5% (n = 832/880) of associated pharmacies stocked weight loss products and 48.2% (n = 424/880) offered a weight management program. Both pharmacists and pharmacy assistants felt that the development of pharmacy-specific educational resources and additional training would help improve their ability to provide weight management services. Australian pharmacists and pharmacy assistants currently appear to be providing weight management services to consumers; however, not all their recommendations are evidence based. The need for additional training for pharmacy staff in areas identified as lacking and the development of pharmacy weight management educational resources needs to be addressed.

Patient engagement strategies used for hypertension and their influence on self-management attributes.

BACKGROUND: Several effective methods to facilitate patient self-management of hypertension are available in primary care. These include direct support from community pharmacists and general practice, and the use of home blood pressure (BP) monitoring. The aim of this study is to establish the prevalence of use of key strategies and to determine their independent relationship with patient self-management attributes. METHODS: A survey of patients with treated hypertension was undertaken in 27 community pharmacies. This established recent use of BP monitoring and advice from health professionals. Patient awareness of BP and targets, appropriateness of BP targets and adherence to anti-hypertensive medications were assessed as indicative self-management outcomes. Predictors of outcomes were determined using binary logistic regression. RESULTS: Overall, 215 surveys were returned. Two-thirds of patients were aged >65 years, and 45% had conditions warranting tighter BP control (<130/80 mmHg). Almost all patients reported monitoring of their BP in the previous year and 63% could report their most recent BP reading. Just 36% reported knowing a target BP, and 78% of reported targets were within guidelines recommendations. One-fifth (22%) monitored their own BP, and 15% reported non-adherence to medication. Doctors provided the large majority of professional advice. Self-monitoring or documentation of BP readings was independently associated with increased likelihood of BP and target BP being known. CONCLUSIONS: Regular monitoring of BP does not automatically translate to professional advice. Increased uptake of patient self-monitoring should be promoted as a means of enabling self-management.

Comparing women pharmacy consumers' experiences with weight loss treatment in Victoria and Nottingham: a cross-sectional study.

BACKGROUND: There has been a recent increase in weight management services available in pharmacies across Australia and England. The aim of this study was to determine the following between women in Victoria and Nottingham: similarities and differences of what weight management options are preferred by women pharmacy consumers; how they feel about pharmacists providing advice in this area; and what they desire in a weight management program. METHOD: Women pharmacy consumers were randomly approached by a researcher in community pharmacies in Victoria and Nottingham and asked to complete a questionnaire regarding their own weight management experiences. The questionnaire was self-completed or researcher-administered and was comprised of four main sections that focused on the participant's general health, previous weight loss experiences, their ideal weight management program and their demographics. Data was entered in SPSS 19 and logistic regression was used to identify any differences in weight loss experiences between women. RESULTS: The participant rates were high: 86% (n = 395/460) in Victoria and 98% in Nottingham (n = 215/220). Overall, women in Victoria and Nottingham were similar with comparable demographics. Approximately 50% (250/507) of women were in the overweight or obese body mass index category, with over 70% (n = 436/610) of women having attempted to lose weight in the past. The majority of women (n = 334/436) felt comfortable receiving advice from pharmacists. In the logistic regression analysis women in Nottingham were found to be significantly less likely to have utilised a pharmacy weight management program in the last five years (OR: 0.23 CI: 0.08, 0.63) and were significantly less likely to want an ideal weight management program located in a pharmacy (OR: 0.49 CI: 0.30, 0.82) compared to women in Victoria. No significant associations between location and feeling comfortable with a pharmacist advising on weight loss or wanting a pharmacist in an ideal weight management program were seen. CONCLUSION: Results from this study have provided information on possible ideal pharmacy weight management programs in both Victoria and Nottingham. Although differences were seen between the two populations, similarities between ideal weight management programs and comfort level with pharmacist interaction were noted.

Exploring weight management recommendations across Australian community pharmacies using case vignettes.

With the increase in the overweight and obese population, it is critical that pharmacy staff are able to provide weight management advice to women at different stages of their life. This study utilized case vignettes to identify pharmacists' and pharmacy assistants' current weight management recommendations to women of different ages, life stages and co-morbidities. A total of 537 pharmacist and 403 pharmacy assistant responses were received. In the case of the pre-pregnancy vignette, only 57% (46/80) of pharmacy assistants were able to correctly identify a woman's weight category based on her body mass index, which was significantly fewer than 86% (86/108) of pharmacists (P < 0.001). In the pregnancy vignette, both pharmacists and pharmacy assistants were able to identify the risks of using a herbal weight loss medication in pregnancy. The need for a 'multi-disciplinary team approach' was seen in the menopause case vignette with pharmacists, highlighting the need for the involvement of other health care professionals for successful weight loss outcomes. Australian pharmacists and pharmacy assistants are currently providing weight management services to their consumers, however, not all of their recommendations are evidence-based. There is a need for pharmacy weight management educational resources to be developed and implemented across community pharmacies.

A critical analysis of the methods used to develop explicit clinical criteria for use in older people.

Older people are the biggest users of medications and with the majority of the population ageing it is important to ensure that their medications are managed properly. Many have developed explicit criteria in order to assist in making appropriate drugs choices in the older population. This paper explores whether the methods used to develop the currently available explicit criteria for appropriate prescribing in older people are applied appropriately, and if not, whether this invalidates the criteria themselves. The wide spread use of the Delphi technique to develop medical criteria indicates that the technique itself should be evaluated for its suitability in the development of criteria in older people before the criteria are themselves evaluated. A number of criteria have been reviewed and none fulfils the requirements for appropriate development. There is a need for new criteria, with transparent referencing of recommendations and rigorous final evaluation.

Potential of pharmacists to help reduce the burden of poorly managed cardiovascular risk.

INTRODUCTION: Rural areas require better use of existing health professionals to ensure capacity to deliver improved cardiovascular outcomes. Community pharmacists (CPs) are accessible to most communities and can potentially undertake expanded roles in prevention of cardiovascular disease (CVD). OBJECTIVE: This study aims to establish frequency of contact with general practitioners (GPs) and CPs by patients at high risk of CVD or with inadequately controlled CVD risk factors. DESIGN, SETTING AND PARTICIPANTS: Population survey using randomly selected individuals from the Wimmera region electoral roll and incorporating a physical health check and self-administered health questionnaire. Overall, 1500 were invited to participate. RESULTS: The participation rate was 51% when ineligible individuals were excluded. Nine out of 10 participants visited one or both types of practitioner in the previous 12 months. Substantially more participants visited GPs compared with CPs (88.5% versus 66.8%). With the exception of excess alcohol intake, the median number of opportunities to intervene for every inadequately controlled CVD risk factor and among high risk patient groups at least doubled for the professions combined when compared with GP visits alone. CONCLUSION: Opportunities exist to intervene more frequently with target groups by engaging CPs more effectively but would require a significant attitude shift towards CPs. Mechanisms for greater pharmacist integration into primary care teams should be investigated.

Standardised assessment of patients' capacity to manage medications: a systematic review of published instruments.

BACKGROUND: Older people are commonly prescribed complex multi-drug regimens while also experiencing declines in the cognitive and physical abilities required for medication management, leading to increased risk of medication errors and need for assisted living. The purpose of this study was to review published instruments designed to assess patients' capacity to self-administer medications. METHODS: Searches of Medline, EMBASE, CINAHL, PsycINFO, International Pharmaceutical Abstracts, Health and Psychosocial Instruments, Google, and reference lists of identified publications were conducted to identify English-language articles describing development and validation of instruments designed to assess patients' capacity to self-administer medications. Methodological quality of validation studies was rated independently against published criteria by two reviewers and reliability and validity data were reviewed. RESULTS: Thirty-two instruments were identified, of which 14 met pre-defined inclusion criteria. Instruments fell into two categories: those that used patients' own medications as the basis for assessment and those that used a simulated medication regimen. The quality of validation studies was generally low to moderate and few instruments were subjected to reliability testing. Most instruments had some evidence of construct validity, through associations with tests of cognitive function, health literacy, activities of daily living or measures of medication management or adherence. Only one instrument had sensitivity and specificity data with respect to prediction of medication-related outcomes such as adherence to therapy. Only three instruments had validity data from more than one independent research group. CONCLUSION: A number of performance-based instruments exist to assess patients' capacity to manage their own medications. These may be useful for identifying physical and cognitive barriers to successful medication management, but further studies are needed to determine whether they are able to accurately and reliably predict medication outcomes.

An analysis of hospital pharmacy practice in six countries of sub-Saharan Africa based on the International Pharmaceutical Federation Basel Statements on the future of hospital pharmacy.

OBJECTIVES: The objective of this study was to update the self-assessment tool and to evaluate current hospital pharmacy practices in six sub-Saharan African countries. METHODS: Questions in the validated survey were edited if the revised Basel Statement changed intent. A total of 13 updates were made. The survey was administered via e-mail to pharmacy personnel in any hospital centre in Ghana (258 total hospitals), Nigeria (17 038 total hospitals), Malawi (499 total hospitals), Uganda (155 total hospitals), Zambia (98 total hospitals) and Zimbabwe (1389 total hospitals). Snowball sampling increased reach of the survey across each country. KEY FINDINGS: Responses were received from all six countries, with nine respondents from Ghana, 15 from Nigeria, two from Malawi, five from Uganda, nine from Zambia and four from Zimbabawe. Uganda had the highest achievement rates for tier one and tier three constructs, and Ghana had the highest achievement rate for tier two constructs. Malawi showed the lowest achievement rates in all three tiers. The six countries achieved an average of 82 per cent (SD = 24) of tier one constructs. Three tier one constructs were achieved less than 25 per cent of the time. CONCLUSION: Multiple tier one (minimum standards in hospital pharmacy practice) constructs were achieved greater than 90% of the time, possibly reflecting efforts made towards hospital pharmacy practice advancement in select countries of sub-Saharan Africa. Additionally, all countries achieved a majority of tier one overarching constructs. Despite these achievements, there are still many areas for growth, including select tier one constructs with low achievement rates.

Infertility information on the World Wide Web: a cross-sectional survey of quality of infertility information on the internet in the UK.

BACKGROUND: The internet is a frequently used source of information for infertile couples. Previous studies suggested that the quality of health information on the internet is poor. The aim of this study was to assess the quality of websites providing information on infertility and its management in the UK. Differences between website types and affiliations were assessed. METHODS: A Google search for the keyword 'infertility' was performed and 107 relevant websites were identified and categorized by type. Websites were assessed for credibility, accuracy and ease of navigation using predefined criteria. RESULTS: The total scores for all types of websites were low, particularly in the accuracy category. Websites affiliated to the UK National Health Service (NHS) scored higher than those affiliated to private fertility clinics and other clinics providing non-conventional fertility treatment. Specifically, NHS websites were more likely to report success rates (92.9% versus 60% and 0%, P < or = 0.05) and display information about their sources of funding (85.7% versus 15% and 14.8%, P < or = 0.0001). CONCLUSIONS: Internet resources available to infertile patients are variable. Differences in the quality of infertility information exist between the different types of websites.

The role of perceptions of clinicians in their adoption of a web-based antibiotic approval system: do perceptions translate into actions?

PURPOSE: Computerized Decision Support Systems have been shown to improve clinicians' performance. Clinicians' adoption of these systems is crucial for their success. Studying clinicians' perceptions can provide an insight into the determinants of clinicians' adoption of such systems. The aim of this study was to measure clinicians' perceptions of ease of use and usefulness of a web-based antibiotic approval system, and to investigate the relationship between the reported perceptions and use of the system. METHODS: Potentially identifiable coded surveys were sent to a total of 70 senior and 150 junior medical staff, and 30 pharmacists all working at a tertiary care referral teaching hospital of Melbourne, Australia. Clinicians' perceptions of ease of use and usefulness of the antibiotic approval system; clinicians' general computer use; and clinicians' usage of the antibiotic approval system were measured. RESULTS: The overall response rate from the clinicians was 53.4%. The majority of the participants (70% and above) found it easy to obtain antibiotic approval using the system. More than 80% of the participants believed that the system will decrease the inappropriate use of antibiotics at the hospital. Clinicians who were more likely to use the system also found it easy to learn (Rho=0.392, p=0.001), easy to show others how to use the system (Rho=0.298, p=0.014), easy to find additional information (Rho=0.317, p=0.009), and easy to use it within their daily workflow (Rho=0.268, p=0.028). In addition, the clinicians were also more likely to use the system if they believed that it will improve their adherence to evidence-based practice (Rho=0.352, p=0.003). CONCLUSION: The majority of clinicians in an independent investigation of the antibiotic approval system found the system easy to use and useful to them. A number of clinicians' perceptions about the system were found to be correlated with the actual usage of the system by the clinicians.

Employing the nominal group technique to explore the views of pharmacists, pharmacy assistants and women on community pharmacy weight management services and educational resources.

OBJECTIVES: The objectives of this study were to investigate how pharmacists, pharmacy assistants and women feel about community pharmacy involvement in weight management, and to identify what pharmacists, pharmacy assistants and women want in weight management educational resources. METHODS: Three homogenous and one heterogeneous nominal group (NG) sessions of up to 120-min duration were conducted with nine women, ten pharmacists and eight pharmacy assistants. The NG technique was used to conduct each session to determine the most important issues that should be considered surrounding community pharmacy weight management services and development of any educational resources. The heterogeneous NG session was used to finalise what women, pharmacists and pharmacy assistants want in educational resources. KEY FINDINGS: Overall, pharmacists, pharmacy assistants and women believe that pharmacy staff have an important role in the management of overweight and obesity because of their accessibility, trust and the availability of products in pharmacy. Regarding the most suitable healthcare professional(s) to treat overweight and obesity, the majority of participants believed that no one member of the healthcare team was most suitable and that overweight and obesity needs to be treated by a multidisciplinary team. The importance of having weight management educational resources for pharmacy staff and women that come from trustworthy resources without financial gain or commercialisation was also emphasised. CONCLUSION: Pharmacists, pharmacy assistants and women feel that community pharmacies have a definite role to play in weight management. Pharmacy-specific weight management educational resources that are readily available to pharmacy staff and women are highly desirable.

Improving Australian care home medicine supply services: Evaluation of a quality improvement intervention.

AIM: The study aims to determine the impact of a quality improvement intervention on how accurately and suitably medicines are supplied to residents of residential aged-care facilities (RACFs). METHODS: Between September 2012 and January 2013, pharmacy-supplied dose administration aids (DAAs) were audited at 45 Victorian RACFs (Australia). RACFs had previously received an intervention (education session/toolkit) and were involved in an earlier DAA audit. Recently supplied DAAs containing regular medicines were compared to prescriber-prepared medicine charts to identify, and classify risks of, inaccurate or unsuitable packing incidents. RESULTS: Of 2389 DAAs audited for 983 residents, 770 incidents in 502 DAAs were identified. The overall DAA incident rate increased significantly from 11.5% pre-intervention to 21.0% post-intervention (P < 0.001). The proportion of DAAs affected by incidents classified as 'insignificant' or 'minor' risk increased post-intervention (P < 0.001). CONCLUSIONS: Further wide-scale evaluation of RACF medicine supply services is needed. Interventions that are effective in reducing DAA incidents should be explored.

A Simulated Learning Environment for Teaching Medicine Dispensing Skills.

OBJECTIVE: To develop an authentic simulation of the professional practice dispensary context for students to develop their dispensing skills in a risk-free environment. DESIGN: A development team used an Agile software development method to create MyDispense, a web-based simulation. Modeled on virtual learning environments elements, the software employed widely available standards-based technologies to create a virtual community pharmacy environment. Assessment. First-year pharmacy students who used the software in their tutorials, were, at the end of the second semester, surveyed on their prior dispensing experience and their perceptions of MyDispense as a tool to learn dispensing skills. CONCLUSION: The dispensary simulation is an effective tool for helping students develop dispensing competency and knowledge in a safe environment.

Factors affecting shear thickening behavior of a concentrated injectable suspension of levodopa.

Previous clinical studies on a subcutaneous injectable suspension of levodopa showed poor injectability into human tissue. When this formulation was rheologically characterised, a clinical shear thickening interval was observed at increased shear rates. The formulation parameters that contributed to this rheological behavior were systematically evaluated with the aim of removing this flow limitation while maintaining the concentration of 60% levodopa to retain the clinical applicability. The three suspension parameters examined were: levodopa volume fraction, concentration of the HPMC suspending vehicle, and particle size distribution. Shear thickening increased with the drug concentration and the critical shear rate was inversely dependent on the drug concentration. Increasing the vehicle concentration retarded the shear thickening but increased the overall suspension viscosity. There was an increase in shear thickening with increased average particle diameter. Combinations of micronized and non-micronized particles were used to prepare bimodal particle size distributions. The rheology of these bimodal distributions resulted in removal of shear thickening. This allowed the preparation of 60% levodopa formulations that showed a range of flow characteristics spanning near Newtonian flow or shear thinning at initial injectable viscosities of about 0.6 Pa.s and final viscosities in the range of 0.1 Pa.s, alleviating the shear thickening limitation of these levodopa formulations.

Pharmacists and prescribing rights: review of international developments.

PURPOSE: Continuity of care, equitable access, and quality and safety are major foci in health services management. The introduction of limited prescribing rights to pharmacists has the potential to reduce fragmentation within the health system, optimise medication management, improve continuity of patient care and improve patient access to medication. RESULTS: Eight models for pharmacists' prescribing have been implemented internationally, varying in their dependency on protocols, formularies and collaboration with physicians. These have also been described using terms such as Supplementary Prescribing and Patient Group Directions. CONCLUSION: Issues relating to practical implementation of pharmacists' prescribing include negotiation of national health policy, pharmacists' training and accreditation, liability, reimbursement and documentation.

The relationships between illness and treatment perceptions with adherence to diabetes self-care: A comparison between Arabic-speaking migrants and Caucasian English-speaking patients.

AIMS: To compare illness and treatment perceptions between Arabic-speaking immigrants and Caucasian English-speaking people with type 2 diabetes, and explore the relationships between these beliefs and adherence to self-care activities. METHODS: A cross-sectional study was conducted in healthcare settings with large Arabic populations in metropolitan and rural Victoria, Australia. Adherence to self-care activities, illness and treatment perceptions, and clinical data were recorded. Bivariate associations for continuous normally distributed variables were tested with Pearson's correlation. Non-parametric data were tested using Spearman's rank correlation coefficient. RESULTS: 701 participants were recruited; 392 Arabic-speaking participants (ASPs) and 309 English-speaking participants (ESPs). There were significant relationships between participants' illness and treatment perceptions and adherence to diabetes self-care activities. ASPs' negative beliefs about diabetes were strongly and significantly correlated with poorer adherence to diet recommendations, exercise, blood glucose testing and foot care. ASPs were significantly less adherent to all aspects of diabetes self-care compared with ESPs: dietary behaviours (P=<0.01; 95% confidence interval (CI)=-1.17, -0.84), exercise and physical activity (P=<0.001, 95% CI -1.14, -0.61), blood glucose testing (P=<0.001) and foot-care (P=<0.001). 52.8% of ASPs were sceptical about prescribed diabetes treatment compared with only 11.2% of the ESPs. 88.3% of ASPs were non-adherent to prescribed medication, compared with 45.1% of ESPs. CONCLUSIONS: Arabic-speaking migrants' illness and treatment perceptions were significantly different from the English-speaking group. There is a pressing need to develop new innovative interventions that deliver much-needed improvements in adherence to self-care activities and key health outcomes.

Flow and injection characteristics of pharmaceutical parenteral formulations using a micro-capillary rheometer.

A micro-capillary rheometer consisted of a fine needle with an internal diameter of 347 microm attached to a 1 ml removable-needle syringe within an Instron device that operated in compression mode to provide various crosshead speeds ranging from 150 to 950 mm min(-1) covering typical clinical injection rates, and that determined the resulting force on the plunger. The crosshead speed and the resulting force were used to calculate the shear rate and the shear stress respectively. These were used in standard capillary flow expressions together with an independent measurement of the wall frictional force and allowed the viscosity of parenteral Newtonian solutions and non-Newtonian suspensions to be measured quantitatively and their rheological behaviour in needles of clinical dimensions to be established. Commercial pharmaceutical parenteral formulations consisting of three oil-based solutions and three aqueous suspensions were chosen for this study. The net injection forces were also obtained and it was shown that both the oil-based solutions and the aqueous suspensions covered similar ranges. The viscosities for the parenteral solutions were determined from the slope of the linear regression (R(2)>0.97) between shear stress and shear rate and ranged between 0.029 and 0.060 Pas. For the aqueous suspensions examined, viscosities decreased from low shear rate to high shear rate, following a power-law model and indicating a pseudo plastic behaviour. Standardisation of the micro-capillary rheometer with Newtonian silicone oils calibrated with a Rheometrics Fluids Spectrometer showed viscosity values consistent between the rotational flow measurements and capillary flow measurements which were within 5% and showed very high degrees of reproducibility between replicate samples. This degree of reproducibility allowed differences in the contribution of the wall frictional force to the required plunger force for both the oil-based and aqueous parenteral formulations to be determined reliably. The wall frictional force values for all formulations were similar (0.6-1.6 N) but the frictional forces of aqueous systems were found to decline significantly with plunger speed. The micro-capillary rheometer has been used to evaluate the impact of concentration changes due to sedimentation on the injectability of one of the aqueous suspensions, where it was shown that not only the viscosity increased but the shear thinning behaviour ceased at higher shear rates. The micro-capillary rheometer which was able to operate in clinical shear rate ranges has been shown to detect deteriorations in the injectable rheology of suspensions, which in the case here was due to pre-injection sedimentation.

Women, pharmacy and the World Wide Web: could they be the answer to the obesity epidemic?

OBJECTIVES: The objective of this article is to explore how giving women access to evidence-based information in weight management through pharmacies, and by utilising the World Wide Web, is a much needed step towards dealing with the obesity crisis. KEY FINDINGS: Women's needs should be considered when developing evidence-based information on weight. Excess weight places them at high risk of diabetes and cardiovascular disease, infertility and complications following pregnancy and giving birth. Women are also an important population group because they influence decision-making around meal choices for their families and are the biggest consumers of weight-loss products, many of which can be purchased in pharmacies. Pharmacies are readily accessible primary healthcare locations and given the pharmacist's expertise in being able to recognise underlying causes of obesity (e.g. medications, certain disease states), pharmacies are an ideal location to provide women with evidence-based information on all facets of weight management. Considering the exponential rise in the use of the World Wide Web, this information could be delivered as an online educational resource supported by other flexible formats. CONCLUSIONS: The time has come for the development of an online, evidence-based educational resource on weight management, which is combined with other flexible formats and targeted at women in general and according to different phases of their lives (pregnancy, post-partum, menopause). By empowering women with this knowledge it will allow them and their families to take better control of their health and wellbeing, and it may just be the much needed answer to complement already existing resources to help curb the obesity epidemic.

Exploring factors that contribute to dose administration aid incidents and identifying quality improvement strategies: the views of pharmacy and nursing staff.

BACKGROUND: Dose administration aids (DAAs) organise medicines that have been repacked according to the day of the week and time of the day in which they must be taken. In Australia, DAAs are commonly prepared by pharmacy staff for residential aged care facility (RACF) medicine administration. Although the limited available literature indicates that DAA incidents of inaccurate or unsuitable medicine repacking do occur, there is a paucity of qualitative research identifying quality improvement strategies for this service. OBJECTIVES: This study aims to investigate the perceived contributing factors to DAA incidents and strategies for quality improvement in RACFs and pharmacies. METHODS: Health professional perceptions were drawn from three structured focus groups, including six pharmacists, five nurses, a pharmacy technician and a personal care worker. Participants were involved in the preparation, supply or use of DAAs at pharmacies or RACFs that were involved in a previous DAA audit. Transcripts were analysed using thematic analysis. KEY FINDINGS: Four major themes were identified as contributing to DAA incidents, with quality improvement strategies aligned to those same four themes: communication, knowledge and awareness, medicine handling and attitude. Strategies included improving interprofessional communication and addressing the limitations associated with RACF medicine records; targeting medicine knowledge gaps and increasing awareness of DAA incidents; encouraging greater care when preparing and checking DAAs; and fostering a team mentality among members of the aged care team. CONCLUSIONS: Recommendations include using current findings to develop multidisciplinary quality improvement initiatives to prevent DAA incidents and to improve the quality of this pharmacy medicine supply service.