Applying a quality use of medicines framework to using essential oils in nursing practice

Nurses are increasingly incorporating complementary therapies into their practices. Aromatherapy is one of the most popular therapies. The basis of aromatherapy is essential oils, which are chemically active substances with a long history of safe traditional use and a growing evidence base to support their use in nursing care. In Australia, essential oils are classified and regulated under the same policies as conventional medicines such as the National Medicines Policy and the Quality Use of Medicines (QUM) framework applies. QUM is a framework for selecting and using medicines safely and effectively if medicines are indicated. The key elements of QUM are a systems-based approach to using medicines based on relevant evidence, partnerships, and informed client consent. Clients are placed at the centre of a QUM medication management process, which is consistent with holistic care. Applying a QUM approach to essential oil use, Quality Use of Essential Oils (QUEO), involves developing effective systems for managing essential oils from an holistic perspective that includes structured assessment and diagnostic processes to enable effective essential oil prescribing and outcome monitoring. In a QUEO approach, essential oils are integrated into the client's overall medication regimen and care plan rather than being used as ‘add-ons’. Adopting QUEO is consistent with the current national focus on the quality use of therapeutic substances, increases the profile of aromatherapy in nursing care and provides important information to guide future aromatherapy practices.

Complexities of medicines safety: communicating about managing medicines at transition points of care across emergency departments and medical wards

To explore how health professionals, patients and family members communicate about managing medicines across transition points of care in two Australian public hospitals.

Pharmacist assessment of adherence, risk and treatment in cardiovascular disease (PAART CVD)

Cardiovascular disease (CVD) accounts for 18% of disease burden in Australia, and 35% of deaths. Evidence- based management of CVD risk requires systematic consideration of individual risk factors and overall CVD risk, and a balanced approach to lifestyle modification, the optimal use of medicines, and medicines adherence.

This project examines a pHot model for primary prevention of CVD in community pharmacy aimed at improving quality of care. Pharmacists from ten pharmacies received training in CVD risk factor management and facilitating patient lifestyle modification.

They recruited 70 participants aged 50-74 years, taking medicines for blood pressure (BP) or cholesterol, and without diabetes or CVD, At baseline, research assistants conducted a clinical assessment of anthropometric and biomedical risk factors, and conducted interviews to examine health behaviours, medicines use and related issues. Data was analysed by a consultant pharmacist and summary reports produced, with recommendations and targets for risk reduction. These were addressed by patients and their community pharmacists over five monthly sessions. At follow up, the relative risk reduction for CVD onset over the next five years was 24%, contributed to by reductions in mean systolic BP (-7mmHg), diastolic PP (-5 mmHg), total:HDL cholesterol ratio (—0.2), waist circumference (—2cm in males, —0.7cm in females) and other risk factors.

Several key health behaviours improved, including diet quality and physical activity levels. Prevalence of non-adherence to cardiovascular medicines dropped by 1 6% to 22%.

The potential health benefits from this intervention need to be confirmed via larger, controlled clinical trials. Overall, this appears to be a feasible and potentially effective public health measure.

Lay meanings and practices of medicinal use in a multicultural context : a qualitative study among Anglo-Celtic and Russian Australians in Melbourne

Describes medicinal use among Anglo-Celtic and Russian Australians. Cultural constructions of medicines are embedded in health beliefs; shaped by experiences with health care within socio-economic and political contexts. Cultural practices of medicinal use are best understood in the context of lay models of rationality and recognition of the conflict existing between the lay and expert models.

Do high-risk medicines alerts influence practice?

Background: Medicine-related adverse events are prevalent, costly and mostly preventable. The High Risk Medicines Working Party (Victoria) developed and distributed three highrisk medicines alerts – wrong route of administration of oral medicines, subcutaneous insulin and unfractionated heparin – and accompanying audit tools in 2008 and 2009.
Aims: To determine the impact of the three high-risk medicines alerts on Victorian health services; to assess the clinical relevance and utility of the audit tools; to identify barriers to implementing recommendations; and to obtain feedback and suggestions for future alert topics.
Method: A cross-sectional survey was undertaken from 6 to 31 July 2009 using an online questionnaire. The questionnaire was distributed to 90 metropolitan, regional and rural public health services in Victoria and approximately 200 members of the Quality Use of Medicines Network (Victoria).
Results: Most of the 90 respondents were pharmacists (53%) and nurses (31%). 53 (59%) respondents reported making changes as a result of receiving the high-risk medicines alerts – 21 (40%) concerned the wrong route of administration, 12 (23%) subcutaneous insulin and 7 (13%) unfractionated heparin. Barriers to implementation included time constraints, inadequate staff and resources, excessive paperwork and competing priorities. A minority of respondents indicated some alerts were not relevant to small rural services. Suggestions for
improving the audit tools included making them less labour intensive, enabling electronic responses and ensuring their distribution is coordinated with other medicine-related tools.
Conclusion: High-risk medicines alerts and the accompanying audit tools facilitated change but there were some barriers to their implementation, such as time and resource constraints. Not all alerts and audit tools were relevant to all health services.

The Pharmaceutical Industry and Access to Medicines in India

Pharmaceutical policy in India as elsewhere is shaped by conflicting economic and social interests and opposing values and priorities. Tensions can be understood as revolving around the contradiction between use value and exchange value in the production of medicinal drugs as commodities, as per Marx’s original analysis. The use value of medicines – if safe and efficacious, of good quality, and prescribed and consumed appropriately – is the prevention, cure or alleviation of ill-health and disease. Health policy is – or should be – aimed at optimising the use value of medicines. For this purpose government agencies administer regulatory oversight of the manufacturing, marketing and distribution of medicines. Drugs made available to patients are expected to meet adequate safety, quality and efficacy standards, but regulation to ensure such standards is subject to controversy in most countries. This is a domain where definition and interpretation of scientific-technological principles and criteria is infused by partiality and bias grounded in social and material interests, as evidenced by recurrent debates about industry ‘capture’ of regulatory agencies, including the world’s most regulator, the US Food and Drug Administration (Angell 2005; Law 2006). In India, a Parliamentary Committee Report in 2012 depicted the Central Drugs Standard Control Organisation (CDSCO) as dysfunctional and influenced inappropriately by the exchange value perspective of manufacturers (Parliamentary Standing Committee on Health and Welfare 2012). The clash between use and exchange value perspectives is starkly illustrated by cases of products known to cause more harm than good, particularly common in poorly regulated markets such as India’s, as shown by Srinivasan & Phadke.

Exploring motivation and confidence in taking prescribed medicines in coexisting diseases: a qualitative study

Aims and objectives: To explore the motivation and confidence of people with coexisting diabetes, chronic kidney disease (CKD) and hypertension to take their medicines as prescribed. Background: These comorbidities are major contributors to disease burden globally. Self-management of individuals with these coexisting diseases is much more complicated than that of those with single diseases and is critical for improved health outcomes. Design: Motivational interviewing telephone calls were made with participants with coexisting diabetes, CKD and hypertension. Methods: Patients aged ≥18 years with diabetes, CKD and systolic hypertension were recruited from outpatient clinics of an Australian metropolitan hospital between 2008-2009. An average of four motivational interviewing telephone calls was made with participants (n = 39) in the intervention arm of a randomised controlled trial. Data were thematically analysed using the modified Health Belief Model as a framework. Results: Participants' motivation and confidence in taking prescribed medicines was thwarted by complex medicine regimens and medical conditions. Participants wanted control over their health and developed various strategies to confront threats to health. The perceived barriers of taking recommended health action outweighed the benefits of taking medicines as prescribed and were primarily related to copious amounts of medicines. Conclusion: Taking multiple prescribed medicines in coexisting diabetes, CKD and hypertension is a perpetual vocation with major psychosocial effects. Participants were overwhelmed by the number of medicines that they were required to take. The quest for personal control of health, fear of the future and the role of stress and gender in chronic disease management have been highlighted. Participants require supportive emotional interventions to self-manage their multiple medicines on a daily basis. Relevance to clinical practice: Reducing the complexity of medicine regimens in coexisting diseases is paramount. Individualised psychosocial approaches that address the emotional needs of patients with regular follow-up and feedback are necessary for optimal chronic disease self-management. © 2013 John Wiley & Sons Ltd.

What are the perceived learning needs of Australian general practice registrars for quality prescribing?

BACKGROUND: Little is known about the perceived learning needs of Australian general practice (GP) registrars in relation to the quality use of medicines (QUM) or the difficulties experienced when learning to prescribe. This study aimed to address this gap. METHODS: GP registrars' perceived learning needs were investigated through an online national survey, interviews and focus groups. Medical educators' perceptions were canvassed in semi-structured interviews in order to gain a broader perspective of the registrars' needs. Qualitative data analysis was informed by a systematic framework method involving a number of stages. Survey data were analysed descriptively. RESULTS: The two most commonly attended QUM educational activities took place in the workplace and through regional training providers. Outside of these structured educational activities, registrars learned to prescribe mainly through social and situated means. Difficulties encountered by GP registrars included the transition from hospital prescribing to prescribing in the GP context, judging how well they were prescribing and identifying appropriate and efficient sources of information at the point of care. CONCLUSIONS: GP registrars learn to prescribe primarily and opportunistically in the workplace. Despite many resources being expended on the provision of guidelines, decision-support systems and training, GP registrars expressed difficulties related to QUM. Ways of easing the transition into GP and of managing the information 'overload' related to medicines (and prescribing) in an evidence-guided, efficient and timely manner are needed. GP registrars should be provided with explicit feedback about the process and outcomes of prescribing decisions, including the use of audits, in order to improve their ability to judge their own prescribing.

Clincial pharmacogenetics and potential application in personalized medicine

The current `fixed-dosage strategy' approach to medicine, means there is much inter-individual variation in drug response. Pharmacogenetics is the study of how inter-individual variations in the DNA sequence of specific genes affect drug responses. This article will highlight current  pharmacogenetic knowledge on important drug metabolizing enzymes, drug transporters and drug targets to understand interindividual variability in drug clearance and responses in clinical practice and potential use in  personalized medicine. Polymorphisms in the cytochrome P450 (CYP) family may have had the most impact on the fate of pharmaceutical drugs. CYP2D6, CYP2C19 and CYP2C9 gene polymorphisms and gene duplications account for the most frequent variations in phase I metabolism of drugs since nearly 80% of drugs in use today are metabolised by these enzymes. Approximately 5% of Europeans and 1% of Asians lack CYP2D6 activity, and these  individuals are known as poor metabolizers. CYP2C9 is another clinically significant drug metabolising enzyme that demonstrates genetic variants. Studies into CYP2C9 polymorphism have highlighted the importance of the CYP2C9*2 and CYP2C9*3 alleles. Extensive polymorphism also occurs in a majority of Phase II drug metabolizing enzymes. One of the most important polymorphisms is thiopurine S-methyl transferases (TPMT) that catalyzes the S-methylation of thiopurine drugs. With respect to drug transport  polymorphism, the most extensively studied drug transporter is  P-glycoprotein (P-gp/MDR1), but the current data on the clinical impact is limited. Polymorphisms in drug transporters may change drug's distribution, excretion and response. Recent advances in molecular research have revealed many of the genes that encode drug targets demonstrate genetic polymorphism. These variations, in many cases, have altered the targets sensitivity to the specific drug molecule and thus have a profound effect on drug efficacy and toxicity. For example, the β2-adrenoreceptor, which is encoded by the ADRB2 gene, illustrates a clinically significant genetic variation in drug targets. The variable number tandem repeat polymorphisms in serotonin transporter (SERT/SLC6A4) gene are associated with response to antidepressants. The distribution of the common variant alleles of genes that encode drug metabolizing enzymes, drug transporters and drug targets has been found to vary among different populations. The promise of pharmacogenetics lies in its potential to identify the right drug at the right dose for the right individual. Drugs with a narrow therapeutic index are thought to benefit more from pharmacogenetic studies. For example, warfarin serves as a good practical example of how pharmacogenetics can be utilized prior to commencement of therapy in order to achieve maximum efficacy and minimum toxicity. As such, pharmacogenetics has the potential to achieve optimal quality use of medicines, and to improve the efficacy and safety of both prospective and licensed drugs.

High prices for generics in Australia : more competition might help

It is commonly believed that dispensed prices of medicines in Australia are substantially lower than those in other developed countries, particularly the US. This article reports the results of an analysis comparing dispensed prices for the most commonly prescribed and the highest cost items in Australia with dispensed prices in the US. Although a large majority of items are less expensive in Australia than in the US, Australian prices are higher for a substantial number of products, particularly generic drugs. This article examines various policies affecting the pricing of generics in Australia. It is postulated that the main cause for higher prices for a substantial number of generic products is the lack of price competition. This results from government policy which ensures that a price reduction by one company is communicated immediately to all competitors in that market along with an invitation to match the reduced price. The dominant strategy for all suppliers is to only reduce their price in response to a reduction in price by a competitor. The result is a lack of differentiation in pricing across brands of a medicine on the Schedule of Pharmaceutical Benefits. The government could improve the structure of the generics market and encourage greater competition by ceasing to disclose competitor firms’ offers to other competitors. The government could conduct pricing reviews of each generic product relatively infrequently (eg, only once annually or every 18 months). At the time of the pricing review, the government would request confidential offers on price for a generic from all players in the market. Brands should then all be listed under the Pharmaceutical Benefits Scheme (PBS) at the offered price. Prices offered by the individual supplier would apply until the next pricing review. The PBS would continue to subsidise up to the price of the lowest priced brand, with brand premiums applying to all brands priced higher than the benchmark price. Such an approach would provide opportunity for players in the market to capture market share by being thelowest priced brand.

Complementary and alternative therapies : regulatory issues

Complementary therapy (CAM) use is common.  CAM includes a variety of medicines, products and therapies used to promote health or treat symptoms and minor illnesses. CAM products are widely available from a variety of sources such as practitioners, pharmacies, supermarkets, health food shops and markets as well as on the internet.  Many CAM and conventional practitioners are concerned about the safety and efficact of CAM products and the lack of a strong regulatory framework for their use. 

"Listening to those rarely heard" : a guide for supporters

This resource guides training facilitators and participants through the workshop titled "People with severe to profound intellectual disabilities leading lives they prefer through supported decision-making: "Listening to those rarely heard". The package consists of a PPT presentation, a training video and a workshop manual.

Small-scale rural pilot programs in chronic illness management - what next?

In recent years, rural SA has been the recipient of significant funding to support a range of new primary health care initiatives. Much of this funding, additional to normal recurrent budgets in our health system, has facilitated effective change and development through demonstration and research projects across the state. The resultant work involves programs such as: ? coordinated care trials (COAG) ? more allied health services (MAHS) ? Commonwealth regional health service initiatives (CRHS) ? quality use of medicines (QUM) ? community packages for aged care services ? Indigenous chronic disease self-management pilot programs (CDSM) ? chronic disease self-management (CDSM) programs - Sharing Health Care SA ? chronic disease self-management (CDSM) programs in Indigenous communities. In addition to the resources listed above, funding was also provided by the Commonwealth to establish the South Australian Centre for Rural and Remote Health (SACRRH) and develop the University Department of Rural Health in Whyalla. While this new funding has led to substantial developmental work in chronic illness management in particular, one needs to ask whether the time might not be right now for these hitherto small-scale change initiatives to be transformed into ongoing mainstream programs, informed and guided by research outcomes to date. Is it time to move beyond tentative chronic illness programs and into mainstream reform? We have shown that there is much to be gained, both for patients and for the system, from improved coordination of primary care services and initiatives such as self-management programs for patients with chronic conditions. Better management leads to improved patient health outcomes and can reduce demand for unplanned hospital and emergency services. Many admissions to rural hospitals requiring expensive services, in terms of infrastructure and staffing, could be either prevented, or patients could be managed more effectively in the community as part of a wider primary health care program.