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Ensuring the Quality
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Indigenous Australians:
Key directions for policy, research
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and practice for cardiovascular health
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An initiative of the Heart Foundation Pharmaceutical Roundtable
ndtable
Alex Brown • 2007
QUM
The Heart Foundation Pharmaceutical Roundtable members:
©2007 National Heart Foundation of Australia. All rights reserved.
This report was prepared by Dr Alex Brown of the Baker Heart Research Institute for the National Heart
Foundation of Australia (the Heart Foundation Pharmaceutical Roundtable). Both the report and its executive
summary are available from www.heartfoundation.org.au.
The views expressed in this report are those of the author and not necessarily those of the National Heart
Foundation of Australia or its partner organisations; Alphapharm, Astrazeneca, Bristol-Myer Squibb, Merck
Sharp & Dohme, Pfizer Australia, Roche, sanofi-aventis, Solvay Pharmaceuticals and Servier Laboratories.
This work is copyright. No part may be reproduced in any form or language without prior written permission
from the National Heart Foundation of Australia (national office). Enquiries concerning permissions should
be directed to copyright@heartfoundation.org.au.
Suggested citation:
National Heart Foundation of Australia (Brown, A on behalf of the Heart Foundation Pharmaceutical
Roundtable). Ensuring the quality use of medicines among Indigenous Australians: key directions for policy,
research and practice for cardiovascular health. Melbourne, Victoria, 2007.
National Library of Australia
Cataloguing-in-Publication data
Brown, Alex, 1971- .
Ensuring the quality use of medicines among Indigenous Australians [electronic resource] : key directions
for policy, research and practice for cardiovascular health.
Bibliography.
ISBN-10: 1-921226-16-1 (pdf).
ISBN-13: 978-1-921226-16-8 (pdf).
1. Aboriginal Australians - Health and hygiene. 2. Aboriginal Australians - Drug use. 3. Heart - Diseases
- Chemotherapy - Australia. I. National Heart Foundation of Australia. II. Heart Foundation Pharmaceutical
Roundtable. III. Title.
616.120610899915
Contents
Introduction ......................................................................................................................................................2
Background......................................................................................................................................................3
Cardiovascular disease among Indigenous Australians ..........................................................................3
Barriers to care for Indigenous Australians with CVD..............................................................................4
Chronic disease co-morbidity among Indigenous Australians .................................................................5
The quality use of cardiovascular medicines .....................................................................................................6
Exploring the policy context of QUM ......................................................................................................6
QUM and the control of chronic diseases ..............................................................................................6
QUM and the control of CVD .................................................................................................................6
Early detection and management of CVD ..............................................................................................6
Exploring the gap between evidence and practice for CVD control ........................................................7
QUM and Indigenous Australians ......................................................................................................................8
Exploring the role of QUM in CVD prevention for Indigenous Australians ................................................8
Barriers to QUM for Indigenous Australians............................................................................................8
What works for improving QUM for Indigenous people? ......................................................................10
Standard Treatment Manuals and Guidelines .......................................................................................10
Creating sustainable health service systems to support QUM ..............................................................10
Improving adherence in Aboriginal communities ..................................................................................11
Methodology ..................................................................................................................................................12
Results ...........................................................................................................................................................13
Barriers to QUM ..................................................................................................................................13
Targets for action .................................................................................................................................15
Tobacco control and vascular health in Aboriginal communities ...........................................................16
Public awareness programs.................................................................................................................17
Continuum of care ...............................................................................................................................17
Risk assessment .................................................................................................................................18
Guideline development ........................................................................................................................19
Access to medicines............................................................................................................................19
Patient information resources...............................................................................................................20
Systems-based approaches to QUM ...................................................................................................21
Improving adherence ...........................................................................................................................22
Research priorities ...............................................................................................................................23
Research and development targets to support QUM among Aboriginal people....................................24
Future directions .............................................................................................................................................25
Policy development and advocacy for QUM among Indigenous Australians .........................................25
Strategic research priorities for QUM among Indigenous Australians ....................................................26
Critical projects for QUM CVD in aboriginal communities .....................................................................26
Conclusion .....................................................................................................................................................29
References .....................................................................................................................................................30
Acknowledgements ........................................................................................................................................32
Appendix A: Indigenous QUM project profile collation .....................................................................................33
Appendix B: Preliminary consultation ..............................................................................................................34
Appendix C: Discussion document questions .................................................................................................35
Ensuring the Quality Use of Medicines among Indigenous Australians
1
Introduction
Despite significant improvements in cardiovascular
disease (CVD) mortality in Australia over several
decades, much remains to be achieved. CVD
remains the primary cause of death for all
Australians, and conservatively cost Australian
society over $14 billion in direct and indirect health
1
expenditure in 2004 . The burden resulting from
CVD extends beyond financial measures, with the
gap between evidence for CVD prevention and
management, and its application in the context
of clinical practice still a major concern. This
disparity is an important contributor to ongoing
suffering and perhaps more importantly, to the
differences between population groups based
on location, ethnicity or socioeconomic status.
The Heart Foundation Pharmaceutical Roundtable
(the Roundtable), established in 2003, brings
together the National Heart Foundation of Australia
(the Heart Foundation) and the pharmaceutical
industry to address issues specific to the
cardiovascular health needs of all Australians. The
overarching principles guiding the Roundtable relate
to reducing suffering from heart, stroke and vascular
disease in Australia. In part, this will be achieved
through the provision of support for research and
the development of cardiovascular health initiatives.
Quality Use of Medicines (QUM) is one of four
central objectives of Australia’s National Medicines
2
Policy and has been defined as: ‘selecting
management options wisely, choosing suitable
medicines if a medicine is considered necessary
3
and using medicines safely and effectively’ . The
quality use of medicines within the context of
prevention and management of CVD and associated
conditions requires a range of specific actions,
supportive policy and infrastructure that assures
access to, guides the selection of, and monitors
population and individual level outcomes.
Ensuring the Quality Use of Medicines among Indigenous Australians
The Heart Foundation and the pharmaceutical
industry (via the Roundtable) seek to identify and
address the most pressing barriers in achieving
QUM in cardiovascular health for the Australian
population as a whole. To this end, the Roundtable
has supported a research project which aims to
identify the barriers to the quality use of medicines
in cardiovascular health and develop solutions for
overcoming them. To date, a project has been
conducted to examine these questions in the
broader Australian population. In addition, the
Roundtable has identified the need to consider
the synergies and potentially unique issues
impeding QUM among Indigenous Australians.
In Australia, work in the QUM area has been well
informed by organisational, political, industry and
consumer input into policy and practice. A large
body of work and interagency coordination has
been established, and QUM has earned its place
within the national health landscape. Unfortunately,
comparatively little attention has focused on
the specific needs of Indigenous Australians.
CVD remains the leading contributor to mortality
experienced by Indigenous Australians. Barriers to
routine primary, secondary and specialist care have
been previously outlined by Aboriginal people, their
representative bodies, health service providers,
researchers and administrators. Access to, and
the quality use of medicines can achieve much
in reducing the absolute and relative disparity in
cardiovascular health outcomes between Aboriginal
and non-Aboriginal populations. However, the
challenges facing the supply, access to, awareness
of, appropriate use of and monitoring of outcomes for
cardiovascular medicines for Indigenous communities
and their health services in rural, remote and urban
settings remain apparent. Reducing the burden
of CVD among Indigenous Australians requires
significant focus on the identification of barriers to
QUM and determining sustainable and effective
methods of ensuring QUM across the continuum of
care within heterogeneous health care environments.
2
Background
Cardiovascular disease among
Indigenous Australians
The health disadvantage experienced by Indigenous
Australians is probably the most enduring health
factors have been demonstrated to be particularly
prevalent among Indigenous Australians. Previously,
it has been shown that Indigenous Australians are
almost twice as likely to die, and 1.5 times as likely
11
to be hospitalised for stroke than other Australians .
4
issue in contemporary Australia . Diseases of the
cardiovascular system remain the single largest
cause of death for Aboriginal and Torres Strait
5-7
Islanders and are largely responsible for the
higher mortality rate among these populations,
where age-adjusted death rates attributed to
CVD are three times higher than those observed
8, 9
in the non-Aboriginal population . Age specific
mortality differentials are even more alarming:
between the ages of 25-54, rates of death due
to CVD are between seven and twelve times
8, 9
that of non-Indigenous people . CVD is also
a leading contributor to the burden of disease
among Aboriginal and Torres Strait Islander
groups. Among Aboriginal people in the Northern
Territory, CVD accounted for 19.1% and 15.7%
of the total Disability Adjusted Life Years (DALY’s)
10
experienced by males and females respectively .
Heart failure (HF) remains a principle cause of illness,
death and disability in Australia, with an estimated
300,000 people with HF, and 30,000 new cases
11
diagnosed each year . Unfortunately, the extent of
chronic heart failure (CHF) among the Indigenous
population is poorly documented. What is known,
is that Indigenous Australians are almost three
times as likely to die and 2-3 times as likely to be
11
hospitalised for CHF as other Australians . Risk
factors for CHF are also higher among Indigenous
Australians, particularly rates of coronary artery
5
disease, hypertension, diabetes and obesity .
Stroke also makes a significant contribution to
CVD burdens across the country, and is ranked
as the second single greatest cause of death after
11
coronary artery disease . This is despite declines
in the rates of death from stroke in the last three
decades among the broader Australian population.
Risk factors for stroke include a history of transient
ischaemic attacks (TIAs), raised cholesterol, atrial
fibrillation, hypertension, smoking, diabetes, harmful
alcohol consumption, low levels of physical activity,
poor diet, and carotid stenosis. Most of these risk
Ensuring the Quality Use of Medicines among Indigenous Australians
Despite the almost complete disappearance of
Acute Rheumatic Fever (ARF) and Rheumatic Heart
Disease (RHD) from much of the industrialized
12,
world these diseases remain important
contributors to the suffering experienced by
13, 14
Indigenous Australians
. In remote Aboriginal
communities of the Northern Territory, between
1-3% of the population has established RHD,
due to repeated infections with group A
streptococci, subsequent episodes of rheumatic
fever and resultant cumulative valve damage.
The most effective approach to controlling RHD
remains prevention, specifically the delivery of regular
antibiotics aimed at preventing the recurrence of
ARF and development of severe RHD, known as
15
secondary prophylaxis . Failure to provide and
receive secondary prophylaxis can be a result of
missed initial diagnoses of ARF, poor continuity of
care, a lack of trust and communication between
patients and health care providers, high staff
turnover, a lack of appropriate and understandable
health education, and perhaps most importantly,
a lack of political and bureaucratic commitment.
Unfortunately, these same factors are likely to
contribute to poor health outcomes among
Indigenous people for other cardiovascular diseases.
The reasons for such enormous disparity in the
cardiovascular disease burden between Indigenous
and non-Indigenous Australians are complex
and multi-factorial, but are likely to include higher
prevalence of traditional risk factors, impaired
access to services, dietary and psychosocial
factors, over-crowding and poor environmental
conditions, extreme socioeconomic disadvantage,
4, 16-19
.
and a lack of political commitment
Despite these issues, funding for action remains
fragmented, short term, and significantly less
than that required to meet the enormous health
and social needs of Indigenous Australians.
3
Sub-optimal utilisation of cardiac
rehabilitation services
Barriers to care for Indigenous
Australians with CVD
Additional barriers exist for Indigenous patients
following discharge. Little has been documented
about the post-discharge care of Indigenous people
with CVD, but the low rates of involvement in cardiac
rehabilitation may indicate the existence of further
Unfortunately, there are significant barriers
to the appropriate care of Indigenous clients
with established CVD and those at elevated
risk of cardiovascular events, which are likely
to contribute to poorer health outcomes.
26, 27
Differentials in health care utilisation
Indigenous Australians utilise health care services
20
differently from the remainder of the population .
The pattern is dominated by publicly provided
services, with under-utilisation of Commonwealth
funds for pharmaceuticals, Medicare, specialist
21
services and general practitioner consultations .
Additionally, access to specialist cardiology services,
early diagnosis, appropriate interventions and
acute care is limited in remote and regional areas
where large numbers of Indigenous Australians
22
tend to reside . Differences in service utilisation
raise important and unique considerations
for QUM across the continuum of care. The
higher rate of hospital utilisation by Indigenous
21
Australians , makes QUM within hospitals and
ensuring continuity between secondary services
and primary care particularly important in improving
health outcomes for Aboriginal people.
Delays in treatment
The combination of delays in treatment for those with
acute heart disease with poorer access to essential
treatment, highlights a significant barrier to QUM at
the initial interface between Indigenous clients and
. Significant
impediments to secondary prevention
barriers to cardiac rehabilitation exist for Indigenous
Australians, including small numbers of Aboriginal
and Torres Strait Islander people across the health
workforce, and difficulties in communication and
education between service providers and clients.
Other reported obstructions to rehabilitation include
poor discharge planning, fragmented continuity
of care and poor linkages between primary,
secondary and allied health services, maintenance
of healthy lifestyles and behaviour changes on
return to communities and significant underinvolvement of Aboriginal clients, communities and
services in the development, implementation and
28
evaluation of cardiac rehabilitation programs .
Some, but not all of these issues have been identified
as barriers to QUM in the broader population. This
is of particular concern because the potential gains
in terms of secondary prevention of coronary heart
disease and its sequelae are undisputed. Best
practice guidelines do exist, and are readily available.
Unfortunately, a paucity of information exists to
assess the provision and outcomes of CVD care
across the continuum for Indigenous populations.
23
hospitals . Furthermore, when admitted to health
services, Indigenous clients have poorer access to
the diagnostic and therapeutic procedures required
for quality cardiovascular care
24, 25
. Coory and
25
Walsh revealed significant differences in procedure
rates between Indigenous and non-Indigenous
patients who had suffered an acute myocardial
infarction (AMI). Indigenous clients were less likely to
undergo percutaneous coronary interventions (PCI) or
coronary artery bypass grafting (CABG). Importantly,
there were significant differences in survival for
Indigenous people suffering AMI, with an almost 80%
increased risk of death in the year after an event.
Ensuring the Quality Use of Medicines among Indigenous Australians
4
Chronic disease co-morbidity
among Indigenous Australians
It is important to consider the high rates of complex,
co-morbid chronic diseases among Indigenous
Australians when determining approaches to CVD
control, specifically with respect to early detection
and management of elevated risk and initiation
of activities aimed at prevention. The clustering
of diabetes, chronic renal impairment and CVD is
evident in Aboriginal people, and must become
a focus for preventing and managing chronic
28
disease and improving health outcomes .
Similarly, the high burden of Diabetes Mellitus
(DM), Insulin Resistance and associated
metabolic disorders among Indigenous people
requires consideration within the context of
17, 35
. Diabetes and related
CVD and its control
metabolic disorders are important contributors
to the absolute burden of disease in Australia,
both directly, and as a risk factor for coronary
artery disease (CAD), renal disease, stroke and
peripheral artery disease. Aboriginal people have
the highest reported rates of diabetes of any
population within Australia, with age-standardised
prevalence four times and mortality up to 15 times
36
Chronic kidney disease (CKD) is a strong
independent predictor of fatal and non-fatal
cardiovascular events for patients without established
29
coronary disease , and for patients suffering from
30
acute coronary syndromes . Between 1993-98,
the average age and sex standardised incidence of
End Stage Renal Disease (ESRD) among Indigenous
Australians was 8 times higher than that observed
that of their non-Indigenous counterparts .
In total, it is estimated that between 10 and 30%
37
of Indigenous Australians suffer from diabetes .
As such, the control of CVD among Indigenous
people must also consider the early detection
and treatment of diabetes and related disorders.
31
for the broader Australian population . High rates
of ESRD are particularly apparent among Aboriginal
32
people residing in remote areas . Mortality from
5
33
CKD and hospitalisations for dialysis are also
significantly higher among Indigenous Australians
than their non-Indigenous counterparts, as are
markers that predict the development of ESRD,
such as overt proteinuria, microalbuminuria and
18, 34
.
elevated urinary albumin/creatinine ratio (ACR)
Detection and treatment (where indicated) of
these markers is likely to be an important step in
the prevention of CVD morbidity and mortality.
Ensuring the Quality Use of Medicines among Indigenous Australians
5
The quality use of
cardiovascular medicines
Exploring the policy context of QUM
Quality Use of Medicines (QUM) is central to
2
Australia’s National Medicines Policy , and has
been defined to include activities which support
the wise selection of management (including
medicine and non-medicine treatments); choosing
suitable medicines if a medicine is considered
necessary (by consideration of the client and their
condition(s), risks, benefits, adverse events, and
costs incurred to both the individual and community);
3
and by the safe and effective use of medicines .
Practical application of these QUM principles must
include the development, implementation and
evaluation of resources to guide the selection and
use of selected therapeutic options, combined
with processes to monitor the utilisation of such
against health outcomes, and education and
information resources to assist health professionals
and consumers in adopting and adhering to
appropriate selection and monitoring of treatments.
QUM and the control of
chronic diseases
These are also specific targets for improving
Indigenous cardiovascular health, which by necessity
must consider QUM across the continuum of risk
and the continuum of care. Integrated chronic
disease care mandates the quality use of all
necessary medicines, as critical to reducing risk,
improving the quality of care, improving outcomes
and quality of life and as a consequence reducing
the burden on health systems. This requires
significant investment, collaboration between
services and providers, and the development
of skills among health care providers to support
evidence based approaches that encourage
the optimal use of medicines. More specifically,
the strategy recognises that measures must be
implemented which will improve access to medicines
for Aboriginal and Torres Strait Islander peoples.
QUM and the control of CVD
The recently developed National Service
Improvement Framework for Heart, Stroke and
Vascular Disease recognises reducing CVD among
36
More specifically, national and regional policy
recognises the central role of QUM within a
36, 38
broader chronic disease control framework
.
The National Chronic Disease Strategy recognises
that prevention of chronic disease must engage
action across the continuum of care, from early
antecedents of chronic disease, through to
supported tertiary and palliative services. Secondly,
early detection and implementation of evidence
based treatment of chronic disease and its risk
factors are critical to improving health outcomes
and reducing the high cost of chronic disease
across Australian society. Thirdly, care for those
identified with, or at risk of, chronic disease must
be integrated between services, providers and
clients. Finally, chronic disease control requires
that clients are active participants in their own
care, which mandates health promotion and
risk reduction, informed decision making, care
plans, medication management, and working with
providers to negotiate complex health systems.
Ensuring the Quality Use of Medicines among Indigenous Australians
Indigenous Australians as a primary objective .
The extended course and complicated natural
history of CVD requires a range of support that
focuses on each individual client, including action
aimed at QUM, self-management, and assisting
clients to negotiate often complex systems of
care. These issues are of particular concern
for Indigenous people, and have been poorly
addressed in research, policy or practice to date.
Early detection and
management of CVD
Early detection and management of individuals at
risk of CVD remains a pivotal target in relation to
CVD control. Cardiovascular prevention strategies
have recently been oriented away from individual
risk factor approaches. The mitigation of risk among
individuals, or at the population level, requires
consideration of the complex and multifactorial
causes of CVD. As such, more appropriate
targeting of individuals requires consideration of
their ‘integrated’, or ‘absolute’ risk of CVD. As
outlined within the National Service Improvement
Framework for Heart, Stroke and Vascular Disease:
6
“Linking estimates of the likely absolute benefit
of interventions with calculation of absolute
risk should reinforce the rationale for lifestyle
measure for all individuals and pharmacological
36
treatment for those at higher risk” .
The consideration of absolute risk of CVD among
Indigenous Australians poses a number of
challenges. In particular, current risk assessment
cannot be reliably extrapolated to Indigenous
people, mostly as a result of inadequate population
specific data. In addition, there is a lack of resources
to develop and sustain supportive systems to
implement the use of absolute risk assessment
tools across Aboriginal health service settings.
Nonetheless, their development should be a priority
target for action given the complex patterns of
co-morbidity, the poor performance of available
19
risk assessment tools , and the need to prioritise
prevention activities within resource limited services.
Exploring the gap between evidence
and practice for CVD control
Clinical practice guidelines have been utilised to
guide clinical and public health practice, service
development, processes of care, benchmarking
and targeted CVD control practices across
the continuum of care. A wide range of clinical
practice guidelines exist for the acute and long
term management of clients diagnosed with, or
at risk of, heart, stroke and vascular disease. This
range includes guidelines targeting Aboriginal
and Torres Strait Islander peoples specifically,
and which have an important role in supporting
a consistent and evidence based approach to
clinical care. However, international data confirms
the presence of a gap between best-practice and
There exists a series of impediments to the effective
utilisation and implementation of evidence based
clinical practice guidelines, which are often magnified
in the complex and poorly resourced setting of
Aboriginal health services. Implementation and
adoption strategies are clearly required if guidelines
are to effect beneficial change within clinical practice,
service models or health provider behaviours.
Factors such as different target groups, consumer
awareness, cultural awareness, resourcing limitations
and supportive infrastructure must all be considered
in the development of guidelines; in particular,
those that target health issues of importance to
minority groups, including Indigenous people.
Incorporating the large volume of research into
clinical practice is especially problematic for
practitioners working in Aboriginal communities.
This is largely due to barriers to obtaining evidencebased information, isolation from peers, time
constraints, and limited or unreliable information
36
technology infrastructure . Decision support tools,
evidence-based guidelines and care pathways,
standard orders and computerised access to valid
and relevant evidence, are important targets for
reducing the gap between evidence and practice
for Indigenous Australians, and indeed for other
populations in rural and remote settings.
39
the actual provision of care in clinical settings .
Ensuring the Quality Use of Medicines among Indigenous Australians
7
QUM and Indigenous
Australians
Exploring the role of QUM
in CVD prevention for
Indigenous Australians
The Heart Foundation has committed to the
objective of reducing CVD burdens among
Indigenous Australians through a range of targeted
advocacy, policy and program activities. The
most critical has been the Aboriginal Torres Strait
Islander Program (ATSIP). The focus of ATSIP has
been to raise the profile of, and nurture political
and organisational commitment to reducing
CVD burdens among Aboriginal and Torres
Strait Islander people. In recent years, ATSIP
has identified four key platforms for action:
■
the development and implementation
of sustainable funding base for
Aboriginal and Torres Strait Islander
cardiovascular health programs
■
to support national, state and territory
cardiovascular training programs for Aboriginal
and Torres Strait Islander Health Workers
■
to support and develop comprehensive
secondary prevention programs (including
cardiac rehabilitation) for eligible Aboriginal
and Torres Strait Islander patients
■
to support the implementation of a
nationally managed program for the
prevention and management of rheumatic
fever and rheumatic heart disease.
Considering these priority areas, it is clear
that QUM policy, principles, and practice,
when supported by sustainable system based
approaches and appropriate resourcing,
have an important role to play in each.
Recently, ATSIP has sought to redefine its activities
for the future. QUM has a necessarily prominent
role in forecasting directions for policy, advocacy
and program development. ATSIP has recognised
that enhancing QUM for Indigenous peoples is a
critical target for improving cardiovascular health
in the short and long term. For example, a focus
on improvements in access to PBS medicines
could well achieve significant improvements within
the domain of QUM. A further area of inequity that
could be addressed by QUM is tobacco control.
Many tobacco control measures that have been
implemented within mainstream Australia have
Ensuring the Quality Use of Medicines among Indigenous Australians
been either lacking or poorly targeted towards
Indigenous Australians. This requires urgent action.
There seems little argument that improving QUM
is one of the most cost effective approaches to
reducing the additional and preventable burden
40
of illness among Aboriginal peoples . Many of
the leading conditions accounting for excess
death among Indigenous people are treatable and
41
preventable and the use of appropriate medication
has a key role in reducing this unacceptable disparity.
A systematic treatment program to modify renal
and cardiovascular disease conducted in the Tiwi
Islands in the Northern Territory demonstrated
improved clinical outcomes through enhanced
primary care that served to aggressively identify
and treat Aboriginal clients at elevated risk of CVD,
diabetes and chronic kidney disease. Treatments
employed included ACE Inhibitors, combined with
other blood pressure lowering therapies, improved
control of blood glucose and lipid levels, and health
education. These interventions were associated
with over 50% reduction in mortality and renal
42
failure . Systematic, primary-health-care-centred
and community supported routine screening,
combined with aggressive management of risk,
can significantly impact on high chronic disease
burdens and mortality among Indigenous peoples,
and must be a critical target for QUM activities.
Barriers to QUM for
Indigenous Australians
43
As outlined by Murray , of the four pivotal elements
2
of the National Medicines Policy , access to
medicines remains the most problematic issue for
Aboriginal people. Despite increased levels of need,
Aboriginal Australians access medicines through
the PBS at a rate one third that of the remaining
44, 45
. Unfortunately, these barriers exist
population
across rural, remote and urban settings. The
introduction of Section 100, legislation and its
utilisation to improve access to pharmaceuticals has
been arguably one of the greatest achievements in
QUM for Aboriginal people. Although the introduction
of Section 100 represents a substantial positive
development in remote Aboriginal health service
46
delivery , further improvement is still required.
8
QUM is a priority target for improving the long
term primary and secondary prevention of CVD
among Aboriginal people. During the development
of Guidelines for Cardiac Rehabilitation among
28
Aboriginal and Torres Strait Islander People ,
identified barriers to medication use among
Indigenous peoples included limited access to
medicines, a lack of appropriate educational
information, poverty, transportation difficulties,
cultural issues and geographical isolation.
Within the context of QUM, discontinuity between
services and providers can also contribute to the
poor utilisation of medicines and potential harm to
47
clients . This is especially important for Aboriginal
people, who often experience difficulty negotiating
systems of care, institutionalised racism, poor
communication and significant geographical barriers
in accessing specialist and hospital services.
their own health. These are clearly important targets
within the context of QUM for Indigenous Australians.
The Better Medication Management for Aboriginal
48
People with Mental Health Disorders project also
identified a number of QUM issues. Medications
were stored under ‘unsafe conditions’ and patients
demonstrated poor knowledge of the exact actions
and potential side effects of prescribed medicines.
Further still, patients were often confused by
alterations in their treatment regime. Health worker
participants in this study outlined the considerable
time they spent in contact with Aboriginal clients who
had received insufficient information about handling
medicines, dosing, side effects and interactions with
other prescribed medications. A range of cultural
factors, as well as limited access to appropriate
and understandable medication information and
differences in patient knowledge are likely contributors
49, 50
In a project aimed at exploring the use of medications
among Aboriginal people with mental illness in
48
South Australia , a range of barriers to QUM were
identified. Specifically, these included a lack of
suitably developed educational material which could
be used to assist Aboriginal clients, family members
and health workers in safe medication use. These
findings have been supported in an evaluation of
49
medication supply to Aboriginal Health Services .
A range of information and patient education needs
were identified through the consultation phase of
the evaluation, including support for advice and
training in all areas of medication management
for health service staff and the provision of upto-date, easy-to-read, plain English medicine
information for client and staff education.
. There
to poorer QUM among Aboriginal people
is evidence to suggest that patients often recognise
medicines by colour and shape, infrequently use
administration aids, often shared medicines with other
family members and commonly ceased therapy when
symptomatic improvement was noted. Furthermore,
Aboriginal clients often face difficulties with drug
43
regimes . Complex co-morbidity (particularly due to
related chronic diseases), educational disadvantage
and lack of suitable medicines information compound
these difficulties. Simplified dosing regimes (i.e. once
or twice daily) are often employed within Aboriginal
43
health services to counter these particular barriers .
An evaluation of PBS medicine supply to Aboriginal
Health Services (AHS) through S100 arrangements
also identified a range of significant barriers to QUM for
49
QUM requires informed decision making by
providers and their clients on appropriate
47
treatment . Prescribers need access to accurate,
comprehensive, and up to date consumer-specific
information to assess the most suitable treatment
and to prescribe the most appropriate, safe and
cost-effective medicine for that person. There are a
number of difficulties faced by Aboriginal and Torres
Strait Islander groups negotiating the health system,
including the cultural appropriateness of information
provided to clients. Information is essential if
Aboriginal clients are to make informed choices
relating to appropriate therapies, and therefore
become active participants in the management of
Ensuring the Quality Use of Medicines among Indigenous Australians
Aboriginal clients . A range of recommendations for
action targeting improved QUM with AHSs, included;
■
information technology (IT) programs
that streamline ordering, dispensing
and supply of medication
■
standards for the delivery of pharmacy
services to Aboriginal Health Services
supported by a set of generic procedures
and protocols to support QUM
■
adaptation/development and distribution of
easy to understand medication information
sheets for use by Aboriginal Health
Service providers and their clients
9
■
the need to develop QUM indicators and
continuous quality improvement auditing
processes to improve QUM within AHSs.
What works for improving QUM
for Indigenous people?
51
As outlined in a review by Abbott , a range of
interventions have been demonstrated to improve
patterns of medication prescribing. The focus has
predominantly been on prescribers, with evidence of
improved prescribing patterns via outreach education
sessions, interactive peer group education, and
problem-based learning case studies. Audit and
regular feedback processes have also been shown
to improve prescribing practices in primary care,
as have the development and implementation of
guidelines specific to the local context. Several of
these tactics have been used specifically in Aboriginal
health services, although few interventions have
been specific to cardiovascular medications.
Standard Treatment
Manuals and Guidelines
Aboriginal people by all members of primary health
43
care teams in rural and remote communities .
The Cardiac Rehabilitation Guidelines for
Aboriginal and Torres Strait Islander People
28
identified several targets for improved use
of medicines within the context of secondary
prevention of cardiac illness, including:
■
the utilisation of available
evidence based guidelines
■
improved discharge recording of
medications and information flow between
hospital and primary care services
■
utilisation of all clinical contacts with clients as an
opportunity for continued medicines education
■
use of and recognition of the pivotal
role of AHW’s in QUM practices
■
using computerised patient information
systems for routine reminders for patient
care and medication reviews.
Creating sustainable health service
systems to support QUM
The Central Australian Rural Practitioners Association
52
(CARPA) Standard Treatment Manual (STM) ,
was first released in 1992. It has been utilised as a
process by which prescribing practices are enshrined
within locally specific guidelines, and supported
through policy aimed at encouraging and ensuring
standardised practices for the investigation, early
detection, treatment and long-term management of a
range of diseases specifically experienced in rural and
remote community settings. Despite its initial focus
on the practice and support of clinical management
within Aboriginal communities of the central region of
the NT, it remains an important resource utilised by
services and providers in South Australia, Western
53
Australia, Queensland and New South Wales .
The CARPA STM maintains strong support among
service providers within Aboriginal communities,
and is aimed at supporting standard practice,
quality assurance and data collection among
Aboriginal Health Workers, nursing and medical
53
staff alike . The utilisation of standardised and
evidence based practice reflects the role that
specific guidelines can play in improving the
judicious and appropriate use of medicines for
Ensuring the Quality Use of Medicines among Indigenous Australians
Impaired access to medicines remains a critical
44
barrier to Aboriginal health gain , however, access
alone is not sufficient to ensure sustainable QUM.
The development of appropriate infrastructure,
workforce training, information technology,
auditing practices and medicines prescribing,
dispensing and monitoring is also required to secure
sustainable QUM for Indigenous Australians.
Interactive peer group meetings and clinical case
scenarios have been developed and implemented
with Aboriginal Medical Services (AMS’s), most
specifically in relation to asthma, diabetes and
hypertension management. Although these programs
have not been formally evaluated, anecdotal reports
suggest that these processes are important in
creating a team environment within AMS’s that is
integral to supporting QUM principles and practice
[Personal communication, Tim Leahy, Feb 2006].
In the largest review of its kind, PBS supply
arrangements under S100 were examined by
49
Kelaher and colleagues . One of the principle
findings of the evaluation was that improved attention
to QUM was a critical contributor to improved
patient outcomes. Adherence to medications
10
improved due to the reduction in financial barriers,
and better access to medicines resulted in more
regular presentations to clinics while improving
monitoring and assessment of medicines use.
Perhaps even more marked, has been the range of
support structures that S100 funds have allowed
AMS’s to develop and sustain. This has been critical
to the improvement in QUM principles within core
service functions. The S100 scheme has been
lauded as a primary contributor to the enhanced role
of community pharmacists within the broader primary
40
health care team of Aboriginal medical services .
S100 funds have allowed community pharmacists
(and other clinic staff) to engage with and develop
implementation plans, medicines storage rooms,
protocols and procedures that support QUM, routine
medicines reviews of individual clients, regular
meetings with clinical staff and ongoing medicines
49
54
education with staff and clients . Clarke reports
the development of an alternate model of pharmacy
services within a remote community, whereby the
pharmacist becomes an integral component of the
‘local health team’. This provided improvements in
patient adherence, enhanced delivery of education
and support to clients, improved prescribing
monitoring and medicines supply, improved the
choice of appropriate medications, and enhanced
efficiencies within the clinic with the follow on effect of
freeing valuable clinical time of other staff members.
in relation to their medications is an important
contributor to lower rates of adherence.
Administration aids, packaging and storage of
medicines have been considered likely targets to
improve QUM for Aboriginal clients. There are two
main types of administration aids: blister packs
and dosette boxes. Both however have significant
49
limitations . A small trial in a remote Aboriginal
community in the NT sought to compare adherence
between patients randomised to receive blister
55
packs of medicines or ‘tablet safes’ . Firstly, and
counter to the often cited poor adherence among
Aboriginal clients, 70% of prescribed medicines
were taken across the study population, although
this was measured only over a short period of
time. The use of blister packs was associated with
a 19% increase in adherence over baseline rates,
and was well accepted by clients. However, there
were no improvements in adherence among those
randomised to receive a ‘pill safe’, despite the high
number of recipients who felt the intervention had
benefited them. Despite these benefits, blister packs
also placed significant pressures on clinic finances,
staff time, and clinic operations, and are difficult to
alter once the pack has been made up. Additionally,
49
Kelaher et al’s review of S100 supply of medicines
identified access to and funding for improved dosage
administration aids for use in Aboriginal community
settings as a key priority for improving QUM.
Improving adherence in
Aboriginal communities
Despite the existence of anecdotal reports
suggesting that Aboriginal clients with chronic
illness demonstrate poor adherence to therapy,
very little quantitative evidence exists to support
55
this claim . Further still, what limited evidence
exists monitors adherence over the short term,
rather than over extended periods of time. The term
‘non-compliance’, with its negative connotations
has been progressively substituted to reflect the
broader factors, at the level of client, provider
and system, which can negatively impact on
the amount of prescribed medicine that a client
55, 56
43
. As outlined by Murray , the
actually uses
term non-compliance is often used as a defence
against poor standards of clinical practice. In
part, inadequate information provided to the client
Ensuring the Quality Use of Medicines among Indigenous Australians
11
Methodology
The primary objective of this work was to identify a
range of priority projects or programs related to the
Quality Use of Medicines to improve cardiovascular
health among Indigenous Australians that the
Heart Foundation Pharmaceutical Roundtable
could develop or support into the future.
More specifically, the aims of the project were to:
■
■
■
■
consider QUM among Indigenous
Australians within the context of the
National Medicines Policy framework
map key national QUM initiatives
or projects relating to Indigenous
communities, services or individuals
consider and outline the importance of the
Quality Use of Medicines within the context
of Aboriginal cardiovascular health
identify key targets for engaging the expertise
and capacity of Heart Foundation Pharmaceutical
Roundtable stakeholders in relation to QUM that
could be translated to an Indigenous setting
■
identify and prioritise the major
issues requiring action
■
outline targeted projects that the Heart
Foundation Pharmaceutical Roundtable
should consider for future activity.
These preliminary findings were then collated in
order to identify the principle issues, key priorities
and to determine an overarching framework for a
discussion document. This was disseminated for
broader comment among relevant experts, service
providers and organisations involved in health service
delivery, research and advocacy for Indigenous
Australians and their communities [Discussion
Document Questions listed in Appendix C].
Finally, the findings of the discussion document
were collated with interview and workshop findings
specific to QUM and Indigenous Australians
identified from the broader QUM and Cardiovascular
3
Conditions consultation work conducted by RED .
As such, the methodology was an iterative process,
each stage seeking to build a certain level of
consensus through multiple levels of consultation.
In total, responses to questionnaires or interviews
were conducted with 42 individuals or representatives
of organisations involved in the delivery of health
services to Aboriginal communities throughout the
Northern Territory, South Australia, Queensland,
New South Wales, Western Australia and Victoria.
This project involved multiple stages. Firstly, relevant
literature and QUM policy was assessed and collated
with a focus on the particular context and needs of
Indigenous Australians. This was augmented by the
synthesis of information from researchers and service
providers involved in QUM projects conducted within
Indigenous communities or health services [QUM
Project Profile Collation – Appendix A]. This was
conducted with mailed questionnaires, completed
by telephone or through face to face interview.
These initial stages were used to outline the principle
themes or domains of interest to be explored through
semi-structured interviews, which completed the
preliminary consultation phase. These qualitative
key informant interviews were conducted with
Aboriginal service representatives and providers,
researchers, organisational representatives involved
in the cycle of medicine utilisation, Heart Foundation
program staff and committee representatives
[Preliminary Consultation - Appendix B].
Ensuring the Quality Use of Medicines among Indigenous Australians
12
Results
Barriers to QUM
Many respondents outlined their frustration and
at times desperation, at the enormous and rising
burden of cardiovascular and related chronic
conditions within Aboriginal communities. Most
of the major barriers to QUM previously identified
within the literature, and across QUM project
evaluations, were reiterated during consultations.
Importantly, respondents were keen to ensure
that any discussions of barriers to QUM were
considered within the wider context of the
complex and often insurmountable issues faced
by Aboriginal people. These issues range from
pervasive social, educational, environmental,
and political disadvantage, through to the
psychological and lifestyle dependent determinants
of ill health, and include the significant barriers
facing Aboriginal people when seeking necessary
care across the continuum. QUM within the
context of prevention of CVD was seen as
only one issue in a complex list of contributors
to ill-health among Aboriginal Australians.
More specifically, impaired access to healthy and
affordable nutrition was seen as a pivotal barrier to
chronic disease prevention and management within
Aboriginal communities. This was viewed as being
compounded by poverty, poor health awareness,
and geographical isolation and transportation
difficulties. Whilst there was agreement that these
issues were unlikely to be addressed with the
development of QUM programs, interview responses
clearly related that they must be addressed
if the burden of disease is to be reduced.
Access to health care in general, and the existence
of disparities in provision of services between
Indigenous and non-Indigenous patients were
seen as impacting upon the ability to establish and
maintain sustainable approaches to CVD prevention
and management within Aboriginal communities.
Rapid staff turnover (often a critical issue in Aboriginal
communities and primary health care settings)
was seen as a key barrier to the development of
long term, trusting relationships between client
and provider, fundamental to the development and
delivery of QUM programs within this (and probably
any) context. Furthermore, the much higher rates
of risk factors among Aboriginal populations, in the
context of often poorly resourced primary health
Ensuring the Quality Use of Medicines among Indigenous Australians
care services, made CVD prevention in general, and
QUM in particular, difficult to develop and sustain.
As a result, respondents felt that any projects that
were to be developed by the Roundtable, had to
contribute to or support, sustainable QUM activities.
In terms of specific barriers to QUM, participants
articulated that access to medications and medicine
delivery devices remains the primary barrier. They
identified this as limited further by poor quality
of care, significant gaps between evidence and
practice, difficulty in access to comprehensive
primary health care services, sub therapeutic
dosing of necessary medicines, costs and physical
availability. Notably, the majority of interviews
discussed the restriction of urban Aboriginal
community controlled services from benefiting from
S100 financing arrangements as an enormous
barrier to QUM and as a consequence, health gain
for Aboriginal people. Despite the existence of safety
net arrangements, participants highlighted that
cost remains a barrier to QUM within these (and
other disadvantaged) populations, complicated by
difficulties in comprehension of extensive paper work
and bureaucratic processes associated with claiming.
Given the differences in access to medicines and
other necessary care between urban and remote
Aboriginal communities, the heterogeneity of
settings was seen as important in deciding the
most important priorities for future action and their
delivery. Most respondents felt that the Roundtable
and the Heart Foundation should provide sustained
support to local services to develop solutions
identified as appropriate for their own communities.
The impact of poor access to medicines was
felt to be compounded by the limited access
to cardiac rehabilitation and specialist cardiac
services. Furthermore, most participants felt that
Nicotine Replacement Therapies (NRTs) and other
tobacco cessation methods were significantly
underutilised in Aboriginal specific settings.
Of particular note remains the unique burden of
complex chronic disease co-morbidity experienced
by Aboriginal people, which not only constitutes a
barrier to cardiovascular health within this population,
but also requires specific consideration within
future QUM activities. The broad range of drugs,
with their attendant and increasingly complex
interactions and regimes, the ever changing evidence
13
base in regards to cardiovascular prevention
and management, and the demanding and often
resource intensive implementation of evidence
based guidelines, were articulated as making it
more difficult for health care personnel to manage
CVD and related conditions. Most respondents
felt that these guidelines were rarely disseminated
in a fashion that AMS’s can easily access, utilise
and implement in their day to day practice.
Health care staff identified that the majority of
their clients had poor knowledge of CVD and
cardiovascular medicines, their functions, effects
and benefits, and their potential for interactions
with other drugs. The majority of respondents
felt that currently available medicines information
resources - such as Consumer Medicines Information
(CMI) - were inadequate for use with the majority
of their Aboriginal client base. The reliance on
written, often ‘legalistic’ patient information was
a key barrier to QUM within these settings. The
lack of culturally appropriate audiovisual aids to
be used in educating clients and their families
was considered a key target for future action.
There were consistent messages about the need
to improve the systems of support for nursing and
Aboriginal Health Worker (AHW) staff within Aboriginal
primary care settings. Given that nursing and AHW
staff are the principle point of contact between
Aboriginal people and health services, and the
primary agents for ensuring long term QUM, a lack
of support was an important barrier to QUM. Poor
coverage of QUM and health education processes in
undergraduate degree and other training programs
were considered to be contributors to sub-optimal
medicines management within Aboriginal services.
Most respondents felt that there was a critical lack of
training in supporting QUM across the health provider
spectrum, including generalist and specialist medical
personnel. These problems were compounded
by the lack of reliable and consistent information
systems available within Aboriginal Community
Controlled Health Organisations (ACCHOs) and
mainstream services providing for Aboriginal clients.
The inability of Aboriginal Medical Services to gain
access to the broader allied health workforce,
including pharmacists and pharmacy services,
particularly in remote settings, was also highlighted
as a key barrier to QUM. Despite the availability of
Ensuring the Quality Use of Medicines among Indigenous Australians
Medicare Benefits Scheme (MBS) supported Home
Medicines Reviews (HMR), the lack of pharmacists to
support these initiatives was of major concern. Those
who had been fortunate enough to establish HMR’s
within Aboriginal primary care settings found that
they were positive and a useful process in improving
QUM for Aboriginal clients. However, the potential
gain was not being realised due to lack of staff.
Although there were discussions of poor adherence
to medicines among Aboriginal clients as a critical
barrier to QUM, the primary focus was on the
structural barriers inherent in the health care
system. Sub-optimal adherence was seen primarily
as a consequence of a cluster of issues. These
include poor systems to support prescribing and
dispensing, insufficient and increasingly stretched
staffing levels, high costs of medicines, impaired
access to comprehensive primary health care,
lack of transportation, deficits in the level of
trust between patient and provider, complexity
of chronic disease medicines regimes, and the
failure of health services to adequately address
the issue of understanding, health education and
awareness with their clients. Adherence was also
felt to be impaired by the frequent swapping of
medicines and regimes in patients with chronic
illnesses, and the confusing labelling, packaging
and ‘look’ of some preparations of medicines.
These were thought to be important targets for
improvement by pharmaceutical companies.
The issue of inadequate communication between
different health services across the continuum of care
was identified by participants as a major impediment
to QUM for Aboriginal people. Confusion over
medication regimes was a major reason for presenting
to health services after discharge from hospital, and
was the source of great frustration and concern for
health services and patients alike. Most services
expressed that discharge information from hospitals
(particularly discharge medication information) was
usually of poor quality, slow to arrive, and often
insufficient to adequately explain future care, follow
up, medicines management and treatment targets.
This was felt to be a result of poor quality IT systems
and the inability of Primary Health Care (PHC)
services to access specialist reports, outpatient
records, hospital discharge summaries, pathology
reports, imaging studies or pharmacy records.
These barriers were further augmented by the high
14
mobility of Aboriginal people between communities
and health services, and poor communication
between service providers in different locations.
Several informants also discussed the particular
challenges in explaining, educating and supporting
behaviour change within a cross-cultural context
as an important barrier to QUM. Primarily, the
issue of commencing and continuing medicines in
patients without symptoms was seen as particularly
difficult when dealing with Aboriginal clients. In
combination with a lack of appropriate resources
for educating clients, this becomes an enormous
barrier to QUM. Of particular note, was a discussion
from respondents in the Northern Territory about
the cross-cultural understandings of ‘risk’ within
Aboriginal communities. The concept of risk is
central to our efforts in relation to chronic disease
prevention, both primary and secondary, and
forms the major component of education activities
and clinical management of cardiovascular and
related conditions. Unfortunately this concept is
not necessarily well understood by community
members, nor was it felt to be well articulated by
health staff or within health promotion activities.
These failings were considered to have important
ramifications for improving QUM and adherence
in Aboriginal people. Additional issues seen as
important, culturally-specific barriers to QUM and
articulated by participants included the tendency
for Aboriginal clients to consider themselves
‘fixed’ after hospitalisation for cardiac events,
rather than understanding the life-long medicine
and lifestyle changes required; the difficulty in
convincing patients to maintain long term medicines
regimes in the absence of overt symptoms; and
relaying that improvements in symptoms did not
mean cure in the context of chronic diseases.
Finally, the lack of Aboriginal-specific research on
QUM in general, and cardiovascular medicines
in particular, was seen as an important barrier
to identifying the most effective measures within
ACCHOs and tertiary health care services that would
improve CVD outcomes for Aboriginal communities.
Targets for action
Ultimately, there was strong support for the
Roundtable and the Heart Foundation to
develop prevention activities aimed at mitigating
Ensuring the Quality Use of Medicines among Indigenous Australians
risk among a population at incredibly high risk
of cardiovascular events. In particular, it was
considered that action across the continuum of
risk and the continuum of care was critical, but
that the greatest emphasis must remain on primary
prevention. Given the enormous burden of disease,
and the fact that much CVD goes unrecognized
until the development of an acute event,
participants felt that the development of projects
and processes that supported the identification
and mitigation of risk before a cardiovascular
event was the primary priority for action.
Despite the focus on primary prevention, there was
strong support for and recognition of the enormous
gains that could also be obtained by improvement
in secondary prevention. There was agreement
that measures to shift community levels of risk
through promotion of lifestyle changes should be
pursued; however they shouldn’t be seen as a
substitute for proven effective measures, rather as
additional, recognising the difficulties and long time
frame that are required to make sustained changes
in population risk. It was strongly felt that these
activities should be accompanied by a uniform
national and regional process of data collection
pertaining to the burden of disease and associated
risk levels, service delivery, cardiac interventions and
outcomes among Aboriginal populations to monitor
QUM and other interventions for their effectiveness.
There was strong agreement by respondents
that the pattern of shared aetiology of various
chronic diseases which directly confer vascular
risk requires that all conditions remain a target for
action. Improving CVD outcomes for Aboriginal
people necessitates that diabetes, CKD and CVD
are more appropriately and effectively identified,
managed, and prevented. Furthermore, their
contribution to vascular risk, both in isolation and
in synergy, should be a target for research, health
system reform and effective interventions. Many
respondents felt strongly that a combined approach
to ‘Vascular Risk’, incorporating these three chronic
diseases, was important not simply because of
their shared aetiology and frequently shared final
common pathway (cardiovascular events), but also
because they shared common prevention activities.
This was critical for QUM activities specifically, and
vascular prevention activities more generally.
15
The majority of respondents felt that maximising
QUM-derived gain will best be achieved through
the PHC sector and non-tertiary settings, rather
than tertiary referral hospital environments. This is
of particular importance for Aboriginal populations
who may suffer significant barriers to tertiary level/
specialist services. Importantly, there was strong
support for improving the quality of care provided to
Aboriginal patients within hospital settings, through
enhanced continuity of care, reduction in the gap
between evidence and practice, improved follow-up
of Aboriginal clients (particularly through enhanced
delivery of outpatient care within the community
sector) and the development of cardiac rehabilitation
programs for Aboriginal clients and their families.
In terms of specific targets for primary
prevention, there was strong support for a
number of projects that target Aboriginal
community interventions, including:
■
■
■
the development of interactive health
education modules for schools in Aboriginal
communities, preferably created by
Aboriginal educators and artists, aimed at
awareness of chronic diseases, and primary
prevention through lifestyle modification
promotion and funding of community sporting
activities, especially through schools aimed at
improving physical activity, with the inclusion of
intensive education about lifestyle, nutrition, diet
and smoking, possibly associated with screening
for risk and early markers of disease (e.g. RHD)
Tobacco control was seen as providing important
benefits beyond CVD conditions alone, and was
considered particularly beneficial within the context
of co-morbidity within Aboriginal communities.
Several respondents felt that the last 5 years had
witnessed enormous shifts in Aboriginal community
attitudes towards smoking, and the increasing
importance placed on smoking prevention. There
was a strong message that media campaigns
aimed at awareness and prevention specifically
targeting Indigenous communities were missing.
Importantly, most interviewees felt that there
was no need for new tobacco control measures
for Aboriginal people, rather, application of well
evaluated, trialed, established measures that has
worked successfully in mainstream Australian
populations. There was agreement however, that
these measures must be targeted, supported and
tailored to the context of Indigenous communities.
Potential efforts discussed by participants included:
■
the provision of free, or heavily subsidised,
nicotine replacement therapy (NRT)
■
the establishment of and legislative support
for workplace bans and prevention/QUIT
initiatives/smoke free houses, cars and
buildings within Aboriginal communities
■
enhanced community awareness programs
■
improved access to all available smoking
cessation supports, including medicines
and non-medicine interventions
■
the development of culturally appropriate
smoking cessation advice, support
and interventions (including the use of
multidisciplinary primary care learning activities,
supported by trained facilitators to discuss and
inform health staff of successful measures to aid
smoking cessation among Aboriginal clients)
■
generating consumer demand for smoking
cessation support though media and
community awareness activities
■
improved access to NRT in Aboriginal
communities, including single item
purchasing at community stores and
access to NRT in supermarkets.
enhanced promotion of good nutrition.
Tobacco control and vascular
health in Aboriginal communities
Of particular note, was the strong support for
prioritisation of tobacco control within Aboriginal
communities across the country. Virtually all
respondents considered tobacco control a principle
priority for Heart Foundation and Roundtable
activities into the future. Despite recognition of the
enormous level of investment that would be required
to adequately address the issue, respondents felt
that tobacco control represents an important ‘win:
win’ scenario for communities, the Roundtable,
the Heart Foundation and governments.
Ensuring the Quality Use of Medicines among Indigenous Australians
16
Public awareness programs
There was universal support to invest in processes
that improve Aboriginal people’s awareness and
understanding of the risk factors for chronic
disease (including CVD), thereby increasing
opportunities for early detection of disease,
recognising the onset of acute disease, and the
role of lifestyle changes and medicines in reducing
risk of future morbidity and mortality. This was an
activity most people felt was best supported by
the Roundtable and/or the Heart Foundation.
In particular, respondents emphasised that more
gain was likely to be achieved through community
based education and awareness campaigns
than those focused on patients in the context
of health care settings. Community awareness
was seen as better fitting with a broader target
for intervention: that is, utilising families and
communities as key support for behaviour change
and primary and secondary prevention.
The priority targets for community
awareness programs included:
■
smoking prevention, QUIT messages
■
improved diet
■
increasing exercise and the
benefits of physical activity
■
strategies for healthy living
■
utilising and promoting community strengths
and activities for health gain (e.g. recognising
and emphasising the benefits of ceremony,
dance, ‘bush tucker’ and walking)
■
outlining the potential for someone to be
at high risk of vascular disease, even in
the absence of physical symptoms
■
outlining the benefits and role of medicines in
improving people’s cardiovascular health
■
outlining steps and importance of preventing RHD
■
recognising and acting on chest pain,
and any early warning signs
■
the importance of regular ‘check ups’
■
creating demand for preventative
services and equity in care through
community awareness activities
In particular, several respondents spoke of the
potential to engage (through direct funding)
local Aboriginal organisations and high profile
Ensuring the Quality Use of Medicines among Indigenous Australians
Aboriginal personalities in the production of
high quality advertisements for Aboriginal radio,
TV and mainstream media. Quite clearly, these
could deliver a whole range of health messages
related to cardiovascular and related diseases.
One interviewee also raised the possibility of
establishing or supporting local theatre companies
to develop theatre, artwork, radio programs or alike
that discussed health education messages within
Aboriginal communities. These strategies have been
utilised in the context of community development and
health awareness within developing countries, and
may prove beneficial within Aboriginal communities.
Continuum of care
Given the significant barriers across the continuum
of care identified within the literature and throughout
interviews, actions aimed at improving QUM across
various health care settings was seen as a key
priority for support from the Roundtable. These
issues were most obvious in terms of the postdischarge management of Aboriginal patients after
an acute cardiac event or surgical intervention, but
were considered critical at all times that patients
passed from one health care setting to another.
One of the most enduring problems faced by health
care providers when dealing with Aboriginal clients
was the inadequate communication between
hospitals and health centres, and different health
centres that provide services to patients that travel
between communities. Available QUM policy and
3
responses to the RED consultation highlighted the
potential offered by single patient health records to
improve communication across the continuum, and
decrease the risk of medicine related harm among
patients with or at risk of vascular disease. This was
seen as one of several actions that may streamline
the flow of information from one setting to another.
The lack of access to cardiac rehabilitation (CR)
was also highlighted as a critical barrier to QUM
for Aboriginal people, as it was considered
an important process for improving patients’
experience across the continuum of care, and for
improving awareness and adherence to long term
medicine and lifestyle related behaviour changes.
Respondents strongly supported the development of
Aboriginal specific CR programs within the activities
of the Heart Foundation and the Roundtable.
17
Risk assessment
Developing systematic approaches to improving
the screening and early detection of vascular
risk among Aboriginal and Torres Strait Islander
peoples was considered a primary target for future
project development, research, and support from
both the Heart Foudnation and the Roundtable.
Specifically, concern with the significant underdetection of risk prior to the development of acute
cardiovascular events was a primary and recurring
theme during consultations. Most respondents
felt that the first ever documentation of existent
cardiac disease usually occurred at the time of an
acute coronary event. Clinicians in particular felt
that the majority of Aboriginal patients suffering
acute coronary disease die prior to presentation
to care, and those that do survive to hospital
have disease of significantly greater severity
than their ‘average’ non-Indigenous clients.
Respondents felt that risk identification and
comprehensive primary-care-based management
was the principle area for action in reducing the
gap between evidence and practice, which would
deliver significantly more health gain than treatment
of existent disease. Furthermore, significant barriers
to long-term and acute care necessitate the delivery
of risk assessment and management principles at
any time that an Aboriginal patient interfaces with
any level of the health system. Creating coordinated
approaches across the continuum to identification
of risk was considered critical to future activities.
Most respondents felt that these activities
were best performed within the PHC setting,
where trusting relationships were more likely to
have been developed, and where educational
messages about risk and mitigation of risk were
more likely to be successful in the longer term.
Respondents articulated strong support for
consideration - and more importantly implementation
- of assessment and management of absolute
risk of future CVD, rather than continuing with the
current approach of specific risk factor management.
Unfortunately, there were several barriers to the
application of existent measures of risk within
Aboriginal populations. Firstly, available tools
(e.g. Framingham risk equation) significantly underestimate the risk of acute cardiovascular events
Ensuring the Quality Use of Medicines among Indigenous Australians
among Aboriginal patients (particularly at young
ages). Additionally, respondents felt that currently
available tools were not comprehensive enough
to capture the multiple determinants of vascular
risk among Aboriginal populations, excluding (for
example) assessment of psychosocial factors,
socioeconomic position and renal disease. Further
still, respondents identified significant inconsistencies
between risk assessments, the need for treatment
and current PBS criteria for medicine treatment.
Finally, many interviewees in Aboriginal community
controlled primary care services felt that there was
poor integration of available risk assessment tools
with IT and other patient management systems.
Targets for an integrated approach to absolute risk
assessment in Aboriginal people should consider:
■
the adaptation of existing tools to better
predict vascular events in Aboriginal clients
■
integration of a more comprehensive
list of specific determinants of risk
■
development of easy to use risk estimation
algorithms for use specifically in the
Aboriginal primary care setting; linked to
management guidelines; and supported
by access to affordable medicines and
non-medicine risk reduction strategies
■
consideration of ‘different age-based
cutoffs’ for risk assessments
■
development, dissemination and
implementation of easy to use computer
programs and paper-based systems that
support absolute risk assessment, patient
education and patient decision making
■
development of Primary Health Care
training and IT systems for implementing
absolute risk assessment
■
incorporation of absolute risk assessment
into MBS funded Enhanced Primary Care
(EPC) Items for use in Aboriginal community
controlled and mainstream services
■
integration of Evidence Based (EB)
cardiovascular and related chronic disease
guidelines with absolute risk assessment and
management strategies (rather than focusing
on management of individual risk factors).
18
Guideline development
There was strong support for the role that guidelines
and the process of guideline development had to
play in improving health status, quality of care and
QUM within Aboriginal populations. Guidelines
were recognised as an important tool in developing
advocacy frameworks for reducing disparities
in care and outcomes between Indigenous and
non-Indigenous people with cardiovascular and
related illnesses. For all patients, ensuring the
provision of evidence based care was seen as a
pivotal component of reducing the disproportionate
burden of CVD experienced by Aboriginal people.
Unfortunately, most respondents felt that there were
far too many guidelines available, and that they often
contained conflicting protocols for management
of acute disease, and long term prevention. Most
interviews highlighted the continual growth in volume
and complexity of evidence-based guidelines,
particularly relating to complex chronic disease comorbidity. All respondents stated that there was a
critical need to improve the translation of guidelines
into clinical practice. In essence, harmonising these
guidelines (for example via development of a new
guideline, or development of a single algorithm
from existing guidelines) was considered a critical
requirement to any future success in improving QUM.
These discussions were heavily geared
towards the incorporation of ‘absolute risk’,
into any future guidelines to be developed for
cardiovascular and related chronic diseases.
Essentially, utilising absolute risk as a tool for
consolidating prevention and management
was strongly supported by respondents.
Interestingly, despite complaints about the volume
of, and often disparate guidelines available, the
primary barrier was not considered to be the lack
of knowledge of health centre staff, but instead was
described as a composite of resource limitation,
high staff turnover, staff shortages and over-work.
It was considered essential that guidelines are
developed in concert with improved dissemination
and implementation processes specifically tailored
to the needs of Aboriginal primary care settings.
Implementation priorities for consideration included:
Ensuring the Quality Use of Medicines among Indigenous Australians
■
guidelines to be accessible through and be
compatible with commonly available PHC
software packages, and patient management
and information systems to support
system based guideline implementation
■
inclusion/development of easy to follow
decision trees and algorithms that articulates
with reminder/recall systems within PHC
■
incorporation of assessment of absolute risk.
This in itself requires targeting several processes
including – development of reasonable
risk assessment algorithms for Aboriginal
populations; developing a unified approach (and
possibly a single guideline) to global vascular
risk assessment and management; decision
support (electronic or other) to implement this
approach; audit and evaluation measures to
monitor the delivery of guideline-specified care
■
guidance in information systems and data
entry support for analysis was considered
essential in implementation strategies
■
support for staff and system capacity to
implement evidence was discussed. (For
example, in the NT, the CARPA Standard
Treatment Manual has included the development
of legal frameworks to support prescribing and
is linked to ongoing professional development
activities for staff. The system is also linked to
pharmacists to support dispensing. These are
critical elements of QUM within this setting.)
Access to medicines
The principle barrier to QUM within Aboriginal
populations remains access to medicines. There
was significant discussion about the need to not
only improve physical availability of medicines
and their affordability for Aboriginal patients, but
that this must, as a priority, be accompanied
by improvements in access to comprehensive
primary care, medicine delivery devices,
specialist services and cardiac rehabilitation.
The most important step to improving access was
considered to be the lifting of S100 restrictions
to include coverage of urban based Aboriginal
medical services. Whilst this was considered
outside the scope of the Roundtable, there
was strong support for advocacy by the Heart
Foundation and Roundtable in this regard.
19
Improving access to these arrangements within
regional and urban ACCHOs would enhance equity
and widen the benefit through better access to
medicines and system level supports for QUM.
In addition, respondents felt that access to medicines
for Aboriginal clients would be enhanced through
improvements in the level of understanding of
Indigenous health beliefs by non-Indigenous health
staff. Similarly, training and resources that serve
to improve communication between Aboriginal
patients and providers (particularly in relation
to medicine and non-medicine management of
chronic disease) was supported. Unfortunately few
respondents had any specific advice about the
most appropriate methods to achieve these aims.
Patient information resources
Ultimately, the primary aim of medicines
information, as a critical component of QUM,
is to ensure that patients receive sufficient,
understandable, culturally appropriate information,
in order to effectively and appropriately use
all medicine and non-medicine therapies to
reduce the risk of illness or reduce suffering.
Clearly, there are many targets for improvement
in the format, content and methods of patient
education/information resources, particularly in
relation to Aboriginal people. This, by necessity,
should include Consumer Medicine Information
(CMI), counselling and information packs for hospital
discharge medications, medication counselling
for primary care and pharmacy services and aids
to support patients managing their medicines.
All respondents felt that there was a critical need for
the development or adaptation of appropriate patient
education materials, primarily targeted towards
common CVD procedures, medicines and lifestyle
measures to manage or prevent cardiovascular
events. The involvement of Aboriginal and Torres
Strait Islander peoples in the development of
information is essential in order to ensure that
appropriate language and imagery are used. One
interviewee commented that any information
materials would have a greater impact if they were
produced locally, using local artwork, written by
local people and containing local references.
Ensuring the Quality Use of Medicines among Indigenous Australians
Respondents felt that consideration must be given
to the broader target of medicines-information and
health education within Aboriginal communities,
particularly involving family as an important
factor in clients managing their own condition.
Respondents felt that these information sources
should be freely available within Aboriginal
primary care settings, hospitals, online, within
specialists’ rooms, outpatient departments and
in pathology and radiology settings. Principle
topics to be considered within the development
of consumer (and family) information included:
■
prevention
■
early detection of disease
■
warning signs of acute disease which
indicate the need for medical attention
■
diagnosis and treatment of CVD
■
quality use of medicines
■
side effects
■
benefits of treatment
■
rehabilitation and available
support services for CVD
■
the environmental, behavioural and
psychological contributors to risk of
heart, stroke and vascular disease.
There was unanimous support for redefining the
format and content of CMI, which were considered
to be of limited use with many Aboriginal patients
because of the type of language and concepts
used, the layout, format, cross cultural relevance,
and lack of imagery. Respondents felt that CMI and
additional medicine information should be written
in simple English, be available for insertion into
packages of medicines (in addition to usual CMI
inserts), or be developed into leaflets for handing
out to patients and their family. This will support their
use by health centre staff when educating clients,
and should be made accessible from a central
information repository online - one that can interface
with patient information systems within primary care.
This would address the issue of multiple languages
across Aboriginal Australia, as it would provide an
information template through which local service
staff and Aboriginal health workers can develop their
own culturally appropriate educational messages.
20
There was almost unanimous support for the
development of audiovisual materials, which can
supplement health education, medication information
and communication with Aboriginal clients in primary
and tertiary services. Most respondents felt that
pharmaceutical companies had significant audiovisual
resources for educating clients about disease and
disease management. It was felt that resources
that would meet the needs of Aboriginal people
had not yet been developed. Topics to be covered
could include animation or vision of pathological
processes, disease, anatomy, management (e.g.
angiography, PCI) and the beneficial impact of
medicine and non-medicine management.
Systems-based
approaches to QUM
It is clear that improving QUM within the context
of Aboriginal communities and health services
requires a sustainable systems-based approach.
This was a recurring theme throughout interviews
and from responses to the discussion document.
It was most strongly endorsed by rural and
remote primary care practitioners, pharmacists
and health service advocates involved in the
direct delivery of care to Aboriginal people with
vascular disease. Thematic analysis and synthesis
of all sources of information identified several
key elements of what could be considered a
structured systems-based approach to QUM within
Aboriginal primary care settings. These include:
■
access to medicines and nonmedicine management of CVD
■
handling, prescribing and dispensing systems
■
multidisciplinary workforce training,
education and support
■
client information resources
■
improving adherence
■
dose administration and adherence monitoring
■
monitoring and evaluating QUM activities
■
enhancing the role of allied health professionals
■
delivering outreach pharmacy
and preventative services
■
community awareness of cardiovascular
and related disease.
Ensuring the Quality Use of Medicines among Indigenous Australians
It became clear from discussions that there were
a range of critical targets for system level reform,
that were considered necessary ingredients with
which would, as one respondent termed, “Create a
culture within services that supported QUM”. These
were seen as a fundamental first step in creating the
environment in which sustainable, system based
approaches can be developed and nurtured. These
factors included: clearly articulated and accessible
financial, administrative and clinical benefits to
organisations; organisational commitment to QUM
activities; clinical and management leadership to
support QUM (‘champions’); multi-disciplinary team
environments and knowledge sharing; functional
patient information and recall systems; and improving
the creation of linkages between health services
and health sectors to improve continuity of care.
Several respondents were clear in expressing their
concern at the lack of stability and human resources
within Aboriginal primary care that are required to
adequately develop and sustain QUM. This was
identified as having important ramifications for longterm and preventative management of cardiovascular
risk. Furthermore, high staff turnover required the
development of systematic supports for QUM, to
mitigate the negative impact of staffing shortages.
There is often a reliance on the enthusiasm, drive
and expertise of key individuals within PHC settings
to develop and champion QUM (or other programs).
Reliance on key individuals often holds these
activities to ‘ransom’ upon their departure. System
based approaches were seen as a pivotal response.
Respondents felt that there was a critical QUM
skill and capacity shortage in Aboriginal services
and that improving QUM requires commitment to
improving this over the longer term. Health service
personnel felt that achieving sustainable behaviour
change among practitioners will require structured
system level supports, including computer systems
(flags, prompts for reminders of drug interactions,
prompts or alerts for possible poor adherence,
common side effects, educational resources and
links to evidence based guidelines); prescribing
software; integrated patient medicines records that
were transferable between hospital and primary care
services; decision support systems and algorithms;
and support for continuous audit and feedback
cycles via Continuous Quality Improvement (CQI).
21
There was strong support for increasing the
role of pharmacists, and specifically trained and
supported Aboriginal Health Workers within a multidisciplinary team approach to QUM improvement in
Aboriginal services. This could include consideration
of enhanced outreach pharmacist services and
improved coverage of Home Medicines Reviews,
the creation of primary care QUM facilitator
positions to support QUM systems development,
auditing, feedback and patient and staff education.
Several interviewees also mentioned the possibility
of training health workers or other community
members to be employed and supported as
pharmacy technicians within primary care services.
There were significant deficiencies identified in the
training of health centre staff in QUM principles and
their application, auditing and evaluation activities
which could be considered by the Roundtable
for future work. Respondents considered it
critical to develop adequate training programs
and structured policies and procedures that
supported safe medication management for all
personnel with any role in handling, transporting,
storing, providing, prescribing or assisting in the
administration of medicines. These resources
should consider education that supports safe
medication management for family members,
drivers, outreach workers, hostel staff, aged care
facilities, prisons and other institutional settings,
volunteers, police, alcohol and drug workers, mental
health services, shelter workers and others who
are likely to be in a position to be in contact with
Aboriginal people taking medicines for any reason.
There was also significant concern voiced in
relation to the lack of consistency and availability
of data on QUM activities and their effectiveness
within Aboriginal primary care. Standardised,
uniform data collection and evaluation protocols
could be developed (in collaboration with
other interested/relevant bodies), and would
address the gaps in evidence to evaluate
and develop structured QUM activities.
Improving adherence
Less than optimal adherence to prescribed
medications has many determinants within the
context of Aboriginal populations. These include
the asymptomatic nature of many risk factors,
poor communication between health service
providers and patients, lack of understanding
of the reasons for drug therapy, and the cost
and complexity of treatments. Accordingly, most
respondents felt that many strategies may be
required to reduce specific barriers to adherence.
Respondents outlined several targets
for activity to improve adherence to
cardiovascular medicines. These included:
■
reductions in the complexity of dosing by
prescribing and developing (where necessary)
single daily dosing when appropriate
■
ensuring the consistency of tablet colours
and shapes to avoid confusion for those
patients prescribed multiple drugs
■
development of guidelines, auditing tools and
PHC staff education ‘toolkits’ to support the
monitoring of adherence within routine practice
■
commitment to improving understanding
of cardiovascular illness and treatments at
the level of the individual and community
■
support for training of staff in crosscultural communication
■
ensure standardisation of common regimes
of treatment across varying settings, so that
providers can prescribe and patients can
expect, similar regimes across the continuum
of care. Patients expressed concern and
confusion about how they are often prescribed
multiple different brands and formulations
of the same class of drug whenever they
present to a different health care setting
■
increasing support for the involvement
of family in education and awareness
raising activities for patients with CVD.
There was strong support for the development
and release of a range of ‘POLYPILL’ preparations
(multiple drugs in a single tablet) that could be
used in the context of cardiovascular and related
chronic diseases in Aboriginal people, which share
common risk factors and common therapies. Many
Ensuring the Quality Use of Medicines among Indigenous Australians
22
respondents were well aware of the discussions
of the potential benefit of a POLYPILL preparation
in improving adherence and reducing clinical
endpoints, particularly in the context of primary
prevention of vascular disease. Many considered
that the potential for a POLYPILL approach to
CVD prevention in Aboriginal populations has
significant merit for future exploration. Unfortunately,
to date, the perceived benefit of a POLYPILL
remains theoretical, with no clinical trials of their
effectiveness and efficacy yet undertaken. This
was seen as a priority for future activity.
Research priorities
It was felt by all respondents who commented
specifically on research priorities that
there was an enormous gap in available
literature and primary research that helped
identify the most effective ways to:
■
reduce the risk of cardiovascular
and related diseases
■
improve QUM
■
sustain long term improvement in
access to necessary care
■
■
and health service trials of models of care
within Aboriginal health service settings
■
comprehensive national and regional secular data
that monitors the performance of health systems,
cardiovascular care, QUM, access to procedures
and investigations, risk factor levels and
cardiovascular conditions (particularly focused
on CAD, stroke, CHF, RHD and diabetes and
chronic kidney disease) among Aboriginal people
■
development of effective strategies to reduce
disparity in care between Indigenous and nonIndigenous patients across the continuum
■
support for community based outcomes
oriented research, particularly targeting
QUM and the prevention of CVD
■
translational research aimed at implementing
a global approach to absolute risk
assessment and management for Aboriginal
people with, or at risk of, CVD
■
achieving improved understanding of what drives
the evidence practice gap for Aboriginal clients,
and effective interventions that serve to reduce it
■
evaluation research aimed at:
increase health care funding and
equity in delivery of services
obtain data to monitor these factors
within the context of Aboriginal
communities and health services.
●
developing models of QUM that
work in Indigenous contexts
●
community based, holistic
preventative health interventions
●
developing and evaluating system based
approaches to QUM within PHC
These were felt to be the primary targets for research
around QUM and cardiovascular risk in Aboriginal
people. Importantly, respondents felt strongly that
we need not become “slaves to Evidence Based
Medicine and the Randomised Controlled Trial”, but
should develop and support naturalistic experiments
and data collection of clinical experience as well.
■
evaluation of combination or ‘poly’ pills and
assessment of the potential role of directly
observed therapy (DOT) in chronic disease
management in Aboriginal communities
■
evaluating community based, client focused
and family based smoking prevention and
cessation programs in Aboriginal communities.
More specifically, identified research
priorities included:
Research and development
targets to support QUM
among Aboriginal people
■
increasing the evidence base that serves to
directly or indirectly assess the generalisability
of clinical trial results to the specific context
of Indigenous clients with or at risk of
cardiovascular disease. In particular, assessment
of whether the magnitude of benefits are
the same; clinical trials of real-world clients
(often with multiple co-morbid conditions);
Ensuring the Quality Use of Medicines among Indigenous Australians
There were only a few targets for pharmaceutical
researcher and development (R&D) mentioned
throughout interviews and in response to the
discussion document. Principally, respondents
questioned the transferability of cardiovascular
medicine effectiveness data from clinical trials to the
real world settings of Aboriginal patients in usual
23
care. As a consequence, questions were raised
as to whether or not these medicines and regimes
could be assumed to be as effective for Aboriginal
people. The development and trialling of therapies
of importance to reducing the burden of vascular
disease in Aboriginal people should consider the
implications for this population in particular.
Furthermore, respondents felt that there was
little consideration within assessment of costeffectiveness of various medicines, of the particular
circumstances of Aboriginal people. Particularly,
this was expressed in terms of their elevated level
of risk, complex co-morbidity, and the potential
for shared benefit of interventions across chronic
diseases, barriers in access to care, suboptimal
adherence and health and social disadvantage.
This is a clear target for future work of the
pharmaceutical and research communities.
The primary ideas for R&D considered
by interviewees were:
■
assessment of the use and effectiveness of
a range of ‘bush medicines’ or traditional
pharmacopeia used by Aboriginal communities
■
assessment and consideration of the
stability of medications in extreme conditions
often faced in remote Australia (humidity,
extensive transportation in extreme
conditions, heat, dust, lack of storage,
and the lack of access to refrigeration)
■
critical need for a secured and possibly
alternative preparation of long acting penicillin for
use in the prevention of acute rheumatic fever
and rheumatic heart disease. There are a range
of barriers specific to QUM in the context of
long acting penicillin, including pain of injections,
preparation stability, bio-availability of serum
penicillin over extended periods of time, stable
supply from manufacturers and poor adherence.
Respondents would welcome R&D that supports
QUM and alternative delivery and preparations
of long acting penicillin for RHD prevention.
Ensuring the Quality Use of Medicines among Indigenous Australians
24
Future directions
There were a range of priorities identified through
the consultations for action by the Roundtable
and/or the Heart Foundation. Some of these are
not readily or easily achievable, even within the
context of significant additional investment of
human and/or financial resources. Though strongly
supported by participants, the primary prevention
of vascular and related disease among Aboriginal
communities - given the enormous impact of
poverty, disadvantage, marginalisation, health
service resource limitations and barriers to care
- seem to most respondents daunting targets for
reducing CVD. Nonetheless, these issues must,
as a priority, be addressed if we are to reduce the
burden of heart, stroke and vascular disease in
Aboriginal communities. Improving QUM in isolation
is a critical target, but without improvements in
the structural and social determinants of vascular
disease, it will not be sufficient to reduce the health
disparity experienced by Indigenous Australians.
Synthesis of the consultation process, the
available literature and guidance from Aboriginal
health services and their representatives has
determined three principle domains for activity:
■
policy development and advocacy for
QUM among Indigenous Australians
■
strategic research priorities for QUM
among Indigenous Australians
■
critical projects for QUM CVD in
aboriginal communities.
Ensuring the Quality Use of Medicines among Indigenous Australians
Policy development and
advocacy for QUM among
Indigenous Australians
■
Widening access to S100 arrangements to
include urban Aboriginal Health Services.
■
Incorporating dissemination and implementation
frameworks [including patient resources for
education, supports for QUM and methods
for implementation within Indigenous
specific primary care environments] within
all future guidelines produced by the
Heart Foundation and its partners.
■
Improving the level of engagement and
collaboration across jurisdictions and
between critical QUM partners – including
the Pharmaceutical Roundtable, Federal
and jurisdictional Departments of
Health and health services, the Heart
Foundation, NPS and key Aboriginal
organisations and their representatives.
■
Committing to and actioning the reduction
in disparities in care by improving equity
of access to and delivery of standard
care for Aboriginal people with, or at
risk of developing, vascular disease.
■
Defining, articulating and implementing
‘absolute risk’ as the cornerstone strategy to
implement individual through to population-level
reduction in cardiovascular disease burdens.
■
Developing and supporting sustainable
Systems-Based Approaches to QUM
within Aboriginal Health Services in rural,
remote and urban settings and mainstream
services across the continuum.
■
Developing and financing improved pharmacy
service models within Aboriginal Health Services.
■
Committing to and resourcing adequately
comprehensive approaches to tobacco control
for Aboriginal people and their communities.
25
Strategic research priorities for
QUM among Indigenous Australians
■
Investment in research that defines an
evidence base for smoking prevention and
cessation in Aboriginal communities.
■
Supporting the development of alternative
models of cardiac rehabilitation that better
serve the needs of Aboriginal communities.
■
Defining, explaining and reducing the
contributors to evidence-practice gaps in
the delivery of cardiovascular and related
therapies for Aboriginal populations.
■
Improving the articulation and cross-cultural
communication of ‘vascular risk’ and its
mitigation for Aboriginal communities.
Critical projects for QUM CVD
in aboriginal communities
■
Support for the conduct of research that
assesses the effectiveness of medicine
and non-medicine treatments for reducing
vascular risk in Aboriginal populations
(including the translation of the perceived
theoretical benefits of a POLYPILL approach
specifically within Aboriginal populations).
Absolute risk assessment tool and routine
implementation within primary care
■
Contribution to the evidence of effective
QUM interventions specifically designed to
meet the needs of Indigenous Australians.
■
Assessment of the costs of CVD and
related disorders in Aboriginal and
Torres Strait Islander groups.
■
Modifying, validating and implementing
absolute risk assessment and management
processes specifically designed to meet the
needs of Aboriginal people when in contact with
Aboriginal specific and mainstream services.
■
Supporting, funding and translating evidence
of community based interventions aimed
at improving QUM, primary prevention
and secondary prevention of vascular
disease within Aboriginal communities.
■
Enhance the delivery mechanisms (preparation,
adherence and primary care systems) that
improve the effectiveness of long acting
therapies aimed at preventing Acute Rheumatic
Fever and Rheumatic Heart Disease.
■
Development of, or support for, processes
that monitor the performance of health
systems (across the continuum of care),
and outline regional variations and secular
trends in levels of risk and burden of disease
for Indigenous Australians [targeting CHD,
CHF, Stroke, DM and CKD in particular).
Ensuring the Quality Use of Medicines among Indigenous Australians
The Roundtable should consider the development of
an absolute risk assessment tool for use specifically
within Aboriginal communities to support routine
and regular risk identification and management
of elevated risk of CVD. This, by necessity, must
also include the development and/or synthesis
of available evidence based guidelines, patient
education resources to aid informed decision
making, and implementation structures [prescribing
and treatment algorithms, protocols, IT interface
with existing patient information systems, that is
aligned with PBS criteria for medicine eligibility, and
tools/methods to support auditing of performance].
Patient education resources
The Roundtable should develop, as a key priority,
a range of patient information resources for use
with Aboriginal patients and their families across
the continuum of care. This should include
the development of culturally and linguistically
appropriate CMI inserts (to be used in conjunction
with available CMI), involve Aboriginal input
into the format, design and language, and
information resources to support patient and family
education about medicine and non-medicine
treatment of vascular risk (particularly aimed at
hospital discharge and within primary care).
Topics of priority include: prevention and early
detection of vascular disease; diagnosis and
management of vascular disease; the quality
use of medicines; common side effects of
medicines and likely benefits of available
treatments; and contributors to elevated
risk among Aboriginal communities.
26
Implementing a system-based approach
to QUM in Aboriginal primary care
The Roundtable should commit to the development,
dissemination and implementation of resources
that support a system based approach to QUM
within Aboriginal Primary Health Services. This
should include clarification of its elements,
articulation of what it entails and development of
resources that supports its implementation.
One potential activity could include the collaborative
development of a QUM Toolkit to support Aboriginal
services in developing and sustaining QUM
(utilising cardiovascular medicines as a template
for system wide activities). This could include:
audit and evaluation tools to assess QUM activities
within PHC services, staff training packages,
patient education resources (paper-based and
audiovisual), standardised policies and procedures
for QUM, assessment tools for monitoring
adherence to medicines, standardised data
collection templates and performance indicators,
guidelines for the development of pharmacy services
within AMS, and computer and IT interfaces.
■
funding for research to support the
development of an evidence base
that outlines effective tobacco control
initiatives in Aboriginal communities
■
awareness and prevention messages specifically
targeted towards Aboriginal communities
■
improved access (including subsidy where
necessary) to Nicotine Replacement
Therapies and non-medicine related
cessation methods for Aboriginal people
■
development of cessation advice and
methods specifically designed to meet
the needs of Aboriginal people.
Comprehensive vascular awareness
campaign
The Roundtable should commit resources to the
development of a highly visible, professionallydeveloped media campaign aimed at increasing
Aboriginal peoples’ awareness of vascular
disease and health maintenance, and creating
consumer demand for necessary care. The
primary targets for awareness include:
■
smoking prevention
Multimedia DVD development
■
healthy diet
The Roundtable should commit to the collation
(or development where necessary) of audiovisual/
multimedia educational resources across partners
into one standard resource to support the education
of patients (and families of patients) with or at risk
of vascular disease. This resource should collate
images, animation, video and written documents
that outline vascular disease processes, normal
physiology, anatomy, acute disease, long term
effects of risk factors, cardiac investigation and
management options, and benefits of medicine
and non-medicine management strategies.
■
benefits of exercise/increased physical activity
■
healthy living
■
the role of medicines in health
protection and managing disease
■
the importance of regular ‘check ups’
■
identifying acute manifestations of disease
■
supporting the notion of Strong Hearts,
Strong Family, Strong Community.
The priority topics to cover would include CHF,
CHD, Risk Factors, acute cardiac events and
stroke and would become a critical resource
to support practitioners when discussing the
identification and management of vascular disease.
Tobacco control
The Roundtable should commit to supporting and
funding sustainable tobacco control measures for
Aboriginal communities. This should include:
Ensuring the Quality Use of Medicines among Indigenous Australians
Development of a centralised repository of
QUM resources
The Roundtable should develop (in collaboration)
a website/DVD that houses evidence based
guidelines, QUM specific resources, CMI,
patient education resources, staff and patient
education tools, evidence summaries of key
messages supporting risk reduction and vascular
managements, healthy lifestyle activities, and QUM
audit tools. Furthermore, the website/resource
could act as an evidence/project effectiveness
repository for diffusing/spreading innovation in QUM
among Aboriginal services across the country.
27
Creation of an Indigenous vascular
research fund
The Roundtable should consider the creation of
(or support for) a fund that specifically supports
vascular research that improves outcomes for
Aboriginal people. Its priority targets for research
should align with those outlined in this report.
Creation of a Heart Foundation
Roundtable Indigenous Scholarship
Program
The Roundtable should consider directly supporting
the creation of medical, nursing, pharmacy, allied
health and Aboriginal Health Worker student, postgraduate and post-doctoral scholarships to support
capacity development (both QUM and vascularspecific) within the Aboriginal health sector.
QUM facilitators
The Roundtable should consider piloting an
Aboriginal Primary Care QUM Facilitator Project,
to employ/train Aboriginal health staff to audit
and develop systems based approaches to
QUM within primary care, to improve continuity
of care, and to support patient education and
the conduct of Home Medicines Reviews.
Ensuring the Quality Use of Medicines among Indigenous Australians
28
Conclusion
QUM remains central to the landscape of
Australia’s health policy, yet its application within
the context of Indigenous Australians remains
under explored. It is likely that improvement
in sustainable policy and practice in QUM will
have direct and indirect benefits for Indigenous
Australians; however, understanding the context of
ill-health and health service provision for Indigenous
populations requires undertaking a process of
identifying the unique barriers and enablers for
health gain through QUM within this population.
Ultimately, structured, sustainable, system-based
and effective interventions must be developed
if we are to implement and discern significant
improvements in outcomes for Aboriginal people
with cardiovascular and related diseases.
Anything less than such commitment will secure
and compound the unacceptable disparity and
disadvantage experienced by Aboriginal Australia.
Cardiovascular and related conditions are the
primary cause of death for Aboriginal people, and
as a consequence should be a priority target for
health system and health service reform. QUM
has a critical place within any such efforts.
There exist a range of barriers to necessary care
for Indigenous Australians diagnosed with, or
at risk of, CVD. These pertain not only to the
provision of acute life saving therapies, but extend
across the continuum of care. Improvement in
the practice of and systematic approaches to
QUM is likely to significantly improve the health
status of the most marginalized population
group within contemporary Australia.
Whilst a range of particular targets for action have
been repeatedly identified by Indigenous people
and their health care providers, action has been
slow. Improvements in access to pharmaceuticals
for Aboriginal clients have been met with the
realization that access alone is not sufficient to
ensure QUM within this context. The catalogue of
systems disparity cannot be further ignored: deficits
in data quality and auditing processes, discontinuity
between services, patient and provider education
materials, population specific epidemiological data
and risk assessment tools, resourcing, workforce
capacity and support, inadequate early detection
and management of CVD and cardiovascular
risk and the existence of gaps between evidence
based and actual practice in relation to the quality
use of medicines - all require urgent attention.
Ensuring the Quality Use of Medicines among Indigenous Australians
29
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Ensuring the Quality Use of Medicines among Indigenous Australians
31
Acknowledgements
Many thanks must be extended to the time,
passion, commitment, wisdom, experience and
service of the following people and organisations.
Sarah Shaw
Christine Latif
Traven Lea
Anushka Patel
Charlotte de Crespigny
Malcolm McDonald
Tim Leahy
Fran Vaughan
Margie Craig
Ric Day
Amanda Justice
Warren Walsh
Wendy Hoy
Peter Panquee
Kathy Broad
David Lyon
Alan Cass
Ian Ring
Vicki Wade
Andrew Bell
Jo Wright
Sophie Couzos
John Boffa
Peter Abernethy
Michael Lowe
Christine Connors
Mark Harris
Jenny Reath
Andrew Robertson
Warwick Beever
Julie Taylor
Sandy McKellar
Sabina Knight
Pius X Aboriginal Corporation
Consumers’ Health Forum of Australia
3
RED (Rob Wiseman, Anne-Marie Scully,
Hayley Caspers)
National Heart Foundation of Australia
Australian Cardiac Rehabilitation Association
National Prescribing Service
National Aboriginal Community
Controlled Health Organisation
Central Australian Aboriginal Congress
Katherine West Health Board
Council of Remote Area Nurses Australia
Centre for Remote Health (Alice Springs)
Northern Territory Department of
Health and Community Services
Central Australian Rural Practitioners Association
Menzies School of Health Research
The Australian Indigenous Doctors Association
Ensuring the Quality Use of Medicines among Indigenous Australians
32
Appendix A:
Indigenous QUM project profile collation
Quality Use of Medicine among
Indigenous Australians
The Heart Foundation is undertaking a scoping
project to identify the key issues relating to
the Quality Use of Cardiovascular Medicines
(QUCVM) among Indigenous Australians. These
priority issues would be used to inform policy
and future work by the Heart Foundation.
Any such activities would need to build on work that
has been undertaken in the area of QUCVM, and
Quality Use of Medicines in general. The initial stage
of this scoping project therefore includes the mapping
of key national QUM Indigenous health initiatives
that could provide potential points of leverage.
You have been identified through the Department
of Health & Ageing Quality Use of Medicines
initiative database as having undertaken a
project addressing Quality Use of Medicines
among Indigenous Australians. We would greatly
appreciate your input about the key aims,
outcomes and implications of your project, as
well as any recommendations for future work.
Title, Name, Surname:
Current institution/organisation (name & state):
Contact details:
QUM Project Title:
What processes or activities were used
to achieve the aims of the project?
Type of Project:
What were the key findings of your project?
Duration of Project (start year – end year):
What are the ‘real-life’ implications of your project?
Please describe if/ how your findings have been
Institution where project was undertaken:
utilised or applied by either yourself or others to
(if different to current institution)
improve health or broaden knowledge in this area.
Your role in the project:
What major barriers to achieving QUM in indigenous
Australian has your work uncovered?
Describe the hypothesis of your project in a way that
a member of the general public would understand.
Would you be willing to provide input into
future Heart Foundation activities addressing
QUM in Indigenous Australians?
What were the key aims of your project?
Please select
Ensuring the Quality Use of Medicines among Indigenous Australians
Yes
No
33
Appendix B:
Preliminary consultation
Ensuring the Quality Use of
Cardiovascular Medicines among
Indigenous Australians:
Key Directions for Policy, Research
and Practice.
In support of the aims of the consultation to
identify key barriers to achieving the Quality Use of
Medicines for Cardiovascular Diseases among the
general Australian population, the Heart Foundation
and the pharmaceutical industry (via the Heart
Foundation Pharmaceutical Roundtable) is also
seeking input on a range of issues critical to the
Quality Use of Cardiovascular Medicines among
Indigenous Australians. The purpose of the dual
consultation process is to explore synergies between
current and future mainstream and Indigenous
specific projects and policies, and to ensure that
the particular issues specific to QUM among
Indigenous Australians is given due attention.
Q1: Drawing on your expertise and experience, can
you identify barriers to access to cardiovascular
medicines for Indigenous Australians?
Q2: In relation to a number of key pillars of
Australian QUM policy (as listed below),
can you identify any targets for action for
policy or projects specific to cardiovascular
disease in Indigenous Australians?
a)
Consumer Information and Support
b)
Workforce Education and Training
c)
Improving Service Provision
to Indigenous Clients
Q3: Could you mention any activities that you
are aware of that target the QUM among
Indigenous Australians? Please list.
Q4: In your opinion, what are the major gaps in
QUCVM relevant to Indigenous Australians?
In order to achieve this, a range of activities will
be undertaken over the coming months. The
preparatory phase involves targeted interviews with
a range of critical stakeholders and informants, to
outline the scope and context of the Indigenous
specific elements of the consultation process.
We are seeking input to help develop a
consultation paper for circulation to a broader
group of policy, service and community
representatives which will be used to identify
priority projects, advocacy, and research activities
for the Heart Foundation/Pharmaceutical
Roundtable to consider into the future.
Ensuring the Quality Use of Medicines among Indigenous Australians
34
Appendix C:
Discussion document questions
CVD among Indigenous Australians
Reducing Evidence-Practice gaps
a)
i)
What are the priority areas requiring
guideline development in order to improve
CVD among Indigenous Australians?
j)
What must also be addressed in order to
ensure that guidelines are implemented in
actual clinical practice in mainstream and
Aboriginal Health Service settings?
What are the principle targets for action to
reduce the burden of CVD among Indigenous
Australians [from the identification of risk
and primary prevention; recognition and
management of acute events; secondary
prevention; and long term management]?
b) Should the Roundtable focus on all
cardiovascular conditions or are there
conditions requiring priority action?
QUM and prevention of CVD
Barriers to care
k)
What are the key QUM targets for action
by the Heart Foundation Pharmaceutical
Roundtable that will serve to reduce the burden
of CVD among Indigenous Australians?
l)
What activities are required to reduce the
rates of smoking and subsequent tobaccorelated harm among Aboriginal populations?
c)
What are the priority targets for action
to reduce the burden of CVD across the
continuum of care [Primary, Hospital,
Tertiary, and Palliative Care services]?
d) Are there particular differences between
mainstream and Aboriginal Health Services
in Urban versus rural/remote settings that will
require specific action in order to improve QUM
and thus CVD among Aboriginal people?
e)
What particular activities can the Roundtable
support to improve Aboriginal peoples
access to a full range of cardiovascular health
services across the continuum of care?
m) What are the principle targets for potential future
public awareness campaigns for Aboriginal
people diagnosed with, or at risk of, CVD?
Barriers to QUM
n)
What priority actions are required to
improve Aboriginal people’s access
to cardiovascular medicines?
Chronic disease co-morbidity
f)
What particular or unique actions does the
pattern of complex chronic disease comorbidity demonstrated among Indigenous
Australians require in relation to QUM?
o) What are the principle targets for patient
information resources for Aboriginal patients
diagnosed with, or at risk of, CVD?
Early detection and management of CVD
g) How can QUM and the Roundtable
best support the early identification
and management of cardiovascular risk
among Indigenous Australians?
h)
How can ‘absolute risk’ be tailored to the
needs of Aboriginal services and clients?
Ensuring the Quality Use of Medicines among Indigenous Australians
35
Sustainable systems
p) What are the necessary elements of
a ‘systems based approach’ to QUM
for Indigenous Australians (e.g. access
to medicines, medicines handling and
dispensing, staff education, client information
resources, dosage administration, improving
adherence, monitoring and evaluation)?
q) What are the critical workforce training, education
and support structures required to improve
QUM for Indigenous services and clients?
r)
What are the principle data/research
deficiencies requiring action in order to develop,
implement and evaluate QUM activities among
Aboriginal clients with or at risk of CVD?
s)
What are the research priorities for QUM and/or
reducing CVD among Aboriginal people?
t)
What is the role of allied health professionals
within QUM for Aboriginal clients?
u)
What is required to maximise allied health
professionals’ involvement in QUM and
to what extent will it contribute to better
outcomes for Aboriginal clients?
Improving adherence
v)
What actions will improve adherence
to cardiovascular medicines
among Aboriginal clients?
w) How can the complexity of dosage and
medicines regimes for Aboriginal people with
CVD or related chronic conditions be reduced?
x)
What are the priority targets for Research and
Development that will contribute to, or improve,
the quality use of cardiovascular [or related]
medicines or CVD among Aboriginal groups?
Ensuring the Quality Use of Medicines among Indigenous Australians
36
Heart Foundation Offices
Australian Capital Territory
Northern Territory
Tasmania
Canberra
Darwin
Hobart
15 Denison Street
Deakin ACT 2600
Phone (02) 6282 5744
Darwin Central Offices
3rd Floor 21 Knuckey Street
Darwin NT 0800
Phone (08) 8981 1966
86 Hampden Road
Battery Point TAS 7004
Phone (03) 6224 2722
Alice Springs
Shop 1, 9 Parsons Street
Alice Springs NT 0870
Phone (08) 8953 5942
Kings Meadows Community
Health Centre McHugh Street
Kings Meadows TAS 7249
Phone (03) 6336 5116
Newcastle
Queensland
North-West Tasmania
Suite 5, OTP House
Bradford Close
Kotara NSW 2289
Phone (02) 4952 4699
Brisbane
Illawarra
Rockhampton
Kiama Hospital and
Community Health Service
Bonaira Street
Kiama NSW 2533
Phone (02) 4232 0122
6/160 Bolsover Street
Rockhampton QLD 4700
Phone (07) 4922 2195
New South Wales
Sydney
Level 3, 80 William Street
Sydney NSW 2011
Phone (02) 9219 2444
557 Gregory Terrace
Fortitude Valley QLD 4006
Phone (07) 3872 2500
Townsville
Suite 7B, 95 Denham Street
Townsville QLD 4810
Phone (07) 4721 4686
South Australia
Adelaide
155-159 Hutt Street
Adelaide SA 5000
Phone (08) 8224 2888
Northern Tasmania
2nd Floor, Room 232
Community & Health
Services Centre
Devonport TAS 7310
Phone (03) 6421 7704
Victoria
Melbourne
411 King Street
West Melbourne VIC 3003
Phone (03) 9329 8511
Western Australia
Perth
334 Rokeby Road
Subiaco WA 6008
Phone (08) 9388 3343
Ensuring the Quality Use of Medicines
among Indigenous Australians:
Key directions for policy, research and practice for cardiovascular health
An initiative of the Heart Foundation Pharmaceutical Roundtable
Alex Brown • 2007
Cardiovascular disease (CVD) and related
conditions are the primary cause of death
for Aboriginal people, and as a consequence
should be a primary target for health system
and health service reform. Quality Use of
Medicines (QUM) has a critical role within
any such efforts.
This report identified a range of barriers
to necessary care for Indigenous Australians
diagnosed with, or at risk of, CVD. These
pertain not only to the provision of acute life
saving therapies, but extend across the
continuum of care. Despite QUM remaining
central to the broader landscape of
Australia’s health policy, its application within
the context of Indigenous Australia remains
under-explored.
Whilst a range of specific priority targets
to achieve health gain have been repeatedly
identified by Indigenous people and their
health care providers, action has been slow.
Improvements in access to pharmaceuticals
for Aboriginal clients have been met with the
realisation that access alone is not sufficient
to ensure QUM within this context. The
catalogue of systems disparity cannot
be further ignored: deficits in data quality
and auditing processes, continuity between
services, patient and provider education
materials, population specific epidemiological
data and risk assessment tools, resourcing,
workforce capacity and support, inadequate
early detection and management of CVD and
cardiovascular risk and the existence of gaps
between evidence based and actual practice
in relation to QUM in cardiovascular health
- all require urgent attention.
Ultimately, structured, sustainable, systembased and effective interventions must be
developed if we are to enact and discern
significant improvements in outcomes for
Aboriginal people with cardiovascular and
related diseases. Anything less than such
commitment will secure and compound the
unacceptable disparity and disadvantage
experienced by Aboriginal Australia.
www.heartfoundation.org.au
1300 36 27 87
©2007 National Heart Foundation of Australia
RES-005
ABN 98 008 419 761