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National pharmacy database project

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NATIONAL PHARMACY DATABASE
PROJECT

CG Berbatis, VB Sunderland, CR Mills and M Bulsara

June 2003

School of Pharmacy
Curtin University of Technology of Western Australia
GPO Box U1987
Perth WA 6845
C Berbatis and V B Sunderland
School of Pharmacy
Curtin University of Technology of Western Australia
GPO Box U1987 Perth
Western Australia 6845

This project was funded under the Third Community Pharmacy Agreement Research and Development Grants
Program for the project titled “Reference data base of Australia’s community pharmacies: Analysis of national
survey”.

First published in June 2003

Reference database of Australia’s community pharmacies.

Copyright School of Pharmacy, Curtin University of Technology of Western Australia GPO

Box U1987 Perth W Australia 6845.

ISBN: 1 74067 2747.

All rights reserved. This publication may be reproduced with appropriate citation and the prior
informing of the copyright owners and the authors of this report
 Table of Contents
Acknowledgements …………...……………………..………………………………………… 3
Executive summary …………...……………………..………………………………………… 4
Recommendations …………...……………………..………………………………………… 9
Contact details …………...……………………..………………………………………… 16

1. Introduction …………….……………..………………………………………… 17
1.1 Terms of Reference ………………..………..………………………………………… 17
1.2 Origins of the National Pharmacy Database Project ….………………..……… 17
1.3 Review of pharmacy surveys overseas and in Australia ………..…..……… 18
1.4 Methodology …………………….…..…………………………………………… 19
1.4.1Sample and stratification with PhARIA system ……….…………..……… 19
1.4.1.1 Difficulties with the PhARIA system for stratification ….……..………… 20
1.4.2 Participation rate ……………..…….………………………………………… 20
1.4.3 Response rate ……………..…….………………………………………… 21
1.4.4 Questionnaire ……………..…….………………………………………… 22
1.4.5 Implementation and administration of survey …….……………………… 22
1.4.6 Analysis ……………..…….………………………………………………... 23
1.4.7 National estimates …..…….………………………………………………... 24
2. Database (Term of Reference 1, disk attached) …..………………………………..... 25
2.1 Pharmacy activities, facilities, services, PhARIA and estimates …………....... 25
2.2 Pharmacy characteristics and facility/service provision ……………………..... 25
2.3 Pharmacy characteristics and barriers …..………………………………........... 26
3. (Terms of Reference 1, 2 and 5) Discussion by section ……………………........... 27
3.1 Section A Respondent pharmacist details ……………………………….............. 28
3.2 Section B Enhanced pharmacy services paid or unpaid …………………………. 33
3.3 Section C Barriers to and facilitators of enhanced pharmacy services ………. 37
3.4 Section D Prescription-related activities ............………………………………..... 39
3.5 Section E Medication review processes ............………………………………..... 47
3.6 Section F Primary health care, pharmacy and pharmacist-only medicines ……. 51
3.7 Section G Preventive services ……………...........……………………………….... 54
3.8 Section H Harm minimisation or reduction ...........………………………………... 59
3.9 Section I Complementary therapies and herbal medicines …………………….. 63
3.10 Section J Information facilities and programs ....………………………………... 66
3.11 Section K Technologies and health communications ………………………….... 68
3.12 Section L Opinion on the use of technical facilities ………………………….... 72
3.13 Section M Pharmacy and staff …………………………....………………………. 75
4. Pharmacy characteristics, facility/service provision (Term Reference 3) …………….. 83
5. Pharmacy characteristics and barriers (Term of Reference 4) 86
5.1 Barriers to extended services .…….……..…..………………….………. 86
5.2 Facilitators of extended services ………..………………..………………… 88
5.3 Opinions on technical facilities .…………….…………………..………………… 90

6. Glossary and definitions ……………………………..……………..……………………….. 92

7. Technical notes ………………………….…………..……………..………………………… 93
8. References …………………………………………………………………………………….. 94
9. Appendices ………………………….…………..……………..……………………………… 106

1
Acknowledgements
We are indebted to the 1131 respondent pharmacists, the following for their investment of
experience and expertise, many others for their valued contribution and our partners.

National advisory panel

A.Prof C Alderman Director Pharmacy, Daw Park VA Hospital, SA; delegate of SHPA
Mr R Brennan Registrar Pharmaceutical Council of WA; delegate of COPRA
Mr W Kelly Deputy CEO ; delegate of Pharmaceutical Society of Australia
Mr T Logan Pharmacy Guild of Australia; Chairman and delegate of QCPP
Dr M Ortiz Researcher, RTI Health, N Carolina, USA ; delegate of APMA
Dr P Passmore Research and Community pharmacist, South Perth, WA
Prof K Raymond LaTrobe University, Ballarat; delegate of CHAPANZ
Dr M Tatchell Director Health Economics; delegate of Pharmacy Guild of Australia,

International specialist and research pharmacists

Dr S Anderson School of Tropical Health and Hygiene, London, England
Mrs A Burns American Pharmacists Association, Washington DC, USA
A Prof L MacKeigan Faculty of Pharmacy, University of Toronto, Canada
Prof J McElnay School of Pharmacy, Queen’s University, Belfast, N Ireland
Mrs G Norheim American Pharmacists Association, Washington DC,USA
Dr C A Pedersen College of Pharmacy, Ohio State University, Columbus, USA
Mrs K Roberts Area pharmacy specialist - drug misuse, Glasgow, Scotland
Dr A Ruston Greenwich University, England
A Prof J Sheridan University of Auckland, New Zealand
Dr J.W.F.van Mijl Quality Institute for Pharmaceutical Care, Kampen, The Netherlands

Specialist and other pharmacists in Australia

Prof M Garlepp School of Pharmacy, Curtin University of Technology of W Australia
Mr J Gibson Research and Practicing Pharmacist, Nedlands, W Australia
Mr P Hannan Webstercare, Mortlake, NSW, Australia
Mr A Lloyd Pharmacy Consultant, Melbourne Victoria
Mr R Manning Chief Pharmacist, Tiwi Islands, NT, Australia
Mr P Muhlheisen Turning Point Alcohol and Drug Centre, Fitzroy, Victoria
Debbie Rigby Consultant Pharmacy, Pharmaceutical Society Australia (Q)
Mr A Saunders Health Communication Network, Melbourne, Victoria
Mr K Sclavos Chairman QCPP 2001, Pharmacy Guild of Australia (Queensland)
Ms H Stark Formerly ACNielsen Consult, Sydney, Australia
Mr G Stevens Webstercare, Mortlake, NSW, Australia

Focus group and pilot test pharmacists

Mr F Grapsas Kardinya Park Shopping Centre Pharmacy, W Australia
Mr G Lowe 7 Day Pharmacy, Leeming Shopping Centre, Leeming, W Australia
Mr D Manuel Amcal Pharmacy, Tuart Hill, W Australia
Mr P Rees Amcal Chemist, Westfield Shopping Centre, Innaloo, W Australia
Mr M Rollings Pharmacity Chemist Supermart , Perth, W Australia
Mr L Souness Guardian Pharmacy, East Victoria Park (medical centre), W Australia

Mrs M Bou-Samra Pharmacy Guild of Australia, Queensland

Mr R Cox Terry White Chemists, Buranda, Queensland
Mrs S Forrester Soul Pattinson, Palmerston, NT
Ms R Guastella Mount Hospital Pharmacy, Perth
Ms S Holzberger School of Pharmacy, University of Queensland
Mr B Horsfall PSA, Victoria
Ms A Hudson Bob Willis Chemist, NSW
Ms J Kagi Boulevard Pharmacy, Mt Newman, W Australia

2
Ms A Legg Riverview Pharmacy, NSW
Mr K O’Connor Wishart Pharmacy, Queensland
Mr B Moffatt Manley, NSW
Mr S McCahon Amcal Chemist, Kalgoorlie, W Australia
Mrs L Rushton Mayne Pharmacy, Blacktown, NSW
Ms H Stark Seaforth Pharmacy, NSW

Others who assisted exceptionally

Mr G Bridge QCPP, Pharmacy Guild of Australia, Barton, ACT Australia
Mr A Daniels Australian Pharmacist, Deakin, ACT, Australia
Mr P Dragovic Danica Graphic Design studio, Bayswater, W Australia
Mrs C D’Costa WPO-Receptionist, School of Pharmacy, Curtin University
Mrs D D’Souza Administrative Co-ordinator, School of Pharmacy, Curtin University
Mr M Eton Australian Journal of Pharmacy, Sydney, NSW, Australia
Ms J Gilson RN National Pharmacies, Adelaide, South Australia
Ms V Graham Survey Research Centre, University of Western Australia
Mr B Langham Sign Multimedia, Perth, Western Australia
Dr A Rossouw Survey Research Centre, University of Western Australia

This project was funded by the Commonwealth Department of Health and Ageing as part of
the Third Community Pharmacy Agreement.

The Pharmacy Guild of Australia as managers of the Third Community Pharmacy Agreement
Research and Development Grants (CPA R&D Grants) Program.

3
Executive Summary
Background
Up to 2002 there was no database of the nature and frequency of general or specialist health-
related activities performed in Australia’s community pharmacies. Without such a database
accurate time-series comparisons of changes occurring in pharmacy practice could not be
made. Pharmacy practice could not be compared with that in other countries. Pharmacy’s
activities could not be measured against Australia’s health priorities. Those making plans or
policies for undergraduate or continuing pharmacy education or training were doing so with
limited data on the pattern and trends of activities in pharmacy practice. National professional
bodies had little idea of the relative utility of the various drug information resources, the
incursion of the internet in pharmacy or even the utilisation of the telephone in pharmacists’
day-to-day communication. These same bodies and state boards wishing to make
submissions on legislative changes to government agencies or Parliamentarians had little
reliable data on the duty of care activities pharmacists do but do not actually report.
Negotiators in the pharmacy-government agreements were often data-poor on fundamental
statistics of the settings of and areas within pharmacies, the characteristics of pharmacy
owners and staff, the composition of national pharmacy sales, let alone the high prevalence of
dose administration aids (DAAs) and the nil fees for DAAs or supervised dosing in
pharmacies. Students or outside parties had no single reference to the range and frequency
of the health-related activities involved in contemporary pharmacy practice in this country.
The construction of a database of community pharmacy practice in Australia together with
data from other sources may partly overcome some of these deficiencies particularly if it is
updated regularly like Australia’s five-yearly national health surveys.
The ‘National Pharmacy Database Project (the ‘project’) officially commenced in January
2002. The national survey of community pharmacies was conducted from 12 July to 9
September. The resulting frequency data were compiled and summarised from September to
November 2002. The results were analysed from January to April 2003. The report was
completed during May and June 2003.

Aims
The terms of reference or aims of the project were :
1. To construct a national database of the most important types and rates of pharmacy
characteristics including facilities, health-related general and specialised including
preventive services in Australia’s community pharmacies for Australian and overseas
reference or comparisons;
2. To make comparisons between pharmacies in the different PhARIA zones;
3. To test relationships between pharmacy characteristics and facility/service provision;
4. To test relationships between pharmacy characteristics and barriers to facility/service
provision; and
5. To make national estimates of a range of pharmacy services and facilities.

Method
The sample of pharmacies was adequate to meet statistically defined margins of error with
prevalence rates of pharmacy services or facilities down to 1%. The PhARIA (i.e. the physical
and professional remoteness of pharmacies within Australia) was used to stratify to ensure
adequate numbers of rural and remote pharmacies. To overcome the skewness due to the
large bulk of pharmacies in Pharia 1, a 20% random of pharmacies in Pharia 1 and a total
sampling of all pharmacies in Pharias 2 to 6 was done. A questionnaire was developed with
most of the 33 questions and 240 items of data requiring numerical data with which statistical
estimates could be made adding a crucial quantitative value. The questions reflected a
balance of the core general and special activities growing in Australia’s pharmacy practice .
These were largely based on demographics trends, changes made to national health policies
since 1997 often arising from results produced by pharmacy researchers, the occurring in this
country and an inexorable evolution in pharmacy practice proceeding overseas and in
Australia. The questionnaire was designed by a professional graphics artist and reflected the

4
contemporary requirements by the pre-eminent survey methodologist, Professor Don A
Dillman. The implementation of the survey closely followed Dillman’s mixed mode survey
guidelines and was conducted and analysed independently by the University of Western
Australia’s Survey Research Centre and its Biostatistician. A 91% participation and over 81%
response rates were achieved hence non-respondent bias was minimal. A website was
constructed which for the first time in Australian pharmacy research posted results for the
participant pharmacies to observe whether they worked furthest north in the Tiwi Islands on
the coast of the Great Australian Bight to the south-west.

Results
The following table summarise the key findings in the following sections A to M following and
the Sections 4 and 5 which analysed statistically the strength of relationships between
pharmacy variables and the activities in community pharmacies. Details may be found in the
attached database.

Table 1. Key findings from the database : for Term of Reference 1,2.3 -
Section Title Key Findings
A. Respondent pharmacist • Respondents were mainly male with
details. one-third aged greater than 50
years.
• Pharmacies outside Pharia 1 have
fewer female, and also older and
less qualified staff.
• Each respondent group reported
much higher continuing professional
education (CPE) hours than their
counterparts in Great Britain.

B. Enhanced pharmacy services. • All 24 nominated enhanced

C. Barriers and facilitators of
enhanced pharmacy services.
pharmacy services were
represented to some degree in
Australia’s community pharmacy.
• Enhanced services with trained staff
were evident at high levels for
asthma, diabetes, harm reduction,
herbal medicines, hypertension,
smoking cessation and wound care.
• Attention should be given to the
promotion of weight reduction
services as has already occurred for
wound care.
Many of these enhanced services were
provided with trained staff at no charge.
Greatest barriers were:
• lack of time (90.3%), shortage of
pharmacists (78.3%), no extra
remuneration (63.3%) and cannot
find locums (63.2%).
Greatest facilitators were:
• dedicated study time (77.9%)
accreditation (75.6%), closed
counselling areas (72.8%) and
access to patient notes (70.6%).
• The combined resistance and
uncertainty were “appointment
systems” and “clinical testing area.”

5
D. Prescription related activities in • Dose administration aids were
community pharmacies. issued to 9.19 million patients
annually.
• Supervised administration of
individual doses included a range of
analgesics, benzodiazepines,
methadone, buprenorphine and
psychotropic agents and occurred in
community pharmacies for 25,904
patients each week.
• Community pharmacists declined to
dispense 1.075 million prescriptions
annually due to dosages,
interactions, adverse effects or other
problems.
• Counselling occurred in private
locations in the pharmacy on 14.42
million occasions annually.
• CMI computerised formation was
provided on 6.76 million occasions
and other written or printed drug
information to 8.61 million patients
annually.
• 3.71 million patients annually
required special counselling owing
to poor English language.
• compliance interventions by
community pharmacists were
recorded on 14.42 million occasions
annually.

E. Medication review process • 53.7% of community pharmacies

provided medicines to aged care
facilities and 50.8% were approved
for domiciliary medication
management reviews.
• At least 4,600 patients received one
of a range of medication reviews by
community pharmacists each month.
• Most of these reviews were carried
out by a contracted consultant
pharmacist.

F. Primary health care including • 78.2 million consultations occurred

pharmacy and pharmacist only annually in community pharmacies
medicines regarding health and medications.
• At least 4.19 million patients
annually were referred to GPs and
1.77 million to other health workers.
• Misuse of S 2 and S 3 medicines
was suspected in 0.863 million
patients and supply refused on
0.631 million occasions annually.
• Computerised or Self-Care printed
information was provided to patients
on 10.26 million occasions annually.

6
G. Preventive services • 82% of Australia’s community
implemented in this pharmacy pharmacies had a dedicated vaccine
refrigerator.
• Primary prevention actions initiated
by community pharmacists were
annually: 1.452 million nicotine
treatments, 0.687 million low-dose
aspirin , 0.739 million iron
for anaemia, 0.576 million folic
acid in pregnancy, 0.869 million
calcium for osteoporosis.
• 385,288 screening tests were
conducted annually in pharmacies
for undiagnosed chronic conditions
and 25,081 pregnancy tests were
performed.

H. Harm minimisation services • More than 40% of pharmacies are

and detected S4 and S8 active in each of methadone or
forgeries and doctor shopping buprenorphine dosing and needle
in Australia’s pharmacies exchange.
• 18.8% are active in benzodiazepine
or other prescriber contracts.
• 13,519 clients with forged
prescriptions and 23,391 patients
were identified as “doctor shoppers”
annually.

I. Complementary therapies • Community pharmacies refer 44,044

including herbal medicines clients monthly to complementary
practitioners
• Highest referrals were for
naturopathy and homeopathy.

J. Information facilities and • The following information sources

programs were used with a daily frequency in
pharmacies in Australia:
CMI Computerised 23202
CD ROMs (APP/MIMS) 20212
PSA Self Care 11867
MIMS or APP books 10709
AMH 6126
APF 4969

K. Technologies and health • 89.2% pharmacies had a computer

information and with a Pentium processor and 39.8%
communication used the internet and 40.8% email
regularly.
• On average each pharmacy
contacted doctors 3.73 times daily,
patients or their carers 1.95 times
and other health workers 0.68 times
daily by telephone.
L. Opinion on the use of technical • Telephone was strongly agreed to
facilities be the best mode of communicating
with doctors, patients and carers.

7
 • There was some concern that
privacy legislation restricted
telephone communication.
• There is a greater concern that
internet sales will depress OTC
prescriptions by 2004.

M. Pharmacy and staff • The majority of pharmacies are

located in a shopping strip and are
open on average 6.18 days and 55.5
hours per week.
• 50.5% of pharmacies are members
of a wide range of “groups”.
• 54.1% of pharmacies responding
were QCPP accredited.
• 57.2% have one owner and 9.6%
have 3 or more owners and 39.5%
owners are aged over 50 years.
• The majority of proprietors work
hours was spent in the dispensary.

Pharia . Pharmacies in Pharia zones 5 and 6 consistently ranked low in the provision of a
range of services but these results need to be standardised for customer flow and other
variables.

Relationships with enhanced (specialised) pharmacy services - Term of Reference 4

Of the pharmacy variables tested the provision of enhanced and certain other services by
pharmacies was consistently and significantly related to the individual characteristics of
turnover, pharmacy size and group membership. But regression analysis is required to
control for effect modification and confounding variables.

Relationships with barriers and facilitators of pharmacy services - Term of Reference 5

For the provision of enhanced pharmacy services Pharia zone location was significantly
related individually to a number of barriers including shortage of time, shortage of
pharmacists, availability of locums, remuneration and opportunity to meet local GPs. But
regression analysis is required to control for effect modification and confounding variables.
For the provision of enhanced pharmacy services QCPP status was significantly related
individually to facilitators including access to patient notes, clinical testing area, appointment
system, and accreditation for these services. . But regression analysis is required to control
for effect modification and confounding variables.

8
Recommendations
The following recommendations refer to a section and a table in the report with related
evidence. The national and state bodies of pharmacy recommended to implement the
recommendations are listed in the glossary (Section 7).

METHODOLOGY
Recommendation 1: Australia’s community pharmacies were stratified in a national survey for
the first time according to the PhARIA zones 1 to 6 (Section 1.4) . Approximately 81% of
Australia’s community pharmacies are in PhARIA zone 1 which skewed the sampling process
and required much larger samples than planned , much more work and higher costs than
budgeted were required to overcome the difficulties (Section 1.4.1.1) .
Systems other than the PhARIA system should be carefully evaluated for stratification
purposes in future national surveys of community pharmacies. For example, the Socio-
Economic Indexes for Areas (SEIFA) system should be compared with the PhARIA for
stratification.

Recommendation 2: It was found many pharmacies in the lists of registered pharmacies

provided by state pharmacy authorities were invalid because they were no longer operating,
were not community pharmacies, were duplicated, or had operated for a fraction of the whole
year (Section 1.4.2) . During the 12 months ending 30 June 2002 it was found just 4447
approved pharmacies operated for the full 12 months (Section 1.4.7) . This total is much
smaller than the total number of 4824 pharmacies in the pool from which the samples were
drawn and smaller than previously reported national totals of pharmacies. This caused
unnecessary difficulties for calculating the national estimates.
In order to make accurate national estimates the months of operation of pharmacies in the
subject year should be included in future questionnaires to accurately ascertain the number
of full time equivalents of community pharmacies operating during the survey period.

Recommendation 3: For a number of the questions the results were skewed requiring various
statistical adjustments (Section 1.4.7) . With respect to analysis by Pharia zone the results
obtained in this survey provide reference values for a range of questions.
If the PhARIA system is applied to future national surveys using a similar questionnaire, then
a) the two separate best estimates should first be calculated for the results of pharmacies in
PhARIAS 1 and PhARIAS 2-6 so that the corresponding future questions reflect the ranges
of results around the respective best estimate; and b) that separate pilot surveys of Pharia 1
and Pharias 2-6 pharmacies be conducted with questionnaires reflecting ‘regular’ ranges of
estimates around the respective best estimate means in a) above.

Recommendation 4: Many questions in the questionnaire contained the terms “number of

clients” or “number of patients” in relation to prescription-related activities (Section 1.4.7) .
These terms need to be standardised to “number of dispensing occasions” . This requires a
number of key parameters.
To facilitate more accurate national estimates of the activities occurring in Australia’s
community pharmacies the national bodies of pharmacy should arrange to obtain from the
Drug Utilisation Sub-Committee in the Department of Health and Ageing (a) the mean
number of items dispensed per dispensing occasion, (b) the percentage of repeats per
dispensing occasion and (c) the percentage of prescription items dispensed for
institutionalised non-ambulatory patients.

DATABASE RESULTS

Recommendation 5: Pharmacy respondents reported they spent a minimum of 6.8 hours per
month on continuing pharmacy education activities which appears to be at least twice the
level reported by pharmacists in Northern Ireland and England (Section 3.1, A). It was difficult
to compare continuing pharmacy education activities from statistics reported by interstate and

9
overseas bodies of pharmacy. Standardising these activities would expedite more accurate
time-series, interstate and international comparisons . Refer Section 3.1, Table D-A1.
National and State pharmacy bodies in Australia should cooperate to standardise and report
continuing pharmacy education activities by the hours per month spent in these with
appropriate weighting of the activities by representative samples of pharmacists. These
bodies should verify the higher levels of continuing pharmacy education activities reported by
Australian pharmacy respondents compared to UK pharmacists because of the important
implications for the remuneration of pharmacy services .

Recommendation 6: The levels of enhanced pharmacy services reported by community

pharmacies do not reflect Australia’s official priorities in health (Section 3.1, B). Refer Table
D-B7-1.
National and State bodies of pharmacy and university departments of pharmacy should
emphasise the teaching of enhanced pharmacy services by reference to Australia’s national
health priorities (Section B).

Recommendation 7: The marked differences in the enhanced pharmacy services reported

by community pharmacies with trained staff may reflect interstate differences in the training
programs available for enhanced pharmacy services (Section 3.1, B). Refer Table D-B7-1.
National and State bodies of pharmacy should cooperate to produce and adopt nationally
standard pharmacy training programs for enhanced pharmacy services.

Recommendation 8: There was no obvious relationship between fees charged by pharmacies

for enhanced pharmacy services and the availability of trained staff for these services
(Section 3.1, B). Refer Table D-B7-1.
National and State bodies of pharmacy should plan the systematic evaluation of enhanced
pharmacy services to determine the basis for and level of their remuneration by pharmacies
with trained staff.

Recommendation 9: Wound care is an outstanding example of an enhanced pharmacy

service which is practiced by trained staff in a comparatively high percentage of Australia’s
pharmacies and is growing at a high rate (Section 3.1, B). Refer Table D-B7-1.
National and State bodies of pharmacy should assess the training programs and promotional
methods used for the remarkably successful adoption of wound care services in pharmacies
for their application to other enhanced pharmacy services which emphasise Australia’s
national health priorities.

Recommendation 10: Many enhanced pharmacy services were reported from low
percentages of pharmacies in PhARIA zones 5 and 6 where many under-privileged
Indigenous Australians reside (Section 3.1, B). Refer Table D-B7-1.
National and State bodies of pharmacy should produce suitable intensive training programs
for enhanced pharmacy services to be implemented and/or made more accessible to
pharmacists working in pharmacies in PhARIA zones 5 and 6.

Recommendation 11: Pharmacies reported the serious barriers to performing enhanced

pharmacy services were “lack of time”, “shortage of pharmacists” and “no extra remuneration”
(Section 3.1, C). Pharmacies agreed that enhanced pharmacy services were part of their
work. Refer to Table D-C8.
National and State bodies of pharmacy should investigate and produce intensive structured
training programs for specific enhanced pharmacy services most likely to be remunerated in
order to overcome the reported barriers to their adoption by pharmacies .

Recommendation 12: The facilitators reported by pharmacies for performing enhanced

pharmacy services were “dedicated study time”, “accreditation”, “closed counselling areas”
and “access to patient notes” (Section 3.1, C). Refer Table D-C9.
National bodies of pharmacy should promote remunerated, accredited programs for
enhanced pharmacy services and closed counselling areas and access to clients’ clinical
histories for increasing the adoption and competent performance by community pharmacies

10
of enhanced pharmacy services in order to respond to those factors pharmacies reported as
likely to facilitate their implementation of these services.

Recommendation 13: High percentages of Australia’s community pharmacies reported the

weekly provision of dose administration aids and supervised dosing without charging (Section
3.1, D). Refer to Tables D-D11A and D—D11c.
National bodies of pharmacy should organise and publicise the cost-effectiveness evaluations
of the provision of dose administration aids and supervised dosing by pharmacies in order to
establish acceptable remuneration for these services. University departments of pharmacy
should emphasise the benefits and procedures of dose administration aids and supervised
dosing in the routine teaching of pharmacy practice.

Recommendation 14: Approximately 40% of Australia’s pharmacies declined dispensing

prescription drugs for at least one patient weekly because of inappropriate drug, dose or
suspected interaction or contraindication, or for prescription defects (Section 3.1, D). Another
30.7% of pharmacies declined dispensing prescription drugs for at least one patient weekly
for suspected adverse drug effects. Overall, 1.25% of patients dispensed 216 million
prescription items yearly were reported to have had their prescribed medications declined for
the above reasons. Refer to Table D-D12.
The reported rates of pharmacies intervening in the dispensing of prescribed medicines
should be verified by direct observation in a representative sample of pharmacies and
submitted to pertinent agencies by national bodies of pharmacy because they provide strong
evidence for the vigilance by pharmacies in preventing the inappropriate prescribing and
adverse effects of prescription medicines and detecting legally defective prescriptions.

Recommendation 15: Community pharmacies reported counselling in the past 12 months a

minimum of 3.17 million patients with low or poor English speaking ability about their
prescription medicines (Section 3.1, D). Refer to Table D-D13a.
National bodies of pharmacy should verify the extent and evaluate the provision of
counselling to patients with poor English speaking ability for prescription-related activities so
that community pharmacies are adequately remunerated for providing this service.

Recommendation 16: Low percentages of Australia’s community pharmacies reported the use
of clinical testing and the application of laboratory results to the assessment of the effects of
prescribed drugs in patients (Section 3.1, D). Refer to Table D-D13c.
National bodies of pharmacy should investigate and produce software programs for
interpreting laboratory results in routine pharmacy practice to enhance the evaluation of
effects of prescribed medications .

Recommendation 17: Relatively low percentages of community pharmacies reported

performing primary care multidisciplinary care plans, case conferences or case health
assessments compared to the percentage performing home medicine reviews (HMRs) or
medication management reviews in residential age care facilities (Section 3.1, E). Refer Table
D-E14d.
National bodies of pharmacy should consider programs for enhancing the ability of accredited
pharmacists to participate in primary care medication review processes to enhance their wider
adoption by community pharmacies.

Recommendation 18: Pharmacies reported that the rate of self-medication activities for the
management of minor ailments for clients was less than the provision of primary health care
activities including issuing over the counter medications, verbal and printed information and
referral to GPs and other health workers (Section 3.1, F). This ratio of self-medication to
primary care activities appears to be less than found in pharmacies in other developed
countries. This has strong implications for the control of pharmacist-only and pharmacy
medicines and the education and training of student and graduate pharmacists and pharmacy
staff. Refer Table D-F15a.
National bodies of pharmacy need to verify by direct observation the ratio of self-medication
and primary health care activities occurring in a representative sample of community

11
pharmacies in order to compare with results from pharmacies in other countries and to make
time-series comparisons in Australia .

Recommendation 19: Pharmacies reported estimated yearly totals of 36.97 million self-
medication and 41.23 million primary health care activities (Section 3.1, F). These statistics
far exceeded those reported for pharmacies by the 2001 National Health Survey .These
services do not currently attract remuneration for pharmacies. Refer to Table D-F15a.
National bodies of pharmacy need to verify the statistics and organise cost-effectiveness
evaluations of self-medication and primary health care activities in Australia’s pharmacies in
order to accurately represent the magnitude of the national contribution to health care by
pharmacies , the potential costs savings to Australia’s health system and the possible
remuneration of community pharmacy services .

Recommendation 20: Pharmacies reported an estimated 4.19 million clients yearly with
ailments were referred to GPs compared with 1.77 million referred to other health workers
(Section 3.1, F). Refer to Table D-F15a.
National bodies of pharmacy should verify the high rates of referrals of clients with health
ailments by pharmacies to general practitioners and organise the evaluation of referral forms
in pharmacies in order to quantify and lay the basis for remunerating referrals by pharmacies.

Recommendation 21: Pharmacies reported an estimated 10.26 million clients yearly with
health ailments were provided with printed information (Section 3.1, F). Printed information is
a widespread form of conveying health information and needs to be evaluated singly and in
combination with other methods in order to quantify their impact on specific health outcomes.
Refer to Table D-F15a.
National bodies of pharmacy should plan the cost-effectiveness evaluation of printed
information provided in pharmacies for clients with health ailments.

Recommendation 22: Pharmacies reported an estimated total of 0.86 million clients yearly
were suspected of misuse of dependence-producing over-the-counter medicines of whom
0.63 million were refused supply of these medicines (Section F). Refer to Table D-F15b.
The high rates of intervening in the supply of over-the-counter reported by pharmacies
should be verified and submitted to pertinent agencies by national bodies of pharmacy
because they provide strong evidence for the vigilance by pharmacies in preventing the
misuse of over-the-counter medicines.

Recommendation 23: 82% of Australia’s pharmacies reported having vaccine refrigerators

which comply with pharmacy standards (Section 3.1, G). Refer to Table D-G16.
National bodies of pharmacy should ascertain the standards of vaccine refrigerators used in
pharmacies nationwide for their compliance with recognised standards.

Recommendation 24: Pharmacies reported that they initiated non-prescribed medicines for
preventive purposes in more than 5.8 million undiagnosed clients over 12 months (Section
3.1, G). Refer to Table D-G17.
National bodies of pharmacy should obtain further statistics on and plan a cost-effectiveness
evaluation of pharmacies in providing non-medically prescribed medicines for preventative
purposes.

Recommendation 25: Clinical testing for screening undiagnosed patients were reported to
occur in pharmacies which engaged nurses at rates of 2- to 20-fold those of pharmacies
which did not engage nurses (Section 3.1, G). Refer to Table D-G19.
National bodies of pharmacy should identify those pharmacies which engage nurses to
provide screening activities to undiagnosed patients and organise economic evaluations of
these in order to compare the performance of these activities with those pharmacies which
do not engage nurses.

Recommendation 26: Up to 60% of Australia’s pharmacies reported providing harm reduction

activities daily including methadone or buprernorphine dosing, needle supply and issuing
benzodiazepines and other drugs according to patient contracts with prescribers (Section 3.1,

12
H). Australia’s pharmacies rank high internationally in the provision of these services and
studies have found these services are widespread, less costly and more or equally effective
compared with other providers. Refer to Table D-H19a.
National bodies of pharmacy should examine the systematic and appropriate remuneration of
pharmacies active in supervised dosing, prescriber contracts and other harm reduction
services.

Recommendation 27: Pharmacies reported detecting a minimum estimated 13,519 patients

with forged prescriptions and 23,391 ‘doctor shoppers’ in the previous 12 months (Section
3.1, H). These appear to be the highest rates of detecting forgery and ‘doctor shoppers’ of
prescribed opioids and psychostimulants ever reported by pharmacies. Refer to Table D-
H19b.
National bodies of pharmacy should verify the above rates of detection of fraudulent
prescriptions for Schedule 8 drugs as they suggest high vigilance in pharmacies in dispensing
these agents or/and very high rates of Schedule 8 prescription fraud in Australia.

Recommendation 28: Australia has very high rates of the consumption of prescribed opioids
and psychostimulants compared with other developed countries. Reports of illegal or
deceptive procuration, diversion and misuse of these agents imply existing legislation is
defective in allowing pharmacists prevent these malpractices (Section 3.1, H) . Limiting the
source of these agents to a single medical and pharmacy provider and facilitating the online
access by pharmacies to the medication histories of these patients before dispensing are the
most effective actions for pharmacists to stem the misuse of prescribed Schedule 8 agents.
National and State bodies of pharmacy should immediately press for legislation requiring
patients prescribed Schedule 8 drugs to be limited to one medical and one pharmacy
provider of these agents and permit medication histories to be accessed online and discussed
by these providers prior to dispensing of these drugs.

Recommendation 29: Pharmacies reported they referred more than 40,000 clients per 30
days to complementary therapists (Section 3.1, I). Refer to Table D-I20.
The Pharmaceutical Society of Australia should include guidelines in the Australian
Pharmaceutical Formulary and Handbook for the referral of clients to complementary
therapists.

Recommendation 30: Pharmacies reported that they referred approximately 15,000 clients
per 30 days to aromatherapy, homeopathy and iridology practitioners (Section 3.1, I). Refer to
Table D-I20.
Pharmacy Boards in each jurisdiction, the Council of Pharmacy Registering Authorities, the
Pharmaceutical Society of Australia and University departments of pharmacy should identify
and where necessary act decisively on the referral of clients to questionable complementary
practitioners.

Recommendation 31: High percentages of Australia’s pharmacies reported the daily use of a
wide variety of information, facilities and resources for patient care (Section 3.1, J). Refer to
Table D-J21.
National bodies of pharmacy should formulate standard methods for comparing the frequency
of use and the cost-effectiveness of outcomes of information resources in pharmacies applied
routinely in practice to patient care.

Recommendation 32: Just 7.8% of Australia’s pharmacies reported daily or higher use of
web-based drug information facilities (Section 3.1, J). Refer to Table D-J21.
The Pharmaceutical Society of Australia and University departments of pharmacy should
review their teaching and training programs for pharmacy students and practitioners to ensure
the convey the superior benefits of web-based facilities compared with other forms of drug
information facilities in patient care.

Recommendation 33: 89.2% of Australia’s pharmacies reported Pentium processors but just
4.2% reported having broadband facilities in their dispensary computers (Section 3.1, K). The
technological requirements for dispensary computers are changing rapidly in relation to

13
pharmacies participating in the MediConnect system planned to be introduced in 2005. Refer
to Table D-K22a
National bodies of pharmacy should ensure the results of ongoing MediConnect trials in
pharmacies are appropriately promoted so pharmacies can rationally plan to install the correct
computer facilities and enhancements in readiness for participating in the MediConnect
system.

Recommendation 34: More than 10% of pharmacies reported they had web sites which
offered medication-related activities (Section 3.1, K). Refer to Table D-K22b.
The Pharmaceutical Society of Australia and pertinent bodies of pharmacy should organise
an evaluation of existing pharmacy websites against the Australian Pharmaceutical Formulary
and Handbook and other appropriate standards .

Recommendation 35: 34.3% and 24.4% of pharmacies reported they expected respectively
internet sales of over-the-counter and prescription medicines would depress their sales of
these medicines by 2004 Joint actions have been taken in 2003 by national bodies of
pharmacy in the USA and Canada on the basis of safeguarding consumers from preventable
adverse effects of drugs obtained through the internet(Section 3.1, L). Refer to Table D-L24.
National bodies of pharmacy should review actions taken in North America to curtail the
internet sale of prescription medicines by pharmacies and other sources.

Recommendation 36: 93.1% and 75.7% of pharmacies agree respectively the telephone is
the best form of technology for liaising with doctors and patients about health care (Section
3.1, L). Telephone counselling has proven for two decades to be the most cost-efficient
technology in improving the care of patients with chronic disorders. Refer to Table D-L24.
National bodies of pharmacy should plan controlled studies of telephone counselling by
community pharmacies in for example patients discharged with treated mental disorders who
are known to have high rates of relapse and readmission into hospitals.

Recommendation 37: The most common settings of pharmacies were city, suburban or town
shopping strips (41.4%) , followed isolated shops (23.5%) and 18.7% in neighbourhood, 6.3%
in medical and 4.8% in regional shopping centres (Section 3.1, M). The locations and hours of
opening of pharmacies are important for assessing changing patterns in the location of
pharmacies and accessibility to pharmacy services by consumers but it is difficult to ascertain
these factors because of the lack of standard definitions and the lack of information on the
hours of opening and pharmacy settings. Refer to Tables D-M25b and D-M25c.
The Pharmacy Guild of Australia and other national bodies of pharmacy should agree on
standard definitions for the locations of pharmacies and appropriate methods of weighting
access to these locations by the public .

Recommendation 38: The retail, storeroom and dispensary section were the largest in area
and enclosed counselling and forward pharmacy sections the smallest (Section 3.1,M) .
These data are the first known national data on the internal arrangement of pharmacies and
have important ramifications on the performance of certain services ( Sections 3.1 C, F and
H). Refer to Table D-M26.
The Pharmacy Guild of Australia and other national bodies of pharmacy should agree on
standard definitions for the analysis of sections in pharmacies and perform surveys of
representative samples of pharmacies in order to monitor the trends in the internal structures
of pharmacies.

Recommendation 39: Owners and managers reported they spent up to 30.9 of their 41.7
hours per week in dispensaries and 21% of Australia’s pharmacies reported having non-
pharmacist retail managers (Sections 3.1,M) . These are important indicators of the
involvement by pharmacists in patient care activities. Refer Tables D-M29b, D-M32a and D-
M32b)
The Pharmacy Guild of Australia and other national bodies of pharmacy should agree on
standard definitions for the analysis of staff in pharmacies and perform surveys of
representative samples of pharmacies in order to monitor the trends in the internal structures
of pharmacy staff.

14
RELATIONSHIPS OF PHARMACY CHARACTERISTICS AND PHARMACY SERVICES
(Terms of reference 4 and 5)

Recommendation 40: The national survey of British pharmacies found statistically significant
relationships between pharmacists rather than pharmacies and the performance of specialist
or extended pharmacy services whereas these Australian results pointed more to certain
pharmacy characteristics significantly related to the performance of enhanced and other
specialist services in pharmacies (Section 4 ). These results have strong implications for
national policies on the development of professional services in pharmacies but they require
hypothesis testing with the application of logistic regression analyses to define these
relationships. Refer to Table D4.1.
The Pharmacy Guild of Australia and other national bodies of pharmacy should commision
further multivariate analysis ( ie regression analysis) to ascertain the relationship between
pharmacy factors including area, group membership and the implementation of enhanced
pharmacy and other specialist services on a national basis.

Recommendation 41 : Statistically significant relationships were found between certain

pharmacy characteristics and barriers and facilitators to taking on enhanced pharmacy
services which is the first time such relationships have been analysed and reported (Sections
5.1 and 5.2) . But the statistical analyses were limited to t-test and chi-squared tests . Refer to
Tables D5.1 and D5.2.
The Pharmacy Guild of Australia and other national bodies of pharmacy should engage
further multivatiate analysis (ie. regression analysis) to ascertain associations between
pharmacist variables and barriers to the provision of enhanced pharmacy services.

Recommendation 42 : Statistically significant relationships were found between pharmacy

characteristics inferring statistically strong relationships between larger, busier pharmacies
and the use communication technologies (Section 5.3) . But the statistical analyses were
limited to t-test and chi-squared tests . Refer to Table D5.3.
The Pharmacy Guild of Australia and other national bodies of pharmacy should engage
further logistic regression analysis be conducted to continue the statistical analysis to define
the pharmacy variables such as Pharia zone, related to the use or impact of technologies on
the performance of specified patient care activities and the impact on the sales of prescribed
and over-the counter medicines.

Recommendation 43 : The effect of the location of pharmacies in certain PhARIA zones

especially remote rural pharmacies in PhARIA zones 5 and 6 were referred to in Sections 3 A
to M and tested statistically (Sections 4 and 5). But the statistical analyses were limited to t-
test and chi-squared tests . Refer to Tables 5.1, 5.2 and 5.3.
The national bodies of pharmacy should commission further statistical analysis in order to
standardise the data for pharmacies in the rural and remote Pharia zones and extend the
statistical analyses to test relationships between Pharia location and services provided.

15
Contact details
Con Berbatis
Lecturer
School of Pharmacy
Curtin University of Technology
GPO Box U1987
Perth Western Australia 6845

Email: berbatis@git.com.au
Ph: +61 8 9271 7180

16
1 Introduction
The following sections serve as the background to the National Pharmacy Database Project
(the project) which commenced officially in January 2002 and concluded in June2003.

1. 1 Terms of reference
The terms of reference and aims of the ‘National Pharmacy Database Project (the ‘project’)
were:
1. To construct a national database of the most important types and rates of pharmacy
characteristics including facilities, health-related general and specialised including
preventive services in Australia’s community pharmacies for Australian and overseas
reference or comparisons;
2. To make comparisons between pharmacies in the different PhARIA zones;
3. To test relationships between pharmacy characteristics and facility/service provision;
4. To test relationships between pharmacy characteristics and barriers to facility/service
provision; and
5. To make national estimates of a range of pharmacy services and facilities.

The project officially commenced in January 2002 and the national survey of community
pharmacies was conducted from 12 July to 9 September. The resulting frequency data were
compiled and summarised from September to November 2002. The results were analysed
from January to April 2003. The report was completed during May and June 2003.
The terms of reference are fulfilled in this report as follows. Term 1: Full copies of the
database for the project are enclosed in disk and printed forms and summarised in Section 2.
Terms 2 and 5 are included in each of the discussions in Section 3. Terms 3 and 4 are
included in Section 4.

1. 2 Origins of the National Pharmacy Database Project

Since 1970, pharmacy departments in Australia’s teaching hospitals have led pharmacy
practice in this country but community pharmacy is now moving quickly to redress the
imbalance. There is however, a paucity of data on the prevalence, incidence, frequency, and
distribution of established and new services in community pharmacy practice. These data are
needed by our administrators and educators in revising existing programs and devising new
policies.
In 2001, a project entitled ‘A reference database of Australia’s community pharmacies:
analysis of national survey’ was funded under the Third Community Pharmacy Agreement
Research and Development Grants Program. The study commenced in January 2002 and
was finalised in June 20031. The design of this national survey was guided by Australia’s
legal requirements2,3, guidelines and references for the design and implementation of
surveys4-8, and the findings of previous studies9-18. This project operated under necessary
approvals from the Commonwealth Government Statistical Clearing House2, the Pharmacy
Guild of Australia, Curtin University Human Research and Ethics Committee and was
overseen by a national panel consisting of delegates of national bodies and experienced
researchers.
A national survey of a 15% sample of community pharmacies was conducted in stratified
groups (zones 1 to 6 of PhARIA 2001)19. Both random sampling and stratification reduce
bias20-22. Stratification is a sampling tool that divides a large population such as Australia’s
nearly 5000 community pharmacies into specified groups. This allows more accurate
estimates of the prevalence and distribution of variables such as pharmacy services, hence
facilitating comparison of services between zones. This is crucial for policy makers in the
allocation of services and for administrators who are planning education or training programs.
A sample is required because of limited funding and time. A 15% sample, or approximately
750 pharmacies, was statistically calculated to meet defined margins of error with prevalence
rates of pharmacy services or facilities down to 1%, a 75% response rate, and confidence
interval of 95% for pharmacy services23.
To achieve a high response rate (i.e. at least 75%) a series of survey techniques were used 4,
24-28
. These comprised (1) wide publicity in pharmacy newsletters and journals to create
respondent awareness and engender study participation, (2) a prioritised letter from the

17
university investigators introducing the study and requesting participation from the sample of
pharmacies, (3) the construction of a national survey website to reinforce awareness, to
clarify difficulties encountered in responding to the questionnaire and to provide feedback of
results, (4) telephone contact to ensure the introductory letter had been received, obtain
consent for the pharmacy to participate and to identify the pharmacist who would be
responding on behalf of the pharmacy, (5) three consecutive mailings of the questionnaires
at regular intervals starting on the 14 July (one initial and two follow up to non-respondents)
and (6) follow-up reminder calls / faxes. The response rate was further enhanced by (7) the
careful construction and design of the questionnaire according to set guidelines and (8) by
offering incentives (i.e. accreditation points and a cash payment) 2,41 .

1.3 Review of pharmacy surveys overseas and in Australia

The design and conduct of the survey was guided by Australian legal requirements2,3,
guidelines and references for the design and implementation of surveys41 -8 and the finding of
previous studies 9-18. These studies are outlined below.

The Netherlands
In 1998 the Board of Pharmaceutical Practice of the International Pharmaceutical Federation
(FIP) sponsored a series of systematic national surveys of pharmacy practice conducted by
the Quality Institute for Pharmaceutical Care in Kempen, the Netherlands 9, 23. Using a social
pharmacy approach, whereby the prevalence of activities performed by community-based
pharmacy practices was surveyed, this group developed the Pharm Value model with a
questionnaire for community pharmacies and another for the coordinating research centre
9,23
. These questionnaires were used in a survey of community pharmacies in Northern
Ireland. The PharmValue questionnaires and results were assessed for their application in
this study and were found to be unsuitable as their content was not pertinent to the Australian
context.

United Kingdom
In 1996 the Royal Pharmaceutical Society of Great Britain produced a national database.
Results were collated from responses to a 67-question survey, and were completed by 7% of
British community pharmacies10. The interpretation of the results was compromised by the
small sample and low response rate 23.
In 2001, a national data set was produced by a consortium of national pharmacy bodies,
which was led by the Royal Pharmaceutical Society of Great Britain11. The survey focused on
pharmacy services and pharmacy related characteristics. Overall, four mailings of the survey
were conducted and achieved a response rate of 58% 11. The investigators found statistically
significant relationships between certain services and community pharmacy characteristics.
The methodology and questionnaire were relevant and applied to our Australian study.

United States of America

From 1992 to 1994, the Scope of Practice Project was conducted by national pharmacy
bodies and coordinated by the American Pharmaceutical Association 12,23. This survey was
conducted in community, hospital and mixed practice sites and achieved a response rate of
28% of licensed pharmacists and 29% of pharmacy technicians. Demographic data,
responses relating to practice performance and activities in need of development/
enhancement were compared with the results of a national study completed in 1978.
The analysis showed pharmacists spent more time on patient pharmaceutical care and less
on medication purchasing and control; whereas technicians’ time was mainly confined to
dispensary related activities. A revised classification resulted, with expanded and more
defined pharmacy activities. This was made more relevant to educational requirements and
subsequent surveys 11,29,30.
In 1998, the American Society of Health-System Pharmacists began national surveys of
hospital pharmacy practice13. The methodology, implementation and response rates reported
in these national surveys support the sampling, selection and survey modes that were applied

18
in our Australian survey23. The questionnaire was relevant and utilised in developing the
Australian project.

Malta
In 1997, 184 community pharmacies were surveyed (n.b. response rate and other details
were omitted). Data was obtained on the range and rate of health-related activities performed
within the pharmacy, the time spent on each activity, and pharmacy staff and premises 14.
The design of this study was a resource used in designing the survey instrument used in our
Australia survey, but the questionnaire was of limited value.

Australia
A review of national and jurisdictional surveys of community pharmacies conducted in
Australia since 1970, by government agencies, national and state pharmacy bodies and
university researchers summarised the activities of community pharmacists in prescription-
related, primary health care, health promotion, and other services 31. The methodologies
were examined and applied to pertinent parts of the Australian survey.
In 1992, community pharmacies within Western Australia were surveyed, using a structured
questionnaire to document the scope and nature of pharmaceutical services provided for the
elderly. This study achieved a response rate of 42% 15. Investigators found high levels of
first-aid assistance, health information provision and incontinence counselling, but low levels
of monitoring (e.g. blood glucose levels) and advice (e.g. therapeutic drug levels or blood
cholesterol levels). Few respondent pharmacists reported having evaluated the effectiveness
(9%) or the efficiency (4%) of services provided 15, 23. The results of this study provided
insight into the range of activities performed, but the low response rate limits generalising
them.
The Pharmacy Guild of Australia’s 1999-2000 annual financial survey was based on a sample
of 353 Guild member pharmacies. It comprised a small random sample of 193 plus 160
‘consecutive year respondents’ 16. The findings from this study emphasised the benefit of
stratification but generalising the results needs to be validated and hence the need to use
consistent sampling methodology23.
In Australia other studies , of the demand and supply of pharmacists and the pharmacy labour
force 17,18, achieved high response rates demonstrating the importance of survey timing and
the involvement of pharmacy boards .

1.4 Methodology
From January to June 2002 ethics and other approvals were obtained, the national pool of
registered community pharmacies compiled, stratified samples selected, participating
pharmacies resolved and the questionnaire prepared, tested and professionally produced and
printed . These activities occurred in consultation with many researchers and pharmacists and
approved by the national panel for the project (refer Acknowledgements).

1.4.1 Sample and stratification with PhARIA system

Calculations of sample size were based on the confidence interval for a binomial parameter4.
A 15% sample, or approximately 750 pharmacies (refer to table A) was calculated to meet
statistically defined margins of error with prevalence rates of pharmacy services down to 1%,
a 75% response rate and confidence interval of 95% for pharmacy services 23. The
Pharmacy Guild, State and Territory Boards of Pharmacy and Health Departments in each
state provided the pool of registered pharmacies in each of Australia’s jurisdictions.

In order to minimise sampling bias arising from location and to ensure including the relatively
low percentages of remote and rural pharmacies stratification 22,32 was needed . The PhARIA
(i.e. the physical and professional remoteness of pharmacies within Australia) system was
selected 19. This system was produced by the Health Insurance Commission (HIC) with a
university group in 2000. It was based on the ARIA system for stratifying medical practices
principally based on a remoteness index or distance from other medical practices 23. PhARIA
was utilised for determining additional remuneration of rural and remote pharmacies. It had

19
not been used for stratification before this project. On the basis of PhARIA classification the
pharmacies were stratified into one of six groups by a statistician, these being:

PhARIA 1: Highly accessible

PhARIA 2: Accessible (group 1)
PhARIA 3: Accessible (group 2)
PhARIA 4: Moderately accessible
PhARIA 5: Remote
PhARIA 6: Very remote

Due to 81% of the total of community pharmacies (Table 1.1) being in PhARIA 1, a random
sample of 20% of the total PhARIA 1 sample was drawn and used in this study. Due to the
small number of pharmacies in PhARIA 2 to 6 the entire original sample was used.
Furthermore, because of the very small number of pharmacies in PhARIA 5 and 6 this group
was merged to form one “remote” group. Overall, this gave a total of 1641 possible
participants (Table 1.1).

Table 1.1 Sample by PhARIA

PhARIA Pharmacy Minimum response required Original sample
numbers* Freq % Freq %
1 3927 340 45.3 744 45.3
2 321 147 19.6 321 19.6
3 313 143 19.1 313 19.1
4 123 56 7.5 123 7.5
5 and 6 140 64 8.5 140 8.5
Total 4824 750 100 1641 100
* Actual pharmacy numbers at time of survey that could be matched to a PhARIA.

1.4.1.1 Difficulties with PhARIA system for stratification

Difficulties arose due to the large numbers of pharmacies in PhARIA 1 as compared to
PhARIA 2 to 6. The skewness resulted in the need for a random sample of just PhARIA 1,
and a census sample and survey of all pharmacies in PhARIA 2 to 6 (i.e. all pharmacies were
surveyed). This resulted in project costs being higher than anticipated. During sample
preparation it was also found that a number of pharmacies (n=50), did not have a matching
PhARIA for their postcode. These pharmacies were omitted. This resulted in a reduction in
the pool of pharmacies and possibly some selection bias.
Other standard stratification systems based on electoral divisions (which have similar
population numbers), socio-economic features (SEIFA) or other factors need to be
considered 34,35,36. The process of selecting an alternative system should consider
characteristics of the alternative systems and the result of stratification in relation to numbers
of pharmacies in each stratified sample to ensure skewness is minimised, the purposes of the
survey, previous applications of and reports of experiences with the system and assess the
suitability of the system to the samples and identifiers of the pharmacies chosen (e.g.
matching postcodes).

1.4.2 Participation rate

The participation rate refers to the number of pharmacies which were eligible and consented
to participate in the study as a proportion of the total valid sample. Of the original sample of
1641 possible pharmacies, 1391 agreed to participate in this study, 141 refused, 42 were not
contactable and 67 were screened out as the phone number no longer belonged to a
pharmacy or was a duplicate number. The participation rate of pharmacies was therefore
90.8% or 1391 / [1641-42-67] (Figure 1.1 and Table 1.2). Some bias on the basis of refusal
to participate may have occurred as when the non-participants who provided information and
respondents were compared significant differences were found according to pharmacy
description (PhARIA 1 and 2-6), staff numbers (PhARIA 2-6 only), ownership (PhARIA 1 only)
and setting (PhARIA 1 and 2-6). Due to the very high participation rate however the bias is
small.

20
1.4.3 Response rate
Response rate refers to the number of pharmacies which returned their questionnaire as a
proportion of those which consented to participate in the study. In total, questionnaires were
mailed to 1391 participant pharmacies, of which 1131 were completed and returned (Figure
1.1). Data from questionnaires received after 9 September 2002 were not included in the
study. The overall response rate for this study is therefore 81.3% (i.e. 1131/1391). Response
rates by PhARIA are detailed (Table 1.2). Some bias on the basis of refusal to respond may
have occurred as when the non-respondents which provided information and respondents
were compared significant differences were found according to pharmacy description
(PhARIA 1 and 2-6), and setting (PhARIA 1 only). Due to the very high response rate the
effect of this bias is however small.

Figure 1.1 Overall participation and response

Original Sample
(n=1641 pharmacies)

Participant Pharmacies Non-participants & Invalid

(n=1391) sample
141 refused to participate
42 not contactable
67 duplicate number or
no longer a pharmacy

Respondent Pharmacies Non-respondent

Pharmacies
(n=1131) (n=260)

PhARIA 1: n=482
PhARIA 2: n=240
PhARIA 3: n=226
PhARIA 4: n=91
PhARIA 5&6: n=92

Table 1.2. Participant rate and response rate by PhARIA

Participants Response
PhARIA Freq % Freq %
1 611 43.9 482 42.6
2 278 20.0 240 21.2
3 276 19.8 226 20.0
4 110 7.9 91 8.0
5 and 6 116 8.3 92 8.1
Total 1391 100 1131 100

21
1.4.4 Questionnaire
The questionnaire consisted of 10 pages, 13 sections and 33 questions which were divided
into 231 sub-questions ( Table 1.3). Authoritative guidelines and reported international
surveys were reviewed in developing the questionnaire ( Sections 1.2 and 1.3).
Due attention was given to the inclusion of questions relating to Australia’s health priorities
and quality use of medicines. The survey instrument was constructed in consultation with a
wide range of specialist pharmacists , professionally designed by a graphics consultant,
tested, approved by the national panel and independent ethics and national committees and
printed by a professional printer in the period from February to July 2002. Specifically, from
May to July 2002 the questions (wording and code frames) were examined and tested by
academic, administrative, specialist and practicing pharmacists throughout the country
(across PhARIA zones 1 to 6). A focus group of pharmacists was conducted to gain practical
feedback on the questionnaire. On the basis of their comments various changes were made
to the wording of questions. The national panel also commented on the questionnaire and
methodology. A website was developed to enhance participation and provide feedback.

Table 1.3 Sections comprising the national pharmacy questionnaire 2002

Section Question %
Questionnaire
A Respondent pharmacist details 1 to 6 10
B Enhanced pharmacy services paid or unpaid 7 6
C Barriers to and facilitators of enhanced pharmacy services 8 and 9 6
D Prescription related activities in this pharmacy 10a to 13c 18
E Medication review processes 14a to 14f 10
F Primary health care including pharmacy (S2) and 15a and 15b 4
pharmacist only (S3) medicines
G Preventive services implemented in this pharmacy 16 to 18 6
H Harm minimisation or harm reduction activities 19a and 19b 4
I Complementary therapies including herbal medicines 20 3
J Information facilities and programs 21 3
K Technologies and health communications 22a to 23 6
L Opinion on the use of technical facilities 24 4
M Pharmacy and staff 25a to 33b 20

Items within the questionnaire were derived from a number of different sources such as a)
overseas, national and regional questionnaires, b) contributions from specialist pharmacists
or pharmacy consultants throughout Australia, c) a review of a range of contemporary
Australian and overseas literature, d) observations in a range of pharmacies and e) advice
and contributions from specialists in the field of epidemiology and survey research methods 2-
18
. On average the survey took approximately 1hour to complete (i.e. time spent reading the
instructions, answering questions and obtaining information).

1.4.5 Implementation and administration of survey

From March to June 2002 articles were published in the major national pharmacy journals
and circulated through newsletters produced by the Pharmacy Guild of Australia to all
pharmacies to create a national awareness of the project and the need for cooperation and a
high response rate. In June 2002 the School of Pharmacy sent an individualised letter to the
1641 pharmacies explaining the survey , requesting that one owner or manager pharmacist
be selected to be the respondent for the pharmacy and introducing the Survey Research
Centre (SRC) in the School of Population Health, University of Western Australia which would
implement the survey.
Soon after these pharmacies were telephoned by trained SRC interviewers and asked to
participate in this study, of which 1391 agreed (Figure 1.1) . The pharmacies which agreed to
participate in the study were asked to provide the name and contact information of a
pharmacist respondent.

22
The 1391 pharmacies were first mailed the questionnaire on the 12th July 2002, with two
subsequent mail outs at approximately 20 day intervals to non-respondents in July and
August to increase response rates. This was followed by a “follow-up” phone call to the
remaining non-respondents in early September. The cut off date for questionnaires to be
returned was the 9th of September.
Questionnaires that were completed and returned by respondent pharmacies, were data
entered into a Computer Assisted Data Entry (CADE) system by trained clerks. The data
entered into the CADE system was validated using double entry verification. Data entry error
levels were found to be within acceptable levels (i.e. <0.005). The effects of non-differential
information bias would therefore be minimal.

1.4.6 Analysis
Data were extracted from the CADE system and exported to SPSS (Version 11) for analysis.
An experienced biostatistician advised on statistical methods, questionnaire results and
analysis.
Frequencies and percentage of response were generated for each question, followed by
cross tabulations by PhARIA where relevant (refer to the technical notes for formula). If
responses were continuous and numerical (e.g. q11d), descriptive statistics were generated
(i.e. mean, standard deviation, median, minimum and maximum scores) 21,36. Where
responses related to grouped variables (e.g. q19a), descriptive estimates were calculated (i.e.
estimate mean, standard deviation, standard error, upper and lower confidence interval) 36,37.
Relationships between pharmacy characteristics (i.e. PhARIA, state, setting-q25b, days open-
q25c, total area of premises- q26, group membership-q27, QCPP status-q28, existence of a
retail manager-q29b, number of owners-q30a, total number of customers per week-q31 and
turnover-q33a) and service provision (q7, q11c, q12, q13a, q13b, q13c, q14d, q17, q18, q19a,
q19b, q20, q23) were then tested. Service variables were first combined (within questions)
and an overall binary service variable created (e.g. “No service provided” vs. “1 or more
services provided”). If “characteristic” questions were categorical (i.e. PhARIA, state, setting,
group membership, QCPP status, existence of a retail manager, number of owners, total
number of customers per week and turnover), subsections were combined to create new
pharmacy characteristic variables. Characteristic questions were combined on the basis of
respondent numbers, study results and experimenter knowledge of pharmacy characteristic
trends within Australia. This resulted in the following 11 pharmacy characteristic variables:
PhARIA (“PhARIA 1” vs. “PhARIA 2-6”); State (“ACT & NSW”, “NT & WA”, “QLD”, “SA”, “TAS”
and “VIC”); setting (“urban retail” vs. “other”); group membership (“not in a banner group” vs.
“in a banner group”); QCPP status (“QCPP accredited” vs. “not QCPP accredited”); retail
manager (“yes” vs. “no”); number of owners (“1 owner” vs. “2 or more”); customers per week
(“0 to 1400” vs. “1401 to 5001+”) and turnover (“<$1M to $2M” vs. “$2M to >$8M”). To test if
significant relationships existed between individual pharmacy characteristics and provision of
service, separate Pearson chi-square tests were conducted (n.b. where expected cases were
less then five, Fisher’s exact test was calculated). If questions on ‘characteristics of
pharmacies ‘ were numeric (i.e. days open, total area of premises) then significance testing
was conducted using t-tests 21.
To test relationships between pharmacy characteristics (i.e. PhARIA, state, setting-q25b,
days open- q25c, total area of premises- q26, group membership-q27, QCPP status-q28,
existence of a retail manager-q29b, number of owners-q30a, total number of customers per
week-q31 and turnover-q33a) and barriers to provision of service (q8, q9 and q24) binary
agreement variables (within sub-questions) were created (i.e. “strongly disagree, disagree
and neutral” vs. “agree and strongly agree”). Characteristic variables were created as
described above. To test if significant relationships existed between individual pharmacy
characteristics and barriers to provision of service, separate Pearson chi-square tests were
conducted (n.b. where expected cases were less then five, Fisher’s exact test was
calculated). If characteristic questions were numeric (i.e. days open, total area of premises)
then significance testing was conducted using t-tests 21.

23
1.4.7 National estimates
As stated above, frequencies and percentage of response were generated for each question.
If responses were continuous and numerical, descriptive statistics were generated (i.e. mean,
standard deviation, median, minimum and maximum scores) 21,36. Where responses related
to grouped variables or ranges (i.e. 11 to 50 per month), descriptive estimates were
calculated (i.e. estimate mean, standard deviation, standard error, upper and lower
confidence interval) 36,37. Descriptive estimates were calculated (refer to the Technical Notes
for formula) for relevant questions using the midpoint for the range (except in the case of the
last range in which the lowest score was used). It should be noted that this method of
calculation may have resulted in over estimation of the true figure, especially for questions
with ranges of unequal and increasing size. The Lower Confidence Interval (LCI) for the
mean was therefore used consistently to correct for overestimation as discussed above. In
some cases it was evident the LCI inadequately adjusted for this source of overestimation.
The numbers of frequency data in the ranges on either side of the range in which the
midpoint fell, were calculated in certain cases to moderate these data in order to calculate
alternative best estimates and corresponding confidence intervals .

The terms ‘number of clients’ or ‘number of patients’ included in Questions 10b, 11a, 11c,
12,13a, 13b, 13c, 19a, 19b and 21 relate to prescriptions dispensed. The results need to be
carefully reviewed because each client or patient actually refers to a dispensing occasion in
community pharmacies and not just a prescription item dispensed. A dispensing occasion
refers to each case of prescriptions presented in a pharmacy for one patient. There are no
published statistics in Australia of the number of dispensing occasions and little data on
parameters for calculating this figure. These deficiencies need to be remedied by Australia’s
bodies of pharmacy because they affect many areas of decision making. For the purpose of
assessing the results in relation to dispensing occasions for the above questions this report
adopted the following parameters : a) the adopted mean for prescription items dispensed per
occasion was 2.5 and b) the adopted number of items dispensed for patients domiciled, in
aged care facilities and in other situations inhibiting direct pharmacist communication was 15
million. If just original prescriptions are considered c) the adopted percentage for repeat
prescriptions to subtract was 65%. Appropriate other parameters need to be considered for
the results for questions 15a, 15b, 17 and 20. For the total 216,581,000 prescription items
dispensed in 2002 therefore, the estimate of ‘dispensing occasions ‘ was (100-65) x
216,581,000 / 2.5 - 15,000.000) or 25.071 million dispensing occasions. The national totals in
the results for each of the above questions therefore need to be revised according to the
occasions dispensed and not the estimated total of prescriptions dispensed.

To calculate national estimates the overall percentage of pharmacies that positively

responded to a question was multiplied by the corresponding actual number of pharmacies
within PhARIA 1 and PhARIA 2 to 6 (Table 1.1), therefore giving an estimate of total
pharmacies. To calculate the number of services/facilities the lower confidence interval (LCI)
mean estimate was multiplied by the appropriate number of pharmacies. In certain instances,
where skewness to the left or to ranges with smaller numbers was pronounced , appropriate
recalculations of the best estimates were made. For estimates relating to facilities or services
daily, weekly or 30 day estimates the 4824 pharmacies in Table 1.1 was used and for
estimates occurring in pharmacies over a period of 12 months the total of 4,447 pharmacies
was applied being the number of PBS-approved pharmacies which had operated for the full
12 months ending 30 June 2002. That is, the LCI x 4447 was the multiple commonly used for
yearly estimates. These numbers resulted therefore in the most conservative national annual
estimate of services or facilities.

24
2. Database (Term of reference 1, disk attached)
Term of Reference 1 requires a database based on the results of the survey. These are
reported in the following three parts and included in the attached disk and printed copy.
In total the database comprises 288 pages and 810 tables. Due to the word limits for this
report a copy of the database is in the attached disk and hard copy. To assist the reader in
their understanding of the results, separate discussion tables designated Table D - A, B, C,
etc. according to the corresponding section and question number (Table 2.1) in the results
were created and reported in Section 3 of this report.

2.1 Pharmacy activities, facilities, services, PhARIA and estimates

Part 1 in the attached database contains response frequencies, percentage response, cross
tabulation by PhARIA, descriptive/estimate statistics of pharmacy activities, facilities and
services according to the sections in the questionnaire (Table 2.1). These are detailed in
Section 3 of this report

Table 2.1 Pharmacy activities, facilities, services, PhARIA and estimates

Section Question Source (number of tables)

A 1 to 6
B 7
C 8 and 9
D 10a to 13c
E 14a to 14f
F 15a and 15b
G 16 to 18
H 19a and 19b
I 20
J 21
K 22a to 23
L 24
M 25a to 33b
Table 1.1 to 6.2 (26 tables)
Tables 7.1.1 to 7.28.2 (56 tables)
Tables 8.1.1 to 9.7.2 (38 tables)
Tables 10a.1 to 13c.2.2 (73 tables)
Tables 14a.1 to 14f (14 tables)
Tables 15a.1.1 to 15b.2.2 (16 tables)
Tables 16 to 18.7.2 (29 tables)
Tables 9a.1.1 to 19b.2.2 (16 tables)
Tables 20.1.1 to 20.12.2 (24 tables)
Tables 21.1.1 to 21.11.2 (22 tables)
Tables 22a.1 to 23.4 (16 tables)
Tables 24.1 to 24.7 (7 tables)
Tables 25a.1 to 33b (29 tables)

2.2 Pharmacy characteristics and facilities / service provision

Part 3 contains cross tabulations and chi-square tests performed in order to find individual
relationships between pharmacy characteristics and service provision (Table 2.2). These are
detailed in Section 4a of this report:

Table 2.2 Pharmacy characteristics and facility/service provision

Section Question Source (number of tables)

Pharmacy 7 Table 34.1 to 34.12 (12 tables)
characteristics and 11c Table 35.1 to 35.12 (12 tables)
facility/service 12 Table 36.1 to 36.12 (12 tables)
provision 13a Table 37.1 to 37.12 (12 tables)
13b Table 38.1 to 38.12 (12 tables)
13c Table 39.1 to 39.12 (12 tables)
14d Table 40.1 to 40.12 (12 tables)
17 Table 41.1 to 41.12 (12 tables)
18 Table 42.1 to 42.12 (12 tables)
19a Table 43.1 to 43.12 (12 tables)
19b Table 44.1 to 44.12 (12 tables)
20 Table 45.1 to 45.12 (12 tables)
23 Table 46.1 to 46.12 (12 tables)

25
2.3 Pharmacy characteristics and barriers
Part 4 contains cross tabulations and chi-square tests performed in order to assess the
relationships between pharmacy characteristics and barriers to enhanced pharmacy services.
From the low level of invalid or non-response within this study it could be inferred that
respondents had a high level of comprehension for a majority of the questions (Table 2.3).
These are detailed in Section 4b of this report.

Table 2.3 Pharmacy characteristics and barriers

Section Question Source (number of tables)
Pharmacy 8 Table 47.1 to 57.12 (132 tables)
characteristics and 9 Table 58.1 to 63.12 (72 tables)
barriers 24 Table 64.1 to 70.12 (84 tables)

2.4 Pharmacy characteristics and opinion on the use of technical facilities

Part 4 contains also cross tabulations and chi-square tests performed in order to seek
relationships between pharmacy characteristics and barriers to enhanced pharmacy services.
From the low level of invalid or non-response within this study it could be inferred that
respondents had a high level of comprehension for a majority of the questions (Table 2.4).
These are detailed in Section 4c of this report.

Table 2.4 Pharmacy characteristics and opinion on the use of technical facilities

Section Question Source (number of tables)

Opinion on the use 24 Table 47.1 to 57.12 (132 tables)
of technical facilities Table 58.1 to 63.12 (72 tables)
Table 64.1 to 70.12 (84 tables)

26
3. Terms of reference 1, 2 and 5 : characteristics of , facilities
and services and national estimates in Australia’s community
pharmacies by PhARIA zone
Terms of reference 1 (characteristics, facilities and services in Australia’s community
pharmacies), 2 (comparisons between pharmacies in Pharia zones) and 5 (national
estimates) are reported below by each section in order in the questionnaire.
The questionnaire is appended in this report but may be conveniently viewed in the website
constructed for this project: www.curtin.edu.au/curtin/dept/pharmacy/survey/index.html

The discussion for each section in the questionnaire is in a standardised format under the
same subheadings so readers can logically follow the results from the database and to satisfy
the terms of reference relating to national and international comparisons of the data. The
standard subheadings are the title, aims of the data, pertinent question numbers in the
questionnaire , statistical sources from the database, methodology related to the questions
and national estimates, findings in summary tables based on results in the database, results
by PhARIA, national estimates, reviews of the pertinent Australian and overseas literature ,
interpretations and references.

27
3.1 Section A. Respondent pharmacist details
Questions: 1 to 6

Statistical sources: Tables 1.1 to 6.2 (26 tables);

Aims
To compare the demographics and other features of the respondents and owners (Section M)
in Australia’s community pharmacies. To compare features of respondents and owners with
pertinent data from international surveys of community pharmacists.

Background
In Australia, an approved community pharmacy is defined as a pharmacy operating from
premises in respect of which a pharmacists is approved to supply pharmaceutical benefits. 38
Beforehand pharmacies need to be registered by jurisdictional pharmacy boards hence not all
registered pharmacies may be approved pharmacies. In this survey the pool of pharmacies
was drawn from pharmacies registered with the relevant State or Territory (jurisdictional)
authorities which rarely involves any not approved to supply medicines listed in the national
Schedule of Pharmaceutical Benefits and remunerated by the Health Insurance Commission
(HIC). National surveys of the pharmacy workforce are carried out regularly and comparisons
are made with features of those reported since 2000. The respondents in this national survey
were owners, partners, managers or pharmacists-in-charge of Australia’s community
pharmacies. That is those pharmacists who determine and implement the practices in
Australia’s pharmacies. Other terms used in this and other questions are based on those
published in the reference publication Australian Pharmaceutical Formulary and Handbook. 38

Discussion of methods
The questions 1-6 pertaining to the demographics and other characteristics of respondents in
Section A were drawn from recent surveys of the Australian pharmacy workforce and other
data on the continuing professional development from the literature and from national and
State pharmacy administrators. Questions 1-6 were completed after consultation with the
national panel, visits to pharmacies across all Pharia zones in the large States and direct or
telephone discussions with their key staff. The question was tested in a focus group of
pharmacists from a variety of pharmacies in Pharia zones 1 and 2 and a nationwide sample of
practicing and specialist pharmacists in Pharia zones 1 to 6. The questions were framed in
order to be comparable to but appropriately expand on reported regional or national surveys
of Australia’s community pharmacies, from a state survey of pharmaceutical care services in
the USA 39 ,a national survey of pharmacies in the UK 40 and from exchanges with leaders in
pharmacy practice, teaching, research and administration in Australia and internationally.

Findings
The demographics and pharmacy details of the respondents (Tables 1-6) compared with
owners (Section M) showed more respondents were females, they were younger, more held
university degrees and spent more time in continuing pharmacy education (Table A-D1).
Respondents comprised 73.3% owners or partners.
The hours per month spent on CPE by respondents (73% owners and partners) were: in the
last 12 months, we can be 95% confident that respondent pharmacists spent between 6.78
and 7.46 hrs per month on CPE with a best estimate of 7.12 hours per month. In comparison,
the hours per month spent on CPE by owners were (Q30b): 5.63hrs per month (95% CI 5.39,
5.87hrs). The composition of CPE in order of time spent was: 1. journal/personal reading, 2.
CPE courses/lectures, 3. questionnaires in professional journals, 4 conferences and 5.online
CPE.

28
 Table D-A1.Comparison of respondents and owners in Australia’s community pharmacies
2002.

Features Respondents owners

females 31.7% 23.7%
51+ years 32.6% 39.5%
Pre-1970 registration 20.4% NA
Diploma 15.3% 18.2%
CPE >10hours/month 20.1% 13.1%
Owners/partners 73.3% 100%

PhARIA zones
There were marginally less male respondents ( 66% and 64%) from PhARIAs 1 and 2 and 5
and 6 than from PhARIAs 3 and 4 (73% and 76%) . Just 27% of respondents from PhARIA 1
were 51 years or over compared to 30-41% in the others. Just 16% of respondents from
PhARIA 1 were first registered before 1970 compared to 20-32% in the others. Initial
graduates from NSW and Victoria was 55% in PhARIA 1 and 36% in PhARIAs 5&6. Those
with diplomas as their highest qualification (non-baccalaureates) was 11% in PhARIA 1 and
rising to 25% of respondents in PhARIAs 5&6. Less respondents (51%) in PhARIA 1 spent
five hours or less monthly on continuing pharmacy education (CPE) than those for example
in PhARIA 4 (62%) and 55% in PhARIAs 5&6. The higher commitment to CPE in PhARIA 1
respondents was reflected variously across CPE forms . For example 55.8% of respondents
in PhARIA 1 increasing to 82.6% in PhARIAs 5&6 reported under 20% of their CPE time or
‘no response’ to CPE of a participatory nature such as courses and lectures. There was little
difference in PhARIAs in the less participatory forms of CPE such as ‘journals/personal
reading’ and ‘online’ where 22.2% in PhARIA 1 and 22.8% in PhARIAs 5&6 and 88.6% in
PhARIA 1 and 89.1% in PhARIAs 5&6 reported respectively under 20% of their CPE time or
‘no response’ . There are clearly challenges to national pharmacy bodies in identifying and
overcoming barriers to CPE forms of a non-participatory nature throughout he country.

Australia
Three national work force surveys of Australia’s community pharmacists have been published
since 2000 41,42,43,44. The ‘Pharmacy labour force 1998’ reported results of a census survey
(national response 83.8%) of Australia’s pharmacy workforce undertaken in 1996 with the
assistance of State pharmacy boards (AIHW,2000). It is the last available report in a series of
three-yearly national labour force surveys of pharmacy conducted in 1996 and 1999 41 and
portrays the most detailed picture of community pharmacists of any report. In 1996 the total
11,126 community pharmacists comprised 6,617 males and 4,509 females of whom 5301 and
2176 were fulltime. The fulltime pharmacists comprised 42.9% males and 8.6% females
aged 45 years and over (51 years and over in 2002) . Part-time pharmacists comprised
36.1% males and 29.2% females aged 45 years and over. Part-time pharmacists were higher
( 33.7 -33.9%) in cities and metropolitan centres than in remote areas (15.9-6.7%). The
average age of females and males was 41.4 and 49.4 years respectively and females
comprised 60.6% of all community pharmacists aged less than 30 years (36 years in 2002).
Weekly hours worked ranged from 38.4 hours weekly in cities and metropolitan centres to
47.6 hours in remote areas. In the week before the 1996 census 57.9% worked 40 hours and
over weekly. Community pharmacies were located in non-mall shopping centres (71.5%),
mall complexes (22%) and in medical centres ( 6.2%). Community pharmacists became
qualified as follows : 25.6% in 1960-69, 21.0% in 1970-79 and 23.0% in 1980-89 . 41 The
AIHW reported the total 4958 community pharmacies in 1999 reflected a national decline in
numbers; 182.77 million prescriptions were dispensed through the Pharmaceutical Benefits
Scheme (PBS) in 1998 -a 16.5% rise since 1993; community pharmacies employed in 1996
11,126 people equating to 80.4% of the total pharmacy workforce. 41
The 1996 results from community pharmacists were compared with our 2002 results (Table A-
D2). Even with the time differences the respondents comprised less females, were older and
more partners and owners. The initial qualification in pharmacy was obtained in NSW and
Victoria by 50.4% of respondents compared with 54.6% of the total pharmacy graduates from
universities in NSW and Victoria (HIC,2002). These data suggest relatively more opportunities
in non-community pharmacy employment in NSW and Victoria than in other States.

29
 Table D-A2.Comparison of respondents in 2002 and community pharmacists in 1996
(AIHW,2000)

Features 2002 respondents 1996 community

pharmacists
Females 31.7% 40.5%
51+ years 32.6% 54.5% (46+)
Pre-1970 registration 20.4% 43.5%
NSW or Vic. location 52.9% 61.2%
Baccalaureate (Uni) 83.3% NA
CPD >10hours/month 20.1% NA
Owners/partners 73.3% 46.6%

The ‘Study of the demand and supply of pharmacists, 1995-2010’ reported responses from
518 respondents (52.7% ) of an unspecified sample survey of State registrants 43. The
results are not comparable with either the 1996 labour force census41 or the results from this
2002 survey. The ‘Study of the demand and supply of pharmacists, 2000-2010’ reported
responses from 666 respondents (60.4%) of an unspecified sample survey of State
registrants 44. The results are not comparable with either the 1996 labour force census 41 or
the results from this 2002 survey.
Totals of prescriptions dispensed by Australia’s community pharmacies and part or wholly
remunerated by government payers ( PBS and RPBS and HIC ) were provided by
Australia’s Drug Utilization Sub-Committee. In 1999 a total of 191.404 million ( 44.72 million
private and under concession) and in 2000 200.345 million ( 45.02 million private and under
concession) were dispensed . The totals include ‘private’ and ‘under concession’ (dispensing
fee below PBS price) are obtained from surveys organised by the Pharmacy Guild of
Australia. The categories of prescriptions dispensed in Australia’s community pharmacies are
recorded in Table A-D3.

Table D-A3. Total prescription numbers dispensed in community pharmacies by category in

Australia in 2001
(Source : Drug Utilisation Sub-Committee drug utilisation database, December 2002 )
PBS=Pharmaceutical Benefits Scheme; RPBS = Repatriation PBS (Veterans’ Affairs)

Source Patient category Prescriptions

PBS/RPBS Concession safety net 28 115 148
PBS/RPBS Concession non Safety net 98 976 103
PBS/RPBS Doctors’ bag 466 168
PBS/RPBS General non Safety net 18 645 735
PBS/RPBS General Safety net 4 779 598
PBS/RPBS ostomy 10 299
PBS/RPBS Repatriation (VA) Safety Net 2 005 239
PBS/RPBS Repatriation non Safety Net 11 479 076
Survey private 14 397 429
Survey Under concession 31 602 613
Total all 210,477,000

In order to enable validation of the figures on CPE commitment by owner and non-owner
pharmacists, enquiries from national and State bodies of pharmacy proved unsuccessful.

International
The results from Australia’s community pharmacies in this survey are often compared with
data from the USA, UK, Canada , New Zealand and the Netherlands, so a summary of key
national features are made for reference (Table A-D4).

30
 Table D-A4. Key features in Australia and other comparison countries 45

Population Population Population Doctors GDP per head : Purchasing

(million) growth p.a. over 65 per 1000 power parity (USA=100)
years
Australia 19.1 1.1% 12.3% 2.5 73.2
Canada 30.8 0.93% 12.6% 2.1 79.7
Netherlands 15.9 0.52% 13.6% 3.1 75.8
New Zealand 3.8 0.94% 11.7% 2.3 54.3
UK 59.4 0.27% 15.8% 1.8 69.1
USA 283.2 1.05% 12.3% 2.7 100

In the USA national pharmacy bodies 46, government agencies 47 and research groups 48-51
have since 1999 reported the results of national surveys or projections on many aspects of
the US community pharmacist workforce. By 2000 nearly three billion prescriptions were filled
in US community pharmacies 46 similar per capita to the 200.345 million dispensed in 2000 by
Australia’s community pharmacies (Tables D-A3 and D-A4). Third party billing of
prescriptions account for 75% of US prescriptions 46 compared with 78% of Australia’s third
party prescriptions (eg PBS,RPBS) dispensed in Australia’s community pharmacies (Table D-
A3). In both the USA and Australia improved clinical pharmacy education, a large and better
trained pharmacy technician force and modern electronic technology with automation have
grown to meet the challenges of expanded pharmacist roles, surging prescription volumes
and pharmacist shortages 46. Australia, New Zealand and the USA have from 64 to 70
practising pharmacists per 100,000 population 42,47.A survey of US community pharmacists
conducted in 2000 found their time was apportioned 56% to dispensing, 19% to consultation (
eg counselling) , 16% to business management and 9% to drug management including
prescription review and monitoring 49,51. Based on a US labour force model estimates of
increased total and younger female pharmacists per 100,000 were made 47,50. Mapping of
health providers and populations in rural areas by postcode (ZIP code) found localised
shortfalls of health providers suggesting pharmacists may substitute by providing more
primary health care services in these locations 48.
In the UK surveys of working pharmacists in 1997 and 1998 found trends from permanent to
locum work, to reduced hours of work and to dissatisfaction with community pharmacy work,
all of which add to the shortage of available pharmacists 52.
In Great Britain continuing pharmacy education (CPE) is included in the action phase of a
voluntary four-phase model of continuing professional development or CPD commencing
with (1) reflection, (2) planning, (3) action and concluding with (4) evaluation introduced in
200253,54. CPD requires minimally 30 hours annually of CPE. Of 427 respondent pharmacists
(25.6%) in a Northern Ireland survey54 under 1 % did 0 hours pa, approximately 90% did up
to 39 hours pa and about 15% over 40 hours pa. It was found recent graduates (post-1990) ,
females , those working in city, town and chain pharmacies most strongly favoured CPD
while pharmacists were apprehensive to over 30 hours mandatory CPE 54 . Two surveys of
mid-England pharmacists found a mean of 26.4 hours yearly (range 0-90 hours pa) with 43%
achieving 30 hours pa 55. All UK surveys found poor understanding of CPD. The nursing,
dental and medical councils in the UK are at stages of legislating mandatory CPD56.

Interpretations
From national surveys published since 2000 Australia’s fulltime community pharmacists
comprise mainly males who are older and part-time community pharmacists who are mainly
females under 36 years.
Respondents were mainly owners, partners and managers who were male, graduates from
NSW and Victoria, with one-third aged 50 years or more who spent more than 60 hours
annually on CPE or more than double the commitment reported by community pharmacists in
Great Britain. The term CPE needs to be standardised for comparisons to be valid.
Pharmacies outside of PhARIA 1 have older, fewer female and less qualified pharmacists,
owners and managers with a lower participation in CPE than those in PhARIA 1 pharmacies.
CPE commitment was 18% higher in respondents than owners (7.12 Versus 5.63 hours CPE
per month) . Each of these was much higher than either CPE hours reported by pharmacists

31
in Northern Ireland or England or the minimum of 2.5 hours monthly required under Great
Britain’s 2002 pharmacy CPD requirements. Australia’s national bodies should further
develop electronic, more accessible, practical and efficient forms of CPE for pharmacists
residing in rural and remote areas of Australia.
National and State bodies of pharmacy in Australia need to consider standardise CPE
commitment in hours monthly by owner and non-owner pharmacists for international and
time-series comparisons.

National estimates
These were based on percentages reported by respondents and included demographics,
qualifications, position held in pharmacy and CPE activities.

32
3.2 Section B Enhanced pharmacy services (EPS)
Question: 7
Statistical sources Tables 7.1 to 7.28.2 ( 56 tables)

Aim
To quantify the prevalence of trained staff, payment and planned growth of ‘enhanced
pharmacy services’ in Australia’s community pharmacies.

Background
Enhanced pharmacy services refer to those offered in community pharmacies requiring
additional or special skills, knowledge and/ or facilities and are provided to sub-groups with
special needs. They exclude services covered in the prescription-related (Sections D and E),
and OTC-related (Section F) and certain other activities in other sections of the
questionnaire. In Australia, many of these services such as wound management, hospital
discharge (or community liaison), cytotoxic drugs preparation and compounding are
recognised, defined and described for implementation in community pharmacies. 57 While
community pharmacies worldwide routinely provide the safe, effective and rational use of
medically prescribed , pharmacy- and self-selected medicines to all people 58, there is a
growing diversity of additional services which are being developed and remunerated in
developed countries. The main ones are included in Question 7.

Discussion of methods
Question 7 was compiled after consultation with the national panel, visits to pharmacies
across all Pharia zones in the large States and direct or telephone discussions with their key
staff , direct or telephone discussions with leaders of pharmacy bodies and pharmacy groups
and reference to a range of pharmacy business, practice and research journals published in
Australia and internationally. The question was tested in a focus group of pharmacists from a
variety of pharmacies in Pharia zones 1 and 2 and a nationwide sample of practicing and
specialist pharmacists in Pharia zones 1 to 6. The 28 services itemised in Question 7 were
drawn chiefly from defined activities in Australia’s pharmacies 57, reports in Australian
pharmacy journals, questionnaires from a State survey of pharmaceutical care services in the
USA 59, a national survey of pharmacies in the UK 60 and from exchanges with leaders in
pharmacy practice , teaching, research and administration in Australia and internationally.

Findings
Asthma, diabetes , community education, harm reduction with methadone, geriatric care,
herbal medicines/nutritional supplement counselling, hypertension, skin care management,
smoking cessation and weight reduction were the services reported to be provided by over
25% of Australia’s community pharmacies. Of these, trained staff were reported in over 14%
of pharmacies for herbal medicines/nutritional supplement counselling, smoking cessation,
harm reduction, asthma , diabetes and wound care .
2% or more of Australia’s community pharmacies planned to introduce enhanced pharmacy
services by July-September 2003 in the following order . Diabetes (8.1%) , asthma (5.9%),
naturopathy (4.7%), structured community education (3.8%) , smoking cessation (3.8%),
herbal medicines (3.6%), hypertension (3.5%), hyperlipidaemia (3.4%) , geriatric care (3.0%) ,
osteoporosis (2.8%) , community clinics with nurses (2.7%), wound care (2.7%) and weight
reduction (2.1%).
7.5% or more of pharmacies in the following order reported accredited or trained staff for
herbal medicines (23.2%), smoking cessation (19%), diabetes (17.2%), asthma (14.9%),
harm reduction (14.6%), wound care (14.3%), hypertension (13.3%) , skin care management
(11.1%) , geriatric care (9.2%), weight reduction (8.7%) , body piercing ( 7.5%) and
structured community education (7.5%). Only in the cases of harm reduction and body
piercing were higher percentages receiving fees .
6% or more of pharmacies in the following order received payment for harm reduction (31%),
body piecing (13%), specialised compounding (6.4%) and osteoporosis (6.3%) services.
Much lower percentages of pharmacies had trained or accredited staff for all but
osteoporosis services.

33
Only 13.1% of pharmacies reported other unlisted enhanced services including baby nurse,
massage, child care, chiropodist , compression stockings , constipation management , and a
range of other services. Many of these were reported in other sections in the questionnaire.

Pharia zone
Higher percentages of the enhanced services were reported consistently in Pharias 1 , 2 , 3
and 4 . The only services which occurred in significantly higher percentages in pharmacies in
Pharias 4, 5 and 6 were aboriginal health services and herbal medicines. This needs closer
study because smoking and obesity which are risk factors for cardiovascular and other major
chronic disorders are higher in indigenous and rural populations than in people living in areas
served by pharmacies in Pharias 1,2 and 3. Furthermore, the rates of other priority disorders
are also higher in people served by pharmacies in Pharias 4, 5 and 6 implying many
enhanced services relating to priority disorders should be equally represented in them.

Australia
These results are the first known national quantitative data on the range of enhanced services
provided in Australia’s community pharmacies. The evaluation and future remuneration of
enhanced services are being explored in Australia currently. These include services which
improve patient concordance, monitoring of effectiveness of therapy, educating patients on
the better management of their diseases, specialisation in diabetes, weight loss and asthma,
medication reviews in ‘at risk’ recently discharge patients from hospitals 61,62.
Australia’s national health priority areas (NHPAs) are based on the World Health
Organisation’s initiatives and adopted in July 1999. They have been widely promoted and
have been successful according to an independent review 63. These international and national
health priorities form essential references for the introduction of enhanced pharmacy health
services if pharmacies are to fulfil the health needs of the public. In Australia for example the
health priorities in 2003 are asthma, cancer, cardiovascular health, diabetes, injury
prevention, mental health and arthritis and musculoskeletal disorders 64. Probably the most
serious unmanaged risk factor is overweight and obesity which predisposes to type 2
diabetes, cardiovascular disease, osteoarthritis and cancer, all of which are which are health
priorities in this country. Overweight was evident in 6.5 million Australians in 2001 and is
increasing in adults regardless of gender or level of education 65. In comparison, wound
care a condition of much lower frequency than overweight, ranked fifth in both trained staff
and the percentage of pharmacies offering the service with or without payment. Its high
acceptance in community pharmacy practice demonstrates the successful organised
promotion of a pharmacy service which should be examined for applying to other under-
represented health priority services 66,67 .The 4.8% of pharmacies with community clinics and
nurses is probably an artificially low rate as it was found subsequently many pharmacies
engage nurses without necessarily having a community clinic. The role of nurses has in the
past decade expanded rapidly from government and private hospitals into rural, remote ,
aged care and domiciliary settings in primary health care 68 . Their ability to overcome hurdles
opens the way to a range of services such as vaccination and clinical testing in community
pharmacies which may be under-represented in pharmacies 69,70. More active roles in asthma
and related activities have been advocated for pharmacies in rural areas for almost a decade
71
.
International
The World Health Organisation’s international health priorities designated for 2002-2005 are
malaria, tuberculosis, HIV/AIDS, cancer, cardiovascular disease and diabetes, tobacco,
maternal health, food safety, mental health and safe blood 72.
Community pharmacies worldwide routinely provide the safe, effective and rational use of
medically prescribed , pharmacy- and self-selected medicines to all people 58 . Differences in
national health and social systems , consumer needs 73,74 and health priorities 75 are shaping
pharmacy practice in Australia 76-79 and other countries 58,80. As a result many services
performed by pharmacists and non-pharmacists have evolved in community pharmacies to
cater for the special needs of various subgroups in local populations. The effectiveness of
these services is being continuously analysed to identify those that are the most viable for
pharmacies 81-84. Cognitive pharmacy services, pharmaceutical care and disease
management are terms which connote distinct pharmacy services which are capable of
remuneration 61,85,86. In the USA the growth of ‘specialty drug’ pharmacies has focused on

34
drugs for patients with chronic, life-threatening conditions , requiring infusion, injection, or
other non-oral method of administration requiring a health professional, with special
conditions of storage and transport and entailing extensive patient education, clinical
monitoring , follow up and support with total costs for each drug exceeding $USD 10,000
yearly 87.

Table D-B7-1 . Enhanced pharmacy services offered in Australia’s community pharmacies by

trained staff, fees charged and planning in 12 months
(total respondents = 1131; missing = respondents did not tick any of the five possible boxes in the item row/1131)

Enhanced pharmacy Missing Does not Enhanced No Payment In 12

service cases offer service with charge months
trained staff
Aboriginal health 14.2% 81.2% 0.5% 2.4% 1.7% 1.2%
anticoagulation 16.5% 74.1% 2.0% 8.1% <0.1% 0.8%
Asthma 11.3% 43.4% 14.9% 38.3% 0.4% 5.9%
Body piercing 13.9% 69.6% 7.5% 1.4% 13.0% 0.8%
Chemotherapy preparation 15.5% 82.0% 1.1% 1.6% 1.1% 0.4%
Community education 15.2% 58.3% 7.5% 21.6% 1.3% 3.8%
Community clinic + nurses 15.2% 70.6% 4.8% 10.7% 0.8% 2.7%
Diabetes 10.1% 41.7% 17.2% 38.1% 1.6% 8.1%
Discharge for hospital 14.9% 70.1% 3.4% 11.2% 2.3% 1.9%
patients
Drug level monitoring 15.6% 79.1% 1.9% 3.8% 1.1 0.5%
Geriatric care 14.5% 56.9% 9.2% 9.2% 7.3 3.0%
Harm reduction and 10.4% 49.2% 14.6% 6.2% 31.5% 1.5%
methadone
Herbal medicines / 10.3% 34.0% 23.2% 45.1% 3.1% 3.6%
nutritional supplement
counselling
Hyperlipidaemia 14.8% 67.3% 4.5% 14.0% 1.5% 3.4%
Hypertension 11.8% 44.7% 13.3% 36.2% 3.5% 3.4%
Naturopathy 14.4% 62.5% 9.9% 15.2% 3.0% 4.7%
Nutritional support 15.4% 74.3% 3.3% 8.6% 0.9% 0.4%
including
parenteral/enteral nutrition
Osteoporosis 14.1% 62.5% 6.6% 14% 6.3% 2.8%
Ostomy counselling 16.0% 81.9% 0.4% 2.0% 0 0.4%
Paediatric pharmacy 14.8% 66.6% 5.0% 16.2% 0.3% 1.2%
Pain management 13.7% 65.6% 4.9% 18.4% 0.4% 1.3%
Psychiatric pharmacy 15.6% 76.5% 1.7% 6.7% 0.5% 0.4%
Skin care management 13.8% 52.9% 11.1% 28.5% 1.2% 1.3%
Smoking cessation 8.9% 36.1% 19.0% 46.8% 1.5% 3.8%
Specialised compounding 16.1% 66.4% 5.4% 8.7% 6.4% 1.3%
Weight reduction 12.8% 56.9% 8.7% 25.5% 1.6% 2.1%
Wound care 11.8% 45.8% 14.3% 35.5% 1.3% 2.7%
other 86.9% 3.5% 4.2% 3.4% 5.5% 0.8%

Interpretations
Australia’s community pharmacies have reported providing an impressive diversity of
enhanced pharmacy services. Few other services were provided which were not included in
this or other sections of the questionnaire. There are wide disparities between the high
prevalence of certain risk factors and disorders in Australia and the rates of provision of
pertinent enhanced pharmacy services by Australia’s community pharmacies. For example,
obesity in Australian adults now exceeds 20% of the population and is growing at rates
exceeding 5% per annum. Despite this, only 8.7% of pharmacies reported staff trained in
weight reduction, just 1.6% charged for the service and only 2.1% of pharmacies planned to

35
introduce the service by September 2003. Most of the enhanced pharmacy services occurred
at higher rates in pharmacies in Pharias 1,2 and 3 but aboriginal health services and herbal
medicines occurred more frequently in pharmacies in Pharias 4, 5 and 6. The disparities
between the high rates of smoking , substance abuse and obesity which are risk factors for
cardiovascular and other major chronic disorders are higher in indigenous and rural
populations than in people living in other areas. The rates of other priority disorders are also
higher in people served implying many enhanced services relating to priority disorders should
be equally represented in them. These large disparities in Australia need to be addressed by
our national pharmacy bodies. One step would be to evaluate these mismatches between
rates of risk factors or health disorders in each Pharia zone and compare the provision of
services reported by pharmacies in corresponding zones. Another approach is to provide
incentives for pharmacies to introduce and increase the utilisation of devices for screening
of risk factors for these health disorders high proportions of which (eg. obesity and type 2
diabetes) remain under-diagnosed and/or unmanaged.

National estimates
Percentage of Australia’s community pharmacies offering each service, with trained staff,
charging of fees and plan to introduce in the 12 months to July 2002 are reported for the first
time . These national reported percentages and future growth of the services may be
compared with Australia’s national health priorities in order for national bodies of pharmacy to
determine existing deficiencies and appropriate evaluation, educational or training initiatives.

36
3.3 Section C Barriers and facilitators of enhanced
pharmacy services
Questions : 8,9

Statistical sources : Tables 8.1.1 to 8.12.2 (24 tables); and Tables 9.1 to 9.7.2 (14 tables)

Aims : To measure the factors which act as the main barriers to and the main facilitators of
introducing or expanding the enhanced pharmacy services in Question 7.

Background
The concept of identifying barriers to and facilitators of health interventions, or novel disease
management, or preventive practices was introduced during the 1980s in the USA . In
Australia, little pharmacy research has been undertaken in this area.

Discussion of methods
Questions were compiled after consultation with the national panel, visits to pharmacies
across all Pharia zones in some States and direct or telephone discussions with their key
staff, direct or telephone discussions with leaders of pharmacy bodies and pharmacy groups
and reference to a range of pharmacy business, practice and research journals published in
Australia and internationally. Questions were compiled with particular reference to the
national survey of pharmacies conducted in Great Britain in 2000 88 and the barriers were
derived from surveys in Northern Ireland89 and the USA 90 . The questions were tested in a
focus group of pharmacists from a variety of pharmacies in Pharia zones 1 and 2 and a
nationwide sample of practicing and specialist pharmacists in Pharia zones 1 to 6.

Findings
The greatest barriers (Table D-C8) to the introduction of enhanced services in order of
declining priority were ‘lack of time’ (90.3%) , ‘shortage of pharmacists’ (78.3%) , ‘no extra
remuneration’ ( 63.3%), ‘cannot find locums’ (63.2%), ‘customers won’t pay’ (56.3%) and
‘cannot meet with local GPs and health workers’ ( 50.5%). The barriers most strongly
rejected for EPS were ‘not felt to be part of pharmacy job’ ( 71.5%) and ‘ may impair their
relations with local GPs’ ( 52.5%). The facilitators (Table D-C9) most strongly supported for
EPS were ‘ dedicated study time’ (77.9%), ‘accreditation’ (75.6%), ‘closed counselling areas’
(72.8%) and ‘access to patient notes’ (70.6%) . The highest combined resistance and
uncertainty were ‘appointment systems’ and ‘clinical testing area’ (Table D-C9). Only 5.0% of
all pharmacies offered other barriers and just 5.4% other facilitators . Thus those factors listed
in Questions 8 and 9 appeared to be comprehensive.

Pharia zone
Pharmacies (> 80%) in Pharias 2-6 strongly identified ‘shortage of pharmacists’ and ‘unable
to find locums’ as the major barriers to introducing enhanced pharmacy services . Pharmacies
in Pharias 4, 5 and 6 ( < 37%) were less concerned with ‘meeting with GPs’ or ‘GPs not
recognising their skills’ in comparison with pharmacies in other Pharias . Pharmacies in
Pharia 1 to 4 supported ‘access to patient notes’ , ‘closed counselling area’ and ‘accreditation’
as the most important facilitators for the introduction of enhanced pharmacy services
compared to pharmacies in Pharias 4,5 and 6.

Australia
No studies were found from Australian sources .

International
Lack of time is reported as the main barrier to providing enhanced services in British
pharmacies 88 and to pharmaceutical care in Northern Ireland 89 and the USA 90 , while lack of
resources in pharmacies was found to be the main barrier to pharmaceutical care in Danish
pharmacies 91. Further training was found to be the main facilitator in two studies88,91 and
external promotion of these services and changes in the operation in pharmacies were also

37
found to be important. Differences in study design and the object of the barriers and
facilitators in the studies limit the comparison between other studies and this national survey.

Table D-C8. Barriers to enhanced services reported by Australia’s community pharmacies in

2002

Barrier Strongly disagree unsure Strongly agree- No

- disagree agree response
Time shortage 7.3% 1.4% 90.3% 1.0%
Pharmacist shortage 11.8% 7.5% 78.3% 2.4%
Customers won’t pay 16.1% 24.8% 56.3% 2.8%
Cannot find locums 19.1% 13.9% 63.2% 3.8%
Lack knowledge/skills 44.2% 14.6% 38.5% 2.7%
Lack confidence 49.3% 16.4% 31.4% 2.9%
Not part of pharmacy job 71.5% 14.7% 11.3% 2.5%
No extra remuneration 20.7% 14.1% 63.3% 1.9%
Impair relations with local GPs 52.5% 26.2% 20.1% 1.2%0
Cannot meet with GPs or health workers 31.4% 16.3% 50.5% 1.8%
GP’s don’t recognise EHS skills 29.7% 25.0% 43.5% 1.7%
Other 0.5% 0.4% 4.1% 95.0%

Table D-C9.Facilitators for enhanced pharmacy services for Australia’s community

pharmacies in 2002

Facilitator Strong- unsure agree- Missing

disagree strong
Access to patient notes 11.5% 14.9% 70.6% 2.6%
Closed counselling area 15.8% 9.5% 72.8% 1.9%
Clinical testing area 14.3% 17.5% 65.4% 2.7%
Appointment systems 16.2% 20.3% 60.6% 2.8%
Accreditation 10.8% 11.4% 75.6% 2.2%
Study time 8.4% 11.8% 77.9% 1.9%
other 0.3% 0.3% 4.8% 94.6%

Interpretations
The results show agreement on barriers and facilitators in Australia’s pharmacies and
identify factors that, if addressed, may facilitate the increased provision of enhanced
pharmacy services. The major barriers were lack of time and shortage of pharmacists. The
major facilitators were dedicated study time, accreditation, closed counselling areas and
access to patient notes.

National estimates
Pharmacies which selected barriers to, or the facilitators of, enhanced pharmacy services are
grouped as percentages of those who agree or strongly agree, who are unsure, or who
disagree or strongly disagree. The major barriers were lack of time and shortage of
pharmacists. The major facilitators were dedicated study time, accreditation, closed
counselling areas and access to patient notes.

38
3.4 Section D Prescription related activities in community
pharmacies
Questions : 10a - 13c

Statistical sources : Tables 10a to 13c-2.2 (73 tables)

Aims
To quantify the number, nature, external dispensing, supervised dosing, reasons for declining,
counselling type and monitoring activities of prescriptions dispensed by Australia’s community
pharmacies

Background
In Australia, guidelines for dispensing practice, providing medicines information and the terms
prescription, dispensing , counselling , consumer medicine information (CMI) , dose
administration aids and mail order dispensing, are defined for pharmacists 92. For example
CMI is brand-specific manufacturer-produced written information about drug products which
conforms with special provisions set out in Therapeutic Goods Regulations. All prescription
and pharmacy-only medicines will have CMI by December 2002 92. Dose administration aids
(DAAs) are compartmentalised boxes or blister-pack devices used to aid the administration of
solid, oral medications and mail order dispensing refers to the process where a pharmacist
receives and dispenses a prescription and the medication is delivered by mail 92 . Limited
data have been reported on the utilisation or occurrence of these prescription-related
activities for the existing or new types of medication review services or devices performed in
Australia’s community pharmacies.

Discussion of methods
Questions were compiled after consultation with the national panel, visits to pharmacies
across all Pharia zones in some States and direct or telephone discussions with their key
staff, direct or telephone discussions with leaders of pharmacy bodies and pharmacy groups
and reference to a range of pharmacy business, practice and research journals published in
Australia and internationally. For example, Questions 11a and 11b were produced with the
advice from a pharmacist specialising in DAAs in Australia. The questions were tested in a
focus group of pharmacists from a variety of pharmacies in Pharia zones 1 and 2 and a
nationwide sample of practicing and specialist pharmacists in Pharia zones 1 to 6. The
standard equation (LCI x 4447) for national 12 months estimates was applied (Section
1.4.7) in Table D-D10a. For the national estimates in Tables D-D10b d ,D-D11a, D-D11c, D-
D11e, D-D12, D-D13a, D-D13b and D-D13c. For the national estimates per day or seven
days, the LCI was multiplied by the total of 4824 pharmacies (Table 1.1) . The number of
items dispensed per prescription / patient needs to be ascertained in order to standardise the
rates of DAAs issued (Table D-D11a) , prescription activities (Table D-D13 a), counselling in
written , verbal, or other forms (Table D13b), compliance activities (Table D-D13c) and
assessing drug effects ( Table D-D13c). In the absence of available data and for the
purposes of standardising the following national estimates, we adopted a mean of 2.5 items
per prescription form or per patient with prescription forms on each occasion of dispensing.
This equates to 85.8 million occasions of dispensing per annum. Furthermore, for many of
the standardised results in the following tables, the numerator of 85.8 million needs to be
regarded carefully because an unknown proportion of prescription medicines are dispensed
for external patients in residences, private hospitals, aged care and other facilities. If this total
of prescriptions for external patients for example constituted approximately 20% of the total
then the standardised figures need to be increased accordingly.

Findings
The conservative national estimate of 214.516 million prescriptions (Table D-D10a) was found
to be close to the national total prescriptions dispensed in 2001 and 2002 as estimated by
the Drug Utilisation Subcommittee or DUSC (Table D-D10). The DUSC total is based on
prescriptions remunerated by the Health Insurance Commission and two ‘survey’ figures
estimated from data provided by a national sample of pharmacies organised by the Pharmacy

39
Guild of Australia. The DUSC total excludes S100 prescriptions which are not remunerated by
the HIC. For accurate adjustments, the total of full time pharmacy equivalents and less
conservative estimates of the mean may need to be applied. The results for national
estimates in seven days of mail, distance and delivery prescriptions dispensed are the first
known figures (Table D-D10b-d).

The results for national estimates in seven days of DAAs provided to patients in the different
types of aged care and community settings are the first known to be reported (Table D-
D11a). DAAs are used for more than one patient weekly in 78.1% of Australia’s community
pharmacies. There are approximately 3300 residential aged care facilities in Australia . Many
pharmacies provide services and DAAs to a number of facilities. Nursing home patients are
immobile whereas many hostel patients are mobile often resulting in patients in the one
hostel having their medications dispensed by more than one pharmacy. The 29.5% and
40.3% of pharmacies who respectively provided more than one patient weekly with DAAs in
nursing homes and hostels may reflect the differences in patient mobility with hostel patients
possibly obtaining DAAs from different sources (Table D-D11a). DAAs were issued to an
overall estimated total of 9.19 million patients in 12 months or a rate or 10.71 DAAs per 100
prescriptions/ dispensing occasions per annum, or alternatively 189,719 patients weekly
overall in all settings receive DAAs (Table D-D11a) . If these totals are validated by detailed
studies then they reflect the emergence of a major activity in pharmacy practice. The fee
charged for DAAs varies by patient setting. High proportions of pharmacies do not charge for
providing DAAs (Table D-D11b). This is an issue which needs to be examined in detail
particularly if controlled studies demonstrate the cost-effectiveness of DAAs 93.

Table D-D10. Total prescriptions (millions) by category : Australia 1999-2002

(DUSC, 2003)
1999 2000 2001 2002
PBS/RPBS concession/ safety net 114.589 120.54 127.091 137.875
PBS/RPBS doctors 0.520 0.480 0.466 0.441
PBS/RPBS general 19.543 21.81 23.426 20.017
PBS/RPBS ostomy 0.107 0.011 0.001 0.0012
PBS/RPBS Repat 11.562 12.483 13.484 14.617
Survey private 12.404 13.286 14.397 16.014
Survey under-co-payment 32.319 31.736 31.603 27.616
Total 191.044 200.346 210.477 216.581

Table D-D10a. Total prescriptions dispensed in Australia’s community pharmacies in 2002

Prescriptions weekly Monthly Prescriptions yearly Percentage of pharmacies
0 to 300 0-1300 0-15600 6.8
301 to 800 1301-3467 15601-41600 39.7
801 to 1200 3468-5200 41601-62400 27.1
1201 to 2000 5201-8667 62401-104000 19.5
2001 to 3000 8668-13000 100401-156000 4.7
3000 or more 13001- 156001 - 0.5
No response No response No response 1.7
Total Total 214,515,809 Total

Table D-D10b-d. Australia’s community pharmacies by number of patients with mail,

distance and delivery prescriptions per typical seven days

Type of % active Estimated number per National estimate of

prescription pharmacies seven days (LCI) patients per seven days
Mail 14 0.32 1,543
Distance 42.5 2.92 14,086
Delivery 91.3 9.52 45,924

40
 Table D-D11a. Australia’s community pharmacies by patients in aged care and community
settings issued with dose administration aids per typical seven days

Aged or % active Estimate for National estimate National estimate

community Setting pharmacies seven days for seven days per annum
(LCI) (million)
Nursing home 29.5 12.44 60,010 2.877
Hostel 40.3 13.26 63,966 3.066
Community 80.6 13.62 65,702 3.150
Remote clinics 2.8 0.42 2,026 0.097

Table D-D11b. Australia’s pharmacies which charged fees by DAA per patient-week and unit
pack for patients in aged care settings

Best estimate of mean Pharmacies with nil charge (%)

Nursing $2.75 50.7
Hostel $3.00 47.7
Community $3.30 38.6
Remote NA 55.5

The percentage of pharmacies where supervising dosing of patients with a range of drugs
takes place more than once weekly and the total cases of supervised dosing occurring
nationally in Australia’s pharmacies show the emergence of an important pharmacy practice
activity in this country. It appears up to 50% of Australia’s community pharmacies perform
supervised dosing of at least one of the five categories of drugs included in the survey each
week. It was reported that 31% of Australia’s pharmacies in May 2000 were approved to
participate in methadone maintenance programs involving the supervised dosing of
methadone liquid 94. In comparison the total of 46.7% of pharmacies in this study reported
supervised dosing of methadone and/ or buprenorphine more than once weekly implies a
marked increase in participation rates by pharmacies in opioid replacement programs since
May 2000. At least 80% of the pharmacies do not appear to charge for supervised dosing
therefore the reported fees for supervised dosing were estimated from data from pharmacies
which reported charging (Table D-D11d ).

Table D-D11c. Australia’s community pharmacies by drugs and patients with supervised
dosing per typical seven days in pharmacy

Drugs % active pharmacies % pharmacies Pharmacy per National estimate

(>0 per week) (>1 per week) seven days per seven days
(LCI)
Analgesics 21.4 17.3 0.82 3,956
Benzodiazepines 35.9 26.9 1.09 5,258
Buprenorphine 12.5 11.1 0.56 2,701
Methadone 38.1 35.6 2.48 11,963
Other psychotropics 12.6 9.6 0.42 2,026
Other agents 5.0 3.8 NA NA

Table D- D11. Australia’s community pharmacies by reported fees charged per supervised
drug ( mean for fees was skewed hence estimates for active charging pharmacies reported)

Analgesics Benzodiazepines Buprenorphine Methadone Other agents

Estimated 1.50 1.50 4.30 4.00 1.00
mean fee ($)
% invalids, nil and 97.5% 96.7% 89.9% 58.5%; fee 0
invalid charges subsidised in ACT

41
 An estimated conservative total of 1.075 million patients were declined prescriptions in
pharmacies during the previous 12 months for inappropriate drug/s or doses, suspected
adverse effects or prescription defects (Table D-D12) . Of these, an estimated 59.5% or 0.64
million patients during 12 months were declined for reasons of inappropriate drug/s or dose,
or suspected adverse effects .In total, a rate of 12.5 per 1,000 patients were declined their
prescriptions . The rates of pharmacies declining prescriptions at least once weekly for each
of these reasons were 40.9%, 30.7% and 39.3% equating to estimated weekly numbers
nationally of 7574, 5789 and 9069 in each category totalling 22,432 prescriptions declined
weekly in Australia’s pharmacies (Table D-D12) .

Table D-D12. Australia’s community pharmacies by patients in past seven days with
prescriptions declined

Prescriptions declined % active Each pharmacy National estimate National Declined

for following reason pharmacies per seven days per seven days estimate pa per 1000
(>1 weekly) (LCI) (million) Patients*
Drug, dose, interaction, 40.9 1.57 7,574 0.363 4.2
contraindication
Adverse effect 30.7 1.20 5,789 0.277 3.2
Prescription problem 39.3 1.88 9,069 0.435 5.1
* each patient with 2.5 prescribed drugs dispensed

An estimated total of 14.19 million patients with prescriptions or approximately 18 per 100
were provided with computerised or written counselling in the 12 months prior . This was in
addition to the verbal counselling , labelling and other forms of standard activities along with
DAAs provided in pharmacies during the 12 months period (D-D13a ) . CMIs were provided
in a computerised form by 74.2% of pharmacies to one or more patients daily, with the
majority providing in excess of 5 patients daily with CMIs. In addition, an estimated 3.17
million non-or-poor English speaking patients or 3.7% of the estimated 85.8 millions patients
with prescriptions received counselling. Written information produced by computer
programmes other than CMIs were provided by 51.2% of pharmacies to one or more patients
daily. Other written or printed drug information were provided by 51.8% of pharmacies to one
or more patients daily .

Table D-D13a. Australia’s community pharmacies by counselling category per typical day

Counselling type % pharmacies Pharmacy National National estimate Per 100

( >1 daily) daily (LCI) estimate daily per annum (mill) Patients#
Poor English 34.6 2.22 10,709 3.17 3.7
CMI computerised information 74.2 4.73 22,818 6.76 7.9
Other computer information 51.2 2.98 14,376 4.26 5.0
Written or printed information 51.8 3.04 14,665 4.35 5.1
Closed area 19.0 1.43 6,898 2.04 2.4
Unenclosed area 67.8 8.59 41,438 12.28 14.3
Forward pharmacy 7.0 0.07* 338 0.10 0.1
MAS (health insurance) 2.5 0.16 772 0.23 0.3
Other 1.9 NA NA NA NA
*>31/day; #* each patient with 2.5 prescribed drugs dispensed

An estimated total of 16.8 per 100 patients prescriptions were counselled in unenclosed ,
enclosed or forward pharmacy areas . Only 19% of pharmacies provided counselling in a
closed counselling area one or more times with the majority of these counselling five or more
times daily and 67.8% of pharmacies counselled in a private unenclosed area with the
majority of these doing so 15 or more times daily. Counselling in forward pharmacy areas
occurred 31 times or more daily in 0.07% (approximately 34) of Australia’s pharmacies. The
percentage responses to this item need to be reconciled with the percentages of pharmacies
reported to have forward pharmacy areas in Question 26. Pooling the data for counselling in
the three identified areas, the mean value indicates 25,087,361 patients (dispensing

42
 occasions) were counselled per annum in private in community pharmacies. Just 2.5% of
pharmacies in Australia are paid for counselling one or more patients daily with prescription
medicines through the MAS or other health insurance schemes suggesting this form of
payment to pharmacies is in its infancy in Australia.

Verbal questioning for monitoring compliance occurs one or more times daily in 82.7% of
pharmacies with the LCI mean 19.22 patients daily (Table D-D13b). Monitoring compliance
through repeat prescriptions occurs in at least one patient daily in 85% of pharmacies with the
LCI mean 26.51 patients daily. A total 26.9% of pharmacies monitor compliance by repeats in
41 or more patients daily and 16% in more than 80 patients daily. Monitoring by repeat
prescriptions is the most frequent (and convenient) form of monitoring prescription drugs in
Australia’s pharmacies. Dose administration aids (DAAs) have emerged as devices for
enhancing compliance with 60.5% of pharmacies reporting use of DAAs for monitoring
compliance in more that one patient daily. The results show more than the LCI mean 16.69
patients per day have their drugs monitored by DAAs and 14.5% of pharmacies now monitor
compliance with DAAs in 41 or more patients daily and 5.5% in more than 81 patients daily
using DAAs. This result is consistent with the high rate of almost 80% of pharmacies which
now package prescription medicines for community based patients with DAAs one or more
times weekly (refer to Table D-D11a).

Table D-D13b. Australia’s community pharmacies by patients and monitoring for compliance
activities in typical seven days

Method of monitoring % active Estimate for typical National estimate National Per 100
compliance pharmacies seven days per seven days estimate pa Patients*
(>1 daily) (LCI) (mill)
questions 82.7% 19.22 92,717 4.44 5.2
Repeats 85.0% 26.51 127,884 6.12 7.1
DAAs 70.6% 16.69 80,512 3.86 4.5
Other 1.5% NA NA NA NA
* each patient with 2.5 prescribed drugs dispensed

Most pharmacies monitor patient responses to therapy by questioning patients or their carers
The use of methods other than verbal assessment to monitor the effects of prescribed therapy
in patients( Table D-D13c) show 45.4% of pharmacies monitor drug effects with the use of
clinical testing devices such as weight scales, blood pressure and glucose meters more than
once daily with 18.3% using devices for 6 or more patients daily in a typical period of 7 days.
Adverse effects in patient files are used for 6.4 patients per 1000 of whom half or 3.2 per
1000 were reported to have had their prescriptions declined for adverse effects (Table D-
D12). The application of clinical testing devices for clinical monitoring in diagnosed and
managed patients, complement the pharmacies with clinical testing devices reported for the
purpose of screening clients who are neither diagnosed or receiving treatment (Table D-G18).

Table D-D13c. Australia’s community pharmacies by methods for assessing drug effects in
past seven days

Method for % pharmacies Estimate in typical National National Per 1000

assessing drug >1 daily 7 days (LCI) estimate per estimate per Patients*
effects seven days annum (mill)
Clinical testing 45.4 2.45 11,819 0.57 6.6
Laboratory results 5.6 0.22 1,061 0.05 0.6
Adverse effects in 55.1 2.38 11,481 0.55 6.4
patient files
Other 1.5 NA NA NA NA
* each patient with 2.5 prescribed drugs dispensed

43
Only 5.7% of pharmacies reported using laboratory results for monitoring the effects of drugs
in one or more patients weekly. These results are presumably made available by doctors to
be used by pharmacists accredited to conduct DMMRs or other forms of medication reviews
and are available to the pharmacist for assessing patients’ therapies. Adverse effects to drugs
now have a legal importance as well as being an important aspect of patient care. The
recording of adverse drug reactions is necessary to prevent adverse effects from worsening
or recurring with repeat dosing of offending drugs. 55.2% of pharmacies now record adverse
effects in patient files with 11.2% recording these in 6 or more patients weekly.

Pharia zone
Most ( 60% or more) pharmacies in all Pharia zones provided DAAs to 50 or less patients
weekly in nursing homes, hostels , community settings or remote health clinics. Supervised
dosing occurred one or more times weekly in 15-18% of pharmacies in all Pharia zones for
analgesics, 16-30% for benzodiazepines, 4-13% for buprenorphine, 27-46% for methadone
and 8-12% for other psychotropic agents with pharmacies in Pharias 5 and 6 being
consistently lowest. Between 24-40% of pharmacies in all zones declined prescriptions for
one or more patients per week for inappropriate doses and drugs, suspected adverse effects
and for defects in prescriptions.
Six or more non-poor English speaking patients with prescriptions per day were counselled
from 1-5% of pharmacies in Pharia zones 2 to 6 and in 18% of pharmacies in Pharia 1. Six or
patients with prescriptions daily received CMI computerised in 19-28% of pharmacies in
Pharias 1-6, other computer produced information in 9-16% of pharmacies in Pharias 1-6,
other written or printed information in 7-14% of pharmacies with pharmacies in Pharias 5 and
6 providing the least in each category. Six or patients with prescriptions daily were counselled
or administered medicines in closed counselling areas in 5-9% of pharmacies in Pharia
zones 1 to 6 , unenclosed private counselling areas 39-43% of pharmacies in Pharia zones 1
to 6, in forward pharmacy areas in 12-25% of pharmacies in Pharia zones 1 to 6, counselling
paid by MAS or other health insurance in 1-2% of pharmacies in Pharia zones 1 to 6.
Compliance was monitored by questions in one or more patients daily with prescriptions in
73-89% of pharmacies, by repeats in 76-90% of pharmacies, by DAAs in 58-80% of
pharmacies, in Pharia zones 1 to 6.
Therapeutic and adverse effects were monitored with clinical testing devices in one or more
patients with prescriptions weekly in 2-7% of pharmacies, with laboratory test results in 2-7%
of pharmacies and adverse reactions recorded in files in 47 to 59% of pharmacies in Pharia
zones 1-6. The percentage of pharmacies was consistently lowest in Pharia zones 5 and 6.

Australia
Totals of prescriptions dispensed by Australia’s pharmacies are estimated by the Drug
Utilisation Subcommittee (DUSC) from a combination of the number of prescriptions
remunerated by the Health Insurance Commission and data on prescriptions submitted by
regular surveys of pharmacies conducted since 1999 by the Pharmacy Guild of Australia.
Totals of dispensed prescriptions have grown from an estimated 190 million in 1999 to 216
million by 31 December 2002 in Australia ( Table D-D10). From 1999 to 2001 general
prescriptions grew by 20%, Veterans Affairs by 17% , private by 14% and concession
prescriptions by 11% (Table D-D10).
The use of DAAs in medication management is supported by literature and survey evidence
collated by Australian researchers 93. The rate of supervised dosing in pharmacies has grown
substantially from just those involved in Australia’s methadone maintenance programs94 to a
higher percentage regularly supervising dosing the wide range of drugs reported in this
national survey (Table D-D11). A national survey of Australian GPs found an estimated 7.0%
of 104, 700 GP-patient encounters involved non-English background patients95. Little data
exist on the rates of prescription or medication errors, adverse drug reactions or doctor-
pharmacist communications in patients in primary health care 96. Medication management is
improved by collaboration between doctors and pharmacists which is enhanced by
communication and good inter-professional relationships 97. Pharmaceutical company
produced CMIs were introduced in Australia in 1993 as brand-specific, written information
about prescription and pharmacist-only medications in either a one-page package insert or
computer-generated printout. A focus group study found CMIs were long, too technical and
the font size too small and pharmacists were advised to use CMIs as a counselling tool and

44
tailor their advice to optimise the use of medicines 98. Face-to-face counselling with the
patient is the most acceptable way legally to clarify patients’ concerns and to avoid serious
dispensing errors 99.

International
74% of Great Britain’s pharmacies dispensed up to 5000 prescriptions in an average month100
compared with 73.6% of Australia’s pharmacies which reported dispensing up to 1200
prescriptions in a typical seven days or up to 5,142 monthly (Table D-D10a). In the USA an
estimated three billion prescriptions or approximately 11.1 per capita were filled by
pharmacies in 2000 10 which is close to Australia’s estimated 10.5 per capita (Tables D-D10
and D-D10a).
UK pharmacists are under-reporting adverse drug reactions to national authorities 101. In order
to improve adherence with long-term medicines DAAs, appointment reminders and
counselling both patients and their carers were effective while clear verbal and written
instructions achieved adherence with medicines in the short-term (< two weeks)102-104.
Adverse drug events to prescribed medicines were found in 25% of 600 primary care “not ill”
patients older than 18 years of which 1.7 of 3.6 (47%) per 100 patients had preventable
serious adverse effects105. Activities to prevent adverse drug effects included better patient-
doctor communication, educational materials, translation services , web sites for patients for
drug information and allow email contact with prescribers, e -prescribing to dispensing
pharmacies to facilitate more counselling time and better access by patients to pharmacists
who should more actively question patients about drug effects105,106. The above contemporary
activities are reflected in the following results (Tables D-D10-13 and D-DK22b and 23). One
US study found 34.7% of a sample of pharmacies counselled one or more patients daily with
poor or little English comprehension 107. A study of dispensing errors reported to the Institute
for Safe Medication Practices in the USA concluded face-to-face counselling is required for all
new prescriptions, all prescriptions for warfarin and methotrexate because of the number of
fatalities resulting from errors and from asking patients to repeat back important
information108. A study which observed 747 clients presenting NHS prescriptions in 30 English
pharmacies from September 2001 to January 2002 found 103 (13.8%) received unsolicited
counselling and another 30 (4%) were counselled only after prompting the pharmacist and six
pharmacies gave no advice during the study period and the percentage of patients receiving
advice ranged from 0 to 66.7%109. Just 10.7 % of those using prescription collection services
received advice compared with 20.2% of those directly presenting prescriptions109. The type
of pharmacy resulted in different frequencies of advice with just 7.7% of those in supermarket
pharmacies and 27.3% of clients in a small chain of English pharmacies receiving advice 109.
Much higher rates of changes to prescribed doses and drugs and drug discontinuations were
achieved by pharmacists working closely with medical practices110. A study of 141
pharmacies in Holland compared characteristics of “prescriptions that were modified” with a
sample of “nonmodified prescriptions” found at least 30% of pharmacies each corrected 2.8
prescription medicines daily because of clinical consequences which was extrapolated to
4400 prescriptions nationally a day of which 71.8% involved a clarification with the prescriber
111
. This rate compares with Australia’s reported 22,432 estimated patients in pharmacies
who had declined prescriptions in seven days of whom 40.4% involved a prescription defect
(Table D-D12) . Precise comparisons between the above results is not possible . Studies
therefore need to be designed to quantify the rate and nature and combinations of counselling
methods actually occurring in Australia’s pharmacies and to compare verbal and non-verbal
methods in terms of prescription interventions in pharmacies and outcomes for patients.
The use of clinical testing devices in pharmacies according to Australian standards 112 may
help to overcome the barrier to de-scheduling of Schedule 4 agents to S3 status. In the USA
the 1951 Durham-Humphrey Amendment to the Food, Drug and Cosmetic Act requires orally
administered drugs to have “….their effects monitored by a health professional..” to enable
medically prescribed drugs to be eligible to be deregulated to over-the-counter drugs 113 . That
is, if potent but relatively safe orally administered S4 drugs such as the statins
(HMgCoaReductase inhibitors) have their effects monitored they may be eligible for over-the-
counter status. This is being fought for by manufacturers in the USA 113. If clinical testing for
monitoring purposes therefore became widely and frequently performed in community
pharmacies, then the case for widening the range of S3 and pharmacy medicines avail;able
in pharmacies would be strengthened.

45
In the USA studies of fatal or serious medical errors show prescription errors outnumber all
other types (eg in surgery, diagnoses) 114.The Institute for Safe Medication Practices was set
up after 1990 to be a centralised collection of information on medication errors in the USA
which are analysed, reported , with methods recommended to reduce errors and to evaluate
the effectiveness of these methods which include computerised prescribing, prohibiting hand
written prescriptions and clearly identifying high-alert drugs115. In Australia, continuous quality
improvement (CQI) refers to monitoring and assessing clinical practice to identify
opportunities for improvement and change to reduce risk.The PSA has reported CQI
guidelines to be adopted in prescription related activities and other aspects of pharmacy
practice 96.

Interpretations
Australia’s community pharmacies have reported a wide range of data supporting the nature
and frequency of the services provided with prescription drugs. The high widespread
provision of DAAs by most pharmacies often at no charge needs to be assessed for the
implications for improved medication use and addition to the associated PBS dispensing fee.
Similarly, the less widespread practice of supervised dosing for a growing range of drugs
needs to be assess also for the implications for improved medication use and addition to the
associated PBS dispensing fee. The medication care activities in Australia’s community
pharmacies are corroborated by the 7.4 per 1000 clients reported to have prescriptions
declined for therapeutic reasons and 5.1 per 1000 for other prescription defects. Counselling
for 14.7% of clients in unenclosed and 2.4% in enclosed and another 0.1% in forward
pharmacy areas. Counselling for non-poor English speaking occurs in 3.7% of clients.
Monitoring for compliance occurs with questions in 5.2%, checking repeats in 7.1%) and with
DAAs in 4.5% of patients with prescriptions. Effects of therapy are assessed by clinical testing
in 6.6 per 1000 patients, laboratory results in 0.6 per 1000 patients and with files for adverse
effects in 6.4 per 1000 patients with prescribed medications . The results suggest that
pharmacies which hold files on adverse effects for patients may be contributing substantially
to the 3.2 per 1000 patients declined prescriptions for suspected adverse effects. The rates
of verbal counselling and the combinations of counselling aids either with verbal counselling
or individually need to be ascertained by studies specifically for this purpose. Similar
percentages of pharmacies in all Pharia zones performed these various prescription related
activities with the percentage consistently lowest in Pharia zones 5 and 6.

46
3.5 Section E Medication review processes
Questions: 14a - 14f
Statistical sources: Tables 14a- 14f (14 tables).

Aims
To quantify the nature and rates of medication services provided to patients outside to
pharmacies

Background
In Australia a simple medication review is carried out at the time a medicine is dispensed
without the benefit of specific clinical information 116 . Comprehensive medication review
refers to a systematic evaluation of a resident’s/patient’s complete medical treatment regimen
in the context of other clinical information and the resident’s/patient’s health status. It is a
process which is conducted with the resident/patient in collaboration with other members of
the health care team and involves communication of, and follow-up on findings and
recommendations. It facilitates application, by pharmacists, of special skills and knowledge to
support and assist other health professionals and contribute to the care of residents/patients
by ensuring quality use of medicines 116 . The quality use of medicines 116 constitutes use that
is judicious (only when necessary with non-medicinal alternatives considered), appropriate
(taking into account medical conditions, risks and benefits, duration and cost), safe
(minimising misuse, including over and under use), and efficacious ( achieves the goals of
therapy and delivers actual benefits to health outcomes). Pharmacy services to residential
care facilities includes (i) dispensing, supply and distribution of medications; (ii) provision of
information and advice about drugs, with the primary objective being the promotion of quality
use of medicines ; and (iii) pharmacists responding to residents’ medication-related needs to
help them achieve desired health outcomes. A domiciliary medication management review
(DMMR) service is a consumer-focused, structured and collaborative health care service
provided in the community setting, to optimise quality use of medicines and consumer
understanding. It involves the consumer, their general practitioner, pharmacist and other
relevant members of the health care team, such as community nurses or carers116 .

Discussion of methods
Questions were compiled after consultation with the national panel, visits to pharmacies
across all Pharia zones in some States and direct or telephone discussions with their key
staff, direct or telephone discussions with leaders of pharmacy bodies and pharmacy groups
and reference to a range of pharmacy business, practice and research journals published in
Australia and internationally. Questions were compiled with the assistance of researchers in
the panel and interstate and overseas experienced in these activities. The questions were
tested in a focus group of pharmacists from a variety of pharmacies in Pharia zones 1 and 2
and a nationwide sample of practicing and specialist pharmacists in Pharia zones 1 to 6. For
national estimates of monthly rates in Table 14d yearly rates were based on the most
conservative estimate or the LCI (lowest Confidence Interval), excluding pharmacies with ‘no
response’ or ‘none at all’ and multiplying by the 4447 pharmacies operating for the full 12
months. Some of the following results can be reconciled with recently published data 117.

Findings
The following results pertain to pharmacies reporting in July to September 2002. The
numbers of providers of the various medication reviews being approved were increasing
rapidly hence the following estimates need to be considered in the context of this rapid
growth. A total 53.7% or 2590 pharmacies reported supplying medicines to aged care
facilities ( Table D-E14a). An estimated total of 145,182 beds by type of aged care facility
were supplied in the 12 months prior ( Table D-E14b). Numbers of private beds in public
hospitals are supplied by hospital pharmacies. A total 50.8% or an estimated 2450
pharmacies were approved for DMMRs ( Table D-E14c). The estimated beds or cases by
medication review or supply process are recorded in Table D-E14d. The frequency
distributions of DMMRs , medication reviews in aged care facilities and S100 supply of
medicines reflect activities in progress for some years whereas the frequency distributions for
the other review processes signify activities in their infancy (Tables 14d.1-7, Database) . Both

47
S100 and enhanced primary care case health assessment received 1% or less pharmacies
responding which is at or below the lowest percentage for reliable estimates to be made (refer
Section 1.4 methodology). The S100 scheme for supplying Aborigines in remote areas of
Australia with medicines at a reduced rate and the medicines are generally provided through
a local Aboriginal health service. A total 56% or an estimated 2701 pharmacies reported
having access to an AACP-accredited pharmacist (Table D-E14e). The reported position of
the AACP-accredited pharmacist in pharmacies is recorded in Table D-E14f.

Table D-E14a. Australia’s community pharmacies by those supplying medicines to aged care
facilities in July-September 2002

Status Percentage Estimated total#

Yes 53.7 2590
No 45.7 2205
No response 0.6 29
# 4824 pharmacies by % responded

Table D-E14b Australia’s community pharmacies by beds supplied and type of aged care
facility in 2002

Type of facility Mean sd Median * Valid response Estimated Total beds

total # 1999-00
(AIHW,2002)
Nursing homes 35.9 85.7 16.0 47.8% 76,311
Hostels 26.0 44.5 15.0 50.1% 57,927
Private hospitals 10.3 41.0 0.0 23.8% 10,901 25,246
other 9.3 28.5 0.0 10.4% 43
Total 145,182
*Results skewed therefore median calculated
# 4447 x by % responded by mean

Table D-E14c Pharmacies by HIC approval for Domiciliary Medication Management Reviews
in July-September 2002

Approved Percentage Estimated total#

Yes 50.8% 2450
No 43.6% 2103
Don’t know 2.6% 125
No response 3.1% 150
# 4824 pharmacies by % responded by mean

48
 Table D-E14d Australia’s community pharmacies and patients by medication review (MR)
process monthly during 2002

Review Process Percentage Percentage Beds or cases Total beds

pharmacies pharmacies active monthly or cases
involved (≥ 1 per month) (LCI ) monthly#
(≥ 0 per month)
Home medicine reviews or 24.5 16.5 1.30 1416
DMMrs
Medication management 19.7 16.4 3.37 2952
reviews in aged care
facilities
Enhanced primary care 10.9 5.8 0.43 207
multidisciplinary care plan
Enhanced primary care case 3.7 1.6 0.06 10
conference
Enhanced primary care Case 2.6 0.8 0.03 3.5
health assessment
S100 for aborigines 2.1 1.0 0.14 13
Other medication reviews 0.6 NA
# 4447 x by % involved (≥ 1 per month) x LCI

Table D-E14e . Pharmacies by access to Australian Association of Consultant Pharmacy

accredited pharmacist in July-September 2002

Access to AACP pharmacists Percentage Total#

Yes 56.0 2701
No 35.2 1698
Don’t know or no response 8.5 410
Total pharmacies with access 56.0 2701
# 4824 by percentage

Table D-E14f. Position held with AACP-accredited pharmacist in Australia’s community

pharmacies with access in July-September 2002

Position in pharmacy % Estimate#

Proprietor 15.3 413
Manager 2.2 59
Employee full-time 2.5 68
Employee part-time 4.6 124
Consulted or contracted 26.9 727
Other and no response 48.5 1310
Total with AACP-accredited pharmacists 51.5 1442
# 0.56 x 4824 = 2701 by percentage

Pharia zone
Only 31% pharmacies in Pharia zone 1 supply medicines to aged care facilities or private
hospitals compared higher percentages up to 84% of pharmacies in Pharia zone 4 whereas
56% of pharmacies in Pharia zone1 and 55% in Pharia zone 2 are registered with the HIC as
DMMR providers .

Australia
Studies concluded before 2000 in three States of Australia demonstrated the benefits of
comprehensive medication review by pharmacists in aged care facilities and residences118-121.
Pharmacies were able from 1997 to engage and be remunerated for pharmacists accredited
by the Australian Association of Consultant Pharmacy or the Society of Hospital Pharmacists
of Australia to perform comprehensive medication reviews in residential aged care facilities

49
and since 1 October 2001 to perform Domiciliary Medication Management Reviews 117 . The
subsequent development and promotion of programs with pharmacists accredited to perform
comprehensive medication reviews specifically for patients in residential aged care facilities
and in homes have occurred widely in community pharmacy practice 122-124. In July to August
2002, 50.8% of Australia’s community pharmacies were HIC-registered DMMR providers
(Table D-F14c).This had risen to 68% by January 2003 117 reflecting a 33.3% increase in six
months . This trend suggests more than 90% of pharmacies will be DMMR providers in 2004.
The actual number of 2450 DMMR pharmacy providers of DMMRs in July and 2760 in August
2002 is consistent with the estimated total of 2540 (Table D-E14a) . The actual total 146,332
operating residential aged care facilities is close to the estimated total of 145,182 beds
supplied medicines by Australia’s community pharmacies (Table D-E14b). The estimated total
of 1416 DMMRs performed monthly (Table D-E14c) compares with the mean 1220 DMMRs
claimed monthly by Australia’s GPs in 2002 and 1433, 1416 and 1424 DMMRs claimed in
June, July and August 2002 117. The reported rate of over 1400 DMMRs estimated to be
supplied medicines monthly (Table D-F14d) in June-September 2002 (survey period) is
higher than the corresponding GP Item 900 item at that time 117. The difference may be due to
differences in the periods compared, non-HIC remuneration, statistical variation in Confidence
Intervals or other factors . The other rates in Table D-F14d need also to be reconciled against
the relevant HIC or GP Item Numbers. The access to AACP-accredited pharmacists is in
accord with their numbers and distribution compared with numbers of approved pharmacies
with DMMRs (Tables D-F14c, D-F14d and D-F14e). The rates for the other forms of
medication reviews reported and remunerated (Table D14d) need to be reconciled against
actual HIC remuneration data. Australian researchers have reported other steps which need
to be taken to improve medication use in nursing homes117.

International
In the UK the studies of pharmacists’ medication activities in nursing homes or aged care
facilities were limited to the supply of drugs, providing drug information and identification of
drug interactions 125. Research in the USA confirms the high rates of inappropriate prescribing
ranging from 21.3% in domiciled and up to 40% of institutionalised patients126 .

National estimates
The national estimates for DMMR providers, total beds supplied by pharmacies and DMMRs
provided monthly by pharmacies are consistent with official statistics. The other estimates
need to be reconciled.

Interpretations
The rates of comprehensive home medication reviews are consistent with official data. The
rates for other forms of reviews reported in residential aged care facilities and other forms of
medication review processes (Table D-E14d) need to be reconciled against actual HIC
remuneration data. The rates of DMMR provider pharmacies is higher in Pharia zone 1 than
percentages of pharmacies in Pharia zones 2-6. In comparison the rates of pharmacies
supplying medicines to aged care facilities is much lower in Pharia zone than by pharmacies
in Pharia zones 2-6.

50
3.6 Section F Primary health care including pharmacy and
pharmacist-only medicines
Questions: 15a and 15b.

Statistical sources: Tables 15a 1.1- 15a.6.2 (12 tables); Tables 15b.1.1 -15b.2.2 ( 4 tables)

Aim
To quantify primary health care, self-medication and associated activities in pharmacies and
the frequency of detecting misuse and refusal of supply of over-the-counter medicines (S2
and S3).

Background
Australia has standards and guidelines for pharmacists assisting self-medication by
consumers, providing consumer medicine information, general practitioners’ and pharmacists’
inter-professional communication and the provision of pharmacist only and pharmacy
medicines in community pharmacy 127. Self care actions are taken by individuals to manage
their health without paying for services provided by a health worker 128. Primary health care in
developed countries is provided by health workers including doctors and pharmacists who
form the first level of contact with health systems 129. Self-medication, the most frequent form
of health care, refers to patients taking responsibility for the management of minor illnesses
using products they have selected without the assistance of a health worker 128. Community
pharmacists have been documented as active primary health care providers in Great Britain
and Australia since the 19th century 129,130 . In the USA, the Indian Health Service
pharmacists have, since the 1980s, routinely offered primary health care in reservations 131.
Medical bodies in the USA however oppose “…independent pharmacist prescription
privileges and initiation of drug therapy…” 132 . For drug deregulation (switching in the USA)
from medical prescription (Schedule 4 or S4 in Australia) to pharmacist-prescribing (P status
in the UK, or Schedule 3 or S3 in Australia) and non-medical- non-pharmacist agents, the
criteria are stricter in the USA than in the UK or Australia 133,134. Limited pharmacist and nurse
prescribing has commenced in the UK 135-137 . In Australia the S3 (pharmacist-only) status is
under challenge and if Australia’s pharmacists are to retain S3 drugs then they must exercise
duty of care to ensure proper use and minimise harm from adverse effects, misuse or abuse
of these drugs 138. The American Pharmaceutical Association has published a monograph on
pharmacists “assuring appropriate OTC medication use” 139.

Discussion of methods
Questions were compiled after consultation with the national panel, visits to pharmacies
across all Pharia zones in some States and direct or telephone discussions with staff, direct
or telephone discussions with leaders of pharmacy bodies and pharmacy groups and
reference to a range of pharmacy business, practice and research journals published in
Australia and internationally. Additionally, self-medication and other non-prescription health
activities were recorded by trained independent observers in four pharmacies before
finalising Question 15a. A focus group from pharmacies in Pharia zones 1 and 2 and a
nationwide sample of practicing and specialist pharmacists in Pharia zones 1 to 6 tested the
questions. The national estimates of these activities are recorded in Tables D-F15a and D-
F15b.

Findings
The main results are summarised in Tables D-F15a,D-F15b and D-F15c. The conservative
daily estimates per pharmacy are 25.87 self-medication clients and 28.85 clients for heath
requests resulted in national estimates of 36.97 and 41.23 million consultations for a total
78.2 millions per annum in Australia’s pharmacies (Table D-F15a). Printed information
including computerised CMIs and Self Care cards (c. 1.5 million annually) were issued to a
total 12.493 million clients. The estimated 4.19 million (adjusted) referrals to doctors by
pharmacies approximates nearly 5% of the total yearly GP consultations in Australia 140 and
compares with 1.77 million referrals to other health workers and the total of 0.666 million
referred annually to complementary health workers (Table D-I20a).

51
 An estimated 0.863 million clients annually were suspected of misusing a range of
dependence-producing S2 and S3 medicines (pharmacist-only and pharmacy over-the-
counter medicines) and an estimated 0.631million (73.1%) clients (Table D-F15a) were
refused supply in Australia’s pharmacies. The 73.1% refusal is the most decisive of
available actions.

Table D-F15a. Australia’s community pharmacies by primary health care and self medication
activities per typical working day

Health care actions Persons daily Per week per Total in pharmacies Total in
OTCs only per pharmacy pharmacy* per week 1 pharmacies pa
(LCI) (millions ) (millions )#
Self-medication (named S2 or S3) 25.87 159.9 0.771 36.97
Primary care (received assistance) 28.85 178.3 0.860 41.23
Printed information including 7.18 44.4 0.214 10.26
computerised CMIs and Self Care
Referred to GPs 5.93 a 36.6 0.177 8.47
2.93 18.11 0.087 4.19
Referred to other health workers 2.74 b 16.9 0.082 3.92
1.24 7.7 0.037 1.77
* 6.18 x LCI . 1. 6.18 x 4824 x LCI. # 4447 x 6.18 x 52 x LCI.
a = adjusted to 2.93 due to skewness of results ; b= adjusted to 1.24 due to skewness of results .

Table D-F15b. Number of clients with suspected misuse of over-the-counter medicines (S2
and S3) in last seven days

Misuse of OTCs Per week per pharmacy Yearly per pharmacy* Total in pharmacies
(million pa)
Suspected 3.73 194.0 0.863
Refused supply 2.73 142.0 0. 631
* LCIx52 #LCI x 52 x 4447

Table D-F15c. Australia’s community pharmacies by health consultations in past two weeks
by Australians
(Sources: National Health Surveys 1983-4, 1995 and 2001; Berbatis, 1986) 141-143

Consultations 1983-4 1995 2001

Thousands per two weeks 395.0 424.5 789.5
Millions per annum 10.27 11.04 20.53

Pharia zones
The rates of self-medication are consistently less than health care or information provision
overall and in each Pharia zone. The ratio of health requests : self-medication is higher in
Pharia zones 2 to 6 than in 1 reflecting perhaps the more pronounced effects of direct-to-
consumer advertising of pharmaceuticals and marketing by pharmacy banner groups in urban
than rural areas144 .

Australia
The ratio of 25.87: 28.85 (Table D-F15a) or 90:100 of self-medication : primary health serves
as a reference for measuring trends in self-medication resulting from changes in S3
legislation or direct to consumer advertising in Australia 145. The estimated total 1.63 million
cases of self-medication and health assistance weekly reported by pharmacies exceeds by 4-
fold the rate recalled by household consumers in the National Health Survey 2001 (Table D-
F15c). If verified, the reported rates raise pharmacies to second place in health consultations
after doctors and above dentists in Australia142. These reported rates are well below those
recorded by trained independent observers in four pharmacies during the preparation of the
questionnaire. The PSA reported between 1.5 and 2.0 million Self Care cards are procured

52
yearly by Australia’s pharmacies which implies over eight million computerised CMIs are
given yearly by pharmacies to consumers to accompany non-prescribed pharmacy medicines
(Table D-F15a). The need for vigilance in pharmacies for misuse of S2 and S3 medicines in
the case of a possible pseudoephedrine-associated death was reported in 1996 and the
consequent need for pharmacies to retain these medicines was made by a prominent
pharmacist-solicitor 146.

International
National guidelines for pharmacists in the USA assuring the appropriate use of OTC (over the
counter) medication use have been published by the American Pharmaceutical Association
139,147
. In the USA the misuse of self-selected products with pseudoephedrine,
dextromethorphan and antihistamine off the shelves without pharmacist intervention has
been reported in large numbers from Missouri, California, Minnesota, New Jersey and Illinois
148,149
. Reports of misuse of cough and cold products to US Poisons centres rose to 13,393 in
2000 from 9,889 in 1999 148 . Direct to consumer advertising results in increased self-
medication but less likelihood of effectiveness 144,150. The continued promotion of outdated
medicines occurs often in non-pharmacy outlets150. Options to refusing supply are pharmacist
counselling, referral to doctors, increased communication between pharmacies to better
identify strangers or ‘pharmacy shoppers’ and a contract between pharmacy and consumer to
regulate supply as part of a ‘harm minimisation approach’ 148,150,151 .

In the UK a textbook entitled ‘Minor illness or major disease?’ 152 includes action plans for a
range of common disorders encountered in community pharmacies. This book is
complemented by current treatment guidelines with over the counter and pharmacist-only
medicines for the common encountered disorders 153. Surveys of OTC misuse in the UK have
found opioids in males, antihistamines, sympathomimetics and laxatives in females are the
most frequently misused over-the-counter drugs 151,154. Most community pharmacists deal
with suspected misuse by refusing sales150,154 . The rate of 3.73 cases of suspected misuse
per week reported here (Table D-F15b) is much higher than the 1.66 cases weekly of misuse
and abuse of over-the-counter drugs reported by community pharmacies in Northern
Ireland154 .

Interpretation
A total annual 92.2 million non-prescription health care cases comprising 36.97 million cases
of self-medication and 41.23 million advice or pharmacy-selected medication and health
assistance are estimated to occur annually in Australia’s pharmacies . Of these, 13.6%
resulted in CMI or printed information including approximately 1.5 million Self Care cards.
Pharmacies in Pharia 1 have higher self-medication rates relative to primary care than
Pharias 2-6. The rates are four-fold those reported in Australia’s ABS national health surveys.
An estimated 0.863 million cases of OTC misuse were suspected with 73% refused supply
which is over twice the rate reported in overseas studies. Rising misuse of dependence-
producing OTCs in the USA reported by police and poisons centres may result in legislation
for firmer control in US outlets.

53
3.7 Section G Preventive services implemented in this
Pharmacy
Questions: 16-18
Statistical sources: 16 - 18.7.2 (28 tables)

Aims
To quantify a facility (vaccine refrigerator), OTC agents and screening tests used or issued for
preventive purposes in Australia’s pharmacies.

Background
Australia has reference values for laboratory tests and information on immunisation and
protocol for cold chain management in community pharmacies155. The history and rationale of
pharmacists’ involvement in preventive, health promotion or public health activities in
Australia have been reviewed156. Australia has standards and guidelines for pharmacists
assisting self-medication by consumers, providing consumer medicine information, general
practitioners’ and pharmacists’ inter-professional communication and the provision of
pharmacist only and pharmacy medicines in community pharmacy 156,157. The revised
RACGP (2002) guidelines identify by level and strength of evidence the preventive activities
recommended for general medical practice in Australia158. These are generally applicable to
preventive activities in Australia’s community pharmacies but the RACGP (2002) omits
guidelines for the primary prevention of cardiovascular disease in at-risk people and the
secondary prevention of acute myocardial infarction158. Other evidence-based evaluations of
pharmacy services were also taken into account159-162. The trend in Australia towards
approved agents used for primary and secondary prevention (ie chemopreventive agents) is
reflected by cardiovascular agents and vaccines indicated for preventive purposes comprising
32.6% of Australia’s Pharmaceutical Benefits Scheme (PBS) expenditure in 2001-02, up from
29.1% in 2000-01.

Discussion of methods
Questions were compiled after consultation with the national panel, visits to pharmacies
across all Pharia zones in some States and direct or telephone discussions with staff, direct
or telephone discussions with leaders of pharmacy bodies and pharmacy groups and
reference to a range of pharmacy business, practice and research journals published in
Australia and internationally. A focus group from pharmacies in Pharia zones 1 and 2 and a
nationwide sample of practicing and specialist pharmacists in Pharia zones 1 to 6 tested the
questions. The national estimates of these activities are recorded in Tables D-G17 and 18.

Findings
In July-September 2002 ,82% or an estimated 3,956 community pharmacies in Australia
(Table D-G16) had vaccine refrigerators (2-8oC). The percentages of pharmacies which
reported providing over the counter agents for primary preventive purposes and annual total
numbers of preventive OTC agents initiated by Australia’s community pharmacies weekly and
annually are estimated (Table D-G17).
The annual total numbers of screening tests performed in Australia’s community pharmacies
weekly and annually are estimated (Table D-G18) from the results in the database (Tables
18.1.1 to 18.7.1) .Similar percentages of screening services in US pharmacies have been
reported by a nationwide survey of pharmacy customers in the USA (Table D-G18) 163 .
Australia’s community pharmacies in 2002 reported similar percentages to those reported in
US pharmacies 163 and higher percentages ever performing screening services (Table D-
G18) than those reported from Great Britain’s 2000 national survey of pharmacies164. The
percentages reported by British pharmacies were blood glucose by 5%, 11% tested blood
pressure and 3% tested blood cholesterol 164 . Data on clinical testing performed in 2002 were
obtained also from a group of pharmacies which engaged nurses to provide this service every
two to four weeks in urban pharmacies and monthly to a distant pharmacy (Table D-G19).

54
 Table D -G16. Vaccine refrigerators in Australia’s pharmacies
Response % pharmacies Total *
yes 82.0 3956
no 15.9 767
No response 2.1 101
* % x 4824

Table D -G17. Total pharmacist-initiated OTC medicines for primary prevention in Australia’s
pharmacies

Preventive OTC Pharmacy National per National per 12 months Population potential
week (LCI) week (LCI)* (million) #
Nicotine therapy 6.28 30,295 1.452 c. 1.2 million smokers
Aspirin ( ≤ 100mg daily) 2.97 14,327 0.687 c. 3million
Iron for anaemias 3.20 15,437 0. 740 c. 1 million
Folic acid in pregnancy 2.49 12,012 0. 576 c. 250,000 born yearly
Calcium 3.76 18,138 0. 869 c. 1.0 million
Daily multivitamins 6.51 31,404 1.505 c. 0.5 million
* LCI x 4824 ; # LCI x 52 x 4447

Table D G-18. Numbers of screening tests provided by Australia’s pharmacies for

undiagnosed patients in a typical 30 days and 12 months

Screening test 30 days national National in 12 % pharmacies % pharmacies

(LCI) (LCI)* months# ≥ 1 test/ month in USA 9
Anthropometric 0.27 1,303 14,408 6.7% NA
(weight, etc)
Cholesterol 0.23 1,110 12,273 4.9% 17%
Glucose 1.48 7,140 78,979 21.6% 13%
Blood pressure 4.84 23,348 258,282 51.1% 55%
Bone density 0.40 1,930 21,346 8.3% 11%
Pregnancy 0.47 2,267 25,081 8.2% NA
* LCI x 4824 ; # LCI x 12 x 4447

Table D-G19. Screening tests provided in all Australia’s community pharmacies 12 months
by all pharmacies and a sample of 30 pharmacies with nurses in 2002.
Tests pa / pharmacy Tests pa/ pharmacy in pharmacy
in 2002 group with nurse in 2002
Blood pressure 58.1 160.2
Blood glucose 17.8 86.7
Blood cholesterol 4.2 103.4
anthropometric 3.2 7.97

Pharia zone
For OTC agents issued for preventive purposes one or more times in seven days for
undiagnosed clients the pharmacies in Pharia zones 4, 5 and 6 ranked lowest for nicotine
therapies with 76% and 77% respectively . For low dose aspirin the highest (41%) were
pharmacies in Pharia 1 and the lowest (27%) in Pharias 5& 6. For iron supplementation, the
highest (60%) were pharmacies in Pharia 1 and the lowest (47%) in Pharias 5 and 6. For
folate, the highest (60%) were pharmacies in Pharia 1 and the lowest (46%) in Pharias 3, 5&
6. For calcium products, the highest (64%) were pharmacies in Pharia 1 and the lowest (48%)
in Pharias 5 and 6. For daily multivitamins, the highest (84%) were pharmacies in Pharia 1
and the lowest ( 69%) in Pharia 3.
For rates of clinical testing just 4% of pharmacies in Pharia zone 4 provided anthropometric
testing more than once monthly. Just 3% of pharmacies in Pharia zones 4, 5 and 6 provided

55
cholesterol testing more than once monthly. Just 12% of pharmacies in Pharia zones 5 and 6
provided cholesterol testing more than once monthly. Just 36% of pharmacies in Pharia
zones 5 and 6 provided blood pressure testing more than once monthly. Just 6% of
pharmacies in Pharia zones 5 and 6 provided bone density testing more than once monthly.
Just 3% of pharmacies in PhARIA zone 4 provided pregnancy testing more than once
monthly.
The above data need to be standardised for the total number of clientele in order to enable
complete comparisons.

Australia
The prevalence of vaccine refrigerators, rates of OTC agents issued and screening tests
performed reflect the extent and level of prevention (mainly primary preventive) activities
offered by Australia’s community pharmacies. The evidence-based reports above were used
in selecting the agents and tests in Questions 16 to 18 together with advice from pharmacy
practitioners nationwide. In particular OTC preventive agents such as mini-dose aspirin, folate
and calcium are recommended in the RACGP (2002) guidelines as is smoking cessation for
which nicotine replacement agents are an effective treatment 158 . Low dose aspirin (75-150
mg) daily was included because it is recommended for the prevention of stroke and where
transient ischaemic attacks are due to arterial disease 158,165,166 . Its use is well established for
the secondary prevention of serious vascular events including myocardial infarction, transient
ischaemic attacks and stable or unstable angina165,166. For primary prevention low dose
aspirin is warranted in those with a raised cardiovascular risk score 165,167 but should be an
adjunct and not replace the management of existing cardiovascular risk factors 166 .
Antioxidant vitamins are no longer warranted for the prevention of cardiovascular, cancer or
other morbidities 168,169 and are not recommended by the RACGP (2002)158. Daily
multivitamins for nutritional deficiency were included because their low cost and greater
likelihood of benefit than harm at doses not exceeding recommended daily allowances appear
vindicated for the prevention of nutritional deficiency especially in certain subgroups . These
include women who may become pregnant, for elderly who tend to consume Vitamin B12
poorly and are often deficient in vitamin E , persons who regularly consume one or two
alcoholic drinks per day, vegans who require supplemental vitamin B12 and for indigent
people who may be unable to afford adequate intakes of fruit and vegetables170 . Multivitamin
products were included also because of the evidence for preventing infections in vulnerable
populations including diabetics171. The RACGP guidelines (2002) recommend 5.0mg folate
daily for high risk pregnant females and 0. 5mg daily routinely in pregnant women to prevent
neural tube defects in offspring158. Fluoride is recommended routinely for preventing dental
caries in at-risk people158. Calcium is indicated for preventing osteoporosis172. Iron for
preventing anaemias was included because the estimated prevalence of iron deficiency in
the USA is 7% in toddlers (1-2 years) and 9%-16% in females aged 12-49 years and is much
higher among those in ethnic minorities 173 . These rates also appear true in Australia’s
aborigines 174. The latter two agents need to be reviewed for their inclusion in future surveys.
At least one million Australians have undetected and untreated risk factors such as raised
blood pressure, total cholesterol, blood glucose or low bone density who could be screened
by Point of Care Testing in community pharmacies 175,176 . Another estimated two million
Australians have poorly managed obesity and tobacco smoking who may be better managed
with organised interventions in pharmacies. There are legal and practical barriers to clinical
testing in Australia’s community pharmacies 176,177. University teaching of undergraduate and
graduate pharmacists have been introduced by university departments of pharmacy 178. State
surveys of testing in Western Australia’s pharmacies were reported in 1997 for a range of
tests179. Glucose and microalbuminuria found most were done in shopping centre pharmacies
180
. Clinical testing for the screening of blood total cholesterol and glucose performed and
supervised by pharmacists in two Western Australian shopping centre malls found good
acceptability by 76 subjects who were willing to pay up to $10 per test 181. A study of clinical
testing in nine Upper Hunter Valley (NSW) pharmacies including two with a nurse found 75%
of 389 subjects had at least one test result that was outside the reference range. Results
included 53% with raised blood pressure and total cholesterol above 5.0mmol/L and 32% who
had never had cholesterol measured before182. They referred 28% of subjects of whom 58%
visited GPs with 11 prescribed medications involving eight on lipid lowering agents and three
on antihypertensives. The nurse delivered service cost just 60% of the pharmacist service.

56
Both capital and operating costs of the nurse service could be lowered. It was strongly
recommended the nurse-pharmacist model be further evaluated 182.
The national survey revealed a group of 30 pharmacies which had engaged nurses since
1990 to perform screening tests. The group provided results performed in 2002 by category
(Table D-G19). These show much higher rates when compared with the results of all
pharmacies with respect to blood glucose and blood cholesterol each of which requires skin
penetration. Skin penetration is one of the barriers to pharmacies introducing clinical testing
176,177

In Australia, the sales of personal and health products including OTC agents and vitamins are
monitored through wholesale and manufacturers data by IMS Health Australia (manufacturer
and pharmaceutical wholesaler) and AC Nielsen (warehouse, manufacturers and suppliers).
Retail data from pharmacies are reported by the Australian Bureau of Statistics and by Aztec
Information Systems from a national sample of 330 pharmacies stratified into States 183.
These are reported yearly in categories of products and therapeutic groups of OTC
agents183,184. The annual sales figures may potentially be converted to units and reconciled
against the OTCs reported here (Table D-G17). In the monthly pharmacy retail turnovers, the
months of July and August when the survey was conducted, are amongst the highest monthly
national sales in pharmacies each year 183 .

International
No reports were found from Australian or overseas sources on the initiation or issue of OTC
agents for primary preventive activities in community pharmacies. The preventive effects of
OTC agents especially vitamins need to be carefully considered by pharmacy bodies in
Australia. For instance a five year randomised double blind study found 600 mg vitamin E,
250 mg vitamin C and 20 mg β-carotene taken daily by high risk individuals was safe but did
not lower mortality or incidence of any type of vascular disease, cancer or other major
outcome168. Of 710 respondents in a national survey of 1,000 households in the USA held in
2001, 55% reported that their pharmacies screened for hypertension, 17 % for cholesterol,
13% for blood glucose and 11% for osteoporosis 163. Approximately one-third reported their
pharmacies offered immunisation. Evaluative studies reported from the USA and Canada
have shown the effectiveness and acceptance in community pharmacies of testing for the
screening and management of blood pressure, blood cholesterol, blood glucose and bone
density 162,185-189.

In the UK local health authorities coordinate primary health care activities with sharing of
resources between doctors, pharmacists and other health care workers. In a two year study in
an English medical centre 449 patients were divided into three defined cardiovascular risk
groups, screened, then treated by doctors and advised on medication compliance, managing
their lifestyle risk factors and monitored by a pharmacist trained in clinical testing190. The
pharmacist advised on medication changes and measured or recorded body mass index,
smoking, blood glucose, blood pressure and hypercholesterolaemia. Significant reductions in
individual and overall risk factors occurred over two years 190 . Of 40 patients who had
diastolic blood pressure > 100mm Hg, 18 were originally receiving antihypertensive agents .
Of these 11 received medication changes during the study. Of another 20, 13 were started
on antihypertensives and nine were controlled without medications 190.

Interpretations
82% of Australia’s pharmacies reported compliant vaccine refrigerators in 2002. Pharmacies
in Pharia zones 5 and 6 consistently reported the lowest percentages to issue OTC agents for
preventive purposes and to perform screening tests. These results imply that rural and remote
pharmacies have smaller rates of clients, where screening was less uneconomical or
desirable, the pharmacists had less knowledge and skills about these preventive activities or
less pharmacies are located in large shopping centres where the rates of screening are
higher 179 . The high numbers who screen for blood pressure was five fold higher than was
reported by British pharmacies but similar to rates of screening blood pressure, blood
cholesterol, blood glucose and osteoporosis by pharmacy clients in the USA. This may be
due to higher levels of awareness, knowledge and/or skills of screening in Australia’s
community pharmacies compared to British pharmacies and similar levels to US pharmacies.
The higher rate of blood pressure than blood glucose or blood cholesterol screening may be

57
due to a combination of legal or practical barriers to skin penetration or ignorance or
resistance by clients or their carers. The numbers of Australians with raised levels of either
blood pressure, blood glucose or blood cholesterol exceed one million in each category. The
low rates of anthropometric screening in pharmacies is difficult to explain given the 20% of
Australians with obesity, the grave consequences on health of obesity and the low cost, non-
invasive nature and ease of measurement. The much higher rates of screening found in one
group of pharmacies which employed nurses for this task compared with pharmacies overall,
together with the lower costs of clinical testing involving nurses in pharmacies, reinforce the
need to evaluate clinical testing first in those pharmacy groups with nurses.

58
3.8 Section H Harm minimisation services and detected S4 and
S8 forgeries and doctor shopping in Australia’s
pharmacies.
Questions: 19a and 19b

Statistical sources:
Tables 19a.1.1- 19a.6.2 (12 tables); Tables 19b.1.1-19b.2.2 (4 tables)

Aims
To quantify the harm reduction and detection of forgeries and doctor shopping for S8 and S4
drugs of dependence occurring in Australia’s pharmacies.

Background
Standards for the pharmacist management of licit opioids in Australia are set down in State
and national regulations and guidelines 191,192,193 . In Australia, harm minimisation in the
1980s referred mainly to methadone and needle syringe programs but by 1999 the term ‘harm
reduction’ had broadened to efforts which reduced the adverse health, social and economic
consequences of illicit drugs without necessarily reducing their consumption 194. In Australia,
methadone and needle syringe programs first appeared in Australia’s community and hospital
pharmacies around 1970 in the form of providing methadone for treating illicit heroin
addiction195 . Harm reduction in pharmacies in Australia now encompasses a range of
activities including participating in needle syringe programs and programs involving
methadone and other therapies or activities for treating drug or agent dependence, providing
information for reducing harms from the misuse of drugs or agents of dependence, issuing
condoms for the purpose of preventing sexually transmitted diseases in drug or agent
misusers and measures taken to identify and prevent drug or agent misuse in individuals195,196
.
The UK’s National Addiction Centre was the first to conduct systematic national research of
harm reduction activities performed in community pharmacies from the late 1980s197-199. In
Australia the first comprehensive surveys and cost analyses of methadone programs
involving community pharmacies were first performed in 1996 by Victoria ‘s Turning Point
group 200,201. In 1999 and 2000, Curtin University pharmacy researchers (WA) managed a
series of studies in five of Australia’s jurisdictions which reported high client acceptability of
pharmacies in community methadone programs, characteristics of participating pharmacists
and pharmacies, retention of clients in methadone programs, costs in public and private
clinics and factors affecting the prevention and treatment of drug misuse 202. Reviews of
international and UK data corroborated the large and effective roles played by community
pharmacies in the prevention and management of drug misuse 199,203.

Discussion of methods
Questions were compiled with the assistance of pharmacists experienced in harm reduction
activities in pharmacy. The questions were tested in a focus group of pharmacists from a
variety of pharmacies in Pharia zones 1 and 2 and a nationwide sample of practicing and
specialist pharmacists in Pharia zones 1 to 6. The ‘harm reduction’ activities listed in
Question 19a items excluded the sale of condoms and the provision of information; these
were largely disregarded by respondents in the ‘other’ activities. Detected forged
prescriptions and identifying doctor shoppers in Australia’s pharmacies related to medically
prescribed dependence-producing and Schedule 8 agents (opioids and psychostimulants) .

Findings
The prevalence of 34.6% and 10.8% of Australia’s pharmacies involved in methadone and
buprenorphine dosing (Table D-H19a) are consistent with the rates reported in the results for
Questions 7 and 11c. The prevalence of methadone and buprenorphine dosing in 2002 reflect
a marked increase from the 31% of Australia’s pharmacies in May 2000 registered to provide
methadone for opioid-dependent patients 202 . Methadone dispensing occurred more
frequently compared to needle supply in a similar number of pharmacies nationwide (Table D-

59
 H19a) . Benzodiazepine contracts or arrangements with prescribers for other drugs of
dependence193,202 is practiced in 45.5% of Australia’s pharmacies with 18.8% active at least
once daily (Table D-H19a).

Table D-H19a. Pharmacies and harm reduction activities: daily clients and percentage
pharmacies ever involved in July-September 2002

Activity Number daily per National daily total * % of pharmacies

pharmacy (LCI) active ≥ 1 daily
Methadone dosing 2.16 10,420 34.6%
Buprenorphine dosing 0.49 2,364 10.8%
Naltrexone dispensing 0.05 300 0.5%
needle supply or 1.91 9,214 33.9%
exchange
benzodiazepine or other 0.70 3,377 18.8%
prescriber contracts
* LCIx4824

The estimates of forgeries detected in pharmacies are above those estimated from reports of
forgeries by pharmacists in Victoria 204 and estimates of 0.04% forgeries in the USA
equating per capita to 8,800 forgeries pa in Australia. The results imply awareness of
forgeries by pharmacists and/or higher rates of forged prescriptions of prescriptions for S8
and other dependence-producing S4 drugs. The HIC reported 8179 doctor shoppers who
received 1,047,582 prescriptions in the 12 months to 30 June 2000205. This project
terminated on 30 June 2002. Pharmacies reported detecting an estimated 7332 clients with
forgeries which equates to an estimated 12,687 doctor shoppers in the six months to 30 June
2002 (Table D-H19b). These figures may include the multiple detection of the same doctor
shoppers in pharmacies, less strict criteria than the HIC’s applied by pharmacies, many more
actual doctor shoppers exist than reported by the HIC because doctor shopping with private
or other prescriptions for these agents were not accounted for by the HIC, or an overestimate
in the LCI.

Table D-H19b. Numbers of clients with prescription forgeries of S8 and S4 dependence

drugs and doctor shoppers detected from 1 January to 30 June 2002 in Australia’s
community pharmacies 2002

Number per Total six months per Total 12 months % of pharmacies

pharmacy (LCI) pharmacy* per pharmacy# detected ≥ 1
over six months
Forgeries 1.52 7,332 13,519 34.3%
Doctor shopping 2.63 12,687 23,391 49.1%
* LCI x 4824 # LCI x 2 x4447

Pharia zone
The percentage of pharmacies providing each harm reduction service once or more daily was
consistently lowest in Pharia zones 5 and 6. The percentage of pharmacies detecting doctor
shopping or forged prescriptions was lowest in Pharia zones 4, 5 and 6.

Australia
The relatively high rates of methadone and buprenorphine dispensing (Table D-H19a) reflect
the continued success of community pharmacies in primary care-based methadone
maintenance treatment (MMT) programs in Australia . A national evaluation reported
pharmacists are well regarded by MMT clients, the price of methadone dosing in pharmacies
is lower or competitive with private clinics and the retention of patients in MMT programs with
methadone pharmacies is higher than in hospital-based methadone programs202.
Australia’s high world ranking in the per capita consumption of oral morphine, pethidine,
methadone liquid and psychostimulants is associated with 2-5 fold differences between
states and territories and concurrent high rates of misuse reported in serial surveys from

60
jurisdictions with higher consumption 206-209. Pharmacists are required by statute to be alert
to forged prescriptions and exercise reasonable care in assessing prescriptions 210 . Many
pharmacists in Australia are unaware of the extent of forgery nor of their legal and ethical
responsibilities204 . The rising rates of misuse of licit drugs such as morphine, pethidine ,
Panadeine Forte and benzodiazepines have been attributed to the persisting nationwide
shortage of illicit heroin 211,212. The misuse of Schedule 8 drugs in Australia is partly
reflected in the numbers of stolen doctors’ prescription pads throughout the country , reports
of forged prescriptions, from 0.5-1% of doctors in NSW and Victoria self-administering
opioids, excessive prescribing and dispensing by doctors and pharmacies, the numbers of
doctor shoppers (excessive visits to doctors or excessive prescriptions for drugs of
dependence ) , pharmacy break-ins for S8 agents , diversion or sale by recipients of the
drugs to others , the improper administration by injection or other routes and the morbidity or
mortality related to misuse. Doctor shoppers in Australia obtained Schedule 8 drugs and
other drugs of dependence 204,205,211,212 These many examples reflect a state of drug
misuse in Australia requiring high vigilance and preparedness to intervene by pharmacists but
they are currently limited principally because they lack the access to S8 medication histories
of patients when they dispense these agents.
A survey of forged prescriptions undertaken in Victoria from 1999- 2000 included reports of
forgeries received from pharmacies by Victoria’s Department of Human Services’ Drugs and
Poisons Unit 204. In 1997 they comprised 155 pharmacies with 73 alterations to genuine
prescriptions, 99 forged on stolen stationery, involving 146 names and 191 different drugs
sought. In 1998 they comprised 112 pharmacies, 76 and 51 types of forgeries, 121 names
and 124 different drugs. From 1 January to 15 March 1999 (74 days) the figures were 38
pharmacies, 15 alterations with 28 on stolen stationery, 41 names and 38 different drugs.
The survey used for estimating rates of forgery was based on 261 responses from 739
randomly selected pharmacists in the first round and in the second round 56 responses from
300 of the 478 non-respondents. These made a total of 317/739 ( 42.9%) responses or
35.3% ( 261/739) plus 56/300 (18.7%) or 54% based on adding the responses to each
mailing denominator204: 59% of respondents reported between 2-10 per year and 74%
reported 1 or more yearly (pages 39, 60.The Department received concurrently just 13
reports per month thus being “..a major underestimate.. “ of the number occurring (page 60)
204
. The national estimates of reported detected forgeries and doctor shopping (Table D-
H19B) now serve as references for assessing community pharmacists’ performance in this
area.
A variety of methods have been implemented in Australia since 1997 to minimise or prevent
and treat drug dependence. The privacy release of information to prescribers by patients that
allows doctors access to drug histories before prescribing is common in methadone
programs193 . Agreements or undertakings by patients with prescribers to limit their source of
drugs to one prescriber occur in parts of Australia 193 and to one doctor and dispenser in the
Australian Capital Territory 202. Developments are progressing nationally to facilitate access
to patients’ drug histories and for prescribers and dispensers to communicate online through
the MediConnect system formerly known as the Better Medication Management System
which has some similarities with British Columbia’s Pharmnet system 213-216. The technical
requirements for pharmacies to participate in MediConnect system are specified by the
Department of Health and Ageing. The introduction of these different approaches to prevent
prescription drug misuse probably reflect a more serious licit drug misuse problem in Australia
than elsewhere resulting from a national prescribing system designed to provide high access
without adequate resources to monitor or manage abuse of the system , the lack of
information or authority to enable prescribers or dispensers to identify or intervene to prevent
or treat drug misuse. A change to the legislation for Schedule 8 drugs has been proposed to
overcome existing hurdles and to suitably enable pharmacists to intervene to prevent misuse
217
.
The continuing heroin shortage and the more efficient and effective systems developed to
manage opioid dependence and treating heroin overdoses have resulted in falling heroin
overdose fatalities201. This decline may lead to lower demand for methadone and other
maintenance treatments for opioid dependence. The harm reduction activities in community
pharmacies may modify from treating or minimising the harms of the misuse of illicit agents
and drugs such as heroin to preventive misuse of licit dependence-producing agents and

61
drugs including nicotine, alcohol, benzodiazepines, morphine, oxycodone and
dexamphetamine 217 .

International
The terms “ gatekeepers to controlled substances” in the USA218 and “prescriptions custodian”
in Australia 210,219 are synonymous in depicting the key role for pharmacists in properly
managing the issuing of prescribed S8 agents. In the USA, the pharmacists’ responsibilities
for managing opioids in prescriptions or combined with non-narcotic analgesics have focused
on State regulations and programs for controlling opioids for their proper use in pain
management and activities for preventing their diversion 216.
In the UK the pharmacists’ broader recognised role in the detection of licit opioid misuse and
the management of drug misuse and opioid dependence are recognised and well
documented 216 . The most infamous example of the misuse of licit opioids has been the
deaths of more than 100 females in England caused by injections into the victims of
dispensed diamorphine by a doctor from 1987 to 1998. Researchers found ‘mortality
monitoring’ of deaths to be a poor indicator of drug misuse217. The failure of mortality
monitoring to efficiently identify the potential misuse of licit opioids indicates the need for other
methods to detect and prevent the diversion and misuse of S8 agents.

Table D-H19c. International comparison of harm reduction services 222,223

Australia 2002 England and Wales 1998 Scotland 2001

(EMCDDA,2000) (Matheson et al, 2002)
Dispensing opioid 40-55% 50% 81%
dependence therapies
Selling injecting equipment 51.3% 34.5% selling/ 19% 11% selling/19%
and needle exchange exchange a exchange b
a,b = percentages for needles sales and exchange retrieved by Dr J Sheridan (June,2003)

Interpretations
Australia’s pharmacies rank high internationally in providing harm reduction activities. Harm
reduction including methadone dosing is now amongst the most widely practiced and cost-
effective of the specialised services in community pharmacy in this country. The estimated
rates of detected doctor shoppers and forged prescriptions for S8 drugs and drugs of
dependence are the first known reports in the world. The rates suggest pharmacists’ high
vigilance in this area. The possibly high rates of forgeries compared to other countries may
reflect Australia’s high per capita consumption of S8 drugs and concurrent high misuse.
Australia’s very high consumption of S8 agents and high levels of their misuse in this
country, the rate of detecting doctor shoppers along with the trend to licit opioids and other
prescribed agents emphasises the need for access to patient drug histories by pharmacists
when dispensing S8 agents. The need for access to online drug histories before prescribing
and dispensing is reinforced by the failure of mortality monitoring of opioid overdose deaths to
locate and assist to prevent licit opioid misuse reported in England. The requirement to
restrict patients to one medical and pharmacy source for S8 drugs is urgent given the likely
delays in implementing access to patients’ drug histories through the MediConnect system.
State and national bodies of pharmacy should press for appropriate legislative changes to S8
regulations in order to enable pharmacists to take a more effective role in detecting and
preventing the misuse of S8 and other dependence-producing agents.

62
3.9 Section I Complementary therapies including herbal
medicines
Question: 20
Statistical sources: Tables 20.1.1 to 20.12.2 (24 tables)

Aims To quantify the rates of referral by Australia’s community pharmacies to

complementary medicine practitioners or services

Background
Complementary and alternative medicines and services (CAMS) refers to diagnostic,
treatment and preventive techniques or agents which complement mainstream medicine224. In
Australia, complementary medicines include a variety of materials as described in the
Complementary Medicines Schedule (Schedule 14) of the Therapeutics Goods
Regulations225. They include techniques 226-230 and herbal medicines 225 and non-medically
prescribed vitamins, minerals and trace elements 231. Their use has increased markedly since
1990 in the USA and Australia. For example, estimates from sample surveys of population
usage of CAMS products and services vary from $AUD 2.3 billion in 2000 to industry figures
of approximately $1.5 billion in 2000-2001227,232. CAMS products are regulated in Australia as
therapeutic goods231 but the evidence supporting the effectiveness of CAMS products or
services by either consumer ratings233 or controlled trials224 is inconsistent and inadequately
recorded for use by pharmacists. For instance, iridology and negative ion therapy are
regarded as unproven or unprofessional 234-236, or spurious in the case of questionable
products such as gingko or “smart pill” for improving intellectual performance237. In addition
many herbal medicines have adverse effects and interactions 224,225,238.

Discussion of methods
In Australia the legal definition of complementary medicines includes herbal products and an
authoritative summary of therapeutics information are published for pharmacists225.
Complementary use in Australia does not necessarily require the same evidence of efficacy
as required for regulated therapeutic medicines225. Questions were compiled with the
assistance of a pharmacist experienced on complementary medicines and services. The
questions were tested in a focus group of pharmacists from a variety of pharmacies in Pharia
zones 1 and 2 and a nationwide sample of practicing and specialist pharmacists in Pharia
zones 1 to 6. The items in Question 20 were based partly on a questionnaire used in an
earlier survey of Australian general practitioners 226.

63
 Table D-I20. Australia’s community pharmacies by clients referred to or provided
complementary practitioners July-September,2002

Complementary Clients referred per Total clients Pharmacies

activity pharmacy in 30 days referred nationally ≥1/30 days
( LCI ) 30 days* % (total)
acupuncture 0.24 1158 7.0%
aromatherapy 1.28 6175 22.1%
Chiropractic 0.76 3666 19.5%
Homeopathy 1.41 6802 19.8%
Hypnosis 0.04 193 1.5%
Iridology 0.62 2991 8.7%
Meditation 0.34 1640 7.8%
naturopathy 3.07 14810 33.0%
reflexology 0.08 386 2.5%
massage 1.23 5934 23.9%
Spiritual healing 0.06 289 1.8%
other NA NA 2.3%
Total 44,044
GP referrals (Q15)
* LCI x 4824

Findings
The estimated referrals total 44,044 per month for Australia’s 5,000 pharmacies (Table DI-
20). Further study is required into those pharmacies which have a relationship with or provide
the services on site, in adjacent premises or elsewhere. The rate of the ‘complementary’
referrals by pharmacies represent les than 10% of clients referred annually to GPs. If each
‘complementary’ referral generated a $25 cost to consumers then these total $1.101 million
monthly. The highest referrals including naturopathy (14810 monthly), homeopathy (6802),
aromatherapy (6175), massage ( 5934) and iridology ( 1991) need to be further investigated
for professional and economic implications.

Pharia zone
Clients were referred for naturopathy more frequently by pharmacies in Pharia zones 1 and 2.
Clients were referred less frequently for acupuncture, homeopathy or iridology by pharmacies
in Pharia zones 5 and 6.

Australia
Annual sales in 2000-2001 of complementary health care products including vitamins,
minerals and nutritional supplements and herbal aromatherapy and homeopathic products
totalled $AUD 940 million retail. Industry estimates of total complementary products and
practitioner services in 2000-01 was $AUD 1.5 billion, a fall of $100 million from 1999-
2000239 following the introduction of the GST 240 . This total is much less than the estimated
total expenditure in 2000 in Australia of $AUD2.3 billion comprising $AU1,671 million for
complementary agents and $AU616 million for complementary practitioners estimated from a
large telephone survey of a representative population in South Australia 228. Of industry’s
estimated total $1.5 billion on CAMS, $940 million were spent on CAMS products of which
36% were sold in pharmacies equating to $338 million in 2000-01 232. Sales of CAMS
products in Australia is likely to drop in 2003-04 especially in health food stores with
pharmacies and supermarket increasing their shares of sales of CAMS products following the
recall in April and May 2003 by Australia’s Therapeutic Goods Administration of over 1,300
CAMS products 241-244 . Herbal medicines and vitamins comprise 4% of pharmacy sales or
$AUD 368 million annually in Australia (Database Tables 33a and 33b) which is consistent
with industry estimates and survey results with pharmacy constituting approximately 20% of
national total sales228. In the UK 76% of pharmacies sell herbal medicine products and 50%
of sales occur in pharmacies245 . Only 6% of UK consumers use professional advice to
purchase these products whereas 30.9% do so mainly from doctors in Australia 228,245.

64
Australians are concerned with safety, accurate information and fair advertising of
complementary agents 228. In the USA the inclusion of CAM in formal medical education is
advocated 230.
Most of the complementary therapies listed in Table D-I20 were surveyed in July 1997 in a
random sample of 764 of Victoria’s general medical practitioners. The 488 respondents (64%)
were a representative sample by age, gender and geographical distribution226. Respondents
rated their knowledge of effectiveness, safety and medical versus non-medical providers of
these therapies. Most (93%) had referred at least once and 8% at least a few times a year
for complementary therapies. Just under half referred at least a few times a year for
acupuncture, meditation, hypnosis and chiropractic. Only 29% would encourage chiropractic
in contrast to two-thirds for the former three. Herbal medicines, naturopathy, vitamin and
mineral therapy, osteopathy and homeopathy were accepted by a minority of doctors 226.
Australia’s health survey conducted in 2001 by the Australian Bureau of Statistics found
Australians reported 389,900 visits to chiropractors and 29,800 visits to naturopaths in two
weeks 246. When these ABS data are compared with the rates referred by pharmacies (Table
DI-20 ) they suggest pharmacies generate less than 1% of visits to these CAMS practitioners.

International
The total estimated cost for complementary products and practitioners in the USA for 2000
was $US34 billion USA 228,247. Australia ranked third internationally in 2000 in prevalence of
use after Germany and Canada224. A telephone survey of 187 participating (of 248)
pharmacies in Johannessburg found 64.7% consulted for alternative medicines for conditions
of a minor nature and more frequently in those located in shopping centres in middle-higher
income areas. Pharmacists and other staff consulted for CAMS products but ‘alternative
healers’ existed in less than 10% of pharmacies overall and located chiefly in middle-higher
income areas248. Nurses were employed in pharmacies which ran a comprehensive
alternative medicine practice associated with a health clinic.

Interpretations
Overall the reputable literature suggest CAMS products and services need to be reviewed by
state pharmacy boards and national professional bodies and require firm guidelines for their
issuing or referral in Australia’s community pharmacies. The annual retail sales of CAMS
products and services adopted for Australia was the industry estimate of $1.5billion. The total
annual referral of CAMS services reported by Australia’s pharmacies is less than 10% of
annual referrals to general practitioners but is still sizable. The efficacy, safety, recall and
public requirements need to be reviewed in relation to the appropriate use of CAMS
products. This is crucial with the recall in April and May 2003 of over 1300 mainly CAMS
products by Australia’s Therapeutic Goods Administration and likely higher proportion of sales
of CAMS products in pharmacies after May 2003.

65
3.10 Section J Information facilities and programs
Question: 21

Statistical sources: Tables 21.1.1 to 21.11.2 (22 tables)

Aims
To quantify the resources used to provide information to clients in Australia’s community
pharmacies.

Background
In Australia, drug information in pharmacy refers to the provision of written and/or verbal
information or advice about drugs and drug therapy in response to a request from other health
care providers, organisations, committees, patients or members of the public249. This may
relate to a specific patient or consist of general information promoting the safe or effective use
of medications. The purpose of drug information is to optimise patient outcomes by supporting
the quality use of medicines249. Relevant pharmacy standards and guidelines for providing
consumer medicines information (CMI), assisting self-medication, communicating with other
professionals and providing pharmacist-only and pharmacy medicines exist for Australia’s
community pharmacies249 .

Discussion of methods
Questions were compiled with the assistance of pharmacists experienced in information
services. The questions were tested in a focus group of pharmacists from a variety of
pharmacies in Pharia zones 1 and 2 and a nationwide sample of practicing and specialist
pharmacists in Pharia zones 1 to 6. Question 21 focuses on the patient-specific use of
information resources being the purpose of drug information services in Australia’s
pharmacies1. The use of the term ‘patients’ in the question may have lowered the rates
reported compared with the more general term ‘clients’ .

Findings
The percentage of pharmacies using the information resources one or more times daily for
patients were in order CMI computerised information in 71.7% of pharmacies , 66.1% used
CDROM versions of MIMS and APP and the book versions (49.1%) and 46.4% used PSA
Self Care and 32% or less pharmacies used the other listed resources (Table D-J21). The
best estimates of daily use in pharmacies (LCI) were 4.81 for CMI computerised, 4.19 for
CDROMS (MIMS, APP) , 2.46 for PSA Self Care , 2.22 for MIMS or APP books, 1.27 for
Australian Medicine Handbook, 1.03 for APFH and less than one daily for the other resources
(Table D-J21).
CMI computerised information was received nationally by an estimated 23203 patients daily
(Table D-J21) or by an estimated 6.874 million patients in the 12 months up to July-August
2002 (LCI x 6.18 x 52 x 4447). This compares with the estimated total of 6.76 million issued
nationally by pharmacies for prescription-related purposes ( Table D-D13a). The results in
this section need to be reconciled with pertinent results in Section D and F.

Pharia zone
CMI computerised and CD ROMs were used highest daily in 76% and 68% of Pharia 1
pharmacies. MIMS and APP books were most used daily in 52% of Pharia 1 pharmacies
and least used daily in 43% of Pharia 5&6 pharmacies. PSA Self Care cards are used daily in
52% of Pharia 3 pharmacies compared to 44% of Pharia 1 pharmacies. Therapeutic
Guidelines were used highest daily in 24% of Pharia 4 pharmacies compared to 20% in
Pharia 1 pharmacies. Web-based was used highest daily in 9% of Pharia 1 pharmacies and
least daily in 6% of Pharia 2 pharmacies.

66
Australia
No other comparable results on information provision by community pharmacies in Australia
could be found. From 1 November 2002 pharmacists were remunerated at 10 cents per
claimable PBS or RPBS prescription for providing approved Consumer Medicine Information
(CMI) so the data in Table D-21 reported in July and August 2002 indicate a rate of
pharmacies providing CMI before remuneration was introduced 250.

Table D-J21. Australia’s community pharmacies by use of information facilities for patients per
day in July-September 2002

Information usage Per pharmacy Total pharmacies Percentage

per day (LCI) per day nationally* pharmacies
used ≥ 1 daily
AusDI book 0.36 1737 12.0%
AMH 1.27 6126 32.0%
APF 1.03 4969 26.5%
CDROMs (MIMS,APP) 4.19 20212 66.1%
CMI computerised 4.81 23203 71.3%
Martindale 0.90 4342 25.1%
MIMS or APP books 2.22 10709 49.1%
PSA Self Care 2.46 11867 46.4%
Therapeutic Guidelines 0.79 3881 20.1%
Web-based drug 0.32 1544 7.8%
information
Other NA NA 4.3%
* LCI x 4824

International
Pharmacists in the USA and United Kingdom have a range of information resources,
specialised information and internet sources for community pharmacies available. These are
published in their respective countries by the American Pharmaceutical Association 251 and
the Royal Pharmaceutical Society of Great Britain252. No other comparable results on
information provision by community pharmacies in overseas countries were found. The latest
evaluation of six studies and reports of drug information services found poor evidence of the
clinical or economic impacts on patient outcomes 253.

National estimates
The national estimates of each type of drug information resource used in pharmacies directly
for patient use are based on the Lowest confidence interval derived from the Statistical
sources above and the 4824 pharmacies at the time of this survey.

Interpretations
Computerised CMI, CD ROMS of MIMS, APF, and PSA Self Care cards were in order of
those surveyed the most frequently consulted information resource for patients in Australia’s
pharmacies. Web-based drug information was the resource least consulted daily but is
available and has been used in 34.3% of pharmacies which implies a potential for much
higher daily use. Pharmacies in Pharia 1 ranked first or high in daily use of most information
facilities. The rate of use of CMI serves as a reference before the introduction in November
2002 of remunerating for CMI provision for certain categories of PBS and RPBS prescriptions.

67
3.11 Section K Technologies and health information and
communication
Questions: 22a, 22b, 23

Statistical sources: Tables 22 a. 1-6 (6 tables); Tables 22 b. 1-5 (5 tables); Tables 23.1-23.5
(5 tables)

Aim
To report the percentage of pharmacies with pharmacy dispensary computer facilities
required for involvement in the MediConnect system and the percentage with websites and
their specified purposes and the rates of inter-professional communication by telephone, fax
or email.

Background
Official standards exist for internet pharmacy and the content of pharmacy websites in
Australia 254 . Websites with a range of pharmacy and health information have been compiled
for reference by Australia’s pharmacies 254 . Broadband services (eg ADSL, cable, satellite)
expedite high-speed and ‘always-on’ connections to the web. By December 2001 three million
Australians including over 300,000 with ADSL were estimated to be using the internet mainly
for email but also for online transactions such as shopping, banking and pharmacy
services255. Australia in January 2002 ranked internationally third per capita in computers and
eighth in internet users 256. Telephone communication between professionals and patients
has been long known as a means to improve patients’ health indicators257. But there is little
published research on the utilization of information technologies in pharmacy in Australia or
other countries258 even though experts view internet-based business-to-consumer model as
the most successful model for pharmacy in the future 259 .

Discussion of methods
Questions were compiled with the assistance of a pharmacist experienced in surveys of
information technology. The questions were tested in a focus group of pharmacists from a
variety of pharmacies in Pharia zones 1 and 2 and a nationwide sample of practicing and
specialist pharmacists in Pharia zones 1 to 6. The items in Table D-K22a and Table D-K22b
were taken from official requirements254 and the Health Insurance Commission specifications
for pharmacies to participate in the MediConnect system 260 formerly known as BMMS 261,262.
The standards for inter-professional communications for pharmacies in Australia 254 and
requirements for pharmacies in overseas reports 254 were listed in the items in Table D-K 23.
The results were reviewed by pharmacists with current experience in the above areas and
whose views are reflected in the findings and interpretations below.

Findings
Dispensary computers with Pentium processors were present in 89.2% of pharmacies which
was a key requirement at the time of the survey for the MediConnect system . This is an
electronic health system designed to improve the quality and safety in the management of
medications by giving participating doctors and pharmacists access to more complete
information about the medication history and medicines people are using 254,263. But changes
to the MediConnect system and ongoing trials have not clearly defined the nature of the
software or hardware required. Dispensary computers were used regularly for internet, e-mail
and pharmacy website activities in under 50% of pharmacies (Table D-K22a) while
broadband access was present in just 4.2% of pharmacies. Overall, regular internet use in
2002 occurred in 39.8% of Australia’s pharmacies.
For inter-professional communication with doctors initiated in pharmacies by telephone, Fax
or email for prescription medication reasons, doctors were contacted daily by pharmacies
3.73 times, patients or their carers 1.95 times and other health workers or sources 0.68
times for patient health information (Table D-K23). These results equate to each pharmacy in
Australia communicating yearly about patients’ prescription medicines with these facilities on
at least 1,199 occasions with doctors, at least 627 occasions yearly with patients or their

68
carers and at least 219 times yearly with other health workers . Australia’s pharmacies initiate
at least once daily one or more of these communications (Table D-K23).
That is, at least 8.117 million communications with technical facilities were initiated by
pharmacies with doctors and patients or their carers yearly. This total equates to a rate of
approximately 3.75 communications per 100 prescription items initiated in pharmacies with
telephone, fax or email (this is based on 216 million prescriptions dispensed yearly in 2002 in
Australia’s pharmacies in Table D-A3). Excluded from the results and estimates are
communications initiated by doctors or patients for prescription medicines and 0.68 times
daily initiated with other health workers or source for other patient information, other forms of
communications including mail or face-to-face contacts for prescription medicines and the
communications for prescription medicines in pharmacies , or in aged care, domiciliary or
other places outside pharmacies . Included are multiple communications for a single item or
for a single prescription. These totals and rates need to be considered with the prescription-
related communications with patients or carers reported for Questions 11 to 14.

Table D-K22a. Percentage Australia’s pharmacies with dispensary computer features for
MediConnect system (www.mediconnect.gov.au ) in 2002

Computer feature Yes % No / no response %

Pentium processor 89.2 10.8
Regular internet use 39.8 60.2
Regular email use 40.8 59.2
Pharmacy website 11.1 88.9
ADSL (broad band) 4.2 95.8
Other activities 1.1 98.9

Table D-K22b. Percentage of Australia’s pharmacies with following website activities in 2002

Website activity Yes % No / no response %

Offers medications 2.4 97.6
Other products online 3.5 96.5
Home delivery 4.2 95.8
Health information 9.7 90.3
Other 1.0 99.0

Table D-K23. Inter-professional communication activities in pharmacies in a typical day for

health reasons in 2002

Phone, fax or email contacts Daily per pharmacy % of pharmacies % of pharmacies

(LCI mean estimate ) ≥ 1 daily in 2002 > 0 daily in 2002
Doctor- clarify/correct prescription 2.40 69.7 99.1
Doctor - drug, dose, contra- indication or 1.33 40.5 97.1
adverse effect
Patient or carer - for compliance 1.17 31.3 83.9
Patient or carer - effects of therapy 0.78 17.3 70.1
Health worker - for patient health 0.68 19.1 70.7

Pharia zone
Differences in computer facilities or website activities in pharmacies between Pharia zones
were not analysed.

Australia
Professional practice standards exist for internet pharmacy and pharmacy websites in
Australia 254 . A national survey by ACNielsen in 2001 found 91% of respondent pharmacists
had internet access either at home or at work, 67% have Internet access at work, 30%
reported regular internet access at work and 17% used the internet for customer education;

69
46% reported using e-mails in their day to day practice and 28% had a website for the
pharmacy 264,265. The ACNielsen surveyed pharmacists and not pharmacies and the
representativeness of the respondents is not available to make comparisons with these data
265
. The ACNielsen results show higher internet access and higher email use at work than
these results (Tables D-K22a,22b,23) but this may suggest for respondent bias to heavier
users of internet and possibly respondent pharmacists who worked in the same pharmacies
with internet facilities . Internet resources for health information for pharmacies254 and
pharmacy applications have been reported 255.
The specific technical requirements 261,262 and difficulties for Australian pharmacies’
participation in MediConnect system have been reported 13,14 . The pharmacy requirements
for the MediConnect system will be revised as the results of an ongoing trial in a sample of
pharmacies are obtained. There are presently no clear specifications of final speed or type of
connection that will be required to retrieve the MediConnect messages in a timely manner. It
has been found 65% of pharmacies in the trial are running on “…DOS based software which
is not MediConnect-compatible” hence requiring them to upgrade to Windows-based software
which will also need upgrades of hardware. The additions of communication extras such as
security, messaging and encryption standards required by MediConnect will add extra
demands on existing computers . Mediconnect and increased usage of the internet
(especially ‘always on’ broadband) will require further upgrades of the existing systems to
handle security and virus protection. MediConnct will require broadband in pharmacy but with
a managed service including firewall, antivirus and firewall ( P Naismith, May 28, 2003).
One of the MediConnect functions may be like the Pharmanet system in British Columbia in
potentially providing access to patient drug histories with online communication between
dispensers and prescribers allowing pre-dispensing interventions, subject to patient consent
for entering all drugs and access to doctors and pharmacists 267. But the observations of
visiting pharmacists to Vancouver and the lack of published results from the Canadian system
have created concerns about its application in Australia. The results on the pharmacy web
sites do not indicate whether they are active or in the hands of an external party and are
effectively dormant ( B Callaghan May 29, 2003).
Computer use amongst Australia’s GPs has increased from under 10% in 1998 to
approximately 78% in May 2001 the majority of whom use them to generate prescriptions 266.
The practice standards, systems and establishment of office computers for Australia’s GPs
have been reported 268-270. The changes required in GPs’ computer practice to enable them to
be incorporated in the MediConnect system HealthConnect system to improve patient
outcomes have been reported 266,267 .

International
Telephone communications with patients is an efficient medium for improving their
compliance. The American Pharmacists Association has published guidelines for telephone
communications between pharmacists and doctors for improving patient care271. The
rationale and technical requirements for community pharmacies in the USA becoming
internet-based and establishing websites to better serve the health needs of people have
been reviewed and are equally applicable to Australia’s pharmacies 256,259 . A national survey
of pharmacy internet use in the USA found 10% of respondents communicated by e-mail with
patients of whom half did so at least once weekly. More than 20% of respondents emailed
other health professionals with about half at least once weekly. Large US pharmacy groups
are routinely using e-mail to remind patients about repeat prescriptions 256. The future use of
the internet in a wide variety of activities such as e-prescribing where doctors email
prescriptions direct to the patient’s pharmacy, telepharmacy for homebound patients or those
living in rural and remote areas and in disease management clinics where pharmacists
interpret online laboratory results and email suggested prescribing amendments to
prescribers are being assessed 259,272 . A review of electronic or e-prescribing in USA medical
practices found it to be most cost-effective for larger practices273 but by 2002 less than 5% of
prescriptions in the US were processed entirely electronically 274. In Australia e-prescribing is
viewed as a method of retaining clients which has implications for efficient medication reviews
and better monitoring of medication effects in clients. By 2003, approximately 60% of the
50,000 US pharmacies will commence using an “ electronic prescribing gateway” which is
expected to be gradually accepted by US prescribers as the privacy, logistics and other
difficulties are overcome 275. References to internet sources for USA community pharmacies

70
are produced by the American Pharmaceutical Association 276 . A publication comprising 11
chapters contributed by six pharmacists specialised in a variety of the internet, e-pharmacy
and performing prescription- and health-related activities has been published by the American
Pharmaceutical Association 277.
References on internet sources are produced for British pharmacy by the Royal
Pharmaceutical Society of Great Britain 278. But there is little quantitative data on the use of
information technologies in pharmacies 258.

Interpretations
Dispensary computers in Australia’s pharmacies had high compliance with the technical
requirements of the MediConnect system in July-September 2002 but a current trial in
pharmacies and subsequent changes to the system will require broad band access (ADSL in
urban areas) and replacing the prevailing DOS by Windows software. Adapting British
Columbia’s Pharmanet system as a model system which facilitates full medication histories
in pharmacies is uncertain. In 2002, approximately 40% of Australia’s pharmacies reported
regular email and internet use and 11.1% had websites which were active in health-related
and other areas . The foreseeable broadband and Windows software requirements for the
future MediConnect system planned for 2005 should be readily adopted by pharmacies.
Pharmacy websites need to be assessed against existing internet pharmacy standards.
The estimated rates per 100 prescriptions at which pharmacies reported initiating
communications about prescribed medicines with prescribers or patients by telephone, Fax
or email at the rate approximated rates were found to be consistent with estimates for
counselling, monitoring for compliance and for assessing effects of drug therapy in Tables D-
D13a,13b and 13c.

71
3.12 Section L Opinion on the use of technical facilities
Question: 24

Statistical sources: Tables 24.1-24.7 (7tables)

Aims
To test pharmacy attitudes on the relative effectiveness of telephone, fax or email
communication with prescribers and patients or carers, privacy restraints on such
communication and the deleterious impact of growing internet use on the sales of prescription
and non-prescription sales in pharmacies.

Background
Telephones have been known for more than two decades to be an efficient and convenient
mode of health communication between health professionals and between professionals and
patients279. With the wide uptake by pharmacies of the facsimile and email since 1980 and
their increased use there are no known comparisons of the effectiveness or rates of use of
the three modes in community pharmacies. The email and facsimile have the advantage of
recording communications. Australia had 52 telephone lines and 12 internet users per 100
people in January 2002 280 which suggest the email will not seriously challenge the telephone
as the main mode of communication with patients for some years. But the rapid penetration
of the internet amongst health professionals since 1995 , its convenience and directness
along with early results of its relative effectiveness in communication with health
professionals281, suggest email mode may eventually challenge telephones as the main
mode of communication between health professionals and with their clients in places where
there has been a high uptake of internet facilities. On the other hand , the limitations and
disadvantages on internet use are emerging. These include interference by unsolicited
emails dubbed spam, email messages written abruptly often had errors which could be
misunderstood by doctors or patients, emails were recorded so errors will persist and privacy
is threatened and the internet promotions and sale of prescription medicines have caused
problems in Australia and other countries282-284 .

Discussion of methods
In Australia, standards and guidelines exist for internet pharmacy285. Questions were
compiled with the assistance of pharmacists experienced in surveys of information
technology. The questions were tested in a focus group of pharmacists from a variety of
pharmacies in Pharia zones 1 and 2 and a nationwide sample of practicing and specialist
pharmacists in Pharia zones 1 to 6.

72
 Table D-L24. Rating of impact of technologies on doctor, patient and pharmacies

Strong Unsure Agree- No

Disagree - Strong response
Disagree Agree
Telephone best with doctors or other health 3.3% 3% 93.1% 0.6%
workers
Telephone best with patients or carers 15.2 8.3 75.7 0.8%
Privacy laws restrict communications 47.3 24.2 27.5 1.0%
Fax will replace telephones 77.3 15.9 5.8 1.1%
Email will replace telephones 73.8 18.4 6.6 1.1%
Internet will depress prescriptions by 2004 44.4 30.2 24.4 1.0%
Internet will depress OTCs and other health 34.4 30.2 34.3 1.1%
products by 2004

Findings
Respondents agreed or strongly agreed (93.1% and 75.7%) the telephone is the best mode of
communicating with doctors or other health workers and with patients or their carers (Table D-
L 24). The acceptability of the telephone is consistent with respondents disagreeing it will be
replaced by Fax or e-mail (77.3% and 73.8%). More respondents (47.3%) agreed or strongly
agreed than disagreed or strongly disagreed (27.5%) that privacy legislation restricted their
telephone communications. More disagreed or strongly disagreed (44.4%) than agreed or
strongly agreed ( 24.4%) that internet sales will depress their numbers of prescriptions by by
2004 . Respondents were equally divided that the internet will depress OTCs and other health
products in their pharmacies by 2004 (Table D-L 24).

Pharia zone
No analysis was required.

Australia
In an ACNielsen survey of pharmacists in Australia in 2001, 75% of respondents were
concerned with the impact of internet-based pharmacy on their dispensary business, 74%
had customers ask questions about medical information from the internet and another main
concern was the security of clients’ health records 283 . Evidence from aged care facilities and
community settings in Australia are consistent that medication outcomes are improved by
systematic communication between pharmacists, doctors and their clients286.

International
The cost-effectiveness of telephone communication in disease care management continue to
be reported . A recently published randomised trial of 613 community patients with acute
depression found two telephone follow-up calls significantly improved patient outcomes with
lower recurrence and fewer symptoms of major depression at modest cost287 . The practice
of selling drugs by pharmacies in Canada over the internet to patients in the USA has resulted
in lowered prescription sales in the USA 288 . National pharmacy bodies in both countries
agreed patient safety may jeopardised without face-to-face communication and medication
histories are excluded by the practice which were both necessary for proper medication
management and patient safety 284. Websites in the USA widely promote cheaper
medicines and Internet-based discount pharmacies 288. There are many websites promoting
the sale, packaging, billing and shipping of prescription drugs and payment by 285,289,290 credit
card. These websites pose similar problems in Australia as do the Canadian internet
pharmacies to pharmacies and patients in the USA 285.

Interpretations
Telephone communication by pharmacies with doctors, other health workers and patients or
their carers is regarded as superior to fax or email communication. The telephone is unlikely
to be displaced by either fax or email as the preferred mode of communication in pharmacies
with doctors, other health workers and patients or their carers in the foreseeable future. There

73
is higher acceptance that internet sales will depress by 2004 the sales of OTCs and health
products than of prescription-only medicines. Privacy legislation is regarded as restricting
communication between pharmacies and doctors or patients and suggest national bodies of
pharmacy need to clarify for pharmacists the impact of privacy legislation on communicating
with patients, carers and doctors. The practice of internet promotion and sales of prescription-
only and other medicines by Canadian pharmacies to consumers in the USA and the
resulting action by US and Canadian pharmacy authorities needs to studied by Australia’s
pharmacy bodies for appropriate action in this country.

74
3.13 Section M Pharmacy and staff
Questions: 25a - 33b

Statistical sources: Tables 25a, b and c, 26,27,28,29 a and b, 30a, b:1-4, 31.1-3 ,32 1-10,
33a 1-2, 33b (29 tables).

Aims
To quantify characteristics of Australia’s pharmacies relative to their location, size, group
membership, commercial activities, ownership and staff.

Background
In Australia, pharmacies and pharmacists are required to first be registered by state bodies
and to renew registration annually to practice. Pharmacies require approvals or accreditation
by national government agencies in order to dispense prescriptions listed in the Schedule of
Pharmaceutical Benefits or to participate in national programs such as medication review
processes itemised in Section E. These are remunerated by the Health Insurance
Commission. The Pharmacy Guild of Australia manages the Quality Care Pharmacy Program
(QCPP). National sample surveys of pharmacies are conducted regularly by government
agencies such as the Australian Bureau of Statistics and national pharmacy bodies such as
the Pharmacy Guild of Australia or the Pharmaceutical Society of Australia. Regional or state
surveys are often performed by state boards for their or other purposes. Surveys are
frequently performed by university research groups or on behalf of national health research
bodies such as labour force studies conducted by the Australian Institute of Health and
Welfare 291.

Discussion of methods
In Australia the term community pharmacy is defined and standards exist for pharmacy
design and layout 292. Questions were compiled after consultation with the national panel,
visits to pharmacies across all Pharia zones and direct or telephone discussions with their key
staff, direct or telephone discussions with leaders of pharmacy bodies and pharmacy groups
and reference to a range of pharmacy business, practice and research journals published in
Australia and internationally. Questions were compiled with the assistance of researchers in
the panel, interstate and overseas experienced in conducting regional or national pharmacy
surveys in Australia and other countries The questions were tested in a focus group of
pharmacist owners or managers from a variety of pharmacies in Pharia zones 1 and 2 and a
nationwide sample of practicing owners or managers and specialist pharmacists in Pharia
zones 1 to 6.

Findings
The jurisdictional locations of respondents by locations of pharmacies in Great Britain were
38% in inner city or town centres, 11% on housing estates and 17% in a village293. The only
directly comparable category in Australia appears to be group 1 with 41.4% of all pharmacies
( Table D-M25b). Most regional (over 30,000 sq m) shopping centres usually constitute town
or city centres so these would make a total 46.2% (groups 1 and 2, Table D 25b). Most of
Australia’s community pharmacies (64.9%) are located in urban or town shopping strips and
regional or neighbourhood shopping centres (Table D-M25b). The highest number of
pharmacies open six days a week (median) but a large number of pharmacies open seven
days results in a mean of 6.16 days (Table D-M25c). The high percentages of ‘invalid’
responses for areas in pharmacies (Table D-M26) reflect the small percentages of certain
pharmacy areas and large areas due to square feet or miscalculated areas. Most counselling
seems to occur in the schedule area which requires investigation because of lack of privacy
and the small size of this section of the pharmacy. A total of 50.5% of the pharmacies were
reported to be members of groups (Table D-M27a) which is similar to membership reported in
May 2003 294 and compares with 48.7% of pharmacies with PBS approval numbers which
operated for the full 12 months reflecting a small over-representation of pharmacies in groups
among the respondents.

75
Respondents in the Pharmacy Guild-managed Quality Care Pharmacy Program or QCPP
comprised 54.1% (Table D-M28) compared with 48.7% actually QCPP-accredited in October
2002 295. This apparent 5.4% over-representation of QCPP pharmacies was due mainly to
the incentive of 3 CPI offered to accredited QCPP pharmacies who responded. This possible
respondent bias may have affected a range of other results where QCPP-related factors are
important. The characteristics of pharmacy in relation to the role of non-pharmacists and
support for health-related in comparison with other services needs to be studied.
The 53.8% of sole proprietors, their older age and less CPE involvement than other pharmacy
staff are notable (Tables D-M29a, D-M30b-4 ). With 39.5 % of owners over 50 years of age,
succession planning emerges as an issue because 57.2% off pharmacies have one owner
and a minority of the partners are under 40 years of age. (Table D-M29a, D-M30b-1)
Females are under-represented as owners (23.7%). A large majority of owners have
university degrees. A surprisingly high 19.1% have a diploma indicating they graduated
before 1966 and pharmacists of more than 60 years of age (Table D-M30b -3). Postgraduate
degrees amongst owners comprise 2.4% and 1.1% of first and second owners respectively.
The continuing education done by community pharmacy owners in hours per month(Table D-
M30c). The big majority of owners are male and do under six hours monthly of continuing
education (Table D-M30b-4).
The best estimate of customers per pharmacy per week from the respondents’ reports is
1393.5 (CI 95% 1333.62 and 1453.08) which equates to a minimum 6.367 million customers
weekly and 331.16 million per annum in Australia’s pharmacies pa. The majority of hours
served in the dispensary by proprietors reflects the slow acceptance of face to face patient
counselling and the continuing resistance to dispensary assistants who would relieve them of
the technical activities and release pharmacists to the important function of counselling.(Table
D-M32a) The relatively high dispensary commitments apparent in Table D-M32a are repeated
in Table D-M32b. In contrast, the presence of a non-pharmacist retail manager in 21% of
pharmacies (Table D-M29b) is signifies pharmacists focusing on health-related activities.

The results in Table D-M32c suggest the under-utilisation of the dispensary assistants who
work an average of just 32 hours per week. Ideally, dispensary assistants should be engaged
for no less than 38 hours per week to free pharmacists from clerical and low grade technical
activities to the more important patient counselling, patient care and medication review
activities.
The minimum estimated annual turnover per pharmacy is (best estimate of mean $1.84
million; 95% CI 1.76m and $1.91m). Overall 32.5% of pharmacies reported annual turnovers
of $2million or more with 32% of those in Pharia 1, 41% of pharmacies in Pharia 2 and least
were 15% of pharmacies in Pharias 5&6 with annual turnovers of $2million or more.

Pharia zone
By Pharia 36% of pharmacies in Pharia 1 had more than 1401 customers per week with
Pharia 2 pharmacies having 41% , pharmacies in other Pharia zones having less with those in
Pharia 5&6 having least with 21% with more than 1401 customers per week (Table D31).

Australia
The neighbourhood shopping centres ( 10- 100 shops or 2,000-30,000 sq m lettable area )
contain 18.7% of Australia’s community pharmacies (Table D-M25b) and are partly
comparable with 17% of British pharmacies in villages(Table D-M27b)293. The 6.3% of
Australia’s pharmacies situated in medical centres (Table D-M25b) is unlikely to change even
though up to 2000, pharmacies could be located in medical centres if they were not within
2km of another pharmacy. This has been relaxed to 1.5km and is supported by a national
competition policy review and the Australian Medical Association but is difficult to change due
to inconvenience and cost 296 .
A survey in 1999 of 81methadone pharmacies in Australia found 5% in NSW , 4% in WA,
15% in SA and 19% in the ACT reported closed dispensing or dosing booths and 70% overall
having standing dose areas 297 .
A national total of 2165 pharmacies in banner groups equates to 48.7% of the 4,447
pharmacies with PBS approval numbers which operated for the full 12 months to 30 June
2002 or at the time the questionnaires were mailed294. After moderate growth to 2000,
membership of banner groups has slowed from 2156 in 2000294,298. Pharmacy groups based

76
on commercial or promotional features have the majority of Australia’s pharmacies including
Australia’s largest pharmacies hence pharmacy groups probably account for a
disproportionately large majority of total national pharmacy sales or turnover. Australia’s
pharmacy groups compete mainly on commercial grounds. Certain groups offer expanded
pharmacy services such as screening by clinical testing for undiagnosed disorders such as
hypertension and raised blood glucose which represents a health-related service offering an
opportunity to compete 299 .
The Pharmacy Guild collects but doesn’t publish customer numbers and the figure of 74,000
(Table D-M31) is higher than the usually cited 60,000. The turnover figure of $1.84m for 2002
(Table D-M33a) is in line with Pharmacy Guild estimates of $1.74m annual average turnover
for 2000-01 (the last finalised year). The 64.5% for prescriptions as a percentage of total
sales is lower than the Guild’s 2000-01 estimated 67.2% with later indications from monthly
turnover monitor survey that it would have been even higher in 2002. The Guild applies
weightings derived from PBS data received from the Department of Health & Ageing
(originating from HIC) and based on PBS data for 2000-01 showing script volumes
(subsidised scripts only - those paid wholly by the patients are excluded) for each of the 4,447
approval numbers which operated for the whole 12 month period 302 .

Table D-M25 a. Australia’s pharmacies by jurisdiction: respondents and registered

pharmacies (May 2003)

Code Jurisdiction % by jurisdiction Actual (2003)

0-999 ACT 1.1 1.2
1000-1999 NT 0.1 0.6
2000-2999 NSW 32.0 34.8

3000-3999 Victoria 20.9 23.0

4000-4999 Queensland 20.1 19.9

5000-5999 SA 9.2 8.1

6000-6999 WA 10.5 9.7

7000-7999 Tasmania 4.5 2.7

No response 1.7 0
Total 100 100 (5032)

Table D-M25b. Australia’s pharmacies by setting

Location Percentage
City, suburb or town shopping strip 41.4%
Regional shopping centre 4.8
Neighbourhood shopping centre 18.7
Isolated shops 23.5
Medical centre 6.3
Hospital 0.9
Other 1.9
Missing 2.7%

Table D-M25c. Australia’s pharmacies open by hours per day and days per weekly in 2002

77
 Total days per week Total hours per week
Mean 6.18 55.5
Median 6.0 52.0
Standard deviation 0.70 14.4
missing 3.7% 2.7%

Table D-M26. Australia’s pharmacies in 2002: areas of sections in pharmacy

Mean Median SD invalid

Dispensary area 20.9 20.0 11.6 8.9%
Schedule area 11.8 10.0 12.5 9.8%
Forward pharmacy 1.4 0.0 6.6 9.7%
Unenclosed counselling area 3.1 2.0 3.5 9.7%
Enclosed counselling/dosing area 1.2 0.0 2.7 10.3
Retail 114.1 90.0 87.6 9.1
Storeroom, office, other 28.5 20.0 35.1 8.9
Other 3.4 0.0 11.7 11.4
Total area of premises 187.2 160.0 118.3 9.1

Table D-M27a. Australia’s community pharmacies by membership of groups in 2002

Group Percentage Pharmabroker

(total 4950)
Not in a group 48.4% 42.2
Amcal 9.5 8.0
Chem Mart 6.5 4.6
Friendly 2.2 1.2
Guardian 6.3 5.4
Soul Pattinson 4.7 4.6
Other groups 21.3 34.0
Missing 1.1 NA

Table D-M 27b. Great Britain’s community pharmacies in 2000 by group and percentage 301

Pharmacy type Percentage of British pharmacies

Non-pharmacy controlled corporate supermarkets and discount 4.1%
stores (eg Tesco, Sainsbury’s, Safeway, Asda )
Pharmacy-controlled chains or groups 35.5%
(eg Lloydspharmacy, Boots, Moss)
Others : pharmacist- controlled single or small groups 60.4%

Table D-M28. Australia’s community pharmacies by QCPP status July-September 2002

QCPP status Percentage

78
 Not yet registered 9.8%
Partly completed accreditation 27.9
Completed but not accredited 5.2
QCCP accredited 44.1
Re-accredited 10.0
other 1.8
Missing 1.2

Table D-M29a. Australia’s community pharmacies by management of pharmacy

Current management Percentage

Owner 53.8%
Partnership 23.3%
Manager 18.7%
Other 1.2%
Missing 3.1%

Table D-M29b. Australia’s community pharmacies with non-pharmacist retail manager

Yes No Missing
21.0% 77.9% 1.1%

Table D-M30a. Australia’s community pharmacies by number of owners in 2002

Number of owners Percentage

1 57.2
2 23.9
3 7.5
4 or more 2.1
Invalid 0.5

Table D-M30b1. Australia’s community pharmacy owners by cumulative age

Age Cumulative percentage

21-30 7.7
31-40 22.5
41-50 30.3
51-60 24.4
61+ 15.1

Table D-M30b2. Australia’s community pharmacy owners by cumulative gender and CPE
commitment

79
 Gender Cumulative percentage
Male 76.3
Female 23.7

Table D-M30b3. Australia’s community pharmacy owners in 2002 by cumulative highest

pharmacy qualification

Highest qualification Percentage

Diploma 18.2
Bachelor 74.9
Masters 1.9
PhD 0.8
Other 4.2

Table D-M30b4. Australia’s community pharmacy owners by cumulative CPE hours monthly
in 2002

Hours monthly Percentage

0 7.5
1-5 58.2
6-10 21.2
11-20 9.7
Over 20 3.4

Table D-M32-1 Australia’s community pharmacies by customers per week in 2002

Customers weekly Percentage of pharmacies

0-700 21.8
701-1400 39.3
1401-2100 18.8
2101-3500 11.0
3501-5000 3.4
5001 0r more 1.1
No response 4.6

Table D-M32a. Hours in dispensary and patient care by proprietors

Dispensary-Prescriptions Patient care-Counselling

Mean Median Mean Median
1 30.93 SD 14.5 18.8 10.8 SD 10.0 9.00
2 18.8 SD 14.7 18.00 8.2 SD 9.0 5.00
3 15.9 SD 16.1 10.00 8.8 SD 11.5 4.00
4 2.7 SD 5.9 - 0.33 SD 0.71 -

Table D-M32b. Dispensary and patient care by manager, consultant and other pharmacists

Dispensary-Prescriptions Patient care-Counselling

Mean Median Mean Median
Manager 30.93 SD 14.5 18.8 11.2 SD 10.6 8.0

80
 Consultant 18.8 SD 14.7 18.00 9.3 SD 16.3 5.0
Other 15.9 SD16.1 10.00 10.3 SD 14.2 5.0
pharmacists

Table D-M32c. Hours by dispensary assistant or technician

Dispensary Prescriptions
Mean Median
30.93 SD 14.5 30.8

Table D-M33a. Australia’s community pharmacies by total annual turnovers in 2002.

Annual sales ($AUD million) Percentage of total

<$1m 20.9
$1-1.5m 25.6
$1.5-2m 19.0
$2-3m 18.9
$3-4m 8.6
$4-6m 4.1
$6-8m 0.7
$8m+ 0.2
No response 2.0

Table D-M33b Australia’s community pharmacies by categories of sales annually

Mean percentage of total Annual sales ( $ billion)

Prescriptions 64.5 5.934
S2 and S3s 13.7 1.260
Herbals, vitamins 5.0 0.460
Medical aids 2.2 0.202
Other sales 15.4 1.417
Total 9.273

International
The Nevada Board of Pharmacy recommended after reviewing a death related to a
prescription dispensing error that “…the pharmacy be remodelled to better facilitate the
confidential counselling of patients…whose interests should be paramount for all health
professionals, including pharmacists… ” 300. This has implications for the design of
pharmacies in relation to enclosed counselling areas. In Great Britain’s survey of pharmacies
37% reported being not in a group, 29% in groups of up to 20 pharmacies and 38% were in
groups with more than 21 pharmacies293. The percentage in groups of more than 21
pharmacies is similar to a later classification of Great Britain’s pharmacies showing 39.6% are
in large groups (Table D-M27b) 301. In Australia, there appear to be less pharmacies in large
banner groups compared to Great Britain.

Interpretations
The respondent pharmacies differed variously from published figures in location, setting,
group membership and QCPP membership. Data received for areas of sections in
pharmacies, operation, non-pharmacist retail manager and details of owners and pharmacy
staff are not able to be compared in the absence of unavailable data. Customer numbers,
turnover and other data need be carefully validated but the reported data are in line with

81
reported data. Increasing numbers of owners seems to be associated with more time spent
on patient care and counselling

82
4. Provision of services and pharmacy characteristics
(Term of Reference 3)
Questions: 7, 12, 13c,14d, 17, 18,19a, 19b, 20, 23, by 25b,25c,26,27,28,29b,30a,31,33a,
Pharia and state.

Statistical sources: Volume 2 (Database). Table s34.1 -34.12: q7 (12 tables); Tables 35.1 -
35.12 :q7 (12 tables); Tables 36.1 -36.12 :q7 (12 tables); Tables 37.1-37.12 :q7 (12 tables);
Tables 38.1-38.12 (12 tables); Tables 39.1-39.12 q13c; (12 tables) Tables 40.1-40.12 q 14d
(12 tables) ; Tables 41.1-41.12 q17 ( 12 tables) ; Tables 42.1-42.12 q18 (12 tables); Tables
43.1- 43.12 q19a (12 tables); Tables 44.1-44.12 q19b (12 tables); Tables 45.1-45.12 (q20 12
tables); Tables 46.1-46.12 q23 (12 tables) . Total of 156 tables.

Aim
To test and identify individual relationships which are statistically significant between the
provision of selected services against specified characteristics of community pharmacies in
Section M as reported by respondents.

Background
Relationships between implementing important pharmacy services and selected pharmacy
variables have not been previously reported for Australia’s pharmacies. The relationships
found to be statistically significant are intended to provide reference data for national
pharmacy bodies in making policy decisions.

Discussion of methods
The statistical analysis is limited to simple analysis involving hypothesis tests such as t-test
and chi-squared test between the pharmacy service and a single pharmacy variable. Future
comparisons will require more detailed analysis (e.g. logistic regression) to control for
statistical interactions and confounding variables 303.

Findings
Statistically significant relationships were found between the tested pharmacy variables in
Section M and the individual services recorded in Table D-4.1. For example for a pharmacy
performing any enhanced pharmacy service (Question 7), it was significantly related to the
State, setting, days open per week, area of premises, group membership, customers per
week and turnover. An association between EPS and state was found, with the prevalence of
providing one or more EPS being the highest in “ACT and NSW”. A significantly higher
proportion of those in urban retail settings compared to other settings provided one or more
EPS. Those who provided one or more EPS were open for significantly more hours and had
larger premises. A significantly higher proportion of those in a banner group provided one or
more EPS as compared to those not in a banner group. A significantly higher proportion of
those with “1401 to 5001+” customers per week provided one or more EPS as compared to
those with “0 to 1400” customers per week. A significantly higher proportion of those with an
annual turnover of between “2M to >8M” provided one or more EPS as compared to those
with an annual turnover between “<1M to 2M”. Each of these individual relationships are
described in the database. For all significant relationships recorded in Table 4.1 refer to the
corresponding table in the database for a description of the association.

Pharia zone
This was not required.

Australia
No reported analyses of the barriers to enhanced pharmacy services and pharmacy
characteristics have been found.

National estimates
These were not required.

83
 Table 4.1. General, specialised and enhanced pharmacy services by pharmacy
characteristics
“√” represents significant individual association found between service and characteristic

prescription

Counselling

drug effects
compliance
Supervised

Pharmacist
Medication
Monitoring

Monitoring

Processes
Declined

initiated
Review
dosing

drugs

agent
Q13b

Q14d
Q11c

Q13a

Q13c
EPS

Q12

Q17
Q7

PhARIA √
State √ √
Setting √ √ √ √
Days open per √ √ √ √
week
Area of √ √ √ √ √
premises
Group √ √ √ √ √
membership
QCPP status √ √
Retail manager
Number of √ √
owners
Customers per √ √ √ √ √
week
Turnover √ √ √ √ √

Table 4.1 General , specialised and enhanced pharmacy services by pharmacy

characteristics (cont).
Complementary

Communication
minimisation or
reduction

therapies

activities
Fraud
Tests

Harm

Q19b
Q19a
Q18

Q20

Q23

PhARIA √ √
State √ √ √
Setting √ √
Days open per √ √ √ √
week
Area of √ √ √ √
premises
Group √ √ √ √
membership
QCPP status √ √ √
Retail manager √ √
Number of √ √ √ √
owners
Customers per √ √ √ √
week
Turnover √ √ √ √

84
International
Results from the national survey in 2000 of British pharmacies were statistically analysed for
relationships between 39 ‘extended role’ activities from a list of general (eg medication
reviews, compliance assistance) and specialised pharmacy services ( eg needle exchange,
screening ) with 12 ‘business related’ characteristics (eg location, staffing levels, opening
hours, private consultation area), 10 ‘pharmacist related’ characteristics (eg position of
respondent, continuing education workshops, age and gender) and two ‘ inter-related’
characteristics (eg Health Authority accreditation, pharmacists working for Heath and Social
services) 304. Chi-square statistical tests were performed on the provision of the services and
individual pharmacy characteristics. Many individual relationships (significant) were found but
the most consistently related significance with general and specialised services were found
between the pharmacist related and inter-related characteristics. For example general
services such as GP referral for minor ailments, medication reviews and domiciliary and
residential/nursing home visits were significantly associated with the highest number ( two) of
inter-related characteristics which are analogous to Australia’s pharmacies having DMMR
approvals, access to AACP accredited pharmacists and QCCP accreditation. Involvement in
general and specialised pharmacy services was stronger related with a higher number of
pharmacist than business related characteristics 304. Specialised services such as stoma
care and prescribing reviews were related to higher numbers of dispensed prescriptions.
Business related characteristics (eg turnover, group membership) were significantly related to
stoma care and other specialised or ‘extended’ activities. Statistically significant associations
were found between pharmacy group number and domiciliary visits, dedicated counselling
area, PACT analysis, prescribing reviews and formulary development; between private
consultation area and involvement in compliance assessment, stoma care, PACT analysis,
prescribing reviews and formulary development; autonomy and involvement in domiciliary
visits, medication reviews, stoma care, designated counselling area and formulary
development304.
In summary, Health Authority accreditation, postgraduate qualification and pharmacy position
(owner or staff) were associated with a wider range of activities 304. Many of the pharmacy
characteristics and pharmacy services tested were not applicable to Australia’s pharmacies.

Interpretations
The relationships in Table 4.1 suggest more services are provided by characteristics related
to higher turnover as examples. But the interpretation and the limitations on these
relationships require detailed hypothesis testing with the use of logistic regression.

85
5. Barriers / facilitators to service provision by pharmacy
characteristics
Section 5.1. Barriers to enhanced pharmacy services and pharmacy
characteristics (Term of reference 4)

Questions: Question 8 by PhARIA, state, 25b, 25c, 26, 27, 28, 29b, 30a, 31, 33a.

Statistical sources (Database)

Question 8 (barriers). Tables 47.1-47.12 q8a (12); 48.1-48.12 q 8b (12); 49.1-49.12 q8c (12);
50.1 -50.12 q 8d(12); 51.1-51.12 q8e (12); 52.1-52.12 q8f (12); 53.1 - 53.12 q8g (12); 54.1.-
54.12 q8h (12 tables); 55.1-55.12 q8i (12 tables) ; 56.1-56.12 q8j (12 tables); 57.1 - 57.12 q8k
(12 tables). Total of 132 Tables.

Aim
To identify those selected pharmacy variables in Section M which are found to have individual
associations with the barriers listed in Question 8 to enhanced pharmacy services (in
Question 7).

Background
Relationships between implementing important pharmacy services and selected pharmacy
variables in Section M. The relationships found to be statistically significant are intended to
provide reference data for national pharmacy bodies in making policy decisions.

Discussion of methods
A simple analysis involving hypothesis tests such as t-test and chi-squared test between the
pharmacy service and a single pharmacy variable was performed. Future work will require
more detailed analysis (e.g. logistic regression) to control for statistical interactions and
confounding variables303.

Findings
Statistically significant relationships were found between the pharmacy characteristics in
Section M and individual barriers as listed in question 8. Table D-5.1 summarises the
significant and non-significant individual relationships. For example, a shortage of time for
pharmacists as a barrier to EPS (question 8) was found to be individually associated
(significant) with PhARIA, setting and group membership. For all significant relationships
recorded in Table 5.1 refer to the corresponding table in the database for a description of the
association.

Pharia zone
This was not required.

Australia
No reported analyses of the barriers to enhanced pharmacy services and pharmacy
characteristics have been found.

International
Results from the national survey of British pharmacies were statistically analysed for
relationships between 39 ‘extended role’ activities (eg general pharmacy services, specialised
pharmacy services) and a sample of 12 ‘business related’ characteristics (eg location, staffing
levels, opening hours, private consultation area), 10 ‘pharmacist related’ characteristics (eg
position of respondent, continuing education workshops, age and gender) and two ‘ inter-
related’ characteristics (eg Health Authority accreditation, pharmacists working for Heath and
Social services) 304.

National estimates
These were not required.

86
Interpretations
The following relationships are taken from Table 4.1 as examples of interpretation and the
limitations on them hence requiring detailed hypothesis testing with the use of logistic
regression.

Table D5.1. Barriers to enhanced pharmacy services and specified pharmacy characteristics :
statistically significant relationships
“√” represents significant individual association found between barriers / facilitators to service and characteristic

Knowledge and

Remuneration
pharmacists
Shortage of

Shortage of

Confidence
Customers
won’t pay

Locum

skills
time

Q8b

Q8d

Q8g

Q8h
Q8a

Q8c

Q8e

Job
Q8f
PhARIA √ √ √ √ √
State
Setting √
Days open per √
week
Area of √
premises
Group √ √
membership
QCPP status √
Retail manager
Number of
owners
Customers per √ √
week
Turnover

Table D5.1 - Barriers to enhanced pharmacy services and specified pharmacy characteristics
: statistically significant relationships (Cont)
Relationship

Recognition
Opportunity

pharmacist
local GP
with GP

to meet

skill
Q8k
Q8i

Q8j

of

PhARIA √
State √ √
Setting
Days open per
week
Area of √
premises
Group √
membership
QCPP status
Retail manager
Number of
owners
Customers per √
week
Turnover

87
Section 5.2. Facilitators to enhanced pharmacy services and pharmacy
characteristics (Term of reference 4)

Questions: Question 9 by PhARIA, state, 25b, 25c, 26, 27, 28, 29b, 30a, 31, 33a.

Statistical sources
Question 9 (facilitators) . Table 58.1- 58.12 q9a (12 tables) ; 59.1-59.12 q9b (12 tables) ;
60.1-60.12 q9c (12 tables); 61.1-61.12 q9d (12 tables ); 62.1-62.12 q9e (12 tables ); 63.1-
63.12 25c (12 tables); 64.1-64.12 q24a (12 tables); 65.1-65.12 q24b (12 tables); 66.1-66.12
q24c (12 tables); 67.1-67.12 q24d (12 tables); 68.1-68.12 q24e (12 tables); 69.1-69.12 q24f (
12 tables); 70.1-70.12 q24g (12 tables).
Total of 132 tables.

Aim
To identify those selected pharmacy variables in Section M which are found to have
statistically significant associations with the facilitators listed in Question 9 to enhanced
pharmacy services (in Question 7) .

Background
Implementing enhanced pharmacy services are influenced by facilitators identified by
respondents to Question 9. Selected pharmacy variables in Section M are suspected to have
statistically significant relationships which can assist national pharmacy bodies in making
policy decisions for increasing the adoption of enhanced pharmacy services in Australia’s
pharmacies.

Discussion of methods
The statistical analysis is limited to simple descriptive analysis involving hypothesis tests such
as t-test and chi-squared test between the pharmacy service and a single pharmacy variable
303
. Detailed hypothesis testing ( eg by the use of logistic regression) is however necessary to
control for possibly confounding variables.

Findings
Statistically significant relationships were found between pharmacy characteristics in Section
M and facilitators of EPS as recorded in Table 5.2. For example access to detailed patient
notes to facilitate EPS was found to be individually associated with days open per week,
group membership and QCPP status. For all significant relationships recorded in Table 5.2
refer to the corresponding table in the database for a description of the association.

Pharia zone
This was not required.

Australia
No reported analyses of the facilitators to enhanced pharmacy services and pharmacy
characteristics have been found.

International
Ruston (2001) has performed limited analyses of the provision of enhanced pharmacy
services and pharmacy characteristics304.

Interpretations
The following relationships are taken from Table 5.2 as examples of interpretation and the
limitations on them hence requiring detailed hypothesis testing with the use of logistic
regression.

88
Table 5.2. Facilitators of enhanced pharmacy services and specified pharmacy
characteristics : statistically significant relationships

Appointme

Accreditati

Study time
testing are
counsellin

nt system
Clinical
Patient

Closed
g area
notes

Q9b

Q9d
Q9a

Q9c

Q9e

Q9f
on
PhARIA
State √ √
Setting
Days open per √ √
week
Area of √
premises
Group √ √ √ √
membership
QCPP status √ √ √ √
Retail manager √ √
Number of √
owners
Customers per
week
Turnover

89
Section 5.3 Opinions on the use of technical facilities and pharmacy relationships.

The following section was not required under the terms of reference.

Questions
Question 24, by Pharia, state, 25b, 25c ,26,27,28,29b,30a,31,33a.

Statistical sources
The following may be found in the attached Data Base. Tables 64.1q24a-70.12q24g (84
tables).

Aim
To identify those selected pharmacy variables in Section M which are found to have
statistically significant associations with the agreement or disagreement with statements
relating to impact of communication technologies and communications listed in Question 24.

Background
The telephone has been the facility most used in pharmacies for many years to communicate
for medication or health-related reasons with patients, their carers , doctors and other health
workers. With the installation of facsimile, email and internet facilities over the past decade
and the enactment of national privacy legislation in December 2001, certain pharmacy
variables in Section M are suspected to have statistically significant relationships which may
assist national pharmacy bodies in making policy decisions for enhancing the performance of
pharmacy services in Australia’s pharmacies in relation to communication technologies and
patient care or health-related activities .

Discussion of methods
The statistical analysis is limited to simple descriptive analysis involving hypothesis tests such
as t-test and chi-squared test between the pharmacy service and a single pharmacy variable.
Detailed hypothesis testing ( eg by the use of logistic regression) is however necessary to
control for possibly confounding variables. The methods described earlier were applied to this
analysis 303.

Findings
Statistically significant relationships were found between pharmacy characteristics in Section
M and the use or impact of communication technologies on the pharmacies health related
activities during 2002, as recorded in Table 5.3. For example telephone being the first widely
used method to communicate with community patients or carers was found to be individually
associated with days open per week and number of customers per week. For all significant
relationships recorded in Table 5.3 refer to the corresponding table in the above statistical
sources in the database for a description of the association.

Pharia zone
This was not required.

Australia
No reported associations between pharmacy characteristics and existing or future
communication technologies and communications have been reported.

International
No reported associations between pharmacy characteristics and existing or future
communication technologies and communications have been reported from the survey of
British pharmacies or other surveys of pharmacies.

National estimates
These were not required.

90
 Interpretations
For all significant relationships reported in Table 5.3 refer to the corresponding table in the
above statistical sources in the database for a description of the association. There are
limitations on the interpretations hence requiring detailed hypothesis testing with the use of
logistic regression are necessary.

Table 5.3. Opinions on the use of technical facilities for health communication purposes and
pharmacy characteristics : statistically significant relationships

Internet sales of all medicines

medicines depress medicines
communicate with GP, health

communicate with GP, health

Internet sales of prescription

Privacy legislation restricts
Telephone with GP & other

Telephone with patients or

telephone communication

Email replace phone to

prescribed medicines
Fax replace phone to

depress sale of non

workers or patients

workers or patients
health workers

dispensed
Q24b

Q24d

Q24g
Q24a

Q24c

Q24e
carer

Q24f
PhARIA √
State
Setting √
Days open per √
week
Area of √
premises
Group √ √ √
membership
QCPP status
Retail manager √
Number of √
owners
Customers per √ √
week
Turnover √ √

91
6. Glossary and definitions
AACP Australian Association of Consultant Pharmacy
APAC Australian Pharmaceutical Advisory Council
ACT Australian Capital Territory, Australia

CPE Continuing Pharmacy Education

CMI Consumer Medicine Information
COPRA Council of Pharmacy Registering Authorities (replaces APRA)
CHAPANZ Committee of heads of pharmacy in Australia and New Zealand
CMI Consumer Medicine Information

DAA Dose administration aids

DMMR Domiciliary Medication Management Reviews

HMR Home Medicine Reviews

HIC Health Insurance Commission

NSW New South Wales, Australia

NT Northern Territory, Australia

PhARIA Pharmacy Access Remoteness Index of Australia

PBS Pharmaceutical Benefits Scheme
PGA Pharmaceutical Guild of Australia
PSA Pharmaceutical Society of Australia

QCPP Quality Care Pharmacy Program

QLD Queensland, Australia

SA South Australia, Australia

TAS Tasmania, Australia

WA Western Australia, Australia

Pharmaceutical Care The responsible provision of medicine therapy for the purpose
of achieving definite outcomes that improve a patient’s quality
of life.

Screening Detection of unrecognised disease or condition by using

reliable tests, examinations or other procedures that can be
readily applied.

92
7. Technical Notes

n
Mean:
1 ∑ xi
ni i=1
n
Variance:
1 [ (∑ xi2) – nx-2]
i=1
(n-1)

Standard deviation:
√Variance

n
Mean estimate:
1 ∑ fixi
ni i=1
Where xi = midpoint (except last column where lowest score used), fi=
frequency of score and n = number of valid scores.

n n
Variance estimate:
1 2
[ (∑fixi ) – (∑fixi)2 /n ]
i=1 i=1
(n-1)
Where xi = midpoint (except last column where lowest score used), fi=
frequency of score and n = number of valid scores.

Standard deviation
estimate: √Variance estimate

93
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8. Appendix
1. Approvals in 2002.
2. Publicity in 2002.
3. Questionnaire :refer http://www.curtin.edu.au/curtin/dept/pharmacy/survey/index.html

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 This survey has Pharmacy Guild of Australia rating A1 (No.479)
Commonwealth Government Statistical Clearing House Approval No.01189-01
Please provide an estimate of the time taken to complete this form.
Include: The time actually spent reading the instructions, working on the question and
obtaining the information;
The time spent by all employees in collecting and providing this information.
hrs mins

PRIORITY
National Survey - Third Pharmacy Government Agreement
This national survey of pharmacies is being conducted by Curtin
University's School of Pharmacy under the Third Community Pharmacy
Agreement Research and Development (R&D) Grants Program. The
survey is supported by the Pharmacy Boards, Pharmacy Guild, the
Pharmaceutical Society of Australia, University departments of pharmacy
and other national pharmacy bodies.

Survey The main purpose of the survey is to quantify the paid or unpaid
health related activities occurring in Australia's pharmacies so our
national bodies are in a stronger position to negotiate to increase your

of
remuneration for a wider range of pharmacy services.

Questionnaires are the most efficient method of gathering data on

pharmacies but the responses need to be complete and accurate so that
Australia’s the statistics are reliable. These results will allow the University statistician
to quantify national numbers of pharmacy facilities and services for the
community first time in Australia.
pharmacies
2002 The respondent pharmacist manager or owner may need to consult
with other pharmacists or non-pharmacist staff who work at other times or
in different areas in the pharmacy. Please keep the enclosed $10 for
participating. Each accredited Quality Care Pharmacy Program (QCPP)
pharmacy will receive 3 CQI points as part of the annual 8-CQI point
QCPP re-accreditation for completing this questionnaire.

T h e U n i v e r s i t y ' s I n t e r n e t H o m e P a g e
http://www.curtin.edu.au/curtin/dept/pharmacy/survey/index.html
will post the questionnaire and the results of the survey as they become
available.

Queries may be directed to Con Berbatis, School of Pharmacy,

Phone: (08) 9271 7180 (all hours),
Fax: (08) 9266 2769
Email: berbatis@git.com.au

Thank you for participating in this important study.

Informed Consent
I consent to the collection and use of the data in the enclosed form on the
understanding it will be de-identified, processed and analysed in groups and held
confidential according to National Health and Medical Research Council
(NH&MRC, 2001) requirements and the project has been approved by the Human
Research Ethics Committee of the Curtin University of Technology.

Signed: Pharmacy (print):

Name (print): Date: / /2002

SECTION Respondent pharmacist details
A

1 Gender. Please tick Male 1

Female 2

2 Age. Please tick 21-30 1

31-40 2

41-50 3

51-60 4

61+ 5

3 In which year did you first obtain Australian registration as a pharmacist

(any category) in any State or Territory?

4 Please tick ( ) where you obtained your initial qualification in pharmacy? NSW 1
VIC 2
QLD 3
SA 4
WA 5
TAS 6
ACT 7
NT 8
Other country 9

5a Please tick ( ) your highest qualification in pharmacy? Diploma 1

B Pharm 2
M Pharm 3
PhD 4
Other (specify)

5b Please tick ( ) the average number of hours you spent each month on None 1
Continuing Pharmacy Education activities in the last 12 months? 1 to 5 hours 2
6 to 10 hours 3
11 to 20 hours 4
More than 20 hours 5

5c Please tick ( ) the percentage of your involvement in the following forms of Continuing Pharmacy Education (CPE).

% CPE time involvement 0 - 20% 1

21 - 40% 2
41 - 60% 3
61- 80% 4
81 - 100% 5
Conferences
Course/lectures (seminars)
Journals/ personal reading
Online
Questionnaires in professional journals
Other (specify)

6 Please tick ( ) which one of the following best describes your Sole proprietor 1
position in this pharmacy? Partner proprietor 2

Salaried manager 3
Pharmacist in charge 4
Locum pharmacist 5
Consultant pharmacist 6
Employee pharmacist 7

page 1
SECTION
SECTION
B
B
Enhanced pharmacy services paid or unpaid

7 Please tick ( ) the following categories of enhanced pharmacy services over and above routine practice that this pharmacy
offers or plans to offer.
Specially trained or Offers now Plans in
Category of enhanced pharmacy service Does not offer accredited pharmacist Offers at Receives payment
12 months
1 or non-pharmacist 2 no charge 3 for 4 5
Aboriginal health services
Anticoagulation
Asthma
Body piercing
Chemotherapy preparation
Community education, structured
Community clinic services with nurse
Diabetes
Discharge services for hospital patients
Drug level monitoring/kinetic dosing
Geriatric care
Harm reduction including methadone
Herbal medicines/nutritional supplement
counselling
Hyperlipidaemia
Hypertension
Naturopathy
Nutritional support (e.g.
parental/enteral nutrition)
Osteoporosis
Ostomy counselling
Paediatric pharmacy
Pain management
Psychiatric pharmacy
Skin care management
Smoking cessation
Specialised compounding
Weight reduction
Wound care
Other (specify)

SECTION Barriers to and facilitators of

SECTION
B
C enhanced pharmacy services

8 Please tick ( ) the extent to which you agree or disagree that the following are barriers to this pharmacy implementing the
enhanced pharmacy services listed in Question 7.
Barriers to enhanced pharmacy Strongly Disagree Unsure Agree Strongly
services in this pharmacy disagree 1 2 3 4 agree 5
Shortage of time for pharmacist
Shortage of pharmacists
Customers won't pay
Unable to get locum cover for emergencies
Lack of appropriate knowledge/skills
by pharmacists
Lack of confidence by pharmacy staff
It is not felt by pharmacists to be part
of their job
There is no extra remuneration for it
Would impair working relationships
with local general medical practitioners (GP's)
Lack of opportunity to meet with local
GP's or other health workers
GP's do not recognise pharmacists' skills in
enhanced pharmacy services
Other (specify)

page 2
 Please tick ( )the extent to which you disagree or agree that the following will facilitate this pharmacy implementing the enhanced
9
pharmacy services listed in Question 7.
Strongly Strongly
Facilitators of enhanced pharmacy services Disagree Unsure Agree agree
disagree 1 2 3 4 5
Access to detailed patient notes
Designated closed counselling area
Designated clinical testing area
Appointment systems
Accreditation for specific activity
Dedicated study time for pharmacists
Other (specify)

SECTION
SECTION
D Prescription related activities in this pharmacy
B

Please tick ( ) the average number of prescription items dispensed in this pharmacy in a typical period of seven days.
10a
Prescriptions per week 0 to 300 1 301 to 8002 801 to 1,200 3 1,201 to 2,000 4 2,001 to 3,0005 3,000 or more 6
Total

Please tick ( ) the average number of patients in the following categories who were dispensed prescribed drugs in a typical period of seven
10b days in this pharmacy.
None at Less than 1 1 to 5 6 to 10 11 to 20 21 or more
Category of dispensing per week per week per week per week per week
all 1 2 3 4 5 6
Mail order
Distance
Deliveries

Please record the transport fee ($) charged by this pharmacy for the following categories and units of dispensing.
10c
If no transport fee is charged please record zero (0).
please record zero (0). Transport fee Transport fee
Category of dispensing per prescription per patient
$ $
Mail order
Distance
Community deliveries
(specify)

Please tick ( ) the average number of patients in a typical period of seven days in the following settings who receive from this pharmacy
11a prescription items packaged in dose administration aids or DAAs (e.g. Webster-type, Dosette-type).

Aged care or None at Less than 1 1 to 20 21 to 50 51 to 100 101 to 250 251 or more
community setting all 1 per week 2 per week 3 per week 4 per week 5 per week 6 per week 7
Nursing home
Hostel
Community based patients
Remote health clinics
(specify)

Please record the fee charged for each DAA per patient-week or per unit pack to patients in the following settings. If no fee is charged
11b
please record zero (0).

Aged care or community setting Fee per patient-week ($) Fee per unit pack ($)
Nursing home
Hostel
Community based patients
Remote health clinics
(specify)

page 3
SECTION
SECTION Prescription related activities in this pharmacy
D
B (continued)
Please tick ( ) the number of individual (different) patients who receive the following drugs by supervised dosing in this pharmacy
11c during a typical period of seven days.
Drug groups None Less than 1 1to 5 6 to 10 11 to 20 21 or more
dosed in pharmacies per week 1 per week 2 per week 3 per week 4 per week 5 per week 6
Analgesics (specify)

Benzodiazepines (specify)

Buprenorphine
Methadone
Other psychotropic agents
(specify)
Other agents
(specify)

Please record the fee charged per supervised dosing of each of the following prescription drugs in this pharmacy. If no fee is charged please
11d
record zero (0).
Analgesics Benzodiazepines Buprenorphine Methadone Other agents (specify)
1 2 3 4 5

Dosing fee ($)

Please tick ( ) the number of patients in the past seven days who were declined prescription drugs for the following reasons.
12
None at Less than 1 1 to 5 6 to 10 11 to 20 21 or more
Reason for declining prescribed drugs all per week 2 per week per week 4 per week per week
1 3 5 6
Inappropriate drug or dose, suspected
interaction, or contraindication
Suspected adverse effect
Duplication, prescription defects

Please tick ( ) the estimated number of patients with prescription medications who fall into of the following counselling categories in this
13a pharmacy during a typical working day. Forward pharmacy refers to a seated counselling area with dispensary computer.
None at Less than 1 1 to 5 6 to 10 11 to 30 31 or more
Verbal or written counselling
all 1 per day 2 per day 3 per day 4 per day 5 per day 6
Non-or-poor-English speaking patients
CMI computerised
Other computer produced information
Other written or printed drug information
Counselled or administered medicines in
closed counselling area
Counselled or administered medicines in
private unenclosed area
Counselled or administered medicines in a
forward pharmacy area
Medication Assistance Service (MAS) or
activity paid by health insurance
Other (specify)

Please tick ( ) the estimated number of patients who received the following monitoring activities for compliance with their prescribed
13b medications in this pharmacy during a typical period of seven days.
None at Less than 1 1 to 10 11 to 40 41 to 80 81 or more
Monitoring compliance
all 1 per week 2 per week 3 per week 4 per week 5 per week 6
Monitor compliance by appropriate questions
Monitor compliance by frequency of repeats
Monitor with DAAs (e.g. Webster-type, Dosette-type)
Other (specify)

Please tick ( ) the estimated number of patients who received the following monitoring activities for the therapeutic and adverse effects
13c
of their prescribed medications in this pharmacy during a typical period of seven days.
None at Less than 1 1 to 5 6 to 10 11 or more
Monitoring therapeutic and adverse effects per week 2 per week 3 per week 4 per week 5
all 1
Clinical testing in pharmacy with devices such as weight scales,
glucose meters, blood pressure meters, peak flow meters
Laboratory test results to monitor medication effects
Adverse reactions recorded in patient file (e.g. drug allergies)
Other (specify)

page 4
SECTION Medication review processes
E

Please tick ( ) if this pharmacy supplies medicines to patients in residential aged care facilities (eg. nursing homes, hostels) or private
14a
hospitals?

Yes 1
No 2

Please record the number of beds in the following locations supplied with medicines by this pharmacy.
14b

Type of external facility Beds supplied

Nursing homes
Hostels
Private hospitals
Other (specify)

14c Please tick ( ) if this pharmacy is registered with the HIC as an approved Home Medicine Reviews (HMRs) or DMMRs Service Provider.
DMMR refers to Domiciliary Medication Management Review, a term interchanged with HMR.
HMR (DMMR) approval by HIC
Yes
No
Don't know

Please tick ( ) the number of patients in a typical month in 2002 involved in the following medication review processes in which this
14d
pharmacy participated.

Medication review processes None at Less than 1 1 to 10 per 11 to 50 per 51 to 100 101 to 200 201 or more
5 6 7
reimbursed all 1 per month 2 month 3 month 4 per month per month per month
Home Medicine Reviews (HMRs) or
DMMRs
Medication Management Review in
residential aged care facilities
Enhanced Primary Care (EPC)
Multidisciplinary Care Plan
Enhanced Primary Care (EPC) Case
Conference
Enhanced Primary Care (EPC) Case
Health Assessment
Section 100 medicine access scheme for
aborigines
Other form of medication review
(specify)

Please tick ( ) if this pharmacy has access to an Australian Association of Consultant Pharmacy (AACP) accredited pharmacist.
14e
Access to AACP accredited pharmacist
Yes
No
Don't know

Please tick ( ) which of the following positions the AACP accredited pharmacist occupies in this pharmacy
14f
AACP accredited pharmacist
Proprietor
Manager
Employee pharmacist full-time
Employee pharmacist part-time
Consultant or contracted pharmacist
Other (specify) __________________

page 5
SECTION Primary health care including pharmacy (S2)
F and pharmacist-only (S3) medicines
Pharmacy's control of these medicines or products is contentious. To ensure the reliability of the data recorded in 15A please
refer to POS printouts and consider conducting sample surveys. Prescription medicines are excluded here.
Please tick ( ) the average number of clients who received the following services in a typical working day in this pharmacy.
15a
Primary health care activities in this Less than 1 1 to 10 11 to 30 31 to 50 51 to 80 81 or more
pharmacy (excludes prescription medicines) per day 1 per day 2 per day 3 per day 4 per day 5 per day 6
Total who asked for S2s and S3s by name
(i.e. self medication)
Total who received assistance with symptoms,
health problems, or questions
Clients issued computerised CMIs,
printed information (e.g. Self Care card)
Clients referred to GP with ailments
Clients referred to other health practitioners
Other (specify)

Please tick ( ) the estimated number of clients in this pharmacy suspected in the last seven days of misusing S2 or S3 medicines (e.g.
15b
codeine liquids, compound codeine analgesics, diphenhydramine, pseudoephedrine).

Less than 1 1 to 5 6 to 10 11 to 20 21 or more

Suspected S2 or S3 medicine misuse
per week 1 per week 2 per week 3 per week 4 per week 5
Suspected misuse of S2 or S3
Refused supply of S2 or S3

SECTION Preventive services implemented in

G this pharmacy
Please tick( ) if this pharmacy has a vaccine refrigerator which complies with pharmacy standards (constantly between 2 C and 8 C)?
16
Yes 1
No 2

17 Please tick ( ) the estimated number of clients in the last seven days who received one of the following agents initiated in this pharmacy
by a pharmacist and not prescribed by a doctor.
Preventive activities with non-prescribed None at Less than 1 1 to 2 3 to 10 11 to 20 21 to 50 Over 51
medicines all 1 per week 2 per week 3 per week 4 per week 5 per week 6 per week 7
Nicotine replacement therapies
Aspirin (100mg or less per day) for the
primary or secondary prevention of coronary
heart disease
Iron supplementation to prevent anaemias
in females
Folic acid in early pregnancy to prevent
neural-tube defects in offspring
Calcium products to prevent osteoporosis
Daily multivitamins to prevent suspected
nutritional deficiency
Other (specify)

Please tick ( ) the estimated average number of each of the following tests provided to screen undiagnosed patients during a typical period
18
of 30 days in this pharmacy.
None at Less than 1 1 to 2 3 to 10 11 to 20 21 or more
Clinical testing to screen undiagnosed patients
all 1 per month 2 per month3 per month 4 per month 5 per month 6
Anthropometric tests (e.g. body weight,
height and waist circumference)
Blood cholesterol testing
Blood glucose testing
Blood pressure testing
Bone density testing
Pregnancy testing
Other (specify)

page 6
SECTION Harm minimisation or
H harm reduction activities
Please tick ( ) the estimated average number of clients provided with each of the following harm minimisation or harm reduction
19a
activities during a typical working day.
None at Less than 1 1 to 5 6 to 10 11 to 20 21 or more
Harm minimisation or reduction activity all per day 2 per day 3 per day 4 per day 5 per day 6
1
Methadone dosing
Buprenorphine dosing
Naltrexone dispensed
Needle exchange or supply
Benzodiazepine contracts or prescriber
arrangements to prevent diversion and misuse
of drugs of dependence
Other harm minimisation activity (specify)

Please tick ( ) the estimated number of clients detected in this pharmacy from 1 January to 30 June 2002 for prescription fraud including
19b
forgery of prescriptions for medicines such as morphine C-R, dexamphetamine, methadone, oxycodone, temazepam, benzodiazepines,
compound codeine products. ‘Doctor Shoppers’ refers to people who in one year obtain more PBS prescriptions than appears to be
clinically necessary or who see 15 or more general practitioners.
Prescription fraud None at all 1 Less than 1 2 1 to 6 3 6 to 12 4 13 to 30 5 31 or more 6
Forgeries detected January to June 2002
Doctor Shopping detected Jan to June 2002

SECTION Complementary therapies including

I herbal medicines
Please tick ( ) the estimated average number of clients referred to or provided with the following complementary therapies by this
20 pharmacy in a typical period of 30 days.
Complementary therapy Less than 1 1 to 5 6 to 10 11 to 30 31 or more
None at all per month 2 per month per month per month
referred or provided 1 3 per month 4 5 6
Acupuncture
Aromatherapy
Chiropractic
Homeopathy
Hypnosis
Iridology
Meditation
Naturopathy
Reflexology
Massage
Spiritual healing
Other (specify)

SECTION Information facilities and programs

J

Please tick ( ) the estimated number of patients who receive services with reference to one of the following information resources in this
21 pharmacy in a typical working day.
None at Less than 1 1 to 2 3 to 10 11 to 20 21 or more
Information resource or program
all 1 per day 2 per day 3 per day 4 per day 5 per day 6
AusDI book
Australian Medicines Handbook
Australian Pharmaceutical Formulary (APF)
CD ROM's (eg. MIMS, APP Guide)
CMI computerised
Martindale
MIMS or APP Guide books
Pharmacy Self Care
Therapeutic Guidelines
Web-based drug information
Other (specify)

page 7
SECTION
K
Technologies and health communications

Please tick ( )the following features associated with the dispensary computer and its use in this pharmacy.
22a
Dispensary computer feature
Computer with Pentium processor
Regular internet use
Regular e-mail use
Pharmacy website
ADSL broad band access (always on fast connection)
Other (specify)

If this pharmacy has a website, please tick ( ) the medication-related activities currently provided by this pharmacy’s website.
22b
Website activity
Offers medications online
Offers other products online
Offers home delivery services
Offers other health information
Other (specify)

Please tick ( ) the estimated average number of each of the following activities initiated in this pharmacy during a typical working day.
23
Telephone, fax or email contact Less than 1 1 to 2 3 to 10 11 to 20 20 or more
None at all per day 2 per day per day per day per day 6
with prescriber, client, or carer 1 3 4 5
Contacted prescriber to clarify or
correct prescribed medication
Contacted prescriber regarding appropria-
teness of prescribed drug or dose, patient
contraindication, or adverse effects
Contacted patient or carer to
reinforce or monitor compliance
Contacted patient or carer to assess
effects of therapy
Contacted other health worker or source
for patient health information

SECTION
L Opinion on the use of technical facilities

Please tick ( ) the extent to which you agree or disagree with the following statements on the use or impact of communication
24 technologies on this pharmacy's health related activities during 2002.
Strongly Strongly
Technologies and this pharmacy Disagree 2 Unsure Agree
disagree 1 3 4 agree 5

Telephone is the best method to communicate

with community doctors or other health workers
Telephone is the best method to communicate
with community patients or their carers
Privacy legislation restricts telephone
communication by this pharmacy with
community doctors, patients and carers
Fax will replace telephones in this pharmacy
as the best method to communicate with
community doctors, health workers or patients
E-mail will replace telephones in this
pharmacy as the best method to communicate
with community doctors, patients or carers
Internet sales of prescription medicines will
depress the number of medicines dispensed in
this pharmacy within 24 months
Internet sales of all medicines will depress the
sale of non-prescribed medicines or other health
products in this pharmacy within 24 months

page 8
SECTION
M
Pharmacy and staff

Location of this pharmacy by postcode

25a

Please tick ( ) which one of the following best describes the setting of this pharmacy?
25b
City, suburb or town centre strip 1
Regional shopping centre (over 100 shops or over 30,000m2) 2
Neighbourhood shopping centre (under 30,000m2) 3
Isolated (1-9 shops together) 4
Medical centre 5
Hospital 6
Other (specify)

Please record the total hours and days this pharmacy is open.
25c
Total hours per week Total days per week

26 Please record or estimate as accurately as possible the area of each of the following sections in this pharmacy. If a certain area is not
applicable then please enter a value of '0’ (zero).
Dispensary area m21
Schedule area (for S2s and S3s) m22
Forward pharmacy area (seated counselling area m2
with dispensary computer) 3

Private un-enclosed counselling/dosing area m24

Closed counselling/dosing area m25
Retail area m26
Storeroom, office, etc m27
Other (specify) m28
Total area of premises m 29

Please tick ( ) which one of the following describes this pharmacy's group membership.
27
Not in a group 1
Amcal 2
Chem Mart 3
Friendly Societies 4
Guardian 5
Soul Pattinson 6
Other group (specify)

Please tick ( ) the QCPP status of this pharmacy. QCPP refers to Quality Care Pharmacy Program.
28
Not yet registered for QCPP 1
Partially completed QCPP accreditation 2
Completed but not yet accredited 3
QCPP accredited 4
Re-accredited 5
Other (specify)

Please tick ( ) the method of operation of this pharmacy.

29a
Owner operated 1
Partner operated 2
Manager operated 3
Other (specify)

29b Please tick ( ) if this pharmacy has a non-pharmacist retail manager.

Yes No

page 9
SECTION
M
Pharmacy and staff (continued)

Number of proprietors / owners of this pharmacy.

30a
Please complete the following details for each proprietor/owner of this pharmacy.
30b
Proprietor / Owner 1st 2nd 3rd 4th
Age - enter number:
1=21-30, 2=31-40, 3=41-50, 4=51-60, 5=61+
Gender - enter number: 1-Male, 2-Female
Highest pharmacy academic qualification - enter number:
1-Diploma, 2-Bachelor, 3-Masters, 4-PhD,
5-Other (specify)
Continuing pharmacy education-average hours per
month - enter number (estimate if necessary) :
1=zero hours; 2=one to five hours;
3=six to 10 hours; 4=11 to 20 hours; 5= over 20 hours.

Please tick ( ) the total number of customers per week. Please include patients in hospitals and aged care facilities serviced by this
31
pharmacy.
0-700 701-1,400 1,401-2,100 2,101-3,500 3,501-5,000 5,001 or more

Please record the number of current staff or contractors working in this pharmacy and their hours worked in a typical period of
32 seven days. Exclude administration and other work done after hours.
Part time Total hours Hours in Clinical, patient
Pharmacy staff Full time
1 and casuals 2 per week 3 dispensary 4 care or counselling 5
Proprietor 1
Proprietor 2
Proprietor 3
Proprietor 4
Pharmacist manager
Consultant pharmacist
Other pharmacist staff
Non-pharmacist manager (retail)
Dispensary assistant / Pharmacy technician
Non-pharmacist clerical or administration
Other non-pharmacist staff
Complementary or other health practitioners
(Please specify)
Total

Please tick ( ) the estimated annual turnover of this pharmacy.

33a
Total turnover
<$1m $1-1.5m $1.5-$2m $2-3m $3-4m $4-6m $6-8m >$8m
(total pharmacy and other income) 1 2 3 4 5 6 7 8

Please complete details of sales/turnover per year for each of the following categories. If not known for any category, then please estimate.
33b
Total prescription sales (incl. Safety Net and private prescriptions) ______% tumover
S2 and S3 medicines ______% tumover
Herbal products and vitamins sales ______% tumover
Medical aids and medical appliances / equipment (home health care) ______% turnover
Other pharmacy sales ______% tumover

THE END - THANK YOU

Please place the checked and completed questionnaire in the enclosed stamped envelope addressed to
the Survey Research Centre, School of Population Health, University of Western Australia 6009

page 10
 Survey
Australia’s community pharmacies
of
2002
This questionnaire was developed by Con Berbatis with the assistance of the National Panel,
pharmacy colleagues in practice, teaching, and research overseas and throughout Australia.
It was designed to be a tool for quantifying community pharmacists’ health related activities in Australia.
Community pharmacists completed the questionnaire within 50 minutes in the testing phase.
We believe the graphics and layout in the final questionnaire will facilitate less time for respondent pharmacists.

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