QUM in CV Diseases

Quality Use of Medicines
for Cardiovascular Health

An initiative of the Heart Foundation Pharmaceutical Roundtable
Rob Wiseman, Anne-Marie Scully, Hayley Caspers red3 • 2006
QUM
The Heart Foundation Pharmaceutical Roundtable members:
© 2006 National Heart Foundation of Australia. All rights reserved.

National Heart Foundation of Australia (The Heart Foundation Pharmaceutical Roundtable)
This report builds on research reported in:
Wiseman R and White S (2005) Views of Quality Use of Medicines: Stakeholders perceptions
of their needs, values and responsibilities, and the opportunities and barriers for QUM.
Sydney: The Pharmaceutical Alliance.
This is available from: www.pharmalliance.com.au/files/QUM_2005_Report.pdf
The views expressed in this report are those of the authors and not necessarily those of the
Heart Foundation Pharmaceutical Roundtable or its partner organisations: the National Heart
Foundation of Australia, Alphapharm, Astrazeneca, Bristol-Myer Squibb, Merck Sharp & Dohme,
Pfizer Australia, Roche, sanofi-aventis, Solvay Pharmaceuticals and Servier Laboratories.
This work is copyright. No part may be reproduced in any form or language without prior written
permission from the National Heart Foundation of Australia (national office). Enquiries concerning
permissions should be directed to copyright@heartfoundation.com.au.
Suggested citation:
National Heart Foundation of Australia (Wiseman R, Scully, AM and Caspers H on behalf of the
Heart Foundation Pharmaceutical Roundtable). Quality use of medicines in cardiovascular health.
West Melbourne, Victoria, 2006.
National Library of Australia
Cataloguing-in-Publication data
Wiseman, Rob, 1969– .
Quality use of medicine in cardiovascular health (executive summary).
Online:
ISBN-10: 1-921226-06-4
ISBN-13: 978-1-921226-06-9
1. Cardiovascular agents—Australia. 2. Cardiovascular diseases—Australia—Treatment.
3. Pharmaceutical policy—Australia. I. Scully, Anne-Marie. II. Caspers, Hayley. III. Title.
615.71
quality use of cardiovascular medicines in cardiovascular health / 1
contents
background 4
the Heart Foundation Pharmaceutical Roundtable 4
about the project 4
about this report 5
some observations on stakeholders’ contributions 6
stages of QUM in cardiovascular health 7
cardiovascular medicine in Australia 8
risk factors for cardiovascular diseases 9
treatment of cardiovascular diseases 10
medicines used in the treatment of cardiovascular diseases 11
what is QUM 12
building blocks of QUM 13
general QUM actions and principles 13
before a cardiovascular event 15
1. identifying people at risk of cardiovascular disease 15
2. diagnosing cardiovascular diseases 17
3. prescribing lifestyle changes or medicines 18
4. dispensing medicines 22
5. counselling and education 24
6. beginning treatment 25
7. monitoring use of medicines and effects of treatment 28
8. adherence in the longer term 29
during a cardiovascular event 32
1. getting people to hospital 32
2. admission to hospital 32
3. interventions 33
4. providing information in hospitals during recovery 35
5. the short-term focus of hospitals 35
after a cardiovascular event 36
1. discharge—from hospital to home 36
2. coordinating rehabilitation services 40
3. integration of GPs and specialists 40
4. educating consumers and carers 41
5. support groups 41
2 / quality use of cardiovascular medicines in cardiovascular health
supporting environment 43
equity and access 43
links between sectors 43
general practice and practice nurses 47
policy and implementation 48
IT, connectivity and data exchange 50
training, education and information 52
further research, evaluation and modelling 57
missing in action 59
hospital administrators 59
private health insurers 59
nurses 60
support staff in general practice 60
pharmaceutical industry 61
carers 62
supermarkets and food retailers 62
the public media 62
notes 64
glossary
ADGP Australian Divisions of General Practice
AHMAC Australian Health Ministers’ Advisory Council
AMA Australian Medical Association
APAC Australian Pharmaceutical Advisory Council
ASMI Australian Self-Medication Industry
CMC Complementary Healthcare Council
CMI Consumer Medicine Information leaflet
DAA Drug Administration Aid
DoHA Department of Health and Ageing (Commonwealth)
DUSC Drug Utilisation Sub-Committee
GP General Practitioner
HCO Health Consumer Organisation
HMR Home Medication Review
IT Information Technology
LDL Low Density Lipids
MBS Medicare Benefits Scheme
NATRUM National Return of Unwanted Medicines program
NGO Non-Government Organisation
NHMRC National Health and Medical Research Council
NICS National Institute for Clinical Studies
NMP National Medicines Policy
NPS National Prescribing Service
OTC Over-The-Counter Medicines
PBAC Pharmaceutical Benefits Advisory Committee
PBS Pharmaceutical Benefits Scheme
PGA Pharmacy Guild of Australia
PHARM Pharmaceutical Health And Rational use of Medicine
PSA Pharmaceutical Society of Australia
QUCVM Quality Use of Cardiovascular Medicines
QUM Quality Use of medicine
RACGP Royal Australian College of General Practitioners
RACP Royal Australasian College of Physicians
RPBS Repatriation Pharmaceutical Benefits Schedule
SHPA Society of Hospital Pharmacists of Australia
SNAP Smoking, Nutrition, Alcohol and Physical Activity
WHO World Health Organisation
background
T H E H E A R T FO U N D A T I O N P H A R M A CE U T I C A L R O U N DT A B L E
The Pharmaceutical Roundtable is made up of the National Heart Foundation of

Australia and nine pharmaceutical manufacturers: Alphapharm, Astazeneca, Bristol-
Myer Squibb, Merck Sharp & Dohme, Pfizer Australia, Roche, sanofi-aventis, Solvay
Pharmaceuticals and Servier Laboratories.
The mission of the Roundtable is to reduce suffering and death from heart, stroke and
blood vessel disease in Australia. It pursues this goal by:
• funding research
• initiating and supporting cardiovascular health initiatives of interest to both
industry and the Heart Foundation
• working to keep cardiovascular health issues high on the national agenda.
The Pharmaceutical Roundtable is committed to:

• providing funding for independent research in cardiovascular disease (including
support for the training of young scientific investigators of the future)
• enhancing the understanding of the opportunities and challenges facing Australian
cardiovascular researchers
• facilitating public awareness of the outcomes of Heart Foundation research
• developing and funding initiatives to raise public awareness of the dangers of
increased cardiovascular risk
• being informed by national health policies in its work—in particular the National
Medicines Policy and Quality Use of Medicine initiatives.
A B O U T T H E P R O J E CT
In July 2005, the Pharmaceutical Roundtable commissioned RED3 to explore Quality
Use of Cardiovascular Medicines (QUCVM)—provisionally defined as “selecting the
right coronary heart disease treatment or prevention option at the right time and
adhering to it in the right way”. Specific goals of the project were to:
• identify barriers to QUCVM
• helping the Roundtable develop strategies to overcome these barriers
• prioritise actions to help the Roundtable achieve QUCVM.
This project built on previous research undertaken by RED3 for the National Medicines
Policy and The Pharmaceutical Alliance (reported in Views of Quality Use of Medicines1).
This report also comes in the context of QUM activities in other major disease areas by
PHARM, particularly asthma and diabetes2.
RED3 conducted the research in three broad stages. First its researchers interviewed
nearly fifty key stakeholders in cardiovascular health and Quality Use of medicine.
Next, it collated the contributions of these stakeholders and presented the results to a
National Stakeholder Workshop, held in Canberra on 25 November 2005. The event
was structured to fill gaps in the work to date, correct misunderstandings and
mistakes, and to add further detail. It also sought suggestions for practical action to
achieve QUM in Cardiovascular Health. Finally, RED3 combined the products of the
workshops with findings reported in the research literature. This work forms the basis
of this report.
The project also included a separate research strand for Indigenous Australians. This
will be reported separately, as the needs, concerns and resources of Aboriginal and
Torres Strait Islander communities are unlike those of other Australians.
ABOUT THIS REPORT

Stakeholders’ contributions presented a picture consistent with RED3’s previous
research into the larger QUM environment. Rather than duplicating descriptions that
have already been published in Views of Quality Use of Medicines, this report focuses on
actions that the Roundtable and other stakeholders can take.
At the core of this report are 128 suggestions for action to achieve Quality Use of
medicine in Cardiovascular Health. Around these suggestions, we have provided
contextual information, which explains the reasons participants made these
suggestions, along with evidence from the research literature where available.
Some suggestions are large; some are small. Some are technical; some are
commonsense. Some are complex; some are simple. Some are novel; some have been
made before but have not been implemented. Some are focussed and precise; others are
so general it would be better to call them ‘guiding principles’. For some of the more
incomplete ideas, we have extrapolated the practical consequences, but otherwise we
have presented participants’ suggestions much as they were given to us, that is,
without trying to give them a consistency they did not have for participants.
All suggestions include a rank (from ★ to ★★★★★) indicating the impact that
stakeholders believed the action might have. In some places, stakeholders did not
discuss impact. In these instances we have suggested its potential based on research or
principles of continuity. These are marked with ✩ rather than ★. Many of the
suggestions are beyond the Roundtable’s ability to achieve in isolation. This is because:
• many require activity by stakeholders who are not members of the Roundtable
• some suggestions would place large demands on others
• some suggestions are beyond the Roundtable’s means (such as changing
infrastructure, funding, equity, and access).
S O M E O B S E R V A T I O N S O N S T A K E H O LDE R S ’ CO N T R I B U T I O N S
Our discussions with stakeholders were organised around the journey that patients
take through cardiovascular disease. This is also the basis for organising the material in
this report. The main stages in this journey are shown on the next page.
The comments and suggestions from participants in this project were not spread
evenly over this journey. There were some notable gaps we need to point out.
1. Most attention went to the initial stages of cardiovascular disease, including
assessment of cardiovascular risk and initiation of treatment—along with
information and education. Almost absent was discussion of the adherence of
consumers to long-term treatments. This is broadly consistent with approaches to
QUM taken in the past decade.
2. Participants gave more attention to the use of medicine in the community than in
hospitals, and there was no discussion at all of private hospitals.
3. Most concern was with medicine use at particular instants, usually moments of
crisis; rather rare was QUM as a continuum or a large system of interlocking parts.
This may reflect the prevailing mindset of the health community, which remains
focussed on acute episodes rather than managing chronic conditions.
4. We specifically engaged groups that have not been much involved in QUM to this
point—such as allied health workers and specialist physicians. Even so, we did not
generate much detail concerning their work and potential contributions to
cardiovascular health. Chiefly, this is because existing stakeholders have still to
learn about these health professions and how they might contribute to QUM. Some
groups declined to be involved in the project—most notably carers (who have
proved difficult to engage in QUM generally).
5. Some groups with a potential role in QUM were hardly mentioned by those
consulted. They included private health insurers, hospital administrators, support
staff in general practice, the mass media, supermarkets (as the main suppliers of
food), and the marketing sections of pharmaceutical manufacturers (as one of the
chief producers of information on medicines). These are discussed on pages 58–62.
Another point important to note: some of the suggestions made reveal

misunderstandings about QUM and the treatment of cardiovascular disease—most
commonly about the role of the Heart Foundation, but also general practice, nursing
and education. In places, people have suggested actions that are already normal
practice. In the case of the Heart Foundation, people wrongly believed it provides
training, writes guidelines, and develops educational resources. Rather than ‘correct’ or
omit these suggestions, we have left this report as a reflection of people’s false
expectations and misunderstandings. It is important for those involved in QUM to be
aware of such misunderstandings and to correct them.
We stress that the points made in this report are only suggestions, and are not binding
on either the Heart Foundation or members of the Roundtable.
stages of qum in cardiovascular health
before an event
identifying diagnosing
during an event
people at risk disease
1A 1B
cardiovascular
event
prescribing medicine getting

or lifestyle people to
1
2 hospital
lifestyle dispensing
3A 3B
changes 2 admission
medicine
4
counselling and
education intervention
3
taking
5
medicine
4 recovery
monitoring use
6
and effects
5 discharge
7 adhering
after an event
1A 2A 3 4
gp rehab carers support

1B 1C 2B groups
specialist community nurses and

physician pharmacist allied health
cardiovascular medicine in australia

Cardiovascular diseases are the cause of more deaths in Australia than any other
—37.6% of all deaths in 2002. Approximately forty percent of people who have a heart
attack and around a third of those who have a stroke die within a year of the event. The
following table shows the number of deaths in Australia from specific cardiovascular
diseases in 20023
males females persons
Coronary heart disease 13,855 12,208 26,063
Stroke 4,969 7,564 12,533
Peripheral vascular disease 1,347 1,234 2,581
Heart failure 1,033 1,696 2,729
Acute rheumatic fever & chronic rheumatic heart disease 83 191 274
Other heart, stroke and vascular diseases 2,701 3,413 6,114
Total heart, stroke and vascular diseases 23,988 26,306 50,294
Even for those who survive or do not suffer an acute event, cardiovascular diseases are
the leading cause of long-term disability. In 1998, over 1.1 million Australians were
affected—nearly a third of all people living with a disability.
The burden of cardiovascular diseases is growing: in the 1990s, the incidence of heart,
stroke and vascular conditions rose by 18.2 per cent. The following table shows the
number and percentage of Australians who self-reported being affected by major
cardiovascular illnesses in the 2001 National Health Survey. There is no data available
for incidence of peripheral vascular disease, rheumatic heart disease or congenital heart
malformations.
persons percent
Coronary heart disease 355,600 1.9%
Heart failure (estimated) 300,000 1.6%
Stroke 217,500 1.2%
The burden of cardiovascular disease is not spread evenly through the Australian
community. Women are slightly more likely than men to have some form of
cardiovascular disease, but men are over one-third more likely to be hospitalised for
heart, stroke or vascular disease. People in the most disadvantaged socio-economic
groups are over twenty per cent more likely than people in the most socioeconomically
advantaged groups to have a risk factor, a higher incidence of disease, and death due to
cardiovascular disease3. People living in regional and remote areas are more likely to die
of cardiovascular diseases.
Comorbidities are common—especially diabetes, renal failure and depression. Over 80

per cent of elderly Australians have a one chronic illness and half have two or more4.
R I S K FA CT O R S FO R CA R D I O V A S C U LA R D I S E A S E S
The following table shows prevalence of the main risk factors in Australia for those 18
years old and over in 20015.
men women persons men women persons

(’000s) (’000s) (’000s) (%) (%) (%)
Low vegetable consumption 5,086 4,807 9,892 73.2 66.4 69.8
Low fruit consumption 3,726 3,016 6,742 53.7 41.7 47.5
Physical inactivity 2,127 2,337 4,463 30.6 32.3 31.5
Smoking 1,763 1,411 3,173 25.4 19.5 22.4
Obesity 1,087 1,227 2,313 15.6 16.9 16.3
High blood pressure 887 1,063 1,950 12.8 14.7 13.7
Risky alcohol consumption 924 614 1,538 13.3 8.5 10.8
High blood cholesterol 608 572 1,180 8.8 7.9 8.3
Diabetes 269 282 551 3.9 3.9 3.9
One or more risk factors 6,523 6,547 13,070 93.9 90.5 92.2
In 2001, over 92 per cent of Australians had at least one risk factor, and 25 per cent
had three or more5.
men women persons
number of risk factors (%) (%) (%)
none 6.1 9.5 7.8
one 20.5 26.3 23.4
two 29.8 29.3 29.6
three 25.6 20.4 22.9
four 12.9 10.0 11.4
five or more 5.2 4.5 4.8
T R E A T M E N T O F CA R DI O V A S CU LA R DI S E A S E S
Cardiovascular diseases accounted for approximately 11 per cent of all problems
managed by GPs in 2002–2003.
Cardiovascular diseases were the principal diagnosis of 7 per cent of all hospitalisations
in 2001–2002, and 9.8 per cent of total hospitalisations3. In 2001–2002, there were:
• 120 coronary care units and 21 cardiac surgery units in public hospitals
• 26 coronary care and 23 cardiac surgery units in private hospitals3.
There is currently no comprehensive national data on people in rehabilitation.
The primary treatment for all people at risk of cardiovascular diseases remains risk
reduction through lifestyle modification, and secondly by medicine. The following table
shows treatments demonstrated to reduce the risk of cardiovascular morbidity and
mortality from ischaemic heart disease6.
Relative risk reduction
Smoking cessation 50%
Regular physical activity 50%
Reducing blood pressure 15–25%
Reducing cholesterol with diet and statins 30–50%
Antiplatelet therapy with low-dose aspirin 25%
Beta-blockers post myocardial infarction 20–30%
ACE inhibitors post myocardial infarction 20–26%
Controlling blood glucose 14%
M E D I CI N E S U S E D I N T H E T R E A T M E N T O F CA R D I O V A S C U LA R D I S E A S E S
The following table shows prescription medicines used to treat cardiovascular diseases
in the community in Australia in 20003.
scripts a cost b
medicine role in treatment (’000s) ($m)
Blood pressure-lowering drugs
ACE inhibitors limit heart enlargement after an attack, 14,764 421
relieve symptoms
Calcium channel reduce blood pressure and angina 8,729 213
blockers
Beta-blockers reduce blood pressure, reduce angina 4,542 62
pain, reduce risk of further heart attacks
Diuretics reduce blood pressure, symptom relief 3,525 42
Other 987 18
Total blood pressure-lowering drugs 32,547 755
Lipid-lowering drugs
Statins reduce blood LDL cholesterol and blood 10,744 618
Fibrates triglycerides 448 20
Resin binders 46 2
Other 21 0.5
Total lipid-lowering drugs 11,259 641
Other drugs
Nitrates relieve and prevent angina symptoms 2,691 56
Antiarrhythmics restore normal heart beat in arrhythmia 532 16
Inotropes increase the strength of heart 715 6
contractions
Peripheral vasodilators 10 0.2
Total other drugs 3,949 78
Antithrombotic drugs
Anticoagulants prevent formation of blood clots 1,911 20
Antiplatelets prevent formation of blood clots 1,438 49c
Thrombolytics dissolve blood clots 1 2
Total antithrombotic drugs 3,350 72
Total heart, stroke and vascular drugs 51,104 $1,546m
a Prescription drugs subsidised under the PBS and RPBS, and non-subsidised prescription drugs.
b Includes government and patient costs for drugs listed in the PBS only.
c Probably a gross underestimate of actual cost, as over-the-counter aspirin is not included.
what is qum
A recurring problem for the implementation of Quality Use of Medicine has been
uncertainty about the definition of QUM. We found much the same in this project.
Consequently, we advise the Roundtable against any changes to the definition or
terminology that might fragment those tenuous understandings of QUM that have
been achieved to date.
✩ 1 SUGGESTION FOR THE ROUNDTABLE—change terminology from ‘Quality Use
of Cardiovascular Medicines’ (QUCVM) to ‘Quality Use of medicine in
Cardiovascular Health’ (QUM in CVH).
The National Medicines Policy defines QUM as:
1. Selecting management options wisely by:

• considering the place of medicines in treating illness and maintaining health
• recognising that there may be better ways than medicine to manage many
disorders.
2. Choosing suitable medicines if a medicine is considered necessary so that the best

available option is selected by taking into account:
• the individual
• the clinical condition
• risks and benefits
• dosage and length of treatment
• any co-existing conditions
• other therapies
• monitoring considerations
• costs for the individual, the community and the health system as a whole.
3. Using medicines safely and effectively to get the best possible results by
• monitoring outcomes
• minimising misuse, over-use and under-use
• improving people’s ability to solve problems related to medication, such as
negative effects or managing multiple medications.
As participants in the consultation appreciated, in cardiovascular health, each of these

activities entails a large number of related activities, some of which are not strictly
concerned with medicine use. QUM in Cardiovascular Health could involve:
• risk assessment
• diagnosis of disease
• non-medicinal interventions—such as diet, exercise and quitting smoking
• surgery
• management of co-morbidities
• monitoring effectiveness of treatments
• education, training and counselling—for consumers, carers and health
professionals
• provision of information
• data exchange and data management amongst health professionals
• evidence of clinical effectiveness
• funding and resources
• infrastructure to support care
• policy.
Due to the breadth of these topics, we found—as we have in previous QUM

research—that participants felt that there are no clear boundaries around QUM.
Consequently, in this report we have taken a broad view of what achieving QUM in
Cardiovascular Health will involve, rather than focussing narrowly on medicines alone.
B U I LDI N G B LO CK S O F Q U M
The National Strategy for Quality Use of Medicines outlines six ‘building blocks’ necessary
to achieve QUM7. They apply to all stakeholders and care settings. They are:
• policy development and implementation
• facilitation and coordination of QUM initiatives
• provision of objective information and assurance of ethical promotion of
medicines
• education and training
• provision of services and appropriate intervention
• strategic research, evaluation and routine data collection.
Although stakeholders’ suggestions covered all six areas, the building blocks themselves
—like the formal definition of QUM—are not widely recognised or used.
G E N E R A L Q U M A CT I O N S A N D P R I N CI P LE S
As noted in the Background, there were a number of broad principles mentioned
throughout the project, which are too broad to be actionable, but illustrate the type of
approach people wanted QUM in Cardiovascular Health to take.
These principles were:

1. patient-centred health care
2. continuity of care
3. education and information for consumers, carers and health care professionals
4. greater emphasis on prevention of cardiovascular events
5. integration of health care and health care professionals into ‘health teams’
6. transferable health records—along with the necessary IT systems and training to
reduce fragmentation of therapy and health care
7. better and more-equitable access to health care for all Australians
8. better management of costs—for consumers and the community
9. greater awareness that QUM may involve treatments other than medicines
10. greater use of evidence-based medicine by policy makers and health professionals
11. better collection and use of data to track medicine use and outcomes
12. breaking down of policy silos
13. greater use of existing resources—less ‘re-inventing the wheel’
14. greater funding for QUM from the Commonwealth
15. empowerment of consumers
16. cultural, linguistic, geographic and physical barriers to access addressed.
before a cardiovascular event

Actions to reduce the risk of a cardiovascular event, or lessen the severity of an event,
can be divided into:
1. identifying people at risk and diagnosing people with cardiovascular disease
2. prescribing treatments—whether lifestyle changes or medicines
3. dispensing medicines
4. counselling and educating patients
5. beginning treatment
6. monitoring use of medicines and the effects of treatment
7. adherence in the longer term.
There was criticism that not enough is being done—by Australian and State
governments in particular—to promote and support primary prevention.
2 SUGGESTION FOR DOHA, STATE GOVERNMENTS AND NGOS—develop a ★★★

coordinated, national program to increase awareness of the importance of
primary prevention among consumers and health care providers.
1. I DE N T I FYI N G P E O P LE A T R I S K O F CA R DI O V A S CU LA R DI S E A S E
Overwhelmingly, the greatest need in cardiovascular health seen by those we consulted
is identifying people at risk, in order to initiate appropriate preventative management.
In particular, there is strong support for mass screening of Australians—although

stakeholders differ in exactly who ought to be screened: whether the whole population
should be assessed, or just groups at obvious risk, or people above some age threshold.
Early detection of risk would provide greater opportunities for intervention. This may
help reduce overall mortality, improve quality years of life, reduce the severity of
events, and reduce the cost to consumers, their families and the larger community.
Advocates of screening stressed the importance of assessing risk for all major chronic
illness—not just cardiovascular diseases in isolation.
Supporters of screening point to the achievements in breast cancer detection, where

there is now a national screening program: BreastScreen Australia. Since its
introduction, mortality from breast cancer has decreased from 30.5 per 100,000
women in 1991 to 24.7 per 100,000 women in 2001, a reduction of 19%8—a large part
of which is attributed to early detection through a standardised national screening
program.
Many of the key risk factors for cardiovascular disease go undiagnosed and untreated.
For example, the AusDiab study of 11,250 Australians in 1999–2000 found that over
half of people with hypertension were not being treatment for it9. Of these people, 53.5
per cent were at a high absolute risk of cardiovascular disease—which would be
equivalent to about 8 per cent of the Australian population. (These figures may have
improved somewhat in the five years since as management of lipid disorders by general
practice has increased by 24 per cent10.)
A screening program for a substantial proportion of Australian adults would involve:

• getting Australians to their GP or a primary health care facility in order to carry out
risk assessments
• developing and using tools to assess risk (although these might be modified from
trials such as the AusDiab study)
• time and resources for health care professionals to carry out risk assessments
• having effective treatments and interventions for health professionals to provide
to those people who have been identified as being at risk of cardiovascular disease.
Participants felt that the greatest barrier to risk screening is getting Australians
—particularly men—to a health professional. Even well-coordinated screening
programs, such as BreastScreen and Pap screens, only attract around two-thirds of
target populations8. Attendance in these programs is also noticeably lower in remote
areas. Some participants suggested that it may be necessary to provide incentives to
consumers to undertake screening. Apart from getting people to health professionals,
the other great barrier to screening is generating time for health professionals to carry
out a comprehensive risk assessment, as well as appropriate funding for such a scheme.
There are already a number of cardiovascular risk calculators11, but some studies
suggest that many doctors do not use them. Reasons given for this include:
• doctors prefer to rely own their own clinical judgement (which is itself a problem,
as studies have found that Australian doctors routinely over-estimate the absolute
risk of a cardiovascular event12)
• current risk calculators are poorly integrated with practice software
• there are inconsistencies between the calculators and various regulations
(particularly PBS guidelines around use of lipid-lowering medicines), and
• doctors feel that the current factors assessed are incomplete13.
At best, most doctors use the existing tools for patient education.
Some participants stressed that risk assessment needs to take into account not only
patient’s physical state, but also their psychosocial conditions. There is a demonstrated
association between coronary heart disease and depression, limited social support and
social isolation (although apparently not with anxiety, panic, hostility, or work-related
stress)14.
3 SUGGESTION FOR THE ROUNDTABLE: ★★★★★
a. Work with other chronic disease groups to develop practical tools for
general practice to assess risk of chronic disease.
b. Develop guidelines on the sections of the population to screen.
c. Develop and deliver training for GPs, specialists and nurses in the use of
the assessment tools.
d. Lobby the Australian Government and AHMAC for:

(1) a policy of regular assessment of major chronic illness for all Australians
(2) funds to implement the assessment tools
(3) funds for an MBS Item to pay for regular assessments, and
(4) a promotional campaign to get Australians to visit their health
professional for assessment.
e. Seek the assistance of NPS or software makers to distribute and

implement risk assessment tools in general practice.
f. Work with AMA, RACGP and ADGP to reduce other GP workload and
administration, to make screening and administration manageable.
g. Explore what incentives, if any, are required to encourage Australians to

participate in risk assessment.
h. Explore measures that would help make risk assessment highly accessible
—particularly to people from lower socio-economic groups, in remote
areas, and in areas with limited access to health services. Options might
include mobile screening buses and specialised risk assessment clinics.
Potential benefits of a national screening program seen by stakeholders included:

• earlier identification of cardiovascular risk, and hence reduction in morbidity and
possibly mortality from cardiovascular diseases
• creation of greater predictability in health budgets and resource use
• a reduction in the burden on health budgets—by shifting costs from expensive
post-event treatment to relatively cheap preventative treatments
• create the national data set necessary for a tracking of preventable illnesses and
treatment effectiveness.
2. DI A G N O S I N G CA R D I O V A S C U LA R D I S E A S E S
Generally, stakeholders were comfortable that general practitioners and specialists
have the knowledge to correctly diagnose cardiovascular disease. This is at odds with
research, which has found that heart failure, for example, is under-diagnosed and
treatments under-utilised15,16.
One problem is that some general practitioners treat the PBS Schedule as a guide to
clinical decision-making around the selection of medicines (not its intended function).
✩✩ 4 SUGGESTION FOR MEDICARE AUSTRALIA, NPS, DIVISIONS OF GENERAL PRACTICE

AND SPECIALIST PHYSICIANS:
a. encourage general practitioners to use the standard Clinical Practice

Guidelines as the basis of clinical prescribing decisions
b. discourage use of the PBS Schedule as a clinical guide for selecting

medicines (although use it when making decisions about cost and access)
A second problem can occur when a patient sees several doctors and receives
conflicting advice from them. Some studies have found this happens for up to a quarter
of Australian patients generally17—a figure that is probably higher for patients with
cardiovascular disease, as they are more likely to seek a second opinion. Conflicting
advice might be partly reduced through use of a transferable medical record and better
communication between doctors (see pages 50–51).
3. P R E S CR I B I N G LI F E S T YLE CH A N G E S O R M E DI CI N E S
There is evidence that many key medicines that are effective in reducing the risk of
cardiovascular disease—including ACE inhibitors16, beta-blockers16,18 and lipid-lowering
medicines19—are being under-prescribed
emb oldeni ng con sumers

Through out discussions, most stakeholders stressed the importance of consumers
being actively engaged in their health care decisions (that people who are very ill might
reasonably be passive went unremarked by participants). Anecdotally, those that work
with consumers saw a split between older and young generations, with the demarcation
at around 65 years of age:
• older people tend to be more passive and take the view that ‘doctor knows best’
• younger generations tend to be more questioning of health care professionals, and
are more likely to contribute to decisions about their health care.
There are widespread concerns that the former approach by consumers contributes to
medical problems. Action is required by all those that interact with consumers to
embolden them, help them understand their illness, and encourage them to be
proactive about decisions affecting them and the management of their health.
★★★★★ 5 SUGGESTION FOR GPS, SPECIALIST PHYSICIANS, NURSES, CARERS, SUPPORT
GROUPS AND CONSUMER ADVOCATES—teach and encourage consumers to:
• discuss their health, medical history and illnesses with prescribers
• discuss options for treatment, and willingness to try various options
(such as diet, exercise, quitting smoking, and using medicines)
• tell their prescribers about all of the medicines they are taking
—including OTCs and complementaries as well as prescription
medicines
• discuss cost, lifestyle and other constraints on treatments with
prescribers, before selecting treatment options
• find out how to use medicines and other treatments effectively (in
particular, how to take medicines correctly, what results to expect,
when to expect results, how to monitor them, and what to do if
treatment does not work as expected)
• monitor their treatments and, if medicines do not work as expected,
report to the prescriber.
A second concern for many participants was that the majority of patients do not tell
their general practitioners and specialist physicians about complementary medicines
they are taking, increasing the chances of interactions and adverse effects. Recent
research has found that over 50 per cent of patients use complementary or alternative
medicines, and 57 per cent of these did not report using medicines to their doctor20.
6 SUGGESTION FOR GENERAL PRACTITIONERS AND SPECIALIST DOCTORS— ★★

(1) specifically ask consumers all the medicines they are using (including
complementary medicines) before prescribing
(2) document this use on the consumer’s file
(3) advise consumers on possible adverse reactions.
7 SUGGESTION FOR PHARMACEUTICAL COMPANIES AND PROVIDERS OF ★

INSUGGESTION FORMATION ON MEDICINES—specifically include directions in
written consumer information for patients to tell their doctors and
pharmacists about complementary medicines (as well as OTCs) they are
using.
Two other ways of improving disclosure of medicines to doctors when prescribing are:
• using a centralised medical record—including a medicines record (see page 50)
• getting all patients to prepare a medicine record sheet and review it regularly with
their prescribers and dispensers. (Several forms have been developed—such as the
NPS’s Medimate and Medisafe and a PSA sheet—but they are not widely used.)
8 Develop a medicines record for patients to complete, and get it widely ★★★★
distributed and used by both consumers and health professionals.
ena bling genera l prac tition ers

The bulk of risk assessment and prescribing would be done in general practices. As in
previous research, many stakeholders were concerned that general practices are already
under great pressure, and questioned whether they have time and resources to identify
and manage chronic diseases, as well as the associated administration21.
9 SUGGESTION FOR DOHA AND MEDICARE AUSTRALIA—implement strategies to ✩✩✩

reduce the administrative burden developed by the GP Red Tape
Taskforce, and seek other means to reduce the pressure on general
practices.
A particular problem for general practitioners is the constantly growing volume of

clinical evidence and guidelines—far more than they have to time read, and far too
many to remember. They find keeping up-to-date difficult, especially when their
patients have several conditions or are taking several medicines. The information
available to guide them is very fragmented and difficult to access as a whole. There is
growing evidence that guidelines are not being translated into clinical practice22.
★★★★ 10 Develop an easily-searchable portal or website of all medical evidence,
guidelines and treatment options. Access needs to minimise the burden on
health professionals, and material must be easy to remember and act on.
Stakeholders interviewed were concerned that many general practitioners were

unaware of MBS Items specifically intended for the management of chronic diseases.
This may be limiting diagnosis and treatment of preventable conditions.
★★★ 11 SUGGESTION FOR MEDICARE AUSTRALIA AND DOHA—promote the chronic
disease Item to general practitioners.
sel ecting appro priate treat ment o ptions

Interventions for the prevention of cardiovascular disease can be divided into
medicines and lifestyle modifications (such as exercise, diet, quitting smoking, and
psychological support).
Overwhelmingly, stakeholders felt that—unless a person was at a very high risk of a

cardiovascular event—lifestyle interventions should be given priority, and medicine
used only when changes to nutrition and exercise have been ineffective. (Obviously, the
decision to try lifestyle interventions requires the willingness and capacity of patients
and their carers.) Prescribers may require advice on how long to try lifestyle
interventions before considering the use of medicines.
Between 1999 and 2005, general practitioners substantially increased their counselling
on nutrition and weight loss: up from 3.8 per 100 visits in 1999–2000 to 5.3 per 100 in
2004–2005, with the largest increase coinciding with the introduction of the SNAP
guidelines in 200123.
While there is a large amount of basic information on healthy eating and exercise, it is
highly fragmented and frequently inconsistent. For example, the DoHA ‘Healthy
Active’ campaign urges consumers to eat 2 fruit and 5 vegetables a day, while Nutrition
Australia encourages Australians to eat around 30 foods each day24. Much existing
lifestyle advice does not take into account the differing dietary requirements of people
with chronic diseases (such as limiting fluid intake or reducing salt), or explain how to
balance competing demands for people with comorbidities. Likewise, exercise programs
tend to focus on the impact of physical activity on individual diseases, and ignore the
contributions of exercise to general well-being and mental health.
★★★ 12 MAJOR CHRONIC DISEASE GROUPS AND NUTRITION AUSTRALIA—develop
consistent advice on food and exercise for people with chronic diseases
—including adjustments that should be made for people with specific
diseases and combinations of diseases.
13 Develop an easily-searchable portal or website (or reorganise Health ★★★★

InSite) to provide a comprehensive collection of treatment options,
including lifestyle, eating and exercise options. Access needs to be easy for
both consumers and health professionals, and material must be easy to
remember and act on.
In 2005, the Department of Health and Ageing developed ‘lifestyle prescriptions’.

Lifestyle prescriptions are tools for GPs to use when providing lifestyle advice to
patients. Advice may be about quitting smoking, increasing physical activity, eating a
healthier diet, maintaining healthy weight, reducing alcohol consumption, or a
combination of these. Those developed for DoHA did not include any QUM component
(despite the urgings of both the developing consultants and external groups). Although
the materials have been printed, it was unclear to the people consulted how these
‘lifestyle prescription’ sheets are to be implemented or to be used by health
professionals. The Victorian Department of Human Services has also developed healthy
eating and exercise materials.
14 SUGGESTION FOR DOHA, NPS AND THE NATIONAL HEALTH FOUNDATION—review ★★

the DoHA ‘lifestyle prescriptions’ for consistency with QUM principles, and
redevelop as necessary.
As noted earlier, a number of studies have found that key risk-lowering medicines are
under-used by general practitioners16,18,19. Research suggests that the main reason for
this is because GPs are:
• excessively concerned about side effects
• concerned about the effects of these medicines on co-morbidities
• unaware or unconvinced about the benefits of medicines
• lacking experience or confidence in initiating and titrating medicines.
15 SUGGESTION FOR NICS AND NPS—continue and extend guidance for GPs on ✩✩✩✩
appropriate use of cardiovascular medicines.
A number of those we consulted were concerned with over-prescribing, especially

where lifestyle changes may be a more appropriate treatment. Since the available
research focuses on under-prescription, cases of over-prescription are hard to identify.
One place where it can be detected is in PBS claims for individual prescribers, which is
collated by Medicare Australia and provided to prescribers via the NPS ‘Prescriber
Feedback’. This document may be an opportunity to educate prescribers, when
Medicare Australia detects higher-than-usual prescribing.
16 DOHA, NPS AND MEDICINES AUSTRALIA—educate prescribers that they do not ★★

always need to provide a prescription, or else that a ‘lifestyle prescription’
may be more appropriate.
17 SUGGESTION FOR MEDICARE AUSTRALIA, ADGP AND THE NPS—where over- ✩✩

prescribing is detected, include advice to prescribers in the personalised
‘Prescriber Feedback’ on alternatives to medicines and use of lifestyle

prescriptions.
There is evidence that prescription of at least some cardiovascular medicines is affected

by socio-economic factors. For example, one recent Australian study concluded “in men
there is either over-prescribing of statins in the highest socio-economic quintile or
under-prescribing in the lowest.”25 This study also noted discrepancies between men
and women.
None of the participants suggested a management plan for cardiovascular

health—such as is used in asthma and a number of other chronic diseases.
pre scribi ng com plemen tary m edicin e

Although we specifically involved complementary medicine manufacturers and
practitioners, most stakeholders had little to say about the role of complementary
medicine in treating cardiovascular diseases. Over half of Australians use
complementary medicines, primarily to maintain their health. These figures may be
even higher among those diagnosed with cardiovascular disease. Research has also
found that half of those taking complementary medicines do not tell their general
practitioners or specialists about these medicines20.
★★★ 18 SUGGESTION FOR GENERAL PRACTITIONERS AND COMPLEMENTARY HEALTH
PRACTITIONERS—educate consumers to inform all of their health care
providers about all the medicines they are using (including prescription,
over-the-counter and complementaries).
A number of those we interviewed said they felt many general practitioners and
specialists were poorly informed about the benefits and risks of complementary and
alternative medicines—either dismissing them or under-estimating their potential.
★★ 19 SUGGESTION FOR NICS, NPS, RACGP, RACP AND DIVISIONS OF GENERAL
PRACTICE—provide training for general practitioners and specialist doctors
about the uses, benefits and risks of complementary medicines, so they can
advise consumers constructively.
Evidence for the effectiveness of many non-prescription therapies remains limited.

A 1999 review of non-prescription weight loss products available in the Australian
market found “no good evidence for any weight loss benefits”26.
4. DI S P E N S I N G M E DI CI N E S
There was some concern that pharmacists are not identifying contraindications and
medicine interactions—particularly with OTCs and complementary medicines.
★★★★ 20 SUGGESTION FOR PHARMACISTS—specifically ask consumers about their use
of complementary, OTC and prescription medicines when dispensing; and
check for and advise consumers on possible adverse interactions.
Two ways to improve identification of potential interactions are for:

• community pharmacists to keep a record of all medicines they dispense
• consumers to keep a record of all the medicines they use.
The first is normal practice for community pharmacists—at least for their regular
customers. They do not, however, have access to information about medicines
dispensed by other pharmacists, hospitals, supermarkets, complementary medical
practitioners and health food shops. (This could be addressed to some extent by the
development and use of a transferable or centralised electronic medical record.)
21 Develop a medicines record for consumers to complete, and get it widely ★★★★
distributed and used.
22 Develop and implement a campaign to encourage consumers to keep a ★★★★

record of their current medicines, and keep this record up to date.
Some of those we interviewed were concerned that consumers can easily become
confused by pharmacists’ labels on prescription medicines—particularly when buying
medicines from several different pharmacists—because of inconsistent practices and
difficulty consumers can have reading pharmacist labels. (Pharmacists’ labels are
controlled under State and Territory poisons regulations.)
23 SUGGESTION FOR PHARMACISTS, PHARMACY GUILD, PSA, SHPA AND SOFTWARE ★★

PROVIDERS—improve consistency of dispensing information, pharmacists’
labels and warning stickers.
Some people interviewed were concerned about inappropriate use of dose

administration aids (DAAs). While they recognised that there are circumstances when
DAAs are appropriate, they felt their use should be minimised, because they can reduce
consumers’ connection with their medicine-taking. They also saw potential for waste:
when a doctor changes a single medicine, all of the medicines in packs or dosettes are
meant to be discarded. Some people were also concerned that pharmacists’ labels on
DAAs, particularly blister packs, can be difficult for consumers to read.
24 SUGGESTION FOR PHARMACISTS, PHARMACY GUILD, PSA, SHPA AND CONSUMERS ★★

HEALTH SUGGESTION FORUM—develop guidelines about the appropriate use
of dose administration aids, and types suitable to particular patients.
Several people interviewed were concerned that an increasing number of consumers are
ordering medicines on the internet—especially from overseas sources. (We have not
been able to secure data to confirm this.) People had concerns about:
• the quality and safety of such medicines—especially from overseas sources (where
there is a trade in ‘fake pharmaceuticals’)
• the lack of counselling provided at the time of dispensing
• CMI and other consumer information not being provided
• the lack of a record of medicines dispensed to a consumer.
We were told that many doctors and pharmacists are unaware of Regulations 24 and 25
of the PBS Schedule, which permit dispensing of larger or longer-term scripts. Some
people felt that better use of these provisions could reduce consumer costs, by reducing
the need for travel to doctors and pharmacies—particularly for people in remote areas.
Not everyone we interviewed supported these schemes, as they could also reduce
contact with doctors and limit opportunities for monitoring a patient’s condition.
Some people we interviewed also felt it could lead to abuse of medicine.
★★ 25 SUGGESTION FOR MEDICARE AUSTRALIA—Inform doctors of prescribing and
dispensing options that help consumers manage the cost of medicines and
treatment.
5. CO U N S E LLI N G A N D E DU CA T I O N
A major concern for many we consulted is that some patients do not understand what
their doctor tells them. Research for the Department of Veterans Affairs reported that
patient confusion was responsible for 61 per cent of medicine-related problems after
discharge from hospital27. Similar findings have been reported in general practice28.
Consumer research has also repeatedly found that, while consumers are generally
satisfied with the technical knowledge of doctors, they felt that general practitioners’
greatest weakness is in their communication skills29. The problem is not just a matter
of skill, but also a lack of time to counsel patients, particularly when managing chronic
diseases.
Participants suggested several solutions:

• better training for doctors in communicating with their patients
• greater use of nurses in general practice and hospitals to ‘interpret’ doctors’
directions to patients and carers
• greater counselling by pharmacists when dispensing.
★★★★ 26 SUGGESTION FOR GENERAL PRACTICES—make greater use of practice nurses
to provide consumer education about medicines and lifestyle interventions.
For cardiovascular diseases specifically, there is concern that patients have only a vague
idea about the course of the disease and how treatment helps—particularly when
consumers experience no symptoms. This lack of knowledge lowers adherence to
treatment.
★★★★★ 27 SUGGESTION FOR THE HEART FOUNDATION—continue to develop and
distribute information for consumers on:
• specific cardiovascular diseases—their aetiology and progress
• treatment options and how they work.
There is broad criticism that CMI are not being delivered to many consumers—possibly
most consumers—even though pharmacists receive a payment for each CMI provided.
Many stakeholders felt that the Pharmacy Guild guidelines for providing CMI are
inadequate. The most recent review of CMI dispensing found only 12 per cent of
consumers received a CMI30. Also, many professionals—including nurses and specialist
doctors—do not know that CMI exist. There is a widespread belief that consumers do
not know to ask for CMI.
28 SUGGESTION FOR COMMUNITY AND HOSPITAL PHARMACISTS—offer CMI to all ★★★★

consumers.
29 Broaden the distribution of CMI beyond pharmacies. ★★★★
30 SUGGESTION FOR PHARMACISTS, NPS AND MANUFACTURERS—educate GPs, ★★★★

specialist doctors, allied health professionals and nurses about CMI.
Specifically:
• what topics CMI cover
• how to use CMI in counselling
• how to access CMI.
There is some criticism that some CMI are legalistic (to protect the manufacturer,
rather than to help consumers). There is also concern that CMI are too long for many
consumers, and that they are not produced in versions suitable for people with visual
impairments. At the time this report was being written, the Quality Assurance
Reference Group for CMI was revising the guidelines for writing CMI and testing them
with consumers.
6. B E G I N N I N G T R E A T M E N T
ini tiatin g medi cines

Some of the common medicines used to reduce risk of cardiovascular disease—such as
beta-blockers and ACE inhibitors—can have strong initial side effects, and it may take
doctors some time to find a form or combination of medicines that is well-tolerated by
the patient. This can involve switching between medicines, as well as titrating doses up
and down. Many patients do not understand the reasons for these constant changes,
and feel they are being treated as ‘guinea pigs’ by their doctor. Because of this, and the
side effects, some patients refuse treatment.
31 SUGGESTION FOR GENERAL PRACTITIONERS—Before commencing medicine, ★★★★

explain to the consumer why switching and changing doses is often
necessary initially, and how long it may take to find a medicine or
combination of medicines that suits the individual.
Many general practitioners are especially concerned about titrating medicines (that is,
starting patients on a low dose then slowly increasing to full therapeutic strength). The
result is that the bulk of patients are on below-target doses31. Reasons that doctors are
concerned about titrating medicines include:
• uncertainty about dose regimens
• uncertainty about appropriate target doses
• lack of time or resources to monitor their patients.

Titration is a particular problem in remote areas and in medical centres where the
patient does not have a regular GP, because consistent monitoring is often difficult.
★★★★ 32 SUGGESTION FOR RACGP, NICS AND NPS—Provide training and support to GPs
to help them titrate medicines safely and effectively.
Another concern about the prescribing of cardiovascular medicines is the confusion

caused to consumers—particularly the elderly—when their medicines are changed
frequently. This mostly occurs when:
• a new treatment is initiated
• a new class of medicines is being initiated—and the patient’s tolerance is unknown
• the patient moves from one health setting to another (particularly hospital to
community or aged care facility)
• the pharmacist offers a generic medicine.
We have not been able to quantify the frequency of this problem, or its consequences
for consumers and their health. One of the main reasons that doctors swap medicines
is that many cardiovascular medicines are not well-tolerated.
★★ 33 SUGGESTION FOR GENERAL PRACTITIONERS AND SPECIALISTS—develop
protocols that reduce the need for doctors to swap medicines frequently,
and help patients manage change better.
✩✩✩ 34 SUGGESTION FOR MANUFACTURERS—continue research in order to find

cardiovascular medicines that are better tolerated by patients.
mak ing li festyl e chan ges

The main lifestyle changes relevant to improving cardiovascular health are:
• increasing physical exercise
• quitting smoking
• good general nutrition
• reducing saturated fat intake
• reducing alcohol intake.
All of these benefit from social and family support. Changes to diet in particular are far
more effective if everyone in the patient’s household adopts healthy eating habits, and
if healthy eating options are easily accessible and affordable at work.
★★ 35 SUGGESTION FOR EMPLOYERS—provide healthy food in staff canteens and
healthy lifestyle programs for staff.
A perception of some participants in this project was that many consumers do not
know how to make healthy food choices—for example, selecting fruit and vegetables,
or making use of dietary information. (As noted earlier, basic nutritional information is
fragmented, and different organisations make recommendations that sometimes
conflicts.) Some participants also felt that there was a widespread belief that healthy
eating is expensive and time-consuming.
36 Develop and implement more effective consumer education about ★★★

nutrition, so that consumers know how to use the dietary information
already provided on food, in order to make healthy eating choices.
37 Overcome the public belief that healthy living is expensive and ★★

complicated.
Apart from advice to individual consumers and their carers, participants also wanted to
see ‘environmental’ campaigns, promoting healthy lifestyles in the wider community.
38 Link cardiovascular prevention campaigns with the DoHA ‘Healthy Active’ ★★★
(Go for 2 & 5) campaign.
39 SUGGESTION FOR DOHA—re-fund the ‘Life Be In It’ public campaigns and ★★★
activities and other healthy living campaigns.
People we interviewed said many consumers and groups had difficulty obtaining
healthy food at a reasonable price. Groups particularly affected are:
• people with low incomes
• people in remote areas
• the elderly
• people that frequently ate away from home—such as those in the transport sector.
There was also concern that many consumers have only a vague notion of what ‘healthy
food’ involves and how to obtain it. While mnemonics such as the ‘food pyramid’ are
widely recognised, it is not clear that many consumers actually use these tools when
shopping or planning their meals.
As noted earlier, different consumer groups produce widely varying—and sometimes

conflicting—nutritional advice, which some consumers find confusing.
40 SUGGESTION FOR HEALTH CONSUMER GROUPS—work together to produce ★★★

consistent food advice for consumers and health professionals.
A key group that several stakeholders wanted to draw into cardiovascular health are the
food retailers and suppliers—particularly supermarkets. Some of those interviewed felt
that the balance of foods in shops favoured less-healthy food options, simply because
these occupied the bulk of shelf-space.
41 SUGGESTION FOR SUPERMARKETS—supply a wider range of fresh foods and ★★★★

healthy eating options.
One group we interviewed suggested that the distinction between medicines and some
foods was becoming blurred with the introduction of ‘fortified foods’—such as milk
with added minerals, margarine with sterols, bread with added vitamins and so on.
Nutritionists and dieticians were divided on the virtues of these foods and the health
claims made about them.
While there has been great public attention recently on obesity, less recognised is
widespread malnutrition amongst the elderly.
A final problem raised frequently in our discussions was that, even if people could
obtain healthy ingredients, the number of people who cook is believed to be
declining—and the number eating pre-prepared meals is growing. Many schools no
longer teach children cooking or basic home economics, and some people interviewed
thought that many young people do not learn to cook at home. Cooking also takes
time, which can be difficult for people working shift hours or that have busy lives.
★★★★ 42 SUGGESTION FOR DEPARTMENTS OF EDUCATION—have cooking classes in all
high schools, to encourage preparation of healthy meals.
7. M O N I T O R I N G U S E O F M E D I CI N E S A N D E FFE CT S O F T R E A T M E N T
Several people consulted were concerned about monitoring medicine levels, particularly
when patients first begin new treatments. In particular, some felt that many
consumers do not appreciate the importance of monitoring their Warfarin and diuretic
levels. (Several participants also felt that there were problems with the current booklet
for monitoring Warfarin.)
★★★ 43 SUGGESTION FOR THE SAFETY AND QUALITY COMMISSION—Redesign the
Warfarin book.
Participants stressed the importance of health monitoring to good medicine

management, and to cardiovascular health generally. Barriers to monitoring they
pointed to included:
• the cost of visiting a doctor or health clinic
• difficulty in getting time off work or arranging care for children
• difficulty travelling to a doctor—particularly for the elderly, those on concession
cards, and those in non-metropolitan areas
• time of appointment during the day—a problem for many older people.
There was strong support for the value of Home Medication Reviews (HMRs) for
checking that medicines are being used appropriately, identifying problems with use,
tracking medicine use, identifying potential interactions, finding expired medicines,
identifying patients who are hoarding, and reducing over-prescribing. HMRs have been
shown to result in net cost savings to government32. Participants said that some
specialists are particularly keen to have an HMR conducted for their patients before
surgery (but are not currently authorised to order them). HMRs are also seen as
particularly valuable after discharge from hospital to increase patient adherence and
improve medication management.
44 SUGGESTION FOR DOHA, GPS AND THE PHARMACY GUILD—increase use of ★★★★
Home Medication Reviews, particularly before admission to hospital and
at discharge. This will involve:
• increasing the number of pharmacists trained to perform HMRs
• encouraging GPs to order HMRs where appropriate, and use the
results
• giving specialists the authority to order HMRs.
One value of electronic health records (discussed on page 50–51), is that tracking
under-use and overuse would become much simpler, especially if they were linked with
dispensing records.
8. A DH E R E N CE I N T H E LO N G E R T E R M
There is widespread agreement that current adherence to preventative treatments
—both medicinal and lifestyle—is far from optimal. Adherence is believed to be
particularly low among asymptomatic patients and those who have experienced no ill-
effects. Patients’ adherence tends to increase only after a cardiac event or stroke brings
the disease to their attention. Since many of the common medicines prescribed for
cardiovascular disease require minimum concentration levels in the body before they
have any effect, widespread non-adherence could mean that a significant part of
medicinal treatment is under-performing or wasted.
It was striking how little attention those we interviewed gave to adherence. This
appears to reflect a similar absence in the larger medical environment. A recent
Cochrane Review noted that:
with the astonishing advances in medical therapeutics in the past two decades, one
would think that studies of the nature of non-adherence and the effectiveness of
strategies to help patients overcome it would flourish. On the contrary, the literature
concerning interventions to improve adherence with medications is surprisingly weak33.
There is little evidence for long-term adherence rates to cardiovascular medicines

—especially as the duration of most smaller clinical trials is too short for non-
adherence to become apparent, and most trials exclude people with comorbidities (a
major factor in non-adherence). But two recent studies of statin use illustrate the
problem. A 1990–1999 US study of 34,500 elderly patients on statins found that 79 per
cent of patients took sufficient doses during the first three months of treatment; 56
per cent in the second three months, and only 42 per cent after 120 months34. These
particular patients paid little or nothing for their statins. Cost was not a barrier. An
Australian review of 32,384 prescription records conducted in 1999 found an even
more substantial decline in adherence: 30 per cent of patients had stopped taking their
statins in 6–7 months, and up to 60 per cent had stopped within 12 months35.
A 2003 WHO report advised, “Increasing the effectiveness of adherence interventions

may have a far greater impact on the health of the [general] population than any
improvement in specific medical treatments”36. Few of the suggestions made in this

project related to adherence however—most were concerned with prevention, followed
by correcting what are effectively ‘acute’ problems with the existing health system.
The WHO report identified the following factors that impact on patients’ adherence to
cardiovascular treatments:
• conditions where there are no symptoms (such as high blood pressure)
• the long-term nature of cardiovascular diseases
• access barriers
• patient’s acceptance of the disease and perception of the risk involved
• patient’s knowledge of cardiovascular disease
• support from carers and family members
• awareness of the costs and benefits of different treatment options
• degree of the patient’s involvement in monitoring
• relationship between the patient and health care providers (difficult when the
patient does not have a regular doctor, or has limited funds for health care)
• the patient’s tolerance for medicines
• keeping medical appointments
• cost of medicines—especially where the patient has co-morbidities or is prescribed
a number of medicines
• complexity of the treatment regimen (frequency of dosing, number of other
medicines being used, changes to medicines).
Another recent international review reported that adherence depends on “complex

combinations of more convenient care, information, counselling, reminders, self-
monitoring, reinforcement, family therapy, and other forms of additional supervision
or attention”37. It goes on to add that, “even the most effective interventions had
modest effects” and were “not predictably effective”.
A barrier to improving adherence to cardiovascular medicines is that general practice

has traditionally been concerned with short-term care. GP funding and administrative
processes have been structured to provide this: for example, GPs are funded per visit,
not for longer-term treatment programs. Consequently, although general practice has
close and on-going connections with patients, its traditional structures may make it
less well suited to the long-term management of chronic disease. On-going
management will require giving health care practitioners training and support in:
• awareness of adherence as an issue to be addressed in managing chronic diseases
• identifying patients in situations that may lead to non-adherence
• making adherence part of the clinical decision-making process
• using behavioural tools that will help increase patient adherence
• the role of carers and support groups
• the need for integration with other health care providers.
Doctors and other health care professionals need advice on how to distinguish between
non-adherence to treatments and the failure of treatments.
Strategies for doctors that have been found to improve medicine taking in
cardiovascular treatment include:
• prescribing the fewest number of doses to be taken daily (the more doses a person
has to take, the more likely they are to miss a dose)
• considering other medicines that the patient is taking
• explicitly scheduling when patients are to take their medicine
• helping patients select reminders and cues to take their medicines38.
45 SUGGESTION FOR THE ROUNDTABLE, NPS, NICS, RACGP AND HEALTH ✩✩✩✩✩
EDUCATORS—develop a resource kit and training for general practice to
help GPs improve adherence to cardiovascular treatments (and for other
chronic diseases).
46 SUGGESTION FOR THE ROUNDTABLE—develop tools to help health ✩✩✩✩✩

professionals track their patients’ adherence to cardiovascular treatments,
as well as cardiovascular health outcomes.
47 SUGGESTION FOR THE PHARAMCEUTICAL INDUSTRY—develop ‘poly-pills’ that ★★

combine frequently-used preventative medicines, and ‘slow-release’
versions of existing medicines, to reduce the number of medicines and
doses that patients have to take.
Internationally, there is little information available on adherence to non-medical

treatments, but the WHO report suggests that levels are probably even lower than
adherence rates for medicines. There are only a handful of studies that examine non-
medicinal treatments for periods of more than a year. An indication that there is a
sizeable problem in this area can be gauged from the recent Australian Longitudinal
Study of Women’s Health39. It found that, of the 10,561 women involved, only a third
met more than half of thirteen food guidelines, and only two women met all thirteen.
during a cardiovascular event

The people we consulted raised surprisingly few issues about the period that patients
spend in hospital immediately after a stroke or cardiac event. Their main concerns were
with transferring patients and information into and out of this environment.
Topics that they did raise included:

1. getting people to hospital after a cardiovascular event
2. admission procedures
3. the role of cardiac physicians in QUM
4. provision of information to consumers and carers in hospitals
5. the short-term ‘acute’ focus of hospitals.
Participants did not discuss managing acute episodes, such as angina attacks.
1. G E T T I N G P E O P LE T O H O S P I T A L
A problem with all cardiovascular events is getting people to hospital soon enough for
treatment to be possible. Unfortunately, there are many people who do not seek help
until it is too late—and they either die or sustain permanent physical damage.
Approximately a quarter of people die within an hour of their first symptoms, and the
risk is even greater for people that have experienced a previous heart attack. Currently,
half of all heart attack deaths occur before the person reaches hospital3.
★★★★★ 48 SUGGESTION FOR THE HEART FOUNDATION—Educate consumers to recognise
symptoms of cardiovascular events, and what action to take in response.
Ambulances and paramedics were not mentioned in our discussions.
2. A DM I S S I O N T O H O S P I T A L
When a person arrives at hospital—either by ambulance or by themselves—their
condition is assessed in the Emergency department and then they are admitted to an
appropriate unit. Leaving aside known problems with identifying cardiovascular
events, for QUM the key part in the admission process is checking the patient’s
medicines. Developing this list is often difficult because:
• many patients cannot remember what medicines they are using
• after a cardiac event or stroke, the patient may be unable to speak
• patients may not know the names of their medicines—and admissions staff may
have to guess based on the patient’s medical conditions
• most patients do not keep a medicines list with them
• patients or family members may not think to bring medicines when they come to
hospital
• some do not bring packages with them, making identification of tablets difficult
• ambulances sometimes advise patients against taking their medicines to hospital,
because some facilities confiscate or destroy consumers’ medicines
• many patients do not mention OTCs or complementary medicines they are using.
Each hospital has different processes for developing a medicines list—sometimes it will
be done by a pharmacist and sometimes by a nurse. Hospitals also vary in how they
record information for future reference—especially upon discharge. Some hospital
pharmacists will contact the patient’s GP or community pharmacist for help when
developing the medicine list—but they are aware that records can easily be incomplete.
Participants we interviewed felt that the best solution was a transferable or centralised
medicine record (see pages 50–51). In the absence of this, current processes could be
improved by standardising the data gathered across all hospitals. (In 2005, APAC
released its revised Guiding principles to achieve continuity in medication management.)
49 SUGGESTION FOR DOHA, STATE DEPARTMENTS OF HEALTH AND THE QUALITY AND ★★★★★
SAFETY COMMISSION—
(1) develop standard procedures and a standard sheet for recording
patients’ medicine details at admission
(2) disseminate the recording sheet and protocols nationally, and provide
training in their use.
For people at risk of cardiovascular events, assessing medicines at admission would be

easier if they kept an up-to-date record with them at all times.
3. I N T E R V E N T I O N S
Hospital interventions can be divided broadly into surgical and pharmacological.
Participants in this project did not raise issues concerning surgery—such as pacemaker
implants, defibrillators, bypass graft surgery, surgical ventricular restoration, heart
transplant and stents. The medicines relevant to cardiac surgery and recovery are:
• for managing tissue grafts or prosthetic devices
• for managing risk factors—blood clotting, high blood pressure and lipid levels
• for managing pain
• anti-depressants.
spe cialis t phys icians

Most decisions about medicines in hospitals are made by cardiologists, not surgeons.
There was concern amongst those interviewed that cardiologists—and specialist
physicians generally—have not been engaged in QUM (for example, many physicians
appear unaware of CMI).
★★★★ 50 SUGGESTION FOR NPS AND RACP—engage specialists in QUM, to explain

basic concepts and resources available, such as CMI and HMR.
Specialist physicians will be more difficult to engage than GPs because—apart from the
Royal Australian College of Physicians—there are few networks available for reaching
them, and there is nothing comparable to the Divisions of General Practice. Even the
College is divided into 25 specialities (including cardiology and gerontology).
The variety of specialities involved in the care of patients with several comorbidities
can also cause problems. Specialists tend to focus on their own disease areas, rather
than pursuing holistic treatment. Consequently cardiologists, for example, may not be
aware of the interactions of the medicines they prescribe with those used to treat other
illnesses.
med icines in ho spital s

A problem widely recognised in hospitals’ medication management is the variety of
hospital medicine charts and the poor design of many. The Quality and Safety Council
has overseen the development of a National In-Patient Medication Chart, with pilots
now completed in 33 hospitals. The pilots showed substantial reductions in error rates,
and the new Chart is expected to improve patient safety. Consistency across hospital
settings is also expected to improve transfer of information.
★★★★ 51 SUGGESTION FOR HOSPITALS—adopt the National In-Patient Medication
Chart in all hospitals.
A problem for patients’ recovery after discharge is that each hospital has its own
formulary (because hospital pharmacies are funded separately from the PBS). Hospitals
may use medicines that are unobtainable or expensive for consumers after discharge.
In particular, they may use medicines not listed on the PBS. Specialists may be
prescribing medicines that are expensive or unavailable after discharge. When the
patient is discharged, their GP may need to change the medicines they were given in
the ward—and some patients are unwilling to change prescriptions written by their
specialist. This can lead to unnecessarily high costs, patients not filling scripts, double
dosing (as patients take medicines prescribed by both their GP and specialist), and
lower adherence. An area hospital pharmacists could help is advising doctors on the
availability and cost of medicines for consumers after discharge.
★★★★ 52 SUGGESTION FOR PBAC AND HOSPITAL PHARMACIES—develop better alignment
between hospital formularies and PBS Schedule.
★★★★ 53 SUGGESTION FOR PBAC, NPS AND RACP—make specialists aware of medicines
available on the PBS, and the cost implications of their hospital
prescribing. Encourage specialists to select medicines that will minimise
the need for changes after discharge.
Participants made no comments about processes for filling scripts by hospital

pharmacists or administering medicines by nurses.
4. P R O V I DI N G I N FO R M A T I O N I N H O S P I T A L S DU R I N G R E C O V E R Y
In hospitals, it is usually nurses that provide the bulk of information to patients and
families—both formally and informally. Consumers and support groups we
interviewed felt that patients were more comfortable talking candidly with nurses than
doctors, and were freer in asking them questions. Nurses also ‘translated’ information
provided by doctors, explaining the practical, day-to-day implications of treatment in a
non-technical manner.
In practice, ward nurses are often also the gatekeepers of written information
—whether written in-house or by external groups such as the Heart Foundation. This
role does not appear to have been widely appreciated, and nurses are often not
informed of resources available or are uncomfortable providing some materials.
Consequently, many written resources do not reach hospital patients or are underused.
54 Involve nurses in the development of written information for hospital ★★★

patients. Where information is developed by organisations outside
hospitals, nurses should be engaged when materials are delivered.
There are standards for the supply of CMI in hospitals40, but it is unclear how closely
they are followed.
5. T H E S H O R T - T E R M FO CU S O F H O S P I T A LS
A comment made by several people was that, because the focus of hospitals is not
chronic disease management—and they are funded chiefly for acute care—hospitals
often take a short-term or episodic view of cardiovascular health. A challenge seen by
many we interviewed was to shift the traditional acute care model of hospitals, and
integrate it into the longer-term holistic management needed to treat chronic illnesses
like cardiovascular disease.
This short-term focus could also exacerbate problems caused by cost-shifting which
result from the funding split between State and Commonwealth governments. For
example, in many hospitals, public patients are given bare metal stents, whereas
private patients are given coated stents. Because bare metal stents need to be replaced
more often than coated stents, this practice costs both consumers and public funding
more in the longer term. But, in the short term, it is cheaper to the hospital performing
the operation.
after a cardiovascular event

What happens after an event depends on the success of hospital treatment:
• where treatment is either successful, or unsuccessful but not terminal, the patient
returns home and may be enrolled in rehabilitation
• when unsuccessful and the condition is terminal, the patient’s options for the
remainder of their life include palliative care and Hospital in the Home.
From a medical perspective, palliative care is not part of cardiovascular treatment.

However, for many patients and their families, they belong to the one continuum.
Participants raised no QUM issues around palliative care, but several people we
interviewed spoke warmly of the care they had seen provided there, commenting that
hospitals could learn from it.
Elements of care after hospital can be divided into:

1. discharge processes
2. rehabilitation
3. connection of patients with general practitioners—and through them, to
specialists, community pharmacists and allied health workers
4. educating consumers and carers
5. support groups.
An essential part of on-going care is prevention. The QUM issues that participants
raised about it are much the same as they were for treatment before a cardiovascular
event.
1. DI S CH A R G E — FR O M H O S P I T A L T O H O M E
There is general agreement that one of the biggest sources of problems in the use of
cardiovascular medicines—and treatment generally—is at discharge: in the transition
from hospital to home or residential care. This parallels findings of a 2001 study, which
found poor compliance with APAC’s 1998 National guidelines to achieve the continuum of
quality use of medicines between hospital and community41,42. (The original guidelines have
been revised and re-released as the Guiding principles to achieve continuity in medication
management.)
In public hospitals, with pressure to clear beds quickly, discharge can be difficult to
schedule and is often rushed. Discharges are frequently done by junior medical staff,
and often hospital pharmacists are not involved. Discharge procedures vary greatly,
and depend on whether the patient is in a cardiac unit or a general ward.
los s and corrup tion o f info rmatio n

The main problem with discharges is that there is a massive loss of information when a
patient leaves hospital. Usually only a fragment of the material gathered in the hospital
is passed on to those involved in the patient’s continuing care. The information
collected can be highly variable, and anecdotal evidence suggests that it frequently
contains errors. A small quality-improvement study in 2000–200142, looking at
communication between GPs and hospitals reported that, even after a six-month
intervention:
• 22% of GPs were informed that their patients had been admitted to hospital
• 55% of GPs provided medicine details to hospitals
• 32% of GPs received a discharge summary by fax
• 37% of GPs received a form explaining the reason for changes to medicines.
A particular object of criticism is the hospital discharge letter. Problems include:

• many patients are not given a letter
• many patients do not have a doctor to give the letter to
• each hospital has its own discharge letter, leading to inconsistencies and omissions
—and it is easy for GPs to misinterpret them
• many letters do not explain which medicines are to be reduced after discharge
• many letters do not supply contact details in case of questions
• letters frequently contain errors.
A 2001 intervention study found that, before the intervention, only 55 per cent of
patients with acute coronary syndrome had a clinical pharmacist review their
medicines before discharge.
55 SUGGESTION FOR HOSPITALS, DISCHARGE ADMINISTRATORS AND SHPA—Ensure ★★★★

hospital pharmacists are involved in all discharges involving medicines.
There is broad agreement that electronic or transferable health records would be the
best way of reducing the loss of information at discharge. In the absence of electronic
records, an alternative is to improve and standardise discharge processes. (This could
tie in with the Quality and Safety Commission’s work on the National In-Patient
Medication Chart in hospitals and Common Medication Chart for residential aged
care.)
56 SUGGESTION FOR THE QUALITY AND SAFETY COMMISSION—develop standard ★★★★★

discharge documents (or templates) and discharge procedures for use in all
hospitals, to achieve better transition from hospital to general practice
and home care settings. This template should ensure that all information
normally required by GPs, nurses, pharmacists and patients is recorded in
all patient discharges.
★★★★★ 57 SUGGESTION FOR HOSPITALS AND RACGP—develop standard methods for

issuing discharge letters—by fax or e-mail, as well as by mail or hand—so
that the patient’s doctor receives the information they need promptly and
consistently.
med icines at di scharg e

At discharge, patients are normally given a supply of medicines to last them a few days,
until they visit a GP to get a new script. We were told that many patients run out of
medicines—sometimes leading to their re-hospitalisation. This happens for several
reasons:
• patients are unable to see a GP before the hospital supply runs out
• patients do not have a regular GP to go to
• patients wait until they have run out of medicines before making an appointment
• patients feel too unwell to go to the community pharmacist to fill their script—or
do not have someone to go for them
• patients cannot afford to fill the script
• the patient is discharged on a weekend, when community pharmacies are closed
• patients have trouble remembering everything they were told at discharge.
★★★★ 58 SUGGESTION FOR HOSPITALS—arrange an appointment with the patient’s
GP or health centre before the patient is discharged.
★★★★ 59 SUGGESTION FOR HOSPITALS—consider providing medicine supplies for a

longer period than present (maybe up to a week), especially when the
patient is discharged at the weekend or around public holidays.
★★★★ 60 SUGGESTION FOR HOSPITALS—counsel patients and carers about the

importance of continuing medicines.
As noted earlier, each hospital has its own formulary, and they vary considerably in the
medicines they stock. Generally, they are not aligned with the PBS Schedule. This
becomes a problem when patients are discharged, as many GPs do not like to change
what specialists have prescribed (because it reduces adherence). This can result in
significant on-going costs to consumers. And, if GPs do make changes, we were told
that many patients continue to take what their specialist prescribed, along with their
new medicines—which can result in interactions or double-doses.
Some community pharmacists were concerned they could not contact the patient’s
specialists directly to discuss medicine changes made by GPs.
Most hospitals do not send the patient’s revised list of medicines to the community
pharmacist. Even those hospitals that do so may not include the medicines list
generated at admission.
★★★ 61 SUGGESTION FOR HOSPITALS, SHPA, PGA AND PSA—The discharge letter (or
those parts concerned with medicine) should be made available to the
patient’s community pharmacist.
fol low-up
There is strong evidence that follow-up contact with patients is important to recovery.
There was also widespread concern among participants that this was not happening
widely or effectively.
A recent Australian study reported that “[heart failure] programs that incorporate
follow-up by a specialised multidisciplinary team (either in clinic or non-clinic setting)
reduce mortality, heart failure re-hospitalisations and all cause hospitalisations”43.
However, such programs are currently accessible to less than ten per cent of
Australians. A South Australian study of a nurse-led home based intervention for
patients with atrial fibrillation reported fewer readmissions to hospital, fewer days stay
in hospital and fewer fatal events relative to patients receiving the usual post-discharge
care44. Another program involving hospital pharmacists reporting to cardiologists and
community pharmacists has also favourable outcomes45.
62 SUGGESTION FOR HOSPITALS—as appropriate to patients’ conditions and ★★★★★

needs, organise a home visit within 5–10 days after a patient is discharged
to:
• check their progress
• provide counselling (both to the patient and their carers)
• check that the patient’s understanding of their condition and what
they need to do to recover
• check the patient knows what to do to reduce risks of further events,
and prevent further damage
• check medicine use
• check the patient’s links with doctors, pharmacists, nurses,
rehabilitation, physiotherapists and specialists.
While home visits appear to be regarded as the ideal follow-up process, other methods
may also produce good health outcomes. A recent US study of patients who recently
had a defibrillator implanted found that an eight-week education program delivered by
telephone by cardiac nurses significantly lowered anxiety and patient concerns, and
increased their knowledge46. These results were sustained twelve months later47.
For QUM, there is some evidence that medicine reviews shortly after discharge have a
positive impact on patient adherence. However, there is concern that HMRs are not
being well integrated into discharge planning. Currently, only a few hospital
pharmacists are qualified to conduct HMRs—most are done by community
pharmacists, which may also create problems for transitional care.
63 SUGGESTION FOR THE PSA, PHARMACY GUILD AND SOCIETY OF HOSPITAL ★★★
PHARMACISTS—look at ways of making HMRs more accessible and effective
for patients immediately after hospital discharge.
2. CO O R DI N A T I N G R E H A B I LI T A T I O N S E R V I CE S
As well as taking medicines, there is a range of services to help patients recover from
a heart event or stroke—including rehabilitation, physiotherapy, gymnasiums, and
community health centres. People told us that these were often poorly coordinated,
and many were hard for both consumers and medical professionals to
locate—particularly in regional and remote areas. (None of the people we interviewed
appeared to be aware of the Heart Foundation’s Directory of Australian cardiac
rehabilitation programs.)
★★★★ 64 SUGGESTION FOR GOVERNMENT AND REHABILITATION SERVICES—develop and
implement psychological support programs for consumers, especially post-
discharge and post-rehabilitation.
★★★ 65 SUGGESTION FOR THE HEART FOUNDATION—revise its register of cardiac

rehabilitation centres and their services. Make this widely known to
consumers, hospitals and health professionals.
★★★ 66 Develop and publicise a directory of secondary prevention service

providers—including physiotherapists, certified gymnasium instructors,
and Community Health Centres.
There is evidence of under-referral of cardiac patients to rehabilitation. One major

Queensland study found that, while 49 per cent of patients discharged from hospitals
are eligible for outpatient rehabilitation, only 29 per cent were actually referred48.
Fewer than a third of these patients actually completed rehabilitation. In the NSW
Hunter Region, 39% of patients eligible for rehabilitation actually attended49 (and this
figure over-estimates participation as, in this case, only 62 per cent of patients
consented to be on a register which would have made them eligible for rehabilitation.)
Reasons for under-use include:
• referrals to rehabilitation were not standard practice
• rehabilitation is not accessible for all Australians (especially those in rural and
remote areas)
• rehabilitation is not sufficiently attractive for indigenous Australians, older
women, people who do not speak English, and the indigent.
Women tend to use rehabilitation services less than men50.

★★★ 67 HOSPITALS AND REHABILITATION SERVICES—Explore the need for, and
practicality of, gender- and culture-specific rehabilitation.
3. I N T E G R A T I O N O F G P S A N D S P E C I A LI S T S
A concern for general practitioners was getting good contact with the patient’s
specialists. Many GPs want their support and advice on details of their patients’ cases.
Problems that many GPs experience include difficulty making contact, limited time to
discuss issues and receive advice, and problems transferring information.
GPs also value specialists as a source of advice on new medical practices, medicines,
tests and clinical procedures. Specialists present an opportunity for informal education.
Studies show that specialists have a major impact on general practitioners’ prescribing
habits51, and are therefore crucial in achieving QUM.
4. E DU CA T I N G CO N S U M E R S A N D CA R E R S
There is broad agreement that educating consumers about their condition and its
treatment is central to effective treatment, adherence and avoiding re-admission. One
of the greatest barriers to education is that, after an event, many people want to “put it
all behind them”. They do not attend rehabilitation, or visit a GP, or make contact with
a support group.
Participants stressed that carers need support, as well as consumers. Carers need to
hear what they can expect for themselves while caring for the patient, and what
support is available to them. Carers need to be made aware of their own need for
psychological, emotional, social and physical support—and that they are particularly at
risk of depression, fatigue and stress after the patient returns home. During
rehabilitation, while patients usually receive counselling and psychological help, carers
often go unsupported. We were told that many people eligible for help in their local
communities do not get it—up to fifty per cent of people in some States.
68 SUGGESTION FOR CARERS AUSTRALIA, REHABILITATION AND HOSPITALS— ★★★★★

(1) engage carers before and after discharge
(2) provide information to carers on what they can expect
(3) inform carers of the support they need to obtain
(4) provide carers with psychological help as necessary.
Many people we interviewed emphasised the need for carers to be given information on
the patient’s treatment, as well as the patient themselves. This is especially true in
older couples, where one person will often take responsibility for the care of their
spouse. Doctors and support groups said that one partner frequently answers
questions on behalf of other or looks after their medicine. While giving information to
carers is important in all three phases of treatment, it is particularly relevant at
discharge, when the patient may be frail and in pain or discomfort—and hence less
likely to remember information. Like consumers, carers need to ask questions and be
an active partner in treatment.
69 Engage Carers Australia and other support groups in QUM. ★★★
5. S U P P O R T G R O U P S
There is some evidence that membership of a support group helps many patients
recover and adhere to their treatments. Support groups can provide advice, social
support and help patients develop skills to manage their treatment. However, research
criticises GPs for under-referring patients to support groups29, and we were also told
that patients are often not referred during rehabilitation.
★★★ 70 SUPPORT GROUPS—build better links with prevention programs and
rehabilitation programs.
★★★ 71 SUGGESTION FOR HEALTH SUPPORT GROUPS—teach and encourage consumers

to be proactive in questioning their doctors and taking responsibility for
their health and long-term management of chronic illnesses.
Support groups tend not to deal with the most vulnerable patients—the frail,
immobile, socially-isolated, or those unable to travel. These people are typically dealt
with by nurses—if at all.
psy cholog ical s upport

People who have experienced a cardiovascular event commonly suffer from mental
illnesses—particularly depression and anxiety. In part, these are due to the trauma that
their body has experienced; this passes as they heal physically. But these illnesses may
also be due to fears created by the event and concerns about life in the future. Common
sources of anxiety, unhappiness and grief include:
• loss of employment or reduced ability to work
• concerns about supporting a family
• worries about burdening family and friends
• increased dependence on others and loss of freedom
• imposed changes to lifestyle—such as limits on food, exercise, drinking, and
smoking
• the experience of loss
• lack of energy
• reduced quality of life
• loss of sex drive
• cost of treatment
• anticipation of pain and death.
Many of those we interviewed felt that the psychological aspects of cardiovascular

diseases had been poorly recognised, and not well integrated into recovery programs.
Unaddressed, psychological illnesses can contribute to poor recovery or a relapse.
Interventions stakeholders said could help were:
• psychological treatments (such as cognitive–behavioural therapy)
• social support—especially from peers
• telephone-based contact and monitoring
• medicines.
supporting environment
E Q U I T Y A N D A CCE S S
An issue of great concern to many we interviewed was improving equity and access to
cardiovascular treatments and medicines in Australia.
As noted in the Background, cardiovascular diseases and deaths are not spread evenly
in the Australian community. They are primarily concentrated in older populations.
People in lower socio-economic groups are more likely to die of cardiovascular diseases
than people in higher, less-disadvantaged groups. People in regional and remote areas
are more likely to have a cardiovascular disease and to die of it than Australians living
in metropolitan areas.
Throughout our interviews, people stressed that many in the Australian community
lacked the support needed to achieve good cardiovascular health. In particular,
participants were critical of the current health and funding systems, which were—in
the words of one participant—“designed for the middle class by the middle class”.
Australians that fell outside this group had trouble accessing the system. They include:
• those on low incomes
• those aged over 65
• indigenous Australians
• people from non-English-speaking backgrounds
• people with limited literacy
• people in regional and remote areas
• the mentally ill.
Despite concern for these issues of equity and access, participants did not make
concrete suggestions about how these issues might be addressed.
LI N K S B E T W E E N S E CT O R S
Throughout the consultation and workshop, participants stressed the importance of
good partnerships between different stakeholders. It is also a major plank of the
National Medicines Policy. Many participants expressed frustration that some groups
in the Medicines Community were unwilling to partner, or else value their
independence above partnership.
72 ALL STAKEHOLDERS IN THE MEDICINES COMMUNITY—give greater emphasis to ★★★★

partnership, and be less doctrinaire on independence. Where there are
concerns about working with particular stakeholders, develop protocols to

promote openness, transparency, equity, and fairness.
★★★ 73 SUGGESTION FOR THE ROUNDTABLE—Advocate and practise the involvement

of all stakeholders in the development of education and communication
programs, to ensure all stakeholders’ needs are understood and met.
Participants had a number of suggestions for improving interactions involving:

• health care providers
• health consumer organisations (HCOs)
• the pharmaceutical industry.
lin ks bet ween h ealth care p rovide rs

The people we consulted said that the most important links needed to deliver QUM in
cardiovascular health are those between health professionals. These are necessary to:
• achieve continuity of care
• ensure consistency of prescribing
• create networks of professional support
• generate opportunities for informal education
• provide feedback.
As we noted on page 40, among the most urgent is the development of effective,
structured interactions between general practitioners and specialist physicians.
★★★★★ 74 SUGGESTION FOR THE RACGP, RACP AND ADGP—find ways to improve
communication between general practitioners and specialists, and
promote these methods.
One way of bringing health professionals together is through Case Conferences.

Internationally, case conferences that have been shown to improve patient adherence,
improve clinical behaviour and produce some small improvements in health
outcomes52. In 1999, MBS Items for case conferences were introduced as part of the
Enhanced Primary Care package. However, uptake has been poor, as can be seen when
compared with the rapidly growing number of claims for Multidisciplinary Care Plans53.
Reasons put by doctors for not organising or participating in case conferences included:
• the burden of administration involved
• poor understanding of the MBS Item and claiming procedures
• GPs undervaluing their role
• difficulty fitting conferences within the unpredictability of general practice
• difficulty in travelling
• not knowing that teleconferencing can be claimed under the MBS54.
350,000
300,000
250,000
claims for
multidisciplinary care plans
200,000
150,000
100,000
claims for
50,000
case conferences
0
1999 2000 2001 2002 2003 2004 YTD 2005
In 2005, the claims processes were simplified and new Medicare Items released.
However, there remain concerns among those we consulted that many general
practitioners do not know about these new items. Encouraging specialists to organise
case conferences may help, as they have more administrative resources than GPs55.
75 SUGGESTION FOR MEDICARE AUSTRALIA AND DOHA—find new ways to ★★★

encourage GPs and other health professionals to use the new Enhanced
Primary Care items.
An elementary problem for some health providers—particularly general

practitioners—is not knowing what other providers are involved in the care of their
patients. For example, many GPs do not know which community pharmacists dispense
their medicines, and discharge planners do not receive feedback on the outcomes of the
plans they prepare.
76 SUGGESTION FOR THE NPS AND MEDICARE AUSTRALIA—provide general ★★

practitioners with data on the pharmacists dispensing medicines they
prescribe. This could be an adjunct to the existing NPS Prescriber
Feedback, as the necessary data already exists.
A final suggestion from participants was to establish inter-professional work as normal

in the undergraduate training of all health care professionals.
77 SUGGESTION FOR UNIVERSITY MEDICAL COURSES—provide some training ★★★

courses where all those studying to become health care professionals work
together, so young medical professionals accept working in cross-
disciplinary teams as normal and desirable practice.
lin ks amo ng hea lth co nsumer organ isatio ns

Many of the people we interviewed pointed to successful programs outside the
cardiovascular sector to help people with chronic illness. They said that different
groups—consumers groups, advocacy groups, support groups—had much to learn
from one another and to gain by pooling their skills. No one we interviewed appeared
aware of the two major partnerships of the Heart Foundation and other NGOs:
• the Australian Chronic Disease Prevention Alliance (ACDPA), and
• the National Vascular Disease Prevention Alliance (NVDPA).
There was some concern that groups were reinventing the wheel, or preferring to stand
alone for the sake of their ‘brand’ or ‘identity’. The result was that consumers received,
for example, conflicting advice on diet, exercise and medicines.
★★★ 78 SUGGESTION FOR THE HEART FOUNDATION—Develop a high-level public
collaboration with other major chronic disease groups (stroke, diabetes,
asthma, arthritis, kidney, cancer, mental illness, musculoskeletal
conditions) to:
(1) form—with the Chronic Illness Alliance—a powerful lobbying group
(2) ensure better coordination and consistency across chronic disease
areas, particularly consistency of health messages.
★★ 79 SUGGESTION FOR THE HEART FOUNDATION—Work with other chronic disease

groups to explore combining services in remote areas. This will help
provide consistent advice and support, and may be a better use of HCOs’
limited resources.
★★★ 80 SUGGESTION FOR THE HEART FOUNDATION—Link with organisations that

have peer education programs, in order to deliver education programs.
A particular criticism from several participants was the lack of links between the Heart
Foundation and Heart Support Australia, as the chief cardiovascular support group.
★★★ 81 SUGGESTION FOR THE HEART FOUNDATION—build links with support groups.
In particular, rebuild the relationship with Heart Support Australia.
lin ks wit h the pharma ceutic al ind ustry

Consumer groups we spoke with were comfortable partnering pharmaceutical
companies, although some other stakeholders were suspicious of the industry’s
motives. In 2005, the Health Consumers’ Forum and Medicines Australia released
guidelines to help structure industry–HCO relationships, and these may also help allay
concerns.
It is widely believed that the NPS will not partner with pharmaceutical companies or
some consumer groups that receive support from manufacturers. Non-industry
participants appeared unaware that there has been an NPS–industry working group for
the past three years.
82 SUGGESTION FOR THE INDUSTRY AND NPS—Build and promote NPS-industry ★★★
partnership.
G E N E R A L P R A CT I C E A N D P R A CT I CE N U R S E S
Many of the participants in this project recognised that the chief burden for detecting
cardiovascular diseases, initiating prevention, and helping consumers adhere to their
treatments falls on general practice. And they also recognised that general practice is
already under tremendous pressure, which limits Australia’s ability to assess large
numbers of people and to provide effective interventions to those that need them.
Issues that participants said need to be resolved include:
• Medicare Items for managing chronic diseases (and promotion of existing MBS
Items)
• reduction of administrative load on general practices (currently being pursued
through the Red Tape review)
• lack of general practitioners and supporting health professionals—particularly in
regional and remote areas
• long-term declines in bulk-billing
• poor links with peers and with specialist doctors
• limited use of IT, and poor integration of software packages.
The chief suggestion made to help general practice was to encourage the use of practice
nurses in order to reduce the burden of work that currently falls on doctors. In 2004,
only 40 per cent of Australian practices had practice nurses56. A recent review found
that there was little exploration or data on the potential role for practice nurses, but
did point to some recurring themes:
• there is considerable variation between practices in the roles of practice nurses
• practice nurses can potentially facilitate multidisciplinary interventions for
delivering secondary prevention strategies
• practice nurses are viewed favourably by consumers, although there is some
confusion about their role.57
83 Encourage general practice to adopt practice nurses—in particular, for: ★★★★

• health assessments
• pathology tests
• preparing medicine records
• organising multidisciplinary health teams
• education about medicines and lifestyle interventions
• counselling patients—particularly when prescribing medicines and
lifestyle changes
• medication reviews
• providing CMI.
84 SUGGESTION FOR DOHA, RACGP, ADGP AND RACP—continue to find and ★★★★
implement ways to reduce the paperwork and workload of health
professionals—particularly general practitioners.
Some other suggestions for helping general practice, mentioned in the research and
professional literature, include:
• reducing the external administrative burden on general practices
• encouraging general practices to take on practice managers and staff to manage
administration
• helping doctors shift from an acute-care model of health to a chronic-disease-
lifestyle management model of well-being
• encouraging doctors to seek professional support from networks outside their
practices—for instance, through Colleges, Divisions, and specialists
• helping doctors manage the balance between running a medical practice and
running a business.
P O L I CY A N D I M P L E M E N T A T I O N
There were relatively few places where participants felt that basic policy was
lacking—except at the highest level, where some stakeholders want an integrated
National Health Policy and integration of policy across government portfolios with
impacts on health (such as employment, workplaces, family and housing). Some people
stressed the need for a coordinated health policy that would draw together:
• health assessment and monitoring
• prevention
• nutrition and lifestyle
• treatments, health equipment and medicines
• professional standards and training
• resources and health facilities
• research
• public health education.
One of the fundamental barriers seen by many to improving health care in Australia is
the split of responsibilities, policy and funding between the Commonwealth and State
governments. Apart from political disputes over responsibility (which can leave
programs unfunded or under-funded), it creates many opportunities for cost-shifting
that is not in the interests of consumers or their health.
★★★★ 85 SUGGESTION FOR DOHA AND STATE DEPARTMENTS OF HEALTH—develop a
whole-of-life health policy to integrate currently fragmented health
policies.
★★ 86 SUGGESTION FOR ALL GOVERNMENT DEPARTMENTS—develop and promote a

better understanding of the impacts of health on government portfolios
outside of health.
People pointed to three major problems with existing policies.

First, many are fragmented. At the large scale, there is universal agreement of ‘policy
silos’, particularly within DoHA. Policies on medicine, exercise, healthy eating, chronic
disease management, professional development and administration are all largely
uncoordinated. Then there is fragmentation between different parts of medicine policy.
An example noted by several participants is in the discrepancies between Therapeutic
Guidelines, cardiovascular risk assessment tool and the PBS restrictions. They felt this
was a particular concern because, as we noted earlier, some doctors use the PBS
Schedule as a guide to clinical decision-making, and so inconsistencies in policy lead
directly to poor prescribing practices. Some stakeholders also felt that the PBAC itself
was not employing QUM principles in its decisions.
87 SUGGESTION FOR DOHA AND STATE DEPARTMENTS OF HEALTH—develop ★★★★★

practical measures to break down internal policy silos, particularly at the
project level.
88 SUGGESTION FOR PBAC—ensure consistency between the PBS Schedule ★★★

prescribing conditions and assessment tools, therapeutic guidelines and
policy.
89 SUGGESTION FOR PBAC—better illustrate and explain use of QUM principles ★★★
in PBAC determinations.
Second, many existing policies are incomplete. For example, a point made several times
was that many QUM policies do not include goals or outcome measures, ignore
economic issues, or are unsupported by funding. (In part, this is because economic data
and modelling for many diseases and medicine uses does not exist.)
90 SUGGESTION FOR DOHA AND STATE DEPARTMENTS OF HEALTH—make greater ★★★

use of evidence-based medicine in policy decisions.
91 SUGGESTION FOR STATE AND COMMONWEALTH DEPARTMENTS OF HEALTH ★★★

—ensure that all policies state the goals being sought and outcomes that
can be monitored.
92 SUGGESTION FOR DOHA—support cost-effectiveness studies to guide health ★★★

policy and treatment options.
The third and largest criticism is that QUM policies have not been implemented, or are
not in a state that can be implemented. There appears to be a belief on the part of
policy-makers that developing and publishing a policy framework is sufficient to
achieve QUM. What is omitted in this belief is:
• development of practical methods—so people can act on the principles
• training and education for those that have to act on policy
• development of supporting information, educational materials, and administrative
systems
• provision of funds and resources
• promotion of new methods required to achieve policy objectives
• administrative procedures to underpin policy.
An example of the lag between the development of QUM principles and application is
in APAC’s Guidelines for Medication Management in Residential Aged Care. Although
released in 1994, it was not until 2005 that the Victorian Government began to
develop training and support materials to help aged care facilities implement the
policy. In 2006, the Commonwealth Government began work on a Common
Medication Chart—the central tool in managing medicines in aged care facilities.
Another example of poor implementation of QUM policy is the APAC Guidelines to
achieve the continuum of quality use of medicines between hospital and community. While
the guidelines were first released in 1998, studies in 2001 and 2002 reported very poor
application of the principles in practice41,42.
★★★★★ 93 SUGGESTION FOR THE SAFETY AND QUALITY COMMISSION, HEALTH
ADMINISTRATORS AND HEALTH CARE ORGANISATIONS—develop materials,
training and incentives to implement the APAC Continuity of Medication
Management guidelines.
The overwhelming need felt by participants was for governments to fund the
implementation of policies and programs—not further trials, or pilots, or further
research, or to develop ‘innovative’ methods or approaches. There is considerable
frustration that many practical QUM solutions have been developed and trialled, but
they have not been adopted. For example, on the topic of discharge planning
—regarded by participants as an area for urgent action—the QUM Map alone lists 25
projects. Other areas where participants felt State and Commonwealth Government
needed to roll out existing programs were:
• practice nurses
• electronic medical records
• Home Medication Reviews
• NatRUM.
An area where governments were particularly urged to contribute was in further

funding of QUM projects, particularly around continuity of care.
★★★★★ 94 SUGGESTION FOR DOHA AND STATE HEALTH DEPARTMENTS—develop ways to
ensure continuity of funding when transferring between different health
care settings, to ensure financial support for continuity of care.
I T , CO N N E CT I V I T Y A N D DA T A E X CH A N G E
There appears to be overwhelming support for e-health records, whether as a portable
medical record or in a centrally-maintained database. It is believed that they will greatly
reduce error rates, reduce uncertainty when transferring patients between health care
settings, reduce duplication of effort, allow tracking of medicine use—and ultimately
improve health outcomes.
★★★★★ 95 SUGGESTION FOR DOHA AND MEDICARE AUSTRALIA—develop and implement
electronic health records for all Australians.
Apart from e-records, IT was seen as potentially making a substantial contribution to

better communication between health professionals and helping their decision-making.
96 Find practical ways to use IT to improve routine communication and
★★★★
information exchange between general practitioners and specialist doctors.
97 Develop and roll out infrastructure, software and training necessary to ★★★★★
support e-health records and connectivity between health care providers.
The issue of privacy continues to be raised, but the MediConnect trials reveal
acceptance from participating consumers and carers58. Only two groups of people
appear particularly concerned about privacy: those connected with mental illness or
and those concerned about sex and sexuality (including unwanted pregnancies,
abortions, sexually transmitted diseases, and homosexuality). Otherwise, there have
been protocols developed to protect the privacy of e-health records59.
Medical professionals still appear uncertain about what medical information they may
disclose—whether electronically or otherwise. Some people believe this leads to over-
protectiveness of information, to the detriment of consumers and continuity of care.
98 SUGGESTION FOR COLLEGES, DOHA AND STATE DEPARTMENTS OF ★★★

HEALTH—Review privacy laws that limit the provision of information.
Make sure that all health professionals understand what may and may not
be disclosed—to overcome the current over-protectiveness of information
and privacy.
99 SUGGESTION FOR SOFTWARE DEVELOPERS—further develop and implement ★★★

decision support systems for health professionals.
A crucial piece of infrastructure needed to make medical records and health

information widely accessible is information technology. There is a general view that it
is not a priority in the current political and resourcing environment. For example, while
an increasing number of IT systems are being installed in hospitals and medical
practices, people felt that there were not the resources available to train health workers
in their use. We were told that one reason that NPS and NICS have not invested in
decision support systems is because they believe hospitals and medical practices cannot
afford them.
Electronic systems are particularly important for managing long-term diseases and
patients with a number of co-morbidities. While paper-based systems can support
acute care, more complex treatment requires collaboration between many medical
specialities and health settings over many years—and this requires interconnected
information systems.
Because many electronic systems are not interlinked—making information difficult to

access—some medical professionals prefer to retain the familiar paper-based systems.
Also, the links between electronic and paper-based information systems are often not
optimal, leading to incomplete records in both.
T R A I N I N G , E DU CA T I O N A N D I N FO R M A T I O N
The largest group of suggestions raised in this project concerned education—of both
health professionals and consumers—and the training and information required to
support it. Education can be loosely divided into self-directed learning (which relies
heavily on text, printed materials and websites) and inter-personal learning (where
people interact, such as in counselling, informal peer education, professional
development and training courses). Key areas of cardiovascular health where people
wanted education in QUM were for:
• young people
• workplaces
• health care professionals
• consumers and carers (covered in previous sections).
Many participants saw the Heart Foundation as a key body for coordinating
cardiovascular education in Australia.
★★★★ 100 SUGGESTION FOR THE HEART FOUNDATION—Use its established skills to
coordinate broad education of health practitioners and consumers.
you ng peo ple

A number of stakeholders were concerned that young people are at increasing risk of
cardiovascular disease, as they lack skills in:
• making healthy food choices
• healthy cooking
• health literacy
• medicine use.
★★★ 101 IN CONJUNCTION WITH DEPARTMENTS OF EDUCATION—develop a schools
program on
(1) healthy lifestyle and preventive health
(2) medicines and medicine use
★★★ 102 SUGGESTION FOR SCHOOLS—reintroduce cooking classes for all students,
teaching them healthy food choices and cooking methods.
hea lth ca re pro fessio nals

Most suggestions for professional development and undergraduate training have been
addressed elsewhere in this report:
• multidisciplinary training in undergraduate courses (see page 43)
• professional development
• clinical practice guidelines (see page 49–50)
One issue raised by a few participants is that most training in cardiovascular medicine
is done in hospitals. However, this environment is quite unlike the community setting
where the long-term management of most chronic diseases takes place. Consequently,
they felt that many medical professionals’ training may not match the circumstances in
which they will work in or that patients live in.
103 SUGGESTION FOR THE DEANS OF MEDICINE, PHARMACY AND NURSING—Include ★★★
training in community settings as part of medical professionals’ education
in chronic disease management.
wor kplace s
An area that attracted only a small amount of attention was the contribution of
workplaces to cardiovascular health and illness, through stress levels, working hours,
food in staff canteens, travel options, and workplace health programs.
104 SUGGESTION FOR THE HEART FOUNDATION—develop and implement (possibly ★★★★
with support groups) a workplace education program around prevention,
risk assessment and healthy living
pro duct i nforma tion a bout m edicin es

As in previous QUM research, there was criticism of the information that
manufacturers provide with their medicines: on the label, in CMI and in the way they
name their products. There was agreement that information developed by industry has
value—but it is best developed in conjunction with consumers and health
professionals.
105 QARG, TGA AND MANUFACTURERS—revise the design of CMI to make it ★★★
shorter and easier for consumers to use, and more attractive for health
professionals to use as a counselling tool.
106 SUGGESTION FOR THE TGA AND PHARMACEUTICAL INDUSTRY—Ensure packet ★★★
information and labels for medicines can be read easily by older consumers
and people with impaired vision.
107 SUGGESTION FOR THE INDUSTRY—overcome confusion between generic and ★★

brand name medicines by better labelling.
108 SUGGESTION FOR THE INDUSTRY—Continue to develop information and ★★★★

educational materials for consumers and health professionals on
medicines, and their use in the larger treatment of disease.
cli nical practi ce gui deline s

As we noted earlier, one of the burdens on health professionals—particularly general
practitioners—is the growing body of clinical practice guidelines. There is evidence that
many guidelines have little effect on clinical practice. Participants wanted to see the
number of guidelines reduced and make produced easier to read, remember and act on.
109 SUGGESTION FOR EDUCATORS, MEDICAL WRITERS AND HEALTH ADVISORY

★★★★
GROUSP—reduce reliance on published guidelines to change the behaviour
of health professionals, and use more effective educational methods.
★★★★ 110 SUGGESTION FOR THE HEART FOUNDATION—find ways to improve the
adoption of clinical practice guidelines by health professionals.
Most guidelines focus on a single illness or treatment, and do little to help health
professionals manage the common situation where a patient has co-morbidities and
multiple treatments. Most also focus solely or primarily on medical issues, and neglect
the financial, social and lifestyle dimensions of treatment for consumers. (The NHMRC
guides to writing clinical practice guidelines does discuss economics, but their advice
does not seem to be reflected in the actual materials produced.)
★★★★ 111 SUGGESTION FOR THE HEART FOUNDATION—integrate clinical practice
guidelines for cardiovascular treatments with broader chronic disease
management.
★★★ 112 Evidence-based guidelines need to include information on cost, cost-

effectiveness and consumer choices.
Of concern are reports that, although there are now a number of guidelines on
producing clinical practice guidelines, most materials actually produced do not meet
basic quality standards60.
As noted earlier, there is evidence that many general practitioners in particular over-
estimate absolute risk, and cannot tell the difference between relative and absolute
risk. Presumably similar problems are to be found amongst other health care
professionals. Several participants commented decisions about cardiovascular health
need to be made on the basis of absolute risk, and hence absolute risk needs to be used
consistently in materials on cardiovascular health (and presumably other diseases too).
acc ess to infor mation and d issemi nation metho ds

People we interviewed acknowledged that a great deal of information and training
materials on cardiovascular health has already been produced for consumers and health
professionals. Yet, while these resources exist, most are difficult to find —especially in
the limited time that doctors, pharmacists and nurses have available. Many printed
documents, training courses, and educational resources have never been formatted
electronically, and so cannot be accessed online. Another problem is working out
whether medical information is evidence-based, up-to-date and accurate.
Participants wanted to make existing materials more accessible, before more resources
are devoted to producing new materials.
★★★★★ 113 Develop and maintain a central repository or database or portal of:
• educational materials
• clinical evidence
• clinical practice guidelines

• research
• projects underway and completed
• health services
• support groups.
114 SUGGESTION FOR THE ROUNDTABLE—to help health professionals, researchers ★★★★
and funders avoid ‘re-inventing the wheel’, develop and make public an
inventory of cardiovascular programs already in place for:
• exercise
• healthy eating
• quitting smoking
• cardiovascular medicine use
• school, workplace and community programs
• peer education programs
• professional development courses.
While DoHA’s Health Insite was intended to be the online gateway to quality-assured
medical information, many of those interviewed felt that:
• it is not widely known or used
• its coverage is incomplete
• it is difficult to search, and
• the information it contains is fragmented and difficult for people to synthesise.
The Clinical Information Access Program (CIAP) includes key Australian textbooks,
research and databases—including the Australian Medicines Handbook—but it is not
publicly accessible or available outside NSW and the ACT.
Several participants felt that governments and advisory bodies are over-reliant on
written information. They ignored the power of word-of-mouth, discussion groups and
telephone-based systems.
A comment made about the Heart Foundation in particular was that, while it is strong
in producing materials, it is weak at disseminating them or getting them adopted. In
hospitals, for example, participants felt that materials were not being distributed by
cardiologists or nursing staff, and patients were not being made aware of the Heart
Foundation materials that are available.
115 SUGGESTION FOR THE HEART FOUNDATION—Review and improve processes ★★★★
for disseminating Heart Foundation information materials in hospitals,
and getting them used by consumers and carers.
116 SUGGESTION FOR THE HEART FOUNDATION—Review and improve processes ★★★★
for informing GPs and specialists of Heart Foundation materials.
These suggestions reflect a problem about information throughout the Medicines

Community, not just for the Heart Foundation—there is greater focus on preparing
and printing materials than on methods to distribute them and get them effectively
used. Some of those we consulted felt that producers of documents regarded their task
as complete once materials had been printed—neglecting distribution, promotion,
engagement of users, and updating of materials.
dev elopin g effe ctive inform ation and ed ucatio nal ma terial s
Some comments about problems with existing education and information—including
materials produced by the Heart Foundation—can be explained by a development
process that focuses primarily on facts and evidence, and that overlooks:
• who will use the information and the circumstances they use it in
• the skills of these people in these situations
• how these people will obtain the information
• what these people need to be able to do with information—that is, what practical
action they need to be able to take with it.
Another source of problems with much existing information is that it focuses on

specific medical problems, without taking into account other conditions or treatments
that patients may have, or more general causes of illness. This is true of both consumer
information and materials for health professionals—as noted earlier, clinical practice
guidelines, for example, almost invariably focus on single diseases or treatments, even
where there are significant co-morbidities or polypharmacy.
★★★★★ 117 SUGGESTION FOR THE HEART FOUNDATION—Review all existing

cardiovascular information and programs for:
• consistency with QUM principles
• relevance to readers at the time they are provided
• useability by readers in the circumstances they receive the material
• practicality—how well people can act on the advice they are given
• how materials are provided
• overlap between different publications
• inconsistencies with information produced by other chronic disease
groups (particularly those concerned with co-morbidities)
• opportunities to combine publications with those produced by other
chronic disease groups.
the limit s on i nforma tion

While the emphasis on information in this project is encouraging, it also poses some
difficulties. Producing written information in favour of other type of interventions is
attractive to government, industry and NGOs, as it is relatively cheap and has potential
to reach a large number of people with comparatively little effort. However research
has found that information-only interventions are less effective than programs that
teach self-management skills—and, when health outcomes are costed in, they may also
be more expensive in the longer term61.
The focus on instruction and information, in preference to more comprehensive

education and support, suggests a continuing application of acute care models. A US
review reported that:
for short-term regimens (<2 weeks) adherence to medications is readily achieved by
giving clear instructions. On the other hand, improving adherence to long-term
regimens requires combinations of information about the regimen, counselling about
the importance of adherence and how to organise medication taking, reminders about
appointments, and adherence rewards and recognition for the patient’s efforts to
follow the regimen, and enlisting social support from family and friends.62
FU R T H E R R E S E A R C H , E V A LU A T I O N A N D M O DE LL I N G
As we noted earlier, the priority for most people consulted was to get policy and
research implemented. A corollary is that many saw little need for further research,
stakeholder workshops or modelling. A great deal of information has already been
generated; people believe that it needs to be better used.
The few outstanding needs for research and modelling are concerned with:
• the evaluation of communication and health promotion
• economic modelling—in particular, to help argue for equity and access
• clinical trials into complementary medicines to establish a reliable evidence base
• realistic clinical trials of medicines that reflect real life use, not mono-therapies
• better tracking of existing medicine use, and connecting it with health outcomes.
118 Evaluate education and communication programs to establish an evidence ★★★★

base, and find methods that result in predictable changes in behaviour.
119 SUGGESTION FOR THE NATIONAL MEDICINES POLICY—Illustrate how QUM ★★★★
leads to better health outcomes and is cost-effective.
120 SUGGESTION FOR THE INDUSTRY—Design clinical trials to reflect real use of ★★★
medicines.
121 SUGGESTION FOR THE INDUSTRY—Contribute expertise in economic ★★★★

modelling to consumer and disease groups.
122 SUGGESTION FOR THE COMPLEMENTARY MEDICINES INDUSTRY—Conduct ★★

research into complementary, herbal and alternative medicines and
develop a rigorous evidence base for their use (or non-use).
tra cking medici ne use

Currently, the main tracking of medicine use is done using data from the PBS and
RPBS. This however does not capture all medicines in use, because the MBS system is
intended only to track medicines subsidised by the Australian Government. It excludes:
• scripts filled privately
• prescription medicines that cost less than the PBS or RPBS co-payment
• medicines dispensed in many hospitals
• OTC and complementary medicines.
Consequently, data available to researchers and groups such as DUSC (Drug Utilisation
SubCommittee) is incomplete. While DUSC and others conduct supplementary surveys,
this is costly and the data is intermittent. The current monitoring system has difficulty
tracking the effectiveness of treatments or checking interactions between medicines.
Capturing more complete data—at least on medicines sold by pharmacists —would be
easy using existing pharmacy software, but would need legislative changes to gather.
missing in action
The bulk of material in this report was based on direct input from stakeholders and
existing research literature. While this produced a wealth of detail, there are noticeable
gaps in it—and in QUM generally. This final section sketches out groups that have a
major role to play in QUM for cardiovascular health, but attracted little attention.
H O S P I T A L A DM I N I S T R A T O R S
In 2000–01, 46 per cent of all health service expenditure for cardiovascular diseases
was for hospital care ($2,533 million)—easily exceeding the combined total of out-of-
hospital medical services (14% or $782 million), aged care facilities (10% or $526
million) and allied health services (1% or $78 million)63.
Hospital administrators, whose task is to manage these costs and allocate resources,
have not been drawn into QUM. Without their involvement, change in hospital
practices is unlikely.
P R I V A T E H E A LT H I N S U R E R S
In 2003–04, private health insurers paid benefits of $7.290 billion for Australian health
expenses64—(although part of this is funded by the Australian Government through
the 30% rebate on private health insurance).
Private health insurers were almost entirely invisible in the discussions we held with
consumers—or in our previous QUM research. As they fund such a large part of health
spending, they are in a pre-eminent position to influence the uptake of QUM by
hospital health professionals. Although they directly pay for just over one per cent of
non-PBS listed medicines, they cover nearly two-thirds of all expenditure in private
hospitals. They are in a position to encourage health service providers to adopt
methods that reduce risk to consumers—such as early risk assessment and continuity
of care plans. They also have the potential to develop continuity of funding across
different health settings in order to support continuity of care.
Private health insurers are aware of the growing disease burden posed by chronic
illnesses—particularly cardiovascular disease. In 2003, Australian Unity and HBA
funded The Freemason’s Hospital in Melbourne to trial AUSeMED. This is a 12-month
chronic disease management program for people that have already been admitted to
hospital with heart disease, congestive heart failure, respiratory disease, diabetes, or
arthritis. The program:
• links GPs, hospitals, allied health professionals and in-home services
• develops care plans in consultation with the patient’s GP
• develops a transferable medicine record for each patient
• has a 24-hour call centre accessible to patients
• has regular telephone calls from nurses to check progress
• shared medicine records.
The program is currently completing a review of its first 1,500 patients. Initial results
show that re-admissions to hospital and length of hospital stay were both significantly
lower than for other patients.
For insurers, who are uncertain about the scale of potential claims for preventative
cardiovascular care and other chronic disease management, a key issue is reinsurance
—that is, their potential to insure themselves against substantial claims. Ensuring
appropriate reinsurance arrangements may require changes to existing health
insurance regulations.
NUR SES
To date, the health professionals that have received the most attention in QUM
programs have been doctors and pharmacists. Some of those we interviewed felt that
nurses have an important role to play in QUM, especially for cardiovascular health, but
many are unaware of basic QUM principles and lack access to key resources—such as
CMI. Areas that people suggested that nurses might play a larger role include:
• screening
• diet and exercise advice
• checking adherence and medicine use
• discharge planning in hospitals
• managing medical records
• providing counselling and information to consumers and families
• interpreting medical directions and advice for consumers and carers.
★★★★ 123 SUGGESTION FOR THE HEART FOUNDATION—provide training in

cardiovascular QUM specifically for nurses, and support QUM ‘nurse
ambassadors’.
We were also told that there is no on-going education for nurses to support them in
their care of cardiovascular diseases. Indeed, it was not clear who is responsible for the
ongoing education of nurses. This has implications for engaging nurses in QUM.
S U P P O R T S T A FF I N G E N E R A L P R A CT I CE
People we consulted said almost nothing about either practice managers or
administrative support in general practice. Both can have a major impact on the
effectiveness of a medical practice. Researchers report that consumers value practices

with patient managers and friendly receptionists. Receptionists in particular can
streamline waiting times by assessing the urgency of patients’ needs.
Practice Managers may also have an impact on patient safety. For example, an
Australian incident-monitoring survey in 1998 identified administrative errors as one
of the twelve most frequent factors contributing to medical harm (9 cases per 100
incidents)65. Practice Managers can also help improve coordination amongst medical
professionals and improve management of medical records.
P H A R M A CE U T I CA L I N DU S T R Y
Surprisingly little was said concerning the role of the pharmaceutical industry, and
coverage was noticeably incomplete. Issues that were raised by participants included
the conduct of research, manufacturing processes, price-setting, and the quality of
CMI. All of these have been raised in previous QUM research.
Industry roles that were overlooked included:

• the production of information (apart from CMI)
• educational programs for both consumers and health professionals
• marketing and promotion.
A 2001 survey of 259 GPs at an industry-sponsored educational meeting about

cardiovascular disease guidelines found that:
• 75% said they used journals as a source of evidence
• 58% nominated pharmaceutical representatives
• 42% said clinical meetings
• and 22% used the internet66.
While the work of the NPS in recent years has probably altered these figures, they
nonetheless illustrate the importance of the pharmaceutical industry to informing GPs,
and presumably their influence on medical decision-making.
It is not known how greatly doctors’ prescribing habits are influenced by

manufacturers’ promotions and advertising—although most of those we interviewed
felt that manufacturers would not invest in marketing or advertising if it was not
effective. A recent survey found that, for general practitioners, manufacturers
representatives were the second-most valued source of medical evidence on medicines,
after specialists. However, there are also concerns about the quality and completeness
of the material provided. Another recent study of advertisements in Medical Director
(the most widely used general practice software) found that 95 per cent of
advertisements potentially breached Medicines Australia’s own Code of Conduct67.
That study concluded by urging a total ban on all such advertising to prescribers. Since
a ban on advertising is unlikely ever to be implemented, a more practical strategy is to
encourage greater observance of QUM principles by those parts of the pharmaceutical

industry responsible for marketing and promotion.
Since marketing and promotional materials for doctors are produced by the same parts
of industry that are responsible for all other advertising and promotion, it seems
plausible that there are significant problems with all other types of medicine
promotion—although there does not appear to be hard evidence for this in Australia.
✩✩✩✩ 124 SUGGESTION FOR MEDICINES AUSTRALIA, ASMI, AND CMC—ensure that all parts
of the industry—particularly marketing—observes QUM principles in its
activities.
★★ 125 SUGGESTION FOR THE INDUSTRY—Explore QUM-based marketing and

promotion.
Consumer groups suggested that the industry has non-medical resources that would be
of value for helping them achieve QUM.
✩✩ 126 SUGGESTION FOR MANUFACTURERS—contribute economic modelling
expertise, or support independent economic modelling, to predict
economic effects of a national cardiovascular risk assessment program.
CA R E R S
Carers have proved difficult to draw into QUM. Other stakeholders recognise that they
have a large role to play in helping patients make decisions about medicines and adhere
to treatment. Participants also recognised that carers have needs of their own,
especially to deal with the stress, social isolation, depression and anxiety that often
results from supporting a person who has experienced a stroke or cardiac event.
S U P E R M A R K E T S A N D FO O D R E T A I LE R S
The bulk of food consumed by Australians is bought at supermarkets, and the buying
power of major supermarket chains has a large impact on the Australian food
production and manufacturing industries. With national concerns about obesity,
supermarkets have a major role to play in improving nutrition and healthy eating.
T H E P U B LI C M E DI A
Most comments and suggestions about information made during our discussions
focussed on materials produced by health organisations—whether by government,
consumer groups, manufacturers or NGOs. As noted by several participants, these
groups have much less influence over consumers’ decisions than the mass
media—including newspapers and current affairs programs, or health advice in
magazines. By talking about, for example, new treatments or medical research, the
media implicitly advises people on particular treatments and options. Practising GPs
have often complained that a single television news item can bring many patients to
their waiting rooms asking for inappropriate medicines (although we cannot find any
hard evidence to confirm this or how widespread this problem is).
127 Engage the media in health education. In particular, make them aware of:
✩✩✩✩✩
• the impact they have on the lives of consumers and health
professionals, and
• their responsibilities.
There was concern amongst a few participants about the potentially misleading ways
that the media discussed cardiovascular health—particularly research results.
128 Educate the media and medical writers about absolute risk, and how to ★★
interpret medical evidence.
Participants made no distinction between the different parts of the media—such as

hard news, lifestyle (such as magazines), and entertainment (including ‘infotainment’).
Apart from public broadcasters, Australia’s major media are all commercially driven,
which means they that materials are selected for publication in part on their ability to
attract advertising. Most media organisations do not see themselves as being in the
business of education.
notes
1
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2
PHARM (2005) The Quality Use of Medicines in Diabetes. This short report was
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3
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5
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6
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7
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9
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10
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11
For example, New Zealand risk assessment chart (www.nzgg.org.au); Absolute Risk
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Prediction Chart (Heart 1998, 80:S1–29)
12
Peeters A, Ting J, Nelson MR and McNeil JJ (2004) Coronary heart disease risk
prediction by general practitioners in Victoria. Medical Journal of Australia 180:
p252
13
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14
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15
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16
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18
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19
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20
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21
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22
Jones P. (2002) Applying evidence and theory to guide clinical decision
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England Journal of Medicine 349: 868–874.
23
AIHW (2005) General Practice Activity in Australia 2004–05. Canberra: AIHW
24
Nutrition Australia (undated) Food Variety. Sources from
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25
Stocks NP, Ryan P, McElroy H and Allan J (2004) Statin prescribing in Australia:
socioeconomic and sex differences. A cross-sectional study. Medical Journal of
Australia 180:229–231
26
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non-prescription weight loss supplements. Medical Journal of Australia
171:604–608.
27
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Veterans’ Mates 1
28
Bhasale A et al (1998) Analysing potential harm in Australian general practice: an
incident monitoring study. Medical Journal of Australia 169: 73–76.
29
Infante FA, Proudfoot JG, Powell Davis G, Bubner TK, Holton CH, Beilby JJ and
Harris MF (2004) How people with chronic illnesses view their care in general
practice: a qualitative study. Medical Journal of Australia 181:70–73
30
TNS Consultants (2004) Evaluation of the Medicines Information for Consumers (MIC)
Program. Canberra: Pharmacy Guild of Australia
31
Bennet AA, Brien JE, and MacDonald PS (2005) Barriers to diagnosing and
managing heart failure in primary care. Medical Journal of Australia 182(6): 309
32
Pharmacy Guild of Australia, unpublished data
33
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34
Benner JS et al (2002) Long term persistence in use of statin therapy in elderly
patients. JAMA 288:455–461
35
Simons LA, Simons J, McManus P and Dudley J (2000) Discontinuation rates for
statins are high. British Medical Journal 321: 1084
36
WHO (2003) Adherence to long-term therapies. Evidence for action. Quoting Haynes
RB (2001) Interventions for helping patients to follow prescriptions for
medications. Cochrane Database of Systematic Reviews 2001(1)
37
McDonald HP, Garg AX aand Haynes RB (2002) Interventions to enhance patient
adherence to medication prescriptions. JAMA 288:2868–2879
38
Cramer JA (2002) Effect of partial compliance on cardiovascular medication
effectiveness.Heart 88:203–206
39
Ball K, Mishra GD, Thane CW, Hodge A (2004) How well do Australian women
comply with dietary guidelines? Pub Health Nutr 7: 443-452
40
Standards of Practice for the Provision of Consumer Medicines Information by
Pharmacists in Hospitals, Australian Journal of Hospital Pharmacy 2000; 30:
225–228
41
Mant A, Rotem WC, Kehoe L and Kaye KI (2001) Compliance with guidelines for
continuity of care in therapeutics from hospital to community. Medical Journal of
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42
Mant A, Kehoe L, Cockayne NL, Kaye KI, Rotem WC (2002) A Quality Use of
Medicines program for continuity of care in therapeutics from hospital to
community. Medical Journal of Australia 177:32–34
43
McAliter F, Stewart S, Ferrua S, McMurray JJ (2004) Multidisciplinary strategies
for the management of heart failure patients at high risk of re-admission: a
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Cardiologists 44: 810–819.
44
Inglis S, McLennan S, Dawson A, Birchmore L, Horowitz JD, Wilkinson D, Stewart
S (2004) A new solution for an old problem? Effects of a nurse-led,
multidisciplinary, home-based intervention on readmission and mortality in
patients with chronic atrial fibrillation. J Cardiovasc Nurs. 19(2):118–127
45
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heart failure in primary care. Medical Journal of Australia 18:309
46
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efficacy of a telephone intervention by expert nurses after an implantable
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47
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telephone intervention after an ICD. Pacing Clin Electrphysiol. 28(11): 1157–1167
48
Scott IA, Lindsay KA and Harden HE (2003) Utilisation of outpatient cardiac
rehabilitation in Queensland. Medical Journal of Australia 179: 341–345
49
Bunker S and Goble AJ (2003) Cardiac rehabilitation: under-referral and
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50
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51
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52
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53
Sourced from Medicare Australia website,
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statistical_reporting.htm (12 January 2006)
54
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55
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56
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57
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58
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59
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60
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Heart Foundation Offices
Australian Capital Territory Northern Territory Tasmania

15 Denison Street Darwin Hobart
Deakin Third Floor 86 Hampden Road
ACT 2600 Darwin Central Building Battery Point
Phone (02) 6282 5744 21 Knuckey Street TAS 7004
Darwin Phone (03) 6224 2722
New South Wales NT 0800
Northern Tasmania
Sydney Phone (08) 8981 1966
Kings Meadows
Level 3, 80 William Street
Alice Springs Community Health Centre
East Sydney
Shop 1, 9 Parsons Street McHugh Street
NSW 2011
Alice Springs Kings Meadows
Phone (02) 9219 2444
NT 0870 TAS 7249
Newcastle Phone (08) 8953 5942 Phone (03) 6336 5116
Suite 5, OTP House
Queensland North-West Tasmania
Bradford Close
2nd Floor, Room 232
Kotara Brisbane
Community and Health
NSW 2289 557 Gregory Terrace
Services Centre
Phone (02) 4952 4699 Fortitude Valley
23 Steele Street
QLD 4006
Illawarra Devonport
Phone (07) 3872 2500
Kiama Hospital and TAS 7310
Community Health Service Rockhampton Phone (03) 6421 7704
Bonaira Street 6/160 Bolsover Street
Kiama Rockhampton Victoria
NSW 2533 QLD 4700 411 King Street
Phone (02) 4232 0122 Phone (07) 4922 2195 West Melbourne
VIC 3003
Townsville
Phone (03) 9329 8511
Suite 7B
95 Denham Street Western Australia
Townsville
334 Rokeby Road
QLD 4810
Subiaco
Phone (07) 4721 4686
WA 6008
South Australia Phone (08) 9388 3343
155-159 Hutt Street
Adelaide
SA 5000
Phone (08) 8224 2888
Quality Use of Medicines
for Cardiovascular Health
An initiative of the Heart Foundation Pharmaceutical Roundtable
Cardiovascular diseases are In 2005, stakeholders

the greatest cause of death were asked what was
and disability in Australia, needed to achieve Quality
and they are becoming more Use of Medicines (QUM)
common. in cardiovascular health.
Along with healthy lifestyle Consumers, policy-makers,
changes, medications are health professionals
the main treatment for and manufacturers all
cardiovascular diseases. contributed.
The Australian community The result, presented in this
spends over $1.5 billion report, was 128 practical
a year on cardiovascular suggestions for action,
medicines. There is along with a rich description
agreement that many are of the problems and goals
not being used to their best of those concerned with
effect. Some are under- cardiovascular disease, and
prescribed. Many patients an outline of groups still to
do not remain on long- be engaged in QUM.
term treatments. There are
great losses of medicine
information when patients
move between health
care settings—particularly
into and out of hospitals.
Providing consumers, carers
and health professionals with
medicine information is a
continuing problem.
www.heartfoundation.com.au
Heartline 1300 36 27 87
©March 2007 National Heart Foundation of Australia
RES-003 ABN 98 008 419 761

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Quality Use of Medicines

for Cardiovascular Health

© 2006 National Heart Foundation of Australia. All rights reserved.

The Pharmaceutical Roundtable is made up of the National Heart Foundation of

The Pharmaceutical Roundtable is committed to:

ABOUT THIS REPORT

Another point important to note: some of the suggestions made reveal

stages of qum in cardiovascular health

prescribing medicine getting

gp rehab carers support

specialist community nurses and

cardiovascular medicine in australia

Comorbidities are common—especially diabetes, renal failure and depression. Over 80

men women persons men women persons

There is currently no comprehensive national data on people in rehabilitation.

The National Medicines Policy defines QUM as:

1. Selecting management options wisely by:

2. Choosing suitable medicines if a medicine is considered necessary so that the best

As participants in the consultation appreciated, in cardiovascular health, each of these

Due to the breadth of these topics, we found—as we have in previous QUM

These principles were:

before a cardiovascular event

2 SUGGESTION FOR DOHA, STATE GOVERNMENTS AND NGOS—develop a ★★★

In particular, there is strong support for mass screening of Australians—although

Supporters of screening point to the achievements in breast cancer detection, where

A screening program for a substantial proportion of Australian adults would involve:

3 SUGGESTION FOR THE ROUNDTABLE: ★★★★★

b. Develop guidelines on the sections of the population to screen.

d. Lobby the Australian Government and AHMAC for:

e. Seek the assistance of NPS or software makers to distribute and

g. Explore what incentives, if any, are required to encourage Australians to

Potential benefits of a national screening program seen by stakeholders included:

✩✩ 4 SUGGESTION FOR MEDICARE AUSTRALIA, NPS, DIVISIONS OF GENERAL PRACTICE

a. encourage general practitioners to use the standard Clinical Practice

b. discourage use of the PBS Schedule as a clinical guide for selecting

emb oldeni ng con sumers

6 SUGGESTION FOR GENERAL PRACTITIONERS AND SPECIALIST DOCTORS— ★★

7 SUGGESTION FOR PHARMACEUTICAL COMPANIES AND PROVIDERS OF ★

ena bling genera l prac tition ers

9 SUGGESTION FOR DOHA AND MEDICARE AUSTRALIA—implement strategies to ✩✩✩

A particular problem for general practitioners is the constantly growing volume of

Stakeholders interviewed were concerned that many general practitioners were

sel ecting appro priate treat ment o ptions

Overwhelmingly, stakeholders felt that—unless a person was at a very high risk of a

13 Develop an easily-searchable portal or website (or reorganise Health ★★★★

In 2005, the Department of Health and Ageing developed ‘lifestyle prescriptions’.

14 SUGGESTION FOR DOHA, NPS AND THE NATIONAL HEALTH FOUNDATION—review ★★

A number of those we consulted were concerned with over-prescribing, especially

16 DOHA, NPS AND MEDICINES AUSTRALIA—educate prescribers that they do not ★★

17 SUGGESTION FOR MEDICARE AUSTRALIA, ADGP AND THE NPS—where over- ✩✩

‘Prescriber Feedback’ on alternatives to medicines and use of lifestyle

There is evidence that prescription of at least some cardiovascular medicines is affected

None of the participants suggested a management plan for cardiovascular

pre scribi ng com plemen tary m edicin e

Evidence for the effectiveness of many non-prescription therapies remains limited.

Two ways to improve identification of potential interactions are for:

22 Develop and implement a campaign to encourage consumers to keep a ★★★★

23 SUGGESTION FOR PHARMACISTS, PHARMACY GUILD, PSA, SHPA AND SOFTWARE ★★

Some people interviewed were concerned about inappropriate use of dose

24 SUGGESTION FOR PHARMACISTS, PHARMACY GUILD, PSA, SHPA AND CONSUMERS ★★

Participants suggested several solutions:

28 SUGGESTION FOR COMMUNITY AND HOSPITAL PHARMACISTS—offer CMI to all ★★★★