success of the national roll-out
Consistent with the purview of this project, the original evaluation framework for the pilot was not designed to assess the effectiveness of MedsCheck and Diabetes MedsCheck in achieving long term outcomes for patients. However, based on the pilot evaluation, it appears that the MedsCheck and Diabetes MedsCheck pilot program achieved its original objectives that relate to:
increasing patients’ understanding about their medicines;
increasing patient’s knowledge on how to best use and store their medicines;
identifying problems patients may be experiencing with their medicines; and
improving patients effective use of blood glucose monitoring devices through training and education.
See Table 2.1, chapter 2 for a full list of pilot program objectives The evaluation of the pilot program identified that:
pharmacists appear to be targeting people in need of assistance with their medicines (based on individual characteristics of those needing assistance identified in the literature);
patients receiving MedsCheck and Diabetes MedsCheck services appeared to have an improved understanding of their medicines including indications, side effects, interactions and storage;
However, these objectives have not been directly assessed as they were beyond the scope of this evaluation and remain untested.
For the national roll-out of the MedsCheck program, it will be important that suitable indicators are developed to enable monitoring of services to facilitate accountability, foster high quality service provision and promote good patient outcomes. While a detailed performance indicator framework or evaluation framework was not in scope, a number of suggestions for indicators and research studies which could be used to monitor and evaluate the national roll-out are provided in this chapter.
The selection of indicators would ideally reflect the objectives of the program, and how the indicators need to be used e.g. to evaluate the national roll-out and to address any requirements for accountability of the Government, pharmacy proprietors and pharmacists. The suggestions below draw on the findings of the literature review in chapter 4, the analysis and findings in this report and a knowledge of evaluation design techniques and methods.
The program logic developed for the MedsCheck/Diabetes MedsCheck program (Table 2.1, chapter 2) identifies two long-term outcomes:
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adverse events related to the use of medicines by patients living in the community who use multiple medicines and/or have had a recent significant medical event are reduced; and
cost effectiveness: the MedsCheck programs achieve value for money (improved patient health and less wastage of medicines for a reasonable financial investment).
Four medium-term outcomes were also identified:
eligible patients learn more about their medicines including interactions between medicines and disease states;
problems patients are experiencing including adverse events with their medicines are identified and resolved where possible;
medicines are used more effectively and stored correctly following the MedsCheck review; and
an improvement in adherence with medications is observed.
To assess whether the MedsCheck program is generating the desired outcomes for patients, and doing so cost effectively, we suggest it will be important to monitor and investigate the following as part of the national roll-out.
Monitor the characteristics of patients who receive services across several dimensions including age, gender, medicine regimen (e.g. number and type of medicines), SEIFA status, living arrangements (ie living alone), chronic conditions, recent significant medical events, CALD status and Aboriginal and Torres Strait Islander status:
• To achieve both medium and long – term outcomes, MedsCheck and Diabetes MedsCheck services will need to continue to be targeted at patients which the existing literature identifies are most likely to benefit from a medicine review (see chapter 4). These patients have been identified as most likely to be non-adherent with their medicine regimen and as a consequence, are most likely to suffer adverse drug events therefore placing greater burdens on the health system. In addition, these patients are most likely to have gaps in their knowledge regarding their medicines that can be filled by a medicines review service such as MedsCheck or Diabetes MedsCheck. Monitoring patient characteristics will be fundamental in facilitating any future adjustments to the eligibility criteria should demand side factors need to be addressed.
Monitoring the number of MedsCheck and Diabetes MedsCheck services delivered, the state/territory in which they were delivered, the number of pharmacies which provided services and the number of new pharmacies which commence service provision.
• The medium and long-term outcomes of the MedsCheck and Diabetes MedsCheck program are dependent on the uptake of service provision by pharmacies. The pilot program indicated that pharmacies had significant difficulties implementing the program and also with ongoing service provision.
Monitoring the quantifiable aspects of service provision during the national roll-out will enable the Department to detect service provision issues that require further investigation. Also, it will be important to ensure that service numbers are not increasing beyond the funding limits for this program.
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Research whether patient adherence with their medicines pre- and post- their MedsCheck or Diabetes MedsCheck consultation has changed.
• Poor adherence with medication has been associated with poor outcomes (e.g.
reduced therapeutic effect and mortality) and substantial financial costs to the public hospital system, estimated at up to $380 million per year (Irvine et al.
1999) (ACSQHS, 2002 cited in PwC, 2008). The level of a patient’s medication adherence pre and post their MedsCheck or Diabetes MedsCheck is a useful proxy indicator for the impact the MedsCheck program may have on patient knowledge about their medicines, adverse drug events, hospital admissions and ultimately health outcomes. To test the impact of on medication adherence for the national roll-out, measurements of medicine adherence on a random sample of patients receiving these services and a control group would ideally be taken before and at some period after they receive the service. Recent reviews have shown that assessments of medication adherence using patient self report questionnaires have a moderate correlation with electronic monitoring systems such as pill containers containing an electronic chip which records each time the container is opened (Medication Event Monitoring System –MEMS) (Shi et al. 2010a and Shi et al.
2010b). However, self report questionnaires tend to report a higher rate of adherence (Shi et al. 2010a and Shi et al. 2010b). Self report adherence questionnaires are relatively cheap to administer and non-obtrusive compared to electronic monitoring systems (Garfield et al. 2011) Self report questionnaire tools such as the Brief Medication Questionnaire, the four item Morisky Scale or the Medication Adherence Report Scale (MARS) could be used. However, the validity of these tools has been reported both positively in certain patient groups (Svarstad et al. 1998, Morisky et al. 2008), and negatively (PwC, 2008).
Conduct a study of the cost effectiveness of MedsCheck and Diabetes MedsCheck — ie assess the benefits to patient health and use of medicines and the cost of achieving these benefits.
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