Ruth Cooper
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[post_content] => Digital health tools can improve medicine safety and make systems more efficient – but poor system design often doesn’t bring healthcare practitioners and their patients on the journey.
From My Health Record to real-time prescription monitoring, electronic prescriptions and secure messaging, Australian pharmacists routinely use digital health in their daily practice. And there is more to come, as the use of machine learning and AI grows.
When implemented effectively, digital health tools facilitate communication and information sharing between healthcare professionals across various settings, including during transitions of care. For pharmacists, this timely access to clinical information helps to reduce medicine-related harm and improve the quality of care patients receive.
However, integrating new technologies is often not done particularly effectively. This was a key takeaway from a panel discussion at the National Medicines Symposium in November, where experts explored the use of digital tools to support safe medicine management.
Digital health challenges
[caption id="attachment_28530" align="alignright" width="220"]
Professor Melissa Baysari[/caption]
For digital health tools to work in practice, they must be developed with the end user in mind, said University of Sydney Professor of Health Research Melissa Baysari. It sounds obvious and should be the norm. Sadly it isn’t. This results in the common challenges faced by users, including inadequate training, difficult-to-use technology and alert fatigue, when clinicians are inundated with too many notifications.
‘[There is a] surprising lack of involvement of end users in the design and implementation of digital systems. We definitely need more of that in healthcare,’ Prof Baysari said. ‘The technology is just one part of the wider work system. The human-technology fit is the hardest part to get right.
‘I think a lot of people feel these systems are imposed on them from senior levels, but if there was more clinician involvement in the design and understanding what problems need to be solved, people would have more ownership over the technology, and accept it and use it more.’
Another challenge is the varying use of digital health tools across the country, with some areas and settings being more advanced than others. This means the Australian health system ‘is not integrated’, said SA Pharmacy Chief Pharmacy Information Officer Michael Bakker MPS.
‘We have secure messaging, allowing delivery of referrals from a community setting into hospital, or going from hospital straight to a GP or into a patient's My Health Record,’ he said. ‘Those are very valuable, but we also need to see the emergence of tools that help do the blending of the actual workflows.
[caption id="attachment_28533" align="alignright" width="237"]
Michael Bakker MPS[/caption]
‘The patient moves through the system, but you still just have this stack of paperwork. Whether we hand that to a patient as a set of papers that they can access digitally or physically, it doesn't really change that it's very difficult to navigate.’
Increasing health literacy – and digital health literacy – is essential for consumers and healthcare practitioners to interact with digital systems effectively, according to Prof Baysari.
‘I think there's a role for universities to play in ensuring that all our health professionals, as they leave, have some digital health knowledge,’ she said.
Reimagining workflows
Rather than bolting on new tools to existing systems, organisations must look at workflows holistically and identify areas for improvement, Prof Baysari said.
‘One of the challenging things is designing for current workflows to ensure that everything aligns, but also innovating and changing the way we have done things for many years because it might be safer, better or more efficient.
‘We should be designing for work as done, not work as imagined. And we should be designing for a problem, not implementing for the sake of implementation.
‘For example, I think we've overdone decision support for medication safety. We need to take a step back – what are the key problems we need to focus on when it comes to decision support and design of our systems? Let’s take a very problem focused perspective.’
Building systems to meet users’ requirements – rather than what it is assumed their requirements are – will lead to efficiencies, Mr Bakker said.
‘My hope over the next few years or decade is that we start to see tools that are built for the purposes of the people who are using them,’ he added.
Avoiding information overload
While digital health tools are often introduced with the aim of making healthcare practitioner’s lives easier, the opposite can happen, Mr Bakker said.
‘There’s some valuable evidence emerging about digital health stress, going so far as to say it contributes to burnout and people leaving the healthcare workforce altogether. We have an obligation to do something about it.
‘Not only is demand increasing, our patients are more complex, and our healthcare workforce is either not growing, can't grow, or will take too long to grow to meet that demand. We have to try and make some inroads here, appreciating that the way that we do things at the moment is actually burning people out quite a bit.’
Using digital tools to make seemingly small changes can have wide-ranging consequences, he said.
‘In South Australia alone, we have more than 4 million medication orders that are charted a year. On average, that process takes a couple of minutes for each order. If you can shrink that by 10%, you're talking about a lot of person hours that are returned back.’
In future, Prof Baysari said she hopes to see the healthcare sector get the most out of digital tools, both in terms of safety and efficiency.
‘We should be getting the benefits we expect from technology. At the moment, we’re probably achieving more in safety. I can understand there's a bit of a trade off there – if you’re going to be safe and thorough, you might need to be a little bit less efficient… But I think we're not achieving the full potential from technology. So I hope that we will.’
Watch the full panel discussion here.
[post_title] => Does technology in health care deliver on its promise?
[post_excerpt] => Digital health tools can improve medicine safety and make systems more efficient – but poor system design often doesn’t bring healthcare practitioners and their patients on the journey.
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[post_content] => With only two weeks before school resumes, now is the ideal time for pharmacists to help parents catch up with vaccinations for their children.
“As a parent of a four and six-year-old child, I know January is typically the time when kids are getting ready for the school year,” said Jacqueline Meyer MPS, owner of LiveLife Pharmacy Cooroy and PSA Queensland Pharmacist of the Year 2023. “Let’s make sure that includes updating vaccinations.”
Ms Meyer said encouraging parents to take advantage of this window of time could help overcome practical difficulties such as a busy lifestyle, while the availability of an increasing number of vaccines at pharmacies was especially helpful in regional areas where it may be more difficult to see a GP.
Research by the National Vaccinations Insight Project found that 23.9% of parents with partially vaccinated children under the age of five did not prioritise their children's vaccination appointments over other things, while 24.8% said it was not easy to get an appointment.
As well as holidays being free of the hustle and bustle of school routine, getting immunised during the holidays means children don’t have to miss a day of school if they have mild vaccination side effects, said Samantha Kourtis, pharmacist and managing partner of Capital Chemist Charnwood in the ACT and the mother of three teenagers.
Overcoming hesitancy
Ms Meyer said it was crucial that pharmacists familiarised themselves with the laws governing vaccinations in different states and territories so they knew what part they could play in boosting immunisation.
In most states and territories pharmacists may administer vaccines to children over the age of five – in Queensland that age is two years and, in Tasmania, in some cases, 10 years.
This can be most helpful for children who have missed out on immunisations through school programs, or from a medical clinic.
Concerningly, however, new research shows vaccination coverage among children in Australia has declined for the third consecutive year.
In 2020, fully vaccinated coverage rates were 94.8% at 12 months, 92.1 at 24 months and 94.8% at five years of age. In 2023 those rates were 92.8, 90.8% and 93.3% respectively.
Between 2020 and 2023, the proportion of children vaccinated within 30 days of the recommended age also decreased for both the second dose of diphtheria-tetanus-pertussis (DTP) vaccine (from 90.1% to 83.5% for non-Aboriginal and Torres Strait Islander children and 80.3% to 74.6% for Aboriginal and Torres Strait Islander children) and the first dose of measles-mumps-rubella (MMR) vaccine (from 75.3% to 67.2% for non-Aboriginal and Torres Strait Islander children children and 64.7% to 56% for Aboriginal and Torres Strait Islander children).
While access issues played some part in the decline, vaccine acceptance or parents’ thoughts and feelings about vaccines and parents’ social influences have also been a factor, according to the National Centre for Immunisation Research and Surveillance.
Researchers found 60.2% of parents felt distressed when thinking about vaccinating their children.
Pharmacist Sonia Zhu MPS, of Ramsay Pharmacy Glen Huntly, who has a four year old child, said she often has conversations with parents who feel anxious about vaccination.
“Whenever a parent is concerned, I ask them what is making them feel worried and then I am able to talk to them about the risks of the disease as opposed to the vaccine,” she said.
“I can assure them that vaccinations are just like a practice exam for your immune system and that, if their child gets the disease, they will recover better and more quickly if they are vaccinated.”
Mrs Kourtis said it was also important to reduce vaccination anxiety among children with a friendly healthcare environment, especially for younger children.
“We have regular colouring competitions, fairy doors, fun stickers and a donut stool they sit on to have their vaccination,” she said.
“We also talk to parents about what their child needs before being vaccinated. That may be to wear headphones, for example, or other measures for children who are neurodiverse.”
While Ms Zhu said lollipops were offered to children and teens, Ms Meyer said cartoon images, stuffed toys and devices that acted as distraction tools were other accessories used in pharmacies to help create a calm environment.
The teenage challenge
Vaccine rates in adolescents have also declined. Between 2022 and 2023, coverage decreased for having at least one dose of human papillomavirus (HPV) vaccine by 15 years of age (from 85.3% to 84.2% for girls and 83.1% to 81.8% for boys); an adolescent dose of diphtheria-tetanus-pertussis vaccine by 15 years of age (from 86.9% overall to 85.5%) and one dose of meningococcal ACWY vaccine by 17 years of age (from 75.9% overall to 72.8%).
“We certainly have nowhere near the uptake of meningococcal B vaccine we would like in Queensland,” said Ms Meyer.
According to the Primary Health Network Brisbane South, in the 15 to 20-year-old cohort, just under 14% have been immunised, leaving approximately 386,000 eligible adolescents unvaccinated.
The Queensland MenB Vaccination Program announced this year provides free vaccines to eligible infants, children and adolescents, and is the largest state-funded immunisation program ever implemented in the state.
With pharmacists able to administer all of these vaccinations between year 7 and year 10, Ms Meyer sees a clear opportunity to communicate the benefits of vaccination to parents.
“I think pharmacists could reach out to local schools and offer to conduct educational sessions,” said Ms Meyer. “Community pharmacies often employ teenagers for casual or junior shifts so it may start with simply talking to existing staff that may fit the eligibility criteria for demographic.”
Mrs Kourtis said community pharmacists were well placed to have health promotions in store and on social media.
“They can also try to partner with local community and sporting organisations to promote vaccination through them,” she said.
[post_title] => Boosting childhood vaccination rates in the holidays
[post_excerpt] => With only two weeks before school resumes, now is the ideal time for pharmacists to help parents catch up with vaccinations for their children.
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[title_attribute] => Boosting childhood vaccination rates in the holidays
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[post_content] => Turning informal advice into a structured consultation service: pharmacy-based travel health services take flight.
Australians love to travel and they take off to all parts of the globe, whether it be safaris in Africa, a bargain trip to Bali, visiting family in India or cruising through the icebergs within the Arctic Circle.
But as the average age of travellers, population density, pollution and zoonotic diseases increase, so, too, do health risks associated with travel.
Pharmacists have long provided ad hoc advice for travellers in response to patient queries, whether it be guidance on how to store medicines during transit or encouraging patients to see a GP, or dedicated travel doctor service in major cities, for vaccination.1
But with more Australians jetting off to more locations more frequently, more travel health services are needed. Some pioneering pharmacists are leading the way. Enabled by an increasing range of vaccines pharmacists can both prescribe and administer as well as formal pilots and programs from state governments, community-pharmacy based travel health consultation services are taking flight.
How does a formal travel health service differ from ad hoc advice?
Put simply, its more comprehensive. It considers a much wider range of risks than the patient may self-identify and makes recommendations to the traveller proportional to their individual needs.
‘Outside of a formalised program like the Victorian Community Pharmacy Statewide Pilot project,2 the pharmacist may not go into as much depth about [travel health] matters because there’s an expectation the consumer’s GP will have that discussion when a patient asks about vaccines,’ says PSA Victorian State Manager Jarrod McMaugh MPS.
It means pharmacists ‘instead of picking and choosing pieces of information they’re going to add on to a consultation before referring and saying “go to see your GP for these things”, they’re going to address them all directly in a travel health service’, he says.
And to be comprehensive the service needs a deep understanding of the traveller(s), when/where they are going, how they are going to get there – e.g. cruise, fly, drive, trek – and the types of things they’ll do when they are there.
Getting started
Establishment or formalisation of any service has common features: staff training, developing standard operating procedures, setting up documentation systems and advertising. However, a travel health service has two additional aspects, which are critical to success.
Firstly, the practitioners need to really wrap their heads around international travel, the health risks a person is likely to encounter and how to craft a valuable consultation for each traveller.
‘Some pharmacists are avid international travellers, and will have generated substantial knowledge of destinations, transport routes and product availability at pharmacies overseas. This expertise is advantageous in providing bespoke, individualised advice,’ Mr McMaugh says.
‘For example, Australians are often surprised by the high cost of sunscreens overseas, or how unpleasant the taste of oral rehydration products available in other markets are.’
‘Additionally, people often overlook prohibitions on carrying common medicines through common transit points such as Middle Eastern or Asian airport hubs.’
These kinds of insights may not be front-of-mind for travellers when booking in for a consultation, but they are important for risk mitigation and highly valued.
Also important is anticipating risks for which travellers may not be alert. For example, a family holiday to a Thailand beach resort may initially seem lower risk, but activities and excursions where you interact with wildlife such as monkeys are common and carry zoonotic infection risk.
For pharmacists who do not have this knowledge from primary experience, seeking these reflections from colleagues or through careful listening with patients is essential.
Structuring a consultation is something each practitioner needs to find their own way to master. Unlike other services, the approach to these longer consultations isn’t so black and white.
Compared to other expanded scope programs, travel health requires mastering the navigation of the grey.
One of the hundreds of pharmacists offering a travel service under the Victorian pilot is Melbourne’s Tooronga Amcal Pharmacy owner Andrew Robinson MPS, who reflected that ‘[with a UTI treatment service], we follow a protocol guideline and it’s more straightforward to undertake’. With travel, it is like a Pandora’s box that you can open and find you going all over the place with a whole lot of different destinations, a whole lot of different complications, a lot of different needs.’
Finding prospective travellers
A common theme with all pharmacists contacted by AP is that the identification of patients who would benefit from the service has initially been more successful through conversations in patient interactions than via formal advertising.
The trigger for knowing a patient could benefit from a sit-down travel health consultation with a pharmacist could be anything, Mr McMaugh notes.
‘It can literally be a comment in passing: ‘My son is about to travel overseas for the first time.’
Other queries could be related to how to carry medicines safely overseas, or interest in medicines for motion sickness.
Andrew Robinson describes the trial as a ‘significant endorsement by health regulators that pharmacists are capable of delivering more complex services.
‘Before actually doing an appointment, you’ve got to tease it out a bit first. It’s not like some of the other pilot programs that we’ve done, which are very, “you’ve got a urinary tract infection. You fit the criteria. We can undertake the consultation”.’
‘In contrast, you almost need to do a [travel health] consultation to find out whether you need to refer them on. So, I try and garner that before. But I think if we boil it down and keep it simple, the reality is there’s plenty of people out there who are not thinking about travel health that need a typhoid vaccine and a bit of a conversation,’ he said.
Mr Robinson identified that consumers who, at short notice, book a trip to south-east Asia and don’t plan a GP visit have particularly welcomed his travel health consultations.
‘We see this particular pilot really looking at the high-risk patient, the person who sees a cheap flight to Indonesia and in 3 weeks’ time they’re gone. They think of it as just a great way to relax and give very little thought to the risks associated with that travel.’
Susannah Clavin MPS, the owner of the Marc Clavin Pharmacy at Sorrento on Victoria’s Mornington Peninsula, regularly discusses travel health with patients and consumers, and has had success with online bookings.
‘Most [patients] were heading to south-east-Asia. They are all very time-poor, so if the pharmacy is closely located to their home or workplace then I think they will appreciate the convenience. Being able to book online, too, is a bonus.’
Like Mr Robinson, Ms Clavin had also identified patients through conversations at the dispensary.
‘One of the patients had a prescription for the vaccine and asked us for a quote,’ recalls Ms Clavin. ‘We gave the quote and mentioned that we could also administer the vaccine, for a fee. [The patient] was very keen to save a trip to the doctor.’
Fee-for-service
How much should the service charge? While each business needs to make its own decision based on the costs of delivery and business policies, experience in travel doctor clinics and within pilot sites shows consumers are willing to pay for the consultation service, which may include administration of vaccines.
When AP spoke to Mr Robinson, he had conducted about a dozen travel health consultations, charging $50 for a half-hour consultation. Families travelling overseas, he says, have found the consultations particularly attractive because the pharmacist can give advice to an entire family in one appointment.
Looking to the future
Feedback from the Victorian trial shows an effective travel health consultation service is a good fit with pharmacies that have a well-integrated vaccination service, according to Mr McMaugh.
‘If you’re doing the occasional vaccine, you have to change gears, going from doing whatever other services or dispensing you were doing, to administering the vaccine and then coming back into the retail and dispensing space,’ he says.
Mr Robinson hopes travel health consultations become a permanent fixture in the service landscape for pharmacy.
‘Travel is all about having fun. But we need to make sure it stays fun, and you stay healthy, because otherwise it’s a very expensive holiday.’
The rise of zoonotic diseases
Where a person is travelling to and where they are staying matters. A trip to Zimbabwe to see Victoria Falls has a very different risk profile to a walking safari at remote campsites. Similarly, holiday resorts in south-east Asia next to agricultural fields have a different risk profile to city hotels.
Recent decades have seen the rise and reemergence of viral zoonotic diseases.4 The growth of tourism has led to land changes, travel patterns and farming practices which increase the risk of zoonotic diseases, including novel and well-established pathogens.⁵
Travellers and health professionals alike need to keep abreast of these trends. Rabies is a good case in point. The USA continues to log around 4,000 animal rabies cases each year, with >90% of cases from bats, raccoons, skunks and foxes – a shift from the 1960s where dogs were the primary rabies risk to humans.⁶ In contrast, dog bites are the predominant source of rabies infections in Africa.⁷
Karen Carter FPS, partner of Carter’s Pharmacy Gunnedah and owner of Narrabri Pharmacy in north-west NSW, can now offer rabies vaccinations.
‘You think of exotic animals for rabies but sometimes it’s dogs that people are at risk of being bitten by,’ Ms Carter says.
The vaccine isn’t cheap, so considering the exposure risk and access to post-exposure prophylaxis is important when discussing the benefits of the vaccine with patients.
‘We had a gentleman travelling to Africa and then on to South America for his work in the agriculture industry, so we recommended he get the rabies vaccine.’ Ms Carter says. In fact, he not only got the rabies vaccine administered, but the hepatitis A and typhoid vaccines as well before he left.
‘We were also able to refer him to a Tamworth GP clinic for his yellow fever vaccines, Ms Carter adds. ‘He thought it was great that we could do all but one of his vaccines in the pharmacy.’
Other zoonotic infections, such as mpox, avian influenza and Japanese encephalitis also have changing patterns of transmission and distribution, which increasingly require consideration in travel health services.
Case study
Dat Le MPS Owner, Priceline Pharmacy, Knox, Melbourne VIC
This traveller
Mrs L, a 62-year-old regular dose administration aid (DAA) patient, is living with gastro-oesophogeal reflux disease (GORD), hypertension, atrial fibrillation, high cholesterol and osteoarthritis in the knee.
Current medicines
This time Mrs L explains that it will be summer when she arrives in both south-east Asian countries.
Recommendations
Based on her travel plans, I recommend vaccination for:
Mrs L was advised she would have full protection from hepatitis A in 2 weeks and that it may be at least a week before the COVID-19 booster provided full protection.
She was also told that the vaccinations may cause sore arms, some redness, fever or chills.
While her typhoid vaccination would protect her for 3 years, she could have another COVID-19 booster in a year.
For the hepatitis A vaccine, a typical course is two doses – the first at day 0, and the second from 6 months later, ideally before 12 months, if she travels again within the year.
Rehydration preparations were also recommended, along with hand sanitiser, face masks and sunscreen for Mrs L’s holiday group tour to various sight-seeing locations.
When she collected her DAAs, we advised Mrs L how to store her medicines. She was pleased she didn’t need to make a GP appointment, organise vaccine prescriptions, collect them at the pharmacy and then take them back to the doctor to be administered. I reminded her that we would call her about her second hepatitis A dose to complete her course.
We put a note on her next DAA collection asking about her holiday and any problems she may have had such as diarrhoea or tablet storage problems.
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[post_content] => Case scenario
Mrs Johnson, a 65-year-old patient with hypertension, comes to the pharmacy to fill her repeat prescriptions for perindopril 4 mg and amlodipine 5 mg. You notice that Mrs Johnson is getting her repeats dispensed irregularly and offer her a blood pressure (BP) check. Mrs Johnson mentions that her BP has been poorly controlled, and she often forgets to take her medicines.
Learning objectivesAfter reading this article, pharmacists should be able to:
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Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.
Missed or delayed administration of prescribed doses is a common concern in clinical practice and can be viewed under the framework of non-adherence, either intentional or unintentional. Medication adherence refers to the extent to which a person’s behaviour matches with the agreed recommendations from a health care provider.1 Adherence to prescribed dosing regimens is crucial for achieving the best therapeutic outcome.
Understanding the implications of missed doses and how to manage them effectively will assist pharmacists in providing clear and concise instructions to patients who miss a dose.
Different terminologies have been used to describe deviations from prescribed therapies. The terms adherence, compliance and concordance are often used interchangeably. However, compliance implies patient passivity in treatment decisions.2
Adherence and concordance suggest a more active and collaborative approach between the patient and healthcare provider, with concordance specifically highlighting the importance of mutual agreement in treatment decisions.3
Many underlying factors contribute to an individual’s adherence to their medication regimens. When considering the factors contributing to missed medicine doses, several patient-related aspects are particularly relevant for pharmacists. A patient may deliberately skip or delay a dose due to adverse effects, a perceived lack of effect, a lack of motivation, or if they believe the medicine is unnecessary.4 On the other hand, unintentional missed doses may be due to careless factors, including forgetfulness and limited understanding of the prescribed instructions.4
In a survey of patient adherence to medicines for chronic diseases, 60% of participants stated forgetfulness was the reason for missed doses.5 The study found that missed doses were more commonly reported by patients with vitamin D deficiency, followed by hyperlipidaemia.5
The reasons for missed doses may also be a combination of intentional and unintentional factors. For instance, patients who are not motivated to take a medicine may be more likely to forget to take a dose.4
Missed or delayed medicine doses are more likely when regimens are complex due to forgetfulness or when patients have fears and concerns about adverse drug reactions.6 Inadequate communication between healthcare providers and patients can also lead to confusion about medication regimens.6 For other individuals, busy schedules, frequent travel, major life events or interruptions to usual routines can disrupt their ability to take medicines consistently.7
The World Health Organization identified the following five interacting dimensions that affect medication adherence8,9:
Time-critical medicines are ‘medicines where early or delayed administration by more than 30 minutes from the prescribed time for administration may cause harm to the patient or compromise the therapeutic effect, resulting in suboptimal therapy’.10 An example is levodopa-containing products for the treatment of Parkinson’s disease. A short delay can worsen symptoms and cause rigidity, pain and tremor, increase the risk of falls, as well as cause stress, anxiety and difficulty in communicating.11,12 Additionally, anticoagulants (e.g. enoxaparin) require strict adherence to dosing schedules, as clotting complications such as deep vein thrombosis or pulmonary embolism can be life-threatening.13
Identifying whether a medicine is time-critical requires knowledge of the half-life of the medicine, as it is a major determinant of the fluctuation in inter-dose concentrations at a steady state.14 Half-life serves as guidance for making informed recommendations on what to do when a dose of medicine is missed. Four to five half-lives is a general rule of thumb used to approximate the time needed for a medicine to be considered eliminated from the body. At that time point, the plasma concentrations of a given medicine will reach below a clinically relevant concentration.15
While an occasional missed dose of most medicines will have little consequence on therapeutic outcomes, delays or omissions for some medicines can lead to serious harm. For some medicines, such as an antidepressant, it is possible to get withdrawal symptoms within hours of the first missed dose.16
Missing a dose of medicines with a short half-life and/or rapid offset of action in relation to the dosing interval may lead to periods of sub-therapeutic plasma drug concentrations, and therefore insufficient pharmacologic activity.17 In contrast, medicines with a long half-life stay in the body longer. As a result, missing a dose may not cause a significant drop in drug levels, reducing the risk of sub-therapeutic levels. However, it is important to note that the clinical effects of some medicines are not directly related to their half-lives.14 Some examples of these drugs are those that act via an irreversible mechanism (e.g. aspirin), an indirect mechanism (e.g. warfarin), and those that are pro-drugs or metabolised into an active form with a different half-life.14,18
The following are some examples of medicines requiring strict adherence to dosing schedules to avoid significant or catastrophic long-term patient impact:
1. Consumer Medicine Information
The first place a patient should be instructed to look for advice if they forget to take a dose of their medicine at the usual time is the Consumer Medicine Information (CMI) leaflet.
Most commonly dispensed medicines have a CMI leaflet with a section for when a dose is missed.19
Pharmacists should use the CMI to reinforce verbal advice for missed or delayed doses during their counselling as it would prepare patients for this eventuality. Pharmacists should provide approved CMI leaflets to patients when they start prescription medicines, and at each subsequent dispensing according to established guidelines as part of good dispensing practice.18
CMIs are usually included as part of the medicine packaging. Alternatively, the TGA website (www.ebs.tga.gov.au) provides access to the latest approved versions of the CMI and Product Information (PI) provided by the pharmaceutical companies for most of the prescription medicines available in Australia.
2. Other methods
Other ways patients can obtain information about missed medicine doses include20:
3. General advice
When specific information is not available, the general advice to manage a missed or delayed dose is to take the missed dose as soon as it is remembered if the dose is less than 2 hours late.21 If the dose is more than 2 hours late21:
4. Do not take a double dose
It is generally not recommended to take a double dose to make up for a forgotten dose unless specifically advised.21
Many medicines have special instructions on managing missed doses. While it is not possible to include advice for all, Table 1 lists a few examples of some common medicines that pharmacists may encounter in their daily practice.
Strategies to prevent a missed or delayed dosePharmacists play a central role in preventing a missed or delayed dose. The strategies to avoid missed doses lie within the underlying cause.4 In addition to clearly explaining the dosing schedule, pharmacists should also focus on addressing the importance of taking medicine consistently as prescribed, particularly for medicines indicated for asymptomatic conditions or preventive measures, as the benefits may not be realised immediately. One study suggests using strategies such as motivational interviewing or another approach that addresses behavioural intention.4
Pharmacists should consider and act on the barriers patients might face in adhering to their medication regimen, which may include forgetfulness, complex or variable dosing schedules, adverse effects, or other health, dexterity or vision issues. This may require considerations of how the patient’s daily routine or lifestyle might impact their ability to take their medicines as prescribed (e.g. work schedule, travel). For instance, patients with cognitive impairment or those who forget to take their medicines may need memory triggers and a way to check whether or not they took them.4
Pharmacists can suggest the use of dose administration aids, pill organisers, sticky notes, alarm reminders on mobile phones, or “habit stacking” by associating medicine administration with a daily routine such as mealtimes and keeping the medicine visible.5 Some patients may find themselves frequently forgetting if they have taken their medicines, which is common for mundane behavioural decisions. One solution is to create a habit of recording each dose on a calendar, or if it is a pill bottle, simply flip it over every time a dose is taken as a visual reminder. Lastly, consider if alternative formulations (e.g. extended-release or combination formulations) are an option, as this could reduce the frequency of doses, thereby simplifying medication regimens.
Pharmacists can effectively manage missed doses by recommending appropriate action for missed doses and proposing tailored strategies that work best to address a specific barrier for patients. Pharmacists can provide patient education and counselling for medication adherence, collaborate with the patient’s primary care provider to discuss potential adjustments to their treatment plan, as well as offer dose administration aids. These actions can have a substantial impact on patient outcomes, including improved therapeutic outcomes, reduced health complications, improved quality of life and patient empowerment.
Missed medicine doses are common in practice, with potentially serious consequences for patient health, particularly when it comes to time-critical medicines. Pharmacists play a crucial role in providing advice for managing missed doses and supporting patients with their medication regimen management through the various strategies available.
Case scenario continuedYou review Mrs Johnson’s medication regimen and educate her on the importance of medicine adherence. You suggest using a pill organiser and setting daily alarms, and you talk to her GP about changing to a fixed-dose combination of perindopril/amlodipine. You also provide Mrs Johnson with a CMI leaflet and highlight for her the section that explains what to do when a dose is missed. When Mrs Johnson next returns to the pharmacy, you ask her how the interventions are helping. Mrs Johnson reports better adherence and thanks you for your help. Three months later, her blood pressure is well-controlled, significantly reducing the risk of future complications. |
Dr Amy Page (she/her) PhD, MClinPharm, GradDipBiostat, GCertHProfEd, GAICD, GStat, FSHPA, FPS is a consultant pharmacist, biostatistician, and a senior lecturer at the University of Western Australia.
Hui Wen Quek (she/her) BPharm(Hons), GradCertAppPharmPrac is a pharmacist and PhD candidate at the University of Western Australia.
Julie Briggs (she/her) BPharm, MPS, AcSHP
Hui Wen Quek is supported by an Australian Government Research Training Program (RTP) scholarship at the University of Western Australia.
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[post_content] => As temperatures soar, ensuring proper storage of medicines is more critical than ever. Here’s how heat impacts medicine safety and how pharmacists and patients can safeguard their efficacy.
Proper storage of medicines is vital to maintaining their efficacy and safety. But with Australia experiencing record-breaking temperatures, medicine integrity is at risk.
While it’s important to be aware of the effects climate change could potentially have on medicine safety, it may only exacerbate some of the problems we already have, said Dr Manuela Jorg, Senior Lecturer, Faculty of Pharmaceutical Sciences at Monash University.
Which drugs are most heat sensitive?
Medicine dosage forms such as liquids and solutions are more heat sensitive compared with solid compounds, said Dr Jorg. This includes injectable medicines such as insulin, vaccines or antibodies.
‘Sometimes short exposure to heat can have a detrimental effect but often it’s the longer exposure that can cause degradation of a drug,’ she said.
‘Degradation can lead to the medication becoming less effective or a molecule degrading into a different compound which could potentially be toxic and cause harmful side effects.’
How important is it to store medicine correctly?
A key aspect in protecting medicine integrity is ensuring medicines are stored correctly and not exposed to prolonged heat, sunlight or humidity.
Most medicines should be stored below 25⁰C and are tested by pharmaceutical companies at the recommended temperature they should be stored at for the full lifetime of their shelf life. They are also tested at temperatures of up to 40⁰C to ensure they remain stable.
Even with this added layer of testing, Pete Lambert, Director of the Monash Quality of Medicines Initiative, said that many patients may not be aware of the importance of keeping medicines at recommended temperatures and the potential dangers that not following these recommendations could create.
‘It's unlikely that once in the hands of the consumer, products will be stored in the right conditions for extended periods,’ he said ‘For example, simply leaving them in the car for a short period of time, in direct sunlight, or where temperatures can spike, could be problematic.’
Dr Jorg agrees. ‘As soon as we give medication to a patient, we have no control over what happens to the drugs,’ she said. ‘There have been several studies that show as soon as the medicine is in the hands of the patients, either transporting them home or storing them are often done in the wrong conditions.’
Signs of heat-affected medicines
Signs that medicines have been affected by the heat include changes in colour, consistency or smell; unusual softening or melting of solid forms of medicines, clumping of powders, and cracked or chipped coatings on tablets or capsules.
Heat exposure can also cause problems with medicine devices that involve a mechanism such as EpiPens, bronchial inhalers and autoinjectors. High temperatures can cause these to malfunction or even burst in the case of inhalers. Relying on these types of medicines that have been damaged by the heat could be fatal in an emergency.
How does hot weather impact the effects of medicines?
Another important aspect of extreme weather that’s important to consider is how higher temperatures can impact the effects of some medicines, said Mr Lambert. For example, patients who take medicines with a narrow therapeutic index such as warfarin, digoxin or lithium may be at risk of the drug becoming toxic if they become dehydrated in high temperatures.
Similarly, other medicines such as anticholinergic drugs that decrease the thirst response or inhibit sweating can cause patients to be at risk of dehydration and associated illness in hot weather.
Patients should be made aware of these risks and be advised to stay in cool environments, avoid going out in the hottest part of the day, and stay hydrated.
The challenge of online pharmacy providers
With most big banner pharmacy groups offering online ordering of medicines, pharmacists should provide guidance on maintaining medicine integrity where possible, said Mr Lambert.
‘If patients are going to order medicines online, it’s important that pharmacists advise patients to choose reputable providers,’ he said.’ Good providers will be aware of what kind of packaging the product needs to be in when it's shipped, so it’s adequately insulated for this period.'
If medicine is required to be kept in the cold chain, it should be shipped under refrigerated conditions, or with cold packs. If the product needs to be stored at temperatures less than 25⁰C packaging should be adequately insulated to ensure safe transport.
Patients should also know when their medicine is going to be delivered so they can be home and immediately take it into proper storage conditions once it arrives. If no one is home, patients could consider having a cooler bag at the front door where the medicine can be left, helping protect medicines from heat extremes.
What advice should pharmacists provide?
Many people may not know how to ensure their medicine remains safe and effective which is why education around medicine safety is really important, said Dr Jorg.
‘Pharmacists should explain proper storage techniques for particular medicines along with signs that a medicine may have been affected by the heat,’ she said. ‘It’s also important to make sure patients understand that if their medicines looks different to what it usually does, or they have any concerns to check with their doctor or pharmacist before taking it.’
Mr Lambert believes patients should understand medicine safety is often dependent upon adhering to the storage condition, which is on the carton or patient information leaflet, along with checking the expiry date.
‘It’s also important not to take the products out of the packaging they’ve been supplied in, because the stability and recommended storage conditions are based on the medicine being stored in the containers in which they’re supplied,’ he said.
Pharmacists should also explain the risks of leaving medicines in the car where temperatures can spike and recommend patients keep medicines in a cooler bag if they are travelling.
Ensuring patients understand how extreme heat can affect the way they handle their medicine, or how their medicine may affect them in higher temperatures is also important.
In the case of EpiPens, bronchial inhalers and autoinjectors, they mustn’t be left in hot cars or other environments that can become excessively hot, nor should they be exposed to direct sunlight. Keeping them well-insulated will help ensure the medicine and mechanisms to deliver the medicine are protected.
[post_title] => Maintaining medicine integrity in high temperatures
[post_excerpt] => As temperatures soar, ensuring proper storage of medicines is more critical than ever. Here’s how heat impacts medicine safety and how pharmacists and patients can safeguard their efficacy.
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[post_content] => Digital health tools can improve medicine safety and make systems more efficient – but poor system design often doesn’t bring healthcare practitioners and their patients on the journey.
From My Health Record to real-time prescription monitoring, electronic prescriptions and secure messaging, Australian pharmacists routinely use digital health in their daily practice. And there is more to come, as the use of machine learning and AI grows.
When implemented effectively, digital health tools facilitate communication and information sharing between healthcare professionals across various settings, including during transitions of care. For pharmacists, this timely access to clinical information helps to reduce medicine-related harm and improve the quality of care patients receive.
However, integrating new technologies is often not done particularly effectively. This was a key takeaway from a panel discussion at the National Medicines Symposium in November, where experts explored the use of digital tools to support safe medicine management.
Digital health challenges
[caption id="attachment_28530" align="alignright" width="220"] Professor Melissa Baysari[/caption]
For digital health tools to work in practice, they must be developed with the end user in mind, said University of Sydney Professor of Health Research Melissa Baysari. It sounds obvious and should be the norm. Sadly it isn’t. This results in the common challenges faced by users, including inadequate training, difficult-to-use technology and alert fatigue, when clinicians are inundated with too many notifications.
‘[There is a] surprising lack of involvement of end users in the design and implementation of digital systems. We definitely need more of that in healthcare,’ Prof Baysari said. ‘The technology is just one part of the wider work system. The human-technology fit is the hardest part to get right.
‘I think a lot of people feel these systems are imposed on them from senior levels, but if there was more clinician involvement in the design and understanding what problems need to be solved, people would have more ownership over the technology, and accept it and use it more.’
Another challenge is the varying use of digital health tools across the country, with some areas and settings being more advanced than others. This means the Australian health system ‘is not integrated’, said SA Pharmacy Chief Pharmacy Information Officer Michael Bakker MPS.
‘We have secure messaging, allowing delivery of referrals from a community setting into hospital, or going from hospital straight to a GP or into a patient's My Health Record,’ he said. ‘Those are very valuable, but we also need to see the emergence of tools that help do the blending of the actual workflows.
[caption id="attachment_28533" align="alignright" width="237"] Michael Bakker MPS[/caption]
‘The patient moves through the system, but you still just have this stack of paperwork. Whether we hand that to a patient as a set of papers that they can access digitally or physically, it doesn't really change that it's very difficult to navigate.’
Increasing health literacy – and digital health literacy – is essential for consumers and healthcare practitioners to interact with digital systems effectively, according to Prof Baysari.
‘I think there's a role for universities to play in ensuring that all our health professionals, as they leave, have some digital health knowledge,’ she said.
Reimagining workflows
Rather than bolting on new tools to existing systems, organisations must look at workflows holistically and identify areas for improvement, Prof Baysari said.
‘One of the challenging things is designing for current workflows to ensure that everything aligns, but also innovating and changing the way we have done things for many years because it might be safer, better or more efficient.
‘We should be designing for work as done, not work as imagined. And we should be designing for a problem, not implementing for the sake of implementation.
‘For example, I think we've overdone decision support for medication safety. We need to take a step back – what are the key problems we need to focus on when it comes to decision support and design of our systems? Let’s take a very problem focused perspective.’
Building systems to meet users’ requirements – rather than what it is assumed their requirements are – will lead to efficiencies, Mr Bakker said.
‘My hope over the next few years or decade is that we start to see tools that are built for the purposes of the people who are using them,’ he added.
Avoiding information overload
While digital health tools are often introduced with the aim of making healthcare practitioner’s lives easier, the opposite can happen, Mr Bakker said.
‘There’s some valuable evidence emerging about digital health stress, going so far as to say it contributes to burnout and people leaving the healthcare workforce altogether. We have an obligation to do something about it.
‘Not only is demand increasing, our patients are more complex, and our healthcare workforce is either not growing, can't grow, or will take too long to grow to meet that demand. We have to try and make some inroads here, appreciating that the way that we do things at the moment is actually burning people out quite a bit.’
Using digital tools to make seemingly small changes can have wide-ranging consequences, he said.
‘In South Australia alone, we have more than 4 million medication orders that are charted a year. On average, that process takes a couple of minutes for each order. If you can shrink that by 10%, you're talking about a lot of person hours that are returned back.’
In future, Prof Baysari said she hopes to see the healthcare sector get the most out of digital tools, both in terms of safety and efficiency.
‘We should be getting the benefits we expect from technology. At the moment, we’re probably achieving more in safety. I can understand there's a bit of a trade off there – if you’re going to be safe and thorough, you might need to be a little bit less efficient… But I think we're not achieving the full potential from technology. So I hope that we will.’
Watch the full panel discussion here.
[post_title] => Does technology in health care deliver on its promise?
[post_excerpt] => Digital health tools can improve medicine safety and make systems more efficient – but poor system design often doesn’t bring healthcare practitioners and their patients on the journey.
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[post_content] => With only two weeks before school resumes, now is the ideal time for pharmacists to help parents catch up with vaccinations for their children.
“As a parent of a four and six-year-old child, I know January is typically the time when kids are getting ready for the school year,” said Jacqueline Meyer MPS, owner of LiveLife Pharmacy Cooroy and PSA Queensland Pharmacist of the Year 2023. “Let’s make sure that includes updating vaccinations.”
Ms Meyer said encouraging parents to take advantage of this window of time could help overcome practical difficulties such as a busy lifestyle, while the availability of an increasing number of vaccines at pharmacies was especially helpful in regional areas where it may be more difficult to see a GP.
Research by the National Vaccinations Insight Project found that 23.9% of parents with partially vaccinated children under the age of five did not prioritise their children's vaccination appointments over other things, while 24.8% said it was not easy to get an appointment.
As well as holidays being free of the hustle and bustle of school routine, getting immunised during the holidays means children don’t have to miss a day of school if they have mild vaccination side effects, said Samantha Kourtis, pharmacist and managing partner of Capital Chemist Charnwood in the ACT and the mother of three teenagers.
Overcoming hesitancy
Ms Meyer said it was crucial that pharmacists familiarised themselves with the laws governing vaccinations in different states and territories so they knew what part they could play in boosting immunisation.
In most states and territories pharmacists may administer vaccines to children over the age of five – in Queensland that age is two years and, in Tasmania, in some cases, 10 years.
This can be most helpful for children who have missed out on immunisations through school programs, or from a medical clinic.
Concerningly, however, new research shows vaccination coverage among children in Australia has declined for the third consecutive year.
In 2020, fully vaccinated coverage rates were 94.8% at 12 months, 92.1 at 24 months and 94.8% at five years of age. In 2023 those rates were 92.8, 90.8% and 93.3% respectively.
Between 2020 and 2023, the proportion of children vaccinated within 30 days of the recommended age also decreased for both the second dose of diphtheria-tetanus-pertussis (DTP) vaccine (from 90.1% to 83.5% for non-Aboriginal and Torres Strait Islander children and 80.3% to 74.6% for Aboriginal and Torres Strait Islander children) and the first dose of measles-mumps-rubella (MMR) vaccine (from 75.3% to 67.2% for non-Aboriginal and Torres Strait Islander children children and 64.7% to 56% for Aboriginal and Torres Strait Islander children).
While access issues played some part in the decline, vaccine acceptance or parents’ thoughts and feelings about vaccines and parents’ social influences have also been a factor, according to the National Centre for Immunisation Research and Surveillance.
Researchers found 60.2% of parents felt distressed when thinking about vaccinating their children.
Pharmacist Sonia Zhu MPS, of Ramsay Pharmacy Glen Huntly, who has a four year old child, said she often has conversations with parents who feel anxious about vaccination.
“Whenever a parent is concerned, I ask them what is making them feel worried and then I am able to talk to them about the risks of the disease as opposed to the vaccine,” she said.
“I can assure them that vaccinations are just like a practice exam for your immune system and that, if their child gets the disease, they will recover better and more quickly if they are vaccinated.”
Mrs Kourtis said it was also important to reduce vaccination anxiety among children with a friendly healthcare environment, especially for younger children.
“We have regular colouring competitions, fairy doors, fun stickers and a donut stool they sit on to have their vaccination,” she said.
“We also talk to parents about what their child needs before being vaccinated. That may be to wear headphones, for example, or other measures for children who are neurodiverse.”
While Ms Zhu said lollipops were offered to children and teens, Ms Meyer said cartoon images, stuffed toys and devices that acted as distraction tools were other accessories used in pharmacies to help create a calm environment.
The teenage challenge
Vaccine rates in adolescents have also declined. Between 2022 and 2023, coverage decreased for having at least one dose of human papillomavirus (HPV) vaccine by 15 years of age (from 85.3% to 84.2% for girls and 83.1% to 81.8% for boys); an adolescent dose of diphtheria-tetanus-pertussis vaccine by 15 years of age (from 86.9% overall to 85.5%) and one dose of meningococcal ACWY vaccine by 17 years of age (from 75.9% overall to 72.8%).
“We certainly have nowhere near the uptake of meningococcal B vaccine we would like in Queensland,” said Ms Meyer.
According to the Primary Health Network Brisbane South, in the 15 to 20-year-old cohort, just under 14% have been immunised, leaving approximately 386,000 eligible adolescents unvaccinated.
The Queensland MenB Vaccination Program announced this year provides free vaccines to eligible infants, children and adolescents, and is the largest state-funded immunisation program ever implemented in the state.
With pharmacists able to administer all of these vaccinations between year 7 and year 10, Ms Meyer sees a clear opportunity to communicate the benefits of vaccination to parents.
“I think pharmacists could reach out to local schools and offer to conduct educational sessions,” said Ms Meyer. “Community pharmacies often employ teenagers for casual or junior shifts so it may start with simply talking to existing staff that may fit the eligibility criteria for demographic.”
Mrs Kourtis said community pharmacists were well placed to have health promotions in store and on social media.
“They can also try to partner with local community and sporting organisations to promote vaccination through them,” she said.
[post_title] => Boosting childhood vaccination rates in the holidays
[post_excerpt] => With only two weeks before school resumes, now is the ideal time for pharmacists to help parents catch up with vaccinations for their children.
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[post_content] => Turning informal advice into a structured consultation service: pharmacy-based travel health services take flight.
Australians love to travel and they take off to all parts of the globe, whether it be safaris in Africa, a bargain trip to Bali, visiting family in India or cruising through the icebergs within the Arctic Circle.
But as the average age of travellers, population density, pollution and zoonotic diseases increase, so, too, do health risks associated with travel.
Pharmacists have long provided ad hoc advice for travellers in response to patient queries, whether it be guidance on how to store medicines during transit or encouraging patients to see a GP, or dedicated travel doctor service in major cities, for vaccination.1
But with more Australians jetting off to more locations more frequently, more travel health services are needed. Some pioneering pharmacists are leading the way. Enabled by an increasing range of vaccines pharmacists can both prescribe and administer as well as formal pilots and programs from state governments, community-pharmacy based travel health consultation services are taking flight.
How does a formal travel health service differ from ad hoc advice?
Put simply, its more comprehensive. It considers a much wider range of risks than the patient may self-identify and makes recommendations to the traveller proportional to their individual needs.
‘Outside of a formalised program like the Victorian Community Pharmacy Statewide Pilot project,2 the pharmacist may not go into as much depth about [travel health] matters because there’s an expectation the consumer’s GP will have that discussion when a patient asks about vaccines,’ says PSA Victorian State Manager Jarrod McMaugh MPS.
It means pharmacists ‘instead of picking and choosing pieces of information they’re going to add on to a consultation before referring and saying “go to see your GP for these things”, they’re going to address them all directly in a travel health service’, he says.
And to be comprehensive the service needs a deep understanding of the traveller(s), when/where they are going, how they are going to get there – e.g. cruise, fly, drive, trek – and the types of things they’ll do when they are there.
Getting started
Establishment or formalisation of any service has common features: staff training, developing standard operating procedures, setting up documentation systems and advertising. However, a travel health service has two additional aspects, which are critical to success.
Firstly, the practitioners need to really wrap their heads around international travel, the health risks a person is likely to encounter and how to craft a valuable consultation for each traveller.
‘Some pharmacists are avid international travellers, and will have generated substantial knowledge of destinations, transport routes and product availability at pharmacies overseas. This expertise is advantageous in providing bespoke, individualised advice,’ Mr McMaugh says.
‘For example, Australians are often surprised by the high cost of sunscreens overseas, or how unpleasant the taste of oral rehydration products available in other markets are.’
‘Additionally, people often overlook prohibitions on carrying common medicines through common transit points such as Middle Eastern or Asian airport hubs.’
These kinds of insights may not be front-of-mind for travellers when booking in for a consultation, but they are important for risk mitigation and highly valued.
Also important is anticipating risks for which travellers may not be alert. For example, a family holiday to a Thailand beach resort may initially seem lower risk, but activities and excursions where you interact with wildlife such as monkeys are common and carry zoonotic infection risk.
For pharmacists who do not have this knowledge from primary experience, seeking these reflections from colleagues or through careful listening with patients is essential.
Structuring a consultation is something each practitioner needs to find their own way to master. Unlike other services, the approach to these longer consultations isn’t so black and white.
Compared to other expanded scope programs, travel health requires mastering the navigation of the grey.
One of the hundreds of pharmacists offering a travel service under the Victorian pilot is Melbourne’s Tooronga Amcal Pharmacy owner Andrew Robinson MPS, who reflected that ‘[with a UTI treatment service], we follow a protocol guideline and it’s more straightforward to undertake’. With travel, it is like a Pandora’s box that you can open and find you going all over the place with a whole lot of different destinations, a whole lot of different complications, a lot of different needs.’
Finding prospective travellers
A common theme with all pharmacists contacted by AP is that the identification of patients who would benefit from the service has initially been more successful through conversations in patient interactions than via formal advertising.
The trigger for knowing a patient could benefit from a sit-down travel health consultation with a pharmacist could be anything, Mr McMaugh notes.
‘It can literally be a comment in passing: ‘My son is about to travel overseas for the first time.’
Other queries could be related to how to carry medicines safely overseas, or interest in medicines for motion sickness.
Andrew Robinson describes the trial as a ‘significant endorsement by health regulators that pharmacists are capable of delivering more complex services.
‘Before actually doing an appointment, you’ve got to tease it out a bit first. It’s not like some of the other pilot programs that we’ve done, which are very, “you’ve got a urinary tract infection. You fit the criteria. We can undertake the consultation”.’
‘In contrast, you almost need to do a [travel health] consultation to find out whether you need to refer them on. So, I try and garner that before. But I think if we boil it down and keep it simple, the reality is there’s plenty of people out there who are not thinking about travel health that need a typhoid vaccine and a bit of a conversation,’ he said.
Mr Robinson identified that consumers who, at short notice, book a trip to south-east Asia and don’t plan a GP visit have particularly welcomed his travel health consultations.
‘We see this particular pilot really looking at the high-risk patient, the person who sees a cheap flight to Indonesia and in 3 weeks’ time they’re gone. They think of it as just a great way to relax and give very little thought to the risks associated with that travel.’
Susannah Clavin MPS, the owner of the Marc Clavin Pharmacy at Sorrento on Victoria’s Mornington Peninsula, regularly discusses travel health with patients and consumers, and has had success with online bookings.
‘Most [patients] were heading to south-east-Asia. They are all very time-poor, so if the pharmacy is closely located to their home or workplace then I think they will appreciate the convenience. Being able to book online, too, is a bonus.’
Like Mr Robinson, Ms Clavin had also identified patients through conversations at the dispensary.
‘One of the patients had a prescription for the vaccine and asked us for a quote,’ recalls Ms Clavin. ‘We gave the quote and mentioned that we could also administer the vaccine, for a fee. [The patient] was very keen to save a trip to the doctor.’
Fee-for-service
How much should the service charge? While each business needs to make its own decision based on the costs of delivery and business policies, experience in travel doctor clinics and within pilot sites shows consumers are willing to pay for the consultation service, which may include administration of vaccines.
When AP spoke to Mr Robinson, he had conducted about a dozen travel health consultations, charging $50 for a half-hour consultation. Families travelling overseas, he says, have found the consultations particularly attractive because the pharmacist can give advice to an entire family in one appointment.
Looking to the future
Feedback from the Victorian trial shows an effective travel health consultation service is a good fit with pharmacies that have a well-integrated vaccination service, according to Mr McMaugh.
‘If you’re doing the occasional vaccine, you have to change gears, going from doing whatever other services or dispensing you were doing, to administering the vaccine and then coming back into the retail and dispensing space,’ he says.
Mr Robinson hopes travel health consultations become a permanent fixture in the service landscape for pharmacy.
‘Travel is all about having fun. But we need to make sure it stays fun, and you stay healthy, because otherwise it’s a very expensive holiday.’
The rise of zoonotic diseases
Where a person is travelling to and where they are staying matters. A trip to Zimbabwe to see Victoria Falls has a very different risk profile to a walking safari at remote campsites. Similarly, holiday resorts in south-east Asia next to agricultural fields have a different risk profile to city hotels.
Recent decades have seen the rise and reemergence of viral zoonotic diseases.4 The growth of tourism has led to land changes, travel patterns and farming practices which increase the risk of zoonotic diseases, including novel and well-established pathogens.⁵
Travellers and health professionals alike need to keep abreast of these trends. Rabies is a good case in point. The USA continues to log around 4,000 animal rabies cases each year, with >90% of cases from bats, raccoons, skunks and foxes – a shift from the 1960s where dogs were the primary rabies risk to humans.⁶ In contrast, dog bites are the predominant source of rabies infections in Africa.⁷
Karen Carter FPS, partner of Carter’s Pharmacy Gunnedah and owner of Narrabri Pharmacy in north-west NSW, can now offer rabies vaccinations.
‘You think of exotic animals for rabies but sometimes it’s dogs that people are at risk of being bitten by,’ Ms Carter says.
The vaccine isn’t cheap, so considering the exposure risk and access to post-exposure prophylaxis is important when discussing the benefits of the vaccine with patients.
‘We had a gentleman travelling to Africa and then on to South America for his work in the agriculture industry, so we recommended he get the rabies vaccine.’ Ms Carter says. In fact, he not only got the rabies vaccine administered, but the hepatitis A and typhoid vaccines as well before he left.
‘We were also able to refer him to a Tamworth GP clinic for his yellow fever vaccines, Ms Carter adds. ‘He thought it was great that we could do all but one of his vaccines in the pharmacy.’
Other zoonotic infections, such as mpox, avian influenza and Japanese encephalitis also have changing patterns of transmission and distribution, which increasingly require consideration in travel health services.
Case study
Dat Le MPS Owner, Priceline Pharmacy, Knox, Melbourne VIC
This traveller
Mrs L, a 62-year-old regular dose administration aid (DAA) patient, is living with gastro-oesophogeal reflux disease (GORD), hypertension, atrial fibrillation, high cholesterol and osteoarthritis in the knee.
Current medicines
This time Mrs L explains that it will be summer when she arrives in both south-east Asian countries.
Recommendations
Based on her travel plans, I recommend vaccination for:
Mrs L was advised she would have full protection from hepatitis A in 2 weeks and that it may be at least a week before the COVID-19 booster provided full protection.
She was also told that the vaccinations may cause sore arms, some redness, fever or chills.
While her typhoid vaccination would protect her for 3 years, she could have another COVID-19 booster in a year.
For the hepatitis A vaccine, a typical course is two doses – the first at day 0, and the second from 6 months later, ideally before 12 months, if she travels again within the year.
Rehydration preparations were also recommended, along with hand sanitiser, face masks and sunscreen for Mrs L’s holiday group tour to various sight-seeing locations.
When she collected her DAAs, we advised Mrs L how to store her medicines. She was pleased she didn’t need to make a GP appointment, organise vaccine prescriptions, collect them at the pharmacy and then take them back to the doctor to be administered. I reminded her that we would call her about her second hepatitis A dose to complete her course.
We put a note on her next DAA collection asking about her holiday and any problems she may have had such as diarrhoea or tablet storage problems.
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[post_content] => Case scenario
Mrs Johnson, a 65-year-old patient with hypertension, comes to the pharmacy to fill her repeat prescriptions for perindopril 4 mg and amlodipine 5 mg. You notice that Mrs Johnson is getting her repeats dispensed irregularly and offer her a blood pressure (BP) check. Mrs Johnson mentions that her BP has been poorly controlled, and she often forgets to take her medicines.
Learning objectivesAfter reading this article, pharmacists should be able to:
|
Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.
Missed or delayed administration of prescribed doses is a common concern in clinical practice and can be viewed under the framework of non-adherence, either intentional or unintentional. Medication adherence refers to the extent to which a person’s behaviour matches with the agreed recommendations from a health care provider.1 Adherence to prescribed dosing regimens is crucial for achieving the best therapeutic outcome.
Understanding the implications of missed doses and how to manage them effectively will assist pharmacists in providing clear and concise instructions to patients who miss a dose.
Different terminologies have been used to describe deviations from prescribed therapies. The terms adherence, compliance and concordance are often used interchangeably. However, compliance implies patient passivity in treatment decisions.2
Adherence and concordance suggest a more active and collaborative approach between the patient and healthcare provider, with concordance specifically highlighting the importance of mutual agreement in treatment decisions.3
Many underlying factors contribute to an individual’s adherence to their medication regimens. When considering the factors contributing to missed medicine doses, several patient-related aspects are particularly relevant for pharmacists. A patient may deliberately skip or delay a dose due to adverse effects, a perceived lack of effect, a lack of motivation, or if they believe the medicine is unnecessary.4 On the other hand, unintentional missed doses may be due to careless factors, including forgetfulness and limited understanding of the prescribed instructions.4
In a survey of patient adherence to medicines for chronic diseases, 60% of participants stated forgetfulness was the reason for missed doses.5 The study found that missed doses were more commonly reported by patients with vitamin D deficiency, followed by hyperlipidaemia.5
The reasons for missed doses may also be a combination of intentional and unintentional factors. For instance, patients who are not motivated to take a medicine may be more likely to forget to take a dose.4
Missed or delayed medicine doses are more likely when regimens are complex due to forgetfulness or when patients have fears and concerns about adverse drug reactions.6 Inadequate communication between healthcare providers and patients can also lead to confusion about medication regimens.6 For other individuals, busy schedules, frequent travel, major life events or interruptions to usual routines can disrupt their ability to take medicines consistently.7
The World Health Organization identified the following five interacting dimensions that affect medication adherence8,9:
Time-critical medicines are ‘medicines where early or delayed administration by more than 30 minutes from the prescribed time for administration may cause harm to the patient or compromise the therapeutic effect, resulting in suboptimal therapy’.10 An example is levodopa-containing products for the treatment of Parkinson’s disease. A short delay can worsen symptoms and cause rigidity, pain and tremor, increase the risk of falls, as well as cause stress, anxiety and difficulty in communicating.11,12 Additionally, anticoagulants (e.g. enoxaparin) require strict adherence to dosing schedules, as clotting complications such as deep vein thrombosis or pulmonary embolism can be life-threatening.13
Identifying whether a medicine is time-critical requires knowledge of the half-life of the medicine, as it is a major determinant of the fluctuation in inter-dose concentrations at a steady state.14 Half-life serves as guidance for making informed recommendations on what to do when a dose of medicine is missed. Four to five half-lives is a general rule of thumb used to approximate the time needed for a medicine to be considered eliminated from the body. At that time point, the plasma concentrations of a given medicine will reach below a clinically relevant concentration.15
While an occasional missed dose of most medicines will have little consequence on therapeutic outcomes, delays or omissions for some medicines can lead to serious harm. For some medicines, such as an antidepressant, it is possible to get withdrawal symptoms within hours of the first missed dose.16
Missing a dose of medicines with a short half-life and/or rapid offset of action in relation to the dosing interval may lead to periods of sub-therapeutic plasma drug concentrations, and therefore insufficient pharmacologic activity.17 In contrast, medicines with a long half-life stay in the body longer. As a result, missing a dose may not cause a significant drop in drug levels, reducing the risk of sub-therapeutic levels. However, it is important to note that the clinical effects of some medicines are not directly related to their half-lives.14 Some examples of these drugs are those that act via an irreversible mechanism (e.g. aspirin), an indirect mechanism (e.g. warfarin), and those that are pro-drugs or metabolised into an active form with a different half-life.14,18
The following are some examples of medicines requiring strict adherence to dosing schedules to avoid significant or catastrophic long-term patient impact:
1. Consumer Medicine Information
The first place a patient should be instructed to look for advice if they forget to take a dose of their medicine at the usual time is the Consumer Medicine Information (CMI) leaflet.
Most commonly dispensed medicines have a CMI leaflet with a section for when a dose is missed.19
Pharmacists should use the CMI to reinforce verbal advice for missed or delayed doses during their counselling as it would prepare patients for this eventuality. Pharmacists should provide approved CMI leaflets to patients when they start prescription medicines, and at each subsequent dispensing according to established guidelines as part of good dispensing practice.18
CMIs are usually included as part of the medicine packaging. Alternatively, the TGA website (www.ebs.tga.gov.au) provides access to the latest approved versions of the CMI and Product Information (PI) provided by the pharmaceutical companies for most of the prescription medicines available in Australia.
2. Other methods
Other ways patients can obtain information about missed medicine doses include20:
3. General advice
When specific information is not available, the general advice to manage a missed or delayed dose is to take the missed dose as soon as it is remembered if the dose is less than 2 hours late.21 If the dose is more than 2 hours late21:
4. Do not take a double dose
It is generally not recommended to take a double dose to make up for a forgotten dose unless specifically advised.21
Many medicines have special instructions on managing missed doses. While it is not possible to include advice for all, Table 1 lists a few examples of some common medicines that pharmacists may encounter in their daily practice.
Strategies to prevent a missed or delayed dosePharmacists play a central role in preventing a missed or delayed dose. The strategies to avoid missed doses lie within the underlying cause.4 In addition to clearly explaining the dosing schedule, pharmacists should also focus on addressing the importance of taking medicine consistently as prescribed, particularly for medicines indicated for asymptomatic conditions or preventive measures, as the benefits may not be realised immediately. One study suggests using strategies such as motivational interviewing or another approach that addresses behavioural intention.4
Pharmacists should consider and act on the barriers patients might face in adhering to their medication regimen, which may include forgetfulness, complex or variable dosing schedules, adverse effects, or other health, dexterity or vision issues. This may require considerations of how the patient’s daily routine or lifestyle might impact their ability to take their medicines as prescribed (e.g. work schedule, travel). For instance, patients with cognitive impairment or those who forget to take their medicines may need memory triggers and a way to check whether or not they took them.4
Pharmacists can suggest the use of dose administration aids, pill organisers, sticky notes, alarm reminders on mobile phones, or “habit stacking” by associating medicine administration with a daily routine such as mealtimes and keeping the medicine visible.5 Some patients may find themselves frequently forgetting if they have taken their medicines, which is common for mundane behavioural decisions. One solution is to create a habit of recording each dose on a calendar, or if it is a pill bottle, simply flip it over every time a dose is taken as a visual reminder. Lastly, consider if alternative formulations (e.g. extended-release or combination formulations) are an option, as this could reduce the frequency of doses, thereby simplifying medication regimens.
Pharmacists can effectively manage missed doses by recommending appropriate action for missed doses and proposing tailored strategies that work best to address a specific barrier for patients. Pharmacists can provide patient education and counselling for medication adherence, collaborate with the patient’s primary care provider to discuss potential adjustments to their treatment plan, as well as offer dose administration aids. These actions can have a substantial impact on patient outcomes, including improved therapeutic outcomes, reduced health complications, improved quality of life and patient empowerment.
Missed medicine doses are common in practice, with potentially serious consequences for patient health, particularly when it comes to time-critical medicines. Pharmacists play a crucial role in providing advice for managing missed doses and supporting patients with their medication regimen management through the various strategies available.
Case scenario continuedYou review Mrs Johnson’s medication regimen and educate her on the importance of medicine adherence. You suggest using a pill organiser and setting daily alarms, and you talk to her GP about changing to a fixed-dose combination of perindopril/amlodipine. You also provide Mrs Johnson with a CMI leaflet and highlight for her the section that explains what to do when a dose is missed. When Mrs Johnson next returns to the pharmacy, you ask her how the interventions are helping. Mrs Johnson reports better adherence and thanks you for your help. Three months later, her blood pressure is well-controlled, significantly reducing the risk of future complications. |
Dr Amy Page (she/her) PhD, MClinPharm, GradDipBiostat, GCertHProfEd, GAICD, GStat, FSHPA, FPS is a consultant pharmacist, biostatistician, and a senior lecturer at the University of Western Australia.
Hui Wen Quek (she/her) BPharm(Hons), GradCertAppPharmPrac is a pharmacist and PhD candidate at the University of Western Australia.
Julie Briggs (she/her) BPharm, MPS, AcSHP
Hui Wen Quek is supported by an Australian Government Research Training Program (RTP) scholarship at the University of Western Australia.
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[post_content] => As temperatures soar, ensuring proper storage of medicines is more critical than ever. Here’s how heat impacts medicine safety and how pharmacists and patients can safeguard their efficacy.
Proper storage of medicines is vital to maintaining their efficacy and safety. But with Australia experiencing record-breaking temperatures, medicine integrity is at risk.
While it’s important to be aware of the effects climate change could potentially have on medicine safety, it may only exacerbate some of the problems we already have, said Dr Manuela Jorg, Senior Lecturer, Faculty of Pharmaceutical Sciences at Monash University.
Which drugs are most heat sensitive?
Medicine dosage forms such as liquids and solutions are more heat sensitive compared with solid compounds, said Dr Jorg. This includes injectable medicines such as insulin, vaccines or antibodies.
‘Sometimes short exposure to heat can have a detrimental effect but often it’s the longer exposure that can cause degradation of a drug,’ she said.
‘Degradation can lead to the medication becoming less effective or a molecule degrading into a different compound which could potentially be toxic and cause harmful side effects.’
How important is it to store medicine correctly?
A key aspect in protecting medicine integrity is ensuring medicines are stored correctly and not exposed to prolonged heat, sunlight or humidity.
Most medicines should be stored below 25⁰C and are tested by pharmaceutical companies at the recommended temperature they should be stored at for the full lifetime of their shelf life. They are also tested at temperatures of up to 40⁰C to ensure they remain stable.
Even with this added layer of testing, Pete Lambert, Director of the Monash Quality of Medicines Initiative, said that many patients may not be aware of the importance of keeping medicines at recommended temperatures and the potential dangers that not following these recommendations could create.
‘It's unlikely that once in the hands of the consumer, products will be stored in the right conditions for extended periods,’ he said ‘For example, simply leaving them in the car for a short period of time, in direct sunlight, or where temperatures can spike, could be problematic.’
Dr Jorg agrees. ‘As soon as we give medication to a patient, we have no control over what happens to the drugs,’ she said. ‘There have been several studies that show as soon as the medicine is in the hands of the patients, either transporting them home or storing them are often done in the wrong conditions.’
Signs of heat-affected medicines
Signs that medicines have been affected by the heat include changes in colour, consistency or smell; unusual softening or melting of solid forms of medicines, clumping of powders, and cracked or chipped coatings on tablets or capsules.
Heat exposure can also cause problems with medicine devices that involve a mechanism such as EpiPens, bronchial inhalers and autoinjectors. High temperatures can cause these to malfunction or even burst in the case of inhalers. Relying on these types of medicines that have been damaged by the heat could be fatal in an emergency.
How does hot weather impact the effects of medicines?
Another important aspect of extreme weather that’s important to consider is how higher temperatures can impact the effects of some medicines, said Mr Lambert. For example, patients who take medicines with a narrow therapeutic index such as warfarin, digoxin or lithium may be at risk of the drug becoming toxic if they become dehydrated in high temperatures.
Similarly, other medicines such as anticholinergic drugs that decrease the thirst response or inhibit sweating can cause patients to be at risk of dehydration and associated illness in hot weather.
Patients should be made aware of these risks and be advised to stay in cool environments, avoid going out in the hottest part of the day, and stay hydrated.
The challenge of online pharmacy providers
With most big banner pharmacy groups offering online ordering of medicines, pharmacists should provide guidance on maintaining medicine integrity where possible, said Mr Lambert.
‘If patients are going to order medicines online, it’s important that pharmacists advise patients to choose reputable providers,’ he said.’ Good providers will be aware of what kind of packaging the product needs to be in when it's shipped, so it’s adequately insulated for this period.'
If medicine is required to be kept in the cold chain, it should be shipped under refrigerated conditions, or with cold packs. If the product needs to be stored at temperatures less than 25⁰C packaging should be adequately insulated to ensure safe transport.
Patients should also know when their medicine is going to be delivered so they can be home and immediately take it into proper storage conditions once it arrives. If no one is home, patients could consider having a cooler bag at the front door where the medicine can be left, helping protect medicines from heat extremes.
What advice should pharmacists provide?
Many people may not know how to ensure their medicine remains safe and effective which is why education around medicine safety is really important, said Dr Jorg.
‘Pharmacists should explain proper storage techniques for particular medicines along with signs that a medicine may have been affected by the heat,’ she said. ‘It’s also important to make sure patients understand that if their medicines looks different to what it usually does, or they have any concerns to check with their doctor or pharmacist before taking it.’
Mr Lambert believes patients should understand medicine safety is often dependent upon adhering to the storage condition, which is on the carton or patient information leaflet, along with checking the expiry date.
‘It’s also important not to take the products out of the packaging they’ve been supplied in, because the stability and recommended storage conditions are based on the medicine being stored in the containers in which they’re supplied,’ he said.
Pharmacists should also explain the risks of leaving medicines in the car where temperatures can spike and recommend patients keep medicines in a cooler bag if they are travelling.
Ensuring patients understand how extreme heat can affect the way they handle their medicine, or how their medicine may affect them in higher temperatures is also important.
In the case of EpiPens, bronchial inhalers and autoinjectors, they mustn’t be left in hot cars or other environments that can become excessively hot, nor should they be exposed to direct sunlight. Keeping them well-insulated will help ensure the medicine and mechanisms to deliver the medicine are protected.
[post_title] => Maintaining medicine integrity in high temperatures
[post_excerpt] => As temperatures soar, ensuring proper storage of medicines is more critical than ever. Here’s how heat impacts medicine safety and how pharmacists and patients can safeguard their efficacy.
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[post_content] => Digital health tools can improve medicine safety and make systems more efficient – but poor system design often doesn’t bring healthcare practitioners and their patients on the journey.
From My Health Record to real-time prescription monitoring, electronic prescriptions and secure messaging, Australian pharmacists routinely use digital health in their daily practice. And there is more to come, as the use of machine learning and AI grows.
When implemented effectively, digital health tools facilitate communication and information sharing between healthcare professionals across various settings, including during transitions of care. For pharmacists, this timely access to clinical information helps to reduce medicine-related harm and improve the quality of care patients receive.
However, integrating new technologies is often not done particularly effectively. This was a key takeaway from a panel discussion at the National Medicines Symposium in November, where experts explored the use of digital tools to support safe medicine management.
Digital health challenges
[caption id="attachment_28530" align="alignright" width="220"] Professor Melissa Baysari[/caption]
For digital health tools to work in practice, they must be developed with the end user in mind, said University of Sydney Professor of Health Research Melissa Baysari. It sounds obvious and should be the norm. Sadly it isn’t. This results in the common challenges faced by users, including inadequate training, difficult-to-use technology and alert fatigue, when clinicians are inundated with too many notifications.
‘[There is a] surprising lack of involvement of end users in the design and implementation of digital systems. We definitely need more of that in healthcare,’ Prof Baysari said. ‘The technology is just one part of the wider work system. The human-technology fit is the hardest part to get right.
‘I think a lot of people feel these systems are imposed on them from senior levels, but if there was more clinician involvement in the design and understanding what problems need to be solved, people would have more ownership over the technology, and accept it and use it more.’
Another challenge is the varying use of digital health tools across the country, with some areas and settings being more advanced than others. This means the Australian health system ‘is not integrated’, said SA Pharmacy Chief Pharmacy Information Officer Michael Bakker MPS.
‘We have secure messaging, allowing delivery of referrals from a community setting into hospital, or going from hospital straight to a GP or into a patient's My Health Record,’ he said. ‘Those are very valuable, but we also need to see the emergence of tools that help do the blending of the actual workflows.
[caption id="attachment_28533" align="alignright" width="237"] Michael Bakker MPS[/caption]
‘The patient moves through the system, but you still just have this stack of paperwork. Whether we hand that to a patient as a set of papers that they can access digitally or physically, it doesn't really change that it's very difficult to navigate.’
Increasing health literacy – and digital health literacy – is essential for consumers and healthcare practitioners to interact with digital systems effectively, according to Prof Baysari.
‘I think there's a role for universities to play in ensuring that all our health professionals, as they leave, have some digital health knowledge,’ she said.
Reimagining workflows
Rather than bolting on new tools to existing systems, organisations must look at workflows holistically and identify areas for improvement, Prof Baysari said.
‘One of the challenging things is designing for current workflows to ensure that everything aligns, but also innovating and changing the way we have done things for many years because it might be safer, better or more efficient.
‘We should be designing for work as done, not work as imagined. And we should be designing for a problem, not implementing for the sake of implementation.
‘For example, I think we've overdone decision support for medication safety. We need to take a step back – what are the key problems we need to focus on when it comes to decision support and design of our systems? Let’s take a very problem focused perspective.’
Building systems to meet users’ requirements – rather than what it is assumed their requirements are – will lead to efficiencies, Mr Bakker said.
‘My hope over the next few years or decade is that we start to see tools that are built for the purposes of the people who are using them,’ he added.
Avoiding information overload
While digital health tools are often introduced with the aim of making healthcare practitioner’s lives easier, the opposite can happen, Mr Bakker said.
‘There’s some valuable evidence emerging about digital health stress, going so far as to say it contributes to burnout and people leaving the healthcare workforce altogether. We have an obligation to do something about it.
‘Not only is demand increasing, our patients are more complex, and our healthcare workforce is either not growing, can't grow, or will take too long to grow to meet that demand. We have to try and make some inroads here, appreciating that the way that we do things at the moment is actually burning people out quite a bit.’
Using digital tools to make seemingly small changes can have wide-ranging consequences, he said.
‘In South Australia alone, we have more than 4 million medication orders that are charted a year. On average, that process takes a couple of minutes for each order. If you can shrink that by 10%, you're talking about a lot of person hours that are returned back.’
In future, Prof Baysari said she hopes to see the healthcare sector get the most out of digital tools, both in terms of safety and efficiency.
‘We should be getting the benefits we expect from technology. At the moment, we’re probably achieving more in safety. I can understand there's a bit of a trade off there – if you’re going to be safe and thorough, you might need to be a little bit less efficient… But I think we're not achieving the full potential from technology. So I hope that we will.’
Watch the full panel discussion here.
[post_title] => Does technology in health care deliver on its promise?
[post_excerpt] => Digital health tools can improve medicine safety and make systems more efficient – but poor system design often doesn’t bring healthcare practitioners and their patients on the journey.
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[post_content] => With only two weeks before school resumes, now is the ideal time for pharmacists to help parents catch up with vaccinations for their children.
“As a parent of a four and six-year-old child, I know January is typically the time when kids are getting ready for the school year,” said Jacqueline Meyer MPS, owner of LiveLife Pharmacy Cooroy and PSA Queensland Pharmacist of the Year 2023. “Let’s make sure that includes updating vaccinations.”
Ms Meyer said encouraging parents to take advantage of this window of time could help overcome practical difficulties such as a busy lifestyle, while the availability of an increasing number of vaccines at pharmacies was especially helpful in regional areas where it may be more difficult to see a GP.
Research by the National Vaccinations Insight Project found that 23.9% of parents with partially vaccinated children under the age of five did not prioritise their children's vaccination appointments over other things, while 24.8% said it was not easy to get an appointment.
As well as holidays being free of the hustle and bustle of school routine, getting immunised during the holidays means children don’t have to miss a day of school if they have mild vaccination side effects, said Samantha Kourtis, pharmacist and managing partner of Capital Chemist Charnwood in the ACT and the mother of three teenagers.
Overcoming hesitancy
Ms Meyer said it was crucial that pharmacists familiarised themselves with the laws governing vaccinations in different states and territories so they knew what part they could play in boosting immunisation.
In most states and territories pharmacists may administer vaccines to children over the age of five – in Queensland that age is two years and, in Tasmania, in some cases, 10 years.
This can be most helpful for children who have missed out on immunisations through school programs, or from a medical clinic.
Concerningly, however, new research shows vaccination coverage among children in Australia has declined for the third consecutive year.
In 2020, fully vaccinated coverage rates were 94.8% at 12 months, 92.1 at 24 months and 94.8% at five years of age. In 2023 those rates were 92.8, 90.8% and 93.3% respectively.
Between 2020 and 2023, the proportion of children vaccinated within 30 days of the recommended age also decreased for both the second dose of diphtheria-tetanus-pertussis (DTP) vaccine (from 90.1% to 83.5% for non-Aboriginal and Torres Strait Islander children and 80.3% to 74.6% for Aboriginal and Torres Strait Islander children) and the first dose of measles-mumps-rubella (MMR) vaccine (from 75.3% to 67.2% for non-Aboriginal and Torres Strait Islander children children and 64.7% to 56% for Aboriginal and Torres Strait Islander children).
While access issues played some part in the decline, vaccine acceptance or parents’ thoughts and feelings about vaccines and parents’ social influences have also been a factor, according to the National Centre for Immunisation Research and Surveillance.
Researchers found 60.2% of parents felt distressed when thinking about vaccinating their children.
Pharmacist Sonia Zhu MPS, of Ramsay Pharmacy Glen Huntly, who has a four year old child, said she often has conversations with parents who feel anxious about vaccination.
“Whenever a parent is concerned, I ask them what is making them feel worried and then I am able to talk to them about the risks of the disease as opposed to the vaccine,” she said.
“I can assure them that vaccinations are just like a practice exam for your immune system and that, if their child gets the disease, they will recover better and more quickly if they are vaccinated.”
Mrs Kourtis said it was also important to reduce vaccination anxiety among children with a friendly healthcare environment, especially for younger children.
“We have regular colouring competitions, fairy doors, fun stickers and a donut stool they sit on to have their vaccination,” she said.
“We also talk to parents about what their child needs before being vaccinated. That may be to wear headphones, for example, or other measures for children who are neurodiverse.”
While Ms Zhu said lollipops were offered to children and teens, Ms Meyer said cartoon images, stuffed toys and devices that acted as distraction tools were other accessories used in pharmacies to help create a calm environment.
The teenage challenge
Vaccine rates in adolescents have also declined. Between 2022 and 2023, coverage decreased for having at least one dose of human papillomavirus (HPV) vaccine by 15 years of age (from 85.3% to 84.2% for girls and 83.1% to 81.8% for boys); an adolescent dose of diphtheria-tetanus-pertussis vaccine by 15 years of age (from 86.9% overall to 85.5%) and one dose of meningococcal ACWY vaccine by 17 years of age (from 75.9% overall to 72.8%).
“We certainly have nowhere near the uptake of meningococcal B vaccine we would like in Queensland,” said Ms Meyer.
According to the Primary Health Network Brisbane South, in the 15 to 20-year-old cohort, just under 14% have been immunised, leaving approximately 386,000 eligible adolescents unvaccinated.
The Queensland MenB Vaccination Program announced this year provides free vaccines to eligible infants, children and adolescents, and is the largest state-funded immunisation program ever implemented in the state.
With pharmacists able to administer all of these vaccinations between year 7 and year 10, Ms Meyer sees a clear opportunity to communicate the benefits of vaccination to parents.
“I think pharmacists could reach out to local schools and offer to conduct educational sessions,” said Ms Meyer. “Community pharmacies often employ teenagers for casual or junior shifts so it may start with simply talking to existing staff that may fit the eligibility criteria for demographic.”
Mrs Kourtis said community pharmacists were well placed to have health promotions in store and on social media.
“They can also try to partner with local community and sporting organisations to promote vaccination through them,” she said.
[post_title] => Boosting childhood vaccination rates in the holidays
[post_excerpt] => With only two weeks before school resumes, now is the ideal time for pharmacists to help parents catch up with vaccinations for their children.
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[post_content] => Turning informal advice into a structured consultation service: pharmacy-based travel health services take flight.
Australians love to travel and they take off to all parts of the globe, whether it be safaris in Africa, a bargain trip to Bali, visiting family in India or cruising through the icebergs within the Arctic Circle.
But as the average age of travellers, population density, pollution and zoonotic diseases increase, so, too, do health risks associated with travel.
Pharmacists have long provided ad hoc advice for travellers in response to patient queries, whether it be guidance on how to store medicines during transit or encouraging patients to see a GP, or dedicated travel doctor service in major cities, for vaccination.1
But with more Australians jetting off to more locations more frequently, more travel health services are needed. Some pioneering pharmacists are leading the way. Enabled by an increasing range of vaccines pharmacists can both prescribe and administer as well as formal pilots and programs from state governments, community-pharmacy based travel health consultation services are taking flight.
How does a formal travel health service differ from ad hoc advice?
Put simply, its more comprehensive. It considers a much wider range of risks than the patient may self-identify and makes recommendations to the traveller proportional to their individual needs.
‘Outside of a formalised program like the Victorian Community Pharmacy Statewide Pilot project,2 the pharmacist may not go into as much depth about [travel health] matters because there’s an expectation the consumer’s GP will have that discussion when a patient asks about vaccines,’ says PSA Victorian State Manager Jarrod McMaugh MPS.
It means pharmacists ‘instead of picking and choosing pieces of information they’re going to add on to a consultation before referring and saying “go to see your GP for these things”, they’re going to address them all directly in a travel health service’, he says.
And to be comprehensive the service needs a deep understanding of the traveller(s), when/where they are going, how they are going to get there – e.g. cruise, fly, drive, trek – and the types of things they’ll do when they are there.
Getting started
Establishment or formalisation of any service has common features: staff training, developing standard operating procedures, setting up documentation systems and advertising. However, a travel health service has two additional aspects, which are critical to success.
Firstly, the practitioners need to really wrap their heads around international travel, the health risks a person is likely to encounter and how to craft a valuable consultation for each traveller.
‘Some pharmacists are avid international travellers, and will have generated substantial knowledge of destinations, transport routes and product availability at pharmacies overseas. This expertise is advantageous in providing bespoke, individualised advice,’ Mr McMaugh says.
‘For example, Australians are often surprised by the high cost of sunscreens overseas, or how unpleasant the taste of oral rehydration products available in other markets are.’
‘Additionally, people often overlook prohibitions on carrying common medicines through common transit points such as Middle Eastern or Asian airport hubs.’
These kinds of insights may not be front-of-mind for travellers when booking in for a consultation, but they are important for risk mitigation and highly valued.
Also important is anticipating risks for which travellers may not be alert. For example, a family holiday to a Thailand beach resort may initially seem lower risk, but activities and excursions where you interact with wildlife such as monkeys are common and carry zoonotic infection risk.
For pharmacists who do not have this knowledge from primary experience, seeking these reflections from colleagues or through careful listening with patients is essential.
Structuring a consultation is something each practitioner needs to find their own way to master. Unlike other services, the approach to these longer consultations isn’t so black and white.
Compared to other expanded scope programs, travel health requires mastering the navigation of the grey.
One of the hundreds of pharmacists offering a travel service under the Victorian pilot is Melbourne’s Tooronga Amcal Pharmacy owner Andrew Robinson MPS, who reflected that ‘[with a UTI treatment service], we follow a protocol guideline and it’s more straightforward to undertake’. With travel, it is like a Pandora’s box that you can open and find you going all over the place with a whole lot of different destinations, a whole lot of different complications, a lot of different needs.’
Finding prospective travellers
A common theme with all pharmacists contacted by AP is that the identification of patients who would benefit from the service has initially been more successful through conversations in patient interactions than via formal advertising.
The trigger for knowing a patient could benefit from a sit-down travel health consultation with a pharmacist could be anything, Mr McMaugh notes.
‘It can literally be a comment in passing: ‘My son is about to travel overseas for the first time.’
Other queries could be related to how to carry medicines safely overseas, or interest in medicines for motion sickness.
Andrew Robinson describes the trial as a ‘significant endorsement by health regulators that pharmacists are capable of delivering more complex services.
‘Before actually doing an appointment, you’ve got to tease it out a bit first. It’s not like some of the other pilot programs that we’ve done, which are very, “you’ve got a urinary tract infection. You fit the criteria. We can undertake the consultation”.’
‘In contrast, you almost need to do a [travel health] consultation to find out whether you need to refer them on. So, I try and garner that before. But I think if we boil it down and keep it simple, the reality is there’s plenty of people out there who are not thinking about travel health that need a typhoid vaccine and a bit of a conversation,’ he said.
Mr Robinson identified that consumers who, at short notice, book a trip to south-east Asia and don’t plan a GP visit have particularly welcomed his travel health consultations.
‘We see this particular pilot really looking at the high-risk patient, the person who sees a cheap flight to Indonesia and in 3 weeks’ time they’re gone. They think of it as just a great way to relax and give very little thought to the risks associated with that travel.’
Susannah Clavin MPS, the owner of the Marc Clavin Pharmacy at Sorrento on Victoria’s Mornington Peninsula, regularly discusses travel health with patients and consumers, and has had success with online bookings.
‘Most [patients] were heading to south-east-Asia. They are all very time-poor, so if the pharmacy is closely located to their home or workplace then I think they will appreciate the convenience. Being able to book online, too, is a bonus.’
Like Mr Robinson, Ms Clavin had also identified patients through conversations at the dispensary.
‘One of the patients had a prescription for the vaccine and asked us for a quote,’ recalls Ms Clavin. ‘We gave the quote and mentioned that we could also administer the vaccine, for a fee. [The patient] was very keen to save a trip to the doctor.’
Fee-for-service
How much should the service charge? While each business needs to make its own decision based on the costs of delivery and business policies, experience in travel doctor clinics and within pilot sites shows consumers are willing to pay for the consultation service, which may include administration of vaccines.
When AP spoke to Mr Robinson, he had conducted about a dozen travel health consultations, charging $50 for a half-hour consultation. Families travelling overseas, he says, have found the consultations particularly attractive because the pharmacist can give advice to an entire family in one appointment.
Looking to the future
Feedback from the Victorian trial shows an effective travel health consultation service is a good fit with pharmacies that have a well-integrated vaccination service, according to Mr McMaugh.
‘If you’re doing the occasional vaccine, you have to change gears, going from doing whatever other services or dispensing you were doing, to administering the vaccine and then coming back into the retail and dispensing space,’ he says.
Mr Robinson hopes travel health consultations become a permanent fixture in the service landscape for pharmacy.
‘Travel is all about having fun. But we need to make sure it stays fun, and you stay healthy, because otherwise it’s a very expensive holiday.’
The rise of zoonotic diseases
Where a person is travelling to and where they are staying matters. A trip to Zimbabwe to see Victoria Falls has a very different risk profile to a walking safari at remote campsites. Similarly, holiday resorts in south-east Asia next to agricultural fields have a different risk profile to city hotels.
Recent decades have seen the rise and reemergence of viral zoonotic diseases.4 The growth of tourism has led to land changes, travel patterns and farming practices which increase the risk of zoonotic diseases, including novel and well-established pathogens.⁵
Travellers and health professionals alike need to keep abreast of these trends. Rabies is a good case in point. The USA continues to log around 4,000 animal rabies cases each year, with >90% of cases from bats, raccoons, skunks and foxes – a shift from the 1960s where dogs were the primary rabies risk to humans.⁶ In contrast, dog bites are the predominant source of rabies infections in Africa.⁷
Karen Carter FPS, partner of Carter’s Pharmacy Gunnedah and owner of Narrabri Pharmacy in north-west NSW, can now offer rabies vaccinations.
‘You think of exotic animals for rabies but sometimes it’s dogs that people are at risk of being bitten by,’ Ms Carter says.
The vaccine isn’t cheap, so considering the exposure risk and access to post-exposure prophylaxis is important when discussing the benefits of the vaccine with patients.
‘We had a gentleman travelling to Africa and then on to South America for his work in the agriculture industry, so we recommended he get the rabies vaccine.’ Ms Carter says. In fact, he not only got the rabies vaccine administered, but the hepatitis A and typhoid vaccines as well before he left.
‘We were also able to refer him to a Tamworth GP clinic for his yellow fever vaccines, Ms Carter adds. ‘He thought it was great that we could do all but one of his vaccines in the pharmacy.’
Other zoonotic infections, such as mpox, avian influenza and Japanese encephalitis also have changing patterns of transmission and distribution, which increasingly require consideration in travel health services.
Case study
Dat Le MPS Owner, Priceline Pharmacy, Knox, Melbourne VIC
This traveller
Mrs L, a 62-year-old regular dose administration aid (DAA) patient, is living with gastro-oesophogeal reflux disease (GORD), hypertension, atrial fibrillation, high cholesterol and osteoarthritis in the knee.
Current medicines
This time Mrs L explains that it will be summer when she arrives in both south-east Asian countries.
Recommendations
Based on her travel plans, I recommend vaccination for:
Mrs L was advised she would have full protection from hepatitis A in 2 weeks and that it may be at least a week before the COVID-19 booster provided full protection.
She was also told that the vaccinations may cause sore arms, some redness, fever or chills.
While her typhoid vaccination would protect her for 3 years, she could have another COVID-19 booster in a year.
For the hepatitis A vaccine, a typical course is two doses – the first at day 0, and the second from 6 months later, ideally before 12 months, if she travels again within the year.
Rehydration preparations were also recommended, along with hand sanitiser, face masks and sunscreen for Mrs L’s holiday group tour to various sight-seeing locations.
When she collected her DAAs, we advised Mrs L how to store her medicines. She was pleased she didn’t need to make a GP appointment, organise vaccine prescriptions, collect them at the pharmacy and then take them back to the doctor to be administered. I reminded her that we would call her about her second hepatitis A dose to complete her course.
We put a note on her next DAA collection asking about her holiday and any problems she may have had such as diarrhoea or tablet storage problems.
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[post_content] => Case scenario
Mrs Johnson, a 65-year-old patient with hypertension, comes to the pharmacy to fill her repeat prescriptions for perindopril 4 mg and amlodipine 5 mg. You notice that Mrs Johnson is getting her repeats dispensed irregularly and offer her a blood pressure (BP) check. Mrs Johnson mentions that her BP has been poorly controlled, and she often forgets to take her medicines.
Learning objectivesAfter reading this article, pharmacists should be able to:
|
Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.
Missed or delayed administration of prescribed doses is a common concern in clinical practice and can be viewed under the framework of non-adherence, either intentional or unintentional. Medication adherence refers to the extent to which a person’s behaviour matches with the agreed recommendations from a health care provider.1 Adherence to prescribed dosing regimens is crucial for achieving the best therapeutic outcome.
Understanding the implications of missed doses and how to manage them effectively will assist pharmacists in providing clear and concise instructions to patients who miss a dose.
Different terminologies have been used to describe deviations from prescribed therapies. The terms adherence, compliance and concordance are often used interchangeably. However, compliance implies patient passivity in treatment decisions.2
Adherence and concordance suggest a more active and collaborative approach between the patient and healthcare provider, with concordance specifically highlighting the importance of mutual agreement in treatment decisions.3
Many underlying factors contribute to an individual’s adherence to their medication regimens. When considering the factors contributing to missed medicine doses, several patient-related aspects are particularly relevant for pharmacists. A patient may deliberately skip or delay a dose due to adverse effects, a perceived lack of effect, a lack of motivation, or if they believe the medicine is unnecessary.4 On the other hand, unintentional missed doses may be due to careless factors, including forgetfulness and limited understanding of the prescribed instructions.4
In a survey of patient adherence to medicines for chronic diseases, 60% of participants stated forgetfulness was the reason for missed doses.5 The study found that missed doses were more commonly reported by patients with vitamin D deficiency, followed by hyperlipidaemia.5
The reasons for missed doses may also be a combination of intentional and unintentional factors. For instance, patients who are not motivated to take a medicine may be more likely to forget to take a dose.4
Missed or delayed medicine doses are more likely when regimens are complex due to forgetfulness or when patients have fears and concerns about adverse drug reactions.6 Inadequate communication between healthcare providers and patients can also lead to confusion about medication regimens.6 For other individuals, busy schedules, frequent travel, major life events or interruptions to usual routines can disrupt their ability to take medicines consistently.7
The World Health Organization identified the following five interacting dimensions that affect medication adherence8,9:
Time-critical medicines are ‘medicines where early or delayed administration by more than 30 minutes from the prescribed time for administration may cause harm to the patient or compromise the therapeutic effect, resulting in suboptimal therapy’.10 An example is levodopa-containing products for the treatment of Parkinson’s disease. A short delay can worsen symptoms and cause rigidity, pain and tremor, increase the risk of falls, as well as cause stress, anxiety and difficulty in communicating.11,12 Additionally, anticoagulants (e.g. enoxaparin) require strict adherence to dosing schedules, as clotting complications such as deep vein thrombosis or pulmonary embolism can be life-threatening.13
Identifying whether a medicine is time-critical requires knowledge of the half-life of the medicine, as it is a major determinant of the fluctuation in inter-dose concentrations at a steady state.14 Half-life serves as guidance for making informed recommendations on what to do when a dose of medicine is missed. Four to five half-lives is a general rule of thumb used to approximate the time needed for a medicine to be considered eliminated from the body. At that time point, the plasma concentrations of a given medicine will reach below a clinically relevant concentration.15
While an occasional missed dose of most medicines will have little consequence on therapeutic outcomes, delays or omissions for some medicines can lead to serious harm. For some medicines, such as an antidepressant, it is possible to get withdrawal symptoms within hours of the first missed dose.16
Missing a dose of medicines with a short half-life and/or rapid offset of action in relation to the dosing interval may lead to periods of sub-therapeutic plasma drug concentrations, and therefore insufficient pharmacologic activity.17 In contrast, medicines with a long half-life stay in the body longer. As a result, missing a dose may not cause a significant drop in drug levels, reducing the risk of sub-therapeutic levels. However, it is important to note that the clinical effects of some medicines are not directly related to their half-lives.14 Some examples of these drugs are those that act via an irreversible mechanism (e.g. aspirin), an indirect mechanism (e.g. warfarin), and those that are pro-drugs or metabolised into an active form with a different half-life.14,18
The following are some examples of medicines requiring strict adherence to dosing schedules to avoid significant or catastrophic long-term patient impact:
1. Consumer Medicine Information
The first place a patient should be instructed to look for advice if they forget to take a dose of their medicine at the usual time is the Consumer Medicine Information (CMI) leaflet.
Most commonly dispensed medicines have a CMI leaflet with a section for when a dose is missed.19
Pharmacists should use the CMI to reinforce verbal advice for missed or delayed doses during their counselling as it would prepare patients for this eventuality. Pharmacists should provide approved CMI leaflets to patients when they start prescription medicines, and at each subsequent dispensing according to established guidelines as part of good dispensing practice.18
CMIs are usually included as part of the medicine packaging. Alternatively, the TGA website (www.ebs.tga.gov.au) provides access to the latest approved versions of the CMI and Product Information (PI) provided by the pharmaceutical companies for most of the prescription medicines available in Australia.
2. Other methods
Other ways patients can obtain information about missed medicine doses include20:
3. General advice
When specific information is not available, the general advice to manage a missed or delayed dose is to take the missed dose as soon as it is remembered if the dose is less than 2 hours late.21 If the dose is more than 2 hours late21:
4. Do not take a double dose
It is generally not recommended to take a double dose to make up for a forgotten dose unless specifically advised.21
Many medicines have special instructions on managing missed doses. While it is not possible to include advice for all, Table 1 lists a few examples of some common medicines that pharmacists may encounter in their daily practice.
Strategies to prevent a missed or delayed dosePharmacists play a central role in preventing a missed or delayed dose. The strategies to avoid missed doses lie within the underlying cause.4 In addition to clearly explaining the dosing schedule, pharmacists should also focus on addressing the importance of taking medicine consistently as prescribed, particularly for medicines indicated for asymptomatic conditions or preventive measures, as the benefits may not be realised immediately. One study suggests using strategies such as motivational interviewing or another approach that addresses behavioural intention.4
Pharmacists should consider and act on the barriers patients might face in adhering to their medication regimen, which may include forgetfulness, complex or variable dosing schedules, adverse effects, or other health, dexterity or vision issues. This may require considerations of how the patient’s daily routine or lifestyle might impact their ability to take their medicines as prescribed (e.g. work schedule, travel). For instance, patients with cognitive impairment or those who forget to take their medicines may need memory triggers and a way to check whether or not they took them.4
Pharmacists can suggest the use of dose administration aids, pill organisers, sticky notes, alarm reminders on mobile phones, or “habit stacking” by associating medicine administration with a daily routine such as mealtimes and keeping the medicine visible.5 Some patients may find themselves frequently forgetting if they have taken their medicines, which is common for mundane behavioural decisions. One solution is to create a habit of recording each dose on a calendar, or if it is a pill bottle, simply flip it over every time a dose is taken as a visual reminder. Lastly, consider if alternative formulations (e.g. extended-release or combination formulations) are an option, as this could reduce the frequency of doses, thereby simplifying medication regimens.
Pharmacists can effectively manage missed doses by recommending appropriate action for missed doses and proposing tailored strategies that work best to address a specific barrier for patients. Pharmacists can provide patient education and counselling for medication adherence, collaborate with the patient’s primary care provider to discuss potential adjustments to their treatment plan, as well as offer dose administration aids. These actions can have a substantial impact on patient outcomes, including improved therapeutic outcomes, reduced health complications, improved quality of life and patient empowerment.
Missed medicine doses are common in practice, with potentially serious consequences for patient health, particularly when it comes to time-critical medicines. Pharmacists play a crucial role in providing advice for managing missed doses and supporting patients with their medication regimen management through the various strategies available.
Case scenario continuedYou review Mrs Johnson’s medication regimen and educate her on the importance of medicine adherence. You suggest using a pill organiser and setting daily alarms, and you talk to her GP about changing to a fixed-dose combination of perindopril/amlodipine. You also provide Mrs Johnson with a CMI leaflet and highlight for her the section that explains what to do when a dose is missed. When Mrs Johnson next returns to the pharmacy, you ask her how the interventions are helping. Mrs Johnson reports better adherence and thanks you for your help. Three months later, her blood pressure is well-controlled, significantly reducing the risk of future complications. |
Dr Amy Page (she/her) PhD, MClinPharm, GradDipBiostat, GCertHProfEd, GAICD, GStat, FSHPA, FPS is a consultant pharmacist, biostatistician, and a senior lecturer at the University of Western Australia.
Hui Wen Quek (she/her) BPharm(Hons), GradCertAppPharmPrac is a pharmacist and PhD candidate at the University of Western Australia.
Julie Briggs (she/her) BPharm, MPS, AcSHP
Hui Wen Quek is supported by an Australian Government Research Training Program (RTP) scholarship at the University of Western Australia.
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[post_content] => As temperatures soar, ensuring proper storage of medicines is more critical than ever. Here’s how heat impacts medicine safety and how pharmacists and patients can safeguard their efficacy.
Proper storage of medicines is vital to maintaining their efficacy and safety. But with Australia experiencing record-breaking temperatures, medicine integrity is at risk.
While it’s important to be aware of the effects climate change could potentially have on medicine safety, it may only exacerbate some of the problems we already have, said Dr Manuela Jorg, Senior Lecturer, Faculty of Pharmaceutical Sciences at Monash University.
Which drugs are most heat sensitive?
Medicine dosage forms such as liquids and solutions are more heat sensitive compared with solid compounds, said Dr Jorg. This includes injectable medicines such as insulin, vaccines or antibodies.
‘Sometimes short exposure to heat can have a detrimental effect but often it’s the longer exposure that can cause degradation of a drug,’ she said.
‘Degradation can lead to the medication becoming less effective or a molecule degrading into a different compound which could potentially be toxic and cause harmful side effects.’
How important is it to store medicine correctly?
A key aspect in protecting medicine integrity is ensuring medicines are stored correctly and not exposed to prolonged heat, sunlight or humidity.
Most medicines should be stored below 25⁰C and are tested by pharmaceutical companies at the recommended temperature they should be stored at for the full lifetime of their shelf life. They are also tested at temperatures of up to 40⁰C to ensure they remain stable.
Even with this added layer of testing, Pete Lambert, Director of the Monash Quality of Medicines Initiative, said that many patients may not be aware of the importance of keeping medicines at recommended temperatures and the potential dangers that not following these recommendations could create.
‘It's unlikely that once in the hands of the consumer, products will be stored in the right conditions for extended periods,’ he said ‘For example, simply leaving them in the car for a short period of time, in direct sunlight, or where temperatures can spike, could be problematic.’
Dr Jorg agrees. ‘As soon as we give medication to a patient, we have no control over what happens to the drugs,’ she said. ‘There have been several studies that show as soon as the medicine is in the hands of the patients, either transporting them home or storing them are often done in the wrong conditions.’
Signs of heat-affected medicines
Signs that medicines have been affected by the heat include changes in colour, consistency or smell; unusual softening or melting of solid forms of medicines, clumping of powders, and cracked or chipped coatings on tablets or capsules.
Heat exposure can also cause problems with medicine devices that involve a mechanism such as EpiPens, bronchial inhalers and autoinjectors. High temperatures can cause these to malfunction or even burst in the case of inhalers. Relying on these types of medicines that have been damaged by the heat could be fatal in an emergency.
How does hot weather impact the effects of medicines?
Another important aspect of extreme weather that’s important to consider is how higher temperatures can impact the effects of some medicines, said Mr Lambert. For example, patients who take medicines with a narrow therapeutic index such as warfarin, digoxin or lithium may be at risk of the drug becoming toxic if they become dehydrated in high temperatures.
Similarly, other medicines such as anticholinergic drugs that decrease the thirst response or inhibit sweating can cause patients to be at risk of dehydration and associated illness in hot weather.
Patients should be made aware of these risks and be advised to stay in cool environments, avoid going out in the hottest part of the day, and stay hydrated.
The challenge of online pharmacy providers
With most big banner pharmacy groups offering online ordering of medicines, pharmacists should provide guidance on maintaining medicine integrity where possible, said Mr Lambert.
‘If patients are going to order medicines online, it’s important that pharmacists advise patients to choose reputable providers,’ he said.’ Good providers will be aware of what kind of packaging the product needs to be in when it's shipped, so it’s adequately insulated for this period.'
If medicine is required to be kept in the cold chain, it should be shipped under refrigerated conditions, or with cold packs. If the product needs to be stored at temperatures less than 25⁰C packaging should be adequately insulated to ensure safe transport.
Patients should also know when their medicine is going to be delivered so they can be home and immediately take it into proper storage conditions once it arrives. If no one is home, patients could consider having a cooler bag at the front door where the medicine can be left, helping protect medicines from heat extremes.
What advice should pharmacists provide?
Many people may not know how to ensure their medicine remains safe and effective which is why education around medicine safety is really important, said Dr Jorg.
‘Pharmacists should explain proper storage techniques for particular medicines along with signs that a medicine may have been affected by the heat,’ she said. ‘It’s also important to make sure patients understand that if their medicines looks different to what it usually does, or they have any concerns to check with their doctor or pharmacist before taking it.’
Mr Lambert believes patients should understand medicine safety is often dependent upon adhering to the storage condition, which is on the carton or patient information leaflet, along with checking the expiry date.
‘It’s also important not to take the products out of the packaging they’ve been supplied in, because the stability and recommended storage conditions are based on the medicine being stored in the containers in which they’re supplied,’ he said.
Pharmacists should also explain the risks of leaving medicines in the car where temperatures can spike and recommend patients keep medicines in a cooler bag if they are travelling.
Ensuring patients understand how extreme heat can affect the way they handle their medicine, or how their medicine may affect them in higher temperatures is also important.
In the case of EpiPens, bronchial inhalers and autoinjectors, they mustn’t be left in hot cars or other environments that can become excessively hot, nor should they be exposed to direct sunlight. Keeping them well-insulated will help ensure the medicine and mechanisms to deliver the medicine are protected.
[post_title] => Maintaining medicine integrity in high temperatures
[post_excerpt] => As temperatures soar, ensuring proper storage of medicines is more critical than ever. Here’s how heat impacts medicine safety and how pharmacists and patients can safeguard their efficacy.
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[post_content] => Digital health tools can improve medicine safety and make systems more efficient – but poor system design often doesn’t bring healthcare practitioners and their patients on the journey.
From My Health Record to real-time prescription monitoring, electronic prescriptions and secure messaging, Australian pharmacists routinely use digital health in their daily practice. And there is more to come, as the use of machine learning and AI grows.
When implemented effectively, digital health tools facilitate communication and information sharing between healthcare professionals across various settings, including during transitions of care. For pharmacists, this timely access to clinical information helps to reduce medicine-related harm and improve the quality of care patients receive.
However, integrating new technologies is often not done particularly effectively. This was a key takeaway from a panel discussion at the National Medicines Symposium in November, where experts explored the use of digital tools to support safe medicine management.
Digital health challenges
[caption id="attachment_28530" align="alignright" width="220"] Professor Melissa Baysari[/caption]
For digital health tools to work in practice, they must be developed with the end user in mind, said University of Sydney Professor of Health Research Melissa Baysari. It sounds obvious and should be the norm. Sadly it isn’t. This results in the common challenges faced by users, including inadequate training, difficult-to-use technology and alert fatigue, when clinicians are inundated with too many notifications.
‘[There is a] surprising lack of involvement of end users in the design and implementation of digital systems. We definitely need more of that in healthcare,’ Prof Baysari said. ‘The technology is just one part of the wider work system. The human-technology fit is the hardest part to get right.
‘I think a lot of people feel these systems are imposed on them from senior levels, but if there was more clinician involvement in the design and understanding what problems need to be solved, people would have more ownership over the technology, and accept it and use it more.’
Another challenge is the varying use of digital health tools across the country, with some areas and settings being more advanced than others. This means the Australian health system ‘is not integrated’, said SA Pharmacy Chief Pharmacy Information Officer Michael Bakker MPS.
‘We have secure messaging, allowing delivery of referrals from a community setting into hospital, or going from hospital straight to a GP or into a patient's My Health Record,’ he said. ‘Those are very valuable, but we also need to see the emergence of tools that help do the blending of the actual workflows.
[caption id="attachment_28533" align="alignright" width="237"] Michael Bakker MPS[/caption]
‘The patient moves through the system, but you still just have this stack of paperwork. Whether we hand that to a patient as a set of papers that they can access digitally or physically, it doesn't really change that it's very difficult to navigate.’
Increasing health literacy – and digital health literacy – is essential for consumers and healthcare practitioners to interact with digital systems effectively, according to Prof Baysari.
‘I think there's a role for universities to play in ensuring that all our health professionals, as they leave, have some digital health knowledge,’ she said.
Reimagining workflows
Rather than bolting on new tools to existing systems, organisations must look at workflows holistically and identify areas for improvement, Prof Baysari said.
‘One of the challenging things is designing for current workflows to ensure that everything aligns, but also innovating and changing the way we have done things for many years because it might be safer, better or more efficient.
‘We should be designing for work as done, not work as imagined. And we should be designing for a problem, not implementing for the sake of implementation.
‘For example, I think we've overdone decision support for medication safety. We need to take a step back – what are the key problems we need to focus on when it comes to decision support and design of our systems? Let’s take a very problem focused perspective.’
Building systems to meet users’ requirements – rather than what it is assumed their requirements are – will lead to efficiencies, Mr Bakker said.
‘My hope over the next few years or decade is that we start to see tools that are built for the purposes of the people who are using them,’ he added.
Avoiding information overload
While digital health tools are often introduced with the aim of making healthcare practitioner’s lives easier, the opposite can happen, Mr Bakker said.
‘There’s some valuable evidence emerging about digital health stress, going so far as to say it contributes to burnout and people leaving the healthcare workforce altogether. We have an obligation to do something about it.
‘Not only is demand increasing, our patients are more complex, and our healthcare workforce is either not growing, can't grow, or will take too long to grow to meet that demand. We have to try and make some inroads here, appreciating that the way that we do things at the moment is actually burning people out quite a bit.’
Using digital tools to make seemingly small changes can have wide-ranging consequences, he said.
‘In South Australia alone, we have more than 4 million medication orders that are charted a year. On average, that process takes a couple of minutes for each order. If you can shrink that by 10%, you're talking about a lot of person hours that are returned back.’
In future, Prof Baysari said she hopes to see the healthcare sector get the most out of digital tools, both in terms of safety and efficiency.
‘We should be getting the benefits we expect from technology. At the moment, we’re probably achieving more in safety. I can understand there's a bit of a trade off there – if you’re going to be safe and thorough, you might need to be a little bit less efficient… But I think we're not achieving the full potential from technology. So I hope that we will.’
Watch the full panel discussion here.
[post_title] => Does technology in health care deliver on its promise?
[post_excerpt] => Digital health tools can improve medicine safety and make systems more efficient – but poor system design often doesn’t bring healthcare practitioners and their patients on the journey.
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[post_content] => With only two weeks before school resumes, now is the ideal time for pharmacists to help parents catch up with vaccinations for their children.
“As a parent of a four and six-year-old child, I know January is typically the time when kids are getting ready for the school year,” said Jacqueline Meyer MPS, owner of LiveLife Pharmacy Cooroy and PSA Queensland Pharmacist of the Year 2023. “Let’s make sure that includes updating vaccinations.”
Ms Meyer said encouraging parents to take advantage of this window of time could help overcome practical difficulties such as a busy lifestyle, while the availability of an increasing number of vaccines at pharmacies was especially helpful in regional areas where it may be more difficult to see a GP.
Research by the National Vaccinations Insight Project found that 23.9% of parents with partially vaccinated children under the age of five did not prioritise their children's vaccination appointments over other things, while 24.8% said it was not easy to get an appointment.
As well as holidays being free of the hustle and bustle of school routine, getting immunised during the holidays means children don’t have to miss a day of school if they have mild vaccination side effects, said Samantha Kourtis, pharmacist and managing partner of Capital Chemist Charnwood in the ACT and the mother of three teenagers.
Overcoming hesitancy
Ms Meyer said it was crucial that pharmacists familiarised themselves with the laws governing vaccinations in different states and territories so they knew what part they could play in boosting immunisation.
In most states and territories pharmacists may administer vaccines to children over the age of five – in Queensland that age is two years and, in Tasmania, in some cases, 10 years.
This can be most helpful for children who have missed out on immunisations through school programs, or from a medical clinic.
Concerningly, however, new research shows vaccination coverage among children in Australia has declined for the third consecutive year.
In 2020, fully vaccinated coverage rates were 94.8% at 12 months, 92.1 at 24 months and 94.8% at five years of age. In 2023 those rates were 92.8, 90.8% and 93.3% respectively.
Between 2020 and 2023, the proportion of children vaccinated within 30 days of the recommended age also decreased for both the second dose of diphtheria-tetanus-pertussis (DTP) vaccine (from 90.1% to 83.5% for non-Aboriginal and Torres Strait Islander children and 80.3% to 74.6% for Aboriginal and Torres Strait Islander children) and the first dose of measles-mumps-rubella (MMR) vaccine (from 75.3% to 67.2% for non-Aboriginal and Torres Strait Islander children children and 64.7% to 56% for Aboriginal and Torres Strait Islander children).
While access issues played some part in the decline, vaccine acceptance or parents’ thoughts and feelings about vaccines and parents’ social influences have also been a factor, according to the National Centre for Immunisation Research and Surveillance.
Researchers found 60.2% of parents felt distressed when thinking about vaccinating their children.
Pharmacist Sonia Zhu MPS, of Ramsay Pharmacy Glen Huntly, who has a four year old child, said she often has conversations with parents who feel anxious about vaccination.
“Whenever a parent is concerned, I ask them what is making them feel worried and then I am able to talk to them about the risks of the disease as opposed to the vaccine,” she said.
“I can assure them that vaccinations are just like a practice exam for your immune system and that, if their child gets the disease, they will recover better and more quickly if they are vaccinated.”
Mrs Kourtis said it was also important to reduce vaccination anxiety among children with a friendly healthcare environment, especially for younger children.
“We have regular colouring competitions, fairy doors, fun stickers and a donut stool they sit on to have their vaccination,” she said.
“We also talk to parents about what their child needs before being vaccinated. That may be to wear headphones, for example, or other measures for children who are neurodiverse.”
While Ms Zhu said lollipops were offered to children and teens, Ms Meyer said cartoon images, stuffed toys and devices that acted as distraction tools were other accessories used in pharmacies to help create a calm environment.
The teenage challenge
Vaccine rates in adolescents have also declined. Between 2022 and 2023, coverage decreased for having at least one dose of human papillomavirus (HPV) vaccine by 15 years of age (from 85.3% to 84.2% for girls and 83.1% to 81.8% for boys); an adolescent dose of diphtheria-tetanus-pertussis vaccine by 15 years of age (from 86.9% overall to 85.5%) and one dose of meningococcal ACWY vaccine by 17 years of age (from 75.9% overall to 72.8%).
“We certainly have nowhere near the uptake of meningococcal B vaccine we would like in Queensland,” said Ms Meyer.
According to the Primary Health Network Brisbane South, in the 15 to 20-year-old cohort, just under 14% have been immunised, leaving approximately 386,000 eligible adolescents unvaccinated.
The Queensland MenB Vaccination Program announced this year provides free vaccines to eligible infants, children and adolescents, and is the largest state-funded immunisation program ever implemented in the state.
With pharmacists able to administer all of these vaccinations between year 7 and year 10, Ms Meyer sees a clear opportunity to communicate the benefits of vaccination to parents.
“I think pharmacists could reach out to local schools and offer to conduct educational sessions,” said Ms Meyer. “Community pharmacies often employ teenagers for casual or junior shifts so it may start with simply talking to existing staff that may fit the eligibility criteria for demographic.”
Mrs Kourtis said community pharmacists were well placed to have health promotions in store and on social media.
“They can also try to partner with local community and sporting organisations to promote vaccination through them,” she said.
[post_title] => Boosting childhood vaccination rates in the holidays
[post_excerpt] => With only two weeks before school resumes, now is the ideal time for pharmacists to help parents catch up with vaccinations for their children.
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[post_content] => Turning informal advice into a structured consultation service: pharmacy-based travel health services take flight.
Australians love to travel and they take off to all parts of the globe, whether it be safaris in Africa, a bargain trip to Bali, visiting family in India or cruising through the icebergs within the Arctic Circle.
But as the average age of travellers, population density, pollution and zoonotic diseases increase, so, too, do health risks associated with travel.
Pharmacists have long provided ad hoc advice for travellers in response to patient queries, whether it be guidance on how to store medicines during transit or encouraging patients to see a GP, or dedicated travel doctor service in major cities, for vaccination.1
But with more Australians jetting off to more locations more frequently, more travel health services are needed. Some pioneering pharmacists are leading the way. Enabled by an increasing range of vaccines pharmacists can both prescribe and administer as well as formal pilots and programs from state governments, community-pharmacy based travel health consultation services are taking flight.
How does a formal travel health service differ from ad hoc advice?
Put simply, its more comprehensive. It considers a much wider range of risks than the patient may self-identify and makes recommendations to the traveller proportional to their individual needs.
‘Outside of a formalised program like the Victorian Community Pharmacy Statewide Pilot project,2 the pharmacist may not go into as much depth about [travel health] matters because there’s an expectation the consumer’s GP will have that discussion when a patient asks about vaccines,’ says PSA Victorian State Manager Jarrod McMaugh MPS.
It means pharmacists ‘instead of picking and choosing pieces of information they’re going to add on to a consultation before referring and saying “go to see your GP for these things”, they’re going to address them all directly in a travel health service’, he says.
And to be comprehensive the service needs a deep understanding of the traveller(s), when/where they are going, how they are going to get there – e.g. cruise, fly, drive, trek – and the types of things they’ll do when they are there.
Getting started
Establishment or formalisation of any service has common features: staff training, developing standard operating procedures, setting up documentation systems and advertising. However, a travel health service has two additional aspects, which are critical to success.
Firstly, the practitioners need to really wrap their heads around international travel, the health risks a person is likely to encounter and how to craft a valuable consultation for each traveller.
‘Some pharmacists are avid international travellers, and will have generated substantial knowledge of destinations, transport routes and product availability at pharmacies overseas. This expertise is advantageous in providing bespoke, individualised advice,’ Mr McMaugh says.
‘For example, Australians are often surprised by the high cost of sunscreens overseas, or how unpleasant the taste of oral rehydration products available in other markets are.’
‘Additionally, people often overlook prohibitions on carrying common medicines through common transit points such as Middle Eastern or Asian airport hubs.’
These kinds of insights may not be front-of-mind for travellers when booking in for a consultation, but they are important for risk mitigation and highly valued.
Also important is anticipating risks for which travellers may not be alert. For example, a family holiday to a Thailand beach resort may initially seem lower risk, but activities and excursions where you interact with wildlife such as monkeys are common and carry zoonotic infection risk.
For pharmacists who do not have this knowledge from primary experience, seeking these reflections from colleagues or through careful listening with patients is essential.
Structuring a consultation is something each practitioner needs to find their own way to master. Unlike other services, the approach to these longer consultations isn’t so black and white.
Compared to other expanded scope programs, travel health requires mastering the navigation of the grey.
One of the hundreds of pharmacists offering a travel service under the Victorian pilot is Melbourne’s Tooronga Amcal Pharmacy owner Andrew Robinson MPS, who reflected that ‘[with a UTI treatment service], we follow a protocol guideline and it’s more straightforward to undertake’. With travel, it is like a Pandora’s box that you can open and find you going all over the place with a whole lot of different destinations, a whole lot of different complications, a lot of different needs.’
Finding prospective travellers
A common theme with all pharmacists contacted by AP is that the identification of patients who would benefit from the service has initially been more successful through conversations in patient interactions than via formal advertising.
The trigger for knowing a patient could benefit from a sit-down travel health consultation with a pharmacist could be anything, Mr McMaugh notes.
‘It can literally be a comment in passing: ‘My son is about to travel overseas for the first time.’
Other queries could be related to how to carry medicines safely overseas, or interest in medicines for motion sickness.
Andrew Robinson describes the trial as a ‘significant endorsement by health regulators that pharmacists are capable of delivering more complex services.
‘Before actually doing an appointment, you’ve got to tease it out a bit first. It’s not like some of the other pilot programs that we’ve done, which are very, “you’ve got a urinary tract infection. You fit the criteria. We can undertake the consultation”.’
‘In contrast, you almost need to do a [travel health] consultation to find out whether you need to refer them on. So, I try and garner that before. But I think if we boil it down and keep it simple, the reality is there’s plenty of people out there who are not thinking about travel health that need a typhoid vaccine and a bit of a conversation,’ he said.
Mr Robinson identified that consumers who, at short notice, book a trip to south-east Asia and don’t plan a GP visit have particularly welcomed his travel health consultations.
‘We see this particular pilot really looking at the high-risk patient, the person who sees a cheap flight to Indonesia and in 3 weeks’ time they’re gone. They think of it as just a great way to relax and give very little thought to the risks associated with that travel.’
Susannah Clavin MPS, the owner of the Marc Clavin Pharmacy at Sorrento on Victoria’s Mornington Peninsula, regularly discusses travel health with patients and consumers, and has had success with online bookings.
‘Most [patients] were heading to south-east-Asia. They are all very time-poor, so if the pharmacy is closely located to their home or workplace then I think they will appreciate the convenience. Being able to book online, too, is a bonus.’
Like Mr Robinson, Ms Clavin had also identified patients through conversations at the dispensary.
‘One of the patients had a prescription for the vaccine and asked us for a quote,’ recalls Ms Clavin. ‘We gave the quote and mentioned that we could also administer the vaccine, for a fee. [The patient] was very keen to save a trip to the doctor.’
Fee-for-service
How much should the service charge? While each business needs to make its own decision based on the costs of delivery and business policies, experience in travel doctor clinics and within pilot sites shows consumers are willing to pay for the consultation service, which may include administration of vaccines.
When AP spoke to Mr Robinson, he had conducted about a dozen travel health consultations, charging $50 for a half-hour consultation. Families travelling overseas, he says, have found the consultations particularly attractive because the pharmacist can give advice to an entire family in one appointment.
Looking to the future
Feedback from the Victorian trial shows an effective travel health consultation service is a good fit with pharmacies that have a well-integrated vaccination service, according to Mr McMaugh.
‘If you’re doing the occasional vaccine, you have to change gears, going from doing whatever other services or dispensing you were doing, to administering the vaccine and then coming back into the retail and dispensing space,’ he says.
Mr Robinson hopes travel health consultations become a permanent fixture in the service landscape for pharmacy.
‘Travel is all about having fun. But we need to make sure it stays fun, and you stay healthy, because otherwise it’s a very expensive holiday.’
The rise of zoonotic diseases
Where a person is travelling to and where they are staying matters. A trip to Zimbabwe to see Victoria Falls has a very different risk profile to a walking safari at remote campsites. Similarly, holiday resorts in south-east Asia next to agricultural fields have a different risk profile to city hotels.
Recent decades have seen the rise and reemergence of viral zoonotic diseases.4 The growth of tourism has led to land changes, travel patterns and farming practices which increase the risk of zoonotic diseases, including novel and well-established pathogens.⁵
Travellers and health professionals alike need to keep abreast of these trends. Rabies is a good case in point. The USA continues to log around 4,000 animal rabies cases each year, with >90% of cases from bats, raccoons, skunks and foxes – a shift from the 1960s where dogs were the primary rabies risk to humans.⁶ In contrast, dog bites are the predominant source of rabies infections in Africa.⁷
Karen Carter FPS, partner of Carter’s Pharmacy Gunnedah and owner of Narrabri Pharmacy in north-west NSW, can now offer rabies vaccinations.
‘You think of exotic animals for rabies but sometimes it’s dogs that people are at risk of being bitten by,’ Ms Carter says.
The vaccine isn’t cheap, so considering the exposure risk and access to post-exposure prophylaxis is important when discussing the benefits of the vaccine with patients.
‘We had a gentleman travelling to Africa and then on to South America for his work in the agriculture industry, so we recommended he get the rabies vaccine.’ Ms Carter says. In fact, he not only got the rabies vaccine administered, but the hepatitis A and typhoid vaccines as well before he left.
‘We were also able to refer him to a Tamworth GP clinic for his yellow fever vaccines, Ms Carter adds. ‘He thought it was great that we could do all but one of his vaccines in the pharmacy.’
Other zoonotic infections, such as mpox, avian influenza and Japanese encephalitis also have changing patterns of transmission and distribution, which increasingly require consideration in travel health services.
Case study
Dat Le MPS Owner, Priceline Pharmacy, Knox, Melbourne VIC
This traveller
Mrs L, a 62-year-old regular dose administration aid (DAA) patient, is living with gastro-oesophogeal reflux disease (GORD), hypertension, atrial fibrillation, high cholesterol and osteoarthritis in the knee.
Current medicines
This time Mrs L explains that it will be summer when she arrives in both south-east Asian countries.
Recommendations
Based on her travel plans, I recommend vaccination for:
Mrs L was advised she would have full protection from hepatitis A in 2 weeks and that it may be at least a week before the COVID-19 booster provided full protection.
She was also told that the vaccinations may cause sore arms, some redness, fever or chills.
While her typhoid vaccination would protect her for 3 years, she could have another COVID-19 booster in a year.
For the hepatitis A vaccine, a typical course is two doses – the first at day 0, and the second from 6 months later, ideally before 12 months, if she travels again within the year.
Rehydration preparations were also recommended, along with hand sanitiser, face masks and sunscreen for Mrs L’s holiday group tour to various sight-seeing locations.
When she collected her DAAs, we advised Mrs L how to store her medicines. She was pleased she didn’t need to make a GP appointment, organise vaccine prescriptions, collect them at the pharmacy and then take them back to the doctor to be administered. I reminded her that we would call her about her second hepatitis A dose to complete her course.
We put a note on her next DAA collection asking about her holiday and any problems she may have had such as diarrhoea or tablet storage problems.
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[post_content] => Case scenario
Mrs Johnson, a 65-year-old patient with hypertension, comes to the pharmacy to fill her repeat prescriptions for perindopril 4 mg and amlodipine 5 mg. You notice that Mrs Johnson is getting her repeats dispensed irregularly and offer her a blood pressure (BP) check. Mrs Johnson mentions that her BP has been poorly controlled, and she often forgets to take her medicines.
Learning objectivesAfter reading this article, pharmacists should be able to:
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Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.
Missed or delayed administration of prescribed doses is a common concern in clinical practice and can be viewed under the framework of non-adherence, either intentional or unintentional. Medication adherence refers to the extent to which a person’s behaviour matches with the agreed recommendations from a health care provider.1 Adherence to prescribed dosing regimens is crucial for achieving the best therapeutic outcome.
Understanding the implications of missed doses and how to manage them effectively will assist pharmacists in providing clear and concise instructions to patients who miss a dose.
Different terminologies have been used to describe deviations from prescribed therapies. The terms adherence, compliance and concordance are often used interchangeably. However, compliance implies patient passivity in treatment decisions.2
Adherence and concordance suggest a more active and collaborative approach between the patient and healthcare provider, with concordance specifically highlighting the importance of mutual agreement in treatment decisions.3
Many underlying factors contribute to an individual’s adherence to their medication regimens. When considering the factors contributing to missed medicine doses, several patient-related aspects are particularly relevant for pharmacists. A patient may deliberately skip or delay a dose due to adverse effects, a perceived lack of effect, a lack of motivation, or if they believe the medicine is unnecessary.4 On the other hand, unintentional missed doses may be due to careless factors, including forgetfulness and limited understanding of the prescribed instructions.4
In a survey of patient adherence to medicines for chronic diseases, 60% of participants stated forgetfulness was the reason for missed doses.5 The study found that missed doses were more commonly reported by patients with vitamin D deficiency, followed by hyperlipidaemia.5
The reasons for missed doses may also be a combination of intentional and unintentional factors. For instance, patients who are not motivated to take a medicine may be more likely to forget to take a dose.4
Missed or delayed medicine doses are more likely when regimens are complex due to forgetfulness or when patients have fears and concerns about adverse drug reactions.6 Inadequate communication between healthcare providers and patients can also lead to confusion about medication regimens.6 For other individuals, busy schedules, frequent travel, major life events or interruptions to usual routines can disrupt their ability to take medicines consistently.7
The World Health Organization identified the following five interacting dimensions that affect medication adherence8,9:
Time-critical medicines are ‘medicines where early or delayed administration by more than 30 minutes from the prescribed time for administration may cause harm to the patient or compromise the therapeutic effect, resulting in suboptimal therapy’.10 An example is levodopa-containing products for the treatment of Parkinson’s disease. A short delay can worsen symptoms and cause rigidity, pain and tremor, increase the risk of falls, as well as cause stress, anxiety and difficulty in communicating.11,12 Additionally, anticoagulants (e.g. enoxaparin) require strict adherence to dosing schedules, as clotting complications such as deep vein thrombosis or pulmonary embolism can be life-threatening.13
Identifying whether a medicine is time-critical requires knowledge of the half-life of the medicine, as it is a major determinant of the fluctuation in inter-dose concentrations at a steady state.14 Half-life serves as guidance for making informed recommendations on what to do when a dose of medicine is missed. Four to five half-lives is a general rule of thumb used to approximate the time needed for a medicine to be considered eliminated from the body. At that time point, the plasma concentrations of a given medicine will reach below a clinically relevant concentration.15
While an occasional missed dose of most medicines will have little consequence on therapeutic outcomes, delays or omissions for some medicines can lead to serious harm. For some medicines, such as an antidepressant, it is possible to get withdrawal symptoms within hours of the first missed dose.16
Missing a dose of medicines with a short half-life and/or rapid offset of action in relation to the dosing interval may lead to periods of sub-therapeutic plasma drug concentrations, and therefore insufficient pharmacologic activity.17 In contrast, medicines with a long half-life stay in the body longer. As a result, missing a dose may not cause a significant drop in drug levels, reducing the risk of sub-therapeutic levels. However, it is important to note that the clinical effects of some medicines are not directly related to their half-lives.14 Some examples of these drugs are those that act via an irreversible mechanism (e.g. aspirin), an indirect mechanism (e.g. warfarin), and those that are pro-drugs or metabolised into an active form with a different half-life.14,18
The following are some examples of medicines requiring strict adherence to dosing schedules to avoid significant or catastrophic long-term patient impact:
1. Consumer Medicine Information
The first place a patient should be instructed to look for advice if they forget to take a dose of their medicine at the usual time is the Consumer Medicine Information (CMI) leaflet.
Most commonly dispensed medicines have a CMI leaflet with a section for when a dose is missed.19
Pharmacists should use the CMI to reinforce verbal advice for missed or delayed doses during their counselling as it would prepare patients for this eventuality. Pharmacists should provide approved CMI leaflets to patients when they start prescription medicines, and at each subsequent dispensing according to established guidelines as part of good dispensing practice.18
CMIs are usually included as part of the medicine packaging. Alternatively, the TGA website (www.ebs.tga.gov.au) provides access to the latest approved versions of the CMI and Product Information (PI) provided by the pharmaceutical companies for most of the prescription medicines available in Australia.
2. Other methods
Other ways patients can obtain information about missed medicine doses include20:
3. General advice
When specific information is not available, the general advice to manage a missed or delayed dose is to take the missed dose as soon as it is remembered if the dose is less than 2 hours late.21 If the dose is more than 2 hours late21:
4. Do not take a double dose
It is generally not recommended to take a double dose to make up for a forgotten dose unless specifically advised.21
Many medicines have special instructions on managing missed doses. While it is not possible to include advice for all, Table 1 lists a few examples of some common medicines that pharmacists may encounter in their daily practice.
Strategies to prevent a missed or delayed dosePharmacists play a central role in preventing a missed or delayed dose. The strategies to avoid missed doses lie within the underlying cause.4 In addition to clearly explaining the dosing schedule, pharmacists should also focus on addressing the importance of taking medicine consistently as prescribed, particularly for medicines indicated for asymptomatic conditions or preventive measures, as the benefits may not be realised immediately. One study suggests using strategies such as motivational interviewing or another approach that addresses behavioural intention.4
Pharmacists should consider and act on the barriers patients might face in adhering to their medication regimen, which may include forgetfulness, complex or variable dosing schedules, adverse effects, or other health, dexterity or vision issues. This may require considerations of how the patient’s daily routine or lifestyle might impact their ability to take their medicines as prescribed (e.g. work schedule, travel). For instance, patients with cognitive impairment or those who forget to take their medicines may need memory triggers and a way to check whether or not they took them.4
Pharmacists can suggest the use of dose administration aids, pill organisers, sticky notes, alarm reminders on mobile phones, or “habit stacking” by associating medicine administration with a daily routine such as mealtimes and keeping the medicine visible.5 Some patients may find themselves frequently forgetting if they have taken their medicines, which is common for mundane behavioural decisions. One solution is to create a habit of recording each dose on a calendar, or if it is a pill bottle, simply flip it over every time a dose is taken as a visual reminder. Lastly, consider if alternative formulations (e.g. extended-release or combination formulations) are an option, as this could reduce the frequency of doses, thereby simplifying medication regimens.
Pharmacists can effectively manage missed doses by recommending appropriate action for missed doses and proposing tailored strategies that work best to address a specific barrier for patients. Pharmacists can provide patient education and counselling for medication adherence, collaborate with the patient’s primary care provider to discuss potential adjustments to their treatment plan, as well as offer dose administration aids. These actions can have a substantial impact on patient outcomes, including improved therapeutic outcomes, reduced health complications, improved quality of life and patient empowerment.
Missed medicine doses are common in practice, with potentially serious consequences for patient health, particularly when it comes to time-critical medicines. Pharmacists play a crucial role in providing advice for managing missed doses and supporting patients with their medication regimen management through the various strategies available.
Case scenario continuedYou review Mrs Johnson’s medication regimen and educate her on the importance of medicine adherence. You suggest using a pill organiser and setting daily alarms, and you talk to her GP about changing to a fixed-dose combination of perindopril/amlodipine. You also provide Mrs Johnson with a CMI leaflet and highlight for her the section that explains what to do when a dose is missed. When Mrs Johnson next returns to the pharmacy, you ask her how the interventions are helping. Mrs Johnson reports better adherence and thanks you for your help. Three months later, her blood pressure is well-controlled, significantly reducing the risk of future complications. |
Dr Amy Page (she/her) PhD, MClinPharm, GradDipBiostat, GCertHProfEd, GAICD, GStat, FSHPA, FPS is a consultant pharmacist, biostatistician, and a senior lecturer at the University of Western Australia.
Hui Wen Quek (she/her) BPharm(Hons), GradCertAppPharmPrac is a pharmacist and PhD candidate at the University of Western Australia.
Julie Briggs (she/her) BPharm, MPS, AcSHP
Hui Wen Quek is supported by an Australian Government Research Training Program (RTP) scholarship at the University of Western Australia.
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[post_content] => As temperatures soar, ensuring proper storage of medicines is more critical than ever. Here’s how heat impacts medicine safety and how pharmacists and patients can safeguard their efficacy.
Proper storage of medicines is vital to maintaining their efficacy and safety. But with Australia experiencing record-breaking temperatures, medicine integrity is at risk.
While it’s important to be aware of the effects climate change could potentially have on medicine safety, it may only exacerbate some of the problems we already have, said Dr Manuela Jorg, Senior Lecturer, Faculty of Pharmaceutical Sciences at Monash University.
Which drugs are most heat sensitive?
Medicine dosage forms such as liquids and solutions are more heat sensitive compared with solid compounds, said Dr Jorg. This includes injectable medicines such as insulin, vaccines or antibodies.
‘Sometimes short exposure to heat can have a detrimental effect but often it’s the longer exposure that can cause degradation of a drug,’ she said.
‘Degradation can lead to the medication becoming less effective or a molecule degrading into a different compound which could potentially be toxic and cause harmful side effects.’
How important is it to store medicine correctly?
A key aspect in protecting medicine integrity is ensuring medicines are stored correctly and not exposed to prolonged heat, sunlight or humidity.
Most medicines should be stored below 25⁰C and are tested by pharmaceutical companies at the recommended temperature they should be stored at for the full lifetime of their shelf life. They are also tested at temperatures of up to 40⁰C to ensure they remain stable.
Even with this added layer of testing, Pete Lambert, Director of the Monash Quality of Medicines Initiative, said that many patients may not be aware of the importance of keeping medicines at recommended temperatures and the potential dangers that not following these recommendations could create.
‘It's unlikely that once in the hands of the consumer, products will be stored in the right conditions for extended periods,’ he said ‘For example, simply leaving them in the car for a short period of time, in direct sunlight, or where temperatures can spike, could be problematic.’
Dr Jorg agrees. ‘As soon as we give medication to a patient, we have no control over what happens to the drugs,’ she said. ‘There have been several studies that show as soon as the medicine is in the hands of the patients, either transporting them home or storing them are often done in the wrong conditions.’
Signs of heat-affected medicines
Signs that medicines have been affected by the heat include changes in colour, consistency or smell; unusual softening or melting of solid forms of medicines, clumping of powders, and cracked or chipped coatings on tablets or capsules.
Heat exposure can also cause problems with medicine devices that involve a mechanism such as EpiPens, bronchial inhalers and autoinjectors. High temperatures can cause these to malfunction or even burst in the case of inhalers. Relying on these types of medicines that have been damaged by the heat could be fatal in an emergency.
How does hot weather impact the effects of medicines?
Another important aspect of extreme weather that’s important to consider is how higher temperatures can impact the effects of some medicines, said Mr Lambert. For example, patients who take medicines with a narrow therapeutic index such as warfarin, digoxin or lithium may be at risk of the drug becoming toxic if they become dehydrated in high temperatures.
Similarly, other medicines such as anticholinergic drugs that decrease the thirst response or inhibit sweating can cause patients to be at risk of dehydration and associated illness in hot weather.
Patients should be made aware of these risks and be advised to stay in cool environments, avoid going out in the hottest part of the day, and stay hydrated.
The challenge of online pharmacy providers
With most big banner pharmacy groups offering online ordering of medicines, pharmacists should provide guidance on maintaining medicine integrity where possible, said Mr Lambert.
‘If patients are going to order medicines online, it’s important that pharmacists advise patients to choose reputable providers,’ he said.’ Good providers will be aware of what kind of packaging the product needs to be in when it's shipped, so it’s adequately insulated for this period.'
If medicine is required to be kept in the cold chain, it should be shipped under refrigerated conditions, or with cold packs. If the product needs to be stored at temperatures less than 25⁰C packaging should be adequately insulated to ensure safe transport.
Patients should also know when their medicine is going to be delivered so they can be home and immediately take it into proper storage conditions once it arrives. If no one is home, patients could consider having a cooler bag at the front door where the medicine can be left, helping protect medicines from heat extremes.
What advice should pharmacists provide?
Many people may not know how to ensure their medicine remains safe and effective which is why education around medicine safety is really important, said Dr Jorg.
‘Pharmacists should explain proper storage techniques for particular medicines along with signs that a medicine may have been affected by the heat,’ she said. ‘It’s also important to make sure patients understand that if their medicines looks different to what it usually does, or they have any concerns to check with their doctor or pharmacist before taking it.’
Mr Lambert believes patients should understand medicine safety is often dependent upon adhering to the storage condition, which is on the carton or patient information leaflet, along with checking the expiry date.
‘It’s also important not to take the products out of the packaging they’ve been supplied in, because the stability and recommended storage conditions are based on the medicine being stored in the containers in which they’re supplied,’ he said.
Pharmacists should also explain the risks of leaving medicines in the car where temperatures can spike and recommend patients keep medicines in a cooler bag if they are travelling.
Ensuring patients understand how extreme heat can affect the way they handle their medicine, or how their medicine may affect them in higher temperatures is also important.
In the case of EpiPens, bronchial inhalers and autoinjectors, they mustn’t be left in hot cars or other environments that can become excessively hot, nor should they be exposed to direct sunlight. Keeping them well-insulated will help ensure the medicine and mechanisms to deliver the medicine are protected.
[post_title] => Maintaining medicine integrity in high temperatures
[post_excerpt] => As temperatures soar, ensuring proper storage of medicines is more critical than ever. Here’s how heat impacts medicine safety and how pharmacists and patients can safeguard their efficacy.
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Australian Pharmacist is the official journal for Pharmaceutical Society of Australia Ltd.
