C H A P T E R 6
Challenges to effective drug therapy
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to be used by Australians and visitors from a number
of countries where there are reciprocal arrangements,
including New Zealand, the Republic of Ireland and
the United Kingdom. Within the scheme, there exists
a safety net which is set each year. Upon reaching the
safety net for that year, an individual or family is eligible
to receive subsequent medicines at either a concessional
rate or for free, depending on their circumstances.
Quality use of medicines
The Australian Government, through the National
Medicines Policy, operates the Quality Use of Medicines
(QUM) program. The program is underpinned by four
main principles.
Judicious use
requires that medicines
are used when appropriate and after all options have
been considered. Secondly, there should be
appropriate
use
of medicines to treat the condition with all factors,
such as risks and costs, considered. Thirdly,
safe use
of
medicines is required to avoid misuse, while
efficacious
use
requires that medicines used have beneficial health
outcomes. Nurses and midwives play a central role in
enacting this program as they are often the closest to
people and their medicines.
In New Zealand, the New Zealand Medicines
and Medical Devices Safety Authority collects infor-
mation on the safety and quality of medicines and
vaccines through a variety of sources. These activities
are called pharmacovigilance. There are different phar-
macovigilance centres in New Zealand that nurses
and midwives need to be familiar with. The Centre for
Adverse Reaction and Monitoring Centre (CARM) in
Otago, the Intensive Medicines Monitoring Programme
(IMMP), the Medicines Adverse Reaction Committee
(MARC) and a new scheme called the Medicines Moni-
toring (M2). This scheme’s aim is to highlight potential
safety issues identified from reports of suspected adverse
medicine reactions sent to CARM, to stimulate further
reports and to increase the information on these poten-
tial safety signals.
Home care
The home care industry is one of the most rapidly
growing responses to the changes in costs and medical
care delivery. People now routinely go home directly
from surgery with the responsibility for changing their
own dressings, assessing wounds and monitoring their
recovery. People are also being discharged from hos-
pitals because the funded hospital days allowed for a
particular diagnosis have run out. These people may
be responsible for their own monitoring, rehabilitation
and drug regimens. At the same time, the population is
ageing and may be less accepting of all of this respon-
sibility. Community nurses and midwives as well as
hospital in the home programs are taking over some of
the responsibilities that used to be handled in hospitals.
The responsibility for meeting the tremendous
increase in teaching needs of people frequently resides
with the nurse or midwife. People need to know exactly
what medications they are taking (generic and brand
names), the dose of each medication and what each
is supposed to do. They also need to know what they
can do to alleviate some of the adverse effects that are
expected with each drug (e.g. small meals if gastro
intestinal upset is common, use of a humidifier if
secretions will be dried and make breathing difficult);
which OTC drugs or alternative therapies they need to
avoid while taking their prescribed drugs; and what to
watch for that would indicate a need to call the health-
care provider. With people who are taking many drugs
at the same time, this information should be provided
in writing, in language that is clear and understanda-
ble. Many pharmacies provide written information with
each drug that is dispensed, but trying to organise these
sheets of information into a usable and understandable
form is difficult for many people. The nurse or midwife
often needs to sort through the provided information to
organise, simplify, and make sense of it for the person.
The cost of dealing with toxic or adverse effects is often
much higher, in the long run, than the cost of the time
spent teaching and explaining things.
The projections for trends in healthcare indicate
even greater expansion of home healthcare provision,
with hospitals being used for only the most critically ill
people. The role of the nurse and midwife in this home
health system is crucial—as teacher, assessor, diagnosti-
cian and advocate.
Cost considerations
Despite the insurance cover a person may have for
prescription medications, it is often necessary for the
healthcare provider to choose drug therapy based on
the costs of the drugs available. With more and more
of the population reaching retirement age and depend-
ing on a fixed income, costs are a real issue. Sometimes
this may mean not selecting a first-choice drug but
settling for a drug that should be effective. People who
take antibiotics must be reminded to take the full course
and not to stop the drug when they feel better. People
may be tempted to stop taking the antibiotic in order to
save the remaining pills for the next time they feel sick
and to also save the cost of another healthcare visit and
a new prescription. This practice has contributed to the
problem of resistant bacteria, which is becoming more
dangerous all the time.
People also need to be advised not to split tablets
in half unless specifically advised to do so. Some drugs
can be split, and it is cheaper to order the larger size
and have the person cut the tablet. Some people think
that by cutting the drug in half they will have coverage
for twice the time allowed by the prescription and will
