Couzos, S., Smith, D., Buttner, P., and Biros, E. (2020) Assessment of medication appropriateness using the Medication Appropriate Index (MAI) in Aboriginal and Torres Strait Islander patients with chronic disease receiving integrated pharmacist support within Aboriginal Community-Controlled Health Services (IPAC project). External Commissioned Report. Australian Government, Canberra, ACT, Australia.

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Abstract

Objective: Suboptimal prescribing quality is a barrier to achieving equitable health outcomes for Aboriginal and Torres Strait Islander peoples who experience a higher burden of chronic disease than other Australians. The study objective was to assess the effect of an integrated non-dispensing pharmacist on medication appropriateness in Aboriginal and Torres Strait Islander adults with chronic disease compared with usual care pre-intervention.

Design and participants: Participants attended Aboriginal Community Controlled Health Services (ACCHSs) and were enrolled in the Integrating Pharmacists within ACCHSs to improve chronic disease management (IPAC) project- a non-randomised, prospective, pre and post quasi-experimental, community-based, participatory, and pragmatic study. Consented participants were recipients of integrated pharmacist care within ACCHSs that also included a prescription quality review as part of 10 core pharmacist roles. Prescribing quality (medication appropriateness and overuse) was assessed by pharmacists with the medication appropriateness index (MAI). Deidentified participant data was electronically extracted from health records.

Outcome measures: A subset of the enrolled cohort was assessed for change in prescribing quality: summated mean MAI scores per participant and per medication, and the proportion of: medications rated inappropriate according to ten MAI criteria; participants receiving ≥1 medication rated inappropriate and/or unnecessary (≥ 1 overuse MAI criteria); and prescribed medications with an inappropriateness rating by medication type.

Results: Of participants (n=1,456) from 18 ACCHSs involving 26 integrated pharmacists, 390 were selected (non-probabilistic) for MAI assessments at baseline and at the end of the study. Loss to follow-up (n=33 without repeat MAI) left 357 participants for paired data analysis (median interval of 270 days). Participants had cardiovascular disease (CVD), Type 2 diabetes mellitus (T2DM), chronic kidney disease (CKD), or other chronic disease, and 93% were Aboriginal and/or Torres Strait Islander [mean age 57 years (SD 14.4)]. Chronic disease co-morbidity was present in 87.4%. MAI participant characteristics differed little from the remaining cohort (n=1,099). The median number of medications taken by MAI participants at baseline was 7.0 (IQR 5-9). MAI evaluations each took 60 minutes (median) to complete. A total of 2,804 and 2,963 medications were evaluated at baseline and at the end of the study respectively. At baseline, 67.8% (n=242) of participants were prescribed ≥1 medications rated as inappropriate in at least one MAI criterion; 23.1% of all medications had ≥1 inappropriateness rating; the mean MAI score per participant was 6.02 (SD±23.6); and the mean MAI score per medication was 0.76 (SD±8.5). The most common reason for medication inappropriateness was incorrect dosage. The intervention significantly reduced mean MAI scores per participant (to 3.20, SD ±11.7, p=0.003); the mean MAI score per individual medication (to 0.39, SD ±-4.4, p=0.004); the proportion of participants receiving medications rated as inappropriate (to 44.5% n=159, p<0.001), and the proportion of medications with the following prescribing risks: incorrect dosage, impractical directions, unacceptable therapy duration, drug-disease interactions; and unnecessary medications due to absent clinical indications, or lack of clinical effectiveness (all p <0.05). There was a 34.1% relative reduction in the number of participants with medications meeting ≥ 1 medication overuse criteria. Significant reductions in participant numbers prescribed medications with an inappropriateness rating was observed for: cardiovascular (-19.9% absolute reduction, p<0.001), endocrine (-11.2%, p<0.001), and respiratory conditions (-4.5%, p=0.019). Quality prescribing improved for participants with medications for hypertension, diabetes and/or dyslipidaemia (absolute reductions of -5.3%, p=0.01; -9.5%, p<0.001 and -9.8%, p<0.001 respectively).

Conclusion: Nearly two-thirds of participants were prescribed a medication that was rated as inappropriate pre-intervention. Prescribing quality improved significantly for participants following the integrated pharmacist intervention within ACCHSs. Improvements were significant in participants challenged by chronic disease comorbidity and polypharmacy and within a short follow-up period. Prescribing quality improvements are generalisable to the broader subset of IPAC participants, and potentially to other Aboriginal peoples and Torres Strait Islanders in receipt of pharmacist services integrated within primary health care settings such as ACCHSs.

Item ID:	87154
Item Type:	Report (External Commissioned Report)
Keywords:	medication adherence, medication access, chronic disease, Aboriginal, Torres Strait Islander, Pharmacy, pharmacists, integrated care, medication appropriateness
Additional Information:	Report to the Pharmaceutical Society of Australia for the IPAC Project. This report is publicly available at the following website: https://www.health.gov.au/resources/publications/integrating-practice-pharmacists-into-aboriginal-community-controlled-health-services-final-report
Funders:	Australian Government Department of Health & Ageing
Projects and Grants:	Pharmacy Trials Program
Date Deposited:	03 Oct 2025 05:19
FoR Codes:	42 HEALTH SCIENCES > 4203 Health services and systems > 420319 Primary health care @ 50% 32 BIOMEDICAL AND CLINICAL SCIENCES > 3214 Pharmacology and pharmaceutical sciences > 321403 Clinical pharmacy and pharmacy practice @ 50%
SEO Codes:	20 HEALTH > 2001 Clinical health > 200102 Efficacy of medications @ 50% 20 HEALTH > 2001 Clinical health > 200105 Treatment of human diseases and conditions @ 50%
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