Couzos, S., Smith, D., Buttner, P., and Biros, E. (2020) Assessment of change in medication adherence and self-assessed health status 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: To assess the impact of integrated pharmacist interventions on self-reported medication adherence and self-assessed health status in Aboriginal and Torres Strait Islander adults with chronic disease attending Aboriginal Community Controlled Health Services (ACCHSs) enrolled in the IPAC study, compared with usual care (pre-intervention), and to develop and validate the performance of a self-reported adherence tool in this context.

Design and participants: The study was a non-randomised, prospective, pre and post quasi-experimental community-based, participatory, and pragmatic trial that integrated a registered pharmacist within ACCHS in Queensland, the Northern Territory or Victoria. The intervention comprised non-dispensing medicines-related services, collaborative and coordinated care, including the provision of medication management reviews.

Participants were usual patients of the ACCHSs aged 18 years or older with a chronic disease. Participants consented to receive the intervention and were followed for up to 15 months. In order to enable assessment of barriers to medication adherence in the context of the IPAC study, the NACCHO Medication Adherence Response Scale (NMARS) was newly developed and validated following standard principles of psychometric testing.

Methods: The NMARS tool was developed within a formal conceptual framework and was then refined by an expert panel, pre-tested with Aboriginal consumers, and pilot tested involving IPAC participants. Content and construct validity of NMARS was assessed. Reliability was evaluated with Cronbach’s alpha, inter-item, and item-test correlation. Dimensionality was assessed by principal component analysis (PCA). Semi-structured interviews with IPAC pharmacists were conducted to collect feedback about NMARS practicality and suitability.

For comparison of adherence pre- and post-intervention, de-identified participant data were electronically extracted from health records and pharmacist logbook. Main outcome measures included participant scores using a self-reported adherence assessment with a single-item question (SIQ), the adherence assessment according to the NMARS tool, and the self-assessed health status derived from the first question (SF1) of the Short Form (SF)-36 health related quality of life instrument. Adherence testing scores were dichotomised to “adherence” and “non-adherence”, and the 6-point SF1 ordinal results were dichotomised to “very good to excellent” health status versus lesser categories. Changes in binary outcome measures were calculated and are presented with cluster-adjusted (ACCHS) 95% confidence intervals. Statistical comparisons of changes in the three outcome measures were conducted using cluster-adjusted (ACCHS) conditional fixed-effect logistic regression analyses for paired data. The effect of participant, health service, and intervention characteristics on differences of outcome measures were examined, including the influence of Home Medicines Review and other comprehensive medication management reviews, using cluster-adjusted (ACCHS and participant clusters) logistic regression analyses.

Results: NMARS content and construct validation procedures affirmed acceptable validity for the newly developed tool. Cronbach’s alpha was 0.66 indicating the upper limit for validity and acceptable internal consistency for the purpose of the study. PCA analysis supported unidimensionality of the tool. Pharmacists reported the NMARS and SIQ tools were useful to assess participant adherence. Participants with paired SIQ and NMARS data (n= 1,103) and paired SF1 data (n=975) were enrolled from 18 ACCHSs involving 26 integrated pharmacists with a median of 213 (IQR: 134-303) and 201 (IQR: 126-279) days between assessments, respectively. Almost all participants were Aboriginal and/or Torres Strait Islander with a mean age at baseline of 58 (SD 29.8) years. At baseline, 70.8% (781/1103) of participants were adherent according to SIQ (scores 6 or 7), 73.3% (808/1103) were adherent according to NMARS (scores 8 to 11), and 18% (175/975) had ‘excellent to very good’ health status according to SF1. There was a 12.8% (142/1103) and 10.3% (114/1103) net absolute increase in the number of participants adherent to medications at the end of the study compared with baseline (p<0.001), using NMARs and SIQ measures respectively, and a 23.9% (233/975) net absolute increase in the number of participants with improved self-assessed health status (p<0.001).

Conclusion: Integrated pharmacists embedded into usual care within ACCHSs in a range of geographical settings, significantly improved the medication adherence of Aboriginal and Torres Strait islander adults with chronic disease, as well as their self-assessed health status. The NMARS tool was a valid and reliable research tool when used to evaluate the extent of medication adherence and reasons for medication non-adherence in the context of this study.

Item ID:	87224
Item Type:	Report (External Commissioned Report)
Keywords:	Medication adherence, medication utilisation, medication appropriateness, Aboriginal, Torres Strait Islander, pharmacy, pharmacist, integrated care, Medicare, primary health care, chronic disease
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 03:59
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 > 200105 Treatment of human diseases and conditions @ 50% 20 HEALTH > 2001 Clinical health > 200102 Efficacy of medications @ 50%
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