Int J Clin Pharm (2014) 36:460–468 DOI 10.1007/s11096-014-9926-9
RESEARCH ARTICLE
Clinical services for obstructive sleep apnea patients in pharmacies: the Australian experience Carissa A. Hanes • Keith K. H. Wong Bandana Saini
•
Received: 7 December 2013 / Accepted: 11 February 2014 / Published online: 23 February 2014 Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2014
Abstract Background In Australia, certain pharmacies have undertaken a role in the management of the chronic sleep disorder, obstructive sleep apnea. The perspectives of pharmacy staff involved in this niche clinical service have never been formally collated on a national scale. The experiences of Australian pharmacies could provide a template for pharmacies in other health systems to adopt similar roles. Objective To provide an overview of the perspectives of pharmacy staff involved in Continuous Positive Airway Pressure (CPAP) and sleep apnea-related services. Specifically, to describe clinical and structural elements, explore benefits and barriers, investigate viability, and gauge perspectives on future directions. Setting
Electronic supplementary material The online version of this article (doi:10.1007/s11096-014-9926-9) contains supplementary material, which is available to authorized users. C. A. Hanes (&) B. Saini Faculty of Pharmacy, The University of Sydney, Pharmacy Building A15, Science Road, Sydney, NSW, Australia e-mail:
[email protected] C. A. Hanes K. K. H. Wong B. Saini The NHMRC Centre for Integrated Research and Understanding of Sleep (CIRUS), Glebe, NSW, Australia C. A. Hanes K. K. H. Wong B. Saini The Woolcock Institute of Medical Research, Glebe, NSW, Australia K. K. H. Wong Royal Prince Alfred Hospital, Camperdown, NSW, Australia K. K. H. Wong Faculty of Medicine, The University of Sydney, Sydney, NSW, Australia
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Australian community pharmacies involved in CPAP and sleep apnea-related services. Method Cross-sectional mail survey. A questionnaire designed to meet the study objectives was developed by the researchers and mailed to all pharmacies in Australia providing CPAP services during the period of study recruitment. Pharmacies were identified through the distributor lists of the major CPAP manufacturers and a comprehensive Internet search. Nonresponders were contacted in two subsequent recruitment rounds. Main outcome measure Self-reported sleep apnea service specifics. Results A response rate of 55 % was achieved (n = 106 questionnaires valid for data entry). Benefits of providing a CPAP service included meeting patient and community needs, and professional satisfaction. Barriers included the cost of CPAP equipment to patients and lack of time. A majority of pharmacies (71 %) reported the service was financially viable despite most (63 %) not charging a ‘fee for service.’ Respondents expressed the view that CPAP provision should remain a specialist area of practice within the pharmacy profession. Key areas identified for improvement within the service were: (1) Staff training and knowledge (2) Promotion of the service and increasing public awareness (3) Infrastructure and expansion (4) Inter-professional collaboration and communication (5) Patient follow-up. Conclusion The provision of CPAP and sleep apnea-related services can be a viable and rewarding experience for pharmacists. The role may need to remain a specialised area for those willing to invest significantly in the service—in time, staff, resources and finances. Keywords Australia Chronic disease Community pharmacy Community pharmacy services Disease state management Extended clinical service Obstructive sleep apnea Primary care
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Impact of findings on practice •
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Given the public health burden of obstructive sleep apnea and the need to improve patient access to sleep services, pharmacies are poised to play an important role in the management of obstructive sleep apnea. Australian pharmacies showcase an opportunity to contribute to the management of obstructive sleep apnea that the international pharmacy profession is largely yet to adopt.
Introduction Community pharmacies are an important venue in primary healthcare. They are well suited to the management of certain chronic diseases in primary care, due to their widespread community presence, convenience of access for patients, the therapeutic expertise of pharmacists, and the opportunity for long-term follow-up at repeat encounters. Internationally, there is evidence of the benefits of pharmacist-delivered care for chronic conditions such as asthma, diabetes, hypertension, and chronic obstructive pulmonary disease [1–4]. Such care models range from basic clinical interventions to comprehensive disease management programs. Australian pharmacies have been proactive in testing care models for several chronic conditions; notable examples include asthma and diabetes models [5, 6]. In recent years, some Australian community pharmacies have undertaken a role in the management of obstructive sleep apnea (OSA). OSA is a chronic sleep disorder characterised by repeated upper airway closure during sleep [7]. It presents a significant public health burden due to its prevalence and associated mortality and multiple comorbidities [8–10]. The prevalence of sleep-disordered breathing has been estimated to be as high as 24 % in middle-aged men and 9 % in women [8]. The mainstay of treatment for OSA is device-based, involving the delivery of Continuous Positive Airway Pressure (CPAP) during sleep [11]. CPAP therapy has high efficacy in treating OSA, but requires patients to commit to nightly usage of the device on an indefinite basis for full clinical benefits to be realised [12, 13]. Thus, patient acceptability and non-adherence issues often limit the long-term effectiveness of CPAP therapy [13]. The management of OSA as a chronic condition requires device and disease state education, patient support and follow-up, and adherence monitoring. Given that the provision of medical devices and related patient education is considered usual practice for pharmacists [14], the delivery of CPAP services is a potentially viable service offering by
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community pharmacies. Furthermore, the demand for sleep services continues to outweigh supply, leading to potential delays in timely access to treatment for OSA patients [15]. The supply–demand imbalance is compounded by the likely increasing prevalence of OSA, due to its strong association with obesity and ageing [9, 16, 17]. Solutions for improving access to care may involve transferring aspects of treatment to the primary care setting, and expansion of the sleep medicine workforce in order to reduce the burden on under-resourced tertiary sleep centres [18–20]. The role of pharmacists in sleep health is an emerging field of interest, with previous studies primarily focusing on sleep disorders screening and health promotion campaigns [21–24]. Research specific to OSA and CPAP treatment in the pharmacy setting is scant. This is perhaps because the treatment for OSA is primarily nonpharmacological, thus the potential role of pharmacists in this specialised area has, to date, been largely under recognised. Shoukry et al. [25] surveyed patients with OSA who sourced their CPAP through community pharmacies, and found high subjective satisfaction with service provision and convenience of pharmacy location amongst this sample. Another Australian qualitative study surveyed a small sample of pharmacists involved in CPAP supply and identified barriers to service provision, including a general lack of public awareness of OSA [26]. More recently, a quality assessment study that compared pharmacy-based CPAP services with current Australian best practice guideline criteria [27] found variability in the range and quality of CPAP service provision [28]. The decision to undertake a CPAP service in the Australian pharmacy setting is currently at the discretion of individual pharmacists, as CPAP provision is unregulated. Little is known about these services, their feasibility, or the attitudes and experiences of pharmacists undertaking this niche clinical role. The experiences of Australian pharmacies could provide a template for pharmacists- both those contemplating the service and those already involved- and health policy makers in countries with comparable health systems. To the best of our knowledge this data has never been formally collated in the Australian community pharmacy setting or internationally.
Aim of the study The aim of this study was to provide an overview of the perspectives of pharmacy staff involved in CPAP and sleep apnea-related services in Australian community pharmacies. Specifically the objectives were to:
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Describe the clinical and structural aspects of CPAP service provision. Explore the attitudes of pharmacy staff providing these services, including perceived barriers and benefits. Investigate the viability of CPAP services in the community pharmacy setting. Gauge perspectives of these practitioners on future directions.
Ethical approval
Table 1 Demographics of responding pharmacies Pharmacy demographic Geographic location (%) Metropolitan
18
Suburban
29
Regional or semi-rural
33
Rural
17
Remote
2
(Missing data)
1
Total number of staff employeda (Full-time, part-time, and casual)
Ethics approval was obtained for this study from the University of Sydney Human Research Ethics Committee (Protocol 14729).
All staff
17.3 ± 12.5
Pharmacists
(range 3–76) 4.0 ± 2.5 (range 1–15)
Pharmacy assistants
10.1 ± 8.6 (range 0–50)
Method We designed a cross-sectional mail questionnaire to meet the study objectives (see online supporting information). Questionnaire development was informed by a review of the literature, our combined experience, and key industry documents [14, 27, 29]. The questionnaire was pre-piloted for ‘face validity’ with two experienced CPAP-practitioner pharmacists who were excluded from study participation. This report describes the pharmacy demographics, clinical and structural elements of the services offered, attitudes towards these services, business aspects, and possible future directions. The study methods were described previously in a report investigating CPAP service quality [28].
Average number of prescriptions dispensed per week (%)
Fisher & Paykel Healthcare Pty Limited, Melbourne, VIC; Philips Respironics Healthcare, North Ryde, NSW; and ResMed Ltd, Bella Vista, NSW.
1
123
8
501–1,500
47
1,501–2,500
21
[2,500
9
(Missing data)
15
Average hours of operation per weeka
64.7 ± 20.2 (range 42.5–168)
Pharmacy is open 7 days (%)
58
Pharmacy trades on weekend (at some point) (%)
95
Pharmacy is open after 6:00 p.m. on weekdays (%)
37
Pharmacy is QCPPb accredited (%)
99
Other specialised clinical services offered in the pharmacy (%)
Inclusion criteria We aimed to include all community pharmacies in Australia providing CPAP services during the period of study recruitment (May–September 2012). Pharmacies were identified using the distributor lists of the three main CPAP manufacturers in Australia1 and a comprehensive Internet search. The manufacturers included in this study constitute the bulk of the CPAP market in Australia, thus we believe this sampling approach identified the vast majority of community pharmacies providing CPAP services at the time of recruitment.
\500
a
Disease state managementc
52
Clinical interventions servicec
86
Home medicines review
83
Opioid substitution program
59
Mean ± SD
b
QCPP Quality Care Pharmacy Program (the QCPP is a quality assurance program aimed at raising the standards of service pharmacies provide to the public)
c
Formally registered under the 5th Community Pharmacy Agreement (a 5 year agreement between the Australian government and the Pharmacy Guild that provides funding for pharmacy services and programs)
Recruitment Study recruitment was conducted in three rounds. All pharmacies meeting the inclusion criteria were mailed the study questionnaire, a participant information sheet, and a reply-paid, self-addressed envelope. After a period of 3 weeks, the questionnaire pack was re-sent to non-
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Table 2 Clinical sleep apnea-related services offered in pharmacies and importance as ranked by respondents Service
Percentage of pharmacies offering service
Importance of Service (‘Top 10’)
CPAP machine hirea
94
1
Patient education or counselling
97
2
CPAP machine sales
99
3
Home diagnosis machine hire
54
4
Table 3 Structural characteristics of CPAP services CPAP service characteristic Number of days per week comprehensivea CPAP services are availableb
5.2 ± 1.0 (range 2–7)
Proportion of days per week comprehensive CPAP services are offered to number of days per week pharmacy is open.
83 % (range 29–100 %)
Average number of face-to-face CPAP consults per week (%)
Mask fitting
93
5
Patient follow-up
80
6
3 or less
45
94
7
4–10
27
99
8
11–20
16
9
21–40
8
[40
4
Data downloads
b
Mask sales Sale of consumables (e.g. filters, seals, tubing)
100
Mask hire Referrals (to other healthcare professionals)
76 52
15–30 min
24
Screening (sleep disorders related)
26
30–45 min
42
Written correspondence with referring physician: Initial patient visit Written correspondence with referring physician: Ongoing
76
45–60 min
29
[60 min
4
10
47
Supply of educational materials: leaflets
84
Supply of educational materials: DVDs Equipment servicing/ routine device checks
50
Equipment repair
41
Machine pressure checks
59
70
Multiple response analysis. Participants were asked to rank the top three services (listed above) in order of what they felt constituted the major part of their service, with ‘1’ being the ‘most important.’ Aggregate responses from 1st, 2nd, and 3rd rankings were used to rank overall importance
Average length of time for initialc CPAP consultation (%) \15 min 1
Staff member usually involved in an initialc CPAP consultation (%) Pharmacist
41
Pharmacy assistant
34
Dispensary technician
6
‘Other’ (including CPAP nurses)
18
(Missing data)
1
Location of CPAP consultations (%) Private (non-enclosed) area
8
Private (enclosed) area or room
86
Non-private area No designated area
4 1
Other
1
Advertisement method for CPAP service (%) In-store
92
a
CPAP Continuous Positive Airway Pressure
Local media
53
b
Smart card or machine chip adherence monitoring
Referral from physicians
79
Word-of-mouth
88
responders. The third and final recruitment round involved a telephone call to all remaining non-responders; the questionnaire pack was re-sent to staff that requested one during the phone call. Data analysis Questionnaire responses were analysed using the software package IBM SPSS Statistics for Windows, Version 21.0 (Armonk, NY, USA). Chi square analysis was used to test for relationships between categorical variables. Continuous
Promotion amongst local physicians
49
‘Other’ (including websites)
6
Main referral source for CPAP prescriptions (%)d Specialist physician (private clinic)
51
Specialist physician (public hospital/clinic)
31
General practitioner (primary care physician)
41
a
Services besides basic sale of equipment, such as patient appointments
b
Mean ± SD
c
A consult involving machine set-up and mask-fitting
d
Multiple response analysis (some respondents selected more than one response)
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variables are reported as mean ± SD. Open-ended questionnaire responses were thematically analysed.
Results Response rate and pharmacy demographics The sampling approach identified 200 community pharmacies providing CPAP services at the time of study recruitment. Questionnaire responses from all eight Australian states and territories were obtained. This number was later reduced to 174 pharmacies (one address was invalid, 16 pharmacies had discontinued their service, and 9 reported never offering a CPAP service). We estimated that 3–4 % of all community pharmacies in Australia were involved in CPAP provision at the time of recruitment [28] (based on approximately 5,000 community pharmacies in Australia [30]). The study response rate was 55 % (110/199) with 106 questionnaires valid for data analysis. The majority of responding pharmacies (72 %) were located in either a shopping centre or strip mall location. Most were part of a banner group or franchise (61 %), while one-third of pharmacies were brand independent. Table 1 further describes the demographics of responding pharmacies. Clinical sleep apnea services provided by pharmacies Table 2 describes clinical sleep apnea services offered in pharmacies and the ‘top 10’ most important of these services as ranked by respondents. Most pharmacies assisted patients with a trial of CPAP machinery and masks to ensure patients were established on appropriate therapy prior to the patient purchasing their own equipment for long-term use. Structural aspects of sleep apnea services Table 3 outlines the structural aspects of sleep apnea services, including personnel involved in the service. The mean total number of staff trained to provide in-depth CPAP services per pharmacy was 2.3 ± 1.3 (range 0–6); these most commonly comprised pharmacists. The mean total number of staff per pharmacy trained to provide basic CPAP services was 2.2 ± 2.7 (range 0–21); these most commonly comprised pharmacy assistants. The mean proportion of each pharmacy’s staff trained to provide CPAP services (in-depth or basic) was 34 % (range 8–100 %). The most common method for training staff (for both pharmacists and pharmacy assistants) was CPAP manufacturer-run courses, followed by ‘in-house’ training.
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Attitudes towards providing a CPAP service Figure 1 depicts the perceived benefits of providing a CPAP service amongst respondents. Figure 2 lists the ‘top 10’ perceived biggest barriers to providing a CPAP service. Less frequently cited barriers included lack of finances, pharmacy infrastructure, inter-professional relationships, and staff resistance to offering the service. Inter-professional relationships were listed as both a benefit of and a barrier to providing the service. A lack of adequate training was cited as a barrier to providing the service, however, when asked about their confidence in knowledge of OSA, 54 % of respondents indicated they were ‘confident’, and 37 % of respondents were ‘very confident.’ Regarding their knowledge of CPAP, 45 % of respondents were ‘confident’ and 46 % were ‘very confident.’ Respondents were asked what they regarded as the main advantage for patients sourcing CPAP through a community pharmacy (as opposed to other CPAP providers); these responses are shown in Fig. 3. Business and administrative aspects The CPAP service was reported to be financially viable for 71 % of pharmacies, however, 14 % of these respondents indicated the service had initially been run at a loss. Of the 29 % reporting that the service was run at a loss, 6 % indicated the service had initially been viable. There was no significant relationship between the financial viability of the CPAP service and the following demographic variables: rural location (p = 0.17), pharmacy brand (p = 0.07), 7 day trading (p = 0.88), weekly hours of operation (p = 0.36), and average weekly prescription volume (p = 0.52). Financial viability was found to be significantly associated with respondents’ confidence in their knowledge of OSA (p = 0.003) and CPAP (p = 0.02) respectively, and averaging [10 (as opposed to \10) face-to-face CPAP-related consults per week (p = 0.003). Most pharmacies (63 %) did not charge a ‘fee for service’ or consultation fee, but rather charged for the sale, and in some cases rental, of products and equipment. Most pharmacies that charged for CPAP equipment hire waived these fees for patients who purchased a CPAP machine after the trial period. There was no significant relationship between the CPAP service’s financial viability and whether or not a ‘fee for service’ was charged (p = 0.47). Future directions Most respondents (62 %) felt there was not a need for more pharmacies to offer CPAP services, while others (31 %) felt that current demands were not met with existing numbers. Analysis of open-ended responses (n = 28)
Int J Clin Pharm (2014) 36:460–468 Fig. 1 Perceived benefits of providing a continuous positive airway pressure service
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Meets patient and community needs Improved professional image of the pharmacy Professional satisfaction Competitive edge Financial Improved inter-professional relationships Undersupply of pharmacists providing this service 0
10
20
30
40
50
60
70
% of Respondents Fig. 2 ‘Top 10’ perceived barriers to providing a continuous positive airway pressure service. OSA obstructive sleep apnea, CPAP Continuous Positive Airway Pressure
Cost of equipment to patient Online competitors Lack of time Lack of community awareness of OSA Supply vs. demand Turnover of trained staff Lack of staff Nearby competitors Lack of adequate training Patient resistance to accept CPAP… 0
10
20
30
40
50
% of Respondents Fig. 3 Main advantage for patients sourcing continuous positive airway pressure services through community pharmacies (as perceived by respondents). Multiple response analysis (some respondents selected more than one response)
Accessibility and convenience of location Pharmacist familiar with management of chronic diseases Patients able to meet other health needs while in the pharmacy Reduced waiting periods compared to other providers Pharmacist experienced with providing other specialist services Extended trading hours and trading days 0
10
20
30
40
50
60
70
80
% of Responses
revealed a central theme of needing to achieve a balance between enough CPAP providers to raise community awareness and meet patient demands, while still keeping these services viable. Some respondents believed that increasing the number of pharmacies could have a negative effect on the quality of services provided and reduce the ‘professional’ aspect of the service into a ‘retail product.’
Others expressed the view that CPAP provision should remain a specialist area of practice within the pharmacy profession, reserved for those willing to invest considerable time and resources in the service. Respondents also acknowledged that the need for services varied across geographical regions, with some areas having a saturated market and others insufficient services
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to meet patient demands. However, there was no significant relationship between the rurality of respondents’ location and their perceived need for more CPAP services in pharmacies (p = 0.28). Eighty-nine percent of respondents felt there was room for improvement in some aspect of their CPAP service delivery. Analysis of open-ended responses (n = 96) revealed five key areas for improvement: (1) Staff training and knowledge (2) Promotion of the service and increasing public awareness (3) Infrastructure and expansion (4) Interprofessional collaboration and communication (5) Patient follow-up.
Discussion This is the first study to explore on a nationwide scale the specialised role of Australian pharmacies that offer clinical services for obstructive sleep apnea patients. While the results of this study suggest that providing a CPAP service can be a viable and rewarding experience for pharmacists, the role may need to remain a specialised area for those willing to invest significantly in the service- in time, staff, resources and finances. The CPAP services provided by most pharmacies in this sample followed a ‘trial to treatment’ process comparable to the path patients would follow at a tertiary care CPAP clinic. This includes facilitating patient familiarisation and comfort with equipment during a trial period, patient education and troubleshooting support, and establishing adherent trial patients on continuing therapy. This process appeared to be the backbone of the CPAP service for most pharmacies (see Table 2). The transition from ‘hire’ to ‘purchase’ of a machine can be viewed as a marker of success in motivating a patient to adopt and continue with physician-prescribed treatment. Research suggests that early contact and follow-up during the initial treatment experience is important in optimising patient adoption and subsequent long-term adherence to CPAP [13, 31, 32]. Given the evidence supporting pharmacist roles in improving adherence to medications [5, 6, 33, 34], and the accessibility of pharmacies for patient follow-up, pharmacies could play an important role as providers of CPAP services. Patient follow-up is important not only during the initial trial period, but also after a patient has been established on CPAP. Again, pharmacies are ideally situated to provide this ongoing support and adherence monitoring. The vast majority of pharmacies in this study provided data download services (an objective measure of a patient’s nightly hours of CPAP use; see Table 2), suggesting involvement in the patient’s ongoing management. However, less than half reported ongoing correspondence with the patient’s
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referring physician, which may be an area for future practice improvement in a collaborative care model. Pharmacists have expressed a desire for further sleep health training in previous studies [26, 35]. The lack of independent professional training programs currently available through conventional pharmacy channels has been viewed as a barrier to providing sleep services [35]. Given that confidence appeared to be associated with service viability, the role for specialised training programs that fulfill provider need is important. The biggest benefit of providing a CPAP service was reported by respondents as ‘meeting patient and community needs’ (see Fig. 1). This benefit was listed above financial advantages, suggesting a degree of altruism amongst this sample. A previous study found that patients themselves also viewed CPAP provision by pharmacies as a community service [25]. Additionally, respondents listed professional satisfaction above financial benefits, implying non-monetary rewards from providing the service. Indeed, CPAP therapy can dramatically improve quality of life for some patients, providing clear symptomatic benefit, sometimes even after the first night of use [13]. Active involvement in the healthcare of these patients could provide a rewarding experience for practitioners. The main advantages listed for patients sourcing their CPAP through pharmacies (as identified by respondents; see Fig. 3) were consistent with a previous study that directly surveyed patient treatment experiences [25]. Barriers to providing the CPAP service such as time constraints, training inadequacies, and staff shortages, have also been encountered by Australian pharmacists providing other specialised clinical services [36–38]. Barriers unique to OSA services (see Fig. 2) were also identified. Australia’s public health system does not currently subsidise CPAP equipment for the vast majority of patients, and the high cost of these devices was cited as the number one barrier to providing the service. Poor community awareness of OSA was also cited, consistent with previous findings [26]. While most pharmacies reported their CPAP service was financially viable, approximately one-third of pharmacies (29 %) reported running their service at a loss. The viability of a CPAP service is dependent on patient volume and physician referrals, since the diagnosis of OSA and decision to initiate CPAP should be physician-led. Although most pharmacies did not rank screening as an important part of their service, this could be a significant role for future consideration. Pharmacies have been involved in screening services for a variety of conditions, including diabetes, cardiovascular disease, osteoporosis, chlamydia, and sleep disorders [23, 24, 39–44]. Given that an estimated 80–90 % of the population with OSA remains undiagnosed [45], broader uptake and recognition of the role pharmacy can play in screening for OSA may be an
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important area of practice change. Interventions to raise awareness of OSA in the general community are also needed from a public health perspective. As more patients are diagnosed and referred for treatment, pharmacy-based CPAP services may serve community needs well and become increasingly sustainable.
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showcase an opportunity to play a role in the management of OSA that the international pharmacy profession is largely yet to adopt. Acknowledgments C. Hanes is the recipient of scholarships from the Australian Postgraduate Award (APA) and the NHMRC Centre for Integrated Research and Understanding of Sleep (CIRUS), and gratefully acknowledges this support.
Study limitations Funding
The study findings may not be generalisable beyond this sample due to the possibility of participation bias. Findings relating to the viability of services are particularly susceptible to this bias, as those who were not financially viable may have ceased to provide the CPAP service and hence were ineligible to receive the questionnaire. Questionnaire responses were self-reported and thus may be subject to recall and social desirability biases. International implications As sleep disorders become increasingly recognised as public health priority areas around the globe, [46–48] pharmacies may be poised to play an important role in the management of OSA. This is in line with the global trend of extending the clinical services of pharmacists beyond traditional dispensing roles. Considerations to the differences in international healthcare and regulatory systems are required, however the Australian example suggests pharmacists can play a role in the primary care sleep health team. Future directions for the Australian setting Sleep apnea services in Australian pharmacies are yet to be consolidated as formal disease state management programs recognised by the profession. Pharmacists that have implemented CPAP services to date have pioneered them largely unsupported, and without a pharmacy-specific model of care to underpin the service. Research is needed to refine and structure the framework pharmacies operate within. According to the diffusion of innovations theory [49], the profession could be seen to be in the early phase of ‘innovators’ and ‘early adopters’. Formal recognition by pharmacy and sleep medicine professions will facilitate movement beyond this phase and ensure the sustainability of these services.
Conclusion Pharmacies encompass many of the key ‘ingredients’ for chronic disease management services in primary care, and are positioned to take on extended clinical services. Given the public health burden of OSA and the need to improve patient access to sleep services, Australian pharmacies may
None
Conflicts of interest The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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