The vast majority of older patients on multiple medications are not having their medicines properly reviewed – increasing the risk of dangerous drug reactions and overdoses – according to new research using data from the Sax Institute’s 45 and Up Study.
The new study looks at uptake of Home Medicines Reviews (HMRs). This is an Australian Government-subsidised service in which a pharmacist visits a patient at home to check on prescription and over-the-counter drugs the person is taking. The pharmacist can then recommend changes to the list of medications in consultation with a GP. The aim is to minimise the well-known risks of polypharmacy, which is defined as taking five or more medications regularly.
The study shows there is a long way to go before we reach satisfactory uptake of this valuable service.
The research involved over 130,000 participants from the 45 and Up Study who were also concession card holders, as this was the only group for which full PBS records were available. Less than 5% of this group received an HMR over the study’s five-year follow-up period.
Even among patients who were at high risk of a medication-related illness, uptake was very poor. Only 6.8% of participants taking five to nine different medications had had an HMR, the figure rising to 12.7% for patients on over 10 medications.
The rates were no better (8.8%) for patients taking medications with a narrow therapeutic index, such as warfarin or lithium, where small differences in dosages can have serious or even fatal consequences.
Current recommendations are that HMRs should be conducted for patients on five or more medications or who are on medications with a narrow therapeutic index.
“HMR use over a five-year period was generally below 10%, even in high-risk groups, suggesting substantial potential for improvement in uptake and targeting,” write the study authors, who include Professor Fiona Blyth and Professor Emily Banks, both Senior Advisers at the Sax Institute.
Given that the study was restricted to concession card holders, who generally have higher rates of multimorbidity, the authors say rates of HMR uptake may be even lower in the general population.
Studies have shown that HMRs are effective, the authors note. For example, people with heart failure who have had an HMR have fewer hospitalisations than those whose medications have not been reviewed, while patients on warfarin are less likely to have bleeding or drug-related adverse events if they have had an HMR.
Why are patients missing out?
Not only are HMR rates low, according to a paper published by Professional Pharmacists Australia, they have declined since 2013, when caps were first introduced. Currently, providers – either individual pharmacists or accredited organisations – can only claim up to 20 HMRs in a calendar month.
The 2013 introduction of caps on HMRs by the Australian Department of Health, in consultation with the Pharmacy Guild, is controversial in the pharmacy community.
“If the government is serious about providing medication management services that make a valuable contribution to the nation’s health, then the restriction on medicine reviews should be lifted,” argue two academics in an article for The Conversation.
A report published earlier this year found that in Australia, 250,000 hospitalisations a year are medication-related, costing an estimated $1.4 billion. Of those hospital admissions, around half are thought to be preventable.
The report also found that of those who do receive HMRs, 20% are found to be suffering from an adverse medication reaction. An average of four medication problems are found for each person undergoing an HMR.
Patterns of high-risk prescribing and other factors in relation to receipt of a home medicines review: a prospective cohort investigation among adults aged 45 years and over in Australia. BMJ Open 2019.