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A “less is more” update on medicinal matters

The theme dominating so many of our health reform discussions and decisions is that we need to spend more and do more, to improve the population’s health.

That is no doubt true in many areas. But in some cases, spending less and even doing less might bring both economic and health benefits.

“Less is more” is the title of a new series in the US journal, Archives of Internal Medicine, which aims to “highlight situations in which the overuse of medical care may result in harm and in which less care is likely to result in better health”.

Kicking off the series in the current journal is a number of articles documenting some serious adverse effects of proton pump inhibitors (drugs widely used in the treatment of conditions related to gastric acid production), and warning that “harm will result if these commonly used medications are prescribed for conditions for which there is no benefit”.

Meanwhile, a study recently published in the Medical Journal of Australia suggests that Australia is spending many millions of dollars more than comparable countries on the generic versions of cholesterol-lowering drugs called statins.

The authors concluded: “From January 2005 to October 2009, the cumulative loss to the Australian community from paying more than the English price for generic statins was more than $900 million. Expenditure could have been reduced by a further $1087 million if Australia had increased the proportion of generic medications prescribed to match trends in England. Future savings depend on the proportion of statin prescriptions that are subject to lower generic pricing. From January 2009 to December 2019, potential savings from paying English prices could be as high as $3.21 billion, and savings of up to $9.31 billion could be made by paying English prices and using generic statins only.”

You can listen to an ABC Radio National interview with one of the researchers involved, Associate Professor Philip Clarke, to learn more about why our Pharmaceutical Benefits Scheme is no longer considered a world leader in controlling the cost of medicines.

If Treasury hasn’t yet picked up on Clarke’s findings, then they’re just not paying attention. He also had this long piece in The Weekend Australian’s health section, pointing out the variation in the wholesale price of one cholesterol-lowering drug: about $30 a month here for a 40mg dose, compared with about $3 a month in Britain and just $1.50 in New Zealand.

He also argues that the recent four-year agreement between the government and Medicines Australia, aimed at reducing the price of older medications on the PBS, was not the great win for the government (and taxpayers) that it’s been promoted as.

Meanwhile, the Community Pharmacy Agreement is another area where the public interest has traditionally not been as well served as many would like.

Ron Batagol, Pharmacy and Drug Information Consultant from Victoria, has some concerns about the the recently-announced 5th Community Pharmacy Agreement (an overview is available here). He writes:

“One of the more contentious aspects of the recently-announced 5th Community Pharmacy Agreement is to allow pharmacists to issue “pharmacy generated prescriptions” under the medication continuance provisions  in certain circumstances, when patients “run out of” medication prior to a doctor’s  appointment.

Pharmacists will be able to prescribe a standard pack of medication, initially for hormonal contraceptives and lipid modifying agents, which is likely to be extended to other medications for chronic diseases.

Currently, pharmacists are allowed to give up to 3 days emergency medication supply.

Predictably, because of the difficulties patients may experience in accessing a doctor at short notice, especially in rural and remote areas, pharmacy groups have welcomed the new arrangements. However, the AMA believes that they are not in the best interests of patient safety and quality care, and that pharmacists do not have the training to prescribe.

Certainly, by virtue of their training and expertise,  pharmacists are the acknowledged experts within the community in the pharmacological actions, interactions and safe and effective use of medicines.  However, authorising medication beyond the due date for medical review  may, or may not be consistent with the patient’s ongoing medical needs (aside from potential professional liability and hefty professional indemnity insurance premiums,  from claims arising from detrimental health outcomes).

My own concerns over this initiative are on a number of fronts.

My first concern, is that, having worked extensively in the O&G area for many years, is the quantity of oral contraceptives to be restricted to one month, beyond the usual 12 months supply, or will 4 months supply pack be allowed? I suspect most GPs and gynaecologists would not be happy if the period between gynaecological  reviews was 16 months!

Most importantly,  when you extend the medication continuance concept, as is proposed, to patients with chronic diseases such as diabetes, heart disease and hypertension, these are often the very labile group of patients who require periodic and timely review by a doctor, because of the ever-present risk of their condition deteriorating and  requiring (expensive and life-threatening) hospitalisation.

It is also a fact is that no health professionals other than medical practitioners have the required formal training, years of  career experience and  expertise and professional competence to reliably  carry out medical differential diagnosis required in such a review.

The medication continuance proposals also sits in stark contrast to the Federal Government’s own recently announced plans for Primary Health Care Organisations(PHCOs), to be specifically set up to devise community-based  management and treatment plans, utilising the expertise of doctors working collaboratively with health professionals (presumably including pharmacists), to try to manage these chronically-ill, at-risk patients patients, in the community setting.

Furthermore, there is already a legal option  for a pharmacist to dispense further medications for the quantity specified by a doctor’s telephone order, followed by a  subsequent written prescription. At least then, the doctor is confirming a continuance of the patient’s current medication.

And, yes, as a pharmacist, I know only too well that it goes with the territory, that it is sometimes difficult to make telephone contact with a doctor, and that he or she may or may not agree to the request, and, if agreeing, may be quite tardy in following up with a written prescription.

It beggars belief  that this is the best that the collective “rocket scientists” of Pharmacy and Government can come up with to manage the issue of potentially at-risk patients allowing themselves to “run out of” their required medicines.”

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Congress Lowitja 2014
CRANAplus conference 2014
Cultural Solutions - Healing Foundation forum 2014
Lowitja Institute Continuous Quality Improvement conference 2014
National Suicide Prevention Conference 2014
Racism and children/youth health symposium 2014
Rural & Remote Health Scientific Symposium 2014
2015 conferences
#CPHCEforum
#CRANAplus15
#HSR15
#NRHC15
#OTCC15
Population Health Congress 2015
2016 conferences
#AHHAsim16
#AHMRC16
#ANROWS2016
#ATSISPEP
#AusCanIndigenousWellness
#cphce2016
#CPHCEforum16
#CRANAplus2016
#IAMRA2016
#LowitjaConf2016
#PreventObesity16
#TowardsRecovery
#VMIAC16
#WearablesCEH
#WICC2016
2017 conferences
#17APCC
#ACEM17
#AIDAconf2017
#BTH20
#CATSINaM17
#ClimateHealthStrategy
#IAHAConf17
#IDS17
#LBQWHC17
#LivingOurWay
#OKtoAskAu
#OTCC2017
#ResearchTranslation17
#TheMHS2017
#VMIACConf17
#WCPH2017
Australian Palliative Care Conference
2018 conferences
#6rrhss