The very public stoush between GPs and the Pharmacy Guild over extended prescribing has obscured another key policy change on medication issues, according to former senior public servant Charles Maskell-Knight.
Below, he discusses the government’s turnaround on medication reviews in aged care, announced by Minister for Health, Mark Butler at the same time as the move towards 60 day prescriptions and other extended prescribing measures.
Charles Maskell-Knight writes:
One of the many quality issues bedevilling residential aged care is polypharmacy. Far too many residents are taking too many drugs, often with adverse effects on their health. The Aged Care Royal Commission heard that the median number of medicines used by residents is 11 (vol 3A:181).
This is despite the fact that aged care residents are eligible to receive a government-funded Residential Medication Management Review (RMMR) carried out by an accredited pharmacist after referral by a GP.
The pharmacist generates a report at the end of the review, which is provided to the GP to use in revising the resident’s medication plan. The high levels of polypharmacy suggest that this system is not working well.
A pilot study
In 2017 the University of Canberra began a pilot study to improve resident medication management in which a pharmacist was embedded into a Canberra nursing home.
Following promising results from that study, a broader study was commissioned involving 15 nursing homes, seven in the intervention group and eight in the control group.
The report on the broader study found:
the principal result of the intervention was that the activities carried out by the on-site pharmacist were responsible for a reduction in the extent of PIM [potentially inappropriate medication] prescribing.
This means that the likelihood of a resident being prescribed one or more PIM was half (OR: 0.501) in aged care facilities with an on-site pharmacist compared to those with no on-site pharmacist.”
The presence of an on-site pharmacist also “reduced the anticholinergic drug burden of medicines prescribed for residents (anticholinergic burden is associated with cognitive decline, delirium and increased risk of falls) [and] reduced the dose of antipsychotic medicines prescribed for residents”.
In short, the intervention was successful in reducing the potential harms from overprescribing.
Preliminary results from the study were available to the Aged Care Royal Commission, which recommended (rec 38) that pharmacists should be part of the care team in residential aged care.
In the March 2022 Budget, the Morrison Government provided “$345.7 million over four years to improve medication management and safety for aged care residents through on-site pharmacists and community pharmacy services. This responds to a recommendation by the Royal Commission”.
So far, so good. (Although Budget Paper 2 made it clear that much of the cost of the measure was funded by re-directing funding.)
Consultation processes
The Department of Health then set about implementation, releasing a consultation paper in July 2022. In December 2002 it released a post-consultation statement on the scope and intent of the measure. It said:
“Residential aged care homes can choose to employ or engage pharmacists to tailor medication management to best meet the residents’ and facility’s needs… [the benefits] may include:
- continuity in medication management, such as day-to-day review of medications and issue resolution
- easy access to pharmacy advice for staff and residents
- collaboration of on-site pharmacists with the health care team, including local general practitioners, nurses, and community pharmacy
- increased understanding of individual resident needs
- improved medication use and safety in the residential aged care home, including safe and appropriate use of high risk medications”.
As Australian Ageing Agenda reported, the measure was intended to start in 2023-24, with 30 percent of homes in the first year, increasing to 60 percent the following year and 80 percent during the third year. At the same time, RMMRs were to be phased out for residents in homes where a pharmacist was engaged.
As far as we know, all was on track for the measure to begin in July.
A policy turnaround
And then on 26 April, in the media conference announcing extended dispensing, Health Minister Mark Butler said:
In addition, I want to announce a change to a program that we inherited that was announced in the latter part of the former government’s tenure to improve medication compliance and medication reviews in residential aged care facilities. The policy announced by the former government would have had that program delivered through aged care facilities themselves.
I am announcing today a change to that policy, so that the $350 million allocated in the Budget for that measure will instead be delivered by and through community pharmacies, again, giving those pharmacists an opportunity to show the value that they can provide to the community in delivering services rather than just processing repeat scripts.”
In other words, a return to the system of RMMRs, under which residents receive a median of 11 different medicines.
RMMRs are often conducted by the same pharmacists responsible for the supply of the medications being reviewed, meaning there is an inherent conflict of interest facing a pharmacist conducting a review.
The Aged Care Royal Commission found that only one-third of residents received an annual medication review (vol 3A:314), partly due to the eligibility requirements for the reviews. It also found an absence of any mechanism for scrutiny of the quality of the reviews that are conducted.
A 2017 review of RMMRs carried out by the Medical Services Advisory Committee found:
there is [a] low level of evidence to suggest that RMMRs: have a positive impact on drug burden; may lead to more appropriate prescribing; and support identification of medication-related problems… the available evidence does not show an impact on reducing hospitalisations, reducing mortality or improving cognitive functioning [and] there is conflicting evidence on the effect of RMMRs on falls reduction and medication costs, and insufficient evidence in regards to the effect of pharmacist-led RMMR on quality of life.”
The Royal Commission recommended (rec 64) immediate action to increase access to RMMRs, pending implementation of its recommendation to include pharmacists in the care team, and this was broadly accepted by the Morrison Government. However, it is not clear whether Minister Butler now intends to proceed with these changes.
Ignoring the evidence
Two days after Butler’s announcement, Assistant Treasurer Andrew Leigh was hitting the airwaves spruiking the benefits of improved program evaluation. He observed that “firms such as Apple and Google and Amazon are constantly conducting randomised trials. And they’re doing so because that’s a very effective way of testing whether a policy works”.
Unfortunately, Minister Butler didn’t get the memo.
Why else would he junk a new program to improve medicine use in aged care, based on a randomised trial that found it would be successful, and return to a program that has very limited evidence of success and has prima facie failed to curb polypharmacy?
(If he thought that restoring RMMRs as a funding source for community pharmacists would assuage the Pharmacy Guild’s anger at extended prescribing, he was clearly mistaken.)
Let’s hope that some Senators use the forthcoming Senate Estimates hearings to explore the government’s rationale for the abrupt change of course.
See here for Croakey’s archive of stories on aged care
