Available now for public access through both AdPha and RACGP, the Resource Kit
comprises three resources to support clear, accurate and timely communication as
patients transition through care providers:

1. Practice Update: Medication Management at Transitions of Care clearly defines
the role of the hospital pharmacist, general practice pharmacist (GPP), and the
general practitioner (GP) in delivering safe and quality medication management
services to their patients transitioning between acute and primary care.

2. Resource for healthcare professionals: Safe Medication Management at
Transitions of Care supports healthcare professionals in ensuring safe and
effective medication management during patient transitions between care
settings.

3. Resources for consumers: Medication safety when moving between the
community and hospital helps consumers manage their medicines safely when
moving between home and hospital.

The Transitions of Care resources are now available at the following:
– Medication Management at Transitions of Care Resource Kit (AdPha)
– Medication Management at Transitions of Care Resource Kit (RACGP)

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One in ten older people experience ‘adverse drug reactions’ (ADRs) to medications whilst in hospital, the research published in The Journal of the American Medical Directors Association (JAMDA) found.

“As the population is getting older, patients have more chronic medical conditions and are taking a greater number of medications so it’s becoming increasingly important for healthcare systems to focus on preventing harm from medications,” says Dr Joshua Inglis, a researcher with the College of Medicine and Public Health, and Consultant Physician in Flinders Medical Centre’s Department of Clinical Pharmacology.

“We found that in hospitalised patients aged 65 years and older, adverse reactions to medication were associated with longer stays in hospital and a higher risk of death.”

The findings have prompted calls for hospitals to take further steps to prevent medication-related harm.

“Currently, doctors review each patient’s medications during their hospital stay, but there is an opportunity to establish multidisciplinary teams that take a hospital-wide approach to managing specific high-risk medications classes,” says Dr Inglis.

“Medication stewardship programs that monitor the use of high-risk medications, coordinate interventions and work with patients and practitioners can significantly protect older patients during their hospital stay.

“Stewardship programs have been successfully developed for antibiotics and shown to improve patient outcomes and the concept can also be applied to other high-risk medications such as opioids, anticoagulants and psychotropics,” he says.

The study looked at more than 700 patients aged 65 and older admitted to Flinders Medical Centre over three years and found that 72 of them (about 10%) had experienced an unwanted reaction to their medications.

It found that the number of adverse reactions a patient had was linked to how long they stayed in hospital and whether they died during the admission.

The medicines most associated with ADRs include those used to treat high blood pressure and other cardiac conditions, strong painkillers such as oxycodone, and antibiotics such as penicillin.

Examples of unwanted side effects included kidney and liver injuries, low blood pressure, sedation, nausea and vomiting, diarrhoea and bleeding.

“For every reaction that occurred, patients stayed in hospital for longer and were at a higher risk of death during their hospital admission.

“To our knowledge, this is the first study to find an association between experiencing an ADR in hospital and serious consequences for patients.

“Importantly, it highlights the need for healthcare organisations to develop stewardship programs that prevent ADRs from occurring in the first place.”

Dr Inglis says further studies using other patient cohorts, such as older people living with dementia, could provide valuable insights into developing ways to improve health outcomes for the aged population and reduce ADRs.

The research, ‘The Clinical Impact of Hospital-Acquired Adverse Drug Reactions in Older Adults: An Australian Cohort Study’ by Joshua M. Inglis, Sophie Medlin, Kimberley Bryant, Arduino A. Mangoni and Cameron J. Phillips was published in JAMDA (The Journal of the American Medical Directors Association).

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One of the primary challenges for arthritis patients is managing their medications effectively and safely. A frequently overlooked issue in this process is the difficulty many patients experience when trying to manage their medications.

Gerard Stevens AM, an expert in medication management and the creator of the Webster-pak, understands these challenges intimately.

“Arthritis is a common and painful condition affecting many people worldwide. Effective management is crucial, and one key aspect is handling your medications correctly. Arthritis often involves multiple medications, which can be confusing and overwhelming. With some assistance, people with arthritis can regain control of their medication routine and improve their health.” Mr Stevens says.

Recognising the need for innovative solutions, Gerard Stevens developed two ground-breaking devices designed to assist individuals with dexterity issues, including those with arthritis.

One such tool is the Webster-pak, which organises multiple medications into labelled blister packs, ensuring patients take the right medications at the correct times. According to Mr. Stevens, “Webster-Pak’s organised approach simplifies medication management for arthritis patients, reducing the risk of missed doses and complications.”

For those who need extra help, the Pil-Bob is a handy tool for easily getting medication out of the Webster-pak. It’s especially great for people with hand difficulties from arthritis or other conditions. It’s also suitable for caregivers assisting with medication administration.

“When I first came up with the Pil-Bob idea, I gave a prototype to my late mother, who was using a Webster-pak, and asked her what she thought it was for. She instinctively punctured the blister with the serrated tongue, wiggled it, and let the pills fall into the cup. Now, it’s used all over the world,” he said.

Gerard Stevens’ expert tips for managing arthritis medications:

1. Consult a specialist: Seek advice from a doctor with expertise in arthritis to create a personalised treatment plan.
2. Tailored plan: Collaborate with your doctor to develop a plan that suits your specific type of arthritis and medical history.
3. Monitor your medications: Pay attention to how you use your medications and report any side effects to your doctor.
4. Adhere to the plan: Take your medications precisely as prescribed by your doctor and maintain a healthy lifestyle with proper nutrition, exercise, and stress management. Utilise tools like the Webster-pak and Pil-Bob for assistance.
5. Organise your medications: Simplify medication management with tools like the Webster-pak and Pil-Bob to ensure you take the correct doses at the right times.

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Speaking ahead of APP2022, Mr Read says that being unable to manage medications safely at home is one of the reasons people may end up in aged care and this is where the MedAdvisor app and medication reminder service can help.

At the user level, the app allows people to set reminders to take their medicine and refill their prescriptions.

MedAdvisor has also found that their technology has increased by 20% the likelihood of a patient taking their medication as prescribed.

The app also stores prescriptions digitally and users can order refills through their pharmacy ahead of their visit to avoid waiting times.

“But the inability to properly manage medication by either forgetting to take it at the right time and frequency, or not refilling prescriptions in a timely manner can have serious consequences,” says Mr Read.

“Elderly patients’ conditions can deteriorate quickly and they end up needing a greater level of care, which often means moving to an aged-care facility.”

Mr Read says that the platform – the digital prescription wallet – is also beneficial for those who may be away from their regular pharmacy, to have access to their prescriptions.

“The pandemic also showed us that technology and remote access were integral in keeping our lives and economy going,” says Mr Read.

Digitisation of medical records helping pharmacies

Mr Read says that at the pharmacy level the platform can help reduce problems associated with “oversight of patients’ medication regimes, their medication supplies, and any possible issues with other prescribed medications”.

MedAdvisor has also helped general practitioners and pharmacies manage the delivery of medicine and patient care in the aged care sector.

“We have a system or a module of our software that allows the pharmacist to easily connect with GPs that are prescribing to a particular aged care home,” says Mr Read.

“That communication pathway takes a significant amount of time out of ordering scripts and managing scripts at a pharmacy end and equally at the doctor end.

“Doctors can prepare scripts far more quickly when compared to manually writing scripts for 30, 40, or 50 residents a month at a particular facility.”

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As Australia’s population continues to age, and the number of Australians living with dementia increases, medication safety for people living with the disease remains an Australian national health priority area.

This is particularly important as a new study has found that people with dementia may often be prescribed medications incorrectly.

Led by Monash University’s Centre for Medicine Use and Safety (CMUS), a new study has shown that up to two thirds of people with dementia are prescribed potentially inappropriate medications.

Investigating the obstacles and complexities in medication management for people living with dementia through qualitative research that involved four key stakeholders (carers, GPs, nurses and pharmacists), the study found that the barriers to effective medication management include:

• Poor communication and relationships between stakeholders.
• Infrequent medication reviews.
• Lack if practitioner training, evidence and guidelines to navigate prescribing and deprescribing decisions.

According to lead author, Dr Amanda Cross, medication management for those with dementia becomes particularly complicated in the context of polypharmacy, increasing cognitive decline, changing goals of care, multiple stakeholders and multimorbidity.

“Most people with dementia live with multiple chronic diseases, which often require medications to manage symptoms and disease progressions,” says Dr Cross.

“It’s a complex and challenging process, which requires many competing considerations when optimising medication use.”

Dr Cross adds that what makes this process even more challenging is the limited evidence available to guide the process of prescribing and deprescribing for people with dementia.

“We know that up to 90% of people with dementia are exposed to polypharmacy and for each additional medication used, the risk of emergency department presentation and mortality increases.”

Dr Cross advises that collaboration and communication between health professionals is crucial in the optimisation of medication use and that “future interventions should focus on training and evidence-based guidelines”.

The release of the study coincides with the signing of the Seventh Community Pharmacy Agreement (7PCA) between the Australian Government and the Pharmacy Guild of Australia.

The 7CPA includes a commitment to maintaining investment in medication management programs, vital to the care of older people – particularly those with dementia.

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PSA President Associate Professor Chris Freeman says expanding the role of pharmacists in the provision of healthcare for vulnerable older Australians would offer protection from this unnecessary burden.

“With the Royal Commission currently investigating how to improve aged care services, it’s time for everyone to address medication management,” he said.

“In our submission to the Commission and representation to the Commonwealth, we’ve warned that people’s lives are being put at risk under the current system, which limits pharmacists’ capacity to use their expertise in the aged care setting.”

Use of medicines is the most common healthcare intervention in Australia and about 98 per cent of aged care residents have at least one medicine-related problem. Of those, more than half are exposed to at least one potentially inappropriate medicine.

Dementia Australia has reported that about half of all aged care residents and up to 80 per cent of residents with dementia are receiving at least one psychotropic medication, despite evidence showing only about 20 per cent of patients with behavioural and psychological symptoms of dementia would receive benefit from antipsychotics. Antipsychotics can be associated with significant adverse outcomes, including falls, cognitive impairment and increased risk of stroke and death.

“Aged care staff are committed to the wellbeing of their patients and doing their very best, but many are not experts in medication management,” Mr Freeman said.

“We know even with tools like dose administration aids, mistakes can still happen if we aren’t regularly checking doses and medications are still appropriate for the residents’ health and ensuring they don’t interact with any new medications.

“Pharmacists are best placed to improve decision making to ensure the safe and optimal use of medicines for older Australians. Our pharmacist workforce is equipped and eager to contribute and we need more time for pharmacists on the ground in aged care.”

PSA is calling for pharmacists to be able to spend more time in aged care facilities to advise residents and support them with their medicines and medication management. Pharmacists can also assist in improving quality use of medicines facility-wide and reducing harm caused by overuse of medicines.

“More investment in aged care regarding the safe and quality use of medicines should occur without delay to ensure Australians who have worked hard all their life, raised families, contributed to our community and are now entering their later years of life are treated with the care and respect they deserve,” Mr Freeman said.

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The funding includes:

• $215 million over three years from 2020-21 to provide additional remuneration to community pharmacies through increased Administration, Handling and Infrastructure fees on all PBS scripts, which has been partially funded by reallocating funding from 6CPA professional programs.
• $15 million over three years from 2020-21 for additional CSO payments to pharmacy wholesalers.
• $15 million in 2018-19 to promote quality use of medicines by patients through medication management programs in community pharmacy.
• Aligning public and private hospital pharmacy pricing with the community pharmacy pricing arrangements from July 1, 2019.

In addition, as announced and implemented last month, the government says it will improve cashflows for community pharmacies by reducing the nine-to-16-day period it takes to process claims against the PBS to between two and nine days.

This has no impact on the government’s fiscal balance over the forward estimates but will have a $213 million impact on the government’s underlying cash this financial year.

Pharmacy Guild National President George Tambassis welcomed the measures, saying they would assist community pharmacy small businesses to continue serving their patients and employing staff.

The Guild also welcomed the budget decision to introduce an Australian-first PBS-subsidised take-home program for naloxone to help reduce overdose deaths from opioid abuse, saying “this is a $7.2 million commitment which we strongly support”.

This budget featured $331 million for new and amended listings on the PBS, with these including “life-changing” medicines to treat lung, bladder, kidney and skin cancer as well as leukaemia. The Guild says it welcomes these listings, which ensure patients will be able to access these medicines for the general patient co-payment of $40.30 per script, or $6.50 with a concession card.

Health Minister Greg Hunt said: “The Liberal National government has provisioned $40 billion in the forward estimates for life-saving and life-changing medicines. We are averaging 31 new or amended listings per month – approximately one per day.”

Meanwhile, the government’s support of a Canberra trial to partner with community pharmacies in improving quality use of medicines in residential aged care has received strong support.

The Guild says the government recognises that better use of medicines in aged care, including the use of psychotropic medicines, will directly improve the quality of life, care and safety of many senior Australians living in residential aged care.

The Guild says it believes this trial and its outcomes will build on the extensive contribution already being made by community pharmacists all over Australia, as part of the collaborative teams that serve the needs of people in residential aged care.

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ASMI says preventive health, physical activity and healthy eating are key pillars of greater self care and, while greater investment and focus on these areas is welcomed, more needs to be done.

“ASMI is disappointed that health literacy is not a major focus of this budget given that 60 per cent of Australians have less than adequate health literacy levels,” the organisation said. “Greater health literacy empowers Australian consumers and leads to greater self care.

“It is promising that there is additional funding for medical research, and ASMI will be advocating for research projects that build the evidence-base for self care to be included within its scope.”

ASMI says it welcomes a focus on the safety and quality use of medicines in aged care and supports the trial placement of part-time pharmacists in ACT aged care homes.

ASMI recognise pharmacists play a key role in the quality use of medicines by Australians. The government’s announcement that they will provide additional support to pharmacies to help people manage their medication is welcomed and should include a focus on health literacy.

Following the government’s announcement of measures to improve access to medicines, ASMI said: “A key element of this, in our opinion, is the provision of data protection for ‘switch’ applications to increase access to medicines. We will continue to advocate for the greater incentivisation of ‘switch’ applications on behalf of the consumer healthcare products industry.”

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Below is Mr Tambassis’ 26^th March letter in full.

Don’t wreck the best medicine system in the world

All Australians can be rightly proud of our subsidised medicine system the Pharmaceutical Benefits Scheme (PBS).

And they should also be highly sceptical about proposals to tinker with the system in a way that could bring it crashing down.

One such bright idea that has been put forward recently is increasing the quantities of medicines routinely dispensed for a PBS prescription – that is, instead of a month’s supply, maybe dispense two, three or even six months’ supply to cut down on “inconvenient” visits to the local pharmacy and the number of PBS dispensing fees to pharmacists. What could possibly go wrong?

Well, let me tell you, lots could go wrong and it is an idea the Pharmacy Guild resists fiercely on behalf of our patients, our staff, and our health system.

Back in January the Medical Journal of Australia published an article by Dr Evan Ackermann under the headline “Exorbitant costs of routine medication repeats.”  In a nutshell, Dr Ackermann proposed bigger prescription quantities – three to six months’ supply – for people with selected chronic conditions, so that they visit their pharmacy less often and avoid what he called “excessive pharmacy fees.”

Canada and New Zealand are often cited as jurisdictions in which larger quantities are dispensed in some circumstances but these comparisons invariably compare apples with oranges – the system of distribution and dispensing of PBS medicines in Australia is unique the temptation to cherry-pick one aspect of another country’s system must be resisted.

Let me say at the outset that it is true that a reduction in the number of dispensing fees received by community pharmacies for dispensing larger quantities of high-volume medicines would be disastrous for the pharmacy small businesses, and jeopardise the entire network. Frankly I believe it would force many local pharmacies to close their doors. But that’s not the sole reason we strenuously oppose such a change.

In medication management there is a concept known as adherence – the extent to which patients take their medicines on time, in full, and as directed by their prescriber doctor and overseen by their pharmacist. Poor adherence may compromise the effectiveness of treatment, as well as the individual and public health costs in the longer term.

A recent OECD working paper found that poor adherence to medications affects approximately half of the population that receives prescriptions, leading to severe health complications, premature deaths, and an increased use of healthcare services. It identified face-to-face interactions with healthcare professionals as the best way to improve adherence.

It is clear that if a patient is receiving three to six months’ supply of their medicine without a return visit to their pharmacy, the likelihood of low medication adherence is magnified.  Any financial arguments in favour of larger quantity dispensing put quantity and cost ahead of quality use of medicines.

The evidence is overwhelming that having patients consult regularly with their pharmacist has positive benefits. For instance, a PROMISe study, Evaluation of Clinical Interventions in Community Pharmacies, reported that 80% of the interventions were considered to be proactive, that is they were initiated by the pharmacist and were provided in addition to dispensing medication.

The majority of clinical interventions were one of three categories: drug selection problems (22.7 per cent), dosage problems (19.4 per cent) or education or information problems (17.4 per cent), the study found. It should be noted that drug selection problems and dosage problems are errors in the prescribing process – something unlikely to be detected by review by the same practitioner.

The Pharmacy Board of Australia is clear on this issue. Its Guidelines for Dispensing of Medicines state: “Dispensing multiple quantities of particular medicines (whether or not directed by the prescriber) may not be consistent with the safety of the patient.

“When not directed by the prescriber, the simultaneous supply of multiple quantities of a particular medicine (i.e. the supply of multiple repeats at once) may be contrary to the Quality Use of Medicines principles outlined in the National Medicines Policy. It does not promote regular review of therapy and effective provision of medicine information by pharmacists, which may assist in minimising medication misadventure. It may also be contrary to State or Territory legislation.”

The Pharmacy Guild is always open to positive reform of our medicine system in the interests of patients and the sustainability of the PBS. But we will not be silent when ideas emerge which would wreck our network of community pharmacies and devalue a subsidised medicine system which has served Australians well since 1948.

George Tambassis

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