Flag Veterans for Medicines Review

Medicines review provides an opportunity for you to assess how your veteran patient is managing their medicines and the outcomes being achieved.

There are a number of ways of reviewing your patient’s medicines. Home Medicines Review has been demonstrated to be the most effective.¹

What are the benefits to you as a GP?

HMR complements the regular reviews of medicines that GPs undertake by providing information on the patient’s experiences in using their medicines at home.

Following each home visit, you will receive a report from the pharmacist which includes:

• a comprehensive patient medicine list including over-the-counter (OTC) and complementary medicines;
• an assessment of medicine-taking behaviour i.e. exactly what medicines are being taken, when and how they are being taken;
• relevant drug interactions - many prescribing systems flag interactions but the pharmacist can provide information on whether or not these interactions are clinically important;
• information on your veteran’s requirements for additional patient education and training in the use of medicine delivery devices.

HMR provides payment to allow you time to reflect on the patient’s medicines and develop a medication management plan with the veteran.

What are the benefits of a HMR for your veteran patient?

• Greater understanding of their medicines.
  Confusion may arise for a number of reasons including brand substitution. Only 27% of Australian veterans rated their understanding of their medical conditions and medicines as very good prior to a HMR. This rose to 87% after the HMR visit.²
• Improved ability to keep taking their medicines appropriately.
• Reduced risk of medication-related problems.
• Reassurance and peace of mind.
  61% of people are very concerned about taking the wrong medicine and 58% are very concerned about suffering from a drug interaction.³

Home Medicines Review (HMR)

What is it and how is it different from what I already do?

Home medicines review is also known as domiciliary medication management review (DMMR).

In an Australian trial of HMR services, 90% of veterans felt it was important or very important that their doctor and pharmacist work together in helping them manage their medicines.² While GPs regularly review medicines, a collaborative approach involving a pharmacist provides a different perspective and focus. Medicines review can identify difficulties for patients or misunderstandings in handling, storage and use of medicine.

A HMR is patient-focused and is:

• Comprehensive
  Time is taken to assess all medicines, complementary therapies, dietary supplements and OTC medicines that are being taken regularly or intermittently. The HMR visit by a pharmacist usually involves up to one hour with the patient.
• In the home
  Enables checking of all medicines and related equipment e.g. nebuliser or blood glucose meter, to ensure they are in working order.
• Medicine focused
  Promotes discussion with the patient about why, how and when the medicines are to be used. This may involve assessment of techniques e.g. inhaler usage, and provides the opportunity to clarify and reassure veterans about their medicines and enhances their medicine knowledge.

Background

A high proportion of veterans and war widows have multiple co-morbidities which are treated with medicines. There is increased use of long-term medicines amongst veterans. This is in part attributable to:⁴

• increased availability of effective medicines (e.g. ACE-Inhibitors, statins);
• increased evidence for better health outcomes from the use of existing therapies (e.g. benefits of treating hypertension);
• increased use of medicines for disease prevention;
• greater screening for chronic disease and identification of risk factors resulting in more veterans being diagnosed;
• an ageing Australian population.

Why are veterans vulnerable to medication-related problems?

The veteran population is older and uses more medicines than the general Australian population.^5,6 Older people are more vulnerable to medication-related problems. One quarter to one third of unplanned hospital admissions involving the elderly are medication-related. Approximately 50% of these admissions are potentially preventable.⁷

An Australian study of older persons living in the community found that over 90% had at least one problem relating to their medicines, with most having three.¹ The most common medication-related problems involved confusion, or a lack of knowledge and skills needed to manage medicines at home (Figure 1).¹ Australian studies demonstrated home medicines reviews can resolve over 60% of these problems.^1,8

Veterans are likely to benefit from regular review of medicines and patient monitoring, both of which can reduce the risk of medication-related problems.

Figure 1. Medication-related problems amongst older Australians in the community setting

The most common problems involve confusion, or a lack of knowledge and skills needed to manage medicines at home.

How to organise a HMR. Medicines review made easy

Initiate referral

Initiate referral. You, as the veteran's usual GP, must assess the veteran as being likely to benefit and the veteran must consent. The item is payable once every 12 months unless there is demonstrated clinical need for another service. Referrals and medication management plans may be generated using some medical software programs. Further information can be found at http://www.gppaustralia.org.au/content/home-medicines-review The inclusion of relevant information such as vaccination status, current concerns, pathology results (such as biochemistry, blood picture and/or drug levels) will enable the pharmacist to provide you with a more complete assessment of your veteran's medicine-related needs.

Send the referral

Send the referral to the veteran's preferred community pharmacy. The community pharmacy co-ordinates the HMR and report.

Report to GP

Discuss the report

Discuss the report with the accredited pharmacist.

Discussion with patient

Develop a medication management plan

At a follow-up appointment with the veteran, discuss the pharmacist’s report and develop a medication management plan. Claim item MBS 900 once the plan has been developed. Provide a copy of the medication management plan to the veteran and the community pharmacy.

The risk flags

Multiple medicines

Veterans often need multiple medicines for optimal management of chronic disease. Over 70% of veterans use six or more different medicines in a year and more than 40% regularly use combinations of five to ten medicines.

When multiple medicines are used there is an increased risk of interaction. When five medicines are prescribed concurrently, the potential for interaction is approximately 50%. If eight or more medicines are prescribed the potential for interactions approaches 100%.⁹

Using multiple medicines may reflect best practice but it can lead to patient confusion and poor compliance resulting in poorer health outcomes.

Recent hospitalisation

In the past 12 months 38% of veterans have had a hospital admission. Significant patient harm and sub-optimal use of medicines frequently arises after discharge from hospital.

One study found that patient confusion about their medicines was responsible for 61% of medication-related problems post discharge (Figure 2).¹⁰

Confusion, hearing, vision or dexterity problems

92% of Australian veterans report visual problems and 55% report hearing problems: these factors may cause difficulty understanding or following instructions for medicines.

53% of veterans report arthritis, which may result in difficulty opening containers and handling medicines.

Confusion, hearing, vision and dexterity problems also impact on the veteran’s ability to use devices such as inhalers, nebulisers, dose administration aids and monitoring devices including blood glucose meters.

Risk flags:

• Multiple medicines
• Recent hospitalisation
• Confusion, hearing, vision or dexterity problems
• High risk medicines

Figure 2. Medication-related problems identified six weeks after hospital discharge

Patient confusion about their medicines was responsible for 61% of medication-related problems post discharge.

High risk medicines

Some medicines present a greater risk to veterans because of:

• narrow therapeutic index
• high propensity for interactions
• frequent or severe adverse reactions
• monitoring requirements
• requirement for dosage modification with renal impairment.

Warfarin, digoxin, amiodarone and tramadol are examples of high risk medicines.

Particularly for older veterans, renal function may be compromised despite a serum creatinine within the reference range. Reduced cognitive function, medical co-morbidities and use of multiple medicines also compound risks associated with medicines.

References

1. Gilbert AL, Roughead EE, Beilby J, Mott K, Barratt JD. Collaborative medication management services: improving patient care. MJA. 2002;177:189-192.
2. Department of Veterans’ Affairs. Implementation pilot for community medication management. Canberra: Department of Veterans’ Affairs; 1 December 1997 to 30 June 1998.
3. American Society of Health-Systems Pharmacists. ASHP Patient Concerns National Survey Research Report. Bethesda, MD 1999.
4. Zermansky AG, Petty DR, Raynor DK, Lowe CJ, Freemantle N, Vail A. Clinical medication review by a pharmacist of patients on repeat prescriptions in general practice: a randomised controlled trial. Health Technol Assess. 2002;6(20).
5. Department of Veterans’ Affairs. Survey of veterans, war widows and their carers. Canberra: Department of Veterans’ Affairs; 2003.
6. Australian Institute of Health and Welfare. Australia’s Health 2002. Canberra: AIHW; 2002.
7. Roughead EE, Gilbert AL, Primrose JG, Sansom LN. Drug-related admissions: a review of Australian Studies published 1988-1996. MJA. 1998;168:405-408.
8. Bennett A, Smith C, Chen T, Johnsen S, Hurst R. A comparative study of two collaborative models for the provision of domiciliary based medication reviews. Final report. Sydney, Australia: University of Sydney and St George Division of General Practice; 2000.
9. Atkin PA, Shenfield GM. Medication-related adverse reactions and the elderly. A literature review. Adverse Drug Reactions and Toxicological Reviews. 1995;14(3):175-191.
10. Spurling L. A medication liaison service: a community-linked approach. Masters Thesis, University of South Australia. 2001.

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