The HMR cycle: benefits for GPs and veterans.

The first module of Veterans’ MATES in 2004 focused on Home Medicines Reviews (HMRs). The accompanying prescriber feedback identified individual veterans who may benefit from an HMR. This approach was helpful to GPs, with approximately half indicating the feedback was useful and at least one of the identified veterans proceeding to an HMR. In the period following the module 1 mail out, the rate of HMRs increased four fold.

Veterans also received a brochure about medicines review and responded positively, with over 60% saying that they would discuss their medicines with their GP at the next visit.

This therapeutic brief seeks to build on the success of module 1 and assist GPs further in identifying veterans for whom an HMR would be helpful as well as providing practical information on the HMR process.

What are the benefits of an HMR?

• Focuses attention of veterans on the importance of informed medicine use - better informed veterans use medicines with more confidence and are more likely to adhere to prescribed medication regimens.
• Increases awareness of strategies that can be used to detect, manage and prevent medicine-related problems.¹
• Provides a comprehensive and consolidated list of medicines for the patient, the GP and other health care workers.
• Increases patient satisfaction.²
• Facilitates communication between patient and GP about medicines.²
• Facilitates timely and comprehensive follow-up and assists in forward planning for regular review.
• Adds a quality assurance element to medication management through a supplementary review of the medicine regimen.

In addition, a professional payment is available for doctors and pharmacists undertaking the HMR process for the benefit of veterans living at home or in aged care settings (Residential Medication Management Review or RMMR).

High risk veterans

High risk veterans include those with difficulties relating to speech, dexterity and vision, as well as confusion, dementia or other cognitive difficulties, all of which can lead to problems with taking medicines. These also impact on the veteran’s ability to use medical devices (e.g. inhalers, nebulisers) and monitoring devices (e.g. blood glucose meters).¹

Even in the absence of specific disease or acute changes, renal and hepatic function decline with advancing age and drug elimination may be compromised to an extent that can alter or exaggerate drug response. The risk of adverse effects or drug interactions is increased under these circumstances.

In addition, many disease states that are common in the veteran population account for a specific increase in risk for adverse drug events (ADEs). The presence and severity of conditions such as heart failure, chronic obstructive pulmonary disease and depression may influence drug response, and compound the likelihood of adverse outcomes such as pulmonary oedema, pneumonia, cerebrovascular events, falls and fractures. An integrated consideration of pre-existing pathology and the medicine regimen is needed to allow the development of a comprehensive picture of medicine-related risk.

High risk settings

Hospital admission and discharge are high risk settings that may compromise the continuum of care.³ These can result in intentional and unintentional changes to the patient’s medicine regimen.³ This may cause confusion leading to sub-optimal or over use of medicines putting the patient at a high risk of an ADE. For example, an Australian study showed that patient confusion about their medicines was responsible for 61% of medicine-related problems post-discharge.⁴

Another high risk setting occurs when veterans suffer from one or more chronic conditions for which they need multiple medicines.⁵ 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.⁶ While each medicine may be appropriately prescribed, reflecting best practice, the use of multiple medicines in an individual puts them at increased risk of ADEs, potential drug interactions and compliance problems.^5,7,8

High risk medicines

Certain medicines have a greater potential risk of ADEs for veterans. These include those with a narrow therapeutic window, frequent or severe adverse drug reactions and those with frequent monitoring requirements. Warfarin, digoxin, amiodarone and tramadol are examples of high risk medicines.

Medicines such as anti-platelets agents, nonsteroidal anti-inflammatory drugs (NSAIDs) and diuretics are high risk medicines because they are commonly used and account for over 50% of medicine-related hospital admissions.⁹

What information does an HMR provide?

Following an HMR visit the accredited pharmacist will prepare patient-specific written information including:

• a comprehensive patient medicine list which includes over the counter (OTC) and complementary medicines.
• documentation of medicine-taking behaviour; specifically what medicines are taken, when and how they are taken.
• other information about high risk drug-drug or drug-disease combinations that have been identified.
• any medicine-related problems reported by the patient.
• suggestions about additional monitoring.
• additional information for patient education and training in the use of medicine delivery devices, as well as identifying the opportunity for other health professionals to contribute.
• other relevant medicine-related information identified during the interview.

The accredited pharmacist will send the GP a copy of the report and where necessary proactively contact the GP to discuss important aspects of the review.

Veterans’ MATES and the HMR cycle.

Initiate an annual HMR to address medicine-related issues for veterans in “high risk” scenarios.

Who is eligible for an HMR?

Veterans living in the community who may be at risk of medicine-related problems can have an HMR. Medicare Benefits Schedule (MBS) Item 900 relates to HMRs undertaken for veterans residing in the community. The item is payable once every 12 months or more often if there is a signficant change in the veteran’s condition or medicine regimen. Payment can be claimed after completion of the referral form, development of the medication management plan and discussion of the plan with the patient.

What service is available for veterans living in aged-care homes?

Veterans residing in aged-care homes are eligible for an RMMR (MBS Item 903). An RMMR is a collaborative medication review between the GP and pharmacist and is conducted in the residential aged care setting. RMMRs have similar benefits to HMRs. An RMMR can be initiated either by the GP or pharmacist. For more information on RMMRs contact the Medicare Provider enquiry line on 132 150.

Who can provide an HMR service?

The community pharmacy of your patient’s choice may coordinate the HMR. However, the pharmacist who carries out the clinical assessment and prepares the report must be accredited to conduct HMRs. An accredited pharmacist has undergone specified training and assessment.

What to tell your patient

• To remind your doctor to initiate an HMR one year after the last one.
• An HMR can assist you in preparing an up-to-date list of all your medicines.
• The pharmacist conducting the HMR interview will be able to assist you in using medical devices e.g. nebuliser, or monitoring devices such as a blood glucose meter.
• Return to your doctor after an HMR to the discuss results.

References

1. Gilbert A, Roughead E, Beilby J, et al. Collaborative medication management services: improving patient care. Med J Aust 2002;177:189-92.
2. Domiciliary Medication Management-Home Medicines Review. Canberra: Commonwealth of Australia. 2001
3. Australian Pharmaceutical Advisory Council. Guiding principles to achieve continuity in medication management. Commonwealth of Australia, 2005. http://www.health.gov.au/internet/wcms/publishing.nsf/Content/D900D825B95328DACA25705A00181F55/$File/guiding.pdf (accessed 27 September, 2006).
4. Spurling L. A medication liaison service: a community-linked approach [Masters thesis]. Adelaide: University of South Australia; 2001.
5. Denneboom W, Dautzenberg M, Grol R, et al. Analysis of polypharmacy in older patients in primary care using a multidisciplinary expert panel. Br J Gen Pract 2006;56:504-10.
6. American Society of Health-System Pharmacists. ASHP Patient Concerns National Survey Research Report. Bethesda: American Society of Health-System Pharmacists; 1999.
7. Sorenson L, Stokes J, Purdie D, et al. Medication management at home: medication risk factor prevalence and inter-relationships. J Clin Pharm Ther 2006;31:485-91.
8. Vik SA, Maxwell CJ, Hogan DB. Measurement, correlates, and health outcomes of medication adherence among seniors. Ann Pharmacother 2004;38:303-12.
9. Howard RL, Avery AJ, Slavenburg S, et al. Which drugs cause preventable admissions to hospital? A systematic review. Br J Clin Pharmacol 2006 (published online 26 June):doi:10.1111/j.365-2125.006.02698.x.

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