Rational prescribing: where are we now?

Welcome to the Australian Prescriber podcast. Australian Prescriber independent, peer-reviewed and free.

Medicines are at the heart of modern-day healthcare, the source of much that's good, but also the source of much harm that can be improved on. It's high stakes and modifiable, but also complex and ever changing. In an ever more intricate prescribing landscape, it's hard to help encourage this across the board, especially when new challenges keep on coming up. So, looking back 30 years, to when rational prescribing was first workshopped in Australia, to now, what have we learned and what lies ahead?

I'm David Liew, your host for today. It's an honor to welcome Professor Rob Moulds, retired clinical pharmacologist, but one of the founding fathers of rational prescribing and quality use of medicines in Australia, having chaired the Australian Prescriber Executive Editorial Committee, as well as being integral to the establishment of Therapeutic Guidelines and its ongoing success amongst many other things. He's written an editorial in the August 2021 edition of Australian Prescriber about rational prescribing 30 years ago and looking forward. So, I'm very glad to be speaking to him on the podcast today. Rob, welcome to the program.

Thank you very much.

So, tell me, Rob, why is it seemingly so challenging to make rational prescribing happen in practice?

I think it's the complexity of it that you've already alluded to the fact that we're living in a constantly changing world. And you just feel as if you've kept up with things or you've caught up with things and then suddenly they've moved ahead again. And so, I think the things have changed over the years too, the challenges perhaps I should say, have changed a bit over the years, but that principle of having to keep up with constant change, I think is the main challenge that we all face.

I guess there's so many distractions in real-world practice for frontline prescribers and frontline pharmacists, that it makes it really difficult to be able to maintain the, I mean, this is just one of many things that they have to think about at the same time.

Yeah. It's interesting to reflect back on the way these things have changed. But when I look back and think 30 years ago, when we had this, the symposium that we’re talking about, the challenges were very much new classes of drugs. The ACE inhibitors, the statins, then the H₂ antagonists, the PPIs, those sorts of drugs. And they were heavily marketed. There was a lot of money involved in the sense that they were expensive drugs and the pharmaceutical industry had very strong interest in trying to promote their uptake. And so, that was the sort of background that we were dealing with. Perhaps the other thing worth emphasising was the big issue of antibiotic resistance and it reared its head really in the '80s and was clearly a major problem. And so, antibiotic prescribing was a special issue really out on its own.

I mean, I guess that really kind of gives us a clear picture as to why a symposium was needed 30 years ago. And maybe you can tell us a little about what it was and what was so special about that.

Well, I think we all sensed that we were trying to implement things, but we weren't doing it in a vacuum, but we were doing it as individuals to a considerable extent and medical education, as it still is today, was very much centered on individual institutions, individual hospitals, individual universities. And we met and we talked to each other, but there really wasn't very much that was joint activities, particularly things like the Guidelines. Australian Prescriber was really the only Australia-wide publication which was available at that time. And Australian Prescriber should be proud of that, I think, that it goes right back to the, I think it's the late 1970s it first came about. But we were all looking for something. And at the same time, the consumers were too. The consumers were becoming more active and they were recognising that prescribing wasn't always right up to scratch.

And they were particularly concerned I think, about the role of the pharmaceutical industry, that not in a bad way, but the fact that they were sort of driving the agenda and the consumers felt that they should have a bigger say in the agenda than just the commercial interests of the pharmaceutical industry. So, I think that's what brought us together.

And I mean, that, I know that we're so used now to having consumers as such an integral part of so much that we do when we derive policy or we try to determine whether the kind of things that we are trying to do in clinical practice actually are going to work. But I guess that was really fairly novel at that time to be able to have that partnership and set the tone for the next 30 years, really.

Yes. No, it definitely was. It was partly because the consumers had become more active or that they had organisations that they previously hadn't had, but it was also partly, I think the whole culture of medicine was slowly changing for the good, instead of doctor knows best and just instructing the patient what to do. It was becoming more and more recognised that the practice of medicine was very much a partnership between the practitioner and the patient, which of course is the prevailing ethos today.

At the time of that meeting, did you expect that to have the kind of impact that it's had today? And we'll talk through, I guess, the impact of that meeting, but would you expect it to kind of be such a fruitful partnership?

I think we hoped. It wasn't a surprise, put it that way. I suspect that none of us really quite realised just how successful it was going to be in terms of changing things. And I think quite a few things happened, which would not otherwise have happened if that meeting hadn't have been held.

Well, I mean, I think you mentioned one of the big-ticket items before, about what we know now as antimicrobial stewardship, really that it seems incredible that 30 years ago, I think things were very different. That all seemed to evolve from that time and I guess there's a lot of lessons that we could learn from how that's kind of played out, don't you think?

Yes, absolutely. And the antimicrobial stewardship and the role of Antibiotic Guidelines in promoting or facilitating antimicrobial stewardship, that of course was already in place. And I think that in itself, and the success of the Antibiotic Guidelines, was one of the factors which I think gave people encouragement that this is something that we actually can do. This is something that actually works. And so, in a way there was a little bit of a sense of, well, we've succeeded almost beyond our expectations with that particular example, so let's think big. Let's be broader.

Well, I mean, so what kind of things at that time do you think were on the agenda and how have they flowed through now? I mean, government expenditure on medicines, like you said, at the time was enormous concern on new classes of medicines.

Yes. I think that was certainly the driving force behind the funding of the meeting, I might say, that the Department of Health funded it and that was clearly their driving, but I think to give them their due, they didn't say we expect you to save money by having this meeting sort of thing. That was absolutely not the case. And the consumers, I think that was of the good things about having the consumers involved, is that consumers weren't interested in saving money, particularly. What they wanted was the best treatment for patients.

So, what do you think came out of that meeting as far as that field is concerned and yeah, how has it reflected on what we've got today?

Well, it certainly has reflected on what we've got today, I think. As I said, I think some of the things would have happened anyway. There were other forces at work clearly, but I think it was almost a catalyst. It gave everybody involved a focus. It provided a framework. It was a fairly loose framework I might say, but it provided a framework that people could see and they could feel that they were able to work within. I think the big things were the firstly the National Medicines Policy, that came about afterwards. Now, that might well have happened anyway, but I don't think there's any doubt that the meeting provided impetus for that.

And I think the other big thing that came out of it was the impetus for the development of the Australian Medicines Handbook and the National Prescribing Service. Now, they were not in existence at that time. Antibiotic Guidelines was, and Therapeutic Guidelines in a different sort of format was already in existence, but fairly embryonic. And of course the Australian Prescriber was already there, but the Australian Medicines Handbook and the National Prescribing Service were not. Again, they might well have come about anyway. But there's no question, I think that the meeting provided an impetus for that.

I guess talking of consumers and things that have really evolved, consumer medicines information has really come on since that period of time. I mean, what was discussed at that time and how do you think it's played out?

The Consumer Medicines Information, the CMIs, that was clearly the main agenda of the consumers. They basically had two agendas. One was to try and improve prescribing overall and to provide as much support as they could to the different organisations that had as one of their prime purposes to actually improve prescribing. But they had a specific agenda of the Consumer Medicines Information. It was one of their main policies, that’s what they wanted and they got strong support.

So, let's fast forward to the current day. Right now the National Medicines Policy is undergoing review. We're at a bit of a juncture where there are different challenges. So, if we were to hold this kind of meeting now, or we would have that same type of thinking now, let's reflect on how we should act based on what we've learned from the last 30 years? What are the big challenges?

I think the two biggest challenges that I see, are firstly how do you make things available to people for free? I think it's basically an insoluble problem of independent information. How do you make information, which no one's got a vested interest in, the best information that you can, and advice, how do you make that universally available? Because if someone else is paying for it, then it's not independent. And if it is truly independent, well then it's really got to be self-funding and that means that some people will refuse to pay and they won't get it. So, I think it's basically an insoluble problem, but I think it's worthy of major discussion, which would then morph into, I think, the structures that are in place.

I alluded in the editorial to the fact that Australian Prescriber is funded in one way, Therapeutic Guidelines is funded in a different way. AMH is funded in a different way. NPS is funded in a different way. They all have different funding models and different business models. Now that might be very appropriate. That might be very appropriate that a single business model is not going to work for different organisations that basically have the same overall aim, but are filling different niches if I can perhaps put it that way. But I think it's worthy of discussion.

I think the other big thing that I see is the personalised medicine, the whole movement towards highly specialised drugs. And you look at the main drugs on the PBS now, and that are costing money on the PBS, and the list is just a totally different list from what it was 30 years ago, not only in the names of the drugs but the types of drugs and it's all monoclonal antibodies and very expensive biologicals now pretty well.

And they’re drugs that are mainly, if not solely, prescribed by specialists in highly specialised circumstances, becoming very intricately linked in now with diagnostics and the diagnostic procedures, genetic tests, and things like that, so that even the classification of diseases is now totally changing, depending on the current understanding of molecular biology etc. So, that's a huge issue I think that is evolving. And it's not as if there's a problem, let's have a meeting and we'll solve it. That's not going to happen, but I think it probably needs to be better aired, the issues that these things bring up.

How would we move forward on that? I mean, let's take that second issue to start with. Going back 30 years, we can see that the classes of medicine that we were concerned about back then have definitely brought benefit to the healthcare environment and to patients. But at the same time, they needed the nuance of rational prescribing and the quality uses of medicines to get the most out of them. Going forward here, thinking about the potential benefit that a lot of these approaches that we've talked about with biological medicines and personalised medicine might bring, but the potential detriment, how are we going to balance this?

That's a very good question, and I think I'm too old to have the answer. But I think my point was that it needs discussion and it probably needs better minds than mine to try to come up with not necessarily solutions, because as I said, I certainly don't see it as a big problem that requires a solution. I see it as a big issue that requires a lot of good people with good brains to think about. And out of that, hopefully will come the best processes.

And I guess there's always another thing that you've alluded to in the editorial is really about the fact that often you have things like guidelines, which are developed, perhaps not necessarily with value-based healthcare or with cost considerations or rational prescribing considerations in mind. I mean, how can we do better to try and incorporate cutting-edge progression and practice with, really, the benefits of rational prescribing and the quality use of medicines?

Yes. I think that's a very good question. And I think what you're alluding to there I think is there's almost two sorts of guidelines I think. There are the definitive guidelines, which as you say, don't take into consideration cost effectiveness or anything like that. What they are aiming to do is to say, "This is the current state of human knowledge. If you have a certain disease, in a certain situation, then this is the current state of human knowledge saying what is the best way of dealing with that." Then you have more practical type of guidelines, which I think is what you were sort of trying to get at, well how do we translate those state of human knowledge type guidelines to more practical? Well, okay, that is the state of human knowledge, but how do we apply it? How can we put it into practice in a meaningful way so that the most patients will benefit, but it's not pie in the sky. It's not sort of, "Well, okay, that's fine. That's the state of human knowledge. But we actually can't do it." For whatever reasons, the practical problems that make it very difficult to do it anyway. And it's that sort of translational aspect, which I think is the hardest.

And I guess that's, I mean, looking back at trying to integrate the different ways of thinking when it came to statins and ACE inhibitors, I guess there are some parallels as to how we might try and integrate the thinking when we talk about personalised medicine and we think about very expensive oncology and autoimmune disease and orphan disease and other rarer disease kind of therapies.

Yes, I agree. And how to get the relevant specialists involved, I think. I think a lot of the specialists, perfectly understandably and perfectly reasonably, tend to think along the lines of the perfection, that my job as a specialist is to advocate for the best and which is absolutely defensible. And I'm not criticising that. But the best isn't always easily available. And I think how we can get at least some of the specialists, I think some specialists will always think along those lines that it's not my job to provide the resources. It's my job to say what's the best. But I think there are others who think along perhaps more practical lines and would be prepared to very much participate and to try and help those processes of translation. And how to harness those particular skills and those particular specialists, I think is a very important aspect for the future.

I mean, thinking about that integration and that harnessing, I guess some of that also, I mean, it's about trying to bring those skills together and it probably does come to some of the other challenges we face in terms of making sure that at a medical student level, when, and beyond that we have a way of improving people's prescribing skills and an awareness of basic clinical pharmacology principles.

Yes. That's a different challenge I think. All these challenges are related of course, but I think that's a different one and I think it's an important one. We haven't really referred to it now, but at the medical education level, at the particularly undergraduate medical students and whether there should be a prescribing assessment built into medical courses, I think that's an ongoing debate which is occurring. And I'm not up with the latest in that debate. I'm not participating, but I certainly think it's an important one. And I personally would favour there being a prescribing skills assessment.

So if you were to take one message from that very first, well, going back 30 years to that symposium, if we were to take one message from there that we should remind ourselves of now, what do you think that would be?

I would say cooperation. I think the real message that came out of that meeting was that disparate people with seemingly different, like that particular example was the consumers and ASCEPT, which is the professional association for clinical pharmacologists (and experimental pharmacologists, but in this instance we’re mainly talking about clinical pharmacology), that it brought them together in spirit of cooperation, which I personally had not experienced before. And I think it's this cooperation between groups that seemingly are disparate, and yet if they will work together, then often good things come out of it.

Well, Professor Moulds, that's a beautiful message to end on. Thank you so much for your time today and I hope we can take some of those messages and apply them in practice.

Well, thank you very much. It's been a pleasure to participate.

[Music]

The views of the guests and the hosts on this podcast are their own, and may not represent Australian Prescriber or NPS MedicineWise. I'm David Liew. And thank you very much for listening to the Australian Prescriber Podcast.