Professor Keith McNeil
Queensland Health, Brisbane, Australia
Reshaping healthcare: harnessing the potentialToggle information
The digital world has, and is, affecting us in all avenues of life. We are just grasping the digital nettle in healthcare, recognising the opportunities this presents to iteratively improve patient outcomes and experience, to transform from descriptive (retrospective) to predictive and prescriptive analytics at a population level, and to deliver highly personalised and precision medicine at an individual level. From a business perspective, digital technology will underpin the affordable and sustainable system needed to deliver these benefits to individual patients, and to the population as a whole.
So just what is digital transformation and how does it work for busy clinicians whose primary focus is providing high-quality care to the patients they see day in and day out?
Digital transformation in its essence is about data — generating it, aggregating and analysing it, and then feeding back the results of those analyses to better inform decisions whenever and wherever they are made across the healthcare landscape.
Healthcare data is, and always has been, generated at the point of interaction between a clinician and a patient. Collecting that data and analysing it for patterns of disease presentation and response to treatment forms the basis of the practice of medicine today. Luminaries such as William Osler made an art form of clinical observation and pattern recognition based on the meticulous recording, analysis and sharing of data. The difference today is our unprecedented capacity to generate, record, analyse and share data and information via digital platforms and technology. Digital technology and the power of information will disrupt the way we provide healthcare, and in doing so, lead to the system transformation that is so necessary to enable us to deliver the triple aim — better patients outcomes, a better patient experience and affordability.
The prize at the end of all this is the creation of a learning and knowledge-based system that will enable us to be increasingly precise in the way we deliver care to patients, to enhance our ability to improve health at a whole population level, and to provide information in real time for informed decision making, with the combination of these three enabling a sustainable system dynamic into the 21st century.
Dr Hans-Georg Eichler
European Medicines Agency, London, United Kingdom
Adaptive regulatory pathwaysToggle information
The ‘evidence versus access’ conundrum refers to the dual tasks of ensuring rapid access to promising treatments for patients in urgent need on the one hand and ensuring that patients, healthcare professionals and other decision makers possess adequate information on benefits, risks and value at the time of launch on the other hand. Various facilitated regulatory pathways (FRPs), including conditional marketing authorisation in the EU, have been implemented over the past decades in a number of jurisdictions to address the conundrum.
The concept of adaptive pathways (AP) seeks to be broader than FRPs, focusing on existing legal regulatory processes and robust evidence generation while acknowledging that a marketing authorisation per se will not ensure timely patient access when access ultimately hinges on coverage decisions by payers and on other downstream activities.
Conceptually, AP could be described as the pre-planned and smartly designed combination of several building blocks, achieved through repeated dialogue of the principal stakeholders. The building blocks of AP are:
- An initial focus on access for patient (sub) populations in urgent need, with targeted high-quality studies that enable faster assessment
- Rapid increase of the evidence-to-uncertainty ratio by way of a life-span approach to evidence generation
- Utilisation of the full spectrum of study methodologies for evidence generation; randomised controlled trials complemented by real-world data studies
- Adaptive pricing and reimbursement with flexible price points and adjusted reimbursable populations
- A focus on appropriate utilisation to ensure that prescribing mirrors the treatment eligible population as defined by the evolving evidence base
- Close collaboration of all stakeholders by way of scientific advice to drug developers across the product life-span.
The opportunities, challenges and experiences of AP will be discussed during the session.
Professor Lisa Jackson Pulver
Aboriginal & Torres Strait Islander Leadership, Western Sydney University, Australia
Clinical and cultural competence in a fast-changing worldToggle information
There are many historical, political and community-level challenges to Aboriginal and Torres Strait Islander people experiencing what is arguably more than good health—that is ‘quality of life’. The advent of genomic medicine and bespoke solutions individualised to the Australian people may well bypass this part of the population unless we take a step back—and ask “how does this help those who suffer health disparity and social inequality?”
This presentation will offer some insights into how we—as a community of health practitioners—can work with Aboriginal peoples—and draw on their knowledge and practices for the betterment of all Australians.
Professor John Christodoulou
Genetics Research Theme, Murdoch Children’s Research Institute, Melbourne, Australia,
Genomic Medicine, Department of Paediatrics, University of Melbourne, Melbourne, Australia,
Australian Genomics Health Alliance, Melbourne, Australia
Genomic medicine: preparing Australia for this disruptive technologyToggle information
One of the many gains from the Human Genome Project was the development of massively parallel sequencing (aka next-generation sequencing, NGS), and with advances in these technologies has come an unparalleled opportunity to harness this disruptive technology to transform the delivery of healthcare. We could anticipate that benefits will include faster and more cost-effective diagnosis, avoiding in many cases the need for invasive investigations, implementation of early intervention including targeted therapies, and restoration of reproductive confidence.
However, there are potentially many barriers to the successful implementation of genomic technologies into mainstream Australian healthcare at both the state and national levels, including fragmentation in the delivery of state and federal health services potentially leading to an inequity of access to genomic testing, lack of infrastructure for storing clinical and genomic data, an Australian healthcare workforce not prepared for genomic medicine, and ethical and insurance challenges.
The Australian Genomics Health Alliance, an NHMRC-funded health services research project, has been established as a national consortium of over 80 research institutes, healthcare and other organisations, with representation from learned societies and the community. The primary goal of Australian Genomics is to gather the most robust evidence possible to convince healthcare providers and governmental policy makers that genomic technologies should be introduced early in the patient’s diagnostic odyssey and funded accordingly.
A high-level overview of the progress of Australian Genomics will be presented. One of the fundamental strategies is to prospectively collect and evaluate data from patients recruited across the nation within two broad crosscutting disease flagships: cancer and rare diseases. Other points of discussion will include our efforts at developing federated database resources, the health economic merits of and barriers to implementation of NGS technologies, workforce and ethical issues, and community expectations.
Dr Ray Moynihan
Bond University, Gold Coast, Australia
Genomics, personalised medicine and the dangers of overdiagnosisToggle information
There is little doubt that genomics and personalised medicine will bring important benefits for human health, but there is an urgent need to understand the nature and magnitude of their potential harm. As promotion of ‘precision medicine’ grows—and with it the prospect of screening the genes of healthy people—a sober assessment of risks and benefits is timely, if we are to try to prevent a ‘tsunami of overdiagnosis’.
This plenary presentation will focus on the science of overdiagnosis, which is rising against a backdrop of national and global concern about waste and too much medicine. The presentation will explore the evidence about what’s driving overdiagnosis and related overtreatment, what the scientific literature suggests might address the problem, and why this is directly relevant to the rational adoption of new genomic technologies.
Professor Jeremy K Nicholson
Imperial College London, London, United Kingdom
Systems medicine approaches to the challenges of 21st century personalised and public healthcareToggle information
Changes in climate and population densities and distribution plus increasing socioeconomic stresses placed on healthcare systems pose a unique series of challenges in 21st century medicine. A tension exists between the development of new investigative, diagnostic and prognostic technologies and the ability of scientists and healthcare professionals to deliver effective translational solutions.
Systems biology tools can be applied at both individual and population levels to understand integrated biochemical function in relation to disease pathogenesis, but there are still barriers to the clinical actionability of these models that inhibit practical translation. The complex gene—environment interactions that create individual and population disease risks are also responsible for the expression of metabolic phenotypes in different body compartments. Thus systems medicine and metabolic phenotyping approaches offer windows on human systemic function, and spectroscopic tools can help characterise personalised profiles, disease processes and responses to therapy.1
We have developed new scalable and translatable strategies for ‘phenotyping the patient journey’2 using top-down systems biology tools that capitalise on the use of metabolic datasets3 for diagnostic and prognostic biomarker generation to aid clinical decision making at point-of-care. These have been shown to be of value in the development of prognostic marker models for both clinical efficacy and drug toxicity in cancer patients. Such approaches, including those for near real-time applications as in surgery, molecular pathology, oncology and critical care, can be extremely sensitive for the detection of diagnostic and prognostic biomarkers in a variety conditions.4,5 These methods also provide a powerful adjunct to conventional procedures for disease assessment that are required for future developments in ‘precision medicine’ including understanding of the symbiotic influences on patient state.6 Finally, the ‘Metabolome Wide Association Study’7 concept provides powerful tool to discover disease risk biomarkers from epidemiological sample collections. Such population risk models can also link to individual patient healthcare models, thus closing the personal and public healthcare modelling triangle. The ultimate challenge is to take complex validated omics datasets and models on human biology and to visualise these in engaging formats and forms that are clinically actionable in an ever-changing background of health risks.
1. Nicholson JK, Lindon JC. Nature 2008;455:1054-1056.
2. Nicholson JK et al. Nature 2012;491:384-392.
3. Clayton TA et al. Nature 2006;440:1073-1077.
4. Balog J et al. Science Translational Medicine 2013;5(194):194ra93.
5. Veselkov KA et al. PNAS 2014;111(3):1216-1221.
6. Mirnezami R, Nicholson JK, Darzi A. New Eng J Med 2012;366(6):489-491.
7. Elliot P et al. Science Translational Medicine 2015; 7:285ra62
Professor Iven Mareels
IBM Research, Australia
Convergence of engineering, IT and clinical practice: opportunities and challengesToggle information
We would argue that data, technology, human biology and clinical sciences have always worked together to improve health outcomes. Nevertheless, a true convergence of engineering, IT and clinical sciences is emerging.
Artificial intelligence, process automation, robotics and systems engineering working with the enormous advances in quantitative biology and clinical sciences may well herald a new era of superior health care. Nevertheless, this will only succeed if the health ecosystem will embrace a new equilibrium where machines assist and extend the capacity of the clinical, and paraclinical professionals in both a physical and a mental capacity.
We will discuss briefly some of the opportunities convergence offers, and the challenges we face as a society in developing towards this new equilibrium.
Dr Harriet Teare
Deputy Director, Centre for Health, Law and Emerging Technologies, University of Oxford,
Research Fellow, Melbourne Law School
Law, ethics and practice… bringing consumers on the personalised medicine journeyToggle information
The future of medicine is predicted to involve a more personalised, consumer-centric approach. Personalised medicine offers the opportunity to emphasise prevention, while digital health, m-health, electronic medical records and smart phone apps are all designed to allow the consumer to have greater control and oversight of their own health data.
Personalised medicine will fundamentally change the role of the consumer within healthcare, as can already be identified in initiatives which focus on shared decision making, and the different tools that are being introduced to establish new ways to engage with consumers. Dynamic consent is one such tool, which allows consumers to change their consent decisions over time, and provides real-time interaction with the data as they flow between clinical care and research.
Several projects have implemented dynamic consent and are beginning to gather data to better understand how it influences the consumer experience. It is hoped that dynamic consent will allow information to be tailored more appropriately to different communities (delivered through a variety of media), to allow a more diverse range of people to understand how their data are used across healthcare for their benefit and to improve healthcare delivery more broadly. To achieve this in practice, it will be crucial to work closely with different communities and patient populations to better understand specific needs, to co-develop tools to make healthcare more accessible, and to ensure that advances in personalised medicine can genuinely be realised for all.
Lynch Syndrome Australia, Sydney, Australia
Misdiagnosed, misunderstood, missing out: the journey for manyToggle information
Around 85,000 Australians are living with Lynch syndrome, the most prevalent inherited cancer risk. They are misdiagnosed, misunderstood and are missing out on appropriate treatment and care. That’s partly because it’s a complex condition — and partly because a precision medicine approach is rarely applied to their care.
Lynch syndrome carries a 71% lifetime risk of up to 12 different types of cancer, at an average age of 44 for the first cancer. Once you have had a Lynch syndrome-related cancer you are likely to have more, and as many as eight cancers have been recorded by one patient. However, a quarter of people affected will never have a related cancer, and some have genes with much lower cancer risks, yet everyone receives the same advice: to undergo invasive, annual surveillance, radical preventive surgery and to follow a daily regimen of chemo-prevention.
In theory, precision medicine should greatly benefit those with Lynch syndrome: through analysis of their tumour biomarkers, for example, or a detailed understanding of the individual risks associated with each gene mutation. In practice, many of those who could most benefit from individualised strategies are being left behind by this rapid, but unequal, evolution in personalised care.
Dr Barbara Mintzes, Ms Lucy Perry, Ms Alice Bhasale, Dr Danijela Gnjidic
Post-market safety communications and emerging risks of medicines: are we getting it right?Toggle information
The US consumer group Public Citizen famously declared a ‘seven-year rule’ for using most new drugs, since serious risks commonly emerge in the early post-market period.1,2 Regulators communicate emergent risks through website alerts, mass media and letters to health professionals. Yet the impact of these communications is uncertain. Some result in immediate change, while others have minor or unsustained impact.3 Unintended consequences include medicines being stopped abruptly due to exaggerated perceptions of risk.
Regulatory agencies globally are under pressure to harmonise drug approval processes, but concordance in communicating emerging risks has received less attention. The 2004 rofecoxib (Vioxx) withdrawal prompted revisions to both pre- and post-market policy, but has post-market risk communication changed in the interim?
Using preliminary data from a study of 1448 safety advisories in Australia, Canada, the United Kingdom and the United States between 2007 and 2016, the panel will discuss:
- Differences in the frequency and characteristics of advisories — all regulators issued advisories for only 5.9% of safety concerns and Australia released fewer advisories than other regulators
- Illustrative case studies — eg, Australia was one of only two countries to warn of jaw osteonecrosis with the use of denosumab but did not comment on evidence of increased mortality with long-acting beta-agonists, or on fibrates’ limited effectiveness in cardiovascular prevention
- Whether regulatory policy differences explain these trends.
Next steps include studies of drug utilisation, health outcomes, the role of media, and prescriber attitudes. As the study will ultimately generate recommendations on postmarket communications, audience discussion will focus on how to better ensure that these communications protect public health and implications in Australia. Uses for a publicly available database of safety advisories will also be explored.
1. Wolfe SM. Australian Prescriber 2012
2. Downing NS et al. JAMA 2017
3. Dusetzina SB et al. Med Care 2012
Ms Luisa Eckhardt
Mid North Coast Local Health District, Coffs Harbour, Australia
Bowraville Solutions Brokerage-MNCLHD and consumer empowerment in healthcare deliveryToggle information
The Solutions Brokerage declaration for Bowraville afforded the opportunity for a wholeof-government response to work with Bowraville community to facilitate change for a better future. In a call to action, agencies were asked to consider the way business as usual was conducted and what this really translated to in the community. The community (Jaanymili Barwunga) was given a voice and the capacity to govern its space, advocate for what it felt it needed and negotiate how this might actually look within Bowraville.
The Mid North Coast Local Health District (MNCLHD) committed to community engagement and worked alongside Jaanymili Barwunga to design and implement health services that were reflective of the local population health needs — not just indicative from health data but from the voices and expressed needs of the community. From a limited ‘on the ground’ service level to the implementation of clinical services such as child and family health nursing, hearing, occupational therapy and speech therapy to whole-of-population dietetic, mental health, drug and alcohol clinicians now based in Bowraville. The community was instrumental in the design of its health service landscape.
The MNCLHD and Jaanymili Barwunga now communicate on how services are performing based on consumer uptake, models of care and their effectiveness for the community, and mapping service utilisation to promote sustainability and measure improvements in community health. The implementation of patient-reported measures within Bowraville will ensure sustainability of consumer partnerships in service (re)design and flexibility.
All MNCLHD services within this community have dedicated Aboriginal Health Clinicians to ensure that we are dedicated to Closing the Gap with the community and working alongside Bowraville for long-term whole-of-population health improvement.
Lightning Talks Evolving Systems
Dr Rebecca Doolan
Therapeutic Goods Administration, Canberra, Australia
Reforms to advertising of medicines containing Schedule 3 substancesToggle information
Whether a medicine is available on prescription only or can be purchased over the counter (OTC) is determined by the scheduling of the active ingredient in the Poisons Standard (or Standard for Uniform Scheduling of Medicines and Poisons). Scheduling is intended to promote the quality use of medicines and to balance consumer access to medicines with the need to manage risks associated with their use. In addition to regulating access to medicines, this scheduling process also plays a role in determining whether or not certain OTC medicines may be advertised direct to consumers (DTC).
OTC medicines containing substances from Schedule 3 of the Poisons Standard (known as Pharmacist Only Medicines) can only be advertised DTC if the substances are also included in Appendix H of the Poisons Standard. Possibly owing to a certain historical reticence to adding Schedule 3 substances to Appendix H, DTC advertising of Schedule 3 medicines was previously regarded as essentially banned. Recently though, a major review of the regulation of medicines and medical devices recommended (among many other things) that the advertising framework for Schedule 3 medicines should be reviewed.
Following collaboration with the states and territories and two major public consultations regarding this reform work, the Federal Minister for Health together with the Australian Health Ministers Advisory Council decided that the policy intent for the advertising of Schedule 3 substances should be revised to allow these substances to be advertised DTC, unless there is a compelling reason not to.
This presentation will cover the revised requirements for advertisements for medicines containing Schedule 3 substances, and the process for adding current and future Schedule 3 substances to Appendix H of the Poisons Standard.
Dr Jonathan Penm, Prof Neil MacKinnon, Rebecca Mashni, Assoc Prof Michael Lyons, Assist Prof Edmond Hooker, AProf Erin Winstanley, Prof Steve Carlton-Ford, Chloe Connelly, Dr Erica Tolle, Prof Jill Boone
Evaluation of the implementation of the Ohio Emergency and Acute Care Facility Opioid Prescribing GuidelinesToggle information
Background: The United States and the Ohio Department of Health has disseminated emergency department (ED) opioid prescribing recommendations to aid address this issue.
Aim: To evaluate the implementation of the Ohio Emergency and Acute Care Facility Opioid Prescribing Guidelines.
Methods: A survey was distributed to ED medical directors in Ohio following Dillman’s tailored design method, augmented with telephone recruitment/interview. The survey was made available as a paper version and a web-based version via REDCap. Hospital chief executive officers were also contacted by email and mail to encourage their ED medical director to complete the survey. At the end of the survey, respondents were asked to participate in a semi-structured interview to assess barriers related to the implementation of the guidelines.
Results: A 92% response rate was obtained (150/163 hospitals). In total, 112 (75%) of the respondents stated that their hospital had an opioid prescribing policy, was adopting one or was implementing guidelines without a specific policy. Of these 112 hospitals, 81 (72%) based their policy on the Ohio guidelines. The majority of respondents also strongly agreed/agreed that the guidelines increased the use of the drug prescription monitoring program (86%) and reduced inappropriate opioid prescribing (71%). Main themes identified from 20 interviewees included the need for (1) increasing organisational responsibility, (2) workflow issues with the drug prescription monitoring program, (3) reducing the effect of patient satisfaction scores on opioid prescribing and (4) increasing patient involvement.
Conclusion: A large majority of hospitals reported having, in principle, an opioid prescribing policy for their ED. Despite strong support for these guidelines, additional support is needed to ensure they are successfully implemented.
Ms Nadine Hillock, Prof John Turnidge, Prof Jon Karnon, Prof Tracy Merlin
Antimicrobial drugs and the Special Access Scheme: an anomaly or a marker of a system in crisis?Toggle information
Background: Increasing antimicrobial resistance, and the concurrent recent reduction in marketing of new antimicrobials, has resulted in limited available therapeutic options for some infections. Unregistered antimicrobials are imported and prescribed in Australia for individual patients through the Special Access Scheme (SAS).
Objective: To identify the number of unregistered antimicrobials recommended in clinical guidelines, and to quantify their utilisation in Australia and identify any trends in usage over the last 5 years.
Methods: The online version of the Therapeutic Guidelines (eTG) was reviewed to identify all recommendations that included antimicrobials not registered with the Therapeutic Goods Administration. Data on the number of SAS applications for unregistered antimicrobials was obtained from the Department of Health for the period May 2012 to April 2017. Antibiotics imported via the SAS to replace unprocurable licensed products were excluded.
Results: 21 unregistered anti-infective drugs were identified in the eTG, recommended for the treatment of 27 clinical indications. Annual SAS applications increased significantly for a number of these antimicrobials over the last five years, including some of the most frequently used unregistered drugs: pyrazinamide applications increased by 104%, tetracycline by 106% and fosfomycin by 705%.
Conclusions: The relatively large number of unregistered antimicrobials included in clinical guidelines suggests that the regulatory framework in Australia may not cater for the unique attributes of antimicrobials. Usage of some unregistered antimicrobials has increased significantly in the last five years, including agents to cope with increasing antimicrobial resistance. Unregistered products are not funded on the Pharmaceutical Benefits Scheme (PBS), increasing the risk that a patient may not be able to access the treatment outside the public hospital setting. The current regulatory pathway in Australia, in combination with low utilisation of some products, is a disincentive for manufacturers to market antimicrobials to combat multi-drug resistant infections.
Dr Bonny Parkinson, Dr Mutsa Gumbie, Dr Henry Cutler
An economic evaluation framework to inform the scheduling of medicines in AustraliaToggle information
The idea: Decision makers focus on patient risk when deciding whether a medicine should be prescription-only or available over the counter (OTC) (ie, scheduling decisions). However, these decisions can have a wide range of impacts (in addition to patient risk) that may not be given sufficient weight, such as faster symptom relief, increased treatment rates, or avoided adverse events from alternative treatments.
In 2015 a review of medicines and medical devices regulation recommended that a formal risk-benefit methodology may assist scheduling decisions. This study aimed to: develop an economic evaluation framework, a form of risk-benefit analysis, to help inform scheduling decisions; and to demonstrate the framework using a case study, downscheduling the oral contraceptive pill (OCP).
Results: The framework was based on various health economic guidelines, but with consideration of patient and pharmacist behaviour. The OCP case study involved using a Markov model to synthesise evidence regarding uptake and rates of pregnancies, pregnancy outcomes, adverse events and sexually transmitted infections. It was predicted that down-scheduling the OCP will increase health outcomes and be cost-saving, but the benefits decreased with age. More research is needed regarding pregnancy rates when not using contraception and not trying to conceive.
Conclusion: An economic evaluation approach to scheduling decisions has several advantages, including: use of economic modelling to synthesise evidence and predict the impact of re-scheduling; aggregation of different health outcomes into a single measure (quality adjusted life years); consideration of healthcare resource use; and identification of areas needing further research and predicting the impact of different regulatory scenarios through sensitivity analysis. However, while they can provide new insights, they should be considered as a part of the broader body of evidence regarding the types of health impacts, the extent of the available evidence, who will be affected, and the role of medical practitioners and pharmacists in mitigating any risks.
Mr Jared Brown, Ms Jennifer Ly, Ms Rose Cairns
Finding solutions for support workers in medication handling in group homesToggle information
Background: Poisons Information Centres (PICs) receive a large number of calls from support workers in group homes and disability service providers. Over recent years, the number of privatised disability service providers across Australia has increased and subsequently, the number of calls from group homes to PICs. Our study was driven by the need for a development of a medication handling policy in which better standards of practice can be performed in medication handling by staff working in these facilities.
Objective: To characterise the calls made to the NSWPIC from carers in group homes to ultimately draw attention to the need for better standards of practice in these facilities.
Results: A total 65,318 calls were made to the NSWPIC in 2017, of which a preliminary analysis found that 6064 (9.3%) were received from group homes. These calls were received from over 55 different group homes in NSW. The most common call type was about medication administration, which comprised of missed medications (48.1%), medications given at incorrect times (7.0%), clients refusing medications (6.2%), medications given to wrong clients (5.2%) and multiple doses of the same medication given in close proximity (5.8%). The top three medications involved in errors are the high risk drugs valproate, carbamazepine and risperidone.
Conclusion: The prominence of the different call types made by carers from group homes highlights, from a poisons perspective, the number of inappropriate queries that are not suitable for an emergency response hotline. With the type of medication errors occurring and the complexity of different patients’ needs, group homes require alternative referral pathways such as the prescribing doctor or local pharmacist where comprehensive advice may be offered accounting for a patient’s clinical needs. In addition, there is a need for better training and audit of these medication errors to improve medication safety in the community.
Ms Aine Heaney, Ms Lauren Dalton, Ms Katrina Clarke, Ms Aine Cadden, Dr Pradnya Naikpanvelkar, Assoc Prof Nick Wood, Assoc Prof Kristine Macartney
The new national Primary Health Network Immunisation Support Program (PHN-ISP)Toggle information
NCIRS and NPS MedicineWise have partnered to develop the national Primary Health Network Immunisation Support Program (PHN-ISP) on behalf of the Commonwealth Department of Health (DoH). The aim is to better coordinate efforts across Australia to improve implementation of the National Immunisation Program.
In designing the program, extensive consultation was undertaken. Comprehensive desktop research and a literature review were conducted to understand the current landscape and explore challenges and opportunities associated with establishing an effective and efficient program. In addition, semi-structured qualitative interviews were conducted with 28 PHN nominees and eight Jurisdictional Immunisation Coordinators (JICs). Three interactive workshops were also held across the country plus a fourth human-centred design forum with stakeholders to co-design key components of the program. In total, the consultation involved 84 stakeholders including those identified above and others including Public Health Units (PHUs).
A number of challenges for PHNs were identified, including the delivery of education, ensuring immunisation was a priority, complexity of the Australian Immunisation Register, communication among key stakeholders, lack of consistent resources and the changes experienced within PHN staffing.
The themes and opportunities that emerged from the research, which included the need for improved sharing of resources and communication, will see the ISP focus on building a community of practice. This will include the development of a web-based platform for PHNs, PHUs, JICs, DoH and Department of Human Services to share information, resources and education materials, facilitation of networking opportunities, development of resources and education where gaps are identified, and central co-ordination of program activities.
Ms Jessica Pace
University of Sydney, Sydney, Australia, Gosford Hospital, Gosford, Australia
Physician perspectives on post-market data collection and market withdrawal/disinvestment as components of accelerated access to medicinesToggle information
The Therapeutic Goods Administration’s (TGA) provisional approval pathway (to be implemented by mid-2018) allows medicines to be approved on the basis of earlier data, with post-market data collection used to confirm their safety and effectiveness. Meanwhile, ‘managed entry agreements’ allow the Pharmaceutical Benefits Advisory Committee (PBAC) to list promising new medicines at a price supported by current evidence, with further data collection used to determine whether they should remain on the PBS and, if so, at what price. Timely and robust post-market data collection and regulatory withdrawal/disinvestment procedures underpin both of these initiatives.
Physicians will be particularly impacted by these policies. Post-market data collection will increasingly determine the risk-benefit balance of the medicines that they prescribe, and any resulting disinvestment or market withdrawal may alter the therapies available to their patients. We therefore sought to explore the beliefs and values of physicians with regards to post-market data collection and regulatory withdrawal/disinvestment as components of accelerated access to inform policy development in this area.
We conducted semi-structured interviews with 18 Australian physicians. Interviews lasted for 30—75 minutes, were transcribed verbatim and analysed thematically. The majority of physicians were optimistic about increased evidence generation in the post-market phase and emphasised its potential to improve the safety, effectiveness and cost-effectiveness of care provided. For most physicians, post-market data collection, coupled with swift and decisive action by regulators and funders, was sufficient to address the risks posed by accelerated access pathways. However, the extent to which this is achievable in the current political and economic climate is questionable. Our results illustrate some potential misunderstandings among this stakeholder group regarding the role of postmarket data collection and regulatory withdrawal/disinvestment in providing faster access to medicines. They also emphasise the need for further engagement with physicians in order to design policies that are both achievable and address their needs, values and beliefs.
Ms Lisa Robertson, Mr Vaughn Eaton, Dr Nicholas Farinola, Dr Tilenka Thynne
Safety, quality and savings: benefits of implementing a statewide medicines formularyToggle information
Traditionally hospitals within the state have managed their own medicines formulary. In 2012 a multidisciplinary committee formed to establish a statewide medicines formulary. The evaluation of the formulary implementation was undertaken following supporting framework criteria with respect to safety, quality, equity of access and cost-effectiveness.
Initial priorities focused on evaluation denominators where data could be readily accessed and of interest to key stakeholders. Four areas were targeted:
- Quality use of medicines initiatives focused on medicines not included or added with restrictions for safety reasons. Various approaches were utilised including usage, imprest holdings, protocol review and local audits.
- Equity of access was assessed via site implementation surveys.
- Numbers and approval rates of individual patient use (IPU) requests were reviewed to ascertain if the formulary was meeting patient requirements.
- Financial evaluation, using the pharmacy management system, was prioritised for medicines with significant statewide impact post-implementation. These included erythropoietin agonists, echinocandins, G-CSF, 5HT3 antagonists, infliximab, tacrolimus, LMWH, paracetamol, sugammadex and zoledronic acid. Annual expenditure and usage were analysed at least one year pre- and post-implementation.
The identified medicines have shown reduction in expenditure with annual statewide savings in excess of $7 million, with review of biosimilar medicines contributing $4.3 million of savings. Data analysis of medicines not added or restricted due to safety reasons shows reassuring outcomes: reduction in usage, removal from imprest and protocol changes. The formulary has been adopted by 95% of the state’s hospital bed numbers. Site medication governance processes are the main barrier to formulary implementation. IPU requests and approval rates were not affected pre- and postformulary implementation.
Resource limitations have restricted evaluation processes to date; ongoing evaluation is planned.
Establishment of a statewide formulary has improved cost-effectiveness, promotes the safe and quality use of medicines, and ensures equity of access.
Ms Mai Duong, Assoc Prof Rebekah Moles, Dr Betty Chaar, Prof Timothy Chen
Stakeholder roles in managing essential medicine shortagesToggle information
Persistent medicine shortages have highlighted that global access to essential medicines remains problematic. Existing supply chain vulnerabilities impact health systems and risk consumer safety. Further understanding is needed about how different elements of the supply chain and health systems operate, interact and impact access to medicines, in order to highlight management strategies that may reinforce and protect the supply of essential medicines.
Objective: This study aimed to examine how different key stakeholders’ roles facilitate access to essential medicines.
In-depth interviews were conducted with 47 participants across seven stakeholder groups globally, but predominantly from Australia. Stakeholders included government, academics, consumer groups, non-profit organisations, hospital healthcare providers, manufacturers and wholesalers/distributors. Thematic qualitative data analysis was applied to the comprehensive theory of collaboration as an underpinning theory to provide a management context for interpretation of themes. Results were displayed in Ishikawa fishbone diagrams for decision making and the logistics process.
Findings showed that logistics management and therapeutic decision making were managed separately by stakeholders. Interestingly, hospital pharmacists had overlapping roles in patient care decisions and supply chain logistics, highlighting their importance as supply chain managers. Furthermore, despite the significant role that wholesalers/distributors had in managing supply disruptions and shortages, they were not involved in the decision-making process and did not participate in therapeutic selection committees. Additionally, sometimes stakeholders’ intended control mechanisms contributed to increasing the complexity of the supply chain. Management approaches were further confounded by different views of what stakeholders considered to be essential.
There is a need for improved and innovative stakeholder engagement to optimise healthcare and build sustainable systems. Expanding the role of pharmacy to include hospital formulary pharmacists, and including wholesalers/distributors in therapeutic selection committee decisions could improve these collaborations, and may help to align the selection and procurement of medicines.
Lightning Talks Innovation
Dr Madeeha Malik, Sabiha Khan, Azhar Hussain
Perceptions of healthcare professionals regarding quality, safety and price of antidiabetic and antihypertensive drugs in PakistanToggle information
Introduction: The economic benefits of the use of generic medicines cannot be denied; their use is essential to control healthcare spending, especially in treatment of chronic diseases.
Objective: The main objective of the study was to evaluate the perceptions, attitudes and practice of prescribers, pharmacists and nurses regarding quality, safety and price of locally manufactured medicines used for treatment of hypertension and type 2 diabetes in of Pakistan.
Methodology: A descriptive cross-sectional study design was used. A validated semistructured questionnaire was distributed to a total sample of 814 healthcare professionals including physicians (n = 293), pharmacists (n = 346) and nurses (n = 173) using convenience sampling technique. After data collection, the data were cleaned, coded and analysed statistically.
Results: The results of the current study highlighted that majority of the physicians (46.4%, n = 136) were of the view that most of the time low-cost antihypertensive and antidiabetic medicines are being prescribed/procured in the current practice of Pakistan. Most of the pharmacists (40.1%, n = 139) were of the view that most of the time pharmaceutical sales representatives can serve as a source of information for quality, safety and price of antihypertensive and antidiabetic medicines. Most of the nurses (42.3%, n = 124) agreed that patient compliance is comparatively one of the major reasons for prescribing/procurement of locally manufactured antihypertensive and antidiabetic medicines in routine practice.
Conclusion: The results of the present study concluded that physicians and pharmacists positively supported the use of locally manufactured medicines, whereas the majority of nurses preferred medicines manufactured by multinational companies for treatment of diabetes and hypertension.
Keywords: Antidiabetic drugs, antihypertensive drugs, healthcare professionals, local companies, multinational companies, Pakistan, price, quality, safety
Dr Susan Mendez, Dr Yuting Zhang, Prof Anthony Scott
Factors affecting general practitioner decisions to adopt new prescription drugsToggle information
Physician adoption of new technologies is a key issue for population health, especially where the new technology has been shown to be cost-effective. Understanding physician decisions to adopt can assist with policies to better support diffusion of innovations.
We investigated what factors affect Australian general practitioner (GP) decisions to adopt novel oral anticoagulants (NOACs). These are new prescription drugs used for the prevention of stroke or systemic embolism among at-risk patients with non-valvular atrial fibrillation (NVAF). We use detailed individual data on physician characteristics
from the Medicine in Australia: Balancing Employment and Life (MABEL) panel survey of Australian physicians. With physician consent, this unique dataset has been linked to actual drug utilisation from the Australian Pharmaceutical Benefits Scheme (PBS) and the Medicare Benefits Schedule (MBS) for the period 1 January 2012 to 31 December 2015. We measured both the speed and the intensity of adoption.
Our results suggest that having a higher prescribing volume in this drug category, being the principal or partner in the practice rather than an employee, spending less time in a typical consultation, and working in areas with a higher proportion of older patients are all factors which are positively associated with greater speed and higher intensity of adoption. Additionally, we found a strong gender difference in the speed of adoption, with a hazard ratio of 1.5 for being male, but no significant association on intensity. This pattern is also observed for GPs who report being more likely to take clinical risks, who work in more affluent areas and whose practices are located in major cities rather than rural areas. Other characteristics such as physician personality, family circumstances, involvement with public hospitals and teaching activity are not statistically associated with faster or intensive drug adoption.
Dr Mina Bakhit, Prof Tammy Hoffmann, Dr Anna Scott, Ms Elaine Beller, Dr John Rathbone, Prof Chris Del Mar
Bond University, Robina, Australia
Resistance decay in individuals after antibiotic exposure in primary care: a systematic review and meta-analysisToggle information
Background: Many interventions to reduce antibiotic resistance assume that stopping antibiotics results in returned susceptibility. Timeframes and variability by antibiotic class are unknown.
Methods: Systematic review. PubMed, EMBASE and CENTRAL (Inception-May 2017) were searched. Prospective studies in which community-based patients were given antibiotics and the prevalence of resistant bacteria was compared with a control group or comparison time points were eligible. Two authors extracted risk of bias and data. Metaanalysis used a fixed-effects model.
Results: Of 24,492 articles screened, 5 controlled and 20 time-series studies (total 16,353 children, 1461 adults) were eligible.
Resistance in Streptococcus pneumoniae increased after antibiotic exposure (Peto odds ratio (OR) 4.2, 95% CI 3.5 to 5.4); lower after one month (OR 1.7, 95% CI 1.3 to 2.1). After cephalosporins, resistance increased (OR 2.2, 95% CI 1.7 to 2.9); at one month was 1.6 (95% CI 1.2 to 2.3). After macrolide-class antibiotics, resistance increased (OR 3.8, 95% CI 1.9 to 7.6) and persisted at one month (OR 5.2, 95% CI 2.6 to 10.3) and three months (OR 8.1 [95% CI 4.6 to 14.2] from controlled studies; 2.3 [95% CI 0.6 to 9.4] from time-series).
Resistance in Haemophilus influenzae after penicillins did not increase (OR 1.3, 95% CI 0.9 to 1.9) initially but did at one month (OR 3.4, 95% CI 1.5 to 7.6); lowering by three months (OR 1.0, 95% CI 0.5 to 2.2). Data were sparse for cephalosporins and macrolides.
Resistance in Enterobacter increased post-exposure (OR 3.2 [95% CI 0.9 to 10.8] from controlled studies; 7.1 [95% CI 4.2 to 12] from time-series studies), lowering at one month (1.8, 95% CI 0.9 to 3.6).
Conclusion: Resistance increased soon after antibiotic use. For some antibiotic classes and bacteria, it decayed after one month, with less certainty for others.
Ms Aimee Petersen
Wyong Hospital, Central Coast Local Health District, Hamlyn Terrace, Australia
More fun for more learning: Poke-Biotic Go, an innovative approach to Antibiotic Awareness WeekToggle information
To engage junior medical officers (JMOs) in learning about the threat of antimicrobial resistance can be extremely challenging. During Antibiotic Awareness Week (AAW) we strove to promote appropriate antimicrobial use in a fun and innovative way.
Using current fad-game Pokémon-Go as the baseline for an antimicrobial-themed game Poke-Biotic Go, JMOs and pharmacists ‘battled’ to effectively match antimicrobial treatment to pathogen. Every clinical pharmacist wore a cartoon pathogen during AWW. Paper templates of antibiotic capsules/vials were hidden around the hospital. Narrow spectrum antimicrobials, such as amoxicillin, were hidden in large quantities while broad spectrum antimicrobials were a rare find.
Each pathogen depicted a ‘resistance bar’ to represent its level of antimicrobial resistance. Resistance evolved throughout AWW and fewer antimicrobials were available to ‘kill’ them, representing the phenomenon of resistance and the necessity to reserve broad-spectrum antimicrobials. Each JMO was able to ‘kill’ a pathogen once each day by capturing the appropriate antimicrobial and matching it to the pharmacist. Greater points were allocated depending on how optimal their choice was. The JMO with the most points at the end of the week received a giant plush-toy pathogen and a money prize. Social media was used to advertise the leaderboard and drive participation.
Thirty-nine JMOs and all clinical pharmacists participated. Feedback was overwhelmingly positive with JMOs finding the game educational yet fun. Multiple JMOs used the exercise to study pathogen susceptibility in order to make optimal ‘moves’. Anecdotally, every JMO gained take-home messages about resistance previously unknown. This game improved cross-disciplinary relations and communications and introduced JMOs/pharmacists to colleagues they hadn’t interacted with prior.
Multidisciplinary fun is an excellent educational modality to engage and promote important issues such as antimicrobial resistance. This game was run again in 2017 with increased success. The district hopes to continue its success in 2018 with a new innovation.
Dr Andrew Marson, Mr Jeffrey Elliot, Ms Jane London, Prof Debra Rowett, Prof Catherine Hill, Dr Claire Barrett, Prof Rachelle Buchbinder, Ms Leanne Atkins, Dr Jonathan Dartnell
A new model of engaging with specialists: acceptability of PBS Practice Review reports for rheumatologistsToggle information
Background: NPS MedicineWise routinely provides practice review reports to general practitioners (GPs) outlining prescribing of non-authority Pharmaceutical Benefits Scheme (PBS) medicines. Individual data are compared with those of peers to help improve professional practice and patient care.
Objectives: To evaluate the acceptability and usefulness of a co-designed practice review report for rheumatologists regarding their prescribing of authority and non-authority medicines for rheumatoid arthritis (RA).
Method: Key focus areas were identified by an expert working group (rheumatologists, GPs and pharmacists). Rheumatologists and NPS MedicineWise then co-designed the practice review (including reflection points) focusing on disease-modifying antirheumatic drug (DMARD) use. A patient cohort was identified based on when they were first prescribed a biological (b)/targeted synthetic (ts) DMARD; patients were linked to the specialist who initiated treatment. Prescribing (by any GP or specialist) of conventional synthetic DMARDs before, and co-prescribing of methotrexate or corticosteroids after, initiation of b/ts DMARDs was assessed.
Results: Of 273 rheumatologists who were mailed a practice review, 42 completed an online evaluation. Of these, 60% found the practice review ‘somewhat useful’ and 31% found it ‘very useful’. Most agreed or strongly agreed the report data were accurate (66%) and helped them reflect on their prescribing (72%). However, 52% disagreed or strongly disagreed that it would change the way they prescribe RA medicines. Most were satisfied or very satisfied with the level of information (81%), personalisation of prescribing data (79%) and reflection points (70%), and 69% would like to receive another report on the same topic.
Conclusion: Co-designed practice review reports including reflection points and using individualised PBS data can provide useful information for specialists as well as GPs. This may be a suitable tool for ongoing engagement of specialists.
We acknowledge the Australian Government Department of Human Services for provision of the data used in this study
Ms Kim Devery, Ms Deborah Rawlings
Flinders University, Adelaide, Australia
End-of-Life Essentials professional education: what do learners tell us they can change in their own clinical practice?Toggle information
The 2015 National Consensus Statement: essential elements for safe and high-quality end-of-life care by the Australian Commission on Safety and Quality in Health Care¹ (ACSQHC) provided the impetus and framework for a major education initiative, led by Flinders University.
End-of-Life Essentials (EOLE) provides free evidence-based, peer-reviewed online learning modules, to help build health professional capacity in hospitals and is funded by the Australian Government Department of Health.
52% of Australians die in acute hospitals and it is estimated up to 50% of these deaths are expected yet many healthcare professionals working in these settings feel poorly prepared to deliver quality end-of-life care.1
At the conclusion of each module a statement asks for learner response: ‘Tomorrow, the one thing I can change to more appropriately provide end-of-life care is …’ This question allows the clinician learner to consider what they have learned and how practice can immediately change, and allows the researchers to understand the impact of learning and the scope for practice change. We have analysed 3203 responses to this practice change question.
We provide a summary of the top three themes—emotional insight, listening effectively, and goals, needs and expectations of the patient.
These results clarify clinicians’ responses to important national policy by articulating, from their perspective, the clinical opportunities around quality end-of-life care and the Consensus Statement. With the introduction of the second edition of the National Safety and Quality Health Service Standards the results are valuable to organisations and policy makers who are wanting to change healthcare outcomes.
¹ ACSQHC. National Consensus Statement: essential elements for safe and high-quality end-of-life care. Sydney: ACSQHC, 2015.
Dr Johnson George, Ms Jenifer Liang, Prof Michael Abramson, Prof Grant Russell, Prof Nick Zwar, Prof Anne Holland, Prof Billie Bonevski6, Prof Ajay Mahal, Mr Eldho Paul, Ms Kirsten Phillips, Dr Paula Eustace
An interdisciplinary model of care in general practice for smoking cessation support, and early detection and management of COPDToggle information
Chronic obstructive pulmonary disease (COPD) is a major health burden in Australia, with smoking the major risk factor. Prevention, early diagnosis and management can reduce the burden of COPD. We describe the implementation and evaluation of RADICALS — Review of Airway Dysfunction and Interdisciplinary Community-based care of Adult Long-term Smokers — in Australian general practice.
A cluster-randomised trial was conducted across 41 general practice clinics in Melbourne. We recruited current and ex-smokers (aged ≥40 years, ≥10 pack years), regardless of a prior COPD diagnosis. The handheld COPD-6® was used to facilitate case-finding and spirometry was performed to confirm COPD diagnosis. The multidisciplinary intervention consisted of individualised smoking cessation support, physiotherapist-led home-based pulmonary rehabilitation and pharmacist-conducted home medicines review (HMR). Control group participants received Quitline® referral and usual care. Follow-ups were performed at six and 12 months from baseline to assess changes in quality of life (St George’s Respiratory Questionnaire, COPD Assessment Test), dyspnoea, lung function and smoking abstinence.
1050 patients were recruited to identify 272 with COPD; two-thirds were current smokers (690, 65.7%). Of those with a pre-existing COPD diagnosis (n = 245), only half (130, 53%) had spirometric confirmation of COPD. Case-finding and spirometry identified COPD in a further 142/805 (17.6%) who did not have a prior COPD diagnosis. In the intervention group (n = 157 COPD patients), HMR was delivered to 85 (54%) and home-based pulmonary rehabilitation was undertaken by 71 (45%). Six-month (n = 212) and 12-month (n = 190) follow-ups have been completed and final analysis of the efficacy of RADICALS is underway.
Misdiagnosis and underdiagnosis of COPD in primary care can be addressed using casefinding approaches in high-risk populations. Interventions encouraging the uptake of recommended smoking cessation support, and evidence-based approaches such as home-based pulmonary rehabilitation for improving quality of life and HMRs for resolving medication-related issues by GPs and patients, are warranted.
Ms Amy Stashynsky
Empowering and educating mental health consumers with a ‘snowballing’ approach to medicines information provisionToggle information
This work aimed to increase provision of medicines information and education to mental health consumers using a novel strategy, applicable to community and inpatient settings across the district.
The Area Mental Health senior pharmacist designed a medication information card game. Consumers take turns picking question cards. The group and facilitator assist with answering questions if needed and open discussion ensues. Questions include: ‘What happens if you miss a dose?’ and ‘Why do medications have more than one name?’ A facilitator booklet was developed with standardised, referenced answers.
A ‘snowball effect’ is created because the pharmacist runs one group, observed and assisted by nurses and occupational therapists. These staff members then facilitate future groups at their location using the booklet, which contains full instructions and specifies facilitators only provide additional information within their knowledge and scope of practice. The open nature of the group discussion means more complex individual questions may surface. Facilitators are trained to note these and follow up appropriately. The pharmacist remains available for support. The booklet contains master copies of attendance sheets and participant feedback forms which are submitted to the pharmacist after each group for records and analysis.
Within four months, 18 groups had run across eight different sites in the district; 142 consumers, both inpatients and outpatients, had participated and reported finding the group useful. The vast majority enjoyed the group, felt comfortable asking questions and reported learning new information. The implementation of this approach to increasing mental health consumer medicines education provision across the district has been successful thus far. The pharmacist will continue to drive its establishment and monitor its effectiveness through participant feedback and attendance records. There is potential to further develop the material in the future.
Dr Alexandra (Sasha) Bennett, Ms Sarah Dinh, Ms Margaret Jordan, Ms Veta-Marie Peereboom, Ms Aoife Davis, Ms Seniha Karacete, Ms Angela Meaney, Dr Greg Carter, Dr Nick O’Connor
Improving metabolic monitoring of hospitalised patients taking regular antipsychotic medications: the need for local and global interventionsToggle information
Introduction: Barriers to the recognition and diagnosis of metabolic syndrome have contributed to the disparity in care and well-documented early mortality in patients taking antipsychotics. The National Quality Use of Medicines (NQUM) Mental Health (MH) Indicator 7.4 ‘Percentage of patients taking antipsychotic medications who receive appropriate monitoring for the development of metabolic side effects’ measures adherence to best practice recommendations for the monitoring of metabolic adverse effects of antipsychotics.
- To undertake multisite performance assessment, benchmarking and implementation of quality improvement (QI) strategies for routine metabolic monitoring of hospitalised patients taking antipsychotic medications using Indicator 7.4; and
- To train MH clinicians in quality QI methodology.
Methods: Australian hospitals were invited to participate. A multidisciplinary steering group was established to oversee the project. Each hospital convened a multidisciplinary local advisory group to guide data collection, implement QI strategies and identify barriers and enablers to best practice adherence. Baseline audit and intervention phases were undertaken. Post-intervention audits to measure the success of QI strategies are in progress.
Results: Seventeen clinical services across three Australian states with diverse patient populations (acute adult, adolescent, paediatric, forensic and psychogeriatrics) participated. Baseline results for full compliance to the indicator ranged between 0% and 42% (mean 14%); with measurements of waist circumference, fasting lipids and glucose poor. Feedback about enablers and barriers to metabolic monitoring and QI strategies were shared. Local and global interventions include implementation of ‘metabolic days’ for routine monitoring, staff engagement, improving pathology practices and optimising electronic medical records data utilisation. Sites plan to incorporate indicator measurement as an ongoing activity.
Conclusion: Baseline results demonstrate consistent suboptimal metabolic monitoring with common barriers emerging. Multisite studies are a useful means of providing benchmarking data to drive QI, developing skills in collaborative multifaceted improvement strategy innovations and directing advocacy of global solutions.
Dr Lisa Kalisch Ellett, Assoc Prof Nicole Pratt, Ms Jemisha Apajee, Prof Elizabeth Roughead
Initiation of antipsychotic medicines in older Australians during hospital admissionToggle information
Background: International research shows that antipsychotics are frequently initiated during hospital admission for older patients, and that use often continues post-discharge even when there is no clear indication. We located no Australian studies on this topic.
Aim: The aim of this study was to identify the hospital admissions (excluding psychosis) associated with highest risk of antipsychotic initiation and continuation in a cohort of older Australian veterans.
Methods: We conducted a retrospective analysis of Australian Government Department of Veterans’ Affairs administrative claims data. We included people who were admitted to hospital between 1 January 2014 and 31 December 2014, aged ≥65 years, and who were antipsychotic naïve. People who had a hospital admission for psychosis during the year were excluded. We determined the number of hospital admissions associated with antipsychotic initiation, and the diagnoses for admissions most frequently associated with antipsychotic initiation. Where antipsychotics were initiated during an admission, we determined the time to cessation of antipsychotics after discharge.
Results: In 2014 there were 140,389 hospital admissions for 66,386 people who met our inclusion criteria. The median age was 86 years (interquartile range 76—90 years) and 49.9% were male. 733 (0.5%) admissions were associated with antipsychotic initiation, most commonly for primary diagnoses of delirium or dementia (96/733 [13%] admissions associated with antipsychotic initiation) or primary diagnoses of fracture (58/733 [8%] admissions associated with antipsychotic initiation). When secondary diagnoses were considered, 47% (345/733) of admissions with antipsychotic initiation had delirium or dementia as a secondary diagnosis. For people who initiated antipsychotics during admission, 22% had ceased within six weeks and half had ceased within one year.
Conclusion: Initiation of antipsychotics during hospital admission was uncommon in our study population; however, among those who did initiate antipsychotics, long-term use was common, with half continuing to use them at one-year post discharge.
Mr Angus Thompson, Dr Colin Curtain, Dr Mackenzie Williams, Dr Li Shean Toh
Denosumab: how can we optimise use?Toggle information
Background: Prolia (denosumab 60 mg/mL injection) has become the default antiresorptive for many Australian prescribers, with over 450,000 Pharmaceutical Benefits Scheme (PBS) prescriptions dispensed in the year to June 2017. Drug Utilisation Sub-Committee (DUSC) reviews have noted denosumab use has exceeded expectations, with many users switched from an alternative antiresorptive.
Evidence of fracture risk reduction with denosumab comes from trials where participants were routinely supplemented with vitamin D and calcium, but it is not known whether current Australian practice is consistent with this.
Method: We conducted an audit of practice in Southern Tasmania in 2017, using patients referred to the lead investigator for home medicines review (HMR), capturing all medication, both prescribed and non-prescribed.
Results: Of 207 patients, 31 were prescribed Prolia. Of these, the number prescribed vitamin D or calcium supplements was 20 (68%) and 5 (16%), respectively. When use of non-prescribed supplements was included, the corresponding figures were 24 (77%) and 8 (26%). The median daily-equivalent doses of vitamin D and calcium for these patients were 1000 IU (range 333—5000 IU) and 700 mg (range 333—1200 mg) respectively.
Pharmacist reference to fracture risk management was made in 28 (90.3%) HMR reports for those on Prolia, and included recommendations to commence vitamin D and/or calcium, modify existing supplementation (dose, formulation) or optimise dietary calcium intake.
Discussion: Based on these findings, there are significant opportunities to improve alignment between current practice and the approach used in pivotal clinical trials; in particular, a need to consider optimising calcium intake.
While HMRs appear to be one tool to optimise Prolia use, consideration should also be given to other strategies, including the potential for PBS or industry-subsidised supply of vitamin D and/or calcium supplementation for those on Prolia in order to narrow this evidence to practice gap.
Mr Jianyun Wu, Ms Ludmila Ovchinikova, Ms Suzanne Blogg
Using 10% PBS data to investigate medication adherence and its association with the 2014 NPS MedicineWise asthma program in AustraliaToggle information
Background: Non-adherence to prescribed medications is associated with poor health outcomes and increased costs to the healthcare system and patients.
A main reason for poor asthma control is inadequate adherence to preventer medications. In 2014, NPS MedicineWise launched an asthma intervention program with a key message on the relationship between asthma control and adherence.
Adherence to asthma preventer medications has not been widely studied in a large Australian cohort due to lack of information on dosage instruction, frequency of administration and intended prescription duration in the Pharmaceutical Benefits Scheme (PBS) data. However, information available in the PBS data can provide useful insights regarding asthma adherence behaviour in the Australian population.
Objectives: This study investigated the feasibility of measuring asthma preventer medication adherence and its association with the 2014 program using the 10% PBS sample data. The analysis was limited to fluticasone and fluticasone + long-acting betaagonist combination products, which have a 30-day supply per prescription based on clinical guidelines for recommended dosages.
Results: The study cohort was restricted to patients who had more than one prescription dispensed before, during and after the intervention and were alive throughout all three periods. Adherence was measured using the proportion of days covered (PDC) for prescriptions issued for each period.
The final study sample consisted of 21,438 patients. Adequate adherence (PDC ≥80%) to preventer asthma medications was poor, and did not improve over the intervention periods. However, patient characteristics included in the analysis demonstrated results consistent with international studies, including associations of age, gender, concessional status, doctor visit frequency and number of other medications with adherence.
Poor patient adherence to asthma preventer medications is well-documented in Australia and internationally. Future programs should continue to address the importance of adherence to improve patients’ health outcomes and to reduce unnecessary healthcare costs.
Dr Agnes Vitry
University of South Australia, Adelaide, Australia
Development of consumer information tools on the benefits and risks of new cancer medicinesToggle information
Issue: Consumers’ beliefs in the therapeutic value of cancer medicines may be influenced by a complex range of clinical, social and commercial forces. However, there is limited independent, objective and consumer-friendly information available on new cancer medicines in Australia. Pharmaceutical Benefits Advisory Committee (PBAC) outcome summaries may be complex to comprehend for both health professionals and consumers. Several organisations including the American Society of Clinical Oncology (ASCO) and the European Society for Medical Oncology (ESMO) have developed value frameworks to determine the relative benefit of new cancer medicines.
Aims: The project will develop a standardised approach for summarising and grading the magnitude of the clinical benefits of new cancer medicines. We present the results of an exploratory study examining the applicability and the validity of the ASCO and ESMO framework in Australia.
Findings: Preliminary results are presented for 6 medicine-indication pairs: nivolumab (metastatic non-squamous non-small cell lung cancer, metastatic squamous nonsmall cell lung cancer, metastatic squamous non-small cell lung cancer), enzalutamide (metastatic prostate cancer in chemotherapy naïve patients, metastatic prostate cancer after treatment failure with docetaxel), afatinib (metastatic non-small cell lung cancer) and pertuzumab (metastatic HR2+ breast cancer).
There were numerous uncertainties on the correct application of the ASCO and ESMO frameworks because of gaps in explanations. The lack of fully published data and clear definition of minimally important differences for palliation and quality of life data may impact on the robustness of the final scores. The ESMO and ASCO frameworks do not consider factors that are considered by the PBAC such as indirect evidence, the external validity of the trials (eg, applicability to the older population in real life) and the uncertainty of the trial results (eg, lack of blinding, cross-over). Further research is required to develop clear and consistent summaries of the evidence on new cancer medicines.
Ms Joanne Gross
NPS MedicineWise, Melbourne, Australia
Preventive health: engaging patients with technology — let’s develop a patient-controlled preventive health recordToggle information
Background: Most Australians (85%) report good health and we are living longer with more years lived free of disability.1 However, over a million Australians live with chronic disease and 31% of the burden of disease is caused by modifiable risk factors such as tobacco and alcohol use, body weight, physical inactivity and high blood pressure.1,2
The RACGP Red Book outlines a primary care approach to opportunistic/proactive preventive health checks3 and yet 99% of Australian adults have at least one modifiable risk factor for chronic disease and 64% have three or more.4
With recent technological advances consumers and health professionals have access to more personal health data and public health information than ever before and in 2018 the MyHealth Record will allow Australians to securely share medical information across the health system.
Can we harness emerging technology to engage consumers and health professionals in an evidence-based approach to better identify, assess and address behavioural risk factors and implement evidence-based screening tests?
Objective: To develop the proposal of an evidence-based consumer-controlled preventive health record.
Proposal: To explore existing and emerging models of health recording and preventive health assessment and pitch how these could be harnessed to facilitate consumer-centred preventive health partnerships.
To explore potential pilot populations and/or implementation strategies for a consumer controlled preventive health record.
1. AIHW. Australia’s health 2016, 2016.
2. AIHW. Australian burden of disease study: impact and causes of illness and death in Australia 2011, 2016.
3. RACGP. Guidelines for preventive activities in general practice. 9th edn, 2016.
4. AIHW. Risk factors contributing to chronic disease, 2012.
Ms Racha Dabliz, Mrs Katie Hargreaves
e-MEDs reporting for quality use of medicinesToggle information
The South Eastern Sydney Local Health District (SESLHD) in NSW, Australia has implemented the Electronic Medication Management (eMM) system across its five acute care facilities. SESLHD is committed to fostering improvement and innovation in healthcare service delivery. The availability of data from the eMM system was seen as an opportunity to effectively evaluate and monitor the quality use of medicines (QUM) across the district.
By recognising the district priorities for QUM, a reporting framework was developed. The reporting framework identifies key reporting priorities, recommends how each report should be utilised for QUM and aims to standardise QUM reporting across the district. It aims to streamline auditing processes to support the National Safety and Quality Health Service Standards and KPI reporting. This encourages a culture of collaboration between all stakeholders which is critical to maximise feasibility and build capacity.
District priority areas were identified as: medication reconciliation, the safe use of medicines, high-risk medicines, management of psychotropic medications and antimicrobial stewardship. It has been recognised that the necessary components that underpin successful implementation of electronic reporting and data analysis capabilities include:
- Defined governance structures
- Skilled and capable workforce
- Supportive culture and effective management
- Appropriate analytics tools, technologies and services
- Streamlined processes, protocols and guidelines.
These key priority issues will be addressed in order to effectively implement the reporting framework, maximise the benefits of eMM and support QUM. If capability is adequately resourced and led, DUE activity and quality improvement should also be enhanced as a result.
Implementation and distribution of the reporting framework will be led by the District Executive. It is recognised that further development of the required analytics capabilities is needed and ongoing review and update of the framework are planned to ensure its direction remains relevant to the needs of the district.
Mrs Noni Richards, Assoc Prof David Reith, Assoc Prof Michael Stitely, Dr Alesha Smith
Prescribing medicines safely during pregnancy: anti-epileptic drugs as a test caseToggle information
Background: Anti-epileptic drugs (AEDs) are used by pregnant women even though they pose a risk to the developing fetus. Maternal use of AEDs increases the risk of congenital malformations and some, particularly sodium valproate, can cause developmental delay in children. Despite these risks, women typically continue treatment with AEDs during pregnancy to avoid the serious consequences of a worsening of the chronic health condition the AEDs are used to treat (eg, epilepsy or bipolar disorder). The effect of pregnancy on the plasma concentration of some AEDs and co-ordinating the care of women across multiple health professions can present additional challenges.
Studies conducted using New Zealand’s national data collections have shown that:
- The risk of spontaneous abortion is higher in women who have taken AEDs during pregnancy.
- Women taking lamotrigine and levetiracetam do not have sufficient therapeutic drug monitoring or dose adjustment during pregnancy.
- Children exposed to some AEDs in utero are at increased risk of developmental concerns at age four.
Objectives: To elicit feedback from the panel and audience about how best to develop and deliver this information as a tool/resource which better informs those prescribing medicines in pregnancy. Using AEDs as a test case, the tool/resource will provide advice on medicine selection, dose adjustment and monitoring.
Pitch presentation: Questions for the panel and audience about the development and delivery of a prescribing tool or educational resource:
- How is it delivered? Integrated into prescribing software (with alerts when prescribing to pregnant women), as a cloud-based stand-alone product or as a website?
- Who can access it? Only available to prescribers or in a format suitable for access by consumers? How is it individualised to meet the needs of different women?
- How is it scaled up for other medicines? For example, antidepressants.
Dr Nieves Leonardo, Ms Susan Lester, Ms Michelle Graham, Dr Samuel Whittle, Prof Debra Rowett, Prof Rachelle Buchbinder, Prof Catherine Hill
Methotrexate information sources and perception in patients with rheumatoid arthritisToggle information
Objective: To investigate the beliefs of patients with rheumatoid arthritis (RA) regarding methotrexate (MTX), and factors influencing their perspective, including sources of MTX information.
Methods: Australian Rheumatology Association database (ARAD) participants with RA who had completed an online questionnaire within 12 months (N = 1010) were invited to participate in an online questionnaire (Survey Monkey) regarding their use of MTX, sources they consulted for MTX information, and perceptions of this information. Only responses from participants reporting current or previous MTX use were analysed. Beliefs about medicine questionnaire (BMQ), consisting of MTX-specific (necessity and concerns) and general medication (overuse and harm) scales, was used.
Results: The response rate was 804/1010 (80%). 742 RA participants reported current/previous MTX use (mean age 59 years, 76% female). Rheumatologists (98%), GPs (55%), internet search engines (39%), educational websites (38%) and pharmacists (36%) were the most frequent MTX information sources. Participants consulted multiple information sources (median 3, IQR 1—5). Patients who were younger, more highly educated and who had higher MTX-specific concerns and general medication BMQ scores accessed more resources (p <0.05).
MTX information was more likely to be perceived as positive when obtained from rheumatologists (93%), GPs (67%), educational websites (56%) and pharmacists (49%), and negative when obtained from relatives (62%), social media (60%), internet chat rooms (59%), friends (52%) and pharmacists (23%). Positive information from rheumatologists (p <0.001) and educational websites (p = 0.021) was influential on favourable MTX-specific necessity and concerns BMQ scores.
Conclusions: Most RA patients consult a variety of sources for MTX information. However, the perception of this information varies widely among patients. Rheumatologists and educational websites, such as Arthritis Australia, are the most important information sources in terms of consultation frequency, positive information and influence on the patient’s perception of MTX. Information from pharmacists was more commonly perceived as negative than information from other health professionals.
Mr Shaun O’Connor, Mr Adam Chapman, Ms Helen Matthews
VicTAG Chemotherapy Audit Toolkit: facilitating health services to prevent errors in the futureToggle information
Cytotoxic chemotherapy is commonly associated with adverse medication incidents in hospitals. Use of detailed treatment protocols is one way to reduce non-evidence-based variation and to standardise care, both of which are fundamental principles for improving patient safety.
In July 2016, the New South Wales (NSW) government released the final report resulting from the inquiry into off-protocol prescribing of chemotherapy for patients with head and neck cancer in a Sydney hospital. Over a period from January 2006 to February 2016, 129 people were treated with off-protocol flat dose carboplatin. While it is not known whether these cases resulted in poor outcomes, it has raised questions within Victoria as to whether similar practices are in existence.
In a survey of Victorian health service chemotherapy quality processes, conducted by the Victorian Department of Health and Human Services (DHHS) following the NSW incidents, 73% of health services reported that regular auditing of compliance with chemotherapy protocols was not undertaken. Therefore, health services may not be able to readily identify the extent and/or appropriateness of off-protocol chemotherapy prescribing.
In an effort to evolve this system and reduce the risk of unwanted variation, DHHS has engaged the Victorian Therapeutics Advisory Group (VicTAG) to develop and pilot a chemotherapy prescribing audit tool for use in Victorian hospitals. The audit tool will enable health services to retrospectively compare chemotherapy prescribing and administration practices to the approved protocol. Identified protocol variations will be presented to senior clinicians for assessment and, if required, allow further investigation into clinical appropriateness and the governance systems in place to support these decisions.
Initially the audit tool will be piloted by a small number of health services using oncology e-health systems. Following further evolution of the tool, piloting will be extended to a broader range of health services, including those without e-health systems.
Improving Medicine Use
Ms Kristen Anderson, Dr Christopher Freeman, Prof Michele Foster, Assoc Prof Ian Scott
Individualising deprescribing decisions: a general practitioner-led deprescribing intervention in community-living older people with polypharmacyToggle information
Issue: Harm from potentially inappropriate polypharmacy remains a major health issue for older Australians. Clinician-supervised withdrawal of inappropriate medicines, or deprescribing, aims to improve patient outcomes. General practitioners (GPs) are well positioned to partner with community-living older people (defined as those 65 years and older) in deprescribing potentially inappropriate medications. This study investigated the feasibility and effectiveness of an innovative, GP-led and co-designed deprescribing intervention based on a framework to individualise deprescribing decisions.
Scope: A mixed-method controlled study in metropolitan South-East Queensland was conducted, involving 20 GPs and 145 patients. The intervention comprised a deprescribing training workshop for GPs and an extended appointment to review the medications of patients with whom GPs had an established therapeutic relationship. The primary outcome was the mean difference (MD) in the number of regular medications deprescribed (ie, ceased or reduced) per patient. Secondary outcomes included intervention impact on patients’ medication regimens, self-reported health status and attitudes towards medicines and deprescribing.
Findings and implications: The MD between intervention (n = 78) and usual care (n = 67) groups in the number of regular medications deprescribed per patient over 18 weeks was –0.55, 95% CI –0.897 to –0.212, p = 0.002. Intervention patients were 2.3 times more likely to have at least one regular medication deprescribed (incidence rate ratio [IRR] 2.3; 95% CI 1.297 to 3.964, p = 0.004). Medications most commonly deprescribed included supplements, acid suppressants, statins, oral hypoglycaemics and diuretics. Health-related quality of life was not adversely affected, and a subset of intervention patients reported greater certainty about the appropriateness of their medications at study completion.
Patients and GPs derived satisfaction from the deprescribing appointment, irrespective of whether successful medication withdrawal was achieved. This intervention appears safe and acceptable in the short term and challenges the ongoing need and appropriateness of some long-term medications in community-living older people.
Ms Rayan Nahas, Prof Sarah Hilmer, Dr Danijela Gnjidic, Ms Jenny Crane, Dr Lisa Kouladjian O’Donnell, Dr Terry Finnegan, Dr Emily Reeve
Minimising the functional burden of medications in older inpatients: implementation of the drug burden indexToggle information
The Drug Burden Index (DBI) is a score that measures exposure to anticholinergic and sedative medications and has been associated with poorer physical function, hospitalisation and mortality in older people. The aim was to investigate the impact of a pharmacist-led intervention using DBI as a clinical risk assessment tool for older inpatients on changes in DBI score from admission to discharge, and six months after discharge. Secondary objectives were to explore changes in DBI on mortality, falls, length of stay (LOS), readmissions and new adverse drug events (ADEs).
Patients ≥70 years admitted to a tertiary referral hospital in Sydney, with DBI >0, were recruited and randomised to intervention or control (usual care) arms. In the intervention group, on admission the pharmacist calculated DBI score using the DBI Calculator© and discussed the report and their recommendations with the treating team. The primary outcome was a proportion of patients in whom DBI was decreased, unchanged or increased at discharge (chi-squared analysis, SPSS®).
Intervention (n = 122) and control groups (n = 131) had median age 85 years. DBI score was decreased during admission for 67.8% of participants in the intervention and 29.2% in the control group (P <0.001). Fewer new ADEs during admission were reported in the intervention (20.2%) than in the control group (34.4%; P <0.01). There was no significant difference between groups in LOS, falls or mortality during hospitalisation.
Of those followed up six months after discharge, DBI score was further decreased in 30% of participants in the intervention (n = 80) and 18.9% in the control group (n = 90) (n.s.), with no significant difference between groups in the number of deaths, falls, readmissions or new ADEs.
Our intervention targeting older inpatients’ DBI scores significantly decreased DBI on discharge with no significant adverse effects detected. This suggests that DBI may be a useful clinical risk assessment and communication tool to assist pharmacists reviewing medications for inpatients.
Prof Sarah Hilmer, Ms Rayan Nahas, Mr Patrick Sutton, Dr Danijela Gnjidic, Dr Emily Reeve, Dr Lisa Kouladjian, Dr James Hardy, Dr Fiona Robinson, Dr Terence Finnegan
Insights from a multidisciplinary deprescribing intervention in hospital targeting older patients with hyperpolypharmacyToggle information
Hyperpolypharmacy (≥10 medications) increases the risk of adverse drug events (ADEs). An acute hospitalisation provides an opportunity to review a patient’s medications, including deprescribing inappropriate medications. We evaluated whether a Multidisciplinary Multiple Medicines Management Service (4MS) for patients aged ≥65 years with hyperpolypharmacy would facilitate deprescribing during admission.
Patients were recruited prospectively for this pre-/post-intervention study from six clinical teams at a tertiary referral hospital in Sydney, NSW. The 4MS intervention involved the pharmacist comprehensively reviewing the patient’s medications and generating a 4MS report with recommendations, which was discussed with the patient’s treating team, the patient/carer, general practitioner and specialists. The intervention focused on reducing any medications for which the risk outweighed benefit for the individual, using the Drug Burden Index to describe anticholinergic and sedative load, and using published deprescribing guidelines for proton pump inhibitors (PPIs), antipsychotics, benzodiazepines and hypoglycaemics.
Eighty-three patients were recruited (median age 80 years, majority lived independently) and 30% had a documented ADE during admission. The median number of medications increased during admission similarly in both the intervention and control groups.
In the intervention group (n = 22), 24/331 (7.3%) medications were identified by 4MS as inappropriate and targeted for deprescribing. During admission, nine medications were ceased in the intervention group, two of which were recommended by 4MS, and 20 potentially chronic medications were initiated. The most prevalent target drugs were PPIs (taken by 15 participants, considered inappropriate by 4MS in two). Hospital staff, consumers and general practitioners gave positive feedback on the intervention.
While participants took large numbers of medications and had a high prevalence of ADEs, few were identified as inappropriate by 4MS and a minority could be stopped during admission. Future studies will investigate whether selecting patients by medication type rather than by number and by patient factors (eg, frailty, end-of-life) facilitates deprescribing.
Assoc Prof Melissa Baysari, Ms Mai Duong
Dr Amy Nguyen, Dr Wu Yi Zheng, Dr Brendan Ng, Ms Sarita Lo, Dean Andrew McLachlan, Prof David Le Couteur, Ms Rosemary Burke, Dr Angus Ritchie, Dr Alexandra Bennett, Prof Fiona Blyth, Prof Rosalie Viney, Ms Cynthia Stanton, Dr Patrick Hooper, Dr Peter Kennedy, Assoc Prof Anne Miller, Ms Jo Hegarty, Mr Magnus Blomqvist, Dr Marty Sterrett, Mr Keith Passmore, Mr Malcolm Brown, Ms Katie Willey, Prof Sarah Hilmer
Innovations in computerised decision support in hospitals to reduce inappropriate polypharmacy in older adultsToggle information
One in five medicines taken by older adults is harmful or unnecessary (inappropriate), with 20% to 30% of hospital admissions due to medicine-related events. Inappropriate medicines are a major burden for older adults and the health system. Most older adults would like to have a medicine withdrawn. Supervised withdrawal of inappropriate medicines (deprescribing) is safe and may improve quality-of-life in older people. Computerised decision support in hospital may facilitate review of inappropriate polypharmacy if it provides the right information at the right time to the right person.
1. To explore current processes of in-hospital medicine review and associated communication with the patient’s general practitioner (GP) and consumers.
2. To determine how best to design computerised decision support and consumer information to facilitate medicine review and deprescribing.
Researchers, clinicians, consumers, local health districts (LHDs), primary health networks and NSW Health pillars were involved in the design and development of several decision support tools. The study was conducted in six hospitals across two LHDs (Sydney and Northern Sydney), and with GPs and consumers. Semi-structured interviews and focus groups were conducted with hospital clinicians (doctors, pharmacists and nurses), GPs and consumers to explore current views of medicine review processes, polypharmacy, deprescribing and future decision support. Observations of hospital clinicians were conducted and clinician workflow was incorporated into the design.
Ms Nashwa Masnoon, Prof Sepehr Shakib, Dr Lisa Kalisch-Ellett, Dr Gillian Caughey
Development of a tool to assess polypharmacyToggle information
Polypharmacy is commonly defined as the use of five or more medicines. This definition does not identify appropriateness of therapy. While there are polypharmacy assessment tools, many have not been associated with patient outcomes. No tool accounts for medicines at the patient-specific level, providing individualised deprescribing guidance to optimise outcomes.
The aim of this study was to develop a patient-specific polypharmacy assessment tool which provides a scoring system regarding the burden of polypharmacy, provides deprescribing guidance based on the polypharmacy score and has been validated to improve patient outcomes.
A systematic review of polypharmacy tools resulted in the shortlisting of 42 tools, fewer than 50% of which had been associated with patient outcomes. A survey of expert clinicians and pharmacists (n = 22) revealed that while the number of medicines is important, experts consider a range of other factors such as the indication for therapy, medicines duplication and drug—drug interactions.
A subgroup of expert clinicians (n = 4) was presented with the literature and survey findings. Clinicians indicated that a new polypharmacy assessment tool should focus on medicines without an indication, medicines exhibiting the same pharmacological effect as other agents, medicines which are associated with harm such as sedatives and anticholinergics, and drug—drug interactions, resulting in various algorithms for combining these factors for a new polypharmacy tool.
The different algorithms are being tested using de-identified data from clinical practice (n = 603 patients, mean age 79.3 years) to determine the association of polypharmacy scores with patient outcomes such as hospitalisation. A cut-off score for inappropriate polypharmacy is being determined which will help flag potential options for deprescribing, based on specific medicines contributing to the overall score. This tool will be a significant advance from the current polypharmacy definition and assessment tools, and serve as guidance for clinicians to drive improved patient outcomes.
Mr Gizat Molla Kassie, Dr Lisa Kalisch Ellett, Dr Tuan Nguyen, Prof Libby Roughead
Use of medicines associated with delirium prior to hospitalisation in older AustraliansToggle information
Medicines are known to be a precipitating factor for delirium, but the extent of their use prior to hospitalisation where delirium occurred is unknown. This study aimed to determine the frequency of use of medicines associated with delirium in elderly hospitalised Australian patients where a delirium diagnosis was recorded.
A retrospective observational study was conducted using de-identified data from the Australian Government Department of Veterans’ Affairs covering all gold card holders aged 65 years or older who had a hospital record with a delirium diagnosis (ICD-10 code F05) between 1 January 2010 and 31 December 2015. Medicines known to be associated with delirium were identified from the literature. The identified medication classes included psycholeptics (N05), opioids (N02A) and antidepressants (N06A).
There were 22,923 hospitalised patients with a delirium diagnosis. A total of 62 different types of medicines known to be associated with delirium were used by patients at the time of admission. Thirty-nine per cent of patients (n = 8906) were taking at least one medicine known to be associated. The most frequently used medicines known to be associated with delirium were psycholeptics (used by 21.1% of patients), opioid analgesics (15.3%) and tricyclic antidepressants (5.7%).
More than one-third of older patients who had a hospital admission where a delirium diagnosis was recorded were taking at least one medicine known to precipitate delirium. There is an opportunity to decrease medication-associated delirium by stopping, reducing doses or switching to less risky medications.
Dr Juanita Westbury, Prof Greg Peterson
Same old problem but substitutes and altered practice: continued overuse of psychotropic medication in residential aged careToggle information
For at least two decades, concerns have been raised about inappropriate psychotropic prescribing in residential aged care facilities (RACFs) due to their modest therapeutic benefit and increased risk of adverse effects, including falls and mortality. This issue has attracted political and media focus, resulting in two Federal Ministerial Roundtables, a Senate Committee Inquiry and a dedicated Dementia Australia report on psychotropic medication in people with dementia (2014). In addition, several guidelines to promote the appropriate use of psychotropics in older people have been released along with tightened Pharmaceutical Benefits Scheme (PBS) restrictions for risperidone and quetiapine. To date, the majority of data on RACF psychotropic utilisation has been collected in Sydney exclusively and it is not known if recent initiatives to promote appropriate psychotropic prescribing in this setting have impacted usage.
We aimed to perform the first comprehensive analysis of psychotropic use in a nationally representative sample of Australian RACF residents. The sample for our cross-sectional, retrospective cohort study was obtained from 150 RACFs distributed nationally during April 2014 to October 2015. Antipsychotic, anxiolytic/hypnotic and antidepressant utilisation was assessed, in conjunction with anticonvulsant and antidementia drug use.
Full psychotropic prescribing data were available for 11,368 residents. Nearly two-thirds (61%) were taking psychotropic agents regularly, with over 41% prescribed antidepressants, 22% antipsychotics and 22% taking benzodiazepines daily. Of major concern was the finding that over a third of residents were charted for prn (as required) benzodiazepines and antipsychotics (30% and 11%, respectively). Over 16% were taking sedating antidepressants, predominantly mirtazapine.
We can conclude that although antipsychotic use appears to have decreased in Australian RACFs, benzodiazepine prevalence is high, particularly in South Australia. Sedating antidepressant and prn psychotropic prescribing is widespread. Effective interventions to reduce the continued reliance on psychotropic management, in conjunction with active promotion of non-pharmacological strategies, are urgently required.
Dr Lisa Kouladjian O’Donnell, Dr Mouna Sawan, Dr Emily Reeve, Dr Danijela Gnjidic, Assoc Prof Simon Bell, Prof Timothy Chen, Assoc Prof Patrick Kelly, Prof Sarah Hilmer
Implementation of the Goal-Directed Medication Review Electronic Decision Support System (G-MEDSS)Toggle information
People with dementia living in the community are prescribed more medications compared with people without dementia, and are particularly vulnerable to adverse effects (eg, falls, hospitalisation) of high-risk medications (eg, anticholinergics and sedatives), which can be measured using the Drug Burden Index (DBI). Implementation studies of computerised clinical decision support systems (CCDSS) have demonstrated effective improvement in appropriate prescribing in older adults.
We have developed the Goal-Directed Medication Review Electronic Decision Support System (G-MEDSS), a CCDSS that incorporates validated deprescribing tools and guides applicable to patients with and without dementia, and their carers (eg, the DBI, patient attitudes towards deprescribing questionnaire and goals of care) in pharmacist-led home medicines review (HMR). We anticipate that the G-MEDSS will reduce anticholinergic and sedative medications, and incorporate patients’ attitudes towards describing and goals in the HMR. This may reduce the use of inappropriate medications and improve clinical outcomes in older adults.
We are conducting a two-arm parallel group, cluster-randomised trial (ACTRN12617000895381) to test the efficacy and safety of the addition of G-MEDSS in HMR to reduce anticholinergic and sedative medication use in patients with or without dementia. Accredited pharmacists (AP) who meet the inclusion criteria will be randomised into the intervention (HMR + CCDSS + G-MEDSS report provided to the patient and patient’s referring general practitioner) or control (HMR) group. Accredited pharmacists will collect data (eg, medication profile, cognitive function) from patients at baseline (during HMR interview) and at three-months follow-up. The primary outcome will be the proportion of patients with reduced anticholinergic and sedative medication use. Secondary outcomes will be changes in clinical and functional outcomes. To date, 32 APs have been enrolled in the trial and 97 patients have consented to participate. We will present the issues relevant to conducting clinical trials in the HMR setting and analysis of baseline data.
Digital Data Stream
Ms Rachel Hayhurst, Ms Yuen Ai Lee, Ms Vanessa Halter, Ms Cynthia Lee
NPS MedicineWise, East Melbourne, Australia
MedicineInsight is a unique source of data with the capability to support population to personal healthcare questions.
At NMS 2016, we went through:
- How MedicineInsight started as a pilot project with the University of Melbourne (GRHANITE)
- The technological expansion from a pilot-sized data mart to a sophisticated data warehouse (DW)
- And the use of the data warehouse to prepare data from multiple aspects of patient care (eg, diagnosis, pathology to prescriptions) from two major clinical information systems for analysis.
This year, we will provide a progress report on MedicineInsight including:
- How we have enhanced the data governance aspects of MedicineInsight
• We have extended the data governance committee to represent consumers, general practitioners, academic institutions and researchers.
• We have set up an ethics program.
• We have kicked off a data develop
- How we have extended our data extraction capabilities in collaboration with Precedence Health Care
• We can now extract data for MedicineInsight via the Precedence Connector or cdmNet
• This capability is a new feature that is on all new and existing Precedence Connector installations and opens up the possibility for more practices to participate in MedicineInsight
- How we have started to reap a return on our investment from the DW
• The DW has started supplying data for the therapeutic program, MyHealthRecord studies and immunisation data for the AusVax study
• MedicineInsight data can also be visualised via the Visualisation Portal
- And our next steps in enhancing the value of MedicineInsight. This includes the work to implement both national and international coding systems for conditions and medications, data linkage. We also continue to increase the representation in our data set by actively recruiting more practices into the program.
Ms Clare Delaney, Mr Allan Nash, Ms Grace Wong, Ms Anastasia Van der Linde
Lost in translation: redefining data for optimal patient-centred careToggle information
Background: Primary care settings provide increasingly more complex and individualised care. In a technology and data-driven world, numbers are meaningless without translation into comprehensible improvement pathways. MedicineInsight is the first large-scale data program in Australia that extracts longitudinal de-identified patient health records from general practice software. MedicineInsight was developed and is managed by NPS MedicineWise.
Reports are delivered to participating general practices using a multimodal audit and feedback intervention, enabling clinicians to reflect on their individual and collective performance. The intervention is facilitated by an NPS MedicineWise clinical services specialist. The objectives are to: interpret data and identify evidence-practice gaps, explore roles and responsibilities in the practice, and create, plan and implement agreed changes to improve patient care.
Aim: To review the impact of the audit and feedback multimodal intervention.
Method: Participants were asked to complete an online survey immediately following participation in the intervention to rate their satisfaction and outline their intended actions for change.
Results: Trained facilitators provided 1538 small-group audit and feedback sessions to 5374 health professionals. The online survey was completed by 447 participants (8%). The majority rated the intervention as meeting their learning needs and being entirely relevant to their practice (77% and 81%, respectively). Participants reported being satisfied with the intervention (95%), the presentation of data to help understand current practice (95%), and the facilitator’s ability to assist with action planning (91%). The majority (84%) committed to one or more actions for change, for example reviewing patients without a diabetes annual cycle of care completed (73%).
Conclusion: The multimodal audit and feedback intervention assists clinicians to translate data into tangible actions. The benefit from the patient’s perspective is improved shared decision making, placing their needs above those identified by their GP and ensuring that patient values guide all clinical decisions.
Ms Ornella Care, Ms Tanya Newhouse, Professor Brian Oldenburg
Digital coaching: using avatars to support selfmanagement of type 2 diabetesToggle information
Issues/idea/proposal: Over 1 million Australians have type 2 diabetes and the figure continues to rise. Type 2 diabetes is a chronic disease which involves complex self-management.
To support people to manage this condition we worked with consumers and clinicians to co-design and create a digital health solution called My Diabetes Coach (MDC), an accessible, engaging, digital self-management program. It complements and supports clinical care by offering personalised, guided self-care education and practical tips with the aim of reducing serious diabetes-related complications.
This innovative mHealth solution enables people with type 2 diabetes to be supported 24 hours a day.
Objectives/scope of the work: Through the app, health coach ‘Laura’, an interactive avatar with voice recognition technology, checks in with users for weekly chats to discuss self-management activities that can include blood glucose monitoring, medication taking, physical activity, healthy eating and foot care. Laura helps users set goals and track their progress over time. Chats are tailored based on the user’s responses.
Users can also upload or enter blood glucose readings into the app to receive timely feedback from Laura to help keep their blood glucose levels within the target range agreed with their healthcare professional. The program also raises clinical alerts and can generate reports for follow up by the user’s healthcare team.
Work so far and findings: The program is currently in trial with 187 participants as part of an NHMRC partnership with the University of Melbourne. The research aims to explore the feasibility and usability of the app, as well as implementation facilitators and barriers of the MDC program.
Preliminary results show improvements in HbA1c compared to baseline, and to waitlist participants. Participant engagement has been high, with an average of 18 chats per participant over a six-month period, with an average chat duration of 16 minutes each.
Mr Kishen Kaurah, Ms Gamila MacRury, Dr Kitty Yu
NPS MedicineWise, East Melbourne, Australia
The extended technical and data applications of the MedicineWise app: beyond a consumer medication management appToggle information
The MedicineWise app is a free app developed by NPS MedicineWise to help consumers manage their medicines and their health. Recent enhancements mean the app can deliver featured health and medicine-related content to users based on their medicines and/or health conditions. This ability to source and deliver quality, trusted and accurate consumer-friendly health content in a contextualised, relevant and timely manner is highly desirable, leading us to embark on a project to harness the technology powering this functionality and turn it into a transferable ‘plug-and-play’ product that can then be used by vendors for new or existing systems across any platform.
We created an interconnected ‘package’ of information housed on a FHIR (Fast Healthcare Interoperability Resources) server containing medicine details (eg, active ingredients, strength, form, brand, product barcodes) mapped to standardised terminologies and linked to relevant information on the use of these products and the health conditions they treat (eg, consumer medicine information [CMI], other specific trusted content).
Use case examples:
- A patient can barcode-scan their asthma inhaler to record it on the medicines list of their chosen health app. The patient can then view relevant information such as the CMI, how-to-use videos and tutorial leaflets from within the app.
- A pharmacist can dispense a cholesterol-lowering medicine to a patient and access trusted patient support information such as lifestyle advice directly from the patient’s dispensing record.
- On hospital discharge, a patient’s discharge medicines can automatically map to the same medicine coding system of their GP’s clinical information system, allowing seamless interoperability between the hospital electronic medication management system and the patient’s health record in primary care.
The versatility of this solution brings about exciting innovation possibilities in the consumer healthcare space while encouraging better communication of medicines information and improving patient safety across different healthcare settings.
Dr Andre Andrade, Dr Alline Beleigoli
Evaluating digital health interventionsToggle information
Programs and devices using digital technology (digital health interventions) are being used in healthcare areas such as health behaviour change, medication adherence and promoting online healthcare access, among others. However, despite almost two decades of research, theories underpinning digital health and their intended outcomes are poorly understood.
We use Mohr et al.’s behavioural intervention technology model and UCL behaviour change taxonomy and show how these models can improve the evaluation of digital health interventions. It includes three main areas: (1) action components, the service and content being provided regardless of the delivery; (2) technical instantiation components, including the mode of delivery (smartphone, web, SMS, wearable devices), functionalities, associated non-digital services, optimisation strategies used during implementation, data gathering mode and engagement techniques; and (3) intended usage, including demographic and clinical characteristics of target group, minimum effectiveness dosage (adherence required for effectiveness) and cost.
To illustrate, we describe the POEmaS Project, a digital health intervention for weight loss which is currently the subject of a three-arm RCT comparing waiting list group, basic intervention (access to the platform) and advanced intervention (platform plus individualised coaching through embedded instant messaging service). The study is still ongoing, but preliminary results indicate that very early dropout (users who accessed for <24 hours) is not related to any technical components, suggesting that pre-existing behavioural components dominate these first interactions. However, usage of social network functionalities in the first two weeks (eg, embedded instant messaging and the ‘like’ feature) strongly correlate with continued engagement.
Dr Anna Moffat, Mrs Natalie Blacker, Dr Lisa Kalisch Ellett
Veterans’ MATES: engaging veterans and health professionals to improve health outcomes for veteransToggle information
Since 2004, the Australian Government Department of Veterans’ Affairs (DVA) Veterans’ Medicines Advice and Therapeutics Education Services (Veterans’ MATES) program has been helping to improve the health of the veteran community by encouraging better use of medicines. Veterans’ MATES is a unique initiative that uses the DVA routinely collected administrative health claims data to identify ‘real-life’ medicine use problems for members of the veteran community. We provide timely targeted feedback supported by evidence-based information to the veteran, their GP and other allied healthcare providers.
The activities of the program are underpinned by the principles of Australia’s National Strategy for Quality Use of Medicines and two theoretical behavioural frameworks for behaviour change, social learning theory and the transtheoretical model, as well as the health promotion model Precede-Proceed. Key aspects which are integral to the success of the program are engaging stakeholders, and working with veterans and practitioners to develop the program content. A practitioner and a consumer reference group meet twice a year to provide advice on topics, interventions, practitioner and consumer needs. Another key aspect of Veterans’ MATES is the use of data analytics to develop and evaluate the program. Over the last 14 years Veterans’ MATES has pioneered the way in which health data are managed in Australia and demonstrates how complex data analytics can be used to improve health outcomes.
Session structure: This session will demonstrate how stakeholder engagement is crucial to the success of the Veterans’ MATES program in bridging the evidence—practice gap and improving use of medicines and health outcomes for veterans. We will provide an overview of how we go about engaging stakeholders, and how we have shown that stakeholder engagement has increased the success of the program. We will describe the approaches we use in developing the program with a focus on stakeholder engagement. The use of data analytics to develop and evaluate the program will also be discussed, and results of the Veterans’ MATES program will be presented.
Who should attend: Health professionals, consumers and anyone with an interest in interventions which aim to improve the use of medicines.