Medicines are meant to keep you healthy and out of hospital. But each year in Australia the mismanagement of medicines causes an estimated 140,000 hospital admissions, accounting for 8per cent of hospital bed days and costing the public hospital system around $500 million. Most admissions are for elderly patients who are taking four or more medicines daily.
Medication problems arise from confusion, from the fact that one in five elderly Australians hoard out-of-date medicines, and because 50 per cent of people don't know how to access more information about their medicines. Two-thirds of these hospital admissions are preventable. And behind the adverse events that lead to hospitalisation is an unknown number of people whose lives are affected by untoward side effects such as confusion, falls and nausea due to polypharmacy (too many medicines), inappropriate prescribing, or not taking their medicines as required.
In October 2001 the Howard Government introduced the Home Medication Review program to tackle medication mismanagement. GPs who refer patients taking multiple medicines to an accredited pharmacist are reimbursed $137.05 through Medicare, and the pharmacist is then paid $180 to go to the patient's home and assess how they manage their medication regime. On average, 80 per cent of patients who have a review are found to have a least one problem. These problems can usually be addressed by changes in the medicine prescribed, changes in dose and patient education.
The uptake of this program has been minimal. After six full years of operation only 33,800 reviews were done in 2007 at a cost to Medicare of $4.6 million, less than 50 per cent of the funds budgeted.
In contrast, funding incentives provided to GPs to develop and review management plans for patients with chronic illnesses have had an enthusiastic uptake. Last year, more than 1.7 million chronic disease management plans were developed or reviewed at a total cost to Medicare of more than $170 million.
The difference in uptake between this and the Home Medication Review program is staggering, especially as many people with chronic illnesses will be taking multiple medicines.
The Home Medication Review program has problems that need to be ironed out. A review by the Department of Health and Ageing in 2005 found low referral rates from GPs, low numbers of accredited pharmacists , GP concern at a time-consuming process and a perception among pharmacists that they were paid too little to do reviews, which take three hours on average.
The main reason the program has failed, however, is that it requires health professionals to work together as a team. GPs need pharmacists to conduct the reviews, and pharmacists can't do reviews without referrals from GPs. When teamwork is required in Australia's health system, it suddenly becomes difficult to guarantee collaboration and action that is patient-centred.
To illustrate, even in the comparatively successful chronic disease management program, the number of management plans GPs develop and review on their own (1.2 million in 2007) significantly outnumber those done in collaboration with other health professionals (590,000), despite the fact that most chronic diseases require multidisciplinary care. The role of GPs as gatekeepers and care coordinators has recently been called into question.
Federal Health Minister Nicola Roxon claims GPs are not acting as gatekeepers if people can't get in to see them and end up in a hospital emergency room instead. In contrast, the president of the Australian Medical Association, Dr Rosanna Capolingua, argues that GPs act as gatekeepers because they are the first port of call for most people with minor ailments, the only health professionals able to refer patients for specialist or allied health care, and are primarily responsible for coordinating individual patients' care.
The claimed responsibility for coordinating patient care must extend to working better with pharmacists to address a problem that has a high cost in terms of health outcomes and the health care budget. The National Health and Hospitals Reform Commission must ensure that this issue is addressed as part of health care reform.
Preventing medication errors and ensuring that people most at risk of mismanaging their medicines get education, guidance and monitoring will save lives and dollars.
Dr Lesley Russell is the Menzies Foundation Fellow and Anne-marie Boxall is a research assistant at the Menzies Centre for Health Policy, University of Sydney/Australian National University.
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