How much do HMRs really matter?


medication consultation HMR

A review of discrepancies between medicines information held by the GP and that discovered during HMRs has found a large amount were a potentially serious risk

An Australian study has looked into the impact of Home Medicines Reviews (HMRs)—comprehensive clinical reviews of a patient’s medicines in their home by an accredited pharmacist, on GP referral.

Discrepancies between the medication history in HMR reports and that documented in GP referral letters – arising from a lack of accuracy in GP medication histories – has been associated with serious consequences on admission to hospital in Australian settings and in Canada.

Pharmacist and lecturer Sue Carson from James Cook University in Qld, and Associate Professor Therése Kairuz from the University of Newcastle in NSW analysed HMR reports and GP referral letters for 60 patients across the North Queensland.

There were 833 medications across the 60 patients, of which 13.5% (n = 113) were CAMs. Subjects took between three and 24 medications (average 10.4 per subject), with most medications (74.5%; n = 621) taken daily.

Researchers found a total of 247 discrepancies distributed across 90% of patients.

The largest proportion of discrepancies was related to dose (24.7%)—just over half of the patients (31/60) had dose discrepancies.

There was an average of two altered doses per patient.

Slightly more than one-third (36.6%) of patients were taking prescription medicines which were not documented by the GP (mean 11.3 medications/patient; range 3–15).

Nearly one-quarter of all discrepancies (22.3%) were considered to have potentially serious risk (+++), where serious reflected potential permanent injury, severe consequence or death.

These arose from taking prescribed medications that were not documented in the referral letter, altering the dose of prescribed medicines, or not taking prescribed medications.

Of the discrepancies involving altered doses, nearly one-third had the potential to cause serious clinical consequences due to sub-optimal treatment, toxicity or haemorrhage.

Although ‘altered doses’ was the discrepancy with the highest frequency (61/247), the greatest risk was associated with prescription medicines that were not documented in the referral letter, followed by dose discrepancies and risk associated with not taking prescribed medicines, say the researchers.

In 10% of patients (n = 6/60) there were no discrepancies between referral letters and medication profiles compiled during the HMR.

The hypothetical costs for potential exacerbations, consequences and hospital admissions could add up to thousands of dollars, say Mrs Carson and A/Professor Kairuz in the Journal of Pharmacy Practice and Research.

Reasons for discrepancies may be multi-factorial and include patient and prescriber factors, they suggest.

For example, medications which patients had ceased still remained documented in their referral letters in nearly half of participants, and discrepancies may have resulted from an administrative oversight or from non-adherence.

“Timely identification of discrepancies can minimise risk associated with medication-related problems and avoid potentially serious clinical consequences,” they conclude.

Under the HMR program, which has been in place since 2001, approved practitioners may each conduct and claim for up to a total of 20 HMR services in any calendar month.

There have been frequent calls by consultant pharmacists across the industry for the government to remove the caps on HMRs, however no changes have yet been made.

HMRs are currently undergoing further cost-effectiveness assessment as part of the 6CPA, the results of which will help inform future funding, says the Guild.

A 2010 study into the economic value of HMRs by the University of Tasmania (called VALMER), which analysed 180 HMRs conducted across Australia, found the medication reviews were cost-effective in many patients.

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2 Comments

  1. Karalyn Huxhagen
    10/08/2018

    My n=1 would reiterate this issue. One of the main reasons I am sent to perfrom a HMR is to undertake a medication reconciliation. One of my best prescribers lists the reasons he wants me to see the patient in dot point form and it is always about discrepancies between what is in his records and what the patient tells him they are taking. This is caused by tertiary hospital prescribing, specilaists prescribing and outside influences e.g. pain clinics.

    patients add in CAMs or delete CAMs and things go amiss. I recently discovered that in this GPs software I can obtain a graph of pathology readings e.g. triglycerides. I was able to map the rise in TGs to the cessation of high dose fish oil that occured every time the patient had surgery.

    Graphic representation is an excellent way to map against medications starting and stopping.

    the GPs use me as the medication reconciliator, the educator, the lady with the big stick for adherence and I also provide feedback when asked about lifestyle and coping.

    I saw a 91 yr old yesterday who fell out of a tree picking mandarins. She is not happy that use of ladders is now off her ‘allowed list’ of activities. Her secret for a long life is rain water for her cup of tea and the glass of port and water before bed!

  2. PrescribingSolutions
    12/08/2018

    This is a HUGE issue ! Whilst the majority of meds being taken that are not listed on the referral are OTC, CAMs etc, there are sometimes heavyweight omissions, with potentially dire consequences. I’ve found patients on methotrexate, lithium, dabigatran, where it was not listed on the referral and by default therefore not on GP profile. One lady I saw had been cautiously prescribed low dose tramadol by the GP aware that she was on mirtazapine 15mg, but unaware that she was also on duloxetine (using Rx from previous GP) – ended up with an air transfer to hospital for serotonin toxicity. Sadly the HMR came after this misadventure, but highlights graphically the issue

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