Not enough HMRs: study

Experts say there is a need for more funding and collaboration to improve uptake and targeting of HMRs

Home Medicines Review (HMR) use in Australia was found to be generally below 10%, even in high-risk groups, in a study published in BMJ Open this week.

Researchers from the University of Sydney, Australian National University and the University of Technology used data from the Sax Institute’s 45 and Up Study, a population-based prospective cohort study comprising 267,153 individuals aged ≥45 years in Sydney, NSW.

The final study population comprised 131,483 concession card holders as only this group had complete medication dispensing records through PBS data.

MBS records and hospitalisation data were also included, as were questionnaires on self-reported health conditions and deaths through the NSW Register of Births, Deaths and Marriages.

Over five years of follow up, from July 2009 to June 2014, 4.7% (n=6115) of the 131,483 participants received at least one HMR.

Five-year HMR receipt was: 1.5% in people using <5 medications at baseline; 6.8% with 5-9 medications; 12.7% with ≥10 medications; 8.8% using Narrow Therapeutic Index medicines; 6.8% using Beers Criteria potentially inappropriate medicines; and 7.4% using Drug Burden Index medicines.

HMR incidence increased with age, although it did not vary significantly based on sex or language background.

Increased HMR receipt was also observed in older people, smokers, those who were single, obese, without private insurance, not in paid work, residing remotely, having morbidity such as diabetes and broader health issues such as impaired physical functioning, compared with other study participants.

Overall HMR receipt in this study of older adults was higher in participants who had characteristics consistent with high-risk medication use, particularly greater numbers of medications.

However despite this, over 90% of older adults with these markers did not receive an HMR over the five-year period.

The authors say overall HMR coverage of 4.7% across the study population of concession-card holders and particularly the 8.3% in those taking five and more medications “appears low, especially as it is recommended in the latter group”.

While concession card holders are not directly representative of the general population, given the relative disadvantage and increased morbidity in this group, the observed proportions receiving an HMR may, if anything, be higher than in the general population, they say.

“Although it is evidence that increased HMR receipt among older adults has largely occurred among those with polypharmacy, the majority of older adults with polypharmacy and prescribed high-risk medicines have not had an HMR,” say the researchers.

“Continuing efforts are warranted to extend its delivery to patients of greater need.”

Why is uptake low?

Consultant clinical pharmacist Debbie Rigby says lack of support and continued caps on HMRs have reduced access to vulnerable patients.

“When HMR commenced in 2001 there was substantial support for the implementation service … all that support has dropped off with subsequent Community Pharmacy Agreements,” Ms Rigby tells AJP.

“There is a substantial body of moderate quality evidence of the benefits of HMRs, and yet we are faced with continued caps on the number of HMRs per month, reducing access to vulnerable patients at high-risk of medication misadventure.

“Recommendations of evaluations of the HMR program have not been implemented, contributing to low uptake and poor targeting.”

Dr Geoff March, from the School of Pharmacy and Medical Sciences at the University of South Australia, confirms there was a pulling back of funding and support in his paper Update on Professional Services: Home Medicines Review published by the PPA.

“In the years leading up to the 2011-12 October-December quarter, on average approximately 15,000 claims were processed each quarter,” says Dr March.

“At the end of Fourth Community Pharmacy Agreement, the Campbell Report identified a number of patient groups at high risk of medication misadventure; patients post discharge, culturally and linguistically diverse (CALD) consumers, indigenous consumers, palliative care patients, and those people who are non-adherent, but these groups appear to have rarely received an HMR.

“It appeared many at-risk people were missing out on an HMR. You would have thought that the next CPA would have focused on this and ensured that funding was sufficient for a substantial increase in HMRs.

“However, only $52.1 million dollars over the five years were allocated to this service [in the 5CPA]. Contrast this amount with $9[7] million for Clinical Interventions and $132 million for DAAs.

“Pharmacy owners (and pharmacist employees) were encouraged to embrace the 5CPA programs including HMR and an incentive was provided to pharmacy owners to register for the professional services,” he says.

“Consequently, there was a substantial increase in the number of HMR claims between 2011-12 July to September quarter (which was the start of the new CPA agreement) to 2012-13 October-December quarter with claims increasing from around 10,000 to just over 35,000 per quarter.”

Dr March explains that after the peak in 2012-13 of HMR claims, the Guild and the Department of Health decided to place restrictions on the number of HMR services. This came into effect in March 2013.

Currently each approved HMR provider may conduct and claim up to a total of 20 HMR services in any calendar month.

This cap applies to both the organisation that is submitting the claim, as well as the individual Accredited Pharmacist who completes the service.

Ms Rigby says the lifting of these caps is more important than ever.

“The need for collaborative comprehensive medication reviews has never been greater. The recent Medicine Safety report highlighted 250,000 medication-related hospital admissions, half of which are considered avoidable,” she told AJP.

And according to the PSA’s Pharmacists in 2023 report, one in five people are suffering an adverse medication reaction at the time they receive a HMR.

“There is a pragmatic solution with the limited funding available: better targeting of HMRs using validated tools is required. And a more collaborative approach with GPs is necessary,” says Ms Rigby.

“The introduction of funding for pharmacists in general practice in July this year is an opportunity to enhance the collaborative approach and improve the uptake of HMRs in a targeted manner.

“Allowing non-dispensing pharmacists to access allied health items as part of team care arrangements (TCAs) under MBS will also support with integration of pharmacists in primary care and lead to better collaboration and trust in our competency as medication experts.”

Ms Rigby points out that PSA has called for medication safety to be a health priority.

“HMRs are a valuable, evidence-based program which can improve medication safety and reduce medication-related problems. Hopefully changes to program rules in the future will encourage greater uptake of HMRs and reduce the high burden of medication-related problems,” she says.

See the full BMJ research here (open access)

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