Quality Use of Medicines Australian Experience

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Quality Use of Medicines Australian Experience

• Quebec City, Canada
• May 2004
• Professor Susan Tett,
• School of Pharmacy, University of Queensland,
  Brisbane, Australia
• (with thanks to my PHARM colleagues for
  discussion, ideas, slides and other help!
  Especially Libby Roughead, Andy Gilbert, Tony
  Wade)

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External Vision of a Global Strategy to Improve
Drug Use

• Can the Australian vision and direction help
  Quebec?

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Summary

• Brief overview of relevant Australian medicines
  history
• Development of Australias National Medicines
  Policy (four interlinked arms)
• More focus on the Quality Use of Medicines
  aspects, examples of progress from research
  development through service implementation
  evaluation

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Australias National Medicines Policy 2000

• Quality, safety efficacy of medicines
• Timely access, at affordable cost
• Responsible viable industry
• Quality use of medicines
• www.nmp.health.gov.au/pdf/nmp2000.pdf

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Coming together .

• 1950 Pharmaceutical Benefits Scheme
• to provide equitable access to medicines
• 1958 Therapeutic Goods Administration
• safety, quality and efficacy
• 1988 Pharmaceutical Industry investment program
  and later versions
• viable and responsible industry
• 1992 Policy on the Quality use of Medicines

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Quality, safety efficacy

• Therapeutic Goods Administration
  www.health.gov.au/tga
• Registration process similar to Canada, except
• Australian Drug Evaluation Committee (ADEC)
  Adverse Drug Reaction Advisory Committee (ADRAC)
  . for prescription national expert committees

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Timely access, at affordable cost

• National pharmaceutical benefits scheme (PBS)
  www.health.gov.au/pbs
• Ensures all Australian residents access to
  necessary life-saving medication at an
  affordable price
• All covered. Two different co-payments 23.70 or
  3.80 (a safety net operates)
• About 600 drugs covered, 1500 dosage forms,
  2,500 different brands

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Pharmaceutical Benefits Scheme

• Pharmaceutical Benefits Advisory Committee (PBAC)
  (1954), established by National Health Act
• www.health.gov.au/pbs/healthpro/outcomes_full.htm
• Make recommendations to Minister, consider
  effectiveness and cost, compare with alternative
  (including non-drug) therapies
• Economics Sub-Committee (ESC) (1993),
  cost-effectiveness analysis
• 4,755 million (5 billion) cost to Australian
  Government for year to end Dec 2003

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Responsible, viable medicines industry

• After product registration (TGA), company submits
  application for PBS listing for prescription
  products
• PBAC evaluates and recommends
• Pharmaceutical Benefits Pricing Authority
  negotiates price www.health.gov.au/pbs/pharm
  /med_price.htm
• Industry incentives moved away from PBS eg. P3
  (Industry), tax incentives.
• Pharmaceutical Industry Action Agenda
  www.industry.gov.au/assets/documents/itrinternet/P
  harmAAReport2002.pdf
• Pharmaceuticals Partnership Program
  www.ausindustry.gov.au/

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More on the above

• Discussion, comparisons to Canada and some
  strengths, weaknesses and opportunities presented
  in
• Tett SE. A perspective on Australias National
  Medicines Policy. Canadian Journal of Clinical
  Pharmacology 2004 11 e5 (1-11)
  (http//www.cjcp.ca/hm/)

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Quality Use of Medicines

• Australian Pharmaceutical Advisory Council (APAC)
  and Pharmaceutical Health Rational use of
  Medicines (PHARM) committee
• APAC representation www.nmp.health.gov.au/advis
  ory/apac.htm
• PHARM - 12 people with expertise in QUM
  (appointed by Minister) www.nmp.health.gov.au/adv
  isory/pharm.htm

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What does QUM mean?

• Selecting management options wisely
• Choosing suitable medicines if a medicine is
  considered necessary
• Using medicines safely and effectively to get the
  best possible results
• www.nmp.health.gov.au/quality.htm Plain
  English Edition of The National Strategy for
  Quality Use of Medicines available through
  publications link

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The Original Vision for QUM (1992)
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This has developed .

• From research and development into
  implementation, service and evaluation
• All partners have progressed

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Building blocks needed to achieve QUM

• Policy development and implementation
• Facilitation and coordination of QUM initiatives
• Provision of objective information and ethical
  promotion of medicines
• Education and training
• Provision of services and appropriate
  interventions
• Strategic research, evaluation and routine data
  collection

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Awareness
The Vision
Enabling
Policy development/ implementation
Maintaining
Facilitation and co-ordination
Government
Objective information and ethical promotion
Health professionals
Partnership
Healthy Consumers
Industry
Education training
Services and interventions
Consumers
Strategic research, data collection
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Quality use of medicines initiatives in Australia
include .

• Medication management reviews
• www.qummap.health.gov.au
• National Prescribing Service activities eg.
  facilitators, clinical audits
• National Medicines Symposium
• MediConnect (HealthConnect)
• QUM indicators and their measurement
• QUM building blocks

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QUM - a decade of research, development and
service activity www.nmp.health.gov.au/pdf/qumres
earch.pdf
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Manual of Indicators (1994)

• To measure the effect of initiatives under the
  Quality Use of Medicine arm of the National
  Medicinal Drug policy
• Process indicators
• Impact indicators
• Outcome indicators
• Report baseline 1992 measurement, 1998 update,
  re-measurement, where possible, 2003

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Medication management reviews

• Example of QUM Indicator (process)
• Are there mechanisms to enable consumers to
  regularly have their medicines reviewed
• 1992 No review services/ need recognized
• 1995 studies funded in nursing homes/ community
• 1998 Australian Government funding for aged care
  facilities
• 2001 Australian Government funding for home
  medication review (HMR) services announced.
  Facilitators employed in GP Divisions.

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Home Medicines Review

• Australian Government funded program began Oct
  2001
• Pharmacists remunerated for medication management
  reviews (HMR) for people living in community.
• COLLABORATIVE service
• Payment of 140 GST per service
• Guidelines and standards, more information
• Eg. www.hic.gov.au/providers/incentives_allowances
  /pharmacy_agreement/about_hmr.htm
• www.guild.org.au/public/dmmrfiles/qa.adp

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HMR how did it happen?

• Gathering the evidence finding what works.
  Numerous projects, some funded by Australian
  Government.
• Moving from evidence to national implementation.
  Again, funded implementation trials reduction
  in medication costs to the PBS demonstrated.
• Outcomes Australian Government funded services
  (over 45,000 HMRs), estimated savings between
  27.6 and 51.2 million annually to the health
  system.

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HMRs

• Currently can evaluate process and impact
  indicators
• Yet to describe good outcome indicators
• May be feasible with MediConnect/ HealthConnect

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www.mediconnect.gov.au
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Why MediConnect

• Recognized that at least 80,000 hospital
  admissions each year in Australia are related to
  problems with medicine (eg. Roughead et al MJA
  1998 168 405-8)
• MediConnect reduce adverse drug events and
  hospitalizations due to adverse drug events by
  improving access to more complete medication
  records

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Data that MediConnect can provide

• Complete subsidized prescription record (PBS
  medications)
• In time . Private prescriptions, over the
  counter and complementary medicines
• Links to demographics (only available on a
  population basis for PBS data since 2002, no
  linking to other databases permitted)
• reason for prescribing

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www.nps.org.au
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www.nps.org.au

• National Prescribing Service an independent
  incorporated organization
• Funded by from Australian Government, only on
  proviso of savings to the Pharmaceutical Benefits
  Scheme (initially required to save 45 million
  over 4 years achieved 49 million in first 3
  years current four-year funding of 46 million
  requires 111 million savings over 4 years)

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National Prescribing Service

• Mission create an awareness, culture and
  environment that will support QUM among all
  stakeholders
• Multi-strategic approach draws on evidence in
  education, community development, social
  marketing, health promotion .. Want to achieve
  sustainable behavioral change

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NPS Interventions - examples

• Website (nps.org.au) freely available
  information
• Newsletters
• Prescriber feedback (educational)
• Academic detailing (educational visiting)
• Clinical audit
• Case scenarios
• Peer group meetings ..

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www.australianprescriber.com
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NPS news, Australian Prescriber

• Building block 3 for QUM provision of objective
  information
• New drugs RADAR (Rational Assessment of Drugs
  and Research) www.npsradar.org.au

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www.amh.net.au
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www.tg.com.au
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Back to NPS .

• Regular evaluations - Examples from
  www.nps.org.au/resources/evaluation/report_06.pdf
• Process, scope and reach of NPS
• Changes in awareness, skills and behaviors
  towards QUM
• Changes in prescribing behavior, changes in
  health outcomes

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From NPS Evaluation report No 6 (Dec 2003)
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From NPS Evaluation report No 6 (Dec 2003)
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From NPS Evaluation report No 6 (Dec 2003)
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From NPS Evaluation report No 6 (Dec 2003)
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Other health profession targets

• Pharmacists self-audits (eg. NSAIDs, allergic
  rhinitis) case studies (1st national survey
  indicated that participants had greater knowledge
  about specified topics)
• Students Curriculum and training (nurses,
  pharmacists, medical students PG1)

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Consumer Medicines Information

• In Australia, all new prescription medicines must
  have CMI in specific format as part of the
  application for registration (company prepares
  these, TGA reviews and comments, CMI Quality
  Assurance Reference Group reviews a random
  selection)

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Resources to help .. (www.nmp.health.gov.au/publi
cations.htm)
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So, what impact are we having?

• Not too difficult to measure process indicators
  are services set up, has implementation been
  effective etc
• What is the impact, for example prescribing rates
  for various target drugs are also able to be
  assessed, although hard to link cause and
  effect sometimes

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Impact Indicators improving medication useRatio
of paracetamol to NSAIDs (from E.Roughead)
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Impact Indicators improving medication useRatio
of low-risk to high-risk NSAIDs (from E. Roughead)
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METFORMIN AND SULPHONYLUREAS
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Outcome indicators reducing morbidity
Hospitalization rates for peptic ulcer (from E.
Roughead)
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The quality use of medicines mapping project
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www.qummap.health.gov.au

• 1135 projects entered on the map, end April 2004
• Interactive, web-based tool
• People add their own projects
• QUM building blocks identified
• Search basic and advanced
• (Roughead, Monteith, Harvey, Tett. Evaluating
  Australias National Medicines Policy using
  geographical mapping. Internal Medicine Journal
  20023266-71)

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National Medicines Symposium

• www.nps.org.au/nms2004
• Wed 28th Fri 30th July, Brisbane
• 3rd biennial symposium, run by PHARM and NPS
• Over 190 abstracts, plenary sessions and plenty
  of discussions!! All about QUM!!

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Summary

• Overview of some examples of QUM activities in
  Australia
• Medication management reviews
• www.qummap.health.gov.au
• National Prescribing Service activities
• National Medicines Symposium
• MediConnect (HealthConnect)
• QUM indicators and their measurement
• QUM building blocks