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ISSUE 1 FEBRUARY
Letters to the Editor

Cost shifting and the quality use of medicines

  • Mary Wilkin, Andrew J McLachlan, Ian Coombes

The Editorial Executive Committee welcomes letters, which should be less than 250 words. Before a decision to publish is made, letters which refer to a published article may be sent to the author for a response. Any letter may be sent to an expert for comment. When letters are published, they are usually accompanied in the same issue by their responses or comments. The Committee screens out discourteous, inaccurate or libellous statements. The letters are sub-edited before publication. Authors are required to declare any conflicts of interest. The Committee's decision on publication is final.

Letter to the Editor

Editor, – The recent editorial by Andrew McLachlan (Aust Prescr 2014;37:110-1) overlooked an interesting point about reforms to the Pharmaceutical Benefits Scheme (PBS) in public hospitals. In some states, the reforms have seen patients discharged with one month's supply of their medications, in place of the traditional few days' supply currently given in hospitals not affected by the reform.1 The model of minimal supply forces patients to visit their GP and pharmacy as soon as possible after discharge.1 This has significant impacts on continuity of care - if a month is left from discharge to visiting their GP, problems due to changes in medications at discharge may not be identified.1, 2

PBS reform is intended to decrease confusion about changes to medications. However, it will not achieve this as hospitals will continue to keep only the single contracted brand of medication and there may be an increase in readmissions due to patients not being followed up by the GP after discharge.1 Further to this, the PBS reforms in public hospitals have given pharmacy departments the opportunity to profit from patients' discharge medications, causing hospital pharmacies to focus on supply rather than clinical practices.3, 4 This draws pharmacists away from important clinical roles including medication safety, counselling and education services, not to mention liaison with community services including the GP and pharmacy about the changes to patients' medication regimens.3, 4

Given that it has been shown that clinical pharmacists in hospitals reduce adverse drug events and improve patient safety, funding systems should focus on streamlining processes, community liaison and integration with community-based programs, not on increasing the burden on already short-staffed hospital pharmacy departments.3, 4

Mary Wilkin
Clinical pharmacist
Manning Base Hospital
Taree, NSW


 

Author comments

Andrew McLachlan, author of the article, comments: Mary Wilkin has identified some important realities and possible implications related to medication access and transition of care. Her comments about the possibility of continued confusion related to medicines, and remuneration shifting the clinical role of pharmacists is well made and further highlights the need to carefully consider the implication of change in a complex health system.Mary Wilkin's letter further highlights the need to design well thought out solutions guided by relevant medicines policy.

Ian Coombes, Director of Pharmacy, Royal Brisbane and Women's Hospital, and member of the Australian Prescriber Editorial Executive Committee

Mary Wilkin has highlighted that there are risks when introducing Pharmaceutical Benefits Scheme (PBS) reforms to public hospitals. The reforms could shift the pharmacy's focus towards satisfying PBS regulations for reimbursement. This raises questions about the purpose of each pharmacy department. If public hospitals do not focus on patient-centred review, reconciliation and facilitation of medication liaison with primary care, the quality use of medicines is at risk.

I believe our department learnt the harsh reality that if the hospital pharmacy's primary role becomes dispensing PBS prescriptions and it focuses more on optimising our reimbursement than ensuring appropriateness, then safety and continuity of treatment become secondary. This places the patients at risk of adverse events. 5

As a result of our experience, we chose to actively disinvest in dispensing drugs at discharge where feasible without compromising patient care. We realigned our roles on ensuring early clinical review, completion of medication action plans and close collaboration with patients, carers and hospital staff to optimise medication outcomes in hospital. On discharge our goal is to reconcile all PBS discharge prescriptions and only dispense what is required. We should focus on providing medication information for patients and carers and facilitating medication liaison with the primary care team.

Pharmacy has to use any healthcare reforms as a trigger to re-evaluate its role in a complex system in order to maintain its ability to optimise the quality use of medicines. As we stated in our previous article, 'a focus on tasks and processes in hospitals runs the risk of removing the patient as the focus of care. 5

 

References

  1. Jackson JK. Analysis of the impact of public hospital pharmaceutical reforms on discharge medication supply. Aust J Hosp Pharm 2001;31:295-9.
  2. Morgan TK, Williamson M, Pirotta M, Stewart K, Myers SP, Barnes J. A national census of medicines use: a 24-hour snapshot of Australians aged 50 years and older. Med J Aust 2012;196:50-3.
  3. Department of Health and Ageing. National Medicines Policy. Canberra: Department of Health and Ageing; 2000.
  4. The Society of Hospital Pharmacists of Australia. Position statement: Funding for medicines used in public hospitals. Melbourne: SHPA; 2002.
  5. Doran E, Iedema J, Ryan L, Coombes I. Fatal rhabdomyolysis following voriconazole and simvastatin. Aust Prescr 2012;35:88-9.

Mary Wilkin

Clinical pharmacist, Manning Base Hospital, Taree, NSW

Andrew J McLachlan

Professor of Pharmacy (Aged Care), Faculty of Pharmacy, The University of Sydney, Centre for Education and Research on Ageing, Concord Hospital, Sydney

Ian Coombes

Director of Pharmacy, Royal Brisbane and Women's Hospital, and member of the Australian Prescriber Editorial Executive Committee