Repatriation Pharmaceutical Benefits Scheme Research Articles

Lessons from the Netherlands for Australia: cross-country comparison of trends in antidepressant dispensing 2013-2021 and contextual factors influencing prescribing.

There is concern internationally about increasing antidepressant use. Most antidepressants are prescribed in general practice. The aim of this study was to compare trends in antidepressant dispensing in Australia and the Netherlands over the 9years from 2013 to 2021, and to explore reasons for differences. A convergent mixed methods study including analysis of publicly available antidepressant dispensing data obtained from Australia's Pharmaceutical Benefits Scheme and Repatriation Pharmaceutical Benefits Scheme and the Dutch Foundation for Pharmaceutical Statistics and a search of relevant literature to compare contextual factors influencing prescribing were undertaken. In 2013, antidepressant dispensing rates in Australia were nearly twice as high as those in the Netherlands (82.5 versus 44.3DDD/1000/day) and increased to be more than twice as high by 2021 (115.6 versus 48.8DDD/1000/day). Antidepressant dispensing increased by 40% in Australia over the nine study years, but by only 10% in the Netherlands. Our scan of the literature confirms that while population factors, health system structure, and clinical guideline recommendations are largely consistent across the two countries, a multifaceted approach in the Netherlands involving improved access to non-pharmacological alternatives, initiatives targeting safer antidepressant prescribing, and tight regulation of pharmaceutical industry influence on prescribers, has successfully curtailed increasing antidepressant use. Australia may learn from the Netherlands' approach to redress increasing antidepressant use.

Reduction in Herpes Zoster Antiviral Use Since the Introduction of the Live-Attenuated Zoster Vaccine on Australia's National Immunisation Program: A Population-Based Study from 1994 to 2019.

Zostavax, the live-attenuated vaccine used to prevent herpes zoster (HZ), has been available to individuals aged 70 and 71-79years (phased catch-up) via Australia's National Immunisation Program (NIP) since 2016. There are limited data characterising the incidence of HZ at the level of the Australian population. National prescription data for antivirals used to treat HZ may be used as a proxy for HZ incidence. We aimed to examine trends in antiviral prescriptions supplied for the treatment of HZ in Australia pre- and post-2016, and to assess whether Zostavax's inclusion on the NIP correlated with a reduction in HZ antiviral prescription rates. Using the Australian Pharmaceutical Benefits Scheme and Repatriation Pharmaceutical Benefits Scheme prescribing data, we analysed antiviral prescriptions supplied for the treatment of HZ Australia-wide between 1994 and 2019. Annual prescription rates were calculated, and trends and changes in HZ antiviral use were explored descriptively and using Poisson models. HZ antiviral prescription rates increased 2.6-fold (160%) between 1995 and 2015 [25.4 (95% CI 25.2, 25.6) and 65.3 (95% CI 64.9, 65.6) prescriptions per 10,000 people, respectively], and then decreased 0.45-fold (55%) between 2016 and 2018 [60.9 (95% CI 60.6, 61.2) and 27.5 (95% CI 27.3, 27.9) prescriptions per 10,000 people, respectively]. The prescription rate for the antiviral famciclovir restricted specifically for treating HZ in immunocompromised individuals increased 8.5-fold (750%) between 2006 (year first listed) and 2019 [0.3 (95% CI 0.3, 0.3) and 2.5 (95% CI 2.4, 2.6) prescriptions per 10,000 people, respectively]. The introduction of the live-attenuated HZ vaccine on Australia's formal national vaccination program was associated with a reduction in HZ antiviral prescription rates within the Australian population. The data suggest that the introduction of Shingrix, the non-live subunit zoster vaccine, may also be associated with a similar reduction in HZ antiviral prescriptions used to treat the immunocompromised, as well as the general population, given its accepted greater efficacy over Zostavax.

Consent to Data Linkage in LSAC

IntroductionLinking the existing longitudinal data assets with administrative datasets provide the opportunity to transform longitudinal data into valuable assets to inform research and policy development.
 Objectives and ApproachThis paper will focus on Growing Up in Australia: The Longitudinal Study of Australian Children (LSAC) data linkage landscape and consents which are invaluable for the development of evidence-based health-social-economic policies.
 ResultsLSAC is Australia’s first nationally-representative longitudinal study of child development. Since 2004, two cohorts of 5,000 children and their parents have been interviewed every two years (B (baby) cohort and K (kindergarten) cohort). Over the years, multiple data linkage has been undertaken based on either parental consent or study child consent.
 In 2004 parents were asked to consent on behalf of the study child to link Medicare Benefits Schedule (MBS), Pharmaceutical Benefits Scheme (PBS)/Repatriation Pharmaceutical Benefits Scheme (RPBS) and Australian Childhood Immunisation Register (ACIR) administrative data to LSAC. The consent rate was 93% was for MBS, PBS and ACIR. Nearly 90% of B cohort parents provided consent to link Australian Early Development Census (AEDC)/National
 Assessment Program – Literacy and Numeracy (NAPLAN) and 95.4% of K cohort parents provided consent to link NAPLAN.Then ten years later, children in the K cohort were asked to consent to MBS/PBS and income-support administrative data. The rates were 86.6% for MBS, 85.4% for PBS and 81.2% for income-support administrative data. Parental consent to link their MBS, PBS and income-support administrative data was also sought and these rates varied between 60% to 88%.
 Conclusion/ImplicationsThe discussion will focus on differences in consent rates by time of consent, consenting individual and type of administrative data to be linked. Challenges and considerations that researches should be aware of when designing the linkage consent methodology will also be discussed.

Patterns of opioid use in older people diagnosed with cancer in New South Wales, Australia.

Opioids provide effective analgesia for most cancer patients, but little is known about individual-level opioid use after cancer diagnosis. We examined the patterns of and factors associated with opioid use in older people diagnosed with cancer. We used the Department of Veterans' Affairs (DVA) client data linked with the New South Wales (NSW) Cancer Registry and the Repatriation Pharmaceutical Benefits Scheme data. We included people aged ≥65 years diagnosed with cancer in NSW, Australia in 2005 to 2015. We examined patterns of opioid use in the 12 months after cancer diagnosis and used cause-specific hazards models to examine factors associated with opioid use. Of 13 527 people diagnosed with cancer, 51% were dispensed opioids after their diagnosis. We observed the highest proportions of use in people diagnosed with pancreas, liver, or lung cancers. Opioid use was associated with female sex, younger age, more advanced degree of cancer spread, opioid use before cancer diagnosis, and multimorbidity. Forty-four percentages of all people dispensed opioids had a history of opioid use in the 12 months before their cancer diagnosis; these people had higher median number of different opioids and opioid dispensings, and a shorter time to first opioid dispensing than opioid-naive people. Our study suggests that many older cancer patients were dispensed opioids before their cancer diagnosis. Previously opioid-treated people had more intense opioid use patterns after diagnosis than opioid-naïve people. Acknowledging the history of opioid use is important as it may complicate pain treatment in clinical practice.

Use of analgesics following rescheduling of codeine in Australia: An interrupted time series analysis in the veteran population

BackgroundThe Australian medicines regulator, the Therapeutic Goods Administration (TGA), rescheduled all codeine-containing medicines to be available only on prescription on 1 February 2018. This study was conducted to determine whether use of analgesics changed following codeine re-scheduling to prescription only status, and whether there was a change in the use of codeine preparations and a therapeutic shift to stronger opioids or other analgesics in the Australian veteran population following the change. MethodsInterrupted time series analysis using Repatriation Pharmaceutical Benefits Scheme (RPBS) claims data from the Australian Government Department of Veterans’ Affairs (DVA) for clients with dispensing of opioid and non-opioid analgesics between January 2015 and April 2019. Trends in the monthly rate of analgesic dispensings (opioid and non-opioid) were compared for the period between January 2015 and January 2018 with the period February 2018 to April 2019. ResultsParacetamol with codeine 8mg was the only analgesic with an increased rate of dispensing following the February 2018 codeine scheduling changes. Prior to codeine re-scheduling, the rate of dispensing of paracetamol with codeine 8mg was decreasing by 0.9% each month. Immediately after the scheduling changes, dispensing of paracetamol with codeine 8mg increased by 45% (95%CI=1.282-1.676, p<0.001) and in the fifteen month period thereafter (February 2018 to April 2019), the rate of dispensing increased by 4% each month (95%CI=1.027-1.054, p<0.001). Therapeutic shift from over-the-counter codeine products to other opioids was not observed, with no increase in the rate of dispensing of any of the other opioid (or non-opioid) analgesics following the codeine scheduling changes. ConclusionA significant increase in prescription use of paracetamol with codeine 8mg was observed after the February 2018 codeine re-scheduling. Therapeutic shift to stronger opioid analgesics was not observed in the study population.

Identifying incident cancer cases in dispensing claims: A validation study using Australia's Repatriation Pharmaceutical Benefits Scheme (PBS) data.

IntroductionDispensing claims are used commonly as proxy measures in pharmacoepidemiological studies; however, their validity is often untested.ObjectivesTo assess the performance of a proxy for identifying cancer cases based on the dispensing of anticancer medicines and estimate the misclassification of cancer status and potential for bias researchers may encounter when using this proxy.MethodsWe conducted our validation study using Department of Veterans’ Affairs (DVA) client data linked with the New South Wales (NSW) Cancer Registry and Repatriation Pharmaceutical Benefits Scheme data. We included DVA clients aged ≥65 years residing in NSW between July 2004 and December 2012. We matched clients with a cancer diagnosis to clients without a diagnosis based on demographic characteristics and available observation time. We used dispensing claims for anticancer medicines dispensed between July 2004 and December 2013 as a proxy to identify clients with cancer and calculated sensitivity, specificity, positive predictive values and negative predictive values compared with cancer registrations (gold standard), overall and by cancer site. We illustrated misclassification by the proxy in a cohort of people initiating opioid therapy. Using the proxy, we excluded people with cancer from the cohort, in an attempt to delineate people potentially using opioids for cancer rather than chronic non-cancer pain.ResultsWe identified 15,679 new cancer diagnoses in 14,112 DVA clients from the cancer registry and 62,663 clients without a diagnosis. Sensitivity of the proxy based on dispensing claims was 30% for all cancers and around 20% for specific cancers (range: 10-67%). Specificity was above 90% for all cancers. The dispensing proxy correctly identified 26% of people with a cancer diagnosis who initiated opioid therapy and failed to identify 74% those with a cancer diagnosis; the proxy was most robust for clients with breast cancer where 61% were correctly identified by proxy. ConclusionsUsing dispensing of anticancer medicines to identify people with a cancer diagnosis performed poorly. Excluding patients with evidence of anticancer medicine use from cohort studies may result removal of a disproportionate number of women with breast cancer. Researchers excluding or otherwise using anticancer medicine dispensing to identify people with cancer in pharmacoepidemiological studies should acknowledge the potential biases introduced to their findings.Keywordscancer, diagnosis, proxy, dispensing records, validation study

Financial costs associated with monopolies on biologic medicines in Australia.

Objectives The aim of the study was to estimate the potential savings to the Pharmaceutical Benefits Scheme (PBS) and the Repatriation Pharmaceutical Benefits Scheme (RPBS) in 2015-16 if biosimilar versions of selected biologic medicines (biologics) had been available and listed on the PBS. Methods The research involved retrospective analysis of Australian Medicare expenditure data and PBS price data from 2015-16 for biologics, for which biosimilar competition may be available in future, listed on the PBS. Results Australian Government expenditure on biologics on the PBS and RPBS was estimated at A$2.29 billion dollars in 2015-16. If biosimilar versions of these medicines had been listed on the PBS in 2015-16, at least A$367million dollars would have been saved in PBS and RPBS subsidies. Modelling based on price decreases following listing of biosimilars on the PBS suggests that annual PBS outlays on biologics could be reduced by as much as 24% through the timely introduction of biosimilars. Conclusions Biologic medicines represent a large proportion of government expenditure on pharmaceuticals. Reducing the length of monopoly protections on these medicines could generate savings of hundreds of millions of dollars per year. What is known about the topic? Biologics take up an increasing share of pharmaceutical expenditure, but no previous published studies have examined Australian Government expenditure on biologics or the potential savings from reducing the duration of monopoly protection. What does this paper add? This paper provides new evidence about Australian Government expenditure on biologics and potential savings for selected medicines that are still subject to monopoly protection and thus are not yet subject to biosimilar competition. In 2015-16 Australian Government expenditure on biologics through the PBS and RPBS was estimated at A$2.29 billion dollars. If biosimilar versions of these medicines had been listed on the PBS at that time, at least A$367million dollars would have been saved. What are the implications for practitioners? Reducing the duration of monopoly protection on biologic medicines could save hundreds of millions of dollars annually that could be redirected to other areas of the healthcare system.

We have had a gutful: The need for deprescribing proton pump inhibitors.

Proton pump inhibitor (PPI) prescribing may often be inappropriate and expose patients to a risk of adverse effects, while incurring unnecessary healthcare expenditure. Our objective was to determine PPI usage in Australia since 2002 and review international studies investigating inappropriate PPI prescribing, including those that discussed interventions to address this issue. Australian Pharmaceutical Benefits Scheme (PBS) and Repatriation Pharmaceutical Benefits Scheme (RPBS) data were analysed. A narrative literature review relevant to the objective was conducted. Time series analysis was also used to examine the trend of reported PPI appropriate use across the international studies included in this review. Proton pump inhibitor use in Australia increased between 2002 and 2010 and then gradually decreased. Estimates of the extent of inappropriate use in the international literature had a wide variation (11-84%). There appeared to be little change in the extent of appropriate PPI use reported through 34 international studies from 2000 to 2016. Interventions to address inappropriate use included patient-centred deprescribing, academic detailing, educational programmes and drug safety notifications. Proton pump inhibitors continue to be overused worldwide and should be a focus for deprescribing programmes. Ongoing education and awareness campaigns for health professionals and patients, including electronic reminders at the point of prescribing, are strategies that have potential to reduce PPI use in individuals who do not have an evidence-based clinical indication for their long-term use.

Major depression and depressive symptoms in Australian Gulf War veterans 20 years after the Gulf War

BackgroundRisk of major depression (depression) was elevated in Australia's Gulf War veterans in a 2000–2002 (baseline) study. A follow up study has measured the Gulf War-related risk factors for depression, also the current prevalence and severity of depression, use of anti-depressant medication, and persistence, remittance or incidence of depression since baseline in Gulf War veterans and a military comparison group. MethodsParticipants completed the Composite International Diagnostic Interview v.2.1, the 9-item Patient Health Questionnaire and the Military Service Experience Questionnaire, and consented to Repatriation Pharmaceutical Benefits Scheme (RPBS) and PBS linkage. ResultsPrevalence of depression (9.7% Gulf War veterans and 7.7% comparison group; adj RR=1.2, 95% CI 0.8–1.7), and pattern of persistence, remittance and incidence of depression since baseline, were similar in the two groups, however veterans reported slightly more severe symptoms (adj median difference 1, 95% CI 0.26–1.74) and were more likely to have been dispensed anti-depressant medication (adj RR=1.56, 95% CI 1.05–2.32). Depression amongst veterans was associated with self-reported Gulf War-related stressors in a dose-response relationship (adj RR 1.06, 95% CI 1.02–1.09). LimitationsLower participation rates at follow up resulted in reduced statistical power compared with baseline, Gulf War related stressor data collected at baseline was at risk of recall bias, and RPBS and PBS databases do not capture all dispensed Nervous System medications. ConclusionsMore than 20 years after the Gulf War, veterans are experiencing slightly more severe depressive symptoms than a military comparison group, and depression continues to be associated with Gulf War-related stressors.

Beyond the paper trail: using technology to reduce escalating harms from opioid prescribing in Australia

The paper highlights the extent of pharmaceutical drug misuse problems in Australia and explores how pharmaceutical opioid misuse could be reduced by implementation of a technological tool: a prescription co-ordination program (PCP). The paper explores how enhancements to existing computer-assisted clinical decision support systems through real-time, on-line information to prescribers, pharmacists and regulators could address drug-seeking and improve the quality use of medicines. Trends in national and international prescription opioid use and related harms are examined with attention directed to drug-seeking behaviour and intentional misuse. The international literature concerning PCPs is reviewed and implications for technological advances in Australia are outlined. Australia has a burgeoning problem associated with the misuse of pharmaceutical opioids. There is increased recognition of a range of iatrogenic harms. A number of factors limit Australia's response capacity including lack of technological capacity to provide on-line, real-time information for prescribers and pharmacists. Providing prescribers, pharmacists and regulators with on-line, real-time information about patients' prescription opioid use will improve the quality use of medicines. A national system is required to co-ordinate data on Pharmaceutical Benefits Scheme, Repatriation Pharmaceutical Benefits Scheme and unsubsidised medicines, including private prescriptions. Pharmaceutical opioids are not the only medicines subject to misuse and therefore the need to capture data on other relevant medicines is also addressed.

Prevalence of potentially hazardous drug interactions amongst Australian veterans

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT * Up to 21% of adverse drug event related hospital admissions are due to drug interactions. Clinical significance of drug interactions varies. * Studies which only identified drug interactions of potentially major clinical significance found lower prevalence, of between 2 and 16%. * Prevalence of drug interactions defined 'potentially hazardous' has had limited study, with no publications identified for the Australian population. WHAT THIS STUDY ADDS * In the study population of 287 074, 1.5% of subjects were dispensed potentially hazardous interacting drug pairs. * However, limited to populations on specific medicines, it was found that for patients dispensed verapamil, methotrexate, amiodarone, lithium, warfarin, cyclosporin and itraconazole, potentially hazardous interactions occurred at a rate greater than 5%. * These patients should be the focus of medication review programmes to avoid potentially serious adverse drug events. BACKGROUND Up to 21% of adverse drug event-related hospital admissions are due to drug interactions. Clinical significance of drug interactions varies, and drug interactions defined 'potentially hazardous' are more likely to contribute to morbidity and mortality. AIM The aim of this study was to assess the prevalence of potentially hazardous drug interactions in an elderly Australian veteran population. METHODS This study assessed the prevalence of potentially hazardous drug interactions, where hazardous was defined in three or more international drug interaction references, using Repatriation Pharmaceutical Benefits Scheme pharmacy claims data. Analysis was limited to patients who received regular concurrent dispensings of potentially hazardous interacting medicines. RESULTS Of the 287 074 subjects included in the study, 1.5% were dispensed potentially hazardous interacting drug pairs. For patients dispensed cyclosporin, concomitant use of a statin was common (47%); as was statin use with those dispensed itraconazole (31%). Of those dispensed methotrexate, 24% also received a non-steroidal anti-inflammatory drug; of those on lithium, 18% also received an ACE inhibitor or angiotensin 2 receptor blocker; of those on warfarin, 7.2% and 5.9% were co-dispensed an non-steroidal anti-inflammatory drugs or antiplatelets respectively; for those on verapamil, 5.3% were co-dispensed a beta-blocker, while for those on amiodarone 6.2% were co-dispensed digoxin. CONCLUSIONS Overall prevalence of potentially serious drug interactions appears to be low in the Australian veteran population. However, patients taking cyclosporine, itraconazole, methotrexate, lithium, warfarin, verapamil and amiodarone appear to be most at risk and their medicine use should be regularly reviewed to prevent potentially hazardous drug interactions.

Pharmaceutical brand substitution in Australia: Identifying factors associated with having multiple brand substitutions

Abstract Objective The aim was to determine the frequency with which people have multiple brand changes for more than one medicine and to identify factors associated with having multiple brand substitutions. Method The setting was the Repatriation Pharmaceutical Benefits Scheme, a national subsidised scheme for medicines supply in Australia. We used a retrospective cohort design using prescription claims data for subsidised medicine dispensings from 1 June 2005 to 31 August 2006. Analysis was limited to patients with the opportunity for brand substitution of two or more medicines. ‘Switches’ were identified for each medicine if different brand or generic products were supplied at consecutive dispensings. Multivariate analysis was conducted to identify factors associated with patients who had multiple switches during follow-up. Key findings A total of 84 040 people were included. On average, they received 11 prescription medicines. Forty-nine per cent of people received the same product throughout follow-up for each medicine and 34% had a single brand substitution. Seventeen per cent had multiple switches for one or more medicine; however, only 3% of all patients had multiple switches for more than one medicine. Independent factors associated with having multiple switches were increasing number of hospital admissions, prescription medicines, co-morbidities, prescribers, dispensing pharmacies and living in an aged-care facility or city. Conclusions Most patients do not have multiple brand substitutions of their medicine, even when all medicine use is considered. This is the first study to identify factors associated with having multiple brand substitutions. Quality use of medicines interventions targeting individuals with these risk factors could minimise the potential for patient confusion as a result of multiple brand changes.

Why is the use of clopidogrel increasing rapidly in Australia? An exploration of geographical location, age, sex and cardiac stenting rates as possible influences on clopidogrel use

To explore clopidogrel use within Australia, investigating geography, age, sex and cardiac stenting rates. Data for clopidogrel supply (Pharmaceutical Benefits Scheme (PBS) and Repatriation Pharmaceutical Benefits Scheme (RPBS)) and cardiac stenting procedures (State Health Departments) were obtained for four different geographic regions (very remote/remote and major city in two Australian states). General linear modelling and correlation analyses were used to test for associations and chi2 analyses for proportions. Clopidogrel supply increased rapidly in Australia since introduction, from 1.2 to 9.0 Defined Daily Doses (DDD)/1000 population/day. Among concessional and veteran populations use was much higher. Analysis of geographical area data confirmed an association between clopidogrel supply rates and cardiac stenting rates (r = 0.8-0.9 Spearman's rho, p < 0.01). Sex, age and geographical location were associated with both rates when considered together and when considered independently. Further modelling indicated that between 30 and 73% of clopidogrel supply could be accounted for by people receiving cardiac stents. The supply of clopidogrel increases with age, male sex and living in a major city. These same demographic variables were important for cardiac stenting, an indication which is currently not approved for subsidy by the Australian government, but which modelling indicated could account for between one-third and three quarters of clopidogrel use. A review may be required to ensure subsidised indications reflect current evidence and cost-effective use.

Brand substitution or multiple switches per patient? An analysis of pharmaceutical brand substitution in Australia

To determine the number of times patients have brand and generic products substituted under Australia's Pharmaceutical Benefits Scheme (PBS) brand substitution policy. A retrospective cohort study was conducted using Repatriation Pharmaceutical Benefits Scheme (RPBS) pharmacy claims data. Department of Veterans' Affairs (DVA) treatment card holders with at least two dispensings of atenolol, citalopram, enalapril, metformin, omeprazole or ramipril between 1 January 2001 and 28 February 2006 were included. Patients were followed from first dispensing until death, cessation or study end. The main outcome measure was the number of substitutions per patient during follow-up. Based on this, patients were defined as non-switchers, brand substitution or multiple switchers. Data for 160,145 patients were analysed. Overall more than 80% of patients either had no switches or demonstrated brand substitution. For all study drugs, patients were more likely to be non-switchers than have a brand substitution (RR range 2.6-9.4, p < 0.0001) and were more likely to be non-switchers than multiple switchers (RR range 3.2-35.9, p < 0.0001). Patients who switched were more likely to have a brand substitution than multiple switches (RR range 1.2-3.8, p < 0.0001). Multivariate logistic regression showed greater odds of being a multiple switcher with increasing number of prescribers and dispensing pharmacies, and increasing length of follow-up. Most patients in this study did not substitute products, and those who did were more likely to demonstrate brand substitution than have multiple switches. These results suggest that the brand substitution policy is having its intended effect for most patients.

Do Pharmacists Adhere to Brand Substitution Guidelines? The Example of Simvastatin

ABSTRACTBackgroundAlthough pharmacists have been criticised for not following brand substitution guidelines, evidence is lacking. Brand substitution of simvastatin has been possible since November 2004 when the first generic became available; prior to this 2 non‐substitutable products were available.AimTo identify the rate of switching between brand and generic products of simvastatin.MethodAnalyses were conducted using Repatriation Pharmaceutical Benefits Scheme prescription claims data from 1 November 2002 to 28 February 2006. Switches were identified if different brand or generic products were dispensed consecutively. The change in the rate of switching post‐generics was compared to the pre‐generics baseline.ResultsFollowing introduction of generics the switching rate increased to 78.2 switches per 1000 dispensings. Switching was 22 times more likely post‐generics compared to pre‐generics (rate ratio 21.91 (20.01, 24.00), p &lt; 0.001). The rate of switching did not change when 10 products were available for substitution compared to when there were only 4 (RR 1.02 (0.998, 1.041); p = 0.0664). Post‐generics, 64% of switches occurred when different prescriptions were dispensed consecutively.ConclusionSwitching between simvastatin products was low prior to generic availability, even though 2 products were available. The switching rate increased when bioequivalent products were available, suggesting that pharmacists practice in accordance with brand substitution legislation. Consumers were most vulnerable to switching when different prescriptions were dispensed consecutively. Pharmacists should be aware of this and take steps to ensure that switches do not occur unnecessarily.

Potentially inappropriate prescribing among Australian veterans and war widows/widowers

This study examined the extent of potentially inappropriate medicine, as defined by explicit criteria, dispensed to Australian veterans using the Repatriation Pharmaceutical Benefits Scheme Pharmacy Claims database. Twenty-one per cent of the 192,363 veterans aged 70 years, with an eligible gold card, were dispensed at least one potentially inappropriate medicine in the first 6 months of 2005. Long-acting benzodiazepines, amitriptyline, amiodarone, oxybutynin and doxepin were the medicines most commonly implicated. Strategies to support quality prescribing of medicines to the elderly must include a focus on these medicines.

Improving medication safety: influence of a patient‐specific prescriber feedback program on rate of medication reviews performed by Australian general medical practitioners

To determine if patient-specific prescriber feedback for general medical practitioners (GPs), supported by educational material mailed to their patients, would increase home medicines review (HMR) rates. An observational study was conducted using the Repatriation Pharmaceutical Benefits Scheme (RPBS) Pharmacy Claims Database. The intervention group (n = 40 270) included all veterans aged >/=65 years, dispensed >/=5 unique medicines each month over a 4 month period. Comparison group veterans (n = 49,227) were those who did not have >/=5 or more unique medicines dispensed each month, but did have at least one prescription each month and >/=20 prescriptions over 4 months, of which five were unique medicines, Intervention GPs (n = 11,384) were subdivided into 2 groups: GPs with intervention veterans (n = 2097) and GPs with both intervention and comparison group veterans (n = 9287). The comparison group of GPs (n = 3630) were primary prescribers to the comparison veterans only. Rates of HMRs pre and post-intervention and the number of new GPs participating in HMR services were examined. There was a significant increase in HMR rates in intervention group, from 2.2 per 1000 in the pre-period to 4.6 per 1000 per month in the post-intervention period (Rate Ratio (RR) 2.06, 95% Confidence Interval (CI) (1.90, 2.22), p < 0.0001). HMR rates increased in the intervention group compared with the comparison group (p < 0.0001). HMR rates increased in the intervention group GPs compared with the comparison group (RR 1.79, 95% CI (1.58, 2.02), p < 0.0001). Patient-specific feedback provided to GPs, supported by educational material mailed directly to their patients increased HMR rates for targeted veterans and increased GP participation in the delivery of HMRs.

The funding and use of high-cost medicines in Australia: the example of anti-rheumatic biological medicines

BackgroundSubsidised access to high-cost medicines in Australia is restricted under national programs (the Pharmaceutical Benefits Scheme, PBS, and the Repatriation Pharmaceutical Benefits Scheme, RPBS) with a view to achieving cost-effective use. The aim of this study was to examine the use and associated government cost of biological agents for treating rheumatoid arthritis over the first two years of subsidy, and to compare these data to the predicted outcomes.MethodsNational prescription and expenditure data for the biologicals, etanercept, infliximab, adalimumab, and anakinra were collected and analysed for the period August 2003 to July 2005. Dispensing data on biologicals sorted by the metropolitan, rural and remote zones and by prescriber major specialty were also examined.ResultsA total of 27,970 prescriptions for biologicals was reimbursed. The government expenditure was A$53.1 million, representing only 19% of that expected. Almost all prescriptions were reimbursed by the PBS (98%, A$52 million) and the remainder by the RPBS. Approximately 62% of the prescriptions were for concessional patients (A$32.9 million). There was considerable variability in the use of biologicals across Australian states and territories, usage roughly correlating with the per capita adjusted number of rheumatologists. The total number of prescriptions continued to increase over the study period. Etanercept was the most highly prescribed agent (74% by number of prescriptions), although its use was beginning to plateau. Use of adalimumab increased steadily. Use of infliximab and anakinra was considerably lower. The resultant health outcomes for individual patients are unknown. Prescribers from capital cities and other metropolitan centres provided a majority of prescriptions of biologicals (89%).ConclusionThe overall uptake of biologicals for treating rheumatoid arthritis over the first two years of PBS subsidy was considerably lower than expected. Long-term safety concerns and the expanded clinical uses of these drugs emphasise the need for evaluation. It is essential that there is comprehensive, ongoing analysis of utilisation data, associated expenditure and, importantly, patient outcomes in order to enhance accountability, efficiency and equity of policies that allocate substantial resources to subsidising national access to high-cost medicines.

Matching prescription claims with medication data for nursing home residents:: Implications for prescriber feedback, drug utilisation studies and selection of prescription claims database

Medication data retrieved from Australian Repatriation Pharmaceutical Benefits Scheme (RPBS) claims for 44 veterans residing in nursing homes and Pharmaceutical Benefits Scheme (PBS) claims for 898 nursing home residents were compared with medication data from nursing home records to determine the optimal time interval for retrieving claims data and its validity. Optimal matching was achieved using 12 weeks of RPBS claims data, with 60% of medications in the RPBS claims located in nursing home administration records, and 78% of medications administered to nursing home residents identified in RPBS claims. In comparison, 48% of medications administered to nursing home residents could be found in 12 weeks of PBS data, and 56% of medications present in PBS claims could be matched with nursing home administration records. RPBS claims data was superior to PBS, due to the larger number of scheduled items available to veterans and the veteran's file number, which acts as a unique identifier. These findings should be taken into account when using prescription claims data for medication histories, prescriber feedback, drug utilisation, intervention or epidemiological studies.

High Risk Prescribing in the Veteran Population

Concerns about the frequency and consequences of adverse drug reactions have prompted the Department of Veterans' Affairs to establish a ‘quality use of medicines’ program. This involves several approaches, including patient and pharmacist education and prescriber pharmaceutical feedback. The traditional approach, regulatory change, is also used to influence prescribing. The process of prescribing feedback involves the identification of high risk prescribing situations, such as the prescribing of drug combinations known to interact significantly. Analysis of prescribing information for veterans indicates the extent to which these ‘high risk’ situations occur. Increased regulation for the prescribing of certain of the benzodiazepines on the Repatriation Pharmaceutical Benefits Scheme was introduced in April 1993. Analysis of drug utilisation, using the Department of Veterans' Affairs pharmaceutical database reveals, not surprisingly, that this has had a dramatic effect on the prescribing of the newly restricted drugs. The prescribing of all benzodiazepines including restricted and unrestricted drugs however, has dropped by a net of 11% when comparing twelve month periods before and after the introduction of restrictions. Equally importantly, the prescribing of tricyclic antidepressants (TCA) has not significantly changed implying that prescribers are not routinely changing from benzodiazepines to TCAs.