Andrew GilbertQuality Use of Medicines and Pharmacy Research Centre

Sansom InstituteUniversity of South Australia

Effectiveness of collaborative medicine reviews in reducing

hospitalisations for heart failure patients in the ambulatory

setting: Results of a cohort study.

Disclosure• The research to prepare this paper was conducted under a Contract

Research Grant between the University of South Australia and the Australian Government’s Department of Veterans’ Affairs (DVA) to deliver the Veterans’ Medicines Advice and Therapeutics Education Services (Veterans’ MATES). DVA provides the Veterans’ MATES project team at the University of South Australia with identified PBS/RPBS and Medicare data on all Australia veterans and war widows/widowers. The Veterans’ MATES project team undertook all study design, data analysis and interpretation and writing of this paper.

• Elizabeth Roughead, John Barratt, Emmae Ramsay, Nicole Pratt, Phil Ryan and Andrew Gilbert all declare that they no have competing interest.

• Robert Peck and Graeme Killer are employees of the Department of Veterans’ Affairs, the funder of the research.

Introduction• The Department of Veterans' Affairs (DVA),

operates a national program: Veterans’ MATES. • We use DVA’s database, covering 300,000

veterans, to provide – patient-specific-prescriber-feedback,– therapeutic updates and – Medicines and health care information for veterans

to assist veterans and their health practitioners improve health outcomes.

• Over 12000 veterans are being treated for heart failure.

Background• Medicines play a significant role in the

management of heart failure1. • 44% of patients with heart failure will be re-

hospitalised within six months of discharge1.• Home Medicines Reviews are effective in

preventing and resolving medication-related problems2.

• Some systematic reviews indicate limited effects of pharmacist-led medicines reviews on patient outcomes, such as reduction in hospitalisations3.1. National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand. Guidelines on the contemporary management of the patient with chronic heart

failure in Australia. Sydney: Cardiac Society of Australia and New Zealand, 2002.2. Gilbert AL, Roughead EE, Beilby J, Mott K, Barratt JD. Collaborative medication management services: improving patient care. Med J Aust 2002;177(4):189-92.3. Holland R, Desborough J, Goodyer L, Hall S, Wright D, Loke YK. Does pharmacist-led medication review help to reduce hospital admissions and deaths in older people? A systematic review and meta-analysis. Br J Clin Pharmacol 2008;65(3):303-16.

.

• Randomised controlled trials however demonstrate that the effectiveness of medicines reviews in influencing health outcomes appears to depend on the type of review and disease characteristics3,4

• Australia has funded a collaborative Home Medicines Review services since 2001.

• We aimed to determine if the results from randomised controlled trials for the heart failure population translated into practice as it is currently funded in Australia.

3. Koshman SL, Charrois TL, Simpson SH, McAlister FA, Tsuyuki RT. Pharmacist care of patients with heart failure: a systematic review of randomized trials. Arch Intern Med 2008;168(7):687-94.

4. Holland R, Brooksby I, Lenaghan E, Ashton K, Hay L, Smith R, et al. Effectiveness of visits from community pharmacists for patients with heart failure: HeartMed randomised controlled trial. BMJ 2007;334(7603):1098.

ObjectiveTo determine the impact of general medical practitioner & pharmacist collaborative Home Medicines Review (HMR)5 on time to hospitalisation for heart failure in the population with heart failure

5. Medicare Australia. Home Medicines Review. Canberra: Australian Government, 2009.

Method• Design: Retrospective cohort study using administrative claims data.

Cox proportional hazards models were used to compare time to next hospitalisation for heart failure between the HMR exposed and unexposed groups.

• Setting: The ambulatory veteran and war widow population, Australia

• Time period 1 Jan 2004 until 1 July 2006

• Participants: Veterans >65 years receiving beta-blockers subsidised for heart failure

• Exposure: General medical practitioner and pharmacist collaborative HMR

Method; continued• Exposed group: Veterans who;

• had received a home medicines review, • had all health services fully subsidized by DVA,• had been dispensed a beta-blocker subsidized for heart

failure* in the six months prior to the home medicines review,

• were aged 65 years or over at the time of the review. • Unexposed group: Veterans who;

• had all health services fully subsidized by DVA, • had been dispensed a beta-blocker subsidized for heart

failure,• were aged 65 years and over, but• had not had a home medicines review.

• Exclusions: Veterans resident in aged-care facilities• Main outcome measure: Time to next hospitalisation

for heart failure

*bisoprolol, carvedilol or metoprolol succinate

Method; continued• Eligibility for the unexposed group was

determined each month. • These veterans were randomly allocated

to an index month to match the time of a HMR in the exposed group. (20 to 1)

• Subjects were followed up until time to first hospitalization for heart failure post the index month for the unexposed group or post the home medicines review in the exposed group.

Results

There were 273 veterans exposed to a home medicines review and 5444 unexposed patients.

Demographics of study participants

ExposedN=273

UnexposedN=5444

p-value

Male gender 70% male 74% male 0.11Age 81.6 years (SD 4.8) 81.6 years (SD 4.8) 0.87Number of co-morbidities 7.6 (SD 2.2) 6.7 (SD 2.4) <0.0001Number of prescriptions in year prior 95 (69-123) 76 (54-104) <0.0001Number of changes in medicines over 6 month period in year prior

3 (2-6) 3 (1-5) <0.0001

Number of prescribers 5 (3-6) 4 (3-6) 0.002Number of pharmacies 2 (1-3) 2 (1-3) 0.43Number of occupational therapy visits 0 (0-0) 0 (0-0) 0.16Number of speech therapy visits 0 (0-0) 0 (0-0) 0.4Previously targeted by Veterans’ MATES 7% 6% 0.47Socio-economic index of disadvantage Lowest disadvantage Med/low disadvantage Med/high disadvantage Highest disadvantage

31%25%24%20%

25%25%25%25%

0.01

Prior hospitalisations0 12>2

27%23%22%28%

34%23%17%25%

0.03

RegionRemoteOuter regionalInner regionalMajor city

0%12%29%59%

1%9%31%59%

0.86

Parameter

Para-meter

Estimate

Standard

ErrorChi-Square P value

Hazard

Ratio*

95% Hazard Ratio Confidence Limits

Unadjusted: exposed to home medicines review

-0.47 0.18 7.0035 0.008 0.63 0.44 0.89

Adjusted: exposed to home medicines review

-0.61 0.18 11.96 0.0005 0.54 0.38 0.77

Cox proportional hazards model results for time to hospitalisation for heart failure

*adjusted for age, gender, co-morbidity, socioeconomic index of disadvantage, season, and region of residence as well as the number of prescriptions, prescribers, pharmacies, changes in medications, hospitalizations, occupational therapy visits and speech therapy visits.

Results

• Unadjusted results: HMR group; 37% reduction in likelihood of hospitalisation for heart failure at any time (HR 0.63; 95%CI 0.44-0.89).

• Adjusted results: HMR group; 46% reduction in the likelihood of hospitalisation for heart failure at any time (HR, 0.54 95% CI, 0.38-0.77).

Did home medicines review have an impact?

Increased time to next hospitalisation for HF patients who

received an HMR• The effect is clinically significant• For the 5th percentile of the

population, this delay in time to hospitalisation equated to over 200 days (~7 months).

• 5.5% of the exposed group compared to 12% of the unexposed group were hospitalised for HF within 365 days.

Study limitations• Only 5% of veterans with heart failure have received a

HMR, despite all veterans in this treatment population being eligible for the service.

• The focus of this study on veterans. However veterans• are treated in the same way as non-veteran patients in

both the primary and tertiary care sectors. • receive the same health services, and they are delivered

by the same practitioners, as those visited by non-veterans.

• have slightly more general practice visits (rate ratio 1.17; p < 0.05) and hospitalisations (rate ratio 1.21; p < 0.05) per year than other Australians aged 40 years and over.

• Receive similar numbers of prescription per general practitioner visit as the Australian population; however, because of the higher rate of GP visits, veterans receive slightly more prescriptions annually than other Australians (rate ratio 1.13; p < 0.05).

Conclusion• Outcomes from randomised controlled trials of the effectiveness of collaborative

medication reviews in the heart failure population can be translated into practice.• The effect is clinically significant with a delay in time to hospitalisation of over 200 days for

some patients. • The results are consistent with findings that medication-related problems are contributors

to admissions for heart failure. • With hospitalisations in Australia for heart failure estimated to cost $140 million per

annum these delays to next hospitalisation will contribute to significant cost savings to the health system.

Authors and affiliations• Authors:

• Andrew L Gilbert, PhD1, Elizabeth E Roughead, PhD1, John D Barratt, B. Pharm. Grad Dip C1, Emmae Ramsey, B. App Sc; Grad Dip2, Nicole Pratt, BSc (hons)2, Phillip Ryan, MBBS2, Robert Peck, B. Pharm3 and Graeme Killer, MBBS3.

• Affiliations 1.Sansom Institute, University of South Australia, Adelaide,

South Australia, Australia, 5000;

2.Data Management & Analysis Centre, Adelaide University, Adelaide, South Australia, Australia, 5000 and

3.Department of Veterans' Affairs, Australian Government, Canberra, Australian Capital Territory, Australia, 2600.