How safe is the patient safety net?

In the ‘Blogging on Demand’ series you get to choose the topic. If you have a great idea you want the world to know about, feel free to contact me. Perth GP Dr Jacquie Garton-Smith proposes a change to the PBS safety net to protect vulnerable patients.

“One thing that my patients with chronic disease on lower incomes find difficult,” says Dr Garton-Smith, “is that they have to pay for all their medications until they hit the safety net. Even if people are only paying the lower rate for scripts, it adds up if they are on a number of medications. I have seen it affect compliance at the beginning of the year when they have to decide which medications they need most.”

The general patient safety net threshold is currently $1,453.90, and the concessional threshold $366. When someone or their family’s total co-payments reach this amount, they only have to pay the concessional co-payment amount of $6.10 until the end of the calendar year. Concessional card holders get standard PBS scripts for free after they reach the threshold.

The PBS co-payment and safety net amounts, effective from 1 January 2015:

General patient co-payment: $37.70

Concessional co-payment: $6.10

General safety net threshold: $1,453.90

Concessional safety net threshold: $366.00.

A safer solution

Garton-Smith: “Loading the costs into a few months of the year and then being free the rest of the year for concessional card holders is concerning. My patients tell me the safety net is supposed to help them but doesn’t – until it kicks in. For someone who has diabetes, hypertension, hypercholesterolaemia, arthritis, reflux, depression and sometimes osteoporosis, asthma or COPD, you can see the impact. This is not an unusual scenario.”

“It would be so much easier if the cost could be spread out over the year for people likely to hit the safety net. It would also prevent people attempting to stock-pile at the end of the year. I realise most people don’t get more than 5 scripts a month but those who need to are often managing serious health problems.”

Medication adherence 

Research has shown that when co-payments for medications increase, more people stop their treatment. This includes essential preventive medications, and as a result more visits to the doctor and hospital may be required.

Associate professor Michael Ortiz said in Australian Prescriber: “Some have argued that greater cost sharing does not undermine overall patient health because patients facing rising costs will reduce their consumption of perceived non-essential medications more than their consumption of essential drugs. However, ‘preventive’ drugs are different, because not all patients understand the long-term benefits of taking medicines for conditions such as hypertension and hypercholesterolaemia.”

“Some of my patients need to delay filling scripts they see as less essential

Garton-Smith: “A patient I have seen needs to buy more than ten medications every month at a cost of $85. Sometimes there are extra costs, for example if he needs antibiotics. On a single disability pension he gets $840.20 per fortnight, so approximately 5% of his income is spent on scripts until he reaches the safety net threshold, generally by May. Even though he gets a lot of prescriptions filled just before the end of December, he usually needs to delay filling scripts that he sees as less essential at the start of the year.”

Professor Michael Ortiz in Australian Prescriber: “The current approach to PBS savings is that the Government takes most of the cost savings, but increases co-payments and safety net thresholds each year in line with inflation. Increasing co-payments reduces medication adherence and ultimately may compromise the care of some patients.”

Thanks to Dr Jacquie Garton-Smith for the topic suggestion.

Why doctors run late: 12 red tape challenges

In the ‘Blogging on Demand’ series you get to choose the topic. If you have a great idea you want the world to know about, feel free to contact me. Last week members of the GPs Down Under (GPDU) Facebook group posted their red tape bugbears. Melbourne GP Dr Karen Price, who is an admin of the group, suggested to blog about the issues that slow doctors down.

Patients are often understandably frustrated about waiting times. A couple of years ago I blogged about the reasons why I run late, including the daily healthcare bureaucracy doctors have to deal with. I’m sad to say the amount of red tape hasn’t changed.

Australia is not making good use of its medical workforce. Example: An estimated 25,000 patient consultations are lost every month while doctors are making phone calls to the PBS authority script phone line.

Instead of reducing the amount of paperwork for doctors – so they can see their patients quicker – other professionals are asked to take over parts of the clinical job.

There are of course other reasons why doctors run late, but the focus of this post is on healthcare bureaucracy. So here is a summary of the GPDU Facebook discussion on the abundant red tape that slows doctors down, summarised in 12 points.

#1: Sick notes

Medical certificates for all sorts of issues seem to be increasingly popular, and every day thousands of doctors issue tens of thousands of notes.

This is not only a significant cost to Medicare, it also increases waiting times. Doctors have no problem issuing a genuine sick certificate as part of a consultation, but often people come in when they are getting better, just to get a certificate at the request of their employer.

Sometimes medical certificates seem to be used to shift liability when doctors are asked to declare that someone is fit for certain (recreational) activities. And, do we really always need a medical certificate when our children cannot attend daycare or school?

#2: Provider numbers

Medicare provider numbers are a bugbear for doctors and registrars, and have been for years.

One GP said: “Repeated applications for provider numbers through Medicare with the same information are such a waste of time. Surely they have my name, address, e-mail and multiple provider numbers already. An online portal with a ‘click’ application or submission of paperwork for would be amazing.”

Another GP: “For practices employing a new rural doctor there are at least 14 different forms across Commonwealth and State/Territory jurisdictions – some forms online, some scannable, some mailed, yes, with a stamp, some faxed. Software that would streamline at least some of those forms – even going to different destinations but auto-filled – would encourage practices to take more registrars and more prevocational doctors.”

#3: PBS authority phone line

Another major bugbear: Australian doctors have to ring this phone line before they can prescribe common medications. They must ring every time a script runs out, even if the patient has been taking the medicines for many years. The line is often busy and doctors and their patients are kept waiting. A short consultation can easily become a more expensive long consultation as a result of the waiting time.

Removing some medications from this scheme to a streamlined electronic procedure has not changed prescribing habits, which seems to indicate that the phone line doesn’t really serve a purpose. Also, some countries without a script line have lower antibiotic resistance patterns than Australia.

The approval process is bizarre. Doctors are asked the daily dose for an adrenaline emergency auto injector or have to spell the name of the drug as call centre operators have no clue.

Why doctors run late

A GP said: “After 5 minutes of waiting I’ve run out of small talk with the patient. By 6 minutes I’m almost considering to talk my patient out of starting Champix. And by nearly seven minutes waiting my usually cheerful manner with the call centre operator is gone.”

Another GP: “Sitting on the phone waiting for authority – why do I need permission from a bureaucrat to prescribe something?”

#4: Medicare and Centrelink

Medicare and Centrelink take up a lot of valuable time. The MBS criteria for example have been a constant source of confusion and stress for doctors. The endless paperwork is a challenge for doctors and practice managers.

One GP said: “Centrelink manages to outsource a tremendous amount of form filling in. Surely it contributes to green house gasses…”

Another GP: “Medicare forms… Some you can scan and e-mail back, some must be posted, others can be faxed but not emailed.”

#5: Handwriting charts, notes and scripts

Nearly all GP practices are computerised. Still we get requests from organisations to handwrite important documents.

Residential aged care facilities and community nursing teams often require handwritten medication orders, and don’t accept a printed chart generated by GP desktop software.

Some nursing homes and most hospitals ask that doctors, including visiting GPs, handwrite their notes. This also includes shared antenatal care. One GP said: “While I agree that the handheld obstetric records are exceptionally important, doubling up and having to write in them plus your computerised notes is inefficient – or print out your notes and have multiple loose prices of paper floating around each time.”

“I have some intellectually disabled adult patients in a group home and the script situation is tedious,” a doctor said. “Every panadol, every small change to prescribing, has to be documented and faxed to the chemist, and every consultation requires a form to be filled out and the consultation notes to be printed.”

The law requires doctors to handwrite opiate scripts underneath the printed text – and on both copies of the script – to reduce the risk of forgery. This has become obsolete for many practices as an electronic copy of the script can be sent to the pharmacy to avoid fraud. Other innovative developments such as real-time prescription monitoring will further make handwriting scripts unnecessary.

#6: Working with kids, working with elderly, working with vulnerable elderly checks

These new requirements for AHPRA registered doctors seem unnecessary. “I have to get not one single police check, but three checks,” said a GP. “‘Working with kids’, ‘Working with elderly’ and ‘Working with vulnerable adults’ checks before can work in country hospital, all at my expense. I work in an already highly regulated industry, I am trusted with scalpels and mind-altering drugs, and have an annual AHPRA registration renewal, but must do all this foolishness every few years.”

#7: Proof of AHPRA-registration

Doctors often have to provide a copy of their AHPRA registration, but registration details including the expiry date can be easily looked up by anyone on the APHRA website

#8: Travel cost assistance 

A GP said: “Filling out Patient Assisted Travel Scheme forms for rural patients is getting more tedious: We now have to write a letter stating exactly why our patients need an escort. Ticking the box isn’t enough.”

#9: Pharmacies

Pharmacies can add value in many ways, but when it comes to collaboration there is room for improvement.

One GP said that a pharmacy happily managed her patient’s blood thinners, but when the INR results were outside the normal range they referred back to the GP. “Apparently this service is more ‘convenient’ as well as lucrative for the pharmacist. Until the INR level is more than 2.5…Then, late Friday afternoon, the pharmacy demands I manage the warfarin dose. So then it’s suddenly my problem. They get paid lots of money for a service I do for free.”

A common bugbear of GPs is the ‘owing scripts to pharmacy’ problem. Some pharmacies provide ongoing medications even if the script has run out. As a result patients miss their check-ups with the doctor and request an ‘owing’ script from their GP at a later stage.

In defence of the pharmacy: doctors are not always on time with sending scripts to the pharmacy.

#10: Accreditation

One GP expressed concerns about the never-ending accreditation requirements: “Not the principle, but the realities. Broadly speaking: Individual clinicians need to be accredited multiple times, not just by AHPRA, but by government (working with children checks etc), local hospitals, regional training providers (to be supervisors) etc.”

“Practices need multiple accreditations – separate ones to be training practices for example – and all very painful. Regional training organisations need to go through hoop jumping accreditation processes by the colleges, the colleges by the Australian Medical Council. Never-ending and so much time wasted.”

#11: Care plans, EPCs and mental health care plans

The rules designed by Medicare to manage chronic care in general practice have been the topic of heated debates. For example: Patients with a chronic illness cannot claim their Medicare rebate when the GP does a care plan and treats an acute problem on the same day. This means that many patients have to come back on another day, further increasing waiting times.

“Care plans and mental health plans interrupt my patient contact and workflow,” one GP said. “If a GP was rewarded more this templated rubbish would be done anyway as part of usual care by the good doctors.”

Another doctor said: “Did you know that people used to actually pay to see allied health professionals prior to GP care plans? Now it seems all allied health contact is required to be limited to five free visits per year.”

#12: Hospital bureaucracy

Making an appointment for a patient can be challenging sometimes. One GP said: “The hospital ‘outpatients direct’ won’t let me help organise an appointment for a patient without them being with me at the time, because of confidentiality. But I wrote the referral and need to know the date of the appointment to arrange transport or they won’t get there.”

Many hospitals have referral criteria and they’re not aways flexible: “Queensland public hospitals have extensive referral criteria. They don’t accept GP referrals that don’t tick their boxes – often checked by non-medical staff.”

Hospitals can really slow GPs down with extra paperwork requirements: “The orthopaedic outpatient department doesn’t accept a GP referral until we have provided them with a completed 3-page ‘hip & knee questionnaire’.”

Sometimes hospital doctors send a patient back to the GP for a referral to another hospital doctor. Many GPs feel that in some (especially urgent) cases an internal referral with a copy to the GP would be much more efficient.

Rural GPs often work in hospitals and emergency wards. Transferring sick patients to a bigger hospital is a challenge in some states: “Western Australia has a long way to go: I first have to call the RFDS, then the hospital and speak to the accepting team – if lucky one call, if unlucky several calls. Then I need to call the ED to inform them about the expected patient. I have to call the RFDS for an update. Then the registrar calls back after speaking to their boss. Then the hospital bed manager calls and lets me know there are no beds available, so I need to go to another tertiary hospital etc. I hardly have time to look after the patient and talk to their next of kin.”

One GP said about requesting investigations: “To organise a CT-scan at the hospital from a rural ED, I have to make phone calls to the radiologist, the CT tech, the ED consultant, the specialty registrar (if applicable), and the bed manager. If one of those phone calls is missed… hoo boy, you’d think that I’d killed Santa Claus.”

We need ongoing conversations with each other, managers and decision makers to avoid unnecessary red tape and improve the patient journey across various parts of the health system.

Thanks to Dr Karen Price for the topic suggestion.

Looking after asylum seekers – who is crossing the line?

In the ‘Blogging on Demand’ series you get to choose the topic. If you have a great idea you want the world to know about, send an email, contact me via social media or leave a comment below. Dr Kellie West suggested the topic of this post. She tweeted: “Love to see you tackle the social justice responsibility of doctors [and], health care worker’s responsibility to refugees and asylum seekers.”

I arrived in Australia by plane. My introduction in Australian medicine took place in an empty emergency department and lasted for one hour. The compulsory 4WD course took about eight hours. Afterwards I was flown to a remote hospital, and the next day I found myself on the ward treating patients.

Some people refer to me as an IMG (international medical graduate), others call me an OTD (overseas trained doctor), but according to the government I’m a skilled migrant.

Skilled migrants

I’m grateful to have been given the opportunity to live and work in Australia. I feel welcome here and I see Australia as an example of a tolerant, multicultural immigration country. In the past ten years I have treated thousands of people, mostly in rural areas where many Australian doctors don’t go.

Australia shares in the benefits of global trade, including skilled migration. Annually about 130,000 skilled migrants enter the country. Australia has not paid for my expensive education, which is fair enough. The skilled migrant program is designed to address specific skill shortages and enhance the skill level of the Australian labour force.

Asylum seekers, on the other hand, are a different kettle of fish.

Who’s afraid of boat people?

In nearly forty years, about 70,000 asylum seekers have arrived by boat; an average of 1,750 per year. Compare this to the 130,000 skilled migrants arriving every year, and I can’t help but wonder how a political party can win an election over such a relative minor issue.

It appears strangers in boats change something in the usually tolerant ozzies. Journalist Christos Tsiolkas writes:

We’ll lock up asylum seekers in offshore detention centres, we’ll stand idly by as they slowly go crazy or harm themselves, we’ll refuse journalists the right to speak to them or to name them, we’ll redefine our borders to not let them in, we’ll farm them off to our impoverished, under-developed neighbours rather than construct a humane and efficient system to process their claims for asylum.

Tsiolkas feels that Australians are not convinced about the benefits of globalisation.

Yet, healthcare in rural areas is predominantly delivered by overseas trained doctors like me. Yet, a quarter of the Australian population has been born overseas. Yet, the Australian economy depends on international trade, and millions of Australians travel to Asia, Africa, and other destinations for leisure and business purposes.

Many people have preconceived ideas about asylum seekers. The risk is that prejudice leads to acceptance of a questionable approach to asylum seekers.

Asylum seekers
Image: The annual number of new skilled migrants in Australia is about 130,000. In nearly 40 years, about 70,000 asylum seekers have arrived by boat; an average of 1,750 per year. Note: 40 percent of asylum seekers arrive by boat. Sources: Refugee Council of Australia and Department of Immigration and Border Protection.

Common myths 

Are they economic migrants instead of refugees? Depending on the source you read, between 70-92 percent of arrivals is ‘genuine’, meaning they are not coming for economic reasons but because they are being persecuted.

Are boat people queue jumping? The queue refers to resettlement: The assisted movement of refugees who are unable to return home to safe third countries. Unfortunately these queues do not exist (it’s more like a lottery) and resettlement is only available for the ‘lucky’ one percent of the world’s refugees.

Somehow we have forgotten that seeking asylum is a correct and legal procedure; asylum seekers are not ‘illegal’ and cannot not be penalised for arriving without travel documents.

Australia’s responsibilities

Australia is one of 147 signatory countries to the UN Refugees Convention, which means we are obliged to protect refugees. But is Australia taking its responsibilities? Paul Power, CEO of the refugee council of Australia says:

“The view from Indonesia is of a very wealthy, largely unpopulated country pushing unwanted people back to a much poorer, overpopulated neighbour.

The question is: How sustainable is Australia’s solution? The boats have stopped, but global humanitarian crises haven’t. Power: “I can’t see the international pressures which result in refugee movements and desperation migration decreasing in years to come.”

Australia has been heavily criticised by the UN and other countries for its treatment of asylum seekers and refugees. Power recommends a major review of Australia’s treatment of asylum seekers. We must make sure, he says, that they have the following:

  1. Access to refugee status determination, with access to information, interpretation, funded legal advice and review
  2. Freedom from detention, using existing detention alternatives in all but the most exceptional of circumstances and develop detention alternatives in Nauru and PNG
  3. Giving all asylum seekers the right to work – even if work is hard to find, not robbing them of the hope associated with looking for work
  4. Ensuring all asylum seekers have access to basic services, including adequate shelter, physical and mental health care and education
  5. Access to durable solutions – providing prompt decisions and outcomes and living conditions which are sustainable for recognised refugees
  6. The option to explore alternative entry options for people at risk.

First-rate healthcare

The deaths of asylum-seekers Reza Berati and Hamid Kehazaei were preventable according to many. The Australian Medical Association feels strongly that asylum seekers and refugees should have access to proper healthcare. The AMA’s 2013 pre-election position statement:

  • The AMA wants humanity restored to an otherwise inhumane approach to asylum seekers
  • The next Government must establish a truly independent medical panel to oversee, and report regularly on, the health services that are available to asylum seekers in immigration detention facilities, both onshore and offshore
  • The Panel would inspect the available health services, and detainee access to them, and report quarterly to the Parliament, the Prime Minister, and relevant Ministers.

As far as I can see, these recommendations have not been implemented.

In fact, a recently leaked draft consultant report obtained by the ABC revealed that the government feels that medical staff contracted to take care of asylum seekers were advocating too strongly for refugees.

Don’t cross the line

The AMA’s code of conduct dictates that doctors should refrain from denying treatment to patients because of a judgement based on discrimination.

It also stipulates that, regardless of society’s attitudes, doctors do not support ‘cruel, inhumane, or degrading procedures, whatever the offence of which the victim of such procedures is suspected, accused or convicted.’ This is in line with the Declaration of Geneva and doctors have to uphold this – no matter what the government says or does.

Immediate past president of the AMA Dr Steve Hambleton once said at the National Press Club:

“Let’s stay out of where they are from and why they’re here and all the other stuff. Once we are in control or once we take responsibility for people, we should be providing them with first-rate health care.

Thanks to Dr Kellie West for the topic suggestion.

Chaos alert: GP training in tatters?

Chaos alert: GP training in tatters?

In the ‘Blogging on Demand’ series you get to choose the topic. If you have a great idea you want the world to know about, send an email, contact me via social media or leave a comment below. Karin Calford suggested the topic of this post. She sent an email asking: “With the imminent defunding of GPET*, what happens to GP registrar teaching from this point on? Wondering if you would be willing to blog about this.”

I am so pleased that people ask these questions. Karen wrote that, as a patient, she is concerned about the delivery of effective, patient-centred care in the future. As an example she mentioned the importance of teaching communication skills: “How will this sort of valuable non-clinical registrar training occur in the future?”

The responsibility for the training has been in the hands of GPET since 2001. The organisation was launched as a result of government concerns about the training program from the Royal Australian College of General Practitioners (RACGP). GPET was to give a range of groups a voice in the national GP training program. At the time it made an end to the RACGP’s monopoly as training provider.

From 1 January 2015 GPET is no longer. The Department of Health takes over its responsibilities to achieve administrative efficiencies. Australian Doctor magazine reported: “The Abbott government predicts it will save $115.4 million over four years by a package of cuts that includes abolishing GPET, slashing regional training providers and scrapping the Prevocational General Practice Placements Scheme.”

The current situation can be summarised in one word: Chaos.

The power vacuum

Former chair of GPET Professor Simon Willcock predicted a while back that the axing of the organisation would create a ‘power vacuum at the heart of GP training’. The responsibility for the training program now lies with the Department of Health, but the question remains how well things have been thought through.

It appears GP registrars wanted to get rid of GPET. Shortly after the election of the current government they made suggestions to replace GPET in a ‘draft’ sent to a government policy advisor. Australian Doctor magazine obtained a leaked copy, which “(…) warned of escalating costs facing the government in dealing with the expanding number of options for GP training.”

GP supervisors are now concerned that big corporates will take over the training program, because they “(…) operate with an efficiency that concentrates on urban training to maximise patient throughput, rather than the development of quality general  practitioners.”

What the AMA, RACGP and ACRRM say

AMA president Professor Owler said:

“Abolishing GPET takes away professional control and leadership of GP training. And we believe that the Department of Health does not have the necessary experience to run GP training. The Budget reforms will dismantle the existing GP training infrastructure that has taken many years to put in place.

In the meantime the two GP colleges, RACGP and their rural counterpart ACRRM, have proposed a new framework for the training program. The AMA was not happy about the fact that the colleges kept their plans behind closed doors, but supports a college-led training program as this would be consistent with other medical specialist training programs.

The soap continues: The two colleges were to meet federal health minister Peter Dutton last week, but the get-together was cancelled at the last minute. This promted RACGP president Dr Frank Jones to express his disappointment:

“(The colleges) are extremely disappointed that a meeting scheduled to discuss general practice training with the Federal Minister for Health, The Hon. Peter Dutton MP, was cancelled yesterday. On behalf of the RACGP, I have stressed the critical and urgent need for reassurance regarding the future governance of a general practice training program and will endeavour to reschedule this meeting before Christmas.

It is unknown if Peter had to cancel because of the flu. If that’s the case I hope he has an empathetic doctor – and he’d better ask for a sick note too.

Here’s to hoping that regardless of the government’s administrative ‘efficiencies’, the quality of the Australian GP training will remain world-class.

Thanks to Karin Calford for the topic suggestion.

Social determinants of health: Why I am all tip and no iceberg

Why I am all tip and no iceberg

In the ‘Blogging on Demand’ series you get to choose the topic. If you have a great idea you want the world to know about, send an email, contact me via social media or leave a comment below. Melissa Sweet suggested the topic of this post: ‘Social determinants of health’. She tweeted: “Interested in your take on SDOH & how they play out locally.” Thankfully, to make the task easier, Melissa suggested some background reading: 436 articles from the Croakey archives.

Note: ‘Social determinants of health’ are economic and social conditions that influence the health of people and communities.

 

“Doc, that’s not going to work.” The health worker was standing behind me. She had overheard my consultation with the elderly man. I thought I was doing a great job, as I had taken the time to explain what diabetes was all about – in layman’s terms – and how he should inject the insulin.

The indigenous health worker continued: “He lives mostly outside and keeps his medications under a tree.” I couldn’t believe what she had just said. When the penny dropped I realised she was, of course, right: the insulin wouldn’t last in the excessive heat of the Kimberley.

It was clear that I had no idea of my patients’ living circumstances. I felt like a fool.

The home visit

Another time, another place. I was doing a home visit in a Cape York indigenous community as part of a team consisting of two nurses, a social worker, a health worker, a police officer and a local government representative.

The verandah was covered with rubbish and furniture. It was hot inside. The room was empty, apart from a few mattresses. The concrete floor and walls were dirty. “How many people live here?” I asked. “Between 8-20, depending on when you visit,” said the social worker.

The patient was lying on a mattress – she clearly only had a short time to live. There was not much I could do apart from some small medication changes. Afterwards, we had a long chat on the verandah about fixing the air-conditioning and the tap, and making her last days as comfortable as possible.

All tip and no iceberg

The contribution of doctors and other health care professionals to our wellbeing is relatively small: Depending on what source you read, healthcare contributes for about 25 percent to our health. On the other hand, an estimated 50 percent of our health is determined by economic and social conditions (see image).

One of Australia’s leading researchers on the economic and social determinants of health is Professor of Public Health Fran Baum. “Typically,” she writes in this editorial, “responses to diseases and health problems are knee jerk and concerned with ameliorating immediate and visible concerns.”

Professor Baum calls this the ‘all tip and no iceberg’ approach. Instead of focussing on disease and unhealthy behaviours we should improve the conditions of everyday life.

To combat the chronic disease and obesity epidemic for example, we should not just be advising lifestyle changes and initiating medical treatment. These are tip-of-the-iceberg solutions.

Instead, says Baum, let’s look below the surface at things like urban planning, the availability of unhealthy food, our sedentary lifestyles at home and at work, and equal opportunities for all.

Social determinants of health
Image: About 50% of our health is determined by economic and social conditions (green). Source: Adapted from a presentation by Professor Fran Baum

General practice

In my work the influence of economic and social factors is apparent. Some examples:

  • The 26-year old single mother who cannot afford medications for her children
  • The 38-year old machine operator who gained 10 kg of weight since he started a fly-in-fly-out job in a remote mining community
  • The 50-year old chief executive who makes 14-hour days in a high-pressure environment, and develops anxiety symptoms.

My role as a GP in these scenarios is modest. Ok, ‘all tip and no iceberg’ may be too harsh – apart from the fact that it sounds like ‘all icing and no cake’…

But Professor Baum has an important message: We must not close our eyes to what really makes us ill and, more importantly, change it.

Thanks to Melissa Sweet for the topic suggestion.

Follow me on Twitter: @EdwinKruys

Sources:

Doctor, do I have to stay on these medications?

This is the first article in the ‘Blogging on Demand’ series. If you have a topic you want me to blog about, feel free to send an email, contact me via social media or leave a comment below. Jen Morris picked the topic of this post. She tweeted me saying: “I’d love a GP view on polypharmacy, deprescribing & importance of reviewing and stopping treatment, not just continuing indefinitely.”

I really like this topic. I’ll explain why. It’s fair to say I have a love-hate relationship with medications. They can do a lot of good, but also cause misery. Prescribing drugs is a bit like cooking, and getting the balance of the different ingredients right an art: Use too little and your dinner guests are unimpressed, use too much and it becomes unpalatable.

There are many guidelines in medicine informing us when to use which ingredients, but unlike cooking books, they never tell when a dish should be taken out of the oven, or, in other words, when to stop treatment. This is odd, especially as patients often rightly ask: “Doctor, do I have to stay on these medications for the rest of my life?”

Here is a summary of the why, when and how to stop long-term medications – based on the limited amount of evidence available. For more information I refer to the sources mentioned below.

#1: Why stop medications?

Research shows that elderly people often feel better after their medication is discontinued. One study found that only 2% of the medications had to be restarted because the original symptoms reoccurred. This suggests that many people take medications unnecessarily.

It is estimated that up to 30% of hospital admissions for elderly patients are related to the medications they take. Reviewing the medication list periodically is therefore important, for example after the annual home medication review by the pharmacist.

#2: When to consider stopping

There may be good reasons why, after review, it is better to continue long-term medications. But there are 5 circumstances when stopping should be considered:

  1. A patient is taking multiple (more than 4) drugs
  2. An adverse drug reaction is suspected
  3. The drug doesn’t work (anymore)
  4. A patient experiences falls or cognitive decline
  5. The condition of the patient improves or worsens dramatically.

 #3: How to stop

Deprescribing can be done safely, but is not without risks. Withdrawal symptoms, rebound syndromes and reappearance of the original symptoms may occur. Medication withdrawal should be undertaken in consultation with a doctor.

The literature suggests different methods, but I particularly like the following simple 5-step approach:

  1. Prepare: Always consider the option of deprescribing at the start of a therapy, in case it is required later on.
  2. Recognise the need to stop: are any of the above mentioned 5 circumstances applicable?
  3. Prioritise one drug at a time to stop.
  4. Wean, especially benzodiazepines, opioids, beta blockers, corticosteroids, and levodopa.
  5. Monitor: Look out for withdrawal symptoms, discontinuation and rebound syndromes, reoccurrence of illness, falls, and changes in cognition and quality of life.

Research into deprescribing has mainly been done in elderly people taking multiple drugs. I believe it is not unreasonable to apply the same principles to younger people, even if they are on a smaller amount of long-term medications.

I always find it extremely satisfying if we manage to cut the number or dose of someone’s medications – and most patients seem to be equally pleased. Less is sometimes more.

Thanks to Jen Morris for the topic suggestion.