Atlas 2018 - 5. Repeat analyses

This page lists the Atlas key findings and recommendations for antimicrobial medicines, inappropriate use of antipsychotic medicines, attention deficit hyperactivity disorder medicines (17 years and under), and opioid medicines.

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Antimicrobial medicines

The Atlas found that, between 2013–14 and 2016–17,

  • The rate of antimicrobial prescriptions dispensed per 100,000 people nationally decreased by 9%
  • The magnitude of variation in dispensing rates increased from 4.6-fold to 4.8-fold.

The reduction in dispensing rates has had little effect on the overall volume of antimicrobials supplied on any given day in the Australian community during the four-year period. Volume is as measured by defined daily doses per 1,000 people per day.

The Atlas found that, between 2013–14 and 2016–17

  • Dispensing rates for amoxicillin fell
  • Rates of amoxicillin–clavulanate dispensing did not fall in line with this.

There has also been little change in the volume of either of these antimicrobials supplied on any given day in the Australian community, suggesting that there has been little change in the overall amount of use during the four years. Further efforts to improve use of these antibiotics and antimicrobial use more generally are needed.

Inappropriate use of antipsychotic medicines

Concerns have been raised about prescribing of antipsychotic medicines outside guideline recommendations – such as for behavioural disturbances related to dementia or delirium – before secondary causes have been excluded and non‑pharmacological measures have been tried.

The Atlas found that, between 2013–14 and 2016–17

  • There was no decline in the use of antipsychotic medicines in people aged 17 years and under or in people aged 18–64 years, nationally
  • The rate of antipsychotic medicines dispensed per 100,000 people in both these age groups increased by 8–9% during the four-year period.
  • The magnitude of variation in dispensing  decreased, but was still considerable.
  • For people aged 65 years and over, prescription rates of antipsychotic medicines decreased during the four years; however, the volume of antipsychotic medicines supplied on any given day in the Australian community remained stable, indicating that there has been little change in the overall amount of use during the four years.

The current use of antipsychotic medicines outside current guideline recommendations as a form of restrictive practice to manage behavioural and psychological symptoms of dementia (BPSD) in aged care homes is a matter of grave concern. Efforts to reduce inappropriate use of antipsychotic medicines in Australia have included guidelines, safety warnings education and policy. The Commission proposes a series of regulatory responses.

Attention deficit hyperactivity disorder medicines, 17 years and under

The Atlas found that, between 2013–14 and 2016–17, the rate of ADHD medicines dispensed per 100,000 people aged 17 years and under increased by 30%, nationally.

Further investigation is required to determine whether this is due to increased incidence and diagnosis of ADHD, or increased prescribing outside guideline recommendations. Prescription rates based on practitioner type will be helpful to identify whether targeted strategies are needed. Ongoing vigilance is required to promote appropriate prescribing of these medicines.

Opioid medicines

Opioid medicines are indicated for acute pain and cancer pain, and are highly addictive. The Atlas found that, between 2013–14 and 2016–17, the rate of opioid medicines dispensing per 100,000 people increased by 5% nationally. The magnitude of variation in dispensing rates also increased, from 4.8-fold to 5.1‑fold. It is unclear whether these changes are due to more people requiring opioids for appropriate uses or an increase in inappropriate prescribing. Despite the number of regulatory efforts already in place to minimise harm from these medicines, continued focus on improving medicine use in this area is needed.

Recommendations

A detailed publication showing variation at a local level will be available in 2019 for the repeat analyses, with recommendations to improve appropriateness of care. However, because of the work that has already been undertaken about use of antipsychotic medicines in people aged 65 years and over, and ongoing concerns that these medicines are being prescribed inappropriately, recommendations on this topic are included here.

5a. Prescribers to use antipsychotic medicines for people 65 years and over as a form of restrictive practice only as a last resort, and not until alternative strategies have been considered. The following conditions must be met:

  • i. Informed consent (or from the patient or a properly authorised substitute decision maker)
  • ii. A structured consent form to be mandated for use in aged care homes to help ensure that prescribers comply with clinical and legal requirements
  • iii. A pharmacist to conduct a medicines review after six months, with the outcomes of the review provided to the treating general practitioner and placed in the medication record
  • iv. Approval of pro re nata (PRN) orders to be no more than three times a month, and repeat PRN prescription to be limited so that renewal is only permitted after a further evaluation of the resident by the prescribing practitioner.
  • 5b. Aged care providers to record the use of antipsychotic medicines as a form of restrictive practice on all applicable patients in their aged care home and report on this to the Aged Care Quality and Safety Commission.
  • 5c. The Aged Care Quality and Safety Commission accreditation assessments to review the use of psychotropic agents in aged care homes.
  • 5d. The Aged Care Quality and Safety Commission to commence public reporting from July 2020 on rate of use of antipsychotic medicines, in line with recommendation 13 of the 2014 Senate Community Affairs References Committee on care and management of younger and older Australians living with dementia and BPSD.
  • 5e. The Aged Care Quality and Safety Commission to consider approaches to educating consumers about the risks of prescribing antipsychotic medicines outside guideline recommendations – such as for BPSD – before secondary causes have been excluded and non-pharmacological measures have been tried.
  • 5f. The Therapeutic Goods Administration (TGA) to review product information for all the antipsychotic medicines most commonly prescribed inappropriately for BPSD in older people, to ensure that the lack of evidence of efficacy and the harms associated with use for BPSD are expressed as clearly as possible, and the product information is optimally framed to discourage prescribing for unapproved use for BPSD.
  • 5g. The TGA to establish and/or review risk management plans for atypical antipsychotic medicines commonly prescribed for BPSD outside therapeutic guidelines. This will include requiring sponsors to more proactively provide or support education in appropriate treatment options for BPSD, emphasising the significant clinical risks and lack of efficacy in using antipsychotic medicines for this purpose.
  • 5h. The Pharmaceutical Benefits Advisory Committee to review the relevant PBS streamlined authority as it applies to the prescribing of atypical antipsychotic medicines to ensure sufficient information about the clinical justification for prescribing of these medicines. This should include the condition for which the medicine is being prescribed, and a record that consent or substitute consent has been provided. This information should be specified on the form which is provided to the dispensing pharmacist.

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