health care interventions: choosing

Health Care Interventions: Choosing Wisely U3A Short Course (7th of 8 sessions), April‐June 2015

Dr Ken Harvey

Health Care Interventions: Choosing Wisely

Dr Ken Harvey MB BS, FRCPA

Adjunct Associate Professor, School of Public Health and Preventive Medicine

http://www.medreach.com.au

Short Course (7th of 8 sessions), April‐June 2015, GAA House

Today’s topics:medicines

• Unnecessary antibiotics (minimising antibiotic resistance).

• Polypharmacy (multiple medication) and deprescribing.

• Antipsychotics in dementia.

• Home medicine reviews.

• Consumer medicine information.

• Shared electronic health record.2


Dr Ken Harvey

Antibiotic Resistance ConferenceUppsala, Sweden, 2010

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Antimicrobial Resistance Summit Sydney, Australia, 2011

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Increasing antibiotic resistance coupled with the failure of industry to develop new antibiotics is a

global public health problem and, like global warming, it requires local, national, regional and

international action


Dr Ken Harvey

World Health Organisation 2014‐15

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Draft global action plan on antimicrobial resistance

A post-antibiotic era – in which common infections and minor injuries can kill – far from being an apocalyptic fantasy, is instead a very

real possibility for the 21st Century.

The first antibiotic: Penicillin

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Dr Ken Harvey

History of resistance

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Bacterial evolution vs mankind’s ingenuity

• Adult humans contains 1014 cells; only 10% are human, the rest are bacteria.

• Antibiotic use promotes Darwinian selection of resistant bacterial species.

• Bacteria have efficient mechanisms of genetic transfer to spread resistance.

• Bacteria double every 20 minutes, humans every 30 years.

• Development of new antibiotics has slowed – resistant microorganisms are increasing. 8


Dr Ken Harvey

Antibiotic pipeline is drying up

• Why?

– Only used for short term treatment;

– New drugs restricted to treat resistant micro‐organisms.

• Hence:

– Limited profit before patent expires;

– Not a good return on investment for industry.

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Consequences of resistance

• Increased morbidity & mortality– “best‐guess” therapy may fail with the patient’s condition deteriorating before susceptibility results are available no antibiotics left to treat certain infections

• Greater health care costs– more investigations– more expensive, toxic antimicrobials required– expensive barrier nursing, isolation, procedures, etc.

• Therapy priced out of the reach of the poor

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Dr Ken Harvey

Therapy priced out of the reach of the poor

• A decade ago in New Delhi, India, typhoid could be cured by three inexpensive drugs. Now, these drugs are largely ineffective.

• The cost of treating one person with multi‐drug‐resistant TB is a hundred times greater than the cost of treating non‐resistant cases.

• New York City needed to spend nearly US$1 billion to control an outbreak of multi‐drug resistant TB; a cost beyond the reach of most of the world's cities.

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• Poverty encourages the development of resistance through under use of drugs– Patients unable to afford a full course of medicine

– Sub‐standard & counterfeit drugs lack potency

• In wealthy countries, resistance is emerging for the opposite reason – the overuse of drugs. – Unnecessary demands for drugs by patients are often eagerly met by

health services and stimulated by pharmaceutical promotion

– Culture is also important• Dutch antibiotic use is the lowest in Europe; French use is four times greater (the

highest in Europe); Belgian and Italian use were three times greater; and German use was 1∙5 times greater.

• Protestant countries tend to consume fewer antibiotics than predominantly Catholic countries, perhaps due to the Protestant predilection for austerity and simplicity whereas Catholicism is more about rituals.

Social and cultural factorsfuelling resistance

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Dr Ken Harvey

Overuse of antimicrobials in food production

• Currently, 50%‐80% of all antibiotic production is used in animal husbandry

and aquiculture.

• Antibiotics are used to promote growth and prevent the spread of disease in cramped conditions.

• This year, for the first time, U.S. farmers and ranchers will now need a prescription from a veterinarian before using antibiotics in farm animals.

• Just using the drugs for growth will be disallowed.

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Increased travel ensure resistant strains spread quickly

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Daily global aviation traffic (500 largest airports)

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Dr Ken Harvey

Modern medicine relies upon antibiotics

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Imagine a world without antibiotics

https://www.youtube.com/watch?v=GG4IoKiXHGw 16


Dr Ken Harvey

My own interest started at the RMH

Hospital acquired infection with antibiotic-resistant microorganisms

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The Royal Melbourne Hospital


Dr Ken Harvey

Educational campaigns

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Educational campaigns

Antibiotic use for pneumonia at RMH

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10

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Mar-83 Sep-83 Mar-84 Mar-85

Amox IV

Pen G IV

Educational advertising campaign:pads, pens and posters

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Dr Ken Harvey

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Quality Assurance Cycle

Continually updatedstandards of practice: treatment guidelines

Drug audit / utilisation review

Feedback results to health administrators and guideline authors

Practitioner reflection / targeted education

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Antibiotic Guidelines

• Best practice recommendations concerning the treatment of choice for common clinical problems.

• Written by teams of national experts.

• Evidence based where possible.

• Regularly updated.

• Endorsed by Medical Associations, Colleges, etc.

• Used for medical education, problem look‐up, drug audit and targeted educational campaigns.

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Dr Ken Harvey

Guidelines evolution…

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Scaling up nationally

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Dr Ken Harvey

Strategies

• Policy development and implementation

• National facilitation and co‐ordination (PHARM)

• Independent information

• Ethical behaviour

• Education and training (NPS)

• Campaigns (NPS)

• Evaluation

Quality Use of Medicines Policy

Independent information

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Dr Ken Harvey

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Ethical behaviour

U.S. Justice Department Fines

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Dr Ken Harvey

Unethical conduct

• Trials manipulated; negative results suppressed.

• Journal articles “ghost‐written”.

• Off‐label promotion.

• Well paid, but undeclared, medical opinion leaders used to promote company products (educational mercenaries).

• Excessive hospitality, kickbacks, bribery.

• Consumer groups manipulated.• Spurious patents and legal challenges to

delay the entry of generics.29 29

One book to read

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Dr Ken Harvey

It takes two to tango

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32http://www.youtube.com/watch?feature=player_embedded&v=EcG6B_9hTLU


Dr Ken Harvey

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The Pharma Phacts Pledge

I pledge to accept no money, gifts, or hospitality from the pharmaceutical industry; to seek unbiased sources of information and not rely on information disseminated by drug companies; and to avoid conflicts of interest in my medical education and practice.

http://www.healthyskepticism.org/pharmaphacts/


NPS: Academic detailing

Also: home medication review by pharmacists (Government-

Guild agreement)

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Dr Ken Harvey

NPS: Consumer Campaigns

http://www.nps.org.au/site.php?page=2&content=/resources/ccncs/index.htm

NPS: Consumer Campaigns

36https://www.youtube.com/watch?v=vTC0JUoglB8


Dr Ken Harvey

All 9 URTI antibiotics - 1996 - 2007 rate of prescribing O DOP

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10

20

30

40

50

60

70

80

90

Jul-9

6

Jan-

97

Jul-9

7

Jan-

98

Jul-9

8

Jan-

99

Jul-9

9

Jan-

00

Jul-0

0

Jan-

01

Jul-0

1

Jan-

02

Jul-0

2

Jan-

03

Jul-0

3

Jan-

04

Jul-0

4

Jan-

05

Jul-0

5

Jan-

06

Jul-0

6

Jan-

07

Rat

e p

er 1

,000

co

nsu

ltat

ion

s

Results: antibiotic scripts URTI 1996‐2007

In Hospitals:


Dr Ken Harvey

Action steps for today

• Prevention is better than cure:

– have influenza and pneumococcal vaccines yourself (free if over 65 years).

– make sure your grandchildren, family and friends receive the full schedule of vaccines (and boosters) provided free under the National Immunisation Program.

• Don’t expect antibiotics for the treatment of upper respiratory tract infections such as sore throats and sinusitis (most often viral and antibiotics don’t work) .– Even when bacteria are involved the benefits are much more limited than previously thought and counterbalanced by the risk of drug side effects, such as rash.

– Regular analgesia is more effective than antibiotics in decreasing symptoms for the above conditions.

Action steps for today

• Never share your antimicrobial drugs with others or use leftover prescriptions.

• Finally, break the chain of contagion:– Wash your hands after going to the toilet and before preparing food;

– Stay home when you are sick; – Set a good example!

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Dr Ken Harvey

All counties have the same problem

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All counties have the same problem

All can learn from each other!


Dr Ken Harvey

Polypharmacy and deprescribing

• A study of 1220 patients aged 70 years or older admitted to general medical units of 11 acute care hospitals in two Australian states between July 2005 and May 2010 showed:

– 75% were receiving 5 or more drugs;

– 24% were receiving more than 10 drugs;

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44https://www.youtube.com/watch?v=JNihp-m2Um0


Dr Ken Harvey


• Half of all Australians aged between 65–74 years and two‐thirds of those aged 75 and over report taking 5 or more medicines daily.

• While this level of medicines use may be indicated in older people, it is not without harms.

• The probability of clinically relevant and potentially serious drug–drug interactions is strongly associated with the number of medicines dispensed.

• Polypharmacy is associated with admissions to hospital, functional and cognitive impairment, geriatric syndromes (delirium, falls or frailty) and mortality.

• Other negative consequences include poorer health outcomes, declining nutritional status, and non‐adherence. 45


• Taking 4.5 medicines concurrently is associated with an increase in mortality and falls.

• Taking 5.5 to 6.5 concurrent medicines is associated with increased disability and frailty respectively.

• The risk of mortality, incident falls, disability and frailty increased for every medicine added

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Dr Ken Harvey


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Complex drug–drug interactions • The number of possible drug–drug interactions rises sharply when 5 or more medicines are taken concurrently.

• Thus small increases in the number of medicines taken make large differences to the number of potential drug–drug interactions


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• Consider deprescribing in those at highest risk.

• Discuss benefit–harm trade‐offs.

• Target drugs more likely to be non‐beneficial:– Drugs to avoid in elderly;

– Lacking therapeutic effect;

– Lacking a substantiated indication;

– Unlikely to prevent disease events within the patient’s remaining life span.

• Implement an agreed plan.


Dr Ken Harvey

Antipsychotics in dementia

• People with dementia often exhibit aggressive, violent or socially inappropriate behaviour that places themselves, other patients and their carers at risk of psychological and physical harm.

• Antipsychotics have a long history of being used to reduce the impact of such behaviour, but the evidence for their efficacy is modest and they are associated with serious side effects.

• Antipsychotics may also be used inappropriately to sedate patients as a means of behaviour control.

• Antipsychotics should only be used when non‐pharmacological interventions have failed, and then only for short periods with regular review.

49http://www.nps.org.au/publications/health-professional/health-news-evidence/2013/antipsychotic-dementia


• Antipsychotic medications include haloperidol (first generation), risperidone and olanzapine (second generation).

• All these drugs have an increased risk of mortality and cerebrovascular adverse effects in patients with dementia. The risk is highest in patients with risk factors such as atrial fibrillation, hypertension, diabetes or a history of stroke.

• Due to the possible harms associated with these drugs in people with dementia, informed consent is crucial.

• Most people with moderate‐to‐severe dementia are too impaired to give informed consent this will often be sought from the patient's designated guardian, medical power of attorney or next of kin. 50


Dr Ken Harvey


51https://www.youtube.com/watch?v=uka7mqqTVYk

Consumer medicine information

52https://vimeo.com/116909937


Dr Ken Harvey

Consumer medicine information

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• Find it at http://www.nps.org.au/medicines

• Ask your pharmacist or doctor to print it for you.

• Sometimes you can find it inside the packet or box

Home medication review

54https://www.youtube.com/watch?v=IB5i_bZUXB4


Dr Ken Harvey

eHealth.gov.au

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eHealth.gov.au

56https://www.youtube.com/watch?v=ODgjGfC4opE


Dr Ken Harvey

eHealth.gov.au

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eHealth.gov.au: Problems

• Disparate hospital and GP software creates problems in sharing referral / discharge information.

• While most GPs are now computerised their eRecords are often not up‐to‐date &/or inaccurate (old problems and out‐dated medications still listed, new problems may not be added).

• Personal control means important information may be missing, e.g. HIV‐AIDS status.

• Most specialists still not connected.

• National Broadband Network (NBN) is still a work in progress.

• Opt‐in system has limited the uptake, especially to those with chronic illness who could benefit most (less than 1 in 10 Australians have signed up)

• In response, an opt‐out system is to be trialled and eHealth.gov.au renamed to My Health Record (Budget 2015).

58http://www.abc.net.au/news/2015-05-10/government-to-fund-ehealth-for-all-australians/6457940


Dr Ken Harvey

Conclusions

• Don't take antibiotics unless they are really necessary; this will help preserve them for when they are really needed.

• Remember, the more medicines you take, the greater the risk of adverse effects.

• Ask if you still need all the drugs you are taking and know what they are for.

• If you are taking more than 5‐10 drugs consider asking for a home medication review.

• Use consumer medicine information.

• Sign up for an electronic health record.59

Next week: our last

• Keeping healthy (prevention)

60

health care interventions: choosing

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