Ten-Year Trends in Psychotropic Prescribing and Polypharmacy in Australian General Practice Patients with and without Dementia.

OBJECTIVE: Little research has evaluated trends in psychotropic prescribing and polypharmacy in primary care patients, especially those with dementia. We sought to examine this in Australia from 2011 to 2020 using the primary care dataset, MedicineInsight. METHODS: Ten consecutive serial cross-sectional analyses were performed to evaluate the proportion of patients aged 65 years or more, with a recorded diagnosis of dementia, who were prescribed psychotropic medications within the first six months of each year from 2011 to 2020. This proportion was compared with propensity score-matched control patients without dementia. RESULTS: Before matching, 24,701 patients (59.2% females) with, and 72,105 patients (59.2% females) without, a recorded diagnosis of dementia were included. In 2011, 42% (95% confidence interval [CI] 40.5-43.5%) of patients in the dementia group had at least one recorded prescription of a psychotropic medication, which declined to 34.2% (95% CI 33.3-35.1%; p for trend < 0.001) by 2020. However, it remained unchanged for matched controls (36% [95% CI 34.6-37.5%] in 2011 and 36.7% [95% CI 35.7-37.6%] in 2020). The greatest decline in the dementia groups by medication class was for antipsychotics (from 15.9% [95% CI 14.8-17.0%] to 8.8% [95% CI 8.2-9.4%]; p for trend < 0.001). During this period, the prevalence of psychotropic polypharmacy (use of two or more individual psychotropics) also decreased from 21.7% (95% CI 20.5-22.9%) to 18.1% (95% CI 17.4-18.9%) in the dementia groups, and slightly increased from 15.2% (95% CI 14.1-16.3%) to 16.6% (95% CI 15.9-17.3%) in the matched controls. CONCLUSIONS: The decline in psychotropic prescribing, particularly antipsychotics, in Australian primary care patients with dementia is encouraging. However, psychotropic polypharmacy still occurred in almost one in five patients with dementia at the end of the study period. Programs focused on encouraging further reductions in the use of multiple psychotropic drugs in patients with dementia are recommended, particularly in rural and remote regions.

Enhancing the Detection and Care of Heterozygous Familial Hypercholesterolemia in Primary Care: Cost-Effectiveness and Return on Investment.

BACKGROUND: Heterozygous familial hypercholesterolemia (HeFH) is under-detected and undertreated. A general practitioner-led screening and care program for HeFH effectively identified and managed patients with HeFH. We evaluated the cost-effectiveness and the return on investment of an enhanced-care strategy for HeFH in primary care in Australia. METHODS: We developed a multistate Markov model to estimate the outcomes and costs of a general practitioner-led detection and management strategy for HeFH in primary care compared with the standard of care in Australia. The population comprised individuals aged 50 to 80 years, of which 44% had prior cardiovascular disease. Cardiovascular risk, HeFH prevalence, treatment effects, and acute and chronic health care costs were derived from published sources. The study involved screening for HeFH using a validated data-extraction tool (TARB-Ex), followed by a consultation to improve care. The detection rate of HeFH was 16%, and 74% of the patients achieved target LDL-C (low-density lipoprotein cholesterol). Quality-adjusted life years, health care costs, productivity losses, incremental cost-effectiveness ratio, and return on investment ratio were evaluated, outcomes discounted by 5% annually, adopting a health care and a societal perspective. RESULTS: Over the lifetime horizon, the model estimated a gain of 870 years of life lived and 1033 quality-adjusted life years when the general practitioner-led program was employed compared with standard of care. This resulted in an incremental cost-effectiveness ratio of AU$14 664/quality-adjusted life year gained from a health care perspective. From a societal perspective, this strategy, compared with standard of care was cost-saving, with a return on investment of AU$5.64 per dollar invested. CONCLUSIONS: An enhanced general practitioner-led model of care for HeFH is likely to be cost-effective.

Cluster-randomised trial of the Effectiveness of Quality Incentive Payments in General Practice (EQuIP-GP): Prescribing of medicines outcomes.

BACKGROUND: The Effectiveness of Quality Incentive Payments in General Practice (EQuIP-GP) study investigated whether targeted financial incentives promoting access to a preferred general practitioner, post-hospitalisation follow-up and longer consultations, increase patient-perceived relational continuity in primary care. Secondary outcomes included the use of medicines. OBJECTIVE: To evaluate whether introducing a general practice-level service model incorporating enrolment and continuous and graded quality improvement incentives influenced the total prescriptions written and potentially inappropriate prescribing of medicines. METHODS: A 12-month cluster-randomised controlled trial, whereby participating patients within intervention practices were offered enrolment with a preferred general practitioner, a minimum of three longer appointments, and review within seven days of hospital admission or emergency department attendance. Control practice patients received usual care. Differences between intervention and control groups pre-post trial for total prescriptions were analysed, as an indicator of polypharmacy, along with prescriptions for four groups of drugs known to have common quality of medicines issues: antibiotics, benzodiazepines, opioids and proton pump inhibitors (PPIs). RESULTS: A total of 774 patients, aged 18-65 years with a chronic illness or aged over 65 years, from 34 general practices in metropolitan, regional and rural Australia participated. The mean number of medicine prescriptions per month at baseline was 4.19 (SD 3.27) and 4.34 (SD 3.75) in the control and intervention arms, respectively, with no significant between-group differences in changes pre-post trial and also no significant between-group or within-group differences of prescription rates for antibiotics, benzodiazepines, opioids or PPIs. CONCLUSIONS: Total prescribing volume and the use of key medicines were not influenced by quality-linked financial incentives for offering longer consultations and early post-hospital review for enrolled patients.

Participant experiences of intervention to detect and manage familial hypercholesterolaemia in Australian general practice: A qualitative descriptive study.

BACKGROUND AND OBJECTIVES: General practitioners (GPs) are ideally placed to have a much larger role in detection and management of familial hypercholesterolaemia (FH) among their patients. The aim of this study was to seek the reflections of practice staff and newly diagnosed patients with FH on the implementation of an FH model of care in the general practice setting. METHOD: Qualitative descriptive methodology was used. Interviews were conducted with 36 practice staff and 51 patients from 15 practices participating in the study. RESULTS: Data were analysed thematically and coded into themes - efficacy of GP training, screening for FH, model of care, patient awareness and cascade testing. DISCUSSION: Findings reflect the real-world clinical experience of Australian general practice and the acceptability of the model of care for both patients with FH and practice staff. Patient health literacy is a barrier to both management of FH and cascade testing. A systematic approach to cascade testing is required.

Cost impact of undertaking detection and management of familial hypercholesterolaemia in Australian general practice.

BACKGROUND AND OBJECTIVES: Familial hypercholesterolaemia (FH) can be effectively detected and managed in primary care, but the health economic evidence for this is scarce. The aim of this study was to examine management pathways and cost implications of FH screening and management in Australian general practice. METHOD: Cost-effectiveness outcomes were projected using a life table model. Data was used from 133 patients in 15 Australian general practice clinics from an earlier screening and management study. Costing and mortality data were sourced from governmental sources and published literature. RESULTS: Most patients had a regular general practice consultation at baseline (82%), though the proportion seen under a chronic disease management item at follow-up increased to 23%. The median cost of management was $275 per annum in the first year of management. Managing patients with statins up to the age of 60 years yielded an increase of 248,954 life-years at a cost of $759 million, representing a cost per life-year gained of $3047. DISCUSSION: Screening and management of FH in general practice has the potential for substantial health benefits while requiring relatively modest investments from the health system.

Competing risks of death and kidney failure in a cohort of Australian adults with severe chronic kidney disease.

OBJECTIVES: To examine the competing risks of death (any cause) and of kidney failure in a cohort of Australian adults with severe chronic kidney disease. DESIGN: Population-based cohort study; analysis of linked data from the Tasmanian Chronic Kidney Disease study (CKD.TASlink), 1 January 2004 - 31 December 2017. PARTICIPANTS: All adults in Tasmania with incident stage 4 chronic kidney disease (estimated glomerular filtration rate [eGFR], 15-29 mL/min/1.73 m2 ). MAIN OUTCOME MEASURES: Death or kidney failure (defined as eGFR below 10 mL/min/1.73 m2 or initiation of dialysis or kidney transplantation) within five years of diagnosis of stage 4 chronic kidney disease. RESULTS: We included data for 6825 adults with incident stage 4 chronic kidney disease (mean age, 79.3 years; SD, 11.1 years), including 3816 women (55.9%). The risk of death increased with age - under 65 years: 0.18 (95% CI, 0.15-0.22); 65-74 years: 0.39 (95% CI, 0.36-0.42); 75-84 years, 0.56 (95% CI, 0.54-0.58); 85 years or older: 0.78 (95% CI, 0.77-0.80) - while that of kidney failure declined - under 65 years: 0.39 (95% CI, 0.35-0.43); 65-74 years: 0.12 (95% CI, 0.10-0.14); 75-84 years: 0.05 (95% CI, 0.04-0.06); 85 years or older: 0.01 (95% CI, 0.01-0.02). The risk of kidney failure was greater for people with macroalbuminuria and those whose albumin status had not recently been assessed. The risks of kidney failure and death were greater for men than women in all age groups (except similar risks of death for men and women under 65 years of age). CONCLUSIONS: For older Australians with incident stage 4 chronic kidney disease, the risk of death is higher than that of kidney failure, and the latter risk declines with age. Clinical guidelines should recognise these competing risks and include recommendations about holistic supportive care, not just on preparation for dialysis or transplantation.

Implications of new clinical practice guidance on familial hypercholesterolaemia for Australian general practitioners.

BACKGROUND: Familial hypercholesterolaemia (FH) is a monogenic lipid disorder that may be overlooked in the diagnostic process. OBJECTIVE: The aim of this article is to review the key areas for identification and management of FH that affect Australian general practitioners (GPs). DISCUSSION: Recent consensus advice on the care of patients with FH in Australia provides an opportunity for GPs to increase their awareness and skills in diagnosing and managing FH. New Medicare Benefits Schedule items for genetic testing and Pharmaceutical Benefits Scheme listing for the use of proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors offer GPs additional supports to improve the care of patients with FH. A shared-care approach between GPs and non-GP specialists with expertise in multiple disciplines offers the best option to facilitate genetic testing and management of index cases and affected family relatives. Implementation of this guidance in the primary care setting remains an ongoing challenge and needs to be embraced as a high priority.

Awareness of familial hypercholesterolaemia in Australian primary care: A qualitative descriptive study.

BACKGROUND AND OBJECTIVES: A lack of public and health professional awareness about familial hypercholesterolaemia (FH) leads to an estimated 90,000 Australians remaining undiagnosed. The aim of this study was to establish the level of knowledge and awareness of FH in Australian general practices. METHOD: A qualitative descriptive methodology was used to explore baseline knowledge and perceptions of practice staff about diagnosing and managing FH. Overall, 63 interviews were conducted with general practice staff at 15 practices taking part in a National Health and Medical Research Council partnership grant study (GNT1142883). RESULTS: Data were analysed thematically and coded into themes - knowledge/awareness/recall, management, use of guidelines/referrals, and contacting family members. Most general practitioners treated the high cholesterol component as their primary focus. Guidelines and referrals were rarely used. DISCUSSION: This research reflected a lack of knowledge, awareness and use of guidelines similar to that shown in other published studies. Improved primary care infrastructure, knowledge and awareness of FH need to be addressed.