PBAC delays restricting GP prescribing of antipsychotics in aged care

The ‘substantial risk’ of unintended consequences is too great to implement restrictions on GP prescribing of antipsychotics in residential aged care, the Pharmaceutical Benefits Advisory Committee (PBAC) has determined.
 
Had the recommendation, put forward in the Royal Commission in Aged Care Quality and Safety Final Report, been accepted only psychiatrists or geriatricians would have been able to initially prescribe antipsychotics to people in residential aged care facilities (RACFs).
 
However, the PBAC agreed with submissions from various stakeholders – including the RACGP – to delay implementing the recommendation.
 
‘Following consultation with stakeholders, the PBAC considered Recommendation 65 is not implementable at present due to substantial risk of unintended consequences,’ the committee wrote in a summary of its November meeting, which was released earlier this week.
 
‘The PBAC noted that changes already made to the PBS restrictions for risperidone, the only medicine registered in Australia for the treatment of behavioural and psychological symptoms of dementia, have reduced utilisation.
 
‘The PBAC will continue to monitor the use of antipsychotics in aged care.’
 
The RACGP has long opposed any restriction on GP prescribing in RACFs, and President Dr Karen Price wrote to the PBAC last year to outline general practice concerns related to the recommendation.
 
‘The RACGP acknowledges high antipsychotic prescribing rates are a significant concern in RACFs; however, the proposed restriction of prescribing may worsen patient care and outcomes in the current aged care system,’ she stated.
 
‘The RACGP is particularly concerned by the potential implementation of this recommendation during the ongoing COVID-19 pandemic, which has impacted access to aged care services, as well as workforce mobility.
 
‘GPs must retain the capacity to initiate antipsychotic prescriptions in residential aged care facilities to ensure older people can have immediate access to appropriate medicines.’
 
Dr Price said that high antipsychotic prescribing rates in RACFs are a result of a ‘failing system’ that is under-resourced to deal with the complex health needs of many older people, including those with the behavioural and psychological symptoms of dementia.
 
‘Issues that contribute to high prescribing rates include the current not fit-for-purpose design of RACFS and ongoing workforce challenges, including variable training, high turnover and insufficient staff,’ she wrote.
 
‘The multimorbidity and complex health needs of older people is not matched by the qualifications or numbers of staff in the aged care sector.’
 
There were also concerns that restricting psychotropic prescribing would significantly increase demand for geriatricians and psychiatrists, particularly in rural and remote areas, and could have significant cost implications for the health system by deferring care from GPs.
 
It was also feared that the recommendation would exacerbate current access issues and deny the appropriate prescription of antipsychotics, including as an option for effective palliative care and in the treatment of depression.
 
‘GPs are trained to appropriately prescribe and manage the use of antipsychotic medications for older people, including deprescribing when appropriate,’ the letter stated.
 
‘The ongoing relationship between a GP and a regular patient can yield critical information that informs medical decisions and treatments, as opposed to one-off appointments with other specialists.
 
‘This proposed restriction could [also] lead to the inappropriate transfer of distressed patients to emergency departments when a psychiatrist or geriatrician is unavailable to prescribe short-term or emergency use of antipsychotic medication to manage distress.’
 
Rather than impose prescribing restrictions on GPs, the RACGP has instead proposed the Federal Government focus on ‘evidence-based measures’ such as improved staff education, audit and feedback processes, as well as interdisciplinary reviews, which can ‘significantly reduce prescription of antipsychotics and benzodiazepines’.
 
Other recommendations contained in the RACGP letter include:

• implementing behavioural management programs and adequate staff and infrastructure
• funding to support GP case management, review and supervision, as well as geriatricians and psychiatrists
• new data collection methods that capture hospital-based prescribing that translate to ongoing prescribing in the community
• improvements in the capability of multidisciplinary teams to provide care to older people in RACFs.

aged care antipsychotics royal commission