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Prescription and dispensing duration of medicines for hypertension and other chronic conditions: a review of international policies and evidence to inform the Australian setting

We retrieved information on dispensing and prescription duration limitations from 32 countries [39]. In most countries for which we were able to retrieve relevant information, dispensing durations were either 30, 60 or 90 days, and prescription durations were either 3, 6 or 12 months (Table 1 and Fig. 2) [7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37]. In Australia, the dispensing duration was recently extended from 30 to 60 days for a selection of medicines for chronic health conditions. The number of repeats was kept unchanged, so that the prescription duration for these select medications was extended from e.g., 6 to 12 months [5, 9]. Notably, Italy was the only country with a regulated dispensing duration of 180 days, which was twice that of any other country with regulated dispensing durations [29].

Table 1 Maximum dispensing and prescription durations of medicines for chronic conditions, by country and setting
Fig. 2
figure 2

Maximum prescriptions and dispensing durations of medicines for chronic conditions, by country and setting. Duration limitations are by law, guidelines, or subsidy programme requirements, or if not regulated, as advocated or customary. For some countries, regional examples are used when regulations vary depending on region. Actual durations may be shorter or longer depending on practicing cultures and traditions, as well as medicines package sizes, adherence, and dosage

Medication package sizes

In some countries, regulations also include exemptions for medications that are only available in larger packages. In Sweden, longer than 90-day dispensing durations are allowed within the scope of the drug benefits programme, if package sizes cover more than 90 days’ supply [13]. Likewise in Spain, dispensing of electronic prescriptions may cover at most 30 days, unless the package size corresponds to a longer period [14]. For the same reason, some medications are dispensed for longer durations than what is generally stipulated also in Australia, e.g., indapamide which is only sold in packages of 90 tablets [40]. Another example of regulatory adjustments relating to medicines package sizes is in Ireland, where an additional dispensing is allowed once a year when packages only contain 28 tablets, so that the full year can be covered by 12 dispensings [41]. It has also been discussed whether changes in the size of medication packages may influence dispensing duration patterns [42, 43]. However, it could also be the case that the size of medication packages is adapted by producers to regulations in the market in which they are sold. For example, the blood pressure lowering medication, losartan, is available in packages that cover treatment durations of between 28 and 100 days in Sweden, but only 30-day packages are available in Australia [44,45,46].

Effects on costs and use of resources

When comparing 30 vs 60 or 90-day dispensing durations, studies show that longer durations lead to increased medicine waste, but this seems to be to a small degree [39, 42, 47, 48]. The evidence of increased medicines waste is considered as weak, and none of the available studies were randomised controlled trials [39, 47]. Reasons for medication returns (for disposal) include expired medications, change of drug or dose (strength), discontinuation of medication, side effects or lack of treatment effect, and return of medicines after the death of a patient [49]. Policy change in the UK based on studies on medicines waste has later been criticised for not taking into account other costs and behavioural effects of shorter dispensing durations, nor the increased use of generic branded medicines which has substantially decreased medicine costs and thus the financial implications of medicines waste [48]. Australia, like many countries, has a return of unwanted medicines programme, but most individuals dispose of unused medications in the household rubbish or sewerage [50]. Also, most returned medicines are for acute rather than chronic conditions [50].

Shorter dispensing durations entail higher costs for pharmacy services such as handling fees, which offset the savings of less medicines waste [42, 47, 51]. This is true in both the UK and the US, despite large differences in pharmacy fees [47]. In fact, with short dispensing durations, pharmacy charges in some circumstances may exceed the cost of the actual treatment [48]. For example in Australia in 2022, for hypertension alone, electronic prescription fees and dispensing fees incurred A$ 238 million and 370 million, respectively, which was more than half of the total spending on hypertension treatment [4]. In Australia, ‘dispensing fee’ concerns the direct costs of dispensing (handing over to patient, instructing patient, charging patient), and the ‘Administration, Handling and Infrastructure fee’ concerns the indirect costs of dispensing (administration, infrastructure and handling). Shorter dispensing durations may also increase direct costs for the patients, including costs of transportation to and from the pharmacy, as well as the time consumed [52]. Whether frequent prescription fills also lead to loss of productivity or working hours has not been studied. The need to frequently visit the pharmacy and general practice may be particularly challenging for patients with limited access to health care, such as those living in rural and remote areas [47, 53]. This aspect has particular relevance for Australia, where around 7 million people (or 28% of the population) live in rural and remote areas, including many diverse locations and communities [54]. While some countries like Australia have location rules that support pharmacies being geographically distributed according to the population, access to general practitioners can be limited by supply and waiting times [55,56,57].

In relation to the extension of dispensing durations in Australia, pharmacists have raised concerns that longer durations could strain their financial margins, and that this could result in fewer pharmacies and more restricted opening hours [58]. In the UK, reimbursement schemes for pharmacies could be a source of similar opposition [59]. Such concerns are important to address. Pharmacists have a key role to play as part of team-based care. Their interaction with patients can reduce medication-related harm, help promote uptake of generic branded medicines (to save patient out-of-pocket payments as well as government costs for subsidy programmes), and advise patients on proper medication use to improve adherence, which may both save costs and improve health outcomes [60, 61]. For example, in a cluster randomised trial in Sydney, Australia, pharmacists supporting asthma patients’ in using correct inhalation techniques improved asthma control [62]. However, whether dispensing durations would affect the benefits of such interventions has not been studied.

Finally, a shorter prescription duration may increase the workload and time-burden on busy general practitioners, and patients themselves may experience the process of requesting a renewed prescription as a waste of valuable time for the physician despite the value of regular medical reviews [39, 47, 53]. In low- and middle-income countries with a poor physician-to-patient ratio, longer prescription durations could also free up limited healthcare resources so that the public health care system could increase its reach to a larger proportion of the population [26].

Effects on medication supplies

Pharmacists in Australia have raised concerns that increased dispensing durations may disrupt medications supplies due to medicines shortages [63]. Medication supply issues do occur, as was particularly evident during the COVID-19 pandemic, but as is also on-going with the Australian medicine shortage reports database currently listing 44 medications as critical [64, 65]. However, current regulations in Australia already limit prescription and dispensing of medications with supply issues, and an increased dispensing duration does therefore not apply to such medications [64]. Furthermore, pharmaceutical companies that supply medicines in Australia under its subsidised access scheme are required to maintain a minimum stock holding [66]. Guidelines in some countries indicate that increased patient medication supplies may in fact counteract the negative impact of shortages. In Sweden, the recurring shortages of medications recently motivated the National Board of Health and Welfare to issue a recommendation that patients at all times keep an individual stockpile of at least 1 months’ medication supply [67]. This was proposed as a balancing between preparedness, patient safety, and the risk of medicines waste, and a way to reduce the burden on both the health care and pharmacy systems, including to reduce the risk of overload if a serious event would occur, whether in time of peace or war [67, 68]. Thus, to increase the resilience of the health care system, longer dispensing and prescription durations may be beneficial, whilst in the event of an acute shortage, a temporary restriction on dispensing durations may be necessary.

Effects on adherence and health outcomes

Observational studies suggest that longer dispensing durations are associated with better medication adherence, where most studies have specifically looked at medications of chronic conditions such as hypertension, hyperlipidaemia, and diabetes mellitus [39, 42, 47]. However, evidence is limited by difficulties in separating days of supply from the measures of adherence used, and none of the studies were randomised controlled trials. In one study including over 200,000 newly diagnosed patients with hypertension, comparing prescription durations of less than 28 days with 29 days or more, longer duration prescriptions were associated with better long-term adherence measured by the proportion of days covered [69]. The relatively short prescription durations compared in this study were due to the study of treatment initiation, rather than a stable repeat treatment. More recently, a single centre pre-post implementation study in Thailand of patients undergoing treatment with statins or diabetes medication found that a change from 30- to 90-day prescription periods (as part of universal health coverage) increased adherence (assessed by the medication possession ratio), and to a level on par with similar people at the same hospital who’s health insurance consistently provided 90-day prescriptions [70].

Improved medication adherence is positively associated with health outcomes, including reduced all-cause mortality, as well as reduced hospitalisation and thus health-care costs [39, 47, 71]. However, although one study reported improved serum cholesterol concentrations with 60- vs 30-day dispensing durations, the direct association between prescription time and clinical outcomes has not been sufficiently studied [39, 47].

Finally, the upper limit of prescription durations is sometimes explicitly motivated in regulations by how often it is considered necessary for a clinician to follow-up on a chronic condition, thus intended to work both as a limit of drug retrieval for patients and as a reminder to book a follow-up for clinicians [72].

Patient experiences

Patients describe repeat prescriptions as time-consuming and life-disrupting, and that the effort needed to fill them is increased with 30-day vs longer dispensing durations [59]. In a study of patients with thyroid disease in the UK, 59% of respondents expressed dissatisfaction with 28-day dispensing durations, mainly because of inconvenience and interference with work, but also because it reminded them of their chronic health condition [53].

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