It’s a not-so-logical sequence of events, say both the RACGP and the AMA Tasmania.
Tasmania will make its pharmacist-led UTI prescribing service permanent, despite admitting that it has not measured the impact on GPs and that most patients have not received follow-up contact from a pharmacist.
The island state was also looking to expand the program to more than 20 conditions, in line with Queensland and New South Wales.
Like its northern neighbours, Tasmania’s formal evaluation of pharmacist-led prescribing for uncomplicated cystitis focussed on patient access and satisfaction measures rather than clinical outcomes.
The evaluation team only heard from 120 of the 607 patients it contacted for feedback about the trial, representing just 1.8% of total patient encounters.
Of these 120 participants, two thirds said they chose to see a pharmacist for their UTI symptoms because they had trouble accessing a GP, and 88% said they felt better after receiving treatment. A further 20% said they had needed follow up care. No detail was provided on what this may have entailed.
Survey results from a sample of 20% of participating pharmacists revealed that, in roughly one third of interactions, the pharmacist had been unable to contact the patient’s GP, often due to the patient not consenting to their details being shared or because they reported not having a regular GP.
Pharmacists provided antibiotics to the patient 90% of the time and spent an average of 10 minutes consulting.
The evaluation recommended that UTI treatment services become business as usual across Tasmania, and that routine mandatory follow up should not be required.
By the report’s own admission, there were plenty of unknowns.
“Reduced cost for patients is likely given consultation costs were generally lower than the cost of attending a medical appointment,” it said.
“The pilot likely reduced pressure on GP and hospital-based services by providing an alternative pathway for more than 6,500 UTI consultations; however, the evaluation did not directly measure avoided GP appointments or ED presentations.
“A proportion of patients required a follow-up appointment with a healthcare practitioner, most commonly a General Practitioner (GP). It is not possible to determine whether the frequency of these follow-up appointments was greater or less than would have occurred if those patients had initially presented to a GP, as empiric therapy was highly concordant with the published empiric therapy.”
AMA Tasmania president, GP Dr Meg Creely, told The Medical Republic that she felt the evaluation was incomplete.
“It doesn’t say ‘does this reduce healthcare costs?’, ‘does this reduce pressure on general practice?’ – the one thing it does tell us is that the incredibly small portion of patients surveyed, liked it,” Dr Creely said.
“To me, this just isn’t a report.”
Dr Creely acknowledged that the state government had already put a significant amount of money toward funding the trial, having agreed to reimburse pharmacists at $20 per consultation.
With over 6534 episodes of care delivered over the course of the trial, the cost to the government was $130,680 in services alone – not including costs related to administration, training, or marketing.
When asked whether that sunk cost may have made it harder for the state government to walk away from the trial, Dr Creely said there were other approaches that were still open to the government.
“In a state which doesn’t have a lot of money and is making cuts in many places, I think investing that money was the wrong idea,” she said.
“But I think if there’s two choices, and one is to walk away from a bad decision so as to not create harm, and the other is to keep going ahead with it despite a lack of evaluation and a lack of evidence – then I think, from a patient safety perspective, the right call is to walk away from it and regroup.
“Look at what the evidence tells us works well, particularly our patients in Tasmania who have high rates of chronic and complex disease, often multiple of those.
“We know that having pharmacists within general practice will give those patients better care if we can use both the skills of the GP and the pharmacist to manage their chronic and complex care. That’s what we know works.
“I completely agree that spending however many millions of dollars we’re up to now, has been done. But I think this is a ‘cut your losses and move on’ rather than continuing down a pathway.
“Certainly, of the 23 proposed new protocols we’ve just seen land, there’s a huge amount of work in there. It creates transactional care. Patients don’t just walk into general practice with hypertension alone, or really any of those chronic conditions alone.”
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RACGP Tasmania chair Dr Toby Gardner, who has an interest in urgent care, told TMR he had been keeping record of patients he had seen who had been treated by a pharmacist.
“We’re the ones picking up the missed misdiagnoses, the incorrect diagnoses,” he said.
“I’ve got a ledger of patients who’ve been inappropriately prescribed antibiotics, that I’ve kept, with my patients that I see in our private urgent care who come in with everything from STIs to lichen sclerosis to undiagnosed diabetes.
“People who’ve got really bad thrush because they’ve gone back to pharmacists with dysuria a number of times and been prescribed antibiotics, every time they get antibiotics, their thrush is getting worse.
“I mean, it’s crazy. And the first thing we do, of course, is take their urine and test it, and look to see if it is a UTI or not, and actually get a proper history and examination from the patient, which may include, in this person’s case, a genital examination to discover that, actually, they had really bad thrush.
“This is not something that falls within the wheelhouse of a pharmacist. This is something that we’ve been trained to do, and we have the room set up to do.”
Dr Gardner urged his colleagues not to become complacent about the risk posed by pharmacist-led prescribing.
“If I prescribed an antibiotic to everybody who came in with a cold requesting an antibiotic, I’m sure that’d lead to a lot of patient satisfaction and I’d get five stars for every interaction that I had,” he said.
“But that doesn’t equate to good medical practice or anything to do with quality medical care.
“And in this era of antibiotic resistance – I’m at med school today, and we’re teaching our med students about the importance of antimicrobial stewardship – it’s appropriate to withhold antibiotics and not use them, and yet this just flies in the face of what we’re trying to teach.”
