Defining roles: Part 2

Pharmacist prescribing may present concerns to the average GP, but evidence shows it may improve access to healthcare for patients. How could such a model work in everyone’s favour?

This is the second part of a feature story on pharmacy prescribing. Click to read Part 1 here.

A review of the literature shows a clear pattern that pharmacist prescribing may lead to improved health outcomes for patients.

“There is robust evidence from around the world, including Australia, to suggest models of care that include supplementary pharmacist prescribers provide patients with safe and appropriate access to medications,” says Dr Andrew Hale.

A recent Cochrane review published in December, for example, found that pharmacist prescribers were comparable to medical prescribers for chronic disease outcomes.

The review, led by the researchers from Monash University’s Faculty of Pharmacy and Pharmaceutical Sciences, included 45 studies that compared non-medical prescribing with usual care medical prescribing.

Non-medical prescribing was undertaken by pharmacists in 20 out of the 45 studies, and by nurses in the remaining 25 studies.

The results were positive and suggested that non-medical prescribers were as effective as usual care medical prescribers, in a range of settings and at high levels of prescribing autonomy.

For example, a meta-analysis of chronic disease markers that showed that non-medical prescribers delivered outcomes as effective as medical prescribers for:

  • Diabetes control (High certainty of evidence);
  • High blood pressure (Moderate certainty of evidence);
  • High cholesterol (Moderate certainty of evidence);
  • Patients adhering to their medication regimens (Moderate certainty of evidence);
  • Patient satisfaction with care (Moderate certainty of evidence); and
  • Health-related quality of life (Moderate certainty of evidence).

“Pharmacists and nurses with varying levels of undergraduate, postgraduate, and specific on-the-job training related to the disease or condition were able to deliver comparable prescribing outcomes to doctors,” said the authors.

They concluded that “there is probably no difference in outcomes between non-medical and medical prescribers”.

Other studies have also shown that pharmacist prescribers, in collaboration with doctors, receive high satisfaction rates from patients.

A study led by Dr Hale and Professor Lisa Nissen found most patients were “highly satisfied” in their consultations with prescribing pharmacists.

“The results suggest that patient satisfaction and willingness to engage will not be barriers to the implementation of collaborative doctor-pharmacist prescribing models in Australia,” the authors conclude.

Internationally, patients have reported high satisfaction with appointment times, communication with the pharmacist prescriber, and the services received.

The public supported pharmacist prescribing in limited situations (chronic conditions, minor ailments, repeat medications), according to a Canadian study of international pharmacist prescribing.

However there were concerns about lack of privacy during consultations, and concerns regarding lack of adequate resources to ensure safe prescribing by pharmacists (e.g. lack of access to medical records).

A collaborative approach

While trials show that prescribing pharmacists could make a positive impact on patient health, there is a clear need to address concerns if doctors and pharmacists are to move forward together.

Leaders in the pharmacy space concur that the best way to approach pharmacist prescribing is using a “collaborative” approach.

“I believe the best model for our context here in Australia is a collaborative prescribing model, in which the pharmacist works closely with the patient’s primary prescriber (most often the GP) with the ability to access a set of shared medical notes to help ensure continuity of care, but also to provide the pharmacist with a framework of clinical governance and support,” argues Dr Chris Freeman.

“We have an obligation as outlined in our code of ethics to ensure continuity of care.”

According to Dr Freeman, within the collaborative model of pharmacist prescribing:

  • Pharmacists will be able to prescribe following referral from medical practitioner;
  • Patients would already have diagnosed conditions;
  • Usually the initial treatment decision is already made and initiated;
  • The types of medications would be limited to the area of clinical practice the pharmacist is working in.

“As long as the pharmacists are suitably trained, are working within their defined scope of clinical practice, do not have any conflicts of interest, and have a close working relationship with the patient’s primary GP, then a pharmacist working in any environment should be able to prescribe,” he says.

“Overall, pharmacist prescribing should not be seen as the precipice of clinical pharmacy practice but one of many potentially important ways a pharmacist may contribute to patient care.”

Professor Nissen agrees that pharmacists should be working collaboratively within a healthcare team.

“[Prescribing rights for pharmacists] would extend across the continuum of practice, and assist patient and pharmacists to work collaboratively with the health care team to enhance medicines management. Prescribing would happen as a collaboration with existing prescribers and other members of the care team.

“It’s not about pharmacists ‘taking over’, it’s about collaborative models of care for the betterment of health outcomes and care for patients,” she says.

“Safe, competent pharmacists working in a collaborative care environment within their scope of clinical experience should be able to prescribe medicines relevant to that area. There should not be a situation where we are a profession prescribing only from a restricted list or formula per se.”

Training and frameworks

Pharmacy experts also agree there is a clear need to training and strong frameworks to ensure appropriate prescribing occurs.

“Similar to other countries where pharmacists have prescribing rights, there would need to be a specific education course, experiential and credentialing processes, based on the NPS Prescribing Competencies Framework, says Rigby.

“Mentoring and supervised practice needs to be part of the credentialing process. Up-to-date clinical, pharmacological and pharmaceutical knowledge relevant to the intended area of prescribing practice is essential.

Dr Freeman agrees that additional training followed by supervised practice is essential.

“While pharmacists have unparalleled skills and knowledge in pharmacology and therapeutics, there would be the need to upskill in clinical examination and diagnostics. So I see only suitably trained pharmacists being able to prescribe medication,” he says.

“Appropriate clinical governance is the key here and may take various complementary forms … Appropriate indicators for efficacy and safety should be collected to ensure the model is delivering health outcomes for patients, in a safe manner.”

“There needs to be investment in appropriate training and education to produce fit-for-purpose non-medical prescribers,” argues Dr Hale.

“There is enough robust evidence to suggest it works at least as safely and effectively as usual care, so long as the conditions under which it is implemented are appropriate.

“There needs to be a clear separation of prescribing and dispensing, so a pharmacist legally could not dispense a prescription that they had prescribed.

“A unified approach from the entire pharmacy profession is essential, with agreement on proposed models of care, scopes of practice, and training and education requirements to sustainably produce competent prescribers,” says Dr Hale.

“Without this, progression of the new role, and ensuring the knowledge and skills of pharmacists are utilised to their full potential, will be a major challenge.”

References/Further reading

Famiyeh, I & McCarthy, L 2016, ‘Pharmacist prescribing: A scoping review about the views and experiences of patients and the public’, Research in Social & Administrative Pharmacy, vol. 13, pp. 1-16.

Hale, A, Coombes, I, Stokes, J, Aitken, S, Clark, F & Nissen, L 2015, ‘Patient satisfaction from two studies of collaborative doctors – pharmacist prescribing in Australia’, Health Expectations, no. 19, pp. 49-61.

Hanes, CA & Bajorek, BV 2005, ‘Pharmacist prescribing: Views of Australian hospital pharmacists’, Journal of Pharmacy Practice and Research, vol. 35, no. 3, pp. 178-180.

Hoti, K, Hughes, J & Sutherland, B 2010, ‘Pharmacist Prescribing in Australia’, Journal of Pharmacy Practice and Research, vol. 40, no. 3, p. 175.

Kay, OC, Brien, JE 2004, ‘Pharmacist prescribing: Review of the literature’, Journal of Pharmacy Practice and Research, vol. 34, no. 4, pp. 300-304.

Vracar, D & Bajorek BV 2008, ‘Australian General Practitioners’ Views on Pharmacy Prescribing’, Journal of Pharmacy Practice and Research, vol. 38, no. 2, pp. 96-102.

Weeks, G, George, J, Maclure, K & Steward, D 2016, ‘Non medical prescribing versus medical prescribing for acute and chronic disease management in primary and secondary care’, Cochrane Database of Systematic Reviews, no. 11.

Weeks, G, Marriott, J 2008, ‘Collaborative Prescribing: Views of SHPA Pharmacist Members’, Journal of Pharmacy Practice and Research, vol. 38, no. 4, pp. 271-275.

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1 Comment

  1. Toorisugarino Isha

    What about the safety outcomes in the Cochrane review? It appears as if better outcomes were achieved by non-medical prescribers for blood pressure and glycaemic control, but was it always appropriate? Was better BP achieved at the expense of increased falls due to postural hypotension for example?

    Also, what was the performance of pharmacists as a subgroup? It’s plausible that the nurse prescribers did all the heavy lifting given that nursing training more closely resembles the medical breadth of knowledge and skill set. Can we really conclude from that analysis that pharmacists are non inferior at prescribing?

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