Fund a minor ailments service: study

pharmacist doing consultation mother baby

New Australian research has examined how community pharmacists can help with several minor ailments

The research was a collaborative partnership with Western Sydney Primary Health Network, the PSA and the University of Technology Sydney.

It involved the co-design of a minor ailments service model specifically applicable to the Australian health care system – by patients, GPs, community pharmacists, Primary Health Networks and professional organisations.

“The guiding principles were integration of community pharmacy practice into the health care system, collaboration with general medical practitioners and patients, high quality and safe use of nonprescription medicines and appropriate treatment of minor ailments,” the report says.

Following a co-design phase, a pilot study was conducted, followed by an impact study.

Conditions examined included common colds, coughs, heartburn/reflux, headache (tension and migraine), menstrual pain or primary dysmenorrhea, and acute low back pain.

“Pathways specific to each ailment include questioning, assessment and management. The appropriate course of action includes self-care, nonprescription medicines for symptomatic relief and/ or referral.

“A robust framework for agreed referral was also built-in, outlining red flag criteria to trigger escalation processes, and an appropriate time frame within which a patient was recommended to seek care from a particular health care provider.”

The stakeholder engagement process identified existing GP IT systems to share data and work together through a single platform, HealthLink.

The community pharmacists were to undertake a standardised consultation with patients presenting to the pharmacy with one of the identified conditions – either via a product-based or symptom-based request – and a face-to-face consultation was undertaken in a private consulting room.

Any patient for whom specified red flags popped up was referred appropriately. Otherwise they were given verbal self-care advice and printed or electronic information resources, including PSA Self Care cards.

Following the pilot study, the impact study used a cluster randomised controlled trial design, comparing individuals receiving a structured intervention (AMAS) with those receiving usual care (UC) for specific health ailments.

“The average time of an AMAS consultation was 10.9 minutes (including documentation of the consultation in an iPad). The average time to deliver UC was 3.3 minutes. An additional three minutes was estimated for UC documentation of data for research purposes.

“A total of 33 community pharmacies in WSPHN participated in the impact study. Surrounding general practices consented to receive referral information and details of the pharmacy consultation (150 GPs from 27 practices) for their patients.

“In total, 894 patient consultations were documented during the study period. Of these, 524 (59%) and 370 (41%) patients were recruited into AMAS and UC arms, respectively.

“Of the 894 patients who participated in the study, 82% (n=732) were successfully followed up by telephone.

“Patients receiving AMAS were 1.5 times more likely to receive an appropriate referral by their pharmacist, for medical care meeting the agreed protocols than UC patients (adjusted RR 1.51; 95% CI 1.07 to 2.11; p=0.0175).

“There was strong evidence that patients receiving AMAS were five times more likely to adhere to the pharmacist’s referral and seek medical care within an appropriate timeframe (adjusted RR 5.08; 95% CI 2.02 to 12.79; p=0.0006).

“Pharmacists were 1.2 times more likely to recommend an appropriate non-prescription medicine meeting agreed protocols as a result of the AMAS consultation (adjusted RR 1.2; 95% CI 1.1 to 1.3; p<0.0001).

“Pharmacists were 2.6 times more likely perform a clinical intervention and recommended an alternative medicine that was safer or more appropriate than that requested on presentation by the patient (adjusted RR 2.62, 95% CI 1.28 to 5.38; p=0.0087), compared with UC.

“At follow up, patients were 1.06 times more likely to achieve symptom resolution or relief as result of AMAS (adjusted RR 1.06; 95% CI 1 to 1.13; p=0.0353).

“No change was observed in reconsultation rate between groups. Humanistic results revealed improved health related quality of life for AMAS patients, compared with UC (mean difference 4.08; 95% CI 1.23 to 6.87; p=0.0049).”

The AMAS found that 91% of all non-prescription medicine recommendations were considered appropriate meeting the agreed protocols – compared to 79% in UC.

“Findings demonstrate patients were 1.2 times more likely to receive an appropriate medicine recommendation by their pharmacist as defined by the agreed protocol with AMAS, compared with UC.

“The most common medicines supplied were for symptomatic relief of upper respiratory tract infections (URTIs), including cold or cough preparations, accounting for 63% of all medicines supplied (across both study arms).

“Oral analgesics, including NSAIDs, non-opioid analgesics alone or in combination (22%) were also commonly supplied for the symptomatic relief of pain.

“Gastrointestinal nonprescription medicines for reflux accounted for 10% of medicines supplied and included combination antacids, histamine-2 receptor antagonists and proton pump inhibitors.”

Also, pharmacists performed a clinical intervention in 21% of direct product request presentations with AMAS, compared to 11% in UC.

The report found that the research demonstrated the efficacy of the AMAS for a number of clinical, humanistic and economic indicators in the participating PHN, as well as improved identification of patients presenting with red flag clinical features with AMAS.

It made a number of recommendations, including that a national AMAS system be implemented in Australia; that a national self-care strategy be implemented; and a funding model which reflects the time, quality and complexity of community pharmacist care be established.

“Remuneration needs to reflect quality and value and incentivise pharmacists to focus on care which is of higher value and is of highest impact to the health system,” the report said.

“This may mean revising remuneration models for clinical interventions (ie. to recognise higher significance interventions and quality recording), in addition to models of remuneration such as fee-for-service, practice allowance or based on the number of patients registered for the scheme.

“Funding would include time spent on educating patients to self-care. Incentives to engage in provider collaboration should be considered.

“What is clear, is that a remuneration model should have the objective of achieving patient accessibility and as well as supporting integration of community pharmacists into primary care.”

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