Guild accused of being ‘very secretive’


A leading doctor has cited recent data showing significant vaccine underreporting in an attack on a pharmacy antibiotics trial

Chair of RACGP Queensland Dr Bruce Willett spoke to RACGP publication newsGP saying that pharmacist prescribing for UTIs “won’t work as the Pharmacy Guild is claiming”.

The Urinary Tract Infection Pharmacy Pilot – Queensland (UTIPP-Q) trial went live earlier this month, following the release of the Drug Therapy Protocol for participating pharmacists.

But Dr Willett said that a National Centre for Immunisation Research and Surveillance report published earlier this month undermines the credibility of the UTI trial.

This report showed that between 2016 and 2019, there were 576,780 pharmacist vaccinations recorded with the Australian Immunisation Register.

Data from the AIR and stakeholder interviews for the study suggested that there had been “substantial” underreporting of pharmacist vaccinations to AIR, with more vaccines reported by three pharmacy banner groups in 2019 than were recorded on the AIR by all pharmacy providers that year.

“Of the pharmacies that are registered with jurisdictions as offering vaccination services, the data from 1 July 2018 to 30 June 2019 indicate that only half are supplying valid vaccination data to AIR,” the report concluded.

At the time the data was released, Pharmacy Guild Victorian branch president Anthony Tassone said that the report also highlighted gaps in recording done by other immunisers, and that the Guild “fully supports the use of AIR and recommends community pharmacies record the vaccination services they deliver for patients”.

Now, Dr Willett has used this data to question the UTIPP-Q trial.

“If they can’t get the proper recording of vaccinations right, how can we trust that there will be proper administration of antibiotics?” he said.
 
“This clearly indicates the difference between what the Guild promises and what happens in real life. What occurs in the trial is likely to be very different to what happens when pharmacy prescribing is in the wild.”

Dr Willett said the GPs are concerned that the trial means antibiotics will be more available.

He also said they want training resources for participating pharmacists to be made public.

“We remain concerned that the Guild are not publishing what’s occurring in the training – they’re remaining very secretive about that,” he said.
 
“That should be in the public domain.”

Dr Willett’s comments follow those earlier this week from AMA Queensland president Dr Chris Perry, who said that pharmacist prescribing for UTIs constitutes a “role substitution” which the organisation is now repudiating.

“Queenslanders are being sold this new style of patient care under the guise of choice and convenience, but it’s simply a bargain basement version of health care,” he said, calling on doctors to complete a survey about the current state of the health system.

Pharmacy Guild Queensland branch president Trent Twomey reacted to Dr Perry’s comments by encouraging doctors to reject such “scare campaigns” and work with pharmacists instead.

 

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10 Comments

  1. Jarrod McMaugh
    27/06/2020

    Dr Willet may wish to read previous NCIRS reports carefully – they show that GP immunisers record vaccinations in AIR as low as 50% of the number provided.

    If the rate of AIR utilisation is being used to suggest poor practice, then I wait patiently for Dr Willett to make similar comments about his colleagues

    • Dr Evan Ackermann
      28/06/2020

      Which specific NCIRS report does your 50% quote come from?

      • Jarrod McMaugh
        28/06/2020

        View this report – http://ncirs.org.au/sites/default/files/2019-12/Analysis%20of%20adult%20vaccination%20data%20on%20AIR_Nov%202019.pdf

        It is also a long bow to draw on the discussion with the NCIRS analysis of pharmacist uploads to AIR to claim that pharmacists have provided vaccines that they are not legally allowed to provide in Australia

        • Dr Evan Ackermann
          28/06/2020

          The 50% referred to in the National Centre for Immunisation Research and Surveillance report·
          Of the pharmacies that are registered with jurisdictions as offering vaccination services, only half are supplying valid vaccination data (it does not confirm actually what % of patient vaccinations are reported eg for influenza). In fact – NO private market vaccine distribution data are available.
          ·
          So a definitive performance value for pharmacy is unknown and not calculable. Quite an oversight. I am sure you would agree this needs fixing. However – that only 50% of vaccination registered pharmacies are providing any data isa concern.

          The GP reporting rates for influenza vaccination
          – 60% of patient vaccinations are reported to AIR (Table A2) of vaccines distributed – which would be conservative given the data transfer issues that are known between AIR and GP software systems. (so more than your stated 50% Jarrod)
          ·
          Using similar methodology, an ESTIMATION of pharmacist reporting would be about 25%.ie over 1 million influenza vaccinations were administered in pharmacies in 2018 and over 2 million in 2019 – 10 and 4 times more than those reported to AIR, respectively.

          We await PART C of study which may be more informative

          • Jarrod McMaugh
            28/06/2020

            There are quite a few things you have conflated here – unsure if this is intentional to back up your clear bias against pharmacist-provided health care, or if you are not understanding the reports. I have my opinions on which, but remain to see definitively which.

            Within the report that I linked to, there is discussion that the reporting rate for vaccines is as low as 50%. Refer specifically to the section on varicella vaccine for this discussion.

            Of note, you use the term “performance value” – the NCIRS report is not intended to evaluate the performance of pharmacists or pharmacies in providing vaccines; it was designed to determine the barriers to upload of data to AIR, by comparing pharmacist-entered data vs estimated & reported rates of vaccinations provided in pharmacies. I have been working with NCIRS on this report since they commissioned it, and a significant portion of the discussions in planning and data collection phase were in trying to clearly identify the number of vaccines administered by pharmacists vs vaccines delivered.

            There are a number of issues with the evaluation of this kind of information, all of which should be considered before any spokesperson uses this report to claim that a profession is not capable of a specific health intervention (as per Dr Willett’s claims)

            Firstly, distribution of vaccines to pharmacies is not the same as vaccines administered by pharmacists. This should be quite clear, and a significant number of vaccines administered by GPs are distributed via pharmacies. This means that the total number of vaccines administered by GPs is not adequately estimated by distribution of NIP stock, and influences the actual rate of reporting by GPs down, as the total volume of vaccines provided includes NIP and private market stock. It should also be noted that GPs also purchase private market vaccine as well (hard to track as you’ve noted), further increasing the total volume of vaccines estimated to be provided by GPs. Without reliable methods of measuring total vaccine volume that GPs had access to, estimating upload rate by GPs without this data overestimates the AIR upload rate.

            This also influences the rates of vaccines provided by pharmacists – the number of vaccines variously claimed to have been provided by pharmacy banner groups is based on total volume sold – this includes those administered by pharmacists, those administered by doctors or nurses within a pharmacy service (as occurred quite significantly prior to and during 2018), and those dispensed in pharmacies. The end result is that the total number of pharmacist-administered vaccines vs AIR upload is also more conservative than those quoted.

            Again, this is the purpose of the report – to try and determine the actual rate of vaccination vs the AIR upload rate. There are a significant number of confounding factors, and this report directs us to some of those, allowing for further clarification in future analyses. It should be clear though from reading these reports that trying to determine volume of vaccines provided by a particular workforce based on the way in which those vaccines are distributed is a very unwieldy and inaccurate estimation method.

            Secondly, as you have noted, there are known issues of data transfer from GP provider software to AIR. One of the reasons that the latest report by NCIRS was commissioned was to try and determine if this is also an issue for pharmacy software. From the analysis and feedback provided by pharmacists during the data gathering involved with this report, it seems that this is part of the issue.

            Third, the AIR numbers tell us who registered a vaccine; while this has been analysed as who provided a vaccine, which has been revealed to be a problematic assumption. Overall, this is unlikely to have an impact on the volumes of vaccines provided, but it does highlight the presence of AIR registry entries by pharmacists for vaccines which they cannot initiate (although under medical direction, pharmacist vaccinators are able to administer more vaccines than they can initiate).

            Both of the reports (in fact, all of NCIRS’s reports) are worth reading and understanding – I would recommend them to Dr Willett, and perhaps you yourself would like to read them more thoroughly. I’ve had the privilege of having access to them for quite a while, so I should give you time to catch up, but of note, you should read the sections on upload rate changes over time, and how this was very slow for other vaccinators in the past (especially GPs), and that this trend is expected to be the same for pharmacists, who are the most recent addition to those who can contribute to AIR.

            These reports are examining quite complex systems; it is understandable that there would be errors in conclusions drawn when they are read in a superficial manner looking for “gotcha” moments, but if you invest the time in reading them, you’ll see that there is actually a lot in common between AIR upload rates for pharmacists and for GPs.

          • Dr Evan Ackermann
            29/06/2020

            I will try this once -:
            1. I was trying to compare like for like in influenza vaccinations. Using Zoster vaccinations is less valid as you may have vaccine distributed one year – and administered in the next year. – hence some years it will be above 100-% (shown on page 32). Irrespective, the only results I see for GP rates < 50% is in 2016 with only 3 months of data. Others are pretty high.
            2. Agree with limitations of using distribution of vaccines to pharmacies is not the same as vaccines administered by pharmacists. But you would agree that Pharmacists should report as we all do – how should that happen?
            3. That 50% of vaccine accredited pharmacies that do not do anything is a concern yes/no? Dr Willets criticism remains valid. Nothing you have stated argues against his criticism.
            4. I have read and do UNDERSTAND these documents.
            5. The “vaccines provided outside of pharmacist scope of practice” is dealt with appropriately in the study limitations.
            Rather than “but look over there” and pile-up of "additional issues" – why don’t you respond to Dr Willets criticism.

          • Jarrod McMaugh
            29/06/2020

            NCIRS reports are not solely about influenza vaccine, they are about all vaccines.

            The variations in AIR data provision is relevant, as the purpose of these reports is to identify discrepancies in reported vaccination rates vs AIR uploads. These discrepancies are not isolated to one vaccine type. The original point, to which you commented, is that there is discrepancies in upload rates to AIR for ALL professions if the methodologies used for comparison (ie distribution vs AIR upload) are utilised without further critical analysis

            50% of vaccine accredited pharmacies is not a benchmark figure. There is no way of measuring whether this represents the total number of pharmacies participating in vaccinations in any particular year from the data being analysed. There are various workforce & workflow issues that impact on whether a pharmacy participates in vaccinations in any particular season.

            This report was commissioned in order to understand the differences between upload rates and distribution. It highlighted a few things; the largest issue being that there needs to be a much more sophisticated comparison *for all professions* to have a clearer understanding of barriers to AIR upload (which is actually translatable to other issues, such as MHR upload rates).

            Re: Dr Willett’s comments – I have responded to them but I will reiterate again: Dr Willett has expressed an opinion, and in doing so, has attempted to use the NCIRS report as evidence for his position, yet the NCIRS report is nether able to support such a position due to the nature of the information provided in the report, nor does it differentiate between “good” or “bad” practice as he has attempted to imply – if the NCIRS report *were* to support his position, it would also support the same position when applied to other health professionals – including GPs – that they are failing to upload vaccination details to AIR in adequate numbers.

            Whether you believe the report to be an indictment on pharmacy practice or a discussion on the relative difficulties in identifying AIR upload rates & barriers to this is immaterial; regardless of your position, the reports for all health professionals that have been developed by NCIRS all have the same issue. They consistently show that the perceived vaccination rate is higher than the AIR recording rate regardless of the profession of the person making the entry.

  2. Debbie Rigby
    29/06/2020

    I agree that data is gold, but isn’t the fact that more Australians are having the annual influenza vaccine really the key issue?

    • Dr Evan Ackermann
      29/06/2020

      I would suggest that hospitalisations and deaths from influenza are more important. That means we need to see vaccination rates higher in high risk populations. If all vaccinations go to low risk areas – then we are doing a dis-service. Hence documentation is important.

  3. michael ortiz
    29/06/2020

    It is interesting to watch the Queensland AMA complain whenever Pharmacists try to introduce new professional services that are common practice overseas. I can still remember when the AMA did a “chicken little” pronouncement that letting Pharmacists give Flu vaccines would harm the Australian public. The Queensland vaccination pilot study showed that the AMA concerns were unfounded. The AMA is complaining that pharmacists reported only 50% of vaccinations the AIR. This value may not be reliable as it was calculated from public statements rather than on an official audit.

    GPs grew their vaccine business by 2 million in 2019, Despite this growth, paediatric vaccination rates are still less than the 95% target for children aged less than 5 years. Medical Practitioners and Pharmacists need to work together to improve vaccination rates in Australia.

    The tele-health business must be slow, if the AMA has time to complain about Pharmacy services again. The UTI pilot study is a storm in a tea cup and chicken little has been let out again.

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