‘Misdiagnosis and delayed diagnosis.’

man holding 'no' sign

Representatives of a doctor group have explained why they pulled out of the advisory group for the Queensland pharmacist prescribing trial

Major doctor groups such as the RACGP, AMA and Australian College of Rural and Remote Medicine have withdrawn from the Urinary Tract Infection Pharmacy Pilot (Qld) (UTIPP-Q) Steering Advisory Group.

The RACGP had attended the initial Steering Advisory Group meeting in December 2019, which Dr Bruce Willett, Chair of RACGP Queensland, and Dr Paul Bryan, RACGP Queensland Council Member, noted in a letter to Dr Lisa Nissen, UTIPP-Q Consortium lead.

The letter, dated last month, points out that the RACGP remains opposed to the trial, and that while the December meeting had addressed some fears, it raised others.

Dr Willett and Dr Bryan write that the trial “represents an unacceptable departure from current medication scheduling arrangements conducted by the Therapeutic Goods Administration (TGA) and carries risks in the form of fragmentation of care, misdiagnosis and delayed diagnosis, antibiotic resistance, financial costs to patients, and opportunity costs in the form of missed preventive care”.

“The RACGP notes with concern that there is no allocated funding or practical means by which the impact of the trial on local rates of antibiotic resistance can be meaningfully monitored,” the doctors write.

“This is a significant limitation given that more prescribers will increase the absolute number of antibiotics dispensed to the community (as has been the case in the UK), amidst rising rates of antibiotic resistance.

“Therefore, as to the question of whether the trial should include only trimethoprim or trimethoprim, nitrofurantoin, and cephalexin, we feel the former option carries the lower risk of short and long term harms.

“However, misdiagnosis and delayed diagnosis is perhaps the greatest risk of this trial.”

The doctors note the recent statement from the UK’s Pharmacists’ Defence Association following a number of serious incidents, including deaths, from independent pharmacist prescribers.

This statement highlighted four high-risk situations, two of which pertain to the Queensland trial: undertaking prescribing for walk-in patients where diagnosis may be required, and without reference to their clinical records.

The doctors write that My Health Records are often incomplete or contain inaccuracies, and that 2.5 million Australians have opted out of the system, leading to the latter “high-risk” situation.

They also cite the rescheduling in Australia of chloramphenicol eye drops and eye ointment to S3, saying there is evidence that pharmacists erroneously dispense these for “conditions for which they are best ineffective (such as viral or allergic conjunctivitis) and, at worst, will delay time to definitive diagnosis at the risk of serious patient harm (including keratitis, corneal foreign body, and herpes zoster ophthalmicus)”.

In terms of UTIs themselves, a number of conditions can present with similar symptoms, the doctors write, including pelvic inflammatory disease, appendicitis, pregnancy (including ectopic pregnancy) and bladder malignancy.

The trial needs a comprehensive and reliable way of screening for these, they say, and excluding pregnancy on the word of the patient is “unacceptably unreliable and potentially unsafe”.

The structure of the proposed follow-up by pharmacists—involving a phone call to the patient one or two weeks after the patient presents to pharmacy—will likely increase rates of misdiagnosis and delayed diagnosis, they say.

Concerns addressed included the fact that consultations under the pilot will be undertaken only by pharmacists, not pharmacy assistants; and that participating pharmacies must have a private consulting room.

Dr Willett and Dr Bryan write that the “fundamental flaws” involved in the trial have led the RACGP to withdraw as a member of the Steering Advisory Group.

Earlier this month, Dr Dilip Dhupelia, president of the AMA’s Queensland branch, wrote to the state’s Members of Parliament urging them to pressure the Health Minister, Steven Miles, into stopping the trial.

One of his concerns was lack of GP representation on the Committee, which the AMA had also withdrawn from.

At the time, Trent Twomey, president of the Queensland branch of the Pharmacy Guild, said it was “sad” that the doctors had decided not to remain in the group, and that it was “disappointing that the doctors union would seek to use unfounded fear and scare tactics to further their own interests ahead of the advancement of women’s health”.

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