Pharmacists as good as doctors at prescribing: Cochrane Review

A new Cochrane review has found pharmacist prescribers are 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 majority of studies were conducted in high-income Western countries in a community setting, and comprised randomised controlled trials, cluster randomised controlled trials, controlled before-and-after studies, and interrupted time-series analysis.

The results were positive and suggested that non-medical prescribers are 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);
  • Health-related quality of life (Moderate certainty of evidence); and
  • Adverse events (Low 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.

While the results should be interpreted with caution, the authors say the “certainty of the body of evidence provides support that there is probably no difference in outcomes between non-medical and medical prescribers”.


Pharmacist prescribing in Australia

The results make a strong case to extend pharmacist prescribing rights in Australia, which many believe are currently too limited.

As reader Emily Bird wrote on the AJP forum, “I could not possibly be the only one whom constantly experiences frustration as a result of the limitations which we have placed on us when it comes to prescribing medications.

“How often do you see consultants and registrars delegate discharge prescription writing to that graduate intern that knows little more about prescribing medicines than the average Joe Blow?

“How often do you have to spend half an hour trying to track down that one prescriber whom so insistently chose to inappropriately prescribe azithromycin with a dose regimen that reads ‘take 500 tablets daily for 3 days’ just so that you can get them to reluctantly grant you permission to annotate the script so that it reads a much safer, ‘take 500mg daily for 3 days’?

“Why is it that Australia is choosing to ignore the overwhelming evidence which supports integrating prescribing pharmacists into healthcare systems?” she adds.

On the same forum thread, reader Peter Crothers shared an anecdote.

“A young doctor I know well says she and her friends don’t understand why pharmacists don’t have prescribing roles in hospitals.  The trainee doctors don’t believe they’re competent to do it and find it the most stressful part of their work,” he said.

Meanwhile, commenter Greg Kyle provided a different perspective.

“Pharmacists need to develop a strong professional identity and move away from being anally retentive risk averse checkers,” he wrote.

“Pharmacist prescribing is not a new concept internationally, but the profession seems to kowtow to the medical bullying and turf protection that occurs here, rather than calling it out for what it is – income protection.”

Pharmacy academic Professor Lisa Nissen, from Queensland University of Technology’s School of Clinical Sciences, has echoed the calls for extended prescribing rights.

Pharmacists could make a positive difference in the lives of patients by having a broader role in managing medicines, she said at this year’s PSA conference.

“Doctors have concerns about patient safety and quality. However, we know that [the system] doesn’t work well now.

“You look at young doctors coming out of contemporary medical practice prescribing things they don’t know what they are or what they do,” she said.

As “medicines experts”, pharmacists could add prescribing as an extra tool to the competencies they already have.

“We could be able to make a huge impact in the sector,” she said.

The Cochrane review results certainly seem to support Prof Nissen’s argument and fellow pharmacists’ calls for extended prescribing rights.

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  1. tvren

    Always worthwhile looking at the original Cochrane document – the authors conclusions included: ” It was difficult to determine the impact of non-medical prescribing compared to medical prescribing for adverse events and resource use outcomes due to the inconsistency and variability in reporting across studies. ”

    probably not important to mention this caveat when discussing the findings

    • colio6

      The key message states, “With appropriate training and support, nurses and pharmacists are able
      to prescribe. . . to achieve comparable health management outcomes to doctors.” I don’t think anyone’s arguing that all nurses/pharmacists should be able to prescribe regardless of experience; the study was conducted across countries with radically different nurse/pharm training programs. I’m a clinical pharmacist in the U.S. and after a 4-yr post-grad PharmD program and 2 years of intensive residency which focused exclusively on medication management, I feel well qualified to manage the chronic diseases I see in clinic and the other providers in clinic appreciate having more time for acute issues. Frankly, I’m sometimes horrified by the things I see MDs prescribe because meds are just one of the many things they had to master in school/residency. IMO, it depends on the person/training and not necessarily their job title.

      • vixeyv


        • Mark

          I am a pharmacist and have a medical degree. Managing chronic disease is certainly not all about medication

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