NQ Pharmacy Pilot: another way to prevent doctors from going to rural areas
THE trouble-plagued North Queensland pharmacy pilot would worsen labor shortages in the region, with more than 50% of GPs saying the pilot and its impact on patient safety would deter them from working In the region.
Respondents to an Australian Medical Association (AMA) survey of Queensland criticized the Queensland government’s trial allowing pharmacists to diagnose and sell prescriptions for urinary tract infections (UTIs).
In June 2020, Queensland Health launched the 2-year Urinary Tract Infection Pharmacy Pilot – Queensland (Queensland-wide UTI Pilot) enabling pharmacists across Queensland to provide treatment to women with suspected UTIs . This involves pharmacists diagnosing, prescribing and providing treatment for UTIs, after 120 hours of online training. Although the AMA Queensland, the Royal Australian College of GPs, the Australian College of Rural and Remote Medicine, the National Aboriginal Community Controlled Health Organization and the North Queensland Primary Health Network have withdrawn their participation in the trial, the Government of Queensland extended the trial for 6 more months from June 2022, based on an assessment by Queensland University of Technology which has not been made public.
This expansion would facilitate autonomous prescription by pharmacists for 23 conditions from June 2022.
The AMA Queensland survey had 1,307 respondents, of whom 52% were general practitioners, 26% other specialists and 12% doctors in training. The survey was open to all physicians in Queensland from March 18-28, 2022. Access to the survey was made public through the Queensland Medical Community, GP Alliance, Australasian Medical Publishing Company (publishers of Preview+), the Facebook Business for Doctors group, local medical associations and communications with AMA Queensland members via the bi-monthly Connect newsletter and direct messaging.
More than 50% of GPs who responded said they had been deterred by the pilot from traveling to North Queensland due to “the expectation that GPs would need to ‘pick up the pieces’ and to deal with the consequences of pilot and weakened patient safety”.
Patient safety was the biggest objection to the pilot project by responding physicians, with 96% citing it as their top concern.
With good reason – 240 patient complications have been reported as a result of the UTI pilot.
“The women did not receive the care they needed and an alarming number became sicker as a result of their participation in the trial,” said AMA Queensland President Professor Chris Perry.
“Weirdly, three doctors reported seeing men with complications when the pilot was specifically limited to ‘uncomplicated cystitis in non-pregnant women’.
“At least six pregnant women were sold dangerous antibiotics during the first trimester. One of them had a life-threatening ectopic pregnancy.
“At least nine patients ended up in hospital with sepsis or kidney and bladder infections due to ineffective or delayed treatment.”
More than a third of respondents to the AMA Queensland survey had trained in pharmacy before graduating from medicine, and those respondents were the most scathing about the pilot.
“As a pharmacist, I thought I could [diagnose and treat] and said it several times. However, having trained as a doctor, I realize how insufficient my knowledge and training was in the area of prescribing,” said one pharmacy-trained respondent.
“Pharmacists are not trained to diagnose or treat patients. Having studied both pharmacy and medicine, the latter involves two full-time clinical years seeing patients and learning how to take a history, perform a physical examination, order investigations, and make diagnostic and treatment decisions. management. This process is not able to be delivered over the counter of a pharmacy,” said another.
The AMA Queensland survey also revealed that patients were not completely honest in the pharmacy setting.
“A common theme among doctors’ comments, particularly regarding misdiagnosis of [sexually transmissible infection (STIs)], was patients’ reluctance to provide complete and candid information to a pharmacist in the presence of other customers or to discuss their sexual history over the counter. Failure to disclose sensitive or embarrassing information due to a lack of confidentiality may have contributed to misdiagnoses,” the survey authors reported.
Concerns have also been raised about conflicts of interest and upselling.
“Conflicts of interest related to potential financial incentives in the diagnosis and sale of products have been raised on several occasions. Similarly, physicians were concerned about the upselling of non-essential products and the possibility that pharmacists would feel pressured to sell a drug for every condition, even when conservative management would be more appropriate.
Other results from the AMA Queensland survey:
- The most common misdiagnosis was that the patient had an STI rather than a UTI. These included chlamydia, herpes and gonorrhea. A number of patients have also been reported to have pelvic inflammatory disease.
- Pregnancy has been misdiagnosed as a UTI on at least six occasions, with a number of patients prescribed dangerous antibiotics during the first 12 weeks of pregnancy.
- A patient was reportedly treated for a urinary tract infection when her symptoms were actually related to an ectopic pregnancy.
- Cancerous conditions have been overlooked on at least nine occasions, with doctors reporting incidents of patients being treated for a UTI when symptoms were related to cancer or precancerous conditions, including cancers of the bladder, bowel, cervix and vulva.
- Other misdiagnosed conditions treated as urinary tract infections included lichen sclerosis, prolapse, menopausal symptoms, atrophic vaginitis, 15 cm pelvic mass, renal colic, ruptured ovarian cyst, bladder pain syndrome, pyelonephritis and interstitial cystitis.
- After misdiagnosis, inappropriate or ineffective use of antibiotics was the second most common complication. Of the 240 incidents reported to the survey, about 30% were related to antibiotics;
- Specifically, the comments focused on the resistance of bacteria causing UTIs to the prescribed antibiotic, on the prescription of repeated courses of the same antibiotic, and on the prescription of an antibiotic to which the patients were allergic.
- Through the survey, doctors reported eight cases where misdiagnosis or ineffective treatment led to hospitalization of patients with urosepsis or pyelonephritis.
- Three doctors said they saw complications in male patients being treated for UTIs despite the pilot being specifically limited to “uncomplicated cystitis in a non-pregnant woman.”
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