Doctors respond to leaked pharmacy UTI report

Jolyon Attwooll

17/05/2022 4:55:21 PM

A leaked evaluation of the Queensland UTI prescribing pilot reportedly indicates nearly two thirds of participants were not followed up.

Pharmacist reaching for antibiotics.
Almost two-thirds of the women who took part in the UTI prescribing trial were reportedly not reached for follow-up.

The Australian has reported on a leaked draft evaluation of Queensland Health’s UTI pharmacy prescribing pilot program, which was introduced in June 2020.  
Almost two-thirds of the women who took part in the UTI prescribing trial were not reached for follow-up, according to the article.
It indicates 4342 of participants (64% of the total cited in the report) were not reached for comment after being treated at one of more than 800 participating pharmacies that have been allowed to diagnose and prescribe antibiotics to treat uncomplicated UTI as part of the trial.
The report also suggests that 13% of patients who were reached had unresolved symptoms.
According to The Australian, there were 2409 patients successfully contacted, with 87% of those reported as saying their symptoms had been resolved by antibiotics.
A previous report in Australian Doctor indicated the follow-up consisted of ‘three “reasonable” attempts’ to contact patients seven days after the consultation.
This week’s article in The Australian states that 184 women did not have any resolution of their symptoms but had gone for care elsewhere, while another 86 were ‘verbally referred’ to their GP by the pharmacist.
Those 270 patients account for 11% of the total of 2409 reportedly reached by pharmacists. It is not clear how the remaining 2% are accounted for.
The implementation of the trial was led by the Queensland University of Technology (QUT)’s head of clinical sciences Professor Lisa Nissen. Professor Nissen, who received a Pharmacy Guild award last October for ‘successfully guiding’ the UTI pilot, also wrote the report evaluating its apparent success.

Professor Lisa Nissen, centre, accepting her Pharmacy Guild award alongside former Queensland Chief Health Officer Jeanette Young and Guild senior manager Nicole Floyd. (Image: Pharmacy Guild of Australia)
According to The Australian, the 126-page document was ‘overwhelmingly supportive of the trial’.
Leaked results
The evaluation reportedly references four patients visiting a hospital emergency department after being prescribed antibiotics as part of the trial.
This included one who had an allergic reaction, another diagnosed with a ‘superbug’, another given IV antibiotics, and another who was admitted with appendicitis.
RACGP Vice President and Queensland Chair Dr Bruce Willett said the gist of the report is ‘hardly surprising’.
‘Essentially we have a poorly designed trial with a stated outcome from the beginning resulting in a recommendation for pharmacists by a pharmacist on self-reporting by other pharmacists with no independent assessment of patient outcomes,’ he told newsGP.
‘Hardly an independent, well informed or surprising outcome.’
Dr Willett said the lack of response among patients undermines the trial and also wondered if the issues of antibiotic stewardship and potential conflict of interest had been considered by those looking at the evaluation study.
The QUT were approached by newsGP for further information on the timings and assessment of the report, whether they were comfortable with the way the evaluation was conducted, as well as for confirmation of the details published in The Australian.
However, the university did not respond prior to publication.
Meanwhile, Professor Paul Glasziou, the director of Bond University’s Institute for Evidence Based Healthcare, told newsGP it was not easy to draw any conclusions about the number of patients reported as having ongoing symptoms.
‘I would assume [they] were either resistant infections or misdiagnosis, but [it is] hard to know the split,’ he said.
Professor Glasziou directed newsGP to a previous study he co-authored in the British Medical Journal which noted the efficacy of UTI self-diagnosis in recurrent infections – but highlighted a lack of evidence for those with first infections.
It cited a 92% cure rate from the first antibiotic for those with confirmed cases of uncomplicated UTI.
Last week, the Australian Medical Association Queensland (AMAQ) published a detailed summary of a survey it distributed to doctors’ groups throughout the state which raised a number of concerns about the trial.
Their report, collated from 1307 survey responses, cited ‘at least 239 patients’ having complications after seeing a pharmacist involved in the Queensland UTI prescribing trial.
The most common issues raised in the survey were misdiagnosis, with 73 reported cases of conditions including chlamydia, herpes and gonorrhoea as well as an ectopic pregnancy allegedly taken as UTI.
Pregnancy was labelled UTI on at least six occasions, the AMAQ said.
There has been some confusion over the exact status of the evaluation, with Australian Doctor saying it had been written in January, while the QUT last week said it was yet to be forwarded to Queensland Health.
The timing of the leaked evaluation report closely mirrored a meeting this week between advocacy groups including the AMAQ, the RACGP, and the Queensland Minister for Health Yvette D’Ath.
The outcomes of the UTI trial had not previously made public, apart from being described as a ‘success’ when a six-month extension was announced at the start of this year.
Earlier this month the Pharmacy Guild also stated it ‘understands the independent evaluation report has found the UTI pilot met all the safety standards required’.
The Guild declined to comment to newsGP earlier on how they gained an understanding of an unpublished report it described as ‘independent’.
Queensland Health also declined to answer any further questions on the evaluation report, its timing and if they would release it publicly, when approached by newsGP last week.
A spokesperson previously said that exact details and timings of a proposed North Queensland pharmacy prescribing pilot – which would give further prescribing responsibilities to pharmacists – were yet to be confirmed.
The AMAQ meanwhile said it would not comment on the details of The Australian article.
‘We aren’t prepared to comment on a report we haven’t seen,’ a spokesperson told newsGP. ‘We are still calling on Queensland Health to publicly release the report.’
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Dr Oliver Ralph Frank   18/05/2022 9:31:00 AM

"According to The Australian, there were 2409 patients successfully contacted, with 87% of those reported as saying their symptoms had been resolved by antibiotics." This is making an assumption that is likely to be untrue in at least some and possibly many cases.

It should have more accurately been reported as: ""According to The Australian, there were 2409 patients successfully contacted, with 87% of those reported as saying that they had used an antibiotic and that their symptoms had been resolved." Without any control group who did receive antibiotics, we don't know how many of those patients' symptoms would have resolved anyway.

Dr Andrew Carr   18/05/2022 9:57:20 AM

Do we have evidence that the outcomes are better for uncomplicated UTI in General Practice?

If we do not have robust evidence to suggest that, then isn't it about time we stop pretending this is about patient care and acknowledge this is about business? It's upsetting to see 2 peak healthcare bodies clash as they approach healthcare as if it were a zero sum game. Shouldn't a sustainable healthcare model be about collaboration, not turf wars?
Are we honestly suggesting that there have been no attendances at a GP where there has been cause to revise the diagnosis at a later stage? Does every GP really enforce that the patient not leave the practice until they have produced a urine specimen to dipstick thereby 'proving a UTI', even when the patient says "they can't go right now"?
No, of course they don't. That's nonsense.

We need to start trusting that sometimes, patients have actually worked out what is going on with their body.