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Pharmacy diabetes trial creating ‘serious concerns’
The RACGP has slammed a plan to screen for the disease in pharmacies, saying it could fragment care and put vulnerable patients at risk.
The trial’s initial clinical results saw 14,093 people screened for type 2 diabetes across 339 pharmacies.
Additional costs, duplication of services, and a reduction in care are among the college’s chief concerns about a controversial Pharmacy Diabetes Screening Trial (PDST).
The trial, funded through the Sixth Community Pharmacy Agreement and due to be assessed by the Medical Services Advisory Committee (MSAC) next month, is comparing the effectiveness and cost-effectiveness of three different pharmacy-based diabetes screening models:
- the paper-based AUSDRISK assessment of diabetes risk
- the AUSDRISK followed by a point-of-care HbA1c test
- the AUSDRISK followed by a point-of-care scBGT.
Those with an AUSDRISK score of 12 and above were referred to their GP for further testing.
In 2022,
the trial’s initial clinical results saw 14,093 people screened in 339 pharmacies, with 136 referred participants diagnosed with type 2 diabetes and 338 diagnosed with prediabetes.
Researchers concluded the AUSDRISK followed by a point-of-care HbA1c test is the preferred option for type 2 diabetes screening in pharmacies.
However,
a new RACGP submission has raised significant concerns about the ‘evidence-base underpinning the screening protocol’ and its consequences.
‘The RACGP has serious concerns within this pharmacy trial and the potential for the model to fragment patient care and reduce the comprehensiveness of care,’ the submission said.
‘Opportunistic screening in pharmacy also creates another cost pillar and potential duplication of services.
‘In addition, opportunities to emphasise lifestyle interventions, screen for cardiovascular risks and case-find for mental illness are lost if the person does not see their GP.’
The outcomes of the trial will now undergo an independent Health Technology Assessment (HTA), with a final decision to fund any future programs decided by the Federal Government.
Dr Gary Deed is Chair of RACGP Specific Interests Diabetes and was also on the trial’s steering committee. Rather than risk further fragmenting care, he believes GPs should be incentivised to provide this level of screening, which would have the added benefit of providing patients with ongoing care.
‘The trial did not provide any evidence that pharmacists could provide better support to any identified high-risk individuals than that which exists within the realms of primary care,’ he told
newsGP.
‘It was a “black box” screening trial without acknowledgement of the key role of the continuum that general practice plays in health prevention, and ongoing diagnosis and management that is required to support these risk persons.
‘The RACGP has been shouting for years for health administrators to see this essential fact – that fragmentation has flow-on effects to quality care for people such as those at risk of diabetes.’
The college’s submission raised specific concerns about the participants considered in the trial, who were all adults aged between 35–74 years who did not have a history of diabetes or prediabetes and had not been screened for diabetes in the past 12 months.
‘This implies that people could be screened every year, more often than recommended by evidence-based guidelines,’ it said.
‘The PDST service encourages one-off, opportunistic screening for a single medical condition without the background biopsychosocial information of the individual and history of previous screening.
‘The proposed pharmacy service model has the potential to fragment patient care.’
It also said it remains unclear how many PDST participants were already known by their GP, had a recent diabetes test and were engaged in regular monitoring.
The college likewise held concerns around a selection bias in the trial, with participants engaged in the screening already at moderate risk compared to the general population.
The trial is one of a number of pilot programs currently being rolled out in pharmacies across Australia, including prescribing for urinary tract infections (UTIs) and the contraceptive pill.
In New South Wales alone, since May last year when the UTI stage of the trial began,
11,296 consultations occurred across 937 pharmacies.
However,
the programs have drawn the ire of GPs, with many raising concerns about patient safety and continuity of care.
Dr Deed said moving forward, embedding pharmacists within general practices would allow for integration rather than fragmentation.
In terms of the diabetes trial, he said GPs already have the skills to treat the condition, but need support, not ‘competing programs running in different directions’.
‘Pharmacists can provide simple screenings within their scope of practice, but ultimately there needs to be a primary care link to allow for diagnostic assessment,’ Dr Deed said.
‘Fragmentation and diversion of funding to low-evidence schemes … is not the best application of evidence-based quality of care for people who are at risk of diabetes or living with diabetes.
‘Diabetes, once diagnosed, requires a dedicated level of care.
‘General practice is a core element in supporting each person with diabetes, inter-connecting necessary support services, monitoring goals, and preventing and assessing for complications.’
The RACGP has previously provided a separate submission to the trial, saying screening within a pharmacy setting is an ‘inequitable model of care that limits availability of the service’.
The submission is set to be considered by MSAC next month.
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