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‘Serious concerns’: RACGP criticises pharmacy pain trial
Issues related to fragmentation and the quality of care provided were highlighted in a detailed college submission to the MSAC.
The RACGP identified a number of what it said were flaws in the trial’s design.
A new RACGP submission has identified a host of issues related to a pharmacist-led trial that was aimed at patients taking medication to manage chronic pain.
The Chronic Pain MedsCheck (CPMC) Trial, which began recruiting patients in November 2018 and continued through to February 2020, focused on reviewing participant’s medications and providing education and information to improve the self-management of chronic pain.
Established and implemented by the Pharmacy Guild with the support of a Department of Health grant, the trial involved two groups receiving face-to-face in-pharmacy consultations.
Participants in the first group were offered an initial consultation as well as a follow-up three months later, while the second group also received an additional phone consultation six weeks after the first point of contact. To be eligible, participants had to have been experiencing pain for more than three months.
In its submission, the college said it supports ‘improving access to high-quality care for people living with chronic pain’, but that it has ‘serious concerns’ with the CPMC model and its potential to shift chronic pain diagnosis and management away from medically trained professionals.
In particular, the RACGP said such an approach could lead to isolation and fragmentation of patient care, as chronic pain is ‘best managed through a medical specialist-led multidisciplinary approach’.
There are also concerns around the fact that chronic pain can be difficult to diagnose and may potentially present as a symptom of other conditions.
‘PainAustralia recommends people with chronic pain receive coordinated interdisciplinary assessment and management involving, at a minimum, physical, psychological, and social/environmental risk factors in each patient,’ the submission states.
‘This type of assessment and management sits beyond the scope and training of pharmacists and should remain with medical specialist-led multidisciplinary teams.
‘The CPMC model isolates chronic pain care under a single practitioner model. It does not provide opportunities for confidential discussions about the serious issues that can be associated with chronic pain, nor appropriate pathways to address these issues by more specialised medical professionals and services.’
In addition to doubts over whether pharmacists would be able to replace the care provided by multidisciplinary teams, the college had concerns over ‘potential financial interests in pharmacy’ and the impact it can have on care.
‘In the CPMC Trial, recommending non-pharmacological interventions would result in the pharmacist potentially missing out on additional income,’ the submission states.
‘This represents a clear conflict of interest for participating pharmacists.
‘Given the importance of exploring non-pharmacological interventions for chronic pain, this is a significant and unresolved issue with the trialled CPMC model.’
Of the 1630 pharmacies that registered, 1042 (63.9%) completed the training required to participate, while only 550 pharmacies (33.7%) had at least one participant commence the trial and complete their initial consultation.
In all, 8239 people registered for the trial, but only 53.1% of participants (4374) across both groups received their three-month follow up consultation.
The RACGP said the high drop-out rate ‘could be reflective’ of poor recruitment and governance processes, as well as inadequate quality of care and advice provided throughout the trial. The submission also says it may indicate that many participants did not find the program acceptable and useful.
Another issue raised by the college is that the trial did not incorporate formal links back to general practice to ensure continuity of care.
‘This can result in missed diagnoses, inappropriate prescribing, duplication of tests, missed opportunities for preventive care activities, poorer patient outcomes and increased costs for the health system,’ according to the submission.
‘Continuity of care is linked to better patient–provider relationships, better uptake of preventive care, increased access to care, and reduced healthcare use and costs.
‘It is important to have one person who serves as the primary care doctor – someone who is familiar with the person’s medical history and can coordinate the patient’s overall medical care.
‘The GP is ideally placed to take on this role and ensure care is continuous and coordinated.’
Prior to any continuation of the CPMC, there should be a detailed investigation into what impact the trial’s lack of referral to general practice services had, the RACGP said.
The submission concluded by highlighting what the college said were ‘issues with the trial design and findings’, including (but not limited to):
- no formal control group
- that the analysis of outcomes was only conducted on participants that had a second face-to-face meeting
- that the three-month follow up data is not long enough to determine the medium- to long-term impact on patient outcomes
- inadequate inclusion/exclusion criteria
- a failure to identify regression to the mean.
The Medical Services Advisory Committee (MSAC) will consider all submissions related to the trial at a meeting next month as part of an independent Health Technology Assessment to determine its effectiveness and cost-effectiveness, and inform decisions about any broader rollout.
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