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Twenty unanswered questions: College interrogates UTI pilot


Jolyon Attwooll


22/07/2022 3:55:40 PM

‘For the sake of patient safety’, the RACGP has again urged Queensland Health to reconsider its decision to continue UTI pharmacy prescribing.

Pharmacist with drugs
The Queensland Government has made the decision to continue the trial indefinitely.

The RACGP has submitted a comprehensive critique of Queensland Health’s decision to make the UTI pharmacy prescribing trial permanent.
 
The document, sent to the Acting Director General of Queensland Health this week, raises a host of wide-ranging issues, including unanswered queries over protocol and the evidence gathered.
 
‘We are very concerned that the proposed reforms to health policy have been decided on such poor-quality evidence and will result in poor health outcomes for patients,’ the submission, which is signed by the RACGP Vice President and Queensland Chair Dr Bruce Willett, states.
 
‘We strongly urge the Queensland Government to reconsider this decision as a matter of priority, so that patient safety is not further compromised.’
 
The main issues are summarised in 20 questions, which highlight issues ranging from the trial protocol to concerns over antimicrobial stewardship.
 
The submission also challenges findings from an 118-page evaluation of the Urinary Tract Infection Pharmacy Pilot (UTIPP-Q) trial – authored by the Queensland University of Technology’s Professor Lisa Nissen, who also oversaw the implementation of the trial – which began in June 2020 for 18 months and was extended until the end of June.
 
The much sought-after evaluation was published for the first time earlier this month, days before Queensland Health confirmed that the trial would continue on a permanent basis.
 
The college criticised the capacity to contribute to consultation following the decision to continue prescribing as ‘severely limited’.
 
‘The RACGP believes this feedback should have been undertaken prior to Queensland Government announcements about making this arrangement permanent,’ the document states.
 
The issue of antimicrobial stewardship features prominently in the submission, as does the absence of external regulatory oversight.
 
‘The pharmacist will not be performing this [antimicrobial stewardship] role if they are prescribing,’ the college states.
 
‘[The Queensland] Government has not provided a legislative mechanism to provide external regulatory oversight for pharmacists prescribing, meaning there is no pathway by which inappropriate prescribing can be reviewed.’
 
The college also urges pharmacists ‘be held to the same standard as GPs if providing similar services’.
 
Fragmentation of care is another issue raised, with the RACGP asking the State Government how record-keeping requirements will be maintained.
 
The submission also raises an imbalance in prescribing activity, highlighting that of the 817 pharmacies that took part, just five provided around 10% of the scripts during the pilot.
 
‘This is certainly an outlier group to which the report offers little to no explanation,’ it states.
 
Concerns over possible conflicts of interest are raised, with the college warning that ‘commercial interests can influence the health advice provided by pharmacists’.
 
‘The report stated that half of the pharmacist respondents found charging a $19.95 service fee difficult when they did not supply the antibiotic,’ the submission says.
 
‘If pharmacists can only feel comfortable to recoup their service costs when prescribing, this significantly risks overprescribing [the report shows 96% of women received antibiotics].
 
‘This cannot be ignored and demonstrates potential for further over-prescribing now that this has been made permanent.’
 
A series of questions are posed about the scheme’s adherence to Pharmacy Board recommendations for prescribing, including management of conflicts of interest, access to patient records, and ensuring independent checks and balances.
 
The submission also requests clarity from the Queensland Government on the education and training of pharmacists providing the UTI prescribing service.
 
It cites unease surrounding the number of interns, new graduates or first year pharmacists ‘with limited pharmacy experience’, who may prescribe for UTIs as well as collect clinical information.
 
Concerns over patient outcomes
A ‘major failing’ of the trial, according to the college submission, is the absence of any process to assess if there had been a urine infection in the first place, and whether an antibiotic was needed at all, or if the appropriate antibiotic had been prescribed.
 
The evaluation report shows that 13% of those who responded to follow-up did not have their symptoms resolved.
 
‘The failure to resolve UTI symptoms in 13% of “uncomplicated” cases is clinically significant,’ the college submission states.
 
Among the concerns raised over protocol is the detail, included in the evaluation, that 43 patients were not referred to a GP ‘even though they had reported to the pharmacist they had not had a resolution of their symptoms and had not sought further care’.
 
There were also 40 women who sought further care outside of general practice, according to data collected from follow-up queries.
 
‘The study has not provided information on where these women sought care, though it appears that at least four have volunteered the information that they attended an emergency department,’ the RACGP states in its submission.
 
‘Presumably many, if not all, of the remaining women also attended an emergency department.’
 
Another cause for concern is the fact that 112 patients who had unresolved symptoms and attended a GP received a further antibiotic.
 
‘The study claims this is in keeping with normal UTI management; however, the study does not state what type of antibiotics were given or their indication,’ it states.
 
‘Many, if not all, of these antibiotics may have been given to treat STIs or other non-UTI conditions that were undiagnosed by the pharmacist.
 
‘If this is the case, then the research was incomplete and did not appropriately identify adverse outcomes.’
 
The report mentions that a urine test was not carried out among 52 of the 144 patients who attended a GP with unresolved symptoms.
 
‘This suggests 36.1% who went on to see their GP may have had an obvious non-UTI cause for their symptoms and were inappropriately prescribed antibiotics by the pharmacist,’ the college states.
 
‘The GP was left to manage the treatment failures.’
 
In its submission, the RACGP requests a further meeting with the Queensland Government and Queensland Health to discuss the concerns raised.

The full document can be read on the RACGP website.
 
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Dr Adele Frances Stewart   23/07/2022 8:25:08 AM

GP’s are ridiculously busy and need help AND It seems astonishing and frankly dangerous in a first world country that this poorly thought out plan is .going ahead. Is there anything we grassroots GP’s can do? Is there someone we can write to? I was so shocked to hear that it is actually going ahead.


Dr Peter James Strickland   23/07/2022 4:16:59 PM

The problem with this report is indicated by this Prof Lisa Nissen is the failure to know what an uncomplicated UTI really is. As an example I have many patients with what seemed to be a minor UTI with symptoms only of slight dysuria and smell or colour change of the urine. In one case the patient had a staghorn calculus in the kidney due to Proteus mirabilis alkalising affect causing the stone. This case ended up in partial nephrectomy/adrenalectomy, and needing months of rehabilitation. UTIs HAVE to be evaluated fully by a doctor, and then reviewed by a doctor in almost all cases. In another case of mild UTIs (recurrent) the young woman had massive urinary reflux due to double ureters, and required surgery also.


Dr Tawhid Mohamed Sayed Hassanien   23/07/2022 10:25:43 PM

what is AHPRA position ? are not they suppose to protect patients' safety ? it is strange that politicians decide who treat who. is it time we have a politician as a head of the RACGP ?


Dr Bruce Philip Willett   24/07/2022 9:15:39 PM

Adele, I think there is something grass-roots GP s can do. Encourage patients with poor outcomes or who have first hand knowledge of pharmacies abusing this system, like providing antibiotics for other conditions to report this and let me know.
bruce.willett@racgp.org.au