UTI pharmacy prescribing followed by extra GP visits

More than 40% of patients visited their GP within 28 days of taking part in a pharmacy prescribing consultation for uncomplicated urinary tract infections (UTIs), a newly published analysis has found.
 
The 278-page University of Newcastle evaluation of the Management of Urinary Tract Infections by Community Pharmacists trial, commissioned by NSW Health, was published this week alongside a similar appraisal of the state’s trial to allow pharmacists to resupply the oral contraceptive pill.
 
While most participants reported a positive experience, the RACGP cautioned against using the findings to justify a broader expansion of pharmacy prescribing.
 
The evaluations’ authors acknowledge the absence of a control group as ‘the main limitation’ of both trials, reducing their ability to compare the findings.
 
The participants in the UTI prescribing trial also skewed towards more affluent, metropolitan patients, as well as an older patient cohort.
 
The assessment of the UTI trial, which covered 10 months from 31 July 2023 to 31 May 2024, had its primary outcome as patients self-reporting they were symptom-free seven days after treatment.
 
It found of around 17,300 women who took part in consultations across 1028 participating pharmacies statewide, 79.4% of those who responded to follow-up said their symptoms had cleared up within a week.
 
While researchers found pharmacists referred 7.3% of patients to a GP or hospital emergency department, the numbers proved much higher with 43.2% in total seeing a GP within 28 days of the initial pharmacy consultation.
 
For RACGP NSW&ACT Chair Dr Rebekah Hoffman, the evaluations did not provide clear answers.  
  
‘They’ve done a trial, which arguably is significantly better than other jurisdictions … GPs have been involved in the co-design, which was excellent,’ she told newsGP.  
 
‘But I don’t think it’s actually answered the question, “is this needed?”    
   
‘Particularly when you look at UTIs where a really large proportion of people saw their GP within two days, which means there wasn’t an access problem, and they even still had to see their GP within a month.  
   
‘Again, what was the problem they’re trying to fix?’ 
 
For RACGP President Dr Michael Wright, the findings showed how patients valued improved access, but he said the results are a cause for concern on various levels.
 
‘Fundamentally, the way these trials are run, there is no control to understand what would have happened if we’d done nothing,’ he told newsGP.
 
‘Were the outcomes the same or would they have been better for people who weren’t in that control group?
 
‘That’s obviously one of the main flaws.
 
‘One of the problems we’ve also got is that we don’t actually know those treated with antibiotics did actually have a UTI in the first place, because there were no urine tests taken.’
 
Most participants did not express affordability concerns, but authors of the study found the majority were from higher socioeconomic groups, with few consultations in more remote areas.
 
Dr Wright queried whether the result show the promised potential for filling gaps in healthcare in rural and remote areas, and expressed concerns that the number of subsequent GP visits could indicate duplicated care.
 
‘You do have to wonder how effective the initial prescription was, although once again we don’t have the detail that would allow us to understand what the whole consult was for,’ he said.
 
The evaluation also looked into economic and antimicrobial resistance impacts, concluding it had saved more than $2 million of healthcare costs and that it is ‘highly unlikely’ the antibiotics prescribed had a significant impact on antimicrobial resistance.
 
Of the patients participating, 92.6% received antibiotics as part of the trial, with trimethoprim prescribed for 90.3% of all episodes.
 
At the same time, the evaluation found that more than one in four participants were already resistant to first-line antibiotics.
 
Since the trial took place, the authors note that clinical guidance changed for first-line treatments for UTIs last year, with trimethoprim now a third-line treatment.
 
Patients taking part in the trial reported an average out-of-pocket cost of $20, including for medication, with pharmacists paid $20 per consultation by NSW Health.
 
Affordability ‘remains a key concern’ for Aboriginal and Torres Strait Islander patients, authors warn, with out-of-pocket costs likely to act as a deterrent – and future pharmacy prescribing not likely to attract the same State Government subsidies.
 
The second evaluation covering the NSW pharmacy trial for the resupply of oral contraceptive pills showed a low take-up.
 
While 1299 pharmacies signed up, fewer than half held consultations, and 1946 patients participated overall during the trial period.
 
Around 95.2% of those patients received oral contraceptive resupply and reported high satisfaction ratings at around 91.6 out of 100, and very high adherence to the clinical protocol set out for the trial.
 
Again, there was no control group.
 
For Dr Hoffman the trial was ‘significantly more successful’ than the results shown in the UTI evaluation.   
  
‘There were people that were able to access medications and access them in a timely manner,’ she said.  
 
However, she queried the way success outcomes were measured, as well as raising concern about quality of care.  
 
‘We know that self-reporting isn’t a particularly good measure of determining either negative or positive outcomes,’ she said. 
  
‘And also, for that population of people, we’re talking about 18-to-35-year-old females, I almost never recommend the oral contraceptive pill as a first-line option for these patients.   
  
‘We’re usually talking about a long-acting reversible contraceptive.  
 
‘It’s the same argument that we’ve had when we're discussing the move to pharmacists initiating the contraceptive pill – it’s largely not appropriate for most women to talk about this as their first-line medication.’ 
 
In April, the NSW Government announced an expansion of oral contraceptive prescribing, with eligible pharmacists able to prescribe to women over 18 without the need for them to see their GP.
 
For Dr Wright, that move remains premature even with the publication of the recent research.
 
‘We certainly need much more evidence before we support this type of prescribing, let alone an expanded rollout,’ he said.
 
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New South Wales oral contraceptive pill pharmacy prescribing scope of practice UTI