Can pharmacists and doctors work together? YES WE CAN!

As frequent readers of this blog may know, I am very unimpressed with the recent pharmacy agreement negotiated by the Pharmacy Guild of Australia. We need more teamwork and integration of health services, not fragmentation, and therefore it’s a real shame the Health Minister has signed off on this deal with the pharmacy owners union.

A better proposal has come from the Pharmaceutical Society of Australia (PSA) and the Australian Medical Association. For those who don’t know: The PSA represents Australia’s 28,000 pharmacists working in all sectors and across all locations. The new model encourages close collaboration between pharmacists and GPs.

The PSA and AMA recommend integration of non-dispensing pharmacists in general practice, to improve medication management. The idea is not new. Doctors and pharmacists have argued for this model in the past. There is enough evidence to support collaboration as a way to improve patient care.

Here are the aims of the cooperative model:

  • Medication management reviews conducted in the practice, an Aboriginal Health Service, the home or a Residential Aged Care Facility
  • Patient medication advice to facilitate increased medication compliance and medication optimisation
  • Supporting GP prescribing
  • Liaising with outreach services and hospitals when patients with complex medication regimes are discharged from hospital
  • Updating GPs on new drugs
  • Quality or medication safety audits
  • Developing and managing drug safety monitoring systems.

The evidence

Medication reviews by a pharmacists in the hospital do not appear to reduce mortality or hospital readmissions, although they seem to reduce emergency department contacts. Similarly, medication reviews for nursing home residents do not to reduce mortality or hospitalisation – which is disappointing.

However, in these studies pharmacists and doctors are not working closely together as suggested by the PSA and AMA. This matters because studies have shown that doctors are more likely to change their medication management when there is a close collaboration with a pharmacist. This is not surprising as the basic requirements for effective teams are mutual trust, good communication and shared ideas.

A systematic review of pharmacists working in collaboration with GPs showed significant improvements in blood pressure, diabetes control, cholesterol levels and cardiovascular risk. Another review suggested similar benefits as well as a positive impact on drug-related problems.

A recent trial confirmed that pharmacists working in primary health clinics are succesful in identifying and resolving medication related problems and improving medication adherance. The PINCER trial concluded that pharmacist feedback, educational outreach and dedicated support in a general practice setting was cost-effective and reduced medication errors.

Whether the pharmacist-doctor partnership reduces hospital admissions is less clear-cut. An independent analysis by Deloitte Access Economics (commissioned by the AMA) suggests that every $1 invested in the PSA-AMA model would generate $1.56 in savings to the health system, delivering a net saving of $544.8 million over four years.

The benefits

I spoke to Dr Steve Wilson, Chairman of the AMA (WA) Council of General Practice and senior Lecturer at the School of Medicine, University of Notre Dame.

“We recognised the need for, and the advantage of, having pharmacists within the practice team,” says Wilson. “We have looked at both sides of the coin, the good and the bad, advantages and risks. We have explored the various financial models, for example whether pharmacists should be employed directly, or contracted, and whether to follow the Practice Nurse incentive Payment model or the Mental Health Nurse model.”

Dr Wilson said the strengths of the proposal are:

  • Quality use of medications as over-arching principle
  • In-house reviews as opposed to out-of-house
  • Medication interaction checking
  • Reviewing the currency of medications, for example deleting old antibiotics still on the list
  • Screening for adverse medication events or omissions such as whether medications can be reduced or stopped, or whether certain checks have been performed
  • Checking currency of tests, for example renal function for those on diuretics
  • Explaining medications to people, for example what side effects to look for
  • Working with those from culturally and linguistically diverse people or a non-English speaking background, people more than five medications, people with early cognitive impairment etc
  • Quality Use of Medications meetings within the practice, attracting CPD points

The Pharmacist in General Practice Incentive (PIGPI) system would be structured in the same way as the existing incentive payments provided for nurses working in general practice.

Dr Wilson: “The risk of the program is low, it’s voluntary, doctors and patients don’t have to participate. It’s up to the GP practice to make it work and customise it to their circumstances. There are financial incentives for rural practices. Also practices can share a pharmacist, particularly when closely located to one another.”

“The evidence will build over time. The evaluation component will require input from hospitals and there may be a role for the Primary Health Networks and Local Hospital Networks.”

The proposal has been welcomed by the Consumers Health Forum (they’re requesting feedback here). Although there are clear benefits for patients, evidence-based medicine purists may argue that the evidence for cost-savings through a cooperative model is thin. However, the alternative may be no change at all.

3 examples why health professionals should be online

It was an interesting week to say the least. I was so sorry to hear about the death of 21-year Eloise Parru, who accidentally took an overdose of slimming pills she purchased online. The pills contained a dangerous substance, dinitrophenol or DNP.

The amount of online advertising of drugs and medical devices is overwhelming. Unfortunately buying medications over the internet is a risky business. They can be fake, contain too much or too little of the active ingredient, or they may contain toxic chemicals. There is no doctor or pharmacist to give reliable advice on how to take the drugs and what adverse reactions to look out for.

The Therapeutic Goods Administration has an excellent website explaining the risks of buying medications on international websites. My advice: never do it.

Health blogger and founder of a best-selling health app Belle Gibson was a very influential woman – but unfortunately she made things up. In a recent interview she confessed that she never had cancer and wasn’t cured by natural remedies. The media are all over her, and so far she has not apologised for misleading her followers. I wonder what is going on here.

Online health scams are numerous. As the wellness industry is largely unregulated, I’m afraid this will not change.

forced penetration
Image: Sydney Morning Herald

The Australian vaccination skeptics network was in the news again after it compared vaccinations to ‘forced penetration’. A shocking image (see above) was posted on the Facebook page of the anti-vaccination group to convey their controversial message. It has caused a public outrage, which is probably a good thing. I don’t think it has done the group any good.

A while ago I blogged about the 6 warning signs that online health information may be unreliable and as I said before: don’t rely on one source of information and always ask a registered doctor or health professional if you’re not sure.

I believe we need more health professionals and health organisations promoting reliable, evidence-based information in the online space – including social media – to counterbalance the many untrustworthy health messages.

What do you think?

Doctor, do I have to stay on these medications?

This is the first article in the ‘Blogging on Demand’ series. If you have a topic you want me to blog about, feel free to send an email, contact me via social media or leave a comment below. Jen Morris picked the topic of this post. She tweeted me saying: “I’d love a GP view on polypharmacy, deprescribing & importance of reviewing and stopping treatment, not just continuing indefinitely.”

I really like this topic. I’ll explain why. It’s fair to say I have a love-hate relationship with medications. They can do a lot of good, but also cause misery. Prescribing drugs is a bit like cooking, and getting the balance of the different ingredients right an art: Use too little and your dinner guests are unimpressed, use too much and it becomes unpalatable.

There are many guidelines in medicine informing us when to use which ingredients, but unlike cooking books, they never tell when a dish should be taken out of the oven, or, in other words, when to stop treatment. This is odd, especially as patients often rightly ask: “Doctor, do I have to stay on these medications for the rest of my life?”

Here is a summary of the why, when and how to stop long-term medications – based on the limited amount of evidence available. For more information I refer to the sources mentioned below.

#1: Why stop medications?

Research shows that elderly people often feel better after their medication is discontinued. One study found that only 2% of the medications had to be restarted because the original symptoms reoccurred. This suggests that many people take medications unnecessarily.

It is estimated that up to 30% of hospital admissions for elderly patients are related to the medications they take. Reviewing the medication list periodically is therefore important, for example after the annual home medication review by the pharmacist.

#2: When to consider stopping

There may be good reasons why, after review, it is better to continue long-term medications. But there are 5 circumstances when stopping should be considered:

  1. A patient is taking multiple (more than 4) drugs
  2. An adverse drug reaction is suspected
  3. The drug doesn’t work (anymore)
  4. A patient experiences falls or cognitive decline
  5. The condition of the patient improves or worsens dramatically.

 #3: How to stop

Deprescribing can be done safely, but is not without risks. Withdrawal symptoms, rebound syndromes and reappearance of the original symptoms may occur. Medication withdrawal should be undertaken in consultation with a doctor.

The literature suggests different methods, but I particularly like the following simple 5-step approach:

  1. Prepare: Always consider the option of deprescribing at the start of a therapy, in case it is required later on.
  2. Recognise the need to stop: are any of the above mentioned 5 circumstances applicable?
  3. Prioritise one drug at a time to stop.
  4. Wean, especially benzodiazepines, opioids, beta blockers, corticosteroids, and levodopa.
  5. Monitor: Look out for withdrawal symptoms, discontinuation and rebound syndromes, reoccurrence of illness, falls, and changes in cognition and quality of life.

Research into deprescribing has mainly been done in elderly people taking multiple drugs. I believe it is not unreasonable to apply the same principles to younger people, even if they are on a smaller amount of long-term medications.

I always find it extremely satisfying if we manage to cut the number or dose of someone’s medications – and most patients seem to be equally pleased. Less is sometimes more.

Thanks to Jen Morris for the topic suggestion.

Is the new eRx electronic prescription service beneficial to consumers?

About ten years ago I did a locum in an innovative GP practice in The Netherlands. When prescribing medications, the computer system allowed me to either print the script and hand it to my patient, or send it electronically to the pharmacy. Consumers who elected the second option, were able to collect their medications at the pharmacy twenty minutes later.

I’m not sure how secure the system was, but it was easy to use, saved a lot of paper, and prevented lost scripts and medication errors.

ePrescribing in Australia

Here in Australia doctors are printing or handwriting scripts. This month however I noticed a little QR code in the top right corner after printing a script. It took me a while to figure out what it was for: Patients can scan this code with a mobile device, submit the information electronically to the pharmacy of their choice and pick the script up on a preferred day and time.

eRx express
Source: erxexpress.com.au

The app, developed by the Fred IT Group, is called eRx Express. It can be downloaded for free on mobile devices. It seems that the benefit for health consumers is reduced waiting time at the pharmacy – which is great, especially if people have already been waiting to see their doctor.

I also have a few reservations…

First of all, consumers have to scan and send information via their smart phones, and they still need to bring in the paper script when collecting their medicines at the pharmacy. So it involves a few more steps and we’re not yet saving trees.

Second, as always, I would like to know what happens with the data during and after scanning, transmission over the internet and on the servers of the Fred IT Group and others. Is the information sold or disclosed to third parties?

It would be good if consumer details and their prescription history would not be collected or used for other purposes. But usually, when something is free, we become the product. In other words, there is often a price to pay with regards to our personal data.

The small print

So, after a little search I found this information in the patient terms and conditions and the privacy policy:

You agree that we may disclose your de-identified prescription data to selected third parties for the research and marketing purposes of those third parties.

We do not warrant (…) that any data transmissions between you and us will be secure and that any data you send us shall at all times remain secure.

We reserve the right to (…) charge for the App or service provided to you at any time and for any reason (whether stated or not).

Conclusion

As long as private or governmental organisations want control of our health data for other purposes than patient care, eHealth initiatives will not take off. Of course health consumers are free to use this service, but at the moment the benefits do not seem to outweigh the risks.