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.
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.
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.