NQ Pharmacy Pilot: another way to stop doctors going rural

THE trouble-plagued North Queensland Pharmacy Pilot would exacerbate workforce shortages in the region, with more than 50% of GPs saying the Pilot and its consequences for patient safety would deter them from working in the area.

Respondents to an Australian Medical Association (AMA) Queensland survey were scathing of the Queensland Government trial allowing pharmacists to diagnose and sell prescriptions for urinary tract infections (UTIs).

In June 2020, Queensland Health started the 2-year Urinary Tract Infection Pharmacy Pilot – Queensland (Queensland-wide UTI pilot) allowing pharmacists across Queensland to provide treatment to women with a suspected UTI. This involves pharmacists diagnosing, prescribing and dispensing treatment for UTIs, following 120 hours of online training. Despite AMA Queensland, the Royal Australian College of GPs, the Australian College of Rural and Remote Medicine, the National Aboriginal Community Controlled Health Organisation and the North Queensland Primary Health Network withdrawing their involvement in the trial, the Queensland Government has expanded the trial for 6 more months starting from June 2022, on the basis of a Queensland University of Technology assessment which has not been released to the public.

This expansion would facilitate pharmacists’ autonomous prescribing for 23 conditions from June 2022.

The AMA Queensland survey had 1307 respondents, 52% of whom were GPs, 26% other specialists, and 12% doctors-in-training. The survey was open to all Queensland doctors from 18 to 28 March 2022. Access to the survey was publicised via the Queensland Doctors’ Community, the GP Alliance, the Australasian Medical Publishing Company (publishers of InSight+), the Business for Doctors Facebook group, local medical associations, and communications with AMA Queensland members via the Connect fortnightly newsletter and direct messaging.

More than 50% of the responding GPs said they were put off by the Pilot from going to North Queensland because of “expectations that GPs would need to ‘pick up the pieces’ and deal with the consequences of the Pilot, and the undermining of patient safety”.

Patient safety was the biggest objection to the Pilot by responding doctors, with 96% listing it as their number one concern.

With good reason – 240 patient complications have been reported as a result of the UTI pilot.

“Women did not receive the care they needed and an alarming number became more ill due to their participation in the trial,” said AMA Queensland president Professor Chris Perry.

“Bizarrely, three doctors reported seeing men with complications despite the pilot being specifically limited to ‘uncomplicated cystitis in non-pregnant women’.

“At least six pregnant women were sold antibiotics that are unsafe in the first trimester. One of them had a potentially life-threatening ectopic pregnancy.

“At least nine patients ended up in hospital with sepsis or kidney and bladder infections due to ineffective or delayed treatment.”

More than one-third of respondents to the AMA Queensland survey had pharmacy training before they undertook their medical degrees, and those respondents were the most scathing about the Pilot.

“As a pharmacist, I thought I could [diagnose and treat] and said this multiple times. However, having trained as a doctor, I realise how inadequate my knowledge and training was in the area of prescribing,” said one pharmacy-trained respondent.

“Pharmacists are not trained to diagnose or treat patients. Having studied both pharmacy and medicine, the latter involves two full-time clinical years seeing patients and learning how to take a history, perform a physical examination, order investigations and come to diagnostic and management decisions. This process is not able to be delivered at a pharmacy counter,” said another.

The AMA Queensland survey also found patients were not being completely honest in the pharmacy setting.

“A common theme among doctors’ comments, especially relating to misdiagnosis of [sexually transmissible infection (STIs)], was patients’ reluctance to provide full and frank information to a pharmacist in the presence of other customers or to discuss sexual history over the counter. Non-disclosure of sensitive or embarrassing information due to a lack of privacy may have contributed to misdiagnoses,” the survey authors reported.

Concerns were also expressed about conflict of interest, and upselling.

“Conflicts of interest related to potential financial incentives in both diagnosing and selling products were raised repeatedly. Similarly, doctors held concerns about upselling of non-essential products, and the potential for pharmacists to feel obliged to sell a medication for every condition even when conservative management would be more appropriate.”

Other findings from the AMA Queensland survey:

• The most common misdiagnosis related to the patient having an STI rather than a UTI. These included chlamydia, herpes and gonorrhoea. A number of patients were also reported to have pelvic inflammatory disease.
• Pregnancy was misdiagnosed as a UTI on at least six occasions, with a number of patients prescribed antibiotics that were unsafe in the first 12 weeks of pregnancy.
• One patient was reported to have been treated for UTI when her symptoms were actually related to an ectopic pregnancy.
• Cancerous conditions were overlooked on at least nine occasions, with doctors reporting incidents of patients being treated for UTI when the symptoms related to cancer or pre-cancerous conditions, including bladder, gut, cervical and vulval cancers.
• Other misdiagnosed conditions treated as UTI included lichen sclerosis, prolapse, menopausal symptoms, atrophic vaginitis, a 15 cm pelvic mass, renal colic, ruptured ovarian cyst, bladder pain syndrome, pyelonephritis and interstitial cystitis.
• After misdiagnosis, inappropriate or ineffective antibiotic use was the next most commonly occurring complication. Of the 240 incidents reported through the survey, approximately 30% related to antibiotics.;
• Specifically, comments related to the UTI-causing bacteria being resistant to the prescribed antibiotic, repeated courses of the same antibiotic being prescribed and patients being prescribed an antibiotic to which they were allergic.
• Through the survey, doctors reported eight cases where misdiagnosis or ineffective treatment resulted in hospitalisation of patients with urosepsis or pyelonephritis.
• Three doctors reported having seen complications in male patients treated for UTIs despite the pilot being specifically limited to “uncomplicated cystitis in a non-pregnant woman”.

Subscribe to the free InSight+ weekly newsletter here. It is available to all readers, not just registered medical practitioners.