Will pharmacy prescribing improve healthcare?

Pharmacists do a great job as part of a healthcare team. In hospital and nursing homes, I get expert guidance on dosages of potentially dangerous medications. I am also fortunate to have community pharmacists on a secure electronic messaging platform to discuss issues around medication complications/interactions/dosages and so on for my patients. But, will it improve healthcare to let them treat minor conditions? I expressed my displeasure on Twitter about the recent move to allow pharmacists to treat certain minor ailments: A few pharmacists were not amused. It was pointed out to me that Ontario is one of the last provinces to allow this, and that it has “worked well” in other provinces. But what exactly is the definition of “working well?" Politicians love it, mostly because it allows them to say. 'See! we are taking steps to make your life easier.' Patients love it because they can say, 'Gee, I think I have a bladder infection, now I can just get the antibiotic when I want.' Of course patient satisfaction will be high. Unfortunately, as I wrote about a few years ago in the Huffington Post, patient satisfaction does NOT correlate with good healthcare or outcomes. As counter intuitive as it may seem, higher patient satisfaction scores correlate with a 9% higher cost per patient AND a 12% higher hospital readmission rate. Patient satisfaction should not be used as a metric to determine any healthcare policy. On Twitter, Nathan McCormick suggested that pharmacists have a lot to offer and linked to an article from New Brunswick on how it’s worked well there. Unfortunately, (and I stand ready to be corrected) the article suggests the diagnosis of urinary tract infections was made without a urine culture, or even a urine dipstick test (which is less accurate, but still something). So there’s no way to sort out how many people had a true bladder infection, or simply “felt” like they did, which does happen. The article also puts a strong focus on patient satisfaction and convenience, which as mentioned above, is not the same as good healthcare. Nardine Nakhla asked me to familiarize myself with an article she wrote about how Ontario developed the process. There’s a lot to like in what’s written there: A recognition of overprescription of antibiotics as a worldwide problem A focus on ethical-standards-based behaviour by pharmacists A minimum amount of training for pharmacists before treatment minor ailments The requirement for pharmacists to contact the family doctor or nurse practitioner when treating a minor ailment Once again, this doesn’t really reflect true healthcare outcomes. It also references the aforementioned New Brunswick article and specifically stated there was high patient satisfaction there. Let’s look at just one area of concern: antibiotic usage. Global overprescription of antibiotics is indeed a worldwide concern. It leads to increasing antibiotic resistance and the formation of new, drug resistant bacteria. A look at Canadian data shows that there is intra-provincial variation in the number of antibiotic prescriptions. Newfoundland, where pharmacists have been treating minor ailments for years, has the highest rate of antibiotic prescriptions. British Columbia, where pharmacists are expecting an expansion of their scope this spring, had the lowest. (From CMAJOpen: Interprovincial variation in antibiotic use in Canada, 2019: a retrospective cross-sectional study) Worldwide, of the 10 countries with the most antibiotic use, Cyprus, Romania and Greece allow them to be purchased directly from pharmacies. (I stuck to EU countries with more modern health systems for examples). Kristen Watt wrote a piece in the Medical Post criticizing physicians for complaining about these new powers and asked me on Twitter to provide evidence from other locations. She stated that Ontario was “15 years behind the trailblazing Alberta,” And yet the data in the CMAJ article above shows that Alberta has a higher rate of antibiotic prescriptions per capita. One area I do agree with her is when she wrote, “the government roll-out video, shot in a noticeable big box pharmacy, didn’t help us” That big box is Shoppers Drug Mart, and their CEO Jeff Leger is seen promoting this change on the video. Shoppers Drug Mart recently invested $75 million in Maple, a virtual care company. Gee, if you think you have a sore throat, you can just call a company (that Shoppers invested in), and get an antibiotic without a throat swab (who cares if it’s really strep) and lo and behold, there just happens to be Shoppers nearby that will deliver it to you. Yes, I know patients can request the pharmacy of their choice, but . . . Look, there are other aspects of this process that need review. Accurate diagnosis of a rash for example (several of the new pharmacist powers are for skin ailments). Or communication with the patient's family physician about the treatments given. Probably more. I WANT pharmacists to help. I really, truly am grateful that so many are willing to step up in a time where our healthcare system is collapsing faster every day. But I want pharmacists to help in ways that support good healthcare outcomes. Might I offer three suggestions for how pharmacists can do that: As a group, they can petition Shoppers Drug Mart to put pressure on Maple to change the example on their website. It’s great marketing (focusing on convenience) but terrible healthcare. Get involved with Choosing Wisely, Canada’s leading group looking at all ways to pick the right healthcare treatments. There doesn’t appear to be a pharmacist involved, looking at their leaders. I think pharmacists could provide extremely valuable information on not just anti-biotic stewardship, but also overall medication management (eg. reducing pill burden in the elderly, etc.). Strongly lobby the government for a unified integrated electronic health system that will allow them secure communication with physicians and access to limited healthcare data (eg creatinine clearance). We’ve got this in my neck of the woods, and it’s a huge benefit to physicians, pharmacists and most importantly patients. In order to save what’s left of our healthcare system (if that’s even possible now) we need to focus on outcomes, and ensuring proper an appropriate care. Doing the three things I listed above would be a big help in that direction.

Will pharmacy prescribing improve healthcare?

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