Home Pharmacy practice Twenty unanswered questions: a college interviews a UTI pilot

Twenty unanswered questions: a college interviews a UTI pilot



“In the interest of patient safety”, the RACGP has again urged Queensland Health to reconsider its decision to continue prescribing UTIs in pharmacies.

The Queensland Government has made the decision to continue the trial indefinitely.

The RACGP has submitted a full critique of Queensland Health’s decision to make the UTI pharmacy prescription trial permanent.

The document, sent to Queensland Health’s acting chief executive this week, raises a host of high-profile questions, including unanswered questions about the protocol and the evidence collected.

“We are very concerned that the proposed health policy reforms have been decided on the basis of such poor quality evidence and are resulting in poor health outcomes for patients,” said the document, signed by RACGP Vice President and Queensland President, Dr Bruce Willett, States.

“We strongly urge the Queensland Government to reconsider this decision as a matter of priority, so that patient safety is not further compromised.”

Key issues are summarized in 20 questions, which highlight issues ranging from trial protocol to antimicrobial stewardship concerns.

The submission also challenges the results of a 118-page review of the Urinary Tract Infection Pharmacy Pilot Trial (UTIPP-Q) – authored by Professor Lisa Nissen of Queensland University of Technology, who also oversaw the implementation of the trial – which started in June 2020 for 18 months and was extended until the end of June.

The much-sought assessment was first published earlier this month, days before Queensland Health confirmed the trial would continue on a permanent basis.

The college criticized the ability to contribute to counseling following the decision to continue prescribing as being “severely limited”.

“The RACGP believes that these comments should have been undertaken prior to announcements from the Queensland Government regarding the continuation of this arrangement,” the document said.

The issue of antimicrobial stewardship features prominently in the submission, as does the lack of external regulatory oversight.

‘The pharmacist will not perform this [antimicrobial stewardship] role if they prescribe,” the college states.

‘[The Queensland] The government has not provided a legislative mechanism to provide external regulatory oversight for pharmacists who prescribe, meaning there is no avenue by which inappropriate prescribing can be reviewed.

The college also urges pharmacists ‘to be held to the same standard as GPs if they provide similar services’.

Fragmentation of care is another issue raised, with the RACGP asking the state government how record-keeping requirements will be maintained.

The submission also raises an imbalance in prescribing activity, pointing out that of the 817 pharmacies that participated, only five provided around 10% of the scripts during the pilot.

“This is certainly an outlier group to which the report offers little or no explanation,” he says.

Concerns about possible conflicts of interest are being raised, with the college warning that “commercial interests can influence the health advice provided by pharmacists”.

“The report indicates that half of the pharmacists surveyed find it difficult to charge a $19.95 service fee when they do not provide the antibiotic,” the brief states.

“If pharmacists can only feel comfortable recouping their service costs when prescribing, this risks significantly over-prescribing [the report shows 96% of women received antibiotics].

“This cannot be ignored and demonstrates potential for further overprescribing now that it has become permanent.”

A series of questions are asked about the scheme’s adherence to Pharmacy Board recommendations on prescribing, including managing conflicts of interest, access to patient records and ensuring independent checks and balances.

The submission also seeks clarification from the Queensland Government on the education and training of pharmacists providing the UTI prescribing service.

He cites unease surrounding the number of interns, new graduates or first-year pharmacists “with limited pharmacy experience” who may prescribe for UTIs and gather clinical information.

Concerns about patient outcomes
A “major flaw” in the trial, according to the college brief, is the lack of any process to assess whether there was a urinary tract infection in the first place, and whether an antibiotic was needed or whether the appropriate antibiotic was prescribed.

The evaluation report shows that 13% of those who responded to follow-up did not have their symptoms resolved.

“The failure to resolve UTI symptoms in 13% of ‘uncomplicated’ cases is clinically significant,” states the college’s submission.

Among the concerns raised about the protocol is the detail, included in the assessment, that 43 patients were not referred to a GP “even though they had reported to the pharmacist that they had not had resolution of their symptoms and had not sought further care”.

There were also 40 women who sought additional care outside of general practice, according to data collected from follow-up queries.

“The study did not provide information on where these women sought care, although it appears that at least four of them voluntarily stated that they went to a service urgently”, declares the RACGP in its brief.

“Presumably many, if not all, of the remaining women also attended an emergency department.”

Another cause for concern is that 112 patients who had unresolved symptoms and saw a GP were given another antibiotic.

“The study says this is consistent with normal UTI management; however, the study does not specify what type of antibiotics were administered or their indication,” she says.

“Many, if not all, of these antibiotics may have been given to treat STIs or other non-urinary conditions that were not diagnosed by the pharmacist.

“If so, then the search was incomplete and did not correctly identify the unwanted results.”

The report mentions that a urine test was not carried out in 52 of the 144 patients who consulted a GP with unresolved symptoms.

“This suggests that 36.1% of people who subsequently saw their GP may have had an obvious non-urinary cause for their symptoms and were inappropriately prescribed antibiotics by the pharmacist,” the college states.

“The GP was left to manage treatment failures.”

In its submission, the RACGP requests a further meeting with the Queensland Government and Queensland Health to discuss the concerns raised.

The full document can be read on the RACGP website.

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