Collaborative prescribing roles as part of advanced practice for Australian hospital pharmacists

Background Health system reforms are occurring in many countries to prepare consumers and health professionals for the challenges arising from an ageing population, the growing burden of chronic disease and health workforce shortages. Wider access to healthcare can be met in part by maximising the skills of the current health workforce. Extending scopes of practice to permit non-medical healthcare workers to prescribe has been a policy direction in many countries including the UK, New Zealand, Australia, Canada and the USA. However, pharmacists within Australia, unlike their overseas colleagues or their local colleagues in nursing, optometry and podiatry, have been left behind in the reform process. Regulatory change and the provision of pharmacist prescriber education and credentialing have not occurred. In addition, there has been limited research into the views and readiness of hospital pharmacists to undertake collaborative prescribing, their educational requirements for the role and an evaluation of advanced practice roles with prescribing elements. The hospital setting appears to be the logical place to begin researching models of prescribing, given the ready access to patient records, the existing collaborative team environment, and support from administrators for a system change. A literature review of non-medical prescribing with particular reference to the role of the pharmacist was undertaken to explore the drivers for, and barriers to, the development of pharmacist prescribing. The various models of pharmacist prescribing in the United Kingdom (UK), New Zealand, Canada and the United States of America (USA) were reviewed. Stakeholder views of pharmacist prescribing and research into pharmacist prescribing in Australia to the time of commencing this research were also explored. The aim of this research was to explore and evaluate collaborative pharmacist prescribing as part of advanced practice in the hospital setting in Victoria, Australia. Methods Phase 1: Cochrane systematic review A protocol for a Cochrane systematic review was written and published with the Effective Practice and Organisation of Care (EPOC) Group. A draft review entitled ‘Non-medical prescribing versus medical prescribing for acute and chronic disease management in primary and secondary care’ is ready for submission. The objective of the review was to assess the clinical, economic and humanistic health outcomes of non-medical prescribing for managing acute and chronic health conditions in primary and secondary care settings compared with medical prescribing. An electronic search of databases recommended by EPOC was undertaken to April 2014. Hand searching contributed additional titles for review. Studies included if they met EPOC criteria for randomised controlled trials, controlled trials, controlled before and after studies and interrupted time series. A defined degree of autonomous prescribing by the non-medical prescriber was required for the study to be included. A fixed-effects model was used for meta-analyses and where this was not feasible plain language summaries were reported. Phase 2: Survey of Hospital Pharmacists’ views on collaborative pharmacist prescribing Thirteen hundred and sixty seven members of the Society of Hospital Pharmacists of Australia (SHPA) were invited by mail to complete a four-page questionnaire on current and future issues pertaining to collaborative prescribing. Areas explored included inherent problems within the health system where collaborative prescribing could assist service delivery e.g. discharge, views on transcribing roles, areas of prescribing interest, prescribing as part of clinical pharmacy development, potential roles for collaborative pharmacist prescribers and whether any defacto or unofficial pharmacist prescribing was taking place. Non-responders were sent an email reminder two weeks after the closing date in July 2007. Phase 3: Non-medical prescribing course The first attempt in Australia at ensuring hospital pharmacists’ competency to prescribe was undertaken by organising locally a UK Independent prescribing course. Participants’ experiences of the course were evaluated using qualitative methods. Phase 4: Two models exploring advanced pharmacy practice with collaborative prescribing roles Graduates of the non-medical prescribing course outlined above participated in two studies involving advanced practice with collaborative prescribing roles. Both studies involved mixed quantitative and qualitative methods. The first study sought to evaluate the outcomes of a pharmacist-led lipid clinic in the ambulatory setting for patients with peripheral vascular disease through a randomised controlled trial and qualitative evaluation of patient and pharmacist experiences. Thirty-one patients in each of the control and intervention groups were required to show a 35% difference in the proportions using lipid lowering medications between intervention and control groups. Patient assessments were undertaken at four six weekly visits and adherence and patient satisfaction were measured. In the second study a purposive sample of physicians and pharmacists explored advanced practice roles for emergency department (ED) pharmacists. ED pharmacists at three Victorian tertiary care hospitals prepared medication charts for medical review and two methods of providing therapeutic suggestions during this process were assessed. A qualitative assessment of clinicians’ experiences of the trial was also undertaken. Key findings Phase 1: Cochrane Systematic review and meta-analyses The database searches yielded 11,551 titles. Thirty-eight additional studies were found through hand searching. After removing duplicates, 7651 studies were screened and 180 full text articles were reviewed. One hundred and thirty nine studies did not meet inclusion criteria and were excluded. Forty-one studies were included in the final review: 39 randomised controlled trials (including six cluster randomised controlled trials), one controlled trial and one controlled before and after study. Non-medical prescribing by nurses (22 studies) and pharmacists (17 studies) was compared with usual care (medical prescribing). One study compared pharmacist with nurse-led case management. Another study compared the outcomes of education and guidelines on nurse prescribing versus usual nurse care. No studies were found with non-medical prescribing being undertaken by other health professionals. The education requirement for non-medical prescribing varied with country and location. The studies were of moderate methodological quality with blinding of group allocation not feasible and presence of confounding factors arising from multicomponent interventions. A meta-analysis of surrogate markers of chronic disease (systolic blood pressure, glycated haemoglobin, low density lipoprotein) demonstrated considerable heterogeneity (apart from glycated haemoglobin at 12 months) but showed positive intervention group effects. Two meta-analyses of continuous and dichotomous outcome data showed a significant improvement in adherence in the non-medical prescribing group. Little difference was seen in adverse effects across studies. A meta-analysis of quality of life scores (using Short Form-12 (SF-12) and Short Form-36 (SF-36) found a significant difference favouring usual care for the physical component score but not the mental component score. A wide variety of resource utilisation measures were reported across studies with little difference between groups for hospitalisations, emergency department visits and outpatient visits. In the majority of studies reporting drug use, non-medical prescribers prescribed more drugs, used a greater variety of drugs and intensified drug doses more than usual care medical prescribers. Patients were generally satisfied with non-medical prescriber care. In assessing risk of bias, the overall quality of the studies was moderate. Non-medical prescribing was usually one part of a multifaceted intervention involving collaboration with other healthcare professionals and diversified approaches to disease management including diet, exercise, smoking cessation and self-management. Phase 2: Views on collaborative pharmacist prescribing Five hundred and fifty one SHPA pharmacist members responded to the postal questionnaire providing a response rate of 40% (551/1367). Ninety five percent (509/551) of respondents reported that collaborative pharmacist prescribing could circumvent hospital delays during the admission, inpatient, discharge and outpatient journey. Defacto prescribing was undertaken by 37% (141/384) of practising clinical pharmacists. If a legal and credentialing framework existed, 81% (446/551) of respondents saw a collaborative prescribing role within their area of practice. Phase 3: Non-medical prescribing course Participants (n=15) in the non-medical prescribing course revealed positive themes relating to their understanding of non-medical prescribing and where it could lead. A growth in self-confidence and improved competencies in communication and consultation skills were reported. Negative themes related to local legislative restrictions on pharmacist prescribing, acceptance of the role by other clinicians, varying input from medical mentors, assessment needs during the Period of Learning in Practice (PLP) and the need to customise the course content to Australian conditions. Learnings from this project will assist the development of any Australian non-medical prescribing course for pharmacists. Phase 5: Advanced pharmacy practice models with collaborative prescribing roles In the pharmacist-led lipid clinic for peripheral vascular disease patients, recruitment difficulties prevented reaching the recruitment target of 62 patients (...)