Bad medicine? How pharmacists in North Queensland will diagnose and prescribe for asthma

Dr Evan Ackermann addresses Queensland Health's alarming protocol for asthma care.
Dr Evan Ackermann.

At the heart of the North Queensland pharmacist prescribing trial is bad medicine fuelling the risks of misdiagnosis, inappropriate prescribing and care breakdown.

Not all doctors are aware that Queensland Health has now published a paper listing the protocols and referral pathways for pharmacists to treat asthma, heart disease, COPD and a string of other conditions outside their normal scope of practice.

In this, the first of a series of articles, Dr Evan Ackermann — a former chair the RACGP’s quality and safety committee — examines the alarming protocol developed for asthma care, where pharmacists will be allowed to initiate, alter and cease medication at their own clinical discretion.

You can sign the petition calling for this worrying experiment in healthcare to be stopped by clicking here.

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Dr Evan Ackermann writes:

In the North Queensland pilot, pharmacists plan a comprehensive asthma service, commencing with asthma assessment, and initiating and changing your patients’ current medications.

It is claimed that pharmacists’ expanded scope of practice helps patients, GPs, EDs and hospitals — right?

Well… no.

Its asthma management protocol is founded on the Pharmacy Asthma Management Service (PAMS).  

This was an Australian study that investigated the efficacy of the PAMS in improving asthma symptom control in poorly controlled asthmatics.1

It covered 380 patients in 95 pharmacies and was funded by the Federal Government under the Sixth Community Pharmacy Agreement.

The intervention was pharmacists providing the pharmacy asthma management service to patients with poorly controlled asthma over a 12-month period.

The comparator was “minimal intervention”; that is, a referral to a GP (ie, not necessarily seeing a GP or GP care).

The result? The letter to the GP provided the same result as the pharmacist asthma management.

So the Pharmacy Asthma Management Service provided no improvement in asthma control.

There were no significant differences between self-reported ED visits, hospital admissions or MBS-recorded GP visits when the two arms were compared.

Read Queensland Health’s protocol for pharmacists to manage asthmaclick the ‘+’ button

DescriptionAdditional information
A pharmacist-initiated or health practitioner referral for a pharmacist-led symptom control program for adolescents and adults between 16 and 65 years of age with mild-to-moderate asthma (including exercise-induced bronchoconstriction)

Management will be provided based on a clinical protocol for the service, incorporating elements of the previously piloted PAMS and aligned to current evidence and Australian guidelines

The protocol will include standardised screening assessment; patient education; non-pharmacological interventions, including lifestyle and medication counselling and education (refer to ‘Weight management for overweight and obesity’); and smoking cessation (refer to ‘Smoking cessation’) as appropriate

Where indicated, protocol/structure-based prescribing to initiate pharmacotherapy (for newly identified/untreated patients) or to optimise pharmacotherapy (for patients with an existing diagnosis/currently receiving therapy)

The service model will include an initial screening assessment, asthma action plan development and then follow-up consultations at regular intervals according to the protocol for the service

The patient’s referring health practitioner (and the patient’s GP, if not the referrer) will be advised of the patient’s participation in the Improved Asthma Symptom Control Program and will receive communication at regular intervals
Standardised assessment, including patient history and assessment of asthma control and severity; physical examination, including chest auscultation; and diagnostic testing, including spirometry

Referral pathway
Newly identified/untreated patients will be referred to their GP for further review and collaborative management (program can commence concurrently)

Referral to a medical practitioner is also required for patients:
  • With severe asthma or complex asthma, including:
    • Pregnancy
    • Dual diagnosis of asthma and COPD
    • Recent and/or recurrent asthma flares (program can commence concurrently)
    • History of being hospitalised for asthma treatment (including life-threatening exacerbation or asthma-related ED visits)
    • History of severe exacerbations
    • Asthma associated with anaphylaxis
  • Already being treated by a specialist prescriber (eg, respiratory physician) for management of asthma
  • Suspected occupational asthma
  • Who do not achieve clinical targets or significant improvements within the specified protocol time frames
Referral to other members of the multidisciplinary healthcare team (either directly or via a medical practitioner) as indicated by assessment

Indicative cost
  • Initial consultation (long consultation)
  • Follow-up consultations (short and medium consultations)
  • Cost of spirometry as per protocol
  • Cost of medicines at cost of a private script

The authors sounded a little stunned by this.

“These results ask us to reflect on current standards of usual care, as it appears the standard of asthma care in usual practice has evolved beyond what is reported in the literature,” they wrote.

These Australian asthma study findings are evidence of no benefit for pharmacy asthma care, with no impact on patients, GP or hospital services.

Canadian pharmacists have also rejected pharmacist care of asthma based on lack of effectiveness and cost-effectivenesss.2

Of course, there is more.

As you can see by reading the protocol above, it will include the following:

  • Standardised screening assessment for asthma

Sounds important? I want to point out that screening for asthma has no evidence base and specifically is not recommended for Aboriginal and Torres Strait Islander people.3

Then comes this:

  • Standardised assessment, including patient history and assessment of asthma control and severity, physical examination … and spirometry

Here, there is no documentation to say what is involved, so it is hard for me to comment. But I would suggest that pharmacists do not have the clinical reasoning skills to diagnose asthma — let alone exclude the alternative conditions that mimic asthma.4

  • Where indicated, a [pharmacist could offer] protocol/structured-based prescribing to initiate pharmacotherapy for newly identified/untreated patients …

That means ‘newly diagnosed’ patients.

Again, pharmacists do not have diagnostic confirmatory or exclusive skills. Treatment protocol effectiveness is totally dependent on the quality of the diagnosis. Nothing is worse than treating an occult malignancy with salbutamol.

It continues:

  • … or [pharmacists can] optimise pharmacotherapy for patients with existing disease

The last two bullet points alarm me.

It gives pharmacists the ability to start, alter, cease medication at their own discretion and, by doing so, altering medication to a private script and fee.

The medication list for pharmacists includes many S4 drugs.

Let’s focus on the evidence.

From a safety perspective, I have not seen any robust data or studies that demonstrate a pharmacist’s initiation of asthma medications or dose change improves patient care.

A recent literature review suggests there are no studies regarding asthma medication or dose changes by community pharmacist in the management of asthma.5

The Queensland pilot committee have not published any evidence document supporting the pharmacist activities.

As there is also no robust evidence, trial or any document that evaluates pharmacist prescribing rights in asthma, pharmacists initiating and altering medications is an untested pharmacist activity.

The phrase ‘practising to full scope’ is being used as a facade to implement services of no benefit and to trial new pharmacist prescribing actions on patients in a poorly controlled environment without patient safety netting.

The Queensland State Government backing to this gives it an unjustified legitimacy in the minds of many patients.

That is wrong.

There should be concerns raised by all pharmacy professional groups. Surely the appropriateness and safety of patient care supersede a desire to be a prescriber.

So far, I have heard nothing from pharmacy groups.

It also points to serious deficiencies in the clinical governance and oversight of this trial.

How is it that no concerns have been raised?

Asthma is a serious long-term problem. The evidence suggests that best outcomes are established if pharmacists ensure patients have mastery of their inhaler device technique tested on a regular basis and refer patients when an exacerbation or suboptimal control occurs.6,7,8

There are long-held pharmacist duties covered by PBS arrangements designed to ensure both efficacy and cost–benefit.

Asthma does not need interventions that have been proven to have no benefit.

Remember that this scheme is not being subsidised under Medicare or the PBS; it is not being subsidised by the Queensland Government. It is strictly a private business.

For me, getting patients to pay for PAMS is a scam supported by the Queensland Government.