Doctor - pharmacist collaborative prescribing in a multidisciplinary surgical preadmission clinic: Expanding the role of the preadmission clinic pharmacist

Abstract

Non-medical prescribing has been introduced in to several countries, with prescribing privileges being granted to health practitioners other than doctors, including pharmacists. The objectives behind the introduction of this new model of health care have been to create a more flexible system for the prescribing, dispensing and administration of medicines, increase access for the general public to safe and appropriate prescription medications, and to better utilise the skills of the current health workforce. Current research on non-medical prescribing is predominantly qualitative, with little evidence as to the safety, appropriateness, effectiveness or cost effectiveness of the prescribing. Pharmacist prescribing is yet to be introduced in Australia, and in light of some resistance it is important to ensure that this potential model of care meets expectation, prior to implementation. The overall aim of this thesis is to evaluate a model of pharmacist prescribing in an elective surgery pre admission clinic (PAC), using the validated National Health Performance Framework (NHPF), which was revised and approved by Australian Ministers in 2009. The framework uses six dimensions to assess how a health system performs; ‘effectiveness’, ‘safety’, ‘responsiveness’, ‘continuity of care’, ‘accessibility’ and ‘efficiency and sustainability’. A randomised controlled trial was undertaken in PAC, with 400 patients randomised in to either the intervention or control arm. Patients in the intervention arm were seen by a nurse, Resident Medical Officer (RMO), anaesthetist and the pharmacist prescriber. The pharmacist was responsible for the taking of a medication history, and prescribing the national inpatient medication chart (NIMC) to reflect the patient’s regular medications and the plan for medications peri operatively. Within the pharmacist’s agreed scope of practice was also the initiation of venous thromboembolism (VTE) prophylaxis, following a risk and contraindication assessment. Patients randomised in to the control arm still saw the same four healthcare professionals, including a pharmacist for usual care duties. The prescribing of the medication chart, including VTE prophylaxis, was the responsibility of the Resident Medical Officer (RMO) from the treating surgical team. The primary end point of the study was the safety and accuracy of the NIMC. The secondary end point was the appropriateness of VTE prophylaxis prescribed in clinic. Medications charts were audited against the medication history and plan for medication peri operatively. Medication charts in the intervention arm contained significantly fewer omissions of regular medications, significantly less prescribing errors involving selection of drug, dose or frequency and significantly fewer orders with at least one component of the prescription missing, incorrect or unclear. VTE risk assessments were documented, and prophylaxis was prescribed, significantly more appropriately in clinic. The significant differences between arms in omissions of medication prompted an investigation in to the appropriate of prescribing, and significance of omissions. A multidisciplinary panel was convened, and assessed the appropriateness of prescribing utilising a validated tool, the Medication Appropriateness Index (MAI). Panel members were asked to rate the appropriateness of medications prescribed, and the significance of medication omissions in terms of potential patient harm or ward inconvenience, from a random 5% sample of patients from the main study. For the appropriateness of prescribing, overall results were the same between arms, as judged by individual panel members. Medication charts in the control arm contained significantly more omissions than in the intervention arm, a number of which were rated by the panel members as having the potential for patient harm or ward inconvenience. Patient satisfaction was evaluated using a questionnaire containing 12 closed questions on a 5 point Likert scale, which was given to the patient after the pharmacist appointment. The response rate in PAC was 182/200 (91%). Consultation satisfaction was high, and high percentages of patients agreed that they had a plan for medication explained clearly to them, that their understanding of the plan was checked, that any information given was easy to understand, any questions were answered in a way they easily understood, and their concerns about medications were understood. This led to a high percentage of patients that agreed that the pharmacist had helped prepare them for their surgery. In conclusion, pharmacist prescribing in PAC has been shown to be as safe, effective and appropriate as usual care. Patient perceptions to the model of care appear not be a barrier to implementation. However, this was one pharmacist in one model of care. Future work should focus on the training and education requirements to reliably produce competent and fit for purpose pharmacist prescribers, who can replicate these results across different models of care, and ensure that pharmacists’ skills are utilised to their full potential in the Quality Use of Medicines (QUM).