The Clinical Merits Associated with Utilising a Prescribing Pharmacist

Introduction:

Pharmacist prescribers have been utilised in the United Kingdom, Canada and New Zealand, with American pharmacists now allowed to prescribe Paxlovid^®. Pharmacist/doctor prescribing began in the UK in 2003 and independent pharmacist prescribing commenced in 2006. The latter development meant that pharmacists were “responsible for the assessment and consequent management, including prescribing of both undiagnosed and diagnosed conditions.”

However, the acceptance of this extension to a pharmacist’s scope of practice has been slow to come to fruition in Australia. The following is a brief review of key papers on this topic.

Literature:

More than 12 years ago, it was established that prescription errors account for 70% of medication errors that could potentially result in adverse effects. One teaching hospital reported a mean for prescribing errors with the potential for adverse effects in patients of about 4 per 1000 prescriptions.

In an attempt to reduce prescribing errors in hospitals, numerous studies have been conducted to determine the potential need and possible merits of integrating pharmacists into the prescribing process for patients.

A prospective, multi-center study was conducted by Weant et.al (2014) at four US Emergency Departments (EDs). It investigated the various functions performed by pharmacists and their impact upon medication-error detection in the ED. During 1,000 hours of recorded time and 16,446 patients seen, pharmacists detected 364 medication errors. Computerised orders (54.4%) and verbal orders (32.7%) were the most commonly detected errors. This study demonstrated that clinical pharmacists in the ED can have a significant impact on medication-error detection.

Work by Tong et al. (2015) reported similar advantageous outcomes from credentialed pharmacist charted pre-admission medications with “significantly reduced inpatient medication errors (including errors of high and extreme risk) among general medical and emergency short-stay patients with complex medication regimens or polypharmacy.”

Taking the involvement of hospital pharmacists deeper into the prescribing chain, Poh and colleagues (2018) reported that pharmacists as prescribers made 20 to 25 times less prescribing errors and 3 to 116 times less omissions than doctors when prescribing patients’ usual medications on admission to hospital or in the preoperative setting.

This innovative program is known as a partnered pharmacist medication charting (PPMC) model. It involves a pharmacist taking a medication history, reconciling medications, assessing the risk of venous thromboembolism (VTE), collaboratively making decisions with the admitting medical officer and then charting the medication.

Charting errors are a ubiquitous clinical issue with medication errors among the most common incidents reported in hospitals as well as during the pre-admission stage. Failing to record a patient’s medication history accurately can lead to poor health outcomes and increased costs because the admission errors can easily flow through the patient’s hospital stay and transfers. The initial charting errors can penetrate into and be perpetuated throughout the whole patient’s hospital stay and emerge undetected on the discharge notes which the general practitioner receives. It has been estimated that there only needs to be greater than a 10% reduction in medication discrepancies on discharge for the program cost to be covered.

Addressing these problems, Nguyen et al. (2020) showed that a PeRiopErative and Prescribing (PREP) pharmacist has a significant impact on health outcomes. The benefits included:

• The PREP pharmacist group had fewer errors than the control group: 9% (5/53) versus 96% (49/51; P< 0.001).
• Discharge prescriptions prepared by the PREP pharmacist had fewer errors than control group: 25% versus 78% (P< 0.001).
• More PREP pharmacist patients received a discharge summary with a complete medication list: 75% versus 33% (P= 0.001).
• Inpatient prescribing was more accurate in the PREP pharmacist patients: 0.64 versus 1.31 errors per patient (P= 0.047).

In 2015, Alfred Health piloted the PPMC model with support from the Department of Health and Human Services’ Workforce Innovation Grants program. Through this randomised controlled trial, medication errors fell from 35.5% to 0.5%.

In 2016-2017, the trial was expanded across five health services (seven hospitals) and included 8648 patients. Results included:

• Reduced proportion of patients with at least one medication error (19.2% to 0.5%)
• Reduced length of stay (6.5 days to 5.8 days)
• The estimated savings of $726 per PPMC patient.
• The total savings from the 2,840 admissions where the PPMC model was used for medication charting was, therefore, approximately $1.95M.
• Cost modelling of the number of general medical patients admitted that could be expected to benefit from state-wide roll-out of the PPMC model operating suggested potential savings on inpatient costs of $202M per annum.

In 2020 a multicentre prospective cohort study deploying partnered pharmacist medication charting (PPMC) admitted to public hospitals in Victoria, Australia, compared patient outcomes before and after the intervention of the charting pharmacist.

Patients who had a PPMC were found to have:

• A half-day reduction in the length of stay (LoS) from 4.7 days to 4.2 days (P < 0.001).
• Medication charts that had at least one error were reduced from 66% to 3.6%.
• The number-needed-to-treat to prevent one error was 1.6 patients. (95% Cl:1.57-1.64).
• On average, one pharmacist would be expected to undertake the PPMC model for 5–10 patients per day. This equates to potential savings of $4725 to $9450 per pharmacist per day, with the estimated average cost of a pharmacist of $460 per day.

It was concluded that the expansion of the partnered pharmacist charting model across multiple organisations was effective and feasible and is recommended for adoption by health services.

Importantly, the expansion of the PPMC model of care to enable pharmacist charting of new medications has been shown to be safe in a study by Hua and co-workers (2022).

Further evidence of significantly lower rates of medication errors, lower severity of errors and shorter inpatient length of stay allied to the use of the PPMC model in the regional setting was provided by Tong et al (2022) who studied 669 patients who received standard medical charting during the pre-intervention period. Of this total, 446 (66.7%) had at least one medication error identified compared to 64 patients (9.5%) using PPMC model (p < 0.001). Also, from an economic perspective the median LoS was reduced from 4.8 in the pre-intervention group to 3.7 days (2.0-7.0) for those patients who received PPMC (p < 0.001).

Barriers to PPMC:

Despite the evidence of both a significant clinical and economic benefit from the use of PPMC, barriers to pharmacist prescribing are substantial. These include developing a positive socio-political milieu as well as a credible level of pharmacist prescriber (PP) competency. Hence there is a need for sophisticated training courses of a high academic merit, improvements in the perceptions of the role of a PP within the medical fraternity, and “identifying specific funding, infrastructure and resourcing needs to ensure the smooth integration of pharmacist prescribers within interprofessional clinical teams.”

Conclusion:

The initiation of a PPMC has a proven set of advantages. These include a reduced length of stay in hospital, a decrease in both the errors and the severity of errors, an increased hospital savings of $726 per PPMC patient and 92% patient acceptance of PPMC.

Thus, there appears to be no disadvantages to expanding the scope of practice for pharmacists into the partnered prescribing domain.