OCP resupply trial evaluation released as scope creep continues…

Pharmacists in NSW can now directly prescribe and supply oral contraceptive pills to low-risk women between the ages of 18 and 29.

So far, 30 pharmacists in the state have met the training requirements to initiate OCP prescriptions – but the NSW government is partnering with Family Planning Australia to develop a two-week training course which will launch in October.

They estimate that 250 pharmacists will be on board by the end of the year.

The change is part of a broader national trend. Pharmacists in Queensland and Tasmania who complete additional training have been permitted to initiate hormonal contraception since mid last year. Beginning in July, Victorian pharmacists will be able to initiate oral contraceptives for women over 18. And from January the federal government plans to fund a pilot in which pharmacist prescribing of hormonal contraception and antibiotics for uncomplicated UTIs will be subsidised for women with concession cards (in accordance with state and territory regulations).

Governments claim this will ease the ‘burden’ on GPs.

“This will give women faster access to care while reducing pressure on GPs,” the NSW government press release stated.

“These are common sense changes, which make it easy for women to access essential medication without needing to visit a GP,” NSW Premier Chris Minns said.

The NSW announcement was made in the same week as the University of Newcastle released its evaluation of a pharmacist-led OCP resupply trial funded by NSW Health, which had strict protocols.

The 12-month trial included 1946 women and 2,209 resupply consultations – with just 57 consultations (2.6%) deemed either moderate (n=9) or high risk (n=48). Pills were not resupplied in any of the high-risk cases, and 81% of these were referred to their GP.

Overall, 6.9% of patients were referred to their GP, either based on screening questions, clinical measurements or other criteria.

Changes are outpacing the evidence

Dr Terri Foran, a sexual health physician who helped develop the safety protocols and checklist for the OCP resupply trial, said she would not have been involved if the trial had included pharmacist initiation of pills.

She is concerned that the NSW government has gone way beyond the scope of the original trial report, which she said was academically rigorous and considered.

“The initiation of a pill for a particular woman is quite a complex task. It requires a very complex medical history to do it well. Then of course there is also the need for the ability to fine tune things if the first choice of preparation isn’t the right one for the woman,” Dr Foran said.

“I have absolutely no problem with pharmacists continuing a supply of a pill that’s previously been prescribed by a doctor who’s done those hard yards,” she added.

Dr Foran also noted that while the purpose of the government’s action was ostensibly to increase access, the majority of pharmacies involved in the trial were in urban areas, and most people who accessed the service were from higher socioeconomic groups.

For example, the evaluation showed that 79% of consultations were in metropolitan areas and 47% of the women were from the least disadvantaged quintile, based on postcodes.

Convenience above all else?

Qualitative feedback from patients emphasised the convenience of the service despite the upfront costs, Dr Foran noted.

“Women very much commented on the convenience — for instance if they’d forgotten to get a pill script from their doctor they could go to a pharmacy close to them, rather than making an appointment to see their usual GP who might be in another suburb,” she said.

But while convenience is important, it doesn’t necessarily take into account women with more complex issues who will still need to see their GP, Dr Foran said – or those for whom a different contraceptive option from those available through the pharmacy would be more appropriate or preferable.

“Women starting the pill for the first time need quite a lot of information about how to take it correctly, what to do if you miss pills, and when to return if there are issues or problems. I wonder whether that’s going to be as well covered in this new model as its quite time-intensive,” she added.

Additionally, Dr Foran questioned how pharmacists would respond to an assertive patient demanding the pill even when there were good medical reasons not to initiate or resupply it.

“I think most doctors are comfortable making decisions from a medical perspective that may not suit what the patient wants – and I wonder how easy that’s going to be in a pharmacy situation.”

In the resupply trial, 7.2% of consultations ended without the patient getting a resupply.

While overall satisfaction with the service was good, the evaluation states that consultations that ended without resupply were associated with lower odds of a high satisfaction score.

Healthed survey data suggests there are risks

A Healthed poll of 1851 GPs in March found that around half had encountered at least one adverse outcome arising from pharmacy prescribing more broadly.

At the time of the survey, pharmacists were only allowed to initiate OCPs in Queensland and Tasmania, but 11% of GPs said they had “unsatisfactory experiences” related to pharmacists prescribing them.

“Patients complained that they were guided to the most expensive OCP unnecessarily and felt like they were being upsold to get more money out of them,” one GP said.

Other unsatisfactory experiences included patients not being given comprehensive advice on other available contraceptive options, getting incorrect advice on what to do if they missed a pill, and not getting adequate education about risks.