Initial Perceptions Regarding Changes in the Roles of Ontario Pharmacists

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About this Article: This qualitative study examined the initial perceptions of pharmacy and medical professional organizations and the Ontario government regarding pharmacist prescribing. Although strong opinions were provided on both sides of the issue, there was little evidence to support most of the assertions.

About This Series: The É/Exchange working pa-per series is designed to facili-tate sharing of results and to encourage discussion of con-cepts, practices, and policies in applied health. This series provides a way to disseminate well-written, but not yet pub-lished, reports of research. It is also a way to make re-search conducted by affiliated community members accessi-ble to a wider readership. The series is co-sponsored by The Population Health Improve-ment Research Network (PHIRN), Réseau de recher-che appliquée sur la santé des francophones de l'Ontario (RRASFO); and the Ontario Health Human Resources Research Network (OHHRRN).

There has been increasing recognition in recent years that pharmacists are an underutilized health care system resource, particularly with respect to medication management and prescribing. In response, all Canadian provinces and the Northwest Territories have passed policies authorizing pharmacists limited prescribing rights. In Ontario, pharmacists have been granted prescriptive authority through Bill 179, the Regulated Health Professions Statute Law Amendment Act. The associated regulations are currently awaiting government approval. Once the policy is implemented, pharmacists will be permitted to adapt (e.g., change dosage, formulation) and extend existing prescriptions, and initiate drug therapy (but only for smoking cessation).

wps march2012 1A recent study by Pojskic and colleagues examined the initial perceptions of pharmacy and medical professional organizations and the Ontario government regarding this expanded pharmacist role. Data were obtained through policy documents and interviews with key informants. Several key themes emerged.

Impact on Patients and the Health Care System

Pharmacy organizations and the Ontario government both perceived that pharmacist prescribing would increase patient access to primary health care services by reducing physician workload and enhancing pharmacists’ ability to provide services, such as prescription refills, directly to patients. This expanded pharmacist role was also viewed as improving patient outcomes through improved continuity of drug therapy, reductions in adverse drug events and hospitalizations, and improved patient compliance.

Some stakeholders perceived that pharmacist prescribing could decrease health care costs through re-direction of health care expenditures towards cheaper health professionals (i.e. pharmacists). Others, however, perceived that it might, in fact, increase health care costs by providing patients with more ways to access health care services, which they might then use more frequently.

Pharmacist competency

Pharmacy organizations observed that all pharmacists in Ontario have the skills, knowledge and training to undertake proposed prescribing activities, including modifying, adapting and extending drug therapy, without the need for post-registration training. They further emphasized that pharmacy practice has evolved from a dispensing model to a patient-centered, pharmaceutical care model, and that pharmacists are already undertaking many of the prescribing activities through delegated authority and other mechanisms.

Using the pharmacist to the full extent of their extensive training and education can help to address care gaps, reduce the burdens of family practitioners so that the patients requiring more care can access them, reduce the need to attend at ERs to obtain refill authority for continuing care prescriptions, reduce the morbidities and hospital admissions associated with adverse drug reactions in the elderly and all patients, and increase patient compliance by adapting or modifying the dose or dosage form of a prescribed drug in appropriate circumstances.

- Ontario College of Pharmacists, 2008

wps march2012 2In contrast, medical professional organizations expressed concern that pharmacists do not possess the training to perform diagnosis, which was felt to be essential for safe prescribing.

In addition, medical organizations were concerned that pharmacist prescribing could:

  • patient care, given that pharmacists would be making independent drug therapy decisions without an effective means of communicating these  to the patient’s primary care physician (such as through an integrated electronic medical record);
  • place unreasonable time demands on physicians who would have to review communications pertaining to drug therapy changes;
  • put pharmacists in a conflict of interest position both as the prescriber and dispenser of medications; and
  • impact patient safety due to pharmacists’ lack of access to patient information for making effective prescribing decisions.

Although medical organization policy documents consistently opposed all forms of pharmacist prescribing, most medical informants noted that pharmacist extension of prescriptions would be beneficial for patients.

Given some of these perceived issues with pharmacist prescribing, medical organizations stated that delegated authority is preferred in that it poses less risk to patient safety.

Discussion

Despite strong opinions on both sides of the issue, there is currently a lack of research evidence on pharmacist prescribing to substantiate or refute the assertions. Medical opposition to this expanded pharmacist role largely focused on the issue of patient safety, but it may also be rooted in turf protection and fear of loss of income. There is significant historical evidence that the medical profession has been quite successful in protecting its domain against the encroachment of efforts of other health care occupations.

Interestingly, the sole pharmacist prescribing role supported by medical informants was the renewal of prescriptions. The collaborative work done by the medical and pharmacy professional organizations in the development of the PAPE agreement may have laid the groundwork for the mutual support of this pharmacist role.

This is one of the first studies, in Canada or elsewhere, to shed light on the perceptions of the key stakeholder groups regarding pharmacist prescribing. It will be interesting to see how these issues are addressed as the expanded pharmacist role is implemented in practice.

Reference: Pojskic, N, MacKeigan, L, Boon, H, Austin, Z, Kohler, J and Ellison, P. Initial Perceptions of Key Stakeholders in Ontario Regarding Independent Prescriptive Authority for Pharmacists. Exchange Working Paper Series, Volume 3, Issue 2. University of Ottawa, Ottawa, Canada. Available at rrasp-phirn.ca.

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