1. Introduction
Prescribing pharmacy is a topic that is generating an increasing amount of discussion in healthcare in Edmonton and in Alberta, Canada. Pharmacists are playing an increasing role in patient care, and there is an increasing call for them to be allowed to prescribe some drugs in certain situations and for certain conditions. Currently in Alberta, only some drugs can be prescribed by a pharmacist. The statistics we have can show us certain things about excessive prescribing pharmacy but lack detail that can inform us as to the effectiveness of this service for patients.
The objectives of this paper are to study prescribing pharmacy. I will analyze the limitations of monitoring prescribing pharmacy as it is currently in Alberta. From there, a way to monitor and build evidence around this service will be proposed, including an example of how this could work with prescribing pharmacy for hormonal contraceptives. The scope of pharmacy practice is quickly evolving to produce many varied and necessary healthcare services in which the pharmacist is typically the patient’s first point of entry into the system. Given their training, competency, and established trust relationships with many patients, the addition of prescribing privileges to the scope of pharmacy practice will allow patients, particularly those who may be underserved by primary healthcare, to access medications and other authorized products and care more quickly, safely, and conveniently than before. With the growing number of Alberta pharmacists expressing a professional interest in authorized prescribing, it is critical that we have evidence to support decision-making for both practitioners providing care and policymakers setting the parameters of care. This project is an important stepping stone in our method to systematize understanding, best practice, and quality assurance for prescribing pharmacy services in Alberta and across Canada.
2. Background of Prescribing Pharmacy
Prescribing pharmacy is a multistakeholder-driven initiative currently under development in Edmonton, Canada. As a profession, pharmacy has undergone significant change in recent years. In Alberta, prescribing authority has been added to the profession by government legislators. The two health authorities have had pilot and demonstration projects for the expanded professional practice initiative in severe mental health. Some pharmacists serve on the Alberta College of Pharmacy Influencing Council and have worked within interdisciplinary committees to advance the profession, including moving the Edmonton initiative forward. Some also sit on provincial and national committees that are influenced by this initiative. The Alberta College of Pharmacy, currently in partnership with Alberta Health Services and key stakeholders, is working to begin the process of implementing the framework and process for using pharmacist prescribing within a Health Setting Prescribing Model. Traditionally, pharmacists have been entrusted with the role of medication experts who compound, dispense, manage inventory, and counsel medication users. The key responsibility of pharmacists is the safe and effective use of medications. Pharmacists, alongside physicians, registered nurses, and social workers, are regulated health professionals who work within the interdisciplinary health care team. Various levels of accountability for practice currently guide the roles of these professionals. The role of the pharmacist in Alberta is continually evolving. Public awareness and knowledge about health and medication management have increased with the efforts of Healthy People and Healthy Places.
3. Regulations and Guidelines in Edmonton
In Alberta, where Edmonton, Canada, is located, the provincial regulator of pharmacy is the Alberta College of Pharmacy. The ACPh is the licensing body for pharmacists in Alberta and, as such, has the authority to regulate the scope of pharmacy practice, set standards of practice, and license qualified graduates to practice in the province. The ACPh receives its mandate to do so from the Health Professions Act and its associated regulations. Per this legislation, the pharmacy regulator is charged with ensuring that the profession is considered and a balance is struck between the interests of the profession and the interests of the public, having regard to the paramount importance of the public interest. Like in other jurisdictions around the world, the regulator in Alberta’s role reflects concern for both patient safety guardianship and support for workforce optimization. The combination of patient care and patient safety perspectives is evident in pharmacy regulations, including Alberta’s Food and Drug Act. In the Canadian context, federal controls over prescribing and pharmacists’ roles are set out, including in the Controlled Drugs and Substances Act.
To better define these roles and clarify the competencies of pharmacists as well as the limits on their technical professional conduct, the ACPh and the NAPRA have each established guidelines for pharmacy practice in Alberta. The two have collaborated in the collaborative practice of the non-dispensing pharmacist guideline. Additional guidelines include those that ensure the availability of specific drugs to help women in dealing with the health consequences of an unwanted pregnancy, and in practice, the expanded role of prescribing by pharmacists where collaborative care and a nurse practitioner is the patient’s first point of care, followed by the physician. In prescribing practice, a pharmacist’s practice learning includes patient assessments, investigations, and identification of actual or potential drug-related problems as discussed that were determined to be unresolved after thorough review and care planning, consultation with a multidisciplinary team, and to the patient. Continuing competency and other administrative guideline requirements are standardized for pharmacists with authorization to practice.
4. Benefits of Prescribing Pharmacy
The benefits of engaging pharmacists in the role of prescribing are many. Improved access for prescribing has been shown with individual community pharmacists as well as integrated into primary care clinics. In the community pharmacy setting, when frontline pharmacists have prescriptive authority, patient costs are significantly lower. Hard data comes from expanded pharmacist prescribing, demonstrating improved medication adherence and clinical markers, cost savings, and improved patient-centric care by allowing for collaborative medication management. Notable is a case report where community pharmacists have improved medication management of prescriptions initiated in emergency departments for chronic conditions, resulting in significant savings over two years. Collectively, we see many cases demonstrating that the health benefits of the patient population receiving pharmacist prescriptions across the nation are improving and, in many cases, having healthier metrics than comparative age-matched populations. Research has shown that pharmacists have the skills needed in terms of expertise and competency to manage chronic diseases, suggesting they could manage both the disease and the medications necessary to treat a certain condition. Pharmacists have the opportunity to learn their skills in a structured education plan. Moreover, pharmacists have access to a wide range of educational programs to further their knowledge and ability to prescribe for their practice. Education and training for pharmacists are in place. The objective of the training is to provide pharmacists with the competencies required to begin prescribing independently and to ensure that patients receive safe, effective, and ethical care.
4.1. Improved Patient Access to Medications
In Alberta, where The King’s University is located, several barriers to medication access have been identified. For example, some patients cannot access their medications because of where they live; approximately 12.4% of the population is located in rural Alberta. A lack of local or close pharmacies or practices, combined with long distances to pharmacies where needed prescriptions would be filled, are significant barriers to obtaining medications. Moreover, because of the time required to show up in person at a pharmacy for prescription pick-up, many patients who seek to fill needed medications often report that the wait times are too long to stay at the pharmacy for the time needed.
Pharmacists are uniquely qualified and can, within scope, prescribe medications for patients who need them. The quicker access to such medications has been shown to increase adherence, among other things. This is at least partly due to the higher accessibility of the pharmacist compared to other prescribers. Several initiatives have been in partnership with Alberta Health to reduce restrictions around pharmacist prescribing further and allow an expanded scope in this matter. We believe these initiatives are valuable in terms of broadening pharmacists’ qualifications and believe the further development of collaborative pharmacist prescribing with a physician or other professional is an opportunity to provide greater services to those who need these in different communities. Similarly, pharmacists providing drugs to treat opioid use disorder is a collaborative project designed to increase medication access for a marginalized patient population.
4.2. Enhanced Patient Outcomes
An increasing body of evidence is available to link positive patient outcomes to interventions by pharmacists. Involving a prescribing pharmacist in the medication management of patients has demonstrated effective improvements in patient health as a result of personalized medication therapy management. A study of patients receiving warfarin found that early pharmacist involvement decreased potential errors in medication, with not a single error occurring when a prescribing pharmacist was involved. Similar observations occurred in another study where pharmacist-led medication reconciliation during patient admissions to emergency ambulatory care prevented more than 75% of potential adverse drug events with every occurrence. In the US, the inclusion of pharmacists in the patient care process has led to a reduction in hospital readmission rates currently used as part of health care performance metrics. The use of professionals practicing at the top of their scope within the health care team has also been critical in Canadian hospitals. Not only is pharmacist intervention in hospital care essential, pharmacists’ roles in chronic disease state management are equally essential.
Research into chronic disease and the provision of care for such conditions has frequently highlighted the importance of early and often follow-up with patients. The ability to monitor patient reactions to a new drug or regimen and make the necessary adjustments based on abnormal laboratory test results is one of the founding pillars of evidence-based care. In many Alberta-based pharmacy case studies, the inclusion of the community pharmacist in working with the prescribing physicians has resulted in a large number of successful patient cases. The Alberta-based project of the Enhanced Prescribing Project at a new store has serviced more than 300 patients and has concluded 5 case study summaries, with more projected cases available at the time of publication. In the first year and a half of the program, pharmacists have been instrumental in demonstrating their ability to maintain or improve patients’ A1c, LDL, and cholesterol levels. Upper respiratory tract infections and minor adverse effects were requested improvements from patient interviews and expectations for future treatment care.
4.3. Cost-Effectiveness
Providing care through a prescribing pharmacist can reduce healthcare expenditure in the provision of health. A case can be made for the effectiveness of a new intervention or policy by using this ratio. Two sources of data are used in cost-effectiveness studies: the first is the actual data from a study that has already been carried out, and costs and consequences have been measured or valued. The second source of data is a decision model based on evidence synthesized from many studies. The review finds that pharmacist-led initiatives reduce healthcare costs. Hospitalization appears to be the key element affected by these programs, and there is evidence that pharmacist care results in a reduction in pharmaceutical costs. One reason for more physician visits in the short term might be that the pharmacist is more available for patients and that patients feel they are not taking up valuable physician time with their concerns about medications.
Savings from increased adherence will accrue at the patient, provider, or health system levels. These savings might be health-related. The savings are expected to be considerable based on the results from economic evaluations of pharmacist activities in other settings. In order to quantify the cost savings, further research is needed to evaluate the three models using healthcare outcomes, quality of life, and, if possible, lower cost. Due to selective publication of positive research findings, the cost-effectiveness of using pharmacists to facilitate prescription refills is still controversial. A variety of pharmacy services have been identified as cost-effective while still maintaining or improving the quality of care.
5. Challenges and Limitations
There are challenges that limit the ability of pharmacy prescribers to provide quality patient care and for the practice to be sustainable. Several studies have demonstrated that potential barriers to professional service have been identified from both the health care system and pharmacist perspectives; the majority of these studies were from other jurisdictions, although a lack of time, interest, or urgency from the health care system were often key perceived barriers to service.
Although pharmacist prescribing is implemented and ongoing in several jurisdictions, public awareness of the expanding roles of pharmacy medication experts is not high. A lack of awareness of the extended clinical roles that pharmacists perform and are capable of implementing will also be a temporary barrier to patients utilizing a prescribing pharmacist service. A commitment to further public awareness around the expanded and integrated roles of pharmacists could result in successful awareness discussions surrounding the pharmacy-based prescriber service.
There are fears and negative attitudes surrounding accountability from both a regulatory and safety perspective for prescriber pharmacists. Questions surround who is accountable once the diagnosis and the intervention are decided jointly between the prescriber and pharmacist. Are pharmacists capable of fulfilling their full scope after breaking their career into steps, and who is responsible for the implementation of standard disease state management protocols? Some practitioners and experts are skeptical of the ability of system-level change to happen. Compliance with regulatory boards’ requests for full accounting of patients managed or medications prescribed would be staff time-intensive and require the ability for pharmacy to track patients independently. Development of a stand-alone database of pharmacist-managed or diagnosed patients was seen as just one of the significant hurdles faced and suggested to delay implementation. Informal discussions with regulatory and liability interest groups in subsequent meetings alluded to similar concerns.
Lack of education and training of pharmacists has been raised as a significant limitation to widespread implementation of pharmacist prescribing. Fears that the undergraduate pharmacist training is insufficient and/or under-taught, despite the fact that our non-prescribing counterparts are able to provide information and services to this patient population, are unfounded. For future success, the planning of and participation in joint continuing education for pharmacists and physicians has been highlighted as desirable. Reciprocal and respectful relationships are seen to be key in the inter-professional relationships spearheaded by pharmacist medical prescriptions. In conclusion, the current practice of pharmacy prescribing and the subsequent health research represents the use of protection of the public as the driving force for services.
6. Case Studies and Success Stories
We hope that the following case studies will inspire you to start thinking about how prescribing pharmacists can help transform primary healthcare for those in your practice in ways that medications are optimally used and managed for your patients. Each case describes interventions and the patient outcome in Edmonton.
Research has shown the use and effectiveness of prescribing pharmacists working in interdisciplinary teams. The research has already undertaken a literature review and identified a number of interventions in an ongoing large-scale project. This preliminary project has provided evidence that clearly shows how, when incorporated into an existing primary healthcare team, a pharmacist’s scope of practice can have a dramatic and positive effect on the practice’s ability. The particular interest in “prescribing pharmacist” is that a prescribing qualification extends a pharmacist’s ability to intervene, investigate, and manage patients with chronic disease more fully than by referring prescription-related queries to a pharmacist.
As discussed earlier, the advantages of using a prescribing pharmacist include being able to see more patients in the team; providing more surgery available for patients who need to see a physician; and in situations where the team does not include a family physician, or where family physicians in the team are not accepting new patients, patients have more immediate access to primary healthcare and advice. Patients support the inclusion – or the “embed” of – an alternative primary healthcare provider who is able to fully manage their medications within their primary healthcare team. Yes, put simply: once more, our patients are our teachers, demonstrating what they want and need.
7. Conclusion and Future Directions
It is no doubt that authorizing pharmacists to prescribe has been of great benefit to the population of Edmonton and could continue to improve care for Albertans. The current study provides findings to advocate for the ongoing investment and potential for future research and policy. The current environment reveals that prescribing pharmacy is of critical importance to the community. Healthcare professionals, patients, and the community are demanding pharmacists get the ability to prescribe for improving healthcare. Expanded prescribing practices could further improve health outcomes and reduce the cost of healthcare. Collaborative practices have the potential to improve medication adherence, therapeutics, care, and hospital readmissions. Ongoing education of these practitioners would improve future prescribing. Prescribing pharmacy was beneficial in Edmonton and tends to expand. Future research to evaluate how unconstrained pharmacist prescribing affects healthcare system costs and patient outcomes would be of interest. It would be important to investigate these effects in other jurisdictions before major policy changes are introduced. Areas for future research or policy include assessing the effects of allowing pharmacy to prescribe costly health interventions. Given the high cost of these drugs, it would be important to examine how hospitalizations, primary care services, and drugs were affected. Policy and protocol changes should be explored for all those without limitations on the effects of prescriber education and ability to prescribe for urgent, non-routine drug therapy.
