Prescriptions and prescribers in primary health care

This issue of the Journal of Primary Health Care focuses on research around the use of medications in primary health care settings, and the growing role of non-medical prescribers. The primary care role of the community pharmacist in Aotearoa New Zealand (NZ) has been expanding. Increasingly, community pharmacists are employed within general practice settings. A survey of such pharmacists found they commonly undertook patient consultations, with a third providing prescriptions. They also had practice-facing roles, providing information to other primary health professionals about medicines, conducting medicines use review, medicines therapy assessment and medicines optimisation advice.¹ Pharmacists also play a role in provision of palliative care. A scoping review found that as well as supplying medications, pharmacists provide other services such as recommendations to specialists to improve patients’ pain and symptom management, identify drug-related problems, and provide psychosocial support to dying patients.² This role could be strengthened with further training of pharmacy staff, and increased awareness of other health practitioners and end-of-life patients of the services pharmacists might provide.

Medicines can be classified as prescription-only, restricted (pharmacist-only), pharmacy-only or freely available over-the-counter. A comparative study of medicine classifications between NZ and Australia found that NZ has a less restricted approach, with patients able to access medicines from a pharmacist without prescription, specifically oral contraceptives, sildenafil, antibiotics for urinary tract infection and two COVID-19 antivirals.³ While this might increase equity of access, there is a risk of fragmentation of care, and information sharing, collaboration and communication with the general practitioner is important.

The last two decades have seen pharmacists and nurses prescribing medicines alongside general practitioners (GPs) in primary care settings. While a multi-disciplinary approach offers many advantages in managing patients with multimorbidity, there is a risk of discontinuity and fragmentation of care and medicine-related harms. A qualitative study by Wells and colleagues highlights the importance of good patient–prescriber and interdisciplinary relationships and accurate exchange of medicines-related information across all health settings to maintain medicines-related continuity of care.⁴

Polypharmacy increases the risk of medicines-related harm in older adults. Hikaka and colleagues reviewed medication use of residents from 33 retirement villages and found that polypharmacy (five or more medicines) in 52%, with hyperpolypharmacy (10-plus medicines) in 6%.⁵ An increasing role for GPs is medication review and appropriate deprescribing of patients receiving polypharmacy. Final year medical students at the University of Otago, Wellington undertake a medication review with their GP supervisors. A survey found that this student-led activity led to improved knowledge for both student and supervisor, as well as the patient benefiting from appropriate deprescribing and reduced drug interactions.⁶

Decreasing the unnecessary prescribing of antibiotics is crucial to prevent the spread of antimicrobial resistance. An exploratory qualitative approach by Lim and colleagues found that nurse practitioners, nurse prescribers, and also registered nurses are ideally placed to enhance antimicrobial stewardship, but require educational and organisational support to step up to this role.⁷

An Australian study has found a rise in prescribing of psychotropic medications, particularly by GPs, over the last two decades, and that this further increased during the COVID-19 pandemic.⁸ Women aged 60 and over, and people with low to moderate socioeconomic status had the highest rates, and the authors recommend that health care planners and policy makers monitor and adapt mental health care services to meet the evolving needs of the population and account for population diversity and equity.

Several papers in this issue look at medication use from patients’ point of view. In a study conducted prior to the NZ government’s removal of prescription charges, Isno and colleagues found that patients living in an area of high socio-economic deprivation reported going without medicines until they could afford them, having to choose which of their medicines to pick up, or choosing between medicines and other expenses such as food. Some participants reported previous hospitalisations because of their inability to pay for, and hence take, their medicines, and few had ever discussed the affordability of medicines with their doctor.⁹ South Asians are a high-risk group for cardiovascular disease in NZ, but their medication adherence can be low. A qualitative study of South Asians with diabetes, hypertension and/or dyslipidaemia found that medication use can be influenced by concern and hesitancy to start conventional medications, and a preference for herbal and alternative therapies.¹⁰ Patients with migraine completing a survey reported barriers to obtaining effective migraine management, including feeling stigmatised by health providers, lack of access to secondary care specialists, and perception of poor health professional knowledge about the condition.¹¹

To round off the issue for this year we have our usual column Cochrane Corner on exercise for osteroarthritis of the knee.¹²

Meri Kirihimete, kia haumaru te noho, e hoa mā