Increased access to antibiotics for the Rheumatic Fever Prevention Programme

Medicines

Decision

PHARMAC is pleased to announce the approval of changes that will enable increased amounts of certain antibiotics that can be obtained under a Practitioner’s Supply Order (PSO), for patients with suspected or confirmed Group A Streptococcal throat infections being treated under the Rheumatic Fever Prevention Programme (RFPP).

This was the subject of a consultation letter dated 8 October 2013.

In summary, the effect of the decision is that from 1 December 2013:

  • The rule relating to a PSO in Section A: General Rules of the Pharmaceutical Schedule will enable an increase in the quantity of certain antibiotics that can be ordered by practitioners for patients with suspected or confirmed Group A Streptococcal throat infections that are being treated under the RFPP.
  • Amoxycillin 500 mg capsules and phenoxymethylpenicillin 500 mg capsules will be subsidised on a PSO.
  • The dispensing pharmacy can claim the multiple service fees for dispensing in course-specific amounts as per the Community Pharmacy Services Agreement (the CPSA).

Details of the decision

The following pharmaceuticals will be listed in Section E, Part I Practitioner’s Supply Order of the Pharmaceutical Schedule from 1 December 2013:

Chemical Presentation Quantity subsidised
amoxycillin cap 500 mg 30
phenoxymethylpenicillin (Penicillin V) cap potassium salt
500 mg
20

The maximum quantities will be amended for the following pharmaceuticals as listed in Section E, Part I, Practitioner’s Supply Order, of the Pharmaceutical Schedule from 1 December 2013:

Chemical Presentation Quantity subsidised
amoxycillin grans for oral liq 250 mg per 5 ml 300 ml
erythromycin ethyl succinate tab 400 mg 20
erythromycin ethyl succinate grans for oral liq 200 mg per 5 ml 300 ml
phenoxymethylpenicillin (Penicillin V) grans for oral liq 250 mg per 5 ml 300 ml

Amendment of Rule 5.2.6 of Section A: General Rules

After considering responses to consultation requesting that the proposed rule be simplified, PHARMAC staff has amended the rule as follows (changes are in bold and strike through):

5.2.6   A Practitioner working in the Rheumatic Fever Prevention Programme (RFPP) being implemented by the Ministry of Health may order, under a Practitioner’s Supply Order, such, the Community Pharmaceuticals (identified below) as that he or she requires to ensure medical supplies are available for treatment of patients with suspected or confirmed Group A Streptococcal throat infections for the purposes of the RFPP in the following circumstances:

a) the RFPP provider name is written on the Practitioner’s Supply Order; and

b) the order quantity should be specified in course-specific amounts; and

cb) the total quantity ordered does not exceed a multiple of:

i) ten times the Practitioner’s Supply Order current maximum listed in Section E Part I for amoxicillin grans for oral liq 250 mg per 5 ml, amoxicillin cap 250 mg and amoxicillin cap 500 mg; or
ii) two times the Practitioner’s Supply Order current maximum listed in Section E Part I for phenoxymethyl penicillin grans for oral liquid 250 mg per 5 ml, phenoxymethyl penicillin cap 500mg, erythromycin ethyl succinate grans for oral liq 200 mg per 5 ml and erythromycin ethyl succinate tab 400 mg; and

d) the practitioner must endorse the Practitioner’s Supply Order with the multiple order quantity (i.e. 10 x 300 ml amoxicillin grans for oral liq 250 mg per 5 ml), and the dispensing pharmacy may claim the multiple service fees as per the Community Pharmacy Services Agreement.

c) the Practitioner must specify the order quantity in course-specific amounts on the Practitioner’s Supply Order (e.g. 10 x 300 ml amoxicillin grans for oral liq 250 mg per 5 ml). This will enable the Pharmacist to dispense each course separately and the Contractor to claim multiple service fees in accordance with the current Community Pharmacy Services Agreement. 

Feedback received

We appreciate all of the feedback that we received and acknowledge the time people took to respond. All consultation responses received by 25 October 2013 were considered in their entirety in making a decision on the proposed changes. All responses were supportive of the proposal, and the following issues were raised in relation to specific aspects of the proposal:

Theme Comment

A responder requested that the new PSO rules should apply to all North Island DHBs.

The rules are applicable in any DHB, wherever the RFPP is operating.

A responder raised concerns that antibiotics provided to patients will not be visible in a patient’s electronic dispensing record.

Medicines dispensed under PSO’s are not patient-specific and therefore it is difficult to record at that level the patient that receives the medicine.

However, antibiotics provided to patients must be recorded as part of the Standing Orders.

These comments have been passed to the Ministry of Health (the Ministry). We have suggested that the Ministry continue discussions with the National Health IT Board on an IT solution for this.

Some responders noted that the Rheumatic Fever Guideline on Group A Streptococcal Sore Throat Management (2008) is currently being updated.

They recommended that the following antibiotics also be included

  1. penicillin V 250mg – 40 capsules
  2. cephalexin – for those intolerant to penicillin/amoxicillin.
  3. cephalexin, amoxicillin with clavulanic acid and benzathine penicillin G (used for the treatment of multiple recurrent episodes of GAS pharyngitis) i.e. if it is the patient’s third or more GAS pharyngitis in a three month period.

The Rheumatic Fever Guideline on Group A Streptococcal Sore Throat Management (2008) cited by responders are being updated and are currently in draft form. We would be happy to consider further amendments to the Pharmaceutical Schedule once the 2008 guidelines are updated and confirmed as final.

Amoxicillin with clavulanic acid (30 tablets) and benzathine penicillin G (5 injections) are currently available on PSO. We would be happy to consider an application for funding of higher quantities if evidence could be provided of the need for greater amounts on PSO.

We would be willing to consider an application for funding of cephalexin on PSO.

Community Pharmacy responders requested that:

  • a separate claim code should be created to help with analysis
  • that community pharmacists be provided guidance on their role within the RFPP
  • the proposed Pharmaceutical Schedule rules could be simplified
  • the table similar to the one provided in the consultation document would be helpful.
  • community pharmacy should be paid for providing bottles to the RFPP
  • the Ministry works with community pharmacy in developing guidance relevant to community pharmacy.

It was also noted that there are times where RFPP providers acting under Standing Orders will need to manage wastage of antibiotics.

We will explore how antibiotics dispensed under the RFPP can be best identified by IT systems.

This feedback has been passed to the Ministry regarding community pharmacy’s information needs, and RFPP provider needs around antibiotic reconstitution and wastage. The Ministry will provide guidance to community pharmacy around dispensing and labelling for the RFPP.

A table will be provided to Community Pharmacists, including information on the correct way to enter PSO’s for the RFPP to ensure that the pharmacy is able to correctly claim for the service.

The cost of packaging is covered by the fee being paid to dispense PSOs under the CPSA

A responder requested confirmation that the proposed changes would not require technical rule changes.

They also requested the use of the word “annotation” in the Pharmaceutical Schedule rules rather than endorsement.

They would like it noted that this proposal will cause the integrity of data in the e-prescribing data ‘cloud’ to be corrupted.

No change to the technical rules are required at this stage in order to implement what has been proposed

PHARMAC staff have simplified the proposed Pharmaceutical Schedule rules

E-prescribing is yet to be rolled out nationally.

PSO’s are not patient specific; therefore clinical data will not be compromised.

A responder commended PHARMAC for acknowledging the administrative burden for those working on the RFPP.

They also felt that labelling guidance to community pharmacists is a vital safety measure to ensure courses of antibiotics are labelled individually for specific patients before being allocated to children and their families.

Feedback on labelling has been passed to the Ministry for consideration

Some responders felt the maximum number of courses should be greater than 10 courses

PHARMAC staff will monitor usage and may review the maximum number of courses at a later date if required

More information

If you have any questions about this decision, you can call our toll free number (9 am to 5 pm, Monday to Friday) on 0800 66 00 50.