Ensuring the quality of pre-travel prescribing

Internationally, the number of healthcare professionals providing pre-travel services has increased dramatically, lead primarily by community pharmacists.¹ As pre-travel risk assessments do not require performance of the restricted act defined as making and/or communicating a diagnosis, the key regulatory issue that governs a profession’s provision of pre-travel services is the authorization to perform the restricted act of prescribing. At present, there is no best-practice framework that regulatory authorities can use to guide policies authorizing such pre-travel prescribing, including policies to specify the competencies required of pre-travel prescribers, or the education and practice requirements to achieve and maintain competence. As a result, there is widespread variability in the requirements, conditions and restrictions surrounding non-physician pre-travel prescribing. For example, the six Canadian provinces that authorize pharmacists’ prescribing for pre-travel care range from no additional educational requirements to the need for prescribing-authority certification.² Similarly, as travel health is not a recognized medical specialty, there are no standardized education or practice prerequisites for physicians offering pre-travel care. This variability has led to urgent calls to develop standards to ensure the competence of both physician and non-physician travel health practitioners.³ Doing so requires development of a framework based on best practices in competence development and assurance, beginning with the identification of the competencies required of pre-travel prescribers.

Competencies for pre-travel prescribers

At a level non-specific to travel health, the UK has addressed prescriber variability across the professions by developing ‘A Competency Framework for all Prescribers’.⁴ Ten competencies are defined and divided into four that address prescribing governance and six that address the sequential patient care steps within patient consultation. Appropriate patient assessment and diagnosis, selection of pharmacotherapies including risk assessment, and shared decision-making are competencies that must occur prior to the actual process of prescribing, which is the fourth patient consultation competency. Provision of information and monitoring/review are the final two. Throughout these competencies, the required knowledge, skills and setting/environment needed for quality prescribing are emphasized. Prescribing governance focuses on the competencies required for safe, professional and collaborative prescribing. These ten competencies, therefore, address the full patient care process necessary to ensure quality prescribing and patient outcomes. Australia has developed similar competencies and the Royal College of Physicians and Surgeons of Canada has adapted the UK’s framework for their ‘Prescribing Safely’ campaign for physicians.^5,6

For independent prescribing by non-physician practitioners, the need for physical exam and diagnostic decision-making competencies has proven most controversial as these have been identified as required for quality diagnosis at both the patient’s initial presentation and during follow-up monitoring. However, provided professionals practice within their scope and adhere to the required assessment, triage and referral competencies, pre-travel risk assessments do not require diagnosis of a patient’s signs or symptoms. In turn, this removes the need for physical examination and diagnostic decision-making competencies. However, competencies related to appropriate history and risk assessment, consideration of co-morbidities, allergies and medications, reliance on validated sources of information and clarity of scope and professional competence would remain as required for pre-travel care. As the UK ‘Competency Framework’ includes a full range of competencies from initial diagnosis to follow-up and de-prescribing, a first step in standards development is to use best practice procedures to identify which of the UK competencies must be included in a ‘Competency Framework for Pre-travel Prescribers’. This identification would be informed by literature, including the high-level competencies that have been identified for nurses who provide travel health services at various levels of proficiency.⁷

Standards of prescribing practice

Standards of practice transform general competency statements into measurable expectations detailing the types of patients for which competence is expected and descriptors of the quality of performance required. Standards are specific to, for example, the pre-travel care expectations of all community pharmacists which differ from the standards expected of pharmacists competent to provide specialized pre-travel care. Criteria have been developed identifying patients with specific demographics and travel itineraries who require care by travel health-trained practitioners.⁸ Such patients would, therefore, be excluded from the standards of practice of community pharmacists, nurses or family physicians who do not have additional travel health qualifications. However, further differentiation among patients based on health conditions and/or travel itineraries is necessary to determine patients who could be appropriately cared for by non-travel health qualified nurses, pharmacists and health physicians respectively. Fernandes et al’s⁹ work does suggest that there are some, albeit limited, patients whose travel risks are manageable by community pharmacists with no additional specialized travel health expertise. Clarification is also needed as to the patients with risks who could be managed by travel-health specialized pharmacists and nurses relative to patients who require care by travel-health specialized physicians. Examples of the latter include travellers with severe underlying health conditions (e.g. immunocompromised) or with complex travel itineraries (e.g. missionaries), and high-risk groups, such as pregnant travellers. These analyses are required to identify the patient-types to include in the pre-travel prescribing standards for various physician and non-physician practitioners, and are a necessary step prior to developing the descriptors of the expected performance on the required competencies for prescribing to these patients. For pharmacists, the patient groups and expected performance levels included in the standards of practice would differ for general pharmacists relative to travel-health specialized pharmacists, which would differ again from the standards for travel-health specialized physicians.

Competence assurance

Several travel health programmes, including ISTM’s Certificate of Knowledge™, Part A of the Royal College of Physicians and Surgeons of Glasgow’s (RCPSG) Membership of the Faculty of Travel Medicine exams (MFTM), or the RCPSG’s Travel Medicine Diploma have been developed with the goal of ensuring attainment of the knowledge required for travel health. However, beyond knowledge attainment, the development of competence requires application of knowledge through experience with patients,¹⁰ leading to the need for supervised practice with a sufficient number and type of pre-travel patients. Assessment of competence also requires candidates to demonstrate their prescribing competence across all of patient history, risk assessment, triage, referral and prescribing within simulated or real practice environments. The RCPSG’s MFTM Part B OSCE format is an example of such an assessment, although practice-based assessments are also recommended to assess such competence.¹¹

The evidence is also consistent and overwhelming that competence in complex areas such as diagnostic decision-making and prescribing for one clinical area is not a generic competence that is transferable to other clinical areas, to other clinical skills or from one patient care type to another.¹² This is the rationale for the requirements by some regulatory authorities that healthcare professionals limit their practice to areas where they have demonstrated competence, with specific requirements for practitioners wishing to change their area of practice.

In a similar manner, maintenance of competence in complex skills requires continued practice, thereby leading to policies mandating minimum patient experience for practicing professionals. For pre-travel care, this has been identified as a priority given both the infrequency of patients cared for and the cyclical nature of pre-travel care.³

Summary

Competencies required of all prescribers have been developed that define the knowledge and skills needed for good prescribing governance and quality patient consultation, prescribing and follow-up.^4–6 There is also literature documenting the best practices for competence development. Despite this, regulatory authorities do not typically incorporate such prerequisites and evidence into their policies authorizing physician and non-physician independent prescribing for pre-travel care. For example, in Canada, pharmacists offering pre-travel care are not required to complete either the ISTM Certificate of Knowledge™ or the RCPSG’s Travel Medicine Diploma. Similarly, in the UK pharmacists offering pre-travel care are not required to complete mandatory travel-health specific education. However, prior to being authorized to independently prescribe, they must complete an approved course that includes learning in practice to support competence achievement. This variability in requirements, which is found across the health professions, should be rectified through an evidence-based, consistent approach to determining the competencies required of all pre-travel prescribers, determining the patient-types most appropriately managed by the various physician and non-physician practitioners and developing/implementing valid systems to ensure achievement and maintenance of these competencies.

Author contributions

N.W. and B.S. were involved in the conception and design of this perspective. All authors critically reviewed the drafts, approved the final content and are wholly accountable for its content.

Funding

For this work, all authors report that they received no financial or in-kind assistance.

Conflict of interest

N.W. reports consulting fees from the Nova Scotia College of Pharmacy for review and recommendations related to pharmacists’ prescribing competencies. B.S. receives honoraria from Sanofi Pasteur as part of the Canadian Travel Medicine Working Group and for writing media education articles. B.A. reports research grants, travel fees, chairman fees and honoraria for CME and media events from Sanofi Pasteur; honoraria for CME events from Merck and GlaxoSmithKine; fees for media educational and CME events from Crucell Vaccines Canada (Janssen): and honoraria for chairing, presenting and reviewing CME events from Pfizer.