Australian podiatrists scheduled medicine prescribing practices and barriers and facilitators to endorsement: a cross-sectional survey

In Australia there is a documented shortage of medical practitioners in many areas which impacts on the prescription of scheduled medicines amongst other concerns [1]. This shortage will only increase in the context of increases in life expectancy, rising chronic disease, and rural and remote workforce shortages [2‐4]. Non-medical prescribing is one healthcare reform strategy that has the potential to offer equitable and timely access to scheduled medicines [2, 5], and allied health professionals have been identified internationally as of high value in this role [6]. The increasing use of non-medical prescribing has been shown to be cost effective and to improve patient satisfaction while not compromising care or safety [7‐9]. Such strategies aim to build a flexible, responsive, and sustainable Australian healthcare workforce that fully utilises workforce resources and competencies [3, 4, 10].

Podiatrists frequently assess, diagnosis, and intervene in painful musculoskeletal injuries, inflammatory conditions, skin and soft-tissue infections, high risk and diabetic foot disease, and fungal infections [11]. Therefore, endorsed podiatrists are well positioned to reduce inconveniences and prevent duplicate visits to general practitioners. Timely prescription of scheduled medicines, such as antibiotic therapy for infected foot ulcers, may prevent deterioration and subsequent hospitalisation and/or limb amputation. Similarly, the ability to prescribe appropriate analgesia and anti-inflammatory medications for acute musculoskeletal injuries and inflammatory condition (such as gout) may reduce complications and emergency department presentations.

In Australia medicines and poisons are classified by schedules which correspond to the level of regulatory control over their availability, which are published in the Standard for the Uniform Scheduling of Medicines and Poisons (SUSMP) [12]. The schedules relevant to the National Podiatry Scheduled Medicines List include Schedule 2 (S2) which are substance that require advice from a pharmacist or licenced person for safe use, Schedule 3 (S3) which require professional advice for safe use but do not require a script, Schedule 4 (S4) which are prescription only medicines, and Schedule 8 (S8) which are controlled drugs [13]. Australian podiatrists with general registration, may administer, obtain, possess, sell, supply, or use (recommend) a range of S2 and S3 substances for the treatment of podiatric conditions, and may be authorised to possess and administer local anaesthetic agents as per the state and territory legislation in which they practice [14].

The Health Practitioner Regulation National Law, enacted by all Australian States and Territories, enables the national health practitioner boards to endorse the registration of suitably qualified health practitioners to prescribe scheduled medicines (endordsed) [13]. The minimum requirements established by the Podiatry Board of Australia to gain endorsement include holding an approved qualification (Pathway A) or completing a portfolio of evidence that includes a supervised practice component (Pathway B). This registration allows endorsed podiatrists to administer, obtain, possess, prescribe, sell, supply or use (prescribe) a broader range of medicines including S4 and S8 medicines from the National Podiatry Scheduled Medicines List, for the treatment of podiatric conditions [13]. Importantly, in addition to national regulation, podiatrists must comply with the legislation and regulations of the State and Territory in which they practice [13]. Therefore, the schedule medicines podiatrist can administer, obtain, possess, prescribe, sell, supply, or use may vary across jurisdictions. Although the Podiatry Board of Australia has been able to endorse podiatrists to prescribe scheduled medicines since 2010, less than 3% of Australian registered podiatrists have gained endorsement [15].

Podiatrists are not covered under the Australian Pharmaceutical Benefits Scheme (PBS) [16], which provides medicines at a Government-subsidised price and collates prescription histories. Therefore, there is a lack of quantitative information about prescribing practices of podiatrists, making it difficult to assess if endorsement for podiatrists leads to health system efficiencies or improved patient access and outcomes.

Little is known about why the uptake for endorsement for scheduled medicines remains low among Australian podiatrists. Graham and colleagues [17], in a qualitative thematic analysis of 13 podiatrists with and without endorsement, identified competence and autonomy (i.e. need/desire to broaden current scope of practice); social and workplace influences (i.e. access to mentors, supervised practice opportunities), and extrinsic motivators (i.e. time and cost of becoming in endorsed) are key barriers and facilitators for podiatrists gaining endorsement. These factors are yet to be explored within the broader podiatry population.

The aim of this research was therefore to investigate medicines prescribing and recommendation practices among Australian podiatrists and, to explore barriers and facilitators that influence the uptake of endorsement.

Of the 229 participants who agreed to take part in the survey, four failed to report their profession and were excluded from all further analyses. A total of 225 registered Australian podiatrists were included in the results for this survey, four of whom were podiatric surgeons.

This is the first known survey of Australian podiatrists’ prescribing and recommendation practices, and barriers and facilitators to endorsement for scheduled medicines. Findings from 225 registered podiatrists indicate that approximately one third of survey participants were endorsed podiatrists, well above the percent of endorsed podiatrists (less than 3%) in the Australian podiatry population, which may reflect a greater interest in the survey topic among this group. The most common medications prescribed or recommended by all podiatrists were local anaesthetics, antimycotics, antibacterial agents, and analgesics. These findings are consistent with other studies that examine prescribing and medication use practices among non-medical prescribers [19, 20]. Taken together these findings suggest the management of pain and infection are areas where patients’ patterns of receiving their medications is undergoing change.

Podiatry, with its known association with chronic disease is well placed in the primary health care setting to reduce burden on General Practitioners and the public health care system [4, 10]. These benefits could be maximised if the rate of endorsement is increased in the podiatry profession. While a majority of Non-endorsed participants reported they would like to become an endorsed prescriber, this intention is not converted into behaviour. This intention-behaviour gap could be partly explained by Endorsed participants reported numerous barriers within the process to gain endorsement, with only 12.5% of Endorsed participants reporting no difficulties. Further, 75% indicated that the wait to receive the award after completing training was prolonged. Steps taken by the Podiatry Board of Australia to reduce the wait time to obtain endorsement may address this concern in the future.

The current endorsement Pathway B require a high level of self-motivation. Individuals are tasked with costly enrolment into post-graduate courses (with associated non-Commonwealth supported fees), the commitment to undertake self-directed online case studies, identify and approach a mentor, identify and organise supervised practice opportunities over a broad range of areas, and complete a portfolio of evidence. Hence, it is not unexpected that barriers related to the endorsement process were amongst the most highly reported barriers by Non-endorsed participants. In addition, Non-endorsed participants frequently identified a ‘Lack of understanding of the endorsement training process’. While this could reflect a lack of intent or motivation to engage with the process to become endorsed, it may also reflect the onerous process of completing the requirements to gain endorsement.

The ‘Lack of PBS funding’ was reported as a considerable barrier for Non-endorsed participants to undertake the endorsement process. Eligibility to prescribe medications under the PBS has been viewed as an important factor in providing full episodes of patient care elsewhere [21, 22]. Without PBS subsidies, podiatry patients may incur greater out-of-pocket expenses or choose to return to their General Practitioner for prescriptions, increasing public and healthcare costs.

Many pathology investigations such as blood, urine, or tissue required for the safe and responsible use of scheduled medicines and to provide full episodes of patient care are either not subsided when ordered by podiatrists or podiatrists are unable to request them. Topical antifungal therapies (which are known to have limited efficacy for the treatment of onychomycosis [23]), do not require pathology testing to prescribe and manage and were recommended by up to 67% of Endorsed participants over the last twelve months. While oral terbinafine, which has high quality evidence for efficacy in the treatment of onychomycosis but requires both pathology testing and liver function monitoring [24], was only prescribed by 25% of Endorsed participants over the last twelve months. Such testing can only be accessed by a referral back to a GP, reducing efficiencies. This example demonstrates how limited access to pathology testing may, in-part, explain the prescribing patterns for antifungal medications observed in this study as well as the relatively high proportion of Endorsed participants not prescribing any medications.

In 2018 the estimated total cost to train a podiatrist through the endorsement process in the public hospital system was estimated at over $50,000, inclusive of costs and in-kind costs to the hospital and the podiatrist themselves [25]. Although this appears to be a significant investment, the researchers suggested breakeven could be achieved by averting 0.68 infected diabetic foot ulcers (DFU) from major amputations [25]. DFU is another area of podiatric practice where health system efficiencies and safe prescribing may be further improved by available and/or subsidised pathology testing for podiatrists.

Identifying factors that motivate podiatrists to become endorsed is an important step in developing strategies to increase engagement and participation. The findings of this survey build on the qualitative interviews by Graham et al. [17] confirming that the self-determination theory (SDT) [26, 27] can provide insights into the drivers of motivation. This universal motivational and personality framework is commonly applied in education and health settings and is based on the concept that people naturally develop through acquiring knowledge, skill, and habits they observe that support their basic psychological needs of autonomy, competence, and relatedness [28].

Self-determination theory posits that motivation to undertake learning can be represented on a continuum from extrinsic motivation (e.g. financial rewards) through to intrinsic motivation (e.g. curiosity or finding the content appealing and interesting) [28]. Endorsed participants indicated the intrinsic motivator such as ‘I like to extend my knowledge’ for participating in endorsement training. This may suggest that such intrinsic motivation is more likely to motivate podiatrists to action than the extrinsic factors such ‘Lack of PBS funding’ and ‘No tangible incentives to undertake training’. Interestingly, these were reported as barriers by Non-endorsed participants.

In SDT, internalisation occurs when a behaviour becomes a personally endorsed value such that the behaviour is in harmony with the broader values, commitments, and interests of the person [29, 30]. In-training participants had the highest reporting of ‘I believe it is an essential skill for effective podiatry practice’, followed by endorsed participants, suggesting for them prescribing may have become an internalised behaviour that motivated these participants to overcome the onerous process involved in becoming endorsed.

Several studies have supported aspects of SDT on an organizational level [31]. The history of local anaesthetic (LA) use in podiatry could be one example of internalising prescribing as a behaviour on a profession wide level. Local anaesthetic was introduced as part of undergraduate podiatry training in Australia in 1978 [32] and has seen a wide uptake such that it is now seen by the profession as an essential skill. Findings from this survey support that LA has become an internalised behaviour in podiatry as LA’s were a medication group non-endorsed participants frequently used.

Self-determination theory hypothesises that the need to be connected to others and to be an effective member of the social environment supports the tendency to internalise the values and regulatory processes of their surroundings [31]. In-training participants had the highest reporting of the social and workplace influences of ‘Becoming a valued member of a team’ and ‘Support from employers’. Similarly, In-training participants reported higher levels than Non-endorsed participants of ‘Working in an environment with other endorsed prescribers’, suggesting observing prescribing in the workplace can motivate an individual to master this skill to enable them to better integrate into the larger social structure of the workplace [28]. The lack of internalization by Non-endorsed participants is supported by the reporting of ‘You can be a successful podiatrist without having endorsement’.

This is the first known research to examine the prescribing and medication recommendation practices of podiatrists within Australia, with a key outcome being that podiatrists predominantly prescribe or recommend medications to assist pain, inflammatory, or infectious conditions. However, lack of PBS funding and pathology testing access limit podiatrists’ ability to provide full episodes of patient care. Therefore, the valuable benefits of streamlined care, improved patient access, and improved efficiencies in the health system may not be fully realised and can even be difficult to examine.

Approaches that improve access to mentors and a broad range of supervised practice, such as a increased numbers of endorsed podiatrists or a formalised leadership and mentoring framework are likely strategies that that could improve rates of endoesement. It was also suggested that some barriers to endorsement could be addressed by internalising prescribing as a behaviour in the podiatry profession through supporting staff within leadership roles and teaching institutions to engage with and model the prescription of scheduled medicines. The plan to incorporate the requirements for endorsement into undergraduate education has been demonstrated in the past to be effective in podiatry when used with the prescription of LA. While this may be a long-term strategy, in the short term, improving access to mentors and incentives for the current workforce to become endorsed should be actively considered.