Is a GP-reviewed online questionnaire clinically sufficient to safely prescribe injectable medications without a face-to-face consultation? It depends who you ask.
Two in every three adults and one in four children live with overweight or obesity in Australia – one of the highest rates of obesity in the world.
For many, trying to address their weight gain is an ongoing battle, with an increasing number of people turning to prescriptions medications.
In response to the demand, a number of telehealth companies tied to prescription medicine services have popped up online, with targeted advertising through social media platforms. But concerns have been raised about the appropriateness and quality of the care patients are receiving.
Among the websites being flagged is Australian-based Juniper. The telehealth and medicine subscription service run by Eucalyptus – the umbrella company also behind Pilot, Kin and Software Skin – is marketed to women as a convenient service for weight loss that can be accessed from the ‘comfort of your own home’.
Juniper claims to offer a ‘holistic and clinical approach to weight loss’ by combining ‘breakthrough medication, weekly check-ins with Australian GPs, free access to dietitians and health coaches, and personalised treatment plans delivered to your door’.
However, Dr Terri-Lynne South, Chair of RACGP Specific Interests Obesity Management, is concerned and says the direct-to-consumer marketing approach such companies are taking is ‘disturbing’.
‘I have actually seen the … marketing, it’s come across my Facebook feed,’ she told newsGP.
‘I’ve also looked at some of the claims [they make] with regards to “reset your metabolism”. It’s language that’s trying to hook patients, selling them something that they want to hear. But the medication does not change your metabolism.’
Juniper’s website, which also specialises in menopause, directs people interested in its Weight Reset Program to take a quiz. Once completed, the answers are reviewed by a GP, who assesses the person’s suitability for the program. If approved, the patient has a text-based consultation with a GP, and the weight loss medication is sent via mail.
But Dr South says the approach does not sound adequate and is worried by the lack of continuity of care. She says in her experience patients often overlook and fail to mention vital information a GP may need to make an accurate assessment.
‘They’re missing a whole heap of potential information,’ Dr South said.
‘Oftentimes I’ll have a patient’s chart – years’ worth of history – and it won’t be until I’m looking through and say “oh, hang on, what about this?” [and they’ll say] “oh, I didn’t think that was relevant”.
‘I’d also be concerned that at the moment we’re using things like healthy weight range and BMI in regard to defining when someone should be losing weight – that is not necessarily the best measure.’
But when it comes to the quality of care delivered by Juniper, GP Dr Matthew Vickers, who is the clinical director at Eucalyptus, disagrees.
He said the pre-consultation questionnaire comprises up to 100 questions to gain insight into a patient’s medical history, weight loss journey, biopsychosocial impacts on their health and their goals – and that patients are provided with follow-up care.
‘It’s concerning that many critics seem to have little understanding about the industry or a willingness to engage,’ he told newsGP.
‘Patients are more than capable of providing a medical history with appropriate questioning, and where our GPs do not feel that this is adequate, they simply won’t proceed with a consultation or treatment plan.
‘Consultations do engage in appropriate two-way communication with patients at Eucalyptus and we continually improve the quality of these interactions through technology and alternative models of care, including facilitating synchronous interactions.’
According to Dr Vickers, Eucalyptus is the only telehealth company accredited by the Australian Council on Healthcare Standards. He says while there may be similar services with a ‘complete lack of standards – just like there is in traditional face-to-face settings’ that is not the case with Juniper.
Dr Vickers adds that ‘up to 50%’ of cases do not include pharmacotherapy, despite ‘doctor-prescribed medication’ seemingly being a key selling point on its website.
‘The quiz is not used to provide formulaic or algorithm-based decision-making,’ he said.
‘GPs have the option to request photos, call the patient, order pathology and liaise with other healthcare professionals to corroborate history as required.’
Asked how often this additional information is requested from patients in practice, Dr Vickers said ‘it varies’ depending on the consultation type, patient and practitioner.
‘[It] is at their discretion,’ he said.
While the specific drug being prescribed is not advertised by name on the website due to Australian Therapeutic Goods regulations, AAP claims it is liraglutide (sold as Saxenda). An injectable medication approved by the Therapeutic Goods Administration (TGA) for weight management, it is also used to manage diabetes under a different trade name (Victoza) and replicates the body’s natural GLP-1 hormone, working to suppress appetite and regulates digestion.
When it comes to potential side effects from the medication, Dr Vickers said the company has safeguards in place and that its internal clinicians audit more than 4000 consultations each month.
‘Audit findings are fed back to GPs to constantly improve the safety and quality of the services and tailor the delivery of healthcare services to individual patients,’ he said.
‘One of the enormous benefits of asynchronous telehealth is that it allows such detailed and robust quality assurance work to take place.
‘Eucalyptus also tracks the proportion of patients who report side effects to the Medical Support team, which allows the team to calibrate its proactive patient education and to guide doctors in their consultations.’
Dr Terri-Lynne South is the Chair of RACGP Specific Interests Obesity Management.
The website states that the initial consultation is free of charge. Thereafter the program costs $13 a day – equating to more than $400 a month – for which customers receive the prescription medication, unlimited follow-up consultations and health coaching.
‘This is the same price as what pharmacies charge for the same medication alone,’ the website claims.
Online vs face-to-face
Dr South says that when patients see a GP face-to-face in their local area and a referral is made to allied health services, that care is usually offered in the local community, which she says has practical benefits.
‘Those local practitioners will know of what’s happening in their local community with regards to access to food, what the shops are like, what the tips and practical tricks are in regards lifestyle change,’ she said.
‘So, I just feel that there is less quality of care, less holistic care and I also feel that patients will get more bang for their buck if they actually see their GP face to face because these subscription services don’t get a Medicare rebate either. Your patients would be doing themselves a disservice.’
Dr Vickers, however, says the service aims to provide care for patients across Australia who are ‘not currently under the care of a regular GP’ or ‘who may be having issues with access’.
While Australia is grappling with a shortage of GPs and increased wait times, Dr South says this argument doesn’t stand for weight control and metabolic health.
‘This is a marathon – not a sprint – to help people who live with the chronic complex condition called obesity,’ she said.
‘It’s a lot more complicated than the public knows and it’s actually a lot more complicated than a lot of general healthcare practitioners know. And I’m not just talking about GPs, I’m talking about all primary healthcare.’
Weight-loss medication advertisements under scrutiny
A TGA spokesperson told newsGP that the advertising from services such as Juniper and Mosh – a similar online service – has been ‘brought to the TGA’s attention’.
They also noted that such weight loss services raise a number of considerations, including ‘whether the material directly or indirectly promotes the use or supply of therapeutic goods [and] whether they promote a health service instead or whether they raise any medical practice issues’.
‘The TGA does not regulate the provision of health services or good clinical practice,’ they said.
However, the spokesperson did say that the TGA has been responding to allegations of unlawful advertising related to a group of prescription-only medicines for weight loss since early 2022.
So far the regulator has requested the removal of more than 3500 weight loss medication advertisements, including for GLP1-RAs, over an eight-month period up to 2 March.
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