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Mertens JF, Kempen TGH, Koster ES, Deneer VHM, Bouvy ML, van Gelder T. Pharmacists and pharmacy students' perceptions on how a new teaching model supports their clinical decision-making. CURRENTS IN PHARMACY TEACHING & LEARNING 2024; 16:102136. [PMID: 38955060 DOI: 10.1016/j.cptl.2024.102136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 06/13/2024] [Accepted: 06/16/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND AND PURPOSE Clinical decision-making (CDM) is crucial in pharmacy practice, necessitating effective teaching in undergraduate and postgraduate pharmacy education. This study aims to explore undergraduates and postgraduates' perceptions of how a new teaching model supports their CDM when addressing patient cases. EDUCATIONAL ACTIVITY AND SETTING Implemented in a full-day CDM course for pharmacy students and a half-day course for pharmacists in the Netherlands, the model, accompanied by a learning guide, facilitated CDM in patient cases. Eight courses were conducted between September 2022 to June 2023, followed by an online survey measuring participants' agreement on how the model supported their CDM, using a 5-point Likert scale. Additionally, three open-ended questions were included to elicit learning outcomes and self-development opportunities. FINDINGS Of 175 invited participants, 159 (91%) completed the survey. Most agreed the teaching model supported their CDM, particularly in considering the patient's healthcare needs and context (96%), and exploring all available options (96%). Participants found the model provided a clear structure (97%), and fostered critical thinking (93%). The most frequently mentioned learning outcomes and self-development opportunities included collecting sufficient relevant information, maintaining a broad perspective, and decelerating the process to avoid premature closure. SUMMARY Participants agreed that the teaching model helped them to make clinical decisions. Both undergraduate and postgraduate pharmacy education could possibly benefit from the teaching model's implementation in supporting pharmacy students and pharmacists conducting CDM in pharmacy practice.
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Affiliation(s)
- Josephine F Mertens
- Leiden University Medical Center, Department of Clinical Pharmacy and Toxicology, Postbus 9600, 2300 RC Leiden, the Netherlands.
| | - Thomas G H Kempen
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Ellen S Koster
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Vera H M Deneer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands; Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marcel L Bouvy
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Teun van Gelder
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
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Davidson D, Vasey N, Mundell A, Richardson CL, Rathbone AP. A novel experiential work-based learning model in paediatric secondary care using entrustable professional activities to develop clinical knowledge and communication skills. CURRENTS IN PHARMACY TEACHING & LEARNING 2024; 16:102125. [PMID: 38955064 DOI: 10.1016/j.cptl.2024.102125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 06/05/2024] [Accepted: 06/05/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Initial education and training standards for pharmacists in Great Britain require early clinical exposure to patients using experiential work-based learning. However, there is poor evidence of this approach in some settings, such as paediatric care. The aim of this study was therefore to explore a novel model of experiential work-based learning for student pharmacists in a paediatric setting. METHODS Fourth-year student pharmacists enrolled on a Master of Pharmacy programme were allocated five three-hour placement sessions at a paediatric hospital. Sessions consisted of a briefing, ward activities, scaffolded consultations with children and their carers, followed by a debriefing session with a clinical supervisor. Data were collected relating to the ward, patient details, student reported activities, learning outcomes and if follow up was required by a member of the clinical team. Data were cleaned, quality checked, then descriptive statistical analysis and inductive content analysis were conducted. MAIN FINDINGS Seventy-four students took part in 28 individual sessions and 233 consultations were recorded. Consultations included a best-possible medical history (76%, n = 177), a satisfactory drug history (45%, n = 104), or discussed hospital discharge (11%, n = 26). Students were exposed to patients with diagnosed acute conditions (41%, n = 96) and chronic conditions (33%, n = 76), as well as children awaiting diagnosis (13%, n = 30). Students reported learning about the pathology, diagnosis and symptoms of paediatric conditions (48%, n = 81), medicines used in children (24%, n = 41), patient experiences of recieving care (15%, n = 25), carer experiences (2%, n = 3), the hospital environment (2%, n = 4), career progression (2%, n = 4), and experiences of social care (11%, n = 18). Findings were synthesised with existing entrustable professional activities from the literature to generate novel EPAs specific to paediatric settings. CONCLUSIONS A paediatric setting offers a suitable environment to host experiential work-based learning in pharmacy education. Standards of initial education and training which require pharmacists to prescribe in Great Britain must recognise the importance of exposure to the health needs and experiences of children, young people's and carers prior to graduation.
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Affiliation(s)
- Dylan Davidson
- Newcastle University, Faculty of Medical Sciences, School of Pharmacy, UK
| | - Nicola Vasey
- Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals Foundation Trust, UK
| | - Amy Mundell
- Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals Foundation Trust, UK
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Danielson JH, Jones M, O'Connor SK, Grice G, Adams J. Words matter: Comments in support of diagnosis education in pharmacy. CURRENTS IN PHARMACY TEACHING & LEARNING 2024; 16:102105. [PMID: 38796399 DOI: 10.1016/j.cptl.2024.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 04/30/2024] [Accepted: 04/30/2024] [Indexed: 05/28/2024]
Abstract
Diagnosis education is explicitly included in the Draft Accreditation Standards 2025 and should be wholeheartedly supported. To address the staggering number of diagnostic errors in the US, the National Academy of Medicine advocates for diagnosis education for all health professions. Misperceptions of pharmacists' involvement in diagnosis are exacerbated by use of implicit language and euphemisms, and it's long overdue that we provide clarity. Pharmacists are engaged in diagnosis and diagnostic reasoning in everyday practice whether realized or not. Diagnosis education is implicitly included in US pharmacy curricula in the Pharmacists' Patient Care Process, and it is time to give students the language to engage in it responsibly to be practice-ready in all states. The explicit inclusion of diagnosis in the Draft Standards 2025 has positive implications for education, practice, and graduates.
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Affiliation(s)
- Jennifer Hookstra Danielson
- School of Pharmacy, Southern Illinois University Edwardsville, 200 University Park Drive, Edwardsville, IL 62025, USA.
| | - Mandy Jones
- College of Pharmacy, University of Kentucky, 789 S. Limestone St., Lexington, KY 40505, USA.
| | - Shanna K O'Connor
- College of Pharmacy and Allied Health Professions, South Dakota State University, 2400 S Minnesota Ave, Sioux Falls, SD 57105, USA.
| | - Gloria Grice
- St. Louis College of Pharmacy, University of Health Sciences and Pharmacy, 1 Pharmacy Place, St. Louis, MO 63110, USA.
| | - Jen Adams
- College of Pharmacy, Idaho State University, 1311 E. Central Dr, Meridian, ID 83642, USA.
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Chiang V, Guirguis L, Warren AL, Topps D, Anderson SJ, Hecker KG. Managing common ambulatory conditions: Exploring clinical decision making performance between pharmacists and family physicians. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2023; 12:100357. [PMID: 38023635 PMCID: PMC10663664 DOI: 10.1016/j.rcsop.2023.100357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 09/25/2023] [Accepted: 10/31/2023] [Indexed: 12/01/2023] Open
Abstract
Background Prescribing is part of the expanded scope of practice for pharmacists in Alberta, Canada. Given these responsibilities, clinical decision making (the outcome from the diagnostic and therapeutic decision making process) is an essential skill for pharmacists. The current study compared diagnostic and therapeutic decision-making between Additional Prescribing Authority (APA) pharmacists and family physicians using a set of common ambulatory clinical cases that both practitioners could encounter in the community as part of their daily practice. Objectives To explore clinical decision making performance and behaviors between APA pharmacists and family physicians during the assessment and prescribing of common ambulatory conditions. Methods Eight written ambulatory clinical cases were developed by a panel of experts in both family medicine and pharmacy that were commonly encountered in both professions' daily practice. Participating APA pharmacists and family physicians reviewed the cases and responded with likely diagnoses, recommended treatments, and reported confidence in therapeutic choices. The responses of 18 APA pharmacists and 9 family physicians in community practices were analyzed. Results There were no significant differences in diagnostic accuracy, therapeutic accuracy, confidence in diagnostic choices, and confidence in therapeutic choices between APA pharmacists and family physicians to these common ambulatory presentations. Conclusions This study provides preliminary insights regarding the capabilities of pharmacists in the assessment of common ambulatory community conditions and suggests that APA pharmacists are making similar diagnostic and therapeutic decisions to family physicians. Future research could focus on examining the performance of pharmacists trained in different pharmacy education models, as well as their ability to provide clinical assessment in other specialties, or in more uncommon clinical scenarios.
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Affiliation(s)
- Vincent Chiang
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Canada
| | - Lisa Guirguis
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Canada
| | - Amy L. Warren
- Faculty of Veterinary Medicine, University of Calgary, Canada
| | - David Topps
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Canada
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, Canada
| | - Sarah J. Anderson
- Department of Cell Biology and Anatomy, Cumming School of Medicine, University of Calgary, Canada
| | - Kent G. Hecker
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Canada
- Faculty of Veterinary Medicine, University of Calgary, Canada
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Meijvis VAM, Heringa M, Kwint HF, de Wit NJ, Bouvy ML. Barriers and facilitators for the implementation of the CombiConsultation by general practitioners, pharmacists and practice nurses: a qualitative interview study. Int J Clin Pharm 2023; 45:970-979. [PMID: 37253951 PMCID: PMC10366006 DOI: 10.1007/s11096-023-01597-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 04/23/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND The CombiConsultation is a consultation with the pharmacist for patients with a chronic condition, aligned with the periodic consultation with the practice nurse or general practitioner. Implementation requires adjustments in the working methods of these healthcare providers and therefore behavioural changes. AIM The aim of this study was to identify the barriers and facilitators that determine the behavioural changes by pharmacists, general practitioners and practice nurses required for the implementation of the CombiConsultation. METHOD Ten community pharmacists, 5 practice nurses and 5 general practitioners were sampled from practices enrolled in the CombiConsultation study. Their views regarding the implementation of this clinical pharmacy service were explored using interviews based on the 14 domains of the Theoretical Domains Framework (TDF), which are linked to the Capability-Opportunity-Motivation-Behaviour-model. Barriers and facilitators in the domains were assessed by content analysis. RESULTS Twelve barriers and 23 facilitators were found within 13 TDF domains with high agreement between the healthcare providers. Important facilitators for implementation were the pharmacists' expertise in pharmacotherapy (capability), access to medical data and physical proximity between professional practices (opportunity). Barriers were pharmacists' insufficient consultation- and clinical-reasoning skills (capability), insufficient staff (opportunity) and reimbursement and lack of coordination among all involved healthcare providers (motivation). CONCLUSION All healthcare providers are motivated to implement the CombiConsultation. An existing collaborative practice, with a clear and accepted professional role of the pharmacist is essential. Training of pharmacists in consultation and clinical-reasoning skills can be beneficial, as well as arrangements on the consultation logistics, and reimbursement.
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Affiliation(s)
- Valérie A M Meijvis
- SIR Institute for Pharmacy Practice and Policy, 2331 JE, Leiden, The Netherlands.
- Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.
| | - Mette Heringa
- SIR Institute for Pharmacy Practice and Policy, 2331 JE, Leiden, The Netherlands
| | - Henk-Frans Kwint
- SIR Institute for Pharmacy Practice and Policy, 2331 JE, Leiden, The Netherlands
| | - Niek J de Wit
- Department of General Practice, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Marcel L Bouvy
- Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
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Gregório J, Tavares P, Alves E. Pharmacists' Perceptions on Nutritional Counseling of Oral Nutritional Supplements in the Community Pharmacy: An Exploratory Qualitative Study. PHARMACY 2023; 11:pharmacy11020078. [PMID: 37104084 PMCID: PMC10145172 DOI: 10.3390/pharmacy11020078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 04/28/2023] Open
Abstract
Malnutrition has important health impacts, especially in the elderly. Oral nutritional supplements (ONS) are effective strategies to help balance the nutritional needs of malnourished persons. Multiple ONS are available at community pharmacies, enabling pharmacists to have the possibility to implement strategies for prevention and monitoring of malnourished patients. The aim of this study was to characterize the experience of community pharmacists with the counseling and follow-up of users of ONS. A sample of 19 pharmacists from 19 different community pharmacies were interviewed. Apart from dispensing ONS to support patients that are preparing for diagnostic tests, the most frequently mentioned clinical condition for ONS counseling was malnutrition and dysphagia. When pharmacists consider dispensing ONS, three themes emerge: patient care, related to counselling tailored ONS to each patient's needs; interprofessional collaboration, with a special focus in the collaboration with registered dietitians; and training and education on ONS, looking to improve their knowledge and skills in ONS counselling and follow-up. Future studies exploring new forms of interaction between pharmacists and dietitians in this context should be developed, aiming to determine the workflow of an interdisciplinary service addressing the needs of community dwelling malnourished patients.
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Affiliation(s)
- João Gregório
- CBIOS-Universidade Lusófona's Research Center for Biosciences & Health Technologies, 1749-024 Lisbon, Portugal
| | - Patricia Tavares
- CBIOS-Universidade Lusófona's Research Center for Biosciences & Health Technologies, 1749-024 Lisbon, Portugal
| | - Emilia Alves
- CBIOS-Universidade Lusófona's Research Center for Biosciences & Health Technologies, 1749-024 Lisbon, Portugal
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Mertens JF, Koster ES, Deneer VHM, Bouvy ML, van Gelder T. Clinical reasoning by pharmacists: A scoping review. CURRENTS IN PHARMACY TEACHING & LEARNING 2022; 14:1326-1336. [PMID: 36123233 DOI: 10.1016/j.cptl.2022.09.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 07/27/2022] [Accepted: 09/06/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Clinical reasoning is considered a core competency for pharmacists, but there is a lack of conceptual clarity that complicates teaching and assessment. This scoping review was conducted to identify, map, and examine evidence on used cognitive processes and their conceptualization of clinical reasoning by pharmacists. METHODS In March 2021, seven databases were searched for relevant primary research studies. Included were studies that examined cognitive processes in pharmacists while addressing a clinical scenario in a pharmacy-related setting. Using descriptive analysis, study characteristics, conceptualizations, operationalizations, and key findings were mapped, summarized, and examined. Results were reported using Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. RESULTS From 2252 abstracts, 17 studies were included that examined clinical reasoning in the context of forming a diagnosis (n = 9) or determining medication appropriateness (n = 4). Most studies conceptualized clinical reasoning as a context-dependent cognitive process whereby pharmacists apply and integrate knowledge and clinical experience to interpret available clinical data. Different terms labelled pharmacists' reasoning that showed analytical and intuitive approaches to clinical scenarios, either separately or combined. Medication review studies reported a predominance of analytical reasoning. The majority of diagnosis-forming studies in primary care identified no distinct cognitive reasoning pattern when addressing self-care scenarios. IMPLICATIONS This overview reflects a small but growing body of research on clinical reasoning by pharmacists. It is recommended that this competence be taught by explicating and reflecting on clinical reasoning as separate stage of the clinical decision-making process with transparent cognitive processes.
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Affiliation(s)
- Josephine F Mertens
- Leiden University Medical Center, Department of Clinical Pharmacy and Toxicology, Postbus 9600, 2300 RC Leiden, the Netherlands.
| | - Ellen S Koster
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Vera H M Deneer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands; Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marcel L Bouvy
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Teun van Gelder
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
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Community Pharmacist Consultation Service: A Survey Exploring Factors Facilitating or Hindering Community Pharmacists’ Ability to Apply Learnt Skills in Practice. PHARMACY 2022; 10:pharmacy10050117. [PMID: 36287438 PMCID: PMC9607250 DOI: 10.3390/pharmacy10050117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/12/2022] [Accepted: 09/14/2022] [Indexed: 11/23/2022] Open
Abstract
Background: The NHS Community Pharmacist Consultation Service (CPCS) offers patients requiring urgent care a consultation with a community pharmacist, following referral from general practice or urgent care. The study explored the impact of undertaking a Centre for Pharmacy Postgraduate Education (CPPE) CPCS learning programme, and barriers and enablers to CPCS delivery. Methods: CPPE distributed an online survey to those who had undertaken their CPCS learning. The survey explored participants’ knowledge, confidence and application of taught skills/tools, including clinical history-taking, clinical assessment, record keeping, transfer of care, and Calgary-Cambridge, L(ICE)F and SBARD communication tools. Details on barriers and enablers to CPCS delivery were also included. Results: One-hundred-and-fifty-nine responses were received (response rate 5.6%). Knowledge of, and confidence in, taught skills were high and respondents reported applying skills in CPCS consultations and wider practice. Barriers to CPCS included a lack of general practice referrals, staffing levels, workload, and GP attitudes. Enablers included a clear understanding of what was expected, minimal concerns over indemnity cover and privacy, and positive patient attitudes towards pharmacy. Conclusion: This study demonstrates that community pharmacists can extend their practice and contribute to the enhanced provision of urgent care in England. This study identified barriers, both interpersonal and infrastructural, that may hinder service implementation.
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Osorio-de-Castro CGS, Ferreira TDJN, Silva MJSD, Miranda ES, Teodoro CRDS, Moraes EL, Lima EDC, Santos-Pinto CDB. An ontology of Pharmaceutical Services in the pages of Journal Ciência & Saúde Coletiva. CIENCIA & SAUDE COLETIVA 2020; 25:4887-4916. [PMID: 33295509 DOI: 10.1590/1413-812320202512.19112020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/08/2020] [Indexed: 11/22/2022] Open
Abstract
Pharmaceutical Services (PS) is a growing field which has established itself over the last 25 years in Brazil through scientific publications. This work investigates the evolution of the field in the Brazilian periodical Journal Ciência & Saúde Coletiva. We conducted a scoping review of relevant literature produced in four separate periods (1996-2003, 2004-2010, 2011-2015, and 2016-2019). A search for articles that contained one or more of the pre-established key words in the title was performed by separate pairs of reviewers. The search resulted in 307 articles, 260 of which were included. The findings show that the number of publications increased steadily over the study period. The papers were predominantly open-topic and original articles and written in Portuguese. Most of the lead authors were from the South and Southeastern regions of Brazil and from public universities and Fiocruz. The predominant primary theme was medicine utilization (161 articles), followed by management (56), and tangential aspects of the PM cycle (43). An ontology of PS was created based on the classification of the articles. The findings show that the field of PS encompasses public policy and management and frontline activities involved in the delivery of health care to the population. It is hoped that the diverse range of interrelations in the field of PS will be increasingly addressed in future publications.
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Affiliation(s)
- Claudia Garcia Serpa Osorio-de-Castro
- Departamento de Política de Medicamentos e Assistência Farmacêutica, Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz. R. Leopoldo Bulhões 1480, Manguinhos. 21041-210 Rio de Janeiro RJ Brasil.
| | - Tatiana de Jesus Nascimento Ferreira
- Departamento de Política de Medicamentos e Assistência Farmacêutica, Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz. R. Leopoldo Bulhões 1480, Manguinhos. 21041-210 Rio de Janeiro RJ Brasil.
| | | | - Elaine Silva Miranda
- Departamento de Farmácia e Administração Farmacêutica, Faculdade de Farmácia, Universidade Federal Fluminense. Niterói RJ Brasil
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