Mystery shopping and coaching as a form of audit and feedback to improve community pharmacy management of non-prescription medicine requests: an intervention study

Simulated patient methodology as a "gold standard" in community pharmacy practice: Response to criticism

The simulated patient methodology (SPM) is considered the "gold standard" as covert participatory observation. SPM is attracting increasing interest for the investigation of community pharmacy practice; however, there is criticism that SPM can only show a small picture of everyday pharmacy practice and therefore has limited external validity. On the one hand, a certain design and application of the SPM goes hand in hand with an increase in external validity. Even if, on the other hand, this occurs at the expense of internal validity due to the trade-off situation, the justified criticism of the SPM for investigating community pharmacy practice can be countered.

Pharmacists' use of guidelines for the supply of non-prescription medicines: a cross-sectional survey

OBJECTIVES

Guidelines support best practice for healthcare practice. In Australia, some non-prescription medicines are only accessible after consultation with a pharmacist and are known as Pharmacist Only medicines. Guidelines for providing some Pharmacist Only medicines are available, however, it is currently unknown if and how these guidelines are used in practice.The objective was to characterise pharmacists', intern pharmacists and pharmacy students' use of guidelines for Pharmacist Only medicines.

METHODS

A cross-sectional electronic survey of Australian registered pharmacists, intern pharmacists and pharmacy students was administered in July 2020. Questions explored the participants' use of Pharmacist Only medicine guidelines (available both in print and online; available online only) in the preceding 12 months. Data were analysed descriptively (i.e. frequencies, percentages).

KEY FINDINGS

In total, 574 eligible respondents completed the survey. Overall, 396 (69%) reported accessing the online and in-print guidelines in the previous 12 months with 185 (33%) accessing online-only guidelines. The guideline on emergency contraception was used the most out of all guidelines in the past 12 months (278, 48%). Overall, respondents reported accessing guidelines to update knowledge, check their practice reflected best practice and content familiarisation. Respondents' reasons for not accessing guidelines were due to respondents stating they did not need the information or that they had previously accessed the guidelines more than 12 months ago. These reasons varied between respondent groups.

CONCLUSIONS

Access and use of the Pharmacist Only medicines guidelines varied between pharmacists, interns and students. Further understanding of the influences of the use of these guidelines will help inform professional bodies on how best to develop guidelines to increase consistent use in practice and implement interventions to increase use.

Assessment of the operation status of electronic prescription at community pharmacies in Chengdu, China: a simulated patient study

BACKGROUND

Information and technologies relevant to eHealth have developed rapidly over the past two decades. Based on this, China piloted "Internet + " pattern and some regions piloted electronic prescription services to explore telepharmacy services.

OBJECTIVE

To describe the processes and assess the operation status of electronic prescription services mode for community pharmacies in China.

METHODS

The simulated patient methodology was used to conduct a cross-sectional study in 317 community pharmacies from six districts in Chengdu, China in 2019. Simulated patients expressed three levels of service demands based on scenario about acute upper respiratory tract infections to evaluate the recommendation strength of electronic prescription services and telepharmacy service in community pharmacies. The descriptive statistics was completed to obtain the characteristics of the visit process, student t-test and χ2 test (P < 0.05 was considered statistically significant) were used for inferential statistical analysis to determine differences in characteristics and degree of recommendation between pharmacies.

RESULTS

Three Hundred Seventeen record sheets were effectively collected. The third-party platform was recommended in 195 (61.5%) interactions. The main reason for not recommending is non-prescription dispensing of prescription drugs (27.1%). 90.3% interactions waited less than 1 min, the counseling duration was less than 5 min in all interactions, and most community pharmacies had good network conditions (81.5%). 97.4% remote physicians offered professional counseling, only 22.1% of the pharmacists provided medication advice.

CONCLUSIONS

The electronic prescription services mode for community pharmacies in Chengdu provides a convenient drug purchase process but remains some problems. For example, prescribing drugs without a prescription and services provided by pharmacists was poor, etc. The relevant supporting policies should be improved in future development process.

The role of perceived service quality and price competitiveness on consumer patronage of and intentions towards community pharmacies

BACKGROUND

When consumers choose a service provider, they trade-off their perceptions of service quality with their perceptions of the cost of engaging with the service provider. For community pharmacy owners and managers, it is important to understand the relative impact on loyalty of providing the extra resources to improve service quality versus forsaking gross profit by discounting prices. The aim of this study was to explore the relative effects of consumers' perceptions of service quality (pSQ) and price competitiveness (pPC) on patronage loyalty (patronage history of the rated pharmacy), patronage disloyalty (patronage history at other pharmacies) and loyalty intentions.

METHODS

This was a cross-sectional study conducted within Australia using an online survey administered to members of a consumer marketing panel. Eligible participants were adults taking 2 or more prescription medicines and had attended a community pharmacy within the past 4 weeks. Participants were asked to rate the pharmacy they had last visited, self-report patronage history of that and other pharmacies and report the brand of pharmacy visited. Previously validated scales were used for consumers' perceptions of service quality (pSQ) and loyalty intentions. New scales were developed for pPC and self-reported patronage loyalty and disloyalty. Confirmatory Factor Analysis (CFA) was used to validate the measurement model. Structural Equation Modelling (SEM) with robust estimator (EQS) was used to test the relationships between the variables. Sensitivity analysis, in the presence of covariates were performed with multivariate regression analysis with bootstrapping.

RESULTS

Surveys were completed by 303 participants. Most consumers had visited the rated pharmacy more often than once monthly and most had visited only 1 or 2 pharmacies in the past 12 months for prescription medicines. Overall, participants rated pSQ, pPC highly and expressed high loyalty intentions. The SEM was a good fit for the data. The model predicted 12%, 15% and 69% of the variation in patronage loyalty and patronage disloyalty and loyalty intentions, respectively. The effect of pSQ on patronage was 0.38 (p < 0.05) for loyalty and -0.38 (p < 0.05) on disloyalty whereas the effect of pPC was marginal. The total effect of pSQ and pPC on loyalty intentions was 0.64 (<0.05) and 0.20 (p < 0.05) and in sensitivity analyses, no other covariate, including pharmacy brand was significant.

CONCLUSION

In order to drive loyalty behavior and generate loyalty intentions, providing a high-quality service appears to be far more effective than creating perceptions that the pharmacy has competitive prices. This finding affords a motivation for both discount AND non-discount brand pharmacies to undertake the steps needed to improve service quality.

Dispensing and Purchasing Antibiotics Without Prescription: A Cross-sectional Study Among Pharmacists and Patients in Beirut, Lebanon

Antimicrobial resistance is a global public health issue, exacerbated by dispensing and purchasing antibiotics without a prescription, common in low- and middle-income countries, such as Lebanon. This study aimed to (1) describe behavioral patterns underpinning dispensing and purchasing antibiotics without a prescription among pharmacists and patients, (2) describe reasons for, and (3) attitudes toward these behaviors. A cross-sectional study targeted pharmacists and patients, respectively, identified through stratified random sampling and convenience sampling from all 12 Beirut quarters. Questionnaires assessed behavioral patterns, reasons for, and attitudes toward dispensing and purchasing antibiotics without prescription among the 2 samples. A total of 70 pharmacists and 178 patients were recruited. About a third (37%) of pharmacists supported dispensing antibiotics without a prescription, considering it acceptable; 43% of patients report getting antibiotics without a prescription. Reasons for distributing and purchasing antibiotics without prescription include financial costs associated with the drugs and convenience, coupled with inexistent law enforcement. Dispensing antibiotics without prescription was shared among a relatively high proportion of pharmacists and patients residing in Beirut. Dispensing antibiotics without prescription is common in Lebanon, where law enforcement needs to be stronger. National efforts, including anti-AMR campaigns and law enforcement, must be rapidly implemented to avoid the double disease burden, especially when old and new vaccines are available, and superbugs are making preventative public health efforts more difficult.

Evaluation of pharmacist's practices regarding the antimicrobials dispensing: a simulated patient study

BACKGROUND

The indiscriminate use of antimicrobials is considered a major contributing factor to the increase in antimicrobial resistance. Community pharmacies are the main source of access to antimicrobials, and pharmacists are in a strategic position to promote rational use of these medicines. Therefore, it is important to know dispensing service quality.

OBJECTIVE

To evaluate the behavior of pharmacists in dispensing antimicrobials in community pharmacies in northeast Brazil.

METHODS

This cross-sectional pilot study was conducted from August to October 2021 in a private community pharmacy chain in Sergipe. Dispensing was evaluated using the simulated patient (SP) technique. Two SP asked the pharmacists for the antimicrobials (case clinic 1: upper respiratory infection; case clinic 2: urinary tract infection) and recorded the service through audio. Dispensing practices were independently analyzed by two researchers based on the tools available in the literature. Data were presented using descriptive statistics.

RESULTS

A total of 54 simulated patient visits were conducted. Based on the 12 steps recommended by the research team for good dispensing, pharmacists asked an average of 1 (±1.17) question for upper respiratory infections and 0.3 (±0.54) for urinary tract infections, as well as provided counseling (mean number of recommendations, 2.6 (±1.44) and 4.5 (±2.35), respectively). As for communication skills, pharmacists had a regular score (3.07 ± 0.34). Furthermore, there was no significant difference in the number of steps and counseling recommendations by pharmacists in dispensing clinical cases 1 and 2 (p = 0.0674).

CONCLUSION

The quality of antimicrobial dispensing was evaluated as suboptimal, requiring improvements in practice and multifaceted strategies to promote continuing education of these professionals. In addition, awareness actions for the population must be implemented to promote the rational use of antimicrobials and reduce microbial resistance.

The Quality of Counseling for Headache OTC Medications in German Community Pharmacies Using a Simulated Patient Approach: Are There Differences between Self-Purchase and Purchase for a Third Party?

Background

In Germany-as worldwide-headache is one of the most frequent causes of self-medication. The dispensing of over-the-counter (OTC) medications may only be carried out by community pharmacies (CPs). In doing so, CPs have to ensure "adequate" counseling, for both self-purchase and purchase for a third party, which also occurs in everyday pharmacy practice. The aim of this study was to evaluate the quality of counseling for headache OTC medications in German CPs and, as the first study worldwide, to analyze whether and to what extent there are differences in counseling between self-purchase and purchase for a third party.

Methods

A cross-sectional study was carried out using the covert simulated patient methodology (SPM) in all 42 CPs in the German big city Potsdam. With the help of 8 trained simulated patients (SPs), each CP was visited four times by a different SP. The SPs simulated in each CP two scenarios two times with the demand for an OTC medication against headache, which differed only in whether the demand was for themselves or for their boyfriend/girlfriend.

Results

All 168 planned pharmacy visits (84 visits per scenario) were successfully carried out. Overall, the median counseling score was 3.0 out of 9 points (interquartile range [IQR 2.0]). There were no significant differences between the two scenarios (Wilcoxon signed-rank test; p=0.495, r = 0.053). In a multivariate binary logistic regression analysis, the counseling level and the different scenarios were not significantly associated (adjusted odds ratio [AOR] = 1.635, 95% CI = 0.673-3.972, p=0.278).

Conclusions

Due to the partly considerable deficits in counseling of German CPs, policy-makers and the regional chambers of pharmacists are called upon to take appropriate measures to improve the quality of counseling. It is positive that no differences in counseling between self-purchase and purchase for a third party were found, but further verifying studies with a modified methodology are recommended.

Assessing content and factors influencing responses to information requests in community pharmacies in Jordan: A simulated patients study

OBJECTIVES

To assess the management of requests for information about a prescription only medicine (simvastatin for treatment of dyslipidemia) by pharmacy staff in community settings and explore the factors influencing the information content.

METHODS

A cross sectional study conducted using the stimulated patient (SP) method between November 2018 and May 2019. The SP conveyed the request at the beginning of the encounter in a standardized way based on predetermined plots and was instructed to ask the pharmacy staff directly if information was not discussed spontaneously. After the visit, the SP provided written feedback including information about the scenario and a copy of individualized feedback. The study was reported according to the checklist for reporting research using simulated patient methodology (CRiSP). Factors influencing information content with or without information demand were investigated.

RESULTS

A total of 55 visits were analyzed. The average content score for the information discussed spontaneously was 16.2% with the standard deviation (SD) equal to15.6. The score improved significantly after information was demanded by the SP; the average total information content score became 34.4% (SD = 16) with p < 0.001. The score of information discussed spontaneously was higher for male pharmacy staff, older age, more experience, and a Pharm D degree. When the SP prompted or demanded for information, older pharmacy staff with more experience and with a college degree scored higher. Independent pharmacies, longer visit durations, and less distraction were associated significantly with higher information scores Pharmacy staff aged 35-39 and those with 6-10 years of experience were significant contributors to spontaneous discussion of information with p values = 0.003 and 0.013, respectively. After the SP demanded information, pharmacy staff with less than 5 years of experience and greater confidence as well as longer visits were positively predicting higher information scores with p values of 0.049, 0.04, and 0.04, respectively.

CONCLUSIONS

Information provided by community pharmacists responding to information requests about prescription only medications was found to be suboptimal. Patient requests for information were found to be a positive driver for better information content. Further research of mixed methodologies is required to clarify the factors and motivators enabling information exchange in community settings and to outline true training needs.

Implementing interactive hiring activity in pharmacy management education

BACKGROUND AND PURPOSE

A major element of management is the process of hiring employees. The purpose of this brief is to describe the implementation of a human resources learning activity asking students to choose an employee to hire, describe student responses, and explore student perspectives of the activity.

EDUCATIONAL ACTIVITY AND SETTING

An interactive hiring activity was presented to third-year students (n = 386) at two different institutions, with varied classroom settings. Students were provided with candidates' curricula vitae and then completed a student-led interview using scripted questions presented in a PowerPoint format. The activity asked students to hire one candidate from five qualified candidates of varying backgrounds and traits. A Qualtrics survey collected students' individual hiring choice, hiring rationale, participant demographic information, and activity perceptions. Demographics and candidate choice were assessed using descriptive analysis. Open-ended answers were analyzed for frequency of terms, followed by a latent class analysis.

FINDINGS

Over 90% of students (n = 386) completed the post-activity survey. Demographic data between student cohorts varied, with only student age similar. Hired candidates differed by institution with one college expressing preference for a specific candidate and the other demonstrating a greater diversity of candidate preferences. Influencing factors on student choice were numerous. Overall, students reported a favorable experience with the activity.

SUMMARY

This management hiring activity allowed students to engage in the practice-ready skills of hiring pharmacy technicians in an interactive classroom activity. This activity allowed the educators involved to develop hypotheses about student preferences in hiring for future study.

Allergic rhinitis self-care advice in community pharmacies: A simulated patient study

Background

Pharmacists and pharmacy assistants can support consumers by identifying minor ailments and providing evidence-based advice about treatment options. In the Netherlands, advice is based on national minor ailment guidelines and structured WWHAM questions (Who, What, How long, Action, Medication).

Objectives

To study whether pharmacy assistants provide guideline-compliant advice for allergic rhinitis based on WWHAM and condition-specific questions (When and Familiarity) and their association with appropriate self-care advice.

Methods

A retrospective study of the assessments of simulated patient (SP) visits regarding one condition- and two symptom-based cases of allergic rhinitis in Dutch community pharmacies. Pharmacies that participated in 2014, 2016 and 2018 were selected. SPs documented their observations of the problem analysis, dispensing and client interaction on a standardized scoresheet. Dispensing of an oral antihistamine according to the guideline recommendation was considered as the correct outcome. Chi-square tests were used to analyze differences in scores for problem analysis of pharmacies with correct and incorrect advice provision in 2014 and 2018. Predictors for correct outcome were identified by univariate and multivariate logistic regression analysis.

Results

Data from 673 pharmacies were available for all three years. In 2014 and 2018, problems were presented as a symptom (running nose), and 41.2% and 21.1% of pharmacies dispensed an antihistamine. For the condition-based problem (allergy) in 2016, 96.0% of participating pharmacies dispensed an antihistamine. Both in 2014 and 2018, each additional problem analysis question increased the odds ratio of providing correct advice. Questions asked about ‘hay fever symptoms’, ‘medication’, ‘when symptoms occurred’, and ‘familiar symptoms’ were significant predictors of correct advice provision.

Conclusions

Most pharmacies provided appropriate advice for a condition-based request but less than half of them provided appropriate advice for a symptom-based request. More questions asked was associated with an increased chance of providing correct advice. Addition of condition-specific questions may improve the WWHAM-method.

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An increasing number of questions asked increased the chance of providing correct advice

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The question ‘when symptoms occur’ at least doubled the odds ratio of correct advice

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Solving problems presented as conditions was shown to be easier than those presented as symptoms

Are evidence-based criteria addressed during counseling on over-the-counter products? An observational study in community pharmacies

OBJECTIVE

We examined whether evidence-based criteria were addressed during counseling on over-the-counter products (OTCs) in community pharmacies.

METHODS

Consultations were observed in 10 community pharmacies. We analyzed communications about OTCs to determine if any information on three evidence-based criteria (outcome variables: scientific evidence such as clinical study results, pharmaceutical staff's experience, and customer's experience) was mentioned. Two groups of communications were compared with Pearson's chi-square and Fisher's exact test, as appropriate: The communications about OTCs recommended by the pharmaceutical staff vs. the communications about OTCs requested by customers.

RESULTS

In 379 observed consultations, 300 OTCs were recommended by staff and 390 OTCs were requested by customers. The least included criterion was scientific evidence (in OTCs recommended by pharmaceutical staff - 1% vs. requested by customers - 0%), followed by pharmaceutical staff's experience (5% vs. 1%). The customer's experience was addressed more frequently (14% vs. 41%). Statistically significant differences between the two groups were found for all criteria (p < 0.05).

CONCLUSION

Evidence-based criteria were rarely addressed during counseling on OTCs.

PRACTICE IMPLICATIONS

Pharmaceutical staff should be encouraged to include the three evidence-based criteria more frequently. Additionally, customers should be encouraged to request such information from the staff in community pharmacies.

A Nationwide Mystery Caller Evaluation of Oral Emergency Contraception Practices from German Community Pharmacies: An Observational Study Protocol

To prevent unwanted pregnancies, oral emergency contraception (EC) with the active ingredients levonorgestrel (LNG) and ulipristal acetate (UPA) is recommended by the guidelines of the German Federal Chamber of Pharmacists (BAK). In this respect, community pharmacies (CPs) in Germany have a major responsibility for information gathering, selecting the appropriate medicine, availability and pricing, among other things. Therefore, it would be appropriate to conduct a study with the aim of investigating information gathering, a possible recommendation as well as availability and pricing for oral EC in German CPs. A representative nationwide observational study based on the simulated patient methodology (SPM) in the form of covert mystery calls will be conducted in a random sample of German CPs stratified according to the 16 federal states. Each selected CP will be randomly called once successfully by one of six both female and male trained mystery callers (MCs). The MCs will simulate a product-based scenario using the request for oral EC. For quality assurance of the data collection, a second observer accompanying the MC is planned. After all mystery calls have been made, each CP will receive written, pharmacy-specific performance feedback. The only national SPM study on oral EC to date has identified deficits in the provision of self-medication consultations with the help of visits in the CPs studied. International studies suggest that UPA in particular is not always available. Significant price differences could be found analogous to another German study for a different indication.

Community pharmacists in Virginia dispensing naloxone under a standing order: A qualitative study

BACKGROUND

In 2016, the Virginia Health Commissioner signed a standing order into law allowing licensed pharmacists to dispense opioid receptor antagonists (ORAs) for overdose reversal.

OBJECTIVES

Using the theory of planned behavior as an initial guide to study development, the aim of this qualitative study was to explore community pharmacists' attitudes, subjective norm, perceived behavioral control, and behavioral intention toward dispensing ORAs under a standing order in Virginia.

METHODS

Semi-structured interviews were conducted with community pharmacists across the Commonwealth between June 2018 and October 2019. Interviews were recorded, transcribed verbatim, and thematically analyzed.

RESULTS

Twenty-one community pharmacists were interviewed. Pharmacists were confused about the specifics and the processes involved with dispensing naloxone under the standing order. Furthermore, many recognized the underuse of the standing order. Positive attitudes focused on the life-saving action of ORAs. Negative attitudes included encouraging risky behaviors by patients, negatively affecting the patient-pharmacist relationship, offending or contributing to stigmatizing patrons, and having liability issues to the pharmacy. Subjective norms regarding dispensing of ORAs under the standing order were perceived to be favorable among peer pharmacists and primary care and emergency department physicians but may be seen as profit-seeking by patients. Barriers to service provision included lack of guidance from corporate offices (in chain pharmacies), inadequate training, patient out-of-pocket costs, reimbursement issues, inadequate staffing and time, and stigma. Facilitators comprised the existence of practice site-specific protocols, the REVIVE! training, technician support, increased community awareness, physician collaboration, pharmacist training, and employer guidance. Whereas some pharmacists intended to become more familiarized with the standing order, others did not intend to actively identify patients who were at risk of an opioid overdose.

CONCLUSION

Pharmacists expressed mixed behavioral intention toward dispensing ORAs under the standing order. Future research should focus on quantifying the uptake of the standing order at the state level.

The simulated patient method: Design and application in health services research

The simulated patient method is becoming increasingly popular in health services research to observe the behaviour of healthcare practitioners in a naturalistic setting. This method involves sending a trained individual (simulated patient among other names), who is indistinguishable from a regular consumer, into a healthcare setting with a standardised scripted request. This paper provides an overview of the method, a brief history of its use in health services research, comparisons with other methods, ethical considerations, and considerations for the development of studies using the simulated patient method in health services research, with examples from pharmacy and other fields. Methods of analysis, mixed-methods, and the use of simulated patients with feedback are also discussed.

History taking and response to an adult diarrheal case among community drug retail outlets in Gondar town, north-west Ethiopia: a simulated-client survey

Background

Self-care is one of the growing tasks of community pharmacy professionals. They are highly engaged in consultations in response to specific drug request (product-based presentation) or symptoms clients describe (symptom-based presentation).

Purpose

This study was aimed at assessing the appropriateness of patient assessment and response to an adult diarrheal case among community drug retail outlets in Gondar town, north-west Ethiopia.

Methods

A descriptive cross-sectional study design based on simulated-client method of visit was conducted from 03 August to 21 September, 2020. An adult female diarrheal case scenario was developed and used to guide data collectors to interact with professionals in a standardized and consistent way. All 60 dispensaries in the town during the data collection were included in the study. A pretested data collection tool was used to record the conversation between simulated clients and providers. The data were analyzed using SPSS version 20.

Results

With regard to patient history, age of the patient, whether diarrhea is watery or bloody and onset and duration of diarrhea were the three most commonly requested questions with 59 (98.3%), 55 (91.7%) and 46 (76.7%), respectively. Past-medical and medication history are enquired in none of the visits. Medication was dispensed in 57 (95%) of the visits and no referral to a health facility was recommended in majority (90%) of cases. The most commonly recommended medications were ciprofloxacin 30 (52.6%) and metronidazole 20 (35.1%). ORS was considered in only 6 (10.5%) dispensaries.

Conclusion

Patient assessment, final decisions and treatment recommendations for an adult diarrheal case are inadequate, irrational and illegal. Educational interventions coupled with incentive mechanisms for cognitive pharmaceutical service and strict regulatory enforcement are needed to reduce the problem.

Factors impeding the supply of over-the-counter medications according to evidence-based practice: A mixed-methods study

OBJECTIVE

Despite the positive attitudes pharmacists have toward evidence-based practices (EBPs), its application in community pharmacies in Saudi Arabia is lacking. Therefore, this study aimed to explore and assess EBPs by community pharmacists in Saudi Arabia when they dispense over-the-counter (OTC) medications for three minor ailments: diarrhea, cough, and the common cold.

RESEARCH DESIGN AND METHODS

We used a mixed-methods approach consisting of two study parts. The first was a quantitative investigation that used mystery shoppers. Four researchers, posing as mystery shoppers, visited 214 randomly selected pharmacies in the Riyadh region of Saudi Arabia. They used 14 questions from a standardized checklist to examine EBPs by community pharmacists. The qualitative part of the study entailed three focus-group discussions with 13 pharmacists from different community practice settings and explored factors that affected the application of EBPs when supplying OTC medications from the pharmacists' point of view.

RESULTS

The analysis indicated that 40% of pharmacists dispensed OTC medications according to EBPs. Logistic regression analysis showed that one question, "Describe your symptoms", predicted the correct supply of OTC medications (p = 0.021). The qualitative section of the study identified nine factors that affected EBP. Some of these factors facilitated EBP, such as established patient-pharmacist relationships, some acted as barriers such as conflicts between available evidence, while other factors could either facilitate or hinder EBPs, such as the health literacy of the patient.

CONCLUSION

Given that dispensing OTC medication is a core function of pharmacists, this study uncovered low adherence to EBPs by community pharmacists in Saudi Arabia when dispensing OTC medication for three minor ailments: diarrhea, cough, and the common cold. Furthermore, this study identified a number of explanatory factors for this low adherence. Targeting these factors could help change the behavior of pharmacists and decrease undesirable outcomes.

The Quality of Counselling for Oral Emergency Contraceptive Pills-A Simulated Patient Study in German Community Pharmacies

Background: In Germany, there are two different active substances, levonorgestrel (LNG) and ulipristal acetate (UPA), available as emergency contraception (the “morning after pill”) with UPA still effective even 72 to 120 h after unprotected sexual intercourse, unlike LNG. Emergency contraceptive pills have been available without a medical prescription since March 2015 but are still only dispensed by community pharmacies. The aim of this study was to determine the counselling and dispensing behaviour of pharmacy staff and the factors that may influence this behaviour in a scenario that intends that only the emergency contraceptive pill containing the active substance UPA is dispensed (appropriate outcome). Methods: A cross-sectional study was carried out in the form of a covert simulated patient study in a random sample of community pharmacies stratified by location in the German state of Mecklenburg-Vorpommern and reported in accordance with the STROBE statement. Each pharmacy was visited once at random by one of four trained test buyers. They simulated a product-based request for an emergency contraceptive pill, stating contraceptive failure 3.5 days prior as the reason. The test scenario and the evaluation forms are based on the recommended actions, including the checklist from the Federal Chamber of Pharmacies. Results: All 199 planned pharmacy visits were carried out. The appropriate outcome (dispensing of UPA) was achieved in 78.9% of the test purchases (157/199). A significant correlation was identified between the use of the counselling room and the use of a checklist (p < 0.001). The use of a checklist led to a significantly higher questioning score (p < 0.001). In a multivariate binary logistic regression analysis, a higher questioning score (adjusted odds ratio [AOR] = 1.41; 95% CI = 1.22–1.63; p < 0.001) and a time between 12:01 and 4:00 p.m. (AOR = 2.54; 95% CI = 1.13–5.73; p = 0.024) compared to 8:00 to 12:00 a.m. were significantly associated with achieving the appropriate outcome. Conclusions: In a little over one-fifth of all test purchases, the required dispensing of UPA did not occur. The use of a counselling room and a checklist, the use of a checklist and the questioning score as well as the questioning score and achieving the appropriate outcome are all significantly correlated. A target regulation for the use of a counselling room, an explicit guideline recommendation about the use of a checklist, an obligation for keeping UPA in stock and appropriate mandatory continuing education programmes should be considered.

Impact of a blended learning program on community pharmacists' barriers, knowledge, and counseling practice with regard to preconception, pregnancy and lactation

BACKGROUND

Community pharmacists acknowledge to have an important role in providing pharmaceutical care during preconception, pregnancy and lactation. However, pharmacists' knowledge and counseling regarding this topic is still insufficient. Hence, educational initiatives are urgently needed.

OBJECTIVES

To assess the impact of a blended learning program ('intervention') on community pharmacists' barriers, knowledge, and counseling practice with regard to preconception, pregnancy and lactation.

METHODS

A pre-post study was performed in collaboration with 40 randomly selected pharmacies belonging to a large pharmacy chain in Belgium. All pharmacists employed in these pharmacies were eligible to participate in a blended learning program consisting of an e-learning and an on-site training day. Data were collected using online surveys, mystery shopping visits and pharmacy records. Pharmacy conversations were assessed on information gathering, dispensed product, and case-specific information. A retention knowledge test was completed 3-6 months after the intervention.

RESULTS

In total, 60 pharmacists completed the post-intervention surveys (response rate: 95%). The total number of barriers decreased after the intervention, while organizational barriers such as lack of privacy (73%) and lack of time (67%) became more prevalent. Pharmacists' short and long-term knowledge improved after the intervention (p ≤ 0.001), although knowledge declined again over time (p ≤ 0.001). During counseling, pharmacists more often spontaneously provided information about folic acid when dispensing a pregnancy test, and more often suggested the correct dose/dosage for the dispensed OTC-product against pregnancy-related nausea. However, poor information gathering, dosing errors and incomplete information were still observed.

CONCLUSION

The blended learning decreased pharmacists' barriers and improved their short- and long-term knowledge, while counseling practice only partially improved. Hence, the blended learning was insufficient to enhance pharmacists' information gathering competences and to fully implement pharmaceutical care services with regard to preconception, pregnancy and lactation.

The Quality of Advice Provided by Pharmacists to Patients Taking Direct Oral Anticoagulants: A Mystery Shopper Study

Pharmacists report being less confident in their knowledge of direct acting oral anticoagulants (DOACs) than of vitamin K antagonists, which may influence their ability to detect and manage complications arising from DOAC use. In a mystery shopper study, patient agents were sent into community pharmacies with symptom or product-related requests related to common complications that might arise during treatment with oral anticoagulants, with each visit being assessed for the preferred outcome. Only 10/41 (24.4%) visits resulted in the preferred outcome. A complete history-taking process, obtaining a medical history, patient characteristics and pharmacist involvement were strong predictors of the preferred outcome being achieved. The preferred outcome was not consistently achieved without pharmacist involvement. The potential for strategies that support comprehensive pharmacist involvement in over-the-counter requests should be considered to ensure the provision of optimal care to patients taking high-risk medications such as DOACs.

Use of secret simulated patient followed by workshop based education to assess and improve inhaler counseling in community pharmacy in Jordan

Objectives:

To assess inhaler technique demonstration skills of community pharmacists located in Amman, Jordan via incorporating the trained secret simulated patient (SSP) approach. Secondly, to evaluate the effectiveness of a 2-hour educational workshop focused on SSP feedback.

Methods:

This cross-sectional study involved community pharmacies located in Amman, Jordan. Initially, a trained SSP was involved to enact baseline visits requesting advice on how to use Ventolin® (a pressurized metered-dose inhaler; pMDI) and Pulmicort® (a Turbohaler inhaler, TH). Immediately after each visit, the SSP completed an inhaler technique evaluation form with inhaler checklists based on previously published checklists (consisting of 9 and 10 items for pMDI and TH respectively). The SSP invited all participating pharmacists to a 2-hour workshop that included feedback on their demonstration skills, and the second evaluation of their inhaler technique. The workshop included a summary of the initial visits’ results highlighting pharmacists’ performance.

Results:

Sixty pharmacies were visited and 120 inhaler assessments were completed. During baseline assessment, pharmacists scored an average of 4.5 out of 9 for pMDI and 4.9 out of 10 for TH. Only 11 pharmacists (18.3%) attended the workshop. During the workshop, inhaler technique demonstration skills significantly improved, as scores improved from 5.4 (SD 1.6) to 7.8 (SD 0.9) (p=0.008) and from 4.6 (SD 2.5) to 9.9 (SD 0.6) (p=0.003) for pMDI and TH respectively.

Conclusions:

The SSP approach revealed a lack of ability to demonstrate correct inhaler technique for pMDI and TH inhalers by community pharmacists in Amman, Jordan. A focused educational workshop based on SSP feedback improved inhaler technique significantly.

Do north-eastern German pharmacies recommend a necessary medical consultation for acute diarrhoea? Magnitude and determinants using a simulated patient approach

Background: To determine if pharmacy staff in Germany referred patients to a medical consultation for a scenario in which consulting a doctor was mandatory ('appropriate outcome') and what the quality of questioning and - if a medication was dispensed - the quality of information provided were in this context. Moreover, to determine which factors predicted a necessary referral to a doctor. Methods: A cross-sectional covert simulated patient study was conducted in a random sample of community pharmacies stratified by location in the German state of Mecklenburg-Vorpommern. Each pharmacy was visited once by one of four trained investigators. They simulated a symptom-based request involving a grandmother with acute diarrhoea. A multivariate binary logistic regression analysis using potential variables from bivariate analysis was carried out to determine the predictors for a referral to a doctor. Results: All 199 planned visits were conducted. A necessary referral to a doctor was recommended in 59.8% (n=119) of all test purchases. Multivariate analysis revealed that a non-pharmacist as opposed to a pharmacist and two or more questions as opposed to no questions were significantly associated with a referral to a doctor. Conclusions: Regarding the necessary referral to a doctor, an enormous potential for improvement was revealed for community pharmacies in the German state of Mecklenburg-Vorpommern. The results should make both the Mecklenburg-Vorpommern pharmacy association and legislators aware of the need to significantly escalate their quality management efforts.

Do north-eastern German pharmacies recommend a necessary medical consultation for acute diarrhoea? Magnitude and determinants using a simulated patient approach

Background: In Germany, non-pharmacists (pharmacy technicians and pharmaceutical technical assistants) are permitted to advise on and sell medications in addition to pharmacists. The aim of this study was to determine if pharmacists and non-pharmacists referred patients to a medical consultation for a scenario in which consulting a doctor was mandatory ('appropriate outcome') and what the quality of questioning and - if a medication was dispensed - the quality of information provided were in this context. The study also aimed to determine which factors predicted a necessary referral to a doctor. Methods: A cross-sectional, covert simulated patient study was conducted in a random sample of community pharmacies stratified by location in the German state of Mecklenburg-Vorpommern. Each pharmacy was visited once by one of four trained investigators. They simulated a symptom-based request involving a grandmother with acute diarrhoea. A multivariate binary logistic regression analysis using potential variables from bivariate analysis was carried out to determine the predictors for a referral to a doctor. Results: All 199 planned visits were conducted. A necessary referral to a doctor was recommended in 59.8% (n=119) of all visits. The most commonly asked question was 'for whom is the medication?' (75.4%, n=150), while 'clarification by a doctor' was asked the least (17.6%, n=35). In 87.9% (n=175) of all visits a medication was dispensed. Multivariate analysis revealed that, unlike pharmacists, non-pharmacists have a 2.446 times higher likelihood of recommending a referral to a doctor (p = 0.044; 95% CI = 1.025-5.835). Conclusions: In almost half of the visits a necessary referral to a doctor was not recommended. Furthermore, the quality of questioning and the quality of information were below expectations. Moreover, involvement of non‑pharmacists was surprisingly identified as a relevant factor influencing the appropriate outcome.

A systematic review of the use of simulated patient methodology in pharmacy practice research from 2006 to 2016

OBJECTIVES

Simulated patient (SP) methodology (mystery shopping) is used increasingly to assess quality of pharmacy services, and evaluate impact of interventions. Our objective was to review papers reporting on the use of SP methodology in pharmacy practice research 2006-2016 in community pharmacies worldwide.

METHODS

We searched EMBASE and MEDLINE for papers reporting on the use of mystery shopping in pharmacy settings, using a wide range of terms for SPs, based on previous review. We removed irrelevant papers, duplicates, papers not written in English, and review papers and reviewed remaining papers. Two reviewers carried out data abstraction, using the same tool as the previous review and inserting data into Excel, focusing on how the SP methodology is used.

KEY FINDINGS

A total of 148 papers from 52 countries from all regions of the world were included in the review. A wide range of terms described the method, and simulated patient was the most common (49 papers). Most studies were cross-sectional (124), and most investigated only community pharmacies (115). The most common aim was to evaluate some aspect of pharmacists' or other staff's advice and counselling (94). Number of visits is 2-7785. Many papers did not cover details, such as number of visits planned, and carried out, scenario used, training and background of SPs, and ethical approval for the study.

CONCLUSIONS

The use of SP methodology has increased substantially in the field of pharmacy over the past decade. This is a useful method in a wide range of countries and settings. Greater detail is required in reporting.

Assessment of patient counselling on the common cold treatment at Slovak community pharmacies using mystery shopping

BACKGROUND

Up to now, there have been no data on patient counselling in the Slovak community pharmacies. The literature provides a wide range of activities for which mystery shopping methodology be used, including assessment of patient counselling.

AIMS AND OBJECTIVES

To assess patient counselling on the common cold treatment with OTC medicine containing zinc provided by Slovak community pharmacists. To analyse this counselling considering the set scenarios, counsellors and their age.

METHODS

54 pharmacy students visited 270 different community pharmacies throughout Slovakia in 2 weeks in October 2016 to conduct mystery shopping with set scenarios. For assessment of patient counselling, we defined Counselling Performance. It was conceptualised as weighted mean percentage counselling successes rate of its three categories (Identification, Information and Communication) and their weights. Individual perception of counselling evaluated separately. Student t-test and Person's chi-squared test (p < 0.05) and Cohen delta were used for comparing outcomes and effect size of counselling. A simple linear regression was used to find relationships.

RESULTS

The total Counselling Performance was 39.0 ± 22.4%, Identification 30.6 ± 28.7%, Information 39.8 ± 25.1% and Communication 74.3 ± 11.5%. 26.3% pharmacies achieved the average Counselling Performance (41-60%). Subjective Perception had a success rate of 73.4 ± 21.2%, but it could be predicted by the Counselling Performance and the success rate of the three categories only in 1/5 pharmacies. Spontaneous counselling was provided more by pharmacy technicians (p = 0.0009). The duration of counselling was similar when comparing both scenarios, counsellors and their age. The product-requested scenario achieved a higher success rate in the Information category (p = 0.0304; d = 0.27). Pharmacists achieved a higher Counselling Performance (p < 0.0001; d = 0.48) and success rate in categories Identification (p = 0.0001, d = 0.46), Information (p = 0.0004, d = 0.37), and Perception (p = 0.0007; d = 0.54). The estimated age of counsellors did not have any impact on the counselling.

CONCLUSION

Patient counselling on the common cold showed a suboptimal level, particularly considering its content. In the study, we found a significant relationship between the success of counselling and counsellors.

A simulated patient evaluation of pharmacist's performance in a men's mental health program

Objective

The Headstrong program, a pharmacy based men’s mental health promotion program, was designed to enhance pharmacists’ care of men with mental illness and addictions and was focused on six conditions. A simulated patient (SP) encounter on insomnia was used to evaluate pharmacist’s performance as a part of the Headstrong program.

Results

Six Headstrong pharmacists consented to participate in the SP encounter as part of the evaluation of the Headstrong program. Pharmacists’ mean scores in most categories that were evaluated (e.g., pre-supply/assessment score, sleep score) were lower than expected. In assessing the SP during the encounter, pharmacists’ mean score was 5.7 (SD 2.0) of a possible 13 points. No pharmacists asked about the SP’s age, availability of other supports, allergies, and whether they had an existing relationship with a pharmacist. One pharmacist inquired about medical conditions, and two asked about pre-existing mental health conditions. Three pharmacists inquired about concurrent medications. The Headstrong program was discussed by half of the pharmacists and a resource recommended by the Headstrong program was suggested by one pharmacist. Several pharmacists used self-disclosure as a mechanism to support rapport building. Overall, the SP felt cared for and respected by the pharmacists and had confidence in their knowledge.