Pharmacists' clinical decision making when responding to a self-medication request for a cough in a developing country

BACKGROUND

Some studies have reported that community pharmacies in developing countries, including Indonesia, provided sub-optimal advice when handling patient's self-medication request for cough. The reasons behind such advice, therefore, need to be investigated.

OBJECTIVES

To describe Indonesian pharmacists' clinical decision making when handling self-medication cases for a cough.

METHODS

An open-ended questionnaire consisting of two cough clinical vignettes (case 1: cough due to asthma worsening and case 2: cough as a symptom of common cold) were developed. Pharmacists were interviewed to provide recommendations and reasons for their recommendations for these scenarios. Content analysis was used to analyse participants' statements for the two scenarios. The number of participants who provided appropriate recommendations and reasons were then counted.

RESULTS

A total of 245 community pharmacists participated in the study. In the case of cough due to asthma worsening, recommending a product because the product was indicated to help with the symptoms was the most common recommendation and stated reason (40%). Appropriate recommendation (direct medical referral) with appropriate reasoning (indicating warning symptoms and/or making a symptom diagnosis) was provided by 25% participants. In the case of cough as a symptom of common cold, recommending products to help with the symptoms was also the most common recommendation and stated reason (53%). Appropriate recommendations (recommending product) with appropriate reasoning (providing product to treat the symptoms and/or indicating no warning symptoms and/or making a symptom diagnosis) was provided by 81% participants.

CONCLUSION

The ability of Indonesian community pharmacists to provide appropriate recommendations for cough self-medication requests is dependent on whether triage is required. The inability of most community pharmacists to differentiate between major and minor conditions may lead to serious health implications for patients and therefore educational interventions should be undertaken to improve community pharmacists' differential diagnostic skills for triage.

An online cross-sectional survey of community pharmacists to assess information needs for evidence-based self-medication counselling

BACKGROUND

Community pharmacists play an important role in healthcare. They are frequently visited by patients to receive advice on self-medication products. Little research has been conducted to investigate pharmacists' information needs for evidence-based self-medication counselling.

AIM

To assess community pharmacists' information needs in five predefined areas: general and specific individual needs, quality needs, utilisation needs, implication needs, and access needs for evidence based self-medication counselling.

METHOD

After ethical approval, we conducted an exploratory, semi-quantitative, cross-sectional online survey. Members of three different chambers of pharmacists in Germany were invited to participate anonymously in the survey. They gave informed consent and received no incentive for their participation. Quantitative outcome: Frequency of relevance / importance of items within predefined information needs areas, except for access needs. Qualitative outcome: Open-text responses concerning all information needs.

RESULTS

We analysed data from a total of 823 participants who completed the survey. General and specific information such as dosage (74.2% [611/823]) and when to refer to a physician (64.6% [532/823]) as well as an over-the-counter product's effectiveness according to medical guidelines (71.4% [588/823]) were rated as very important. Participants reported to prefer digital information sources (50.5% [416/823] strongly agreed), especially in the form of an easily accessible database (61.6% [507/823] strongly agreed) that contains regularly updated, manufacturer-independent, critically appraised, concise information.

CONCLUSION

Community pharmacists expressed distinct information needs for evidence-based self-medication counselling. Further information services on essential evidence-based pharmacy knowledge may be necessary to support implementation.

Barriers and facilitators for providing self-care advice in community pharmacies: a qualitative study

BACKGROUND

Community pharmacies are easily accessible for self-care advice. Guidelines for providing self-care advice were introduced in several countries, including the Netherlands in the 1990s. Previous studies have indicated room for improvement in self-care advice in daily pharmacy practice.

AIM

To identify barriers and facilitators for providing self-care advice.

METHOD

Semi-structured interviews were conducted face-to-face or online with pharmacists and pharmacy assistants using a topic guide based on the Theoretical Domains Framework. The interviews were audio-recorded and transcribed verbatim. The transcripts were deductively analysed to identify barriers and facilitators for self-care counselling. COREQ guidelines were followed.

RESULTS

In total, 13 pharmacists and 12 pharmacy assistants were interviewed to reach data saturation. In general, most themes addressed by pharmacists and pharmacy assistants belonged to similar domains. The following domains were frequently mentioned: environmental context and resources (e.g. priority for prescription drugs, privacy, collaboration with general practitioners, access to patients' records), intentions (providing reliable advice), skills (communication, decision-making), knowledge (ready guideline knowledge), beliefs about consequences (patient safety), social influences (patient awareness of pharmacist role), reinforcement (lack of reimbursement for relatively time-consuming advice).

CONCLUSION

This study identifies barriers and facilitators for evidence-based self-care advice. Pharmacists should first support pharmacy assistants by helping them keep their knowledge and skills up to date and creating suitable pharmacy preconditions to facilitate improvements in self-care counselling. Second, collaboration with general practitioners regarding minor ailments should be improved.

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.

Learning From Consultations Conducted by Community Pharmacists in Northern Ireland for Nonprescription Sildenafil: A Qualitative Study Using the Theoretical Domains Framework

INTRODUCTION

Nonprescription sildenafil was introduced to the United Kingdom in 2018 as the first pharmacy service concerning sexual function, an important but often ignored factor for quality of life.

AIM

This study aimed to evaluate pharmacists' views on providing nonprescription sildenafil, their perceptions of the barriers and facilitators to provide this service and strategies to overcome potential barriers, using a theory-based approach.

METHODS

Community pharmacists were purposefully sampled in Northern Ireland, followed by snowball sampling. Face-to-face interviews were conducted between October 2019 and January 2020. The semi-structured interviews used a piloted topic guide based on the 14-domain Theoretical Domains Framework (TDF). All interviews were audio-recorded, transcribed verbatim and anonymized. Transcripts were analyzed deductively in NVivo 13, utilizing the TDF domains as coding categories. Within each domain, content analysis was utilized to identify barriers and facilitators.

MAIN OUTCOME MEASURE

Barriers and facilitators within the TDF domains for pharmacists to provide nonprescription sildenafil.

RESULTS

Ten pharmacists were interviewed to reach data saturation. Eight pharmacists had experience with dispensing nonprescription sildenafil. They valued nonprescription sildenafil as an additional service ("Social/professional role and identity"). Training, concise product guidelines, and private consultation areas were important facilitators ("Environmental context and resources"). The service required trusting clients ("Optimism"), with concerns about abuse and men not visiting their GP. From experience gained, pharmacists became more confident dealing with difficult situations such as patients being vague about their medical history or alcoholism or mental problems as causes for erectile disfunction (ED) ("Skills" and "Beliefs about capabilities"). Pharmacists considered lifestyle and medication causes of ED important but preferred to focus on safe supply. In general, pharmacists were satisfied with the perceived professional recognition, using their clinical knowledge or helping patients resume sexual relationships ("Beliefs about consequences").

CONCLUSION

Pharmacists welcomed nonprescription sildenafil to enhance their role as easily accessible healthcare providers for patients. Gordijn R, Teichert M, Nicolai MPJ, et al. Learning From Consultations Conducted by Community Pharmacists in Northern Ireland for Nonprescription Sildenafil: A Qualitative Study Using the Theoretical Domains Framework. Sex Med 2021;9:100440.

Future Pharmacists' Opinions on the Facilitation of Self-Care with Over-the-Counter Products and Whether This Should Remain a Core Role

Background: The aim was to investigate pharmacy students’ views on the role of the pharmacist in facilitating self-care with over-the-counter (OTC) medicines, particularly in light of new roles, and establish personal practice. Methods: Final year pharmacy students at Queen’s University Belfast were invited to participate. Data were collected via a pre-piloted questionnaire, distributed at a compulsory class (only non-identifiable data were requested). Descriptive statistics were performed, and non-parametric tests were employed for inferential statistical analysis (responses by gender). Results: The response rate was 87.6% (78/89); 34.6% (27/78) males and 65.4% (51/78) females. Over a third [34.6% (27/78)] reported using OTC medicines about once a month. All appreciated the importance of an evidence-based approach to optimize patient care. Most [(96.2% (75/78)] deemed OTC consultations should remain a fundamental responsibility of pharmacists and 69.2% (54/78) thought OTC consultations have the potential to be as complex as independent pharmacist prescribing. Females felt more confident recommending OTC emergency contraception than males (p = 0.002 for levonorgestrel and p = 0.011 for ulipristal acetate). Many [61.5% (48/78)] considered more medicines should not be deregulated from prescription-only status. Conclusions: Data from this single institution suggests that enabling self-medication is an important part of practice but there were confidence issues around deregulations.

Strategic Analysis of the Turkish Over-the-Counter Drugs and Non-pharmaceutical Products Market

Objectives

The over-the-counter (OTC) drug (i.e., non-prescription drugs) market is growing significantly on a global scale. Our study reviews strategies for OTCs, together with other non-pharmaceutical products, such as herbal products, dietary supplements, and other healthcare products. The aim of this study is to analyze the expanded OTC industry to offer possible strategic solutions for existing problems.

Materials and Methods

We utilized integrated SWOT and Fuzzy Analytic Network Process analyses, together with quantitative analysis covering industry professionals' perspectives.

Results

Our findings showed that the most suitable market strategies are WO2 (i.e., to use information and digital technologies, including mobile applications and social media, to reduce marketing costs), SO2 (i.e., to promote self-medication/self-care to grow the OTC market and invest in information and communication technologies for this purpose), and ST2 (i.e., to improve health literacy and increase access to accurate and understandable information via alternative channels, such as the internet and social media). These key strategies are closely related to the utilization of digital technologies. Other strategies, such as SO1 (i.e., to encourage pharmacists to provide consulting for OTC products, which carry high profitability) and ST1 (i.e., to undertake stakeholder training programs to ensure production quality and introduce safe use to improve community health), were examined in detail, and their outcomes were interpreted in this study.

Conclusion

Given the impact of digital transformation, the same strategies can be implemented for other emerging OTC markets. This study underlines the importance of the OTC sector as one of the main drivers for improving community health and reducing health costs.

Exploring community pharmacists' clinical decision-making using think aloud and protocol analysis

BACKGROUND

Clinical decision-making (CDM) is the dynamic process used to gather, interpret and evaluate data to select an evidence-based choice of action. As the role of the pharmacist becomes more patient-focused, effective CDM skills are increasingly vital to achieve patient outcomes centred on quality, safety and efficacy.

OBJECTIVE

To examine how community pharmacists reason through a clinical problem and what factors assist or hinder decision-making.

METHOD

Fifteen New Zealand registered community pharmacists in central Auckland were presented with a bacterial conjunctivitis case. Think Aloud and protocol analysis were employed to examine pharmacists' cognitive processes when working through the case. Factors that affect CDM were explored through semi-structured interviews and analyzed using thematic analysis.

RESULTS

Pharmacists used pattern recognition and analytical reasoning to diagnose and recommend treatment. Three main factors affecting CDM were: 1. community pharmacy environment, where pharmacy size and layout prevented patient privacy; 2. clinical knowledge, which was outdated and limited by poor access to up-to-date resources; and 3. patient factors, where CDM was affected by time, patient's attitudes, and language barriers. When uncertain, pharmacists typically referred patients to their GP to ensure patient safety and believed offering treatment was not within their scope of practice.

CONCLUSION

Pharmacists used dual processing when encountering a familiar case. Further research is required to explore how pharmacists apply CDM when exposed to less familiar, more complex cases presenting greater ambiguity. Barriers in community pharmacy deter effective CDM skills and could inhibit community pharmacists from fulfilling their expanding role within the modern healthcare system.

The role of non-technical skills in community pharmacy practice: an exploratory review of the literature

BACKGROUND

Non-technical skills (NTS) are the cognitive and social skills that complement technical skills in safe and efficient practice, and include leadership, teamwork, task management, decision-making and situation awareness. Other areas within healthcare have heavily invested in producing taxonomies to aid training and assessment of NTS within their disciplines, and have found them to be essential for improving patient safety. In pharmacy, no validated taxonomy has been produced, nor has the existing literature been appraised to aid the future development of a validated taxonomy.

OBJECTIVE(S)

To examine the literature on NTS within a community pharmacy setting and establish the research conducted thus far on each NTS and how they are applied by community pharmacists.

METHODS

A literature search of six electronic databases (EMBASE, PsychINFO, Medline, SCOPUS, CINAHL Plus and HMIC) using the generic list of NTS identified in previous studies. Only empirical studies were included. Examples of behaviours or skills were extracted and categorised within each NTS.

KEY FINDINGS

Seventeen studies were identified that contained one or more examples of NTS specific to community pharmacy practice. Altogether, 16 elements were extracted. Four elements were identified within leadership and task management. A further three were identified within situation awareness and decision-making, and a final two within teamwork and communication.

CONCLUSION

A framework consisting of the skills and how they're applied has been presented which describe the NTS required by community pharmacists from the published literature. This framework can provide a foundation for further investigation into NTS use within pharmacy practice.

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 role of evidence in consumer choice of non-prescription medicines

Objectives

To identify factors influencing Australian consumer decision-making and attitudes towards non-prescription medicine (NPM) purchases, pharmacy's role in providing these medications and views around sources of evidence for effectiveness of these products.

Methods

Cross-sectional survey of a general population sample of 1731 adults using an Australian online consumer panel stratified by gender, age and location (State/Territory). Beliefs about NPM purchases and evidence of their efficacy were assessed using a 5-point Likert scale (strongly disagree-strongly agree). Non-parametric measures (Ridit analysis and Mann–Whitney U-test) were used to explore associations between responses and previous experience with medicines.

Key findings

The most important factors when purchasing NPMs were effectiveness and safety. However, personal experience was the most common method of determining effectiveness. Most respondents believed buying NPMs in pharmacies gave access to advice, but were less likely to agree that pharmacies were associated with safe and effective treatments. Around half the respondents agreed that it is wrong to sell treatments lacking scientific evidence; many also agreed that it is up to consumers to decide what they want even without scientific evidence. Individuals experiencing an ineffective NPM were less likely to trust scientific evidence of efficacy as the sole source of effectiveness information; regular prescription medicine users often agreed that scientific evidence is needed to support effectiveness.

Conclusions

Consumers have conflicting views regarding the need for scientific evidence and the desire for patient autonomy in NPM purchases. This presents a challenge for pharmacists wishing to maintain professional obligations to provide evidence-based treatments to consumers.

Development of a Theory-Based Intervention to Enhance Information Exchange during Over-The-Counter Consultations in Community Pharmacy

(1) Background: Community pharmacy personnel help mitigate risks of self-care by consumers who seek over-the-counter (OTC) medicines or treatment of symptoms and/or conditions. Exchange of information facilitates the OTC consultation, but pharmacy personnel often report difficulties in engaging consumers in a dialogue. The aim of this study was to describe the development of a behaviour change intervention to enhance information exchange between pharmacy personnel and consumers during OTC consultations in community pharmacies. (2) Methods: The Behaviour Change Wheel methodological framework was used to link factors that influence consumer engagement with information exchange during OTC consultations with intervention functions to change behaviour. Options generated were rationalized and the final intervention strategy was derived. (3) Results: Education, persuasion, environmental restructuring, and modelling were determined to be potential intervention functions. The intervention incorporated placing situational cues in the form of posters in the community pharmacy modelling information exchange behaviour, persuading through highlighting the benefits of exchanging information and educating about its importance. (4) Conclusions: A systematic, theoretically underpinned approach was applied to develop candidate interventions to promote information exchange in OTC consultations. The feasibility and efficacy of the intervention strategy has since been tested and will be reported elsewhere.

Ethical responsibilities of pharmacists when selling complementary medicines: a systematic review

Objective

The widespread sale of complementary medicines in community pharmacy raises important questions regarding the responsibilities of pharmacists when selling complementary medicines. This study reviews the academic literature that explores a pharmacist’s responsibilities when selling complementary medicines.

Methods

International Pharmaceutical Abstracts, Embase, PubMed, Cinahl, PsycINFO and Philosopher’s index databases were searched for articles written in English and published between 1995 and 2017. Empirical studies discussing pharmacists’ practices or perceptions, consumers’ expectations and normative studies discussing ethical perspectives or proposing ethical frameworks related to pharmacists’ responsibilities in selling complementary medicines were included in the review.

Key findings

Fifty-eight studies met the inclusion criteria. The majority of the studies discussing the responsibilities of pharmacists selling complementary medicines had an empirical focus. Pharmacists and consumers identified counselling and ensuring safe use of complementary medicines as the primary responsibilities of pharmacists. No formal ethical framework is explicitly employed to describe the responsibilities of pharmacists selling complementary medicines. To the degree any ethical framework is employed, a number of papers implicitly rely on principlism. The studies discussing the ethical perspectives of selling complementary medicines mainly describe the ethical conflict between a pharmacist’s business and health professional role. No attempt is made to provide guidance on appropriate ways to resolve the conflict.

Conclusion

There is a lack of explicit normative advice in the existing literature regarding the responsibilities of pharmacists selling complementary medicines. This review identifies the need to develop a detailed practice-specific ethical framework to guide pharmacists regarding their responsibilities when selling complementary medicines.

Community pharmacists' knowledge, practices and beliefs about complementary and alternative medicine in Palestine: a cross-sectional study

BACKGROUND

Complementary and alternative medicine (CAM) utilization is dramatically increasing among patients. As community pharmacies are a major provider of CAM products, community pharmacists need to have the sufficient knowledge and information to advice their patients, answer their inquiries and to be proactive in the healthcare process to ensure optimal therapy outputs and minimize both drug-drug and drug-herb interactions. Therefore, the main objective of this study was to assess the knowledge, beliefs, and practices of community pharmacists in Palestine about CAM.

METHODS

The study was conducted in a cross-sectional design in which a questionnaire was administered on a sample of licensed community pharmacists from Palestine. The questionnaire was of 5 sections: demographic and practice details of the participants, practice, beliefs, and knowledge about CAM. Mann-Whitney-U or Kruskal-Wallis tests were used to comparison of different issues as appropriate. P-values of <0.05 were considered significant.

RESULTS

A total of 284 community pharmacists were surveyed, however, 281 were included in the analysis as they met inclusion criteria. Out of the 281, 149 (53.0%) of the participants were males and the rest were females. About 40% of the participants were between 20 to 29 years old. Pharmacists frequently recommended CAM modalities. Exercises (84.0%) and food supplements (82.6%) were the most commonly recommended modalities. In the last year, vitamin B₁₂ was the most frequently prescribed supplement. The median knowledge score was 5 out of 8 and the median beliefs about CAM score was 4.0 out of 7.0.

CONCLUSIONS

CAM recommendations by pharmacists appear to be commonplace. Although their knowledge scores were fair to average, pharmacists still need more education and training about CAM in order to be more qualified to provide better pharmaceutical care and improve their patient's outcome.

Is there potential for the future provision of triage services in community pharmacy?

Background

Worldwide the demands on emergency and primary health care services are increasing. General practitioners and accident and emergency departments are often used unnecessarily for the treatment of minor ailments. Community pharmacy is often the first port of call for patients in the provision of advice on minor ailments, advising the patient on treatment or referring the patient to an appropriate health professional when necessary. The potential for community pharmacists to act as providers of triage services has started to be recognised, and community pharmacy triage services (CPTS) are emerging in a number of countries. This review aimed to explore whether key components of triage services can be identified in the literature surrounding community pharmacy, to explore the evidence for the feasibility of implementing CPTS and to evaluate the evidence for the appropriateness of such services.

Methods

Systematic searches were conducted in MEDLINE, EMBASE and International Pharmaceutical Abstracts (IPA) databases from 1980 to March 2016.

Results

Key elements of community pharmacy triage were identified in 37 studies, which were included in the review. When a guideline or protocol was used, accuracy in identifying the presenting condition was high, with concordance rates ranging from 70 % to 97.6 % between the pharmacist and a medical expert. However, when guidelines and protocols were not used, often questioning was deemed insufficient. Where other health professionals had reviewed decisions made by pharmacists and their staff, e.g. around advice and referral, the decisions were considered to be appropriate in the majority of cases. Authors of the included studies provided recommendations for improving these services, including use of guidelines/protocols, education and staff training, documentation, improving communication between health professional groups and consideration of privacy and confidentiality.

Conclusion

Whilst few studies had specifically trialled triage services, results from this review indicate that a CPTS is feasible and appropriate, and has the potential to reduce the burden on other healthcare services. Questions still remain on issues such as ensuring the consistency of the service, whether all pharmacies could provide this service and who will fund the service.

Pharmacy students' use and views on over-the-counter (OTC) medicines: a questionnaire study

INTRODUCTION

The role of the pharmacist centers on ensuring the safe and effective use of medicines, including over-the-counter (OTC) medicines. It is important to ascertain pharmacy students׳ use and opinions on OTC medicines, given that they are the pharmacists of the future and that this market continues to expand. This study aimed to investigate Queen׳s University Belfast (QUB) final-year pharmacy students׳ use and views on OTC medicines. Scarce work has been conducted in this area to date.

METHODS

Following ethical approval and a pilot study, all students (n = 155) were invited to participate in a self-completed questionnaire (n = 20 questions), distributed at a mandatory class. Descriptive statistics and non-parametric tests (Chi-squared and Mann-Whitney U test) were used for data analyses.

RESULTS

The response rate was 99.4% (154/155). The majority (153/155) reported using OTC medicines; the key consideration during personal product selection was effectiveness. Most [96.1% (147/153)] were in agreement that safety was the over-riding concern during OTC consultations. While 96.1% (149/155) considered that using an evidence-based approach improved the quality-of-patient care, 68.0% (104/153) would be prepared to sell a product that lacks evidence of effectiveness, provided it would not cause harm.

CONCLUSIONS

The importance of evidence of effectiveness was acknowledged, yet many students in this study were prepared to recommend unproven products. Further strategies are required at QUB to ensure this routine consideration alongside safety in practice.

A systematic review in select countries of the role of the pharmacist in consultations and sales of non-prescription medicines in community pharmacy

BACKGROUND

Much has been studied in regard to non-prescription medicines (NPMs), but the impact of greater emphasis toward patient self-selection of such agents is still not well understood, and evidence in the literature might be equivocal.

OBJECTIVE

The aim was to examine whether or not pharmacist interventions are important in the sale of NPMs and to summarize the evidence of pharmacists' contribution in maintaining patient safety and improving the quality of consultations involving NPMs.

METHODS

Seven online databases were searched to identify the literature on studies conducted within the UK and in countries comparable to the UK reporting on consultations and selling of NPMs published between 1980 and 2013. All study designs except for quantitative surveys were eligible for inclusion into the review. The data extraction and quality assessment were performed according to the National Institute for Health and Care Excellence guidelines. The data extracted from the studies were analyzed and presented qualitatively.

RESULTS

Eighty-three studies from an original 12,879 citations were included in this review. Just under half of the studies were published between 2000 and 2009 (n = 38; 46%). Thirty-three (44%) of the studies were conducted in the UK. The review showed that in terms of the contribution of community pharmacy staff in consultations for NPMs, non-pharmacist staff dealt with a large proportion of the consultations and pharmacists were usually involved in the consultation through referral from non-pharmacist staff member. Counseling was not consistently offered to everyone. Where counseling was provided it was not always of sufficient quality. Consultations were performed much better when symptoms were presented compared to when people made a direct product request. Pharmacists were reported to conduct better consultations than non-pharmacist staff. There was evidence to suggest that where counseling was appropriately provided this afforded the person a safe environment to utilize their NPMs.

CONCLUSIONS

Seeking methods to develop better engagement with customers accessing pharmacy services for NPMs is necessary to enhance the interaction between these two parties. Efforts to enhance the community pharmacy environment to bring about a more positive experience for people using pharmacy is needed at present and will be important if the model for the selection of NPMs is modified in the UK. More studies are needed to allow a better understanding of the impact self-selection may have on patient safety in the community pharmacy context.

Views of pharmacy graduates and pharmacist tutors on evidence-based practice in relation to over-the-counter consultations: a qualitative study

RATIONALE, AIMS AND OBJECTIVES

Health care services offered to the public should be based on the best available evidence. We aimed to explore pharmacy tutors' and trainees' views on the importance of evidence when making decisions about over-the-counter (OTC) medicines and also to investigate whether the tutor influenced the trainee in practice.

METHODS

Following ethical approval and piloting, semi-structured interviews were conducted with pharmacy graduates (trainees) and pharmacist tutors. Transcribed interview data were entered into the NVivo software package (version 10), coded and analysed via thematic analysis.

RESULTS

Twelve trainees (five males, seven females) and 11 tutors (five males, six females) participated. Main themes that emerged were (in)consistency and contradiction, confidence, acculturation, and continuation and perpetuation. Despite having an awareness of the importance and potential benefits, an evidence-based approach did not seem to be routinely or consistently implemented in practice. Confidence in products was largely derived from personal use and patient feedback. A lack of discussion about evidence was justified on the basis of not wanting to lessen patient confidence in requested product(s) or possibly negating the placebo effect. Trainees became acculturated to 'real-life' practice; university teaching and evidence was deemed less relevant than meeting customer expectations. The tutor's actions were mirrored by their trainee resulting in continuation and perpetuation of the same professional attitudes and behaviours.

CONCLUSIONS

Evidence appeared to have limited influence on OTC decision making. The tutor played a key role in the trainee's professional development. More work could be performed to investigate how evidence can be regarded as relevant and something that is consistently implemented in practice.

Pharmacists in pharmacovigilance: can increased diagnostic opportunity in community settings translate to better vigilance?

The pharmacy profession has undergone substantial change over the last two to three decades. Whilst medicine supply still remains a central function, pharmacist's roles and responsibilities have become more clinic and patient focused. In the community (primary care), pharmacists have become important providers of healthcare as Western healthcare policy advocates patient self-care. This has resulted in pharmacists taking on greater responsibility in managing minor illness and the delivery of public health interventions. These roles require pharmacists to more fully use their clinical skills, and often involve diagnosis and therapeutic management. Community pharmacists are now, more than ever before, in a position to identify, record and report medication safety incidents. However, current research suggests that diagnostic ability of community pharmacists is questionable and they infrequently report to local or national schemes. The aim of this paper is to highlight current practice and suggest ways in which community pharmacy can more fully contribute to patient safety.

“Doctor shopping and pharmacy hopping”: practice innovations relating to codeine

Purpose

– The misuse of pharmaceutical opioid analgesics is identified as a global public health concern. Codeine represents an interesting quandary in terms of its regulated status, with individuals varying in their metabolism of codeine, estimation of safe dosages, risk of adverse health consequences and abuse potential. Efforts to quantify and address hidden non-compliant medical codeine use, overuse and intentional misuse is compromised by availability to the public in prescribed and over the counter forms. The paper aims to discuss these issues.

Design/methodology/approach

– A review of literature on codeine use, misuse and dependence, and associated innovative medical and pharmacy interventions is presented, and was conducted as part of a larger scoping review on codeine.

Findings

– The review highlights the complexities associated with monitoring public health awareness of codeine's abuse potential, and customer/patients trends in non-compliant codeine use for therapeutic and recreational purposes. Aberrant codeine behaviours centre on visiting multiple doctors for prescriptions, repeated lost or stolen prescriptions, forging prescriptions and use of multiple pharmacies. Innovations to monitor misuse of codeine include national prescription databases and recent developments in real-time monitoring of dispensing activity.

Practical implications

– Further development of real-time monitoring processes with process evaluation is advised.

Originality/value

– This viewpoint is intended to demonstrate how efforts to quantify and address codeine use are compromised by its availability. It intends to encourage further policy and practitioner dialogue on how to monitor, support and intervene with consumers misusing codeine.

Does evidence drive pharmacist over-the-counter product recommendations?

RATIONALE, AIMS AND OBJECTIVES

To explore how community pharmacists use evidence to inform their practice when recommending or selling over-the-counter medicines.

METHODS

Semi-structured face-to-face interviews were conducted during February 2013 and analysed using the principles of content analysis.

RESULTS

Sixteen pharmacists were interviewed. Pharmacists were aware of evidence-based medicine and practice but relied on personal judgement augmented with patient feedback to make product recommendations. This was primarily due to the acknowledgement that many non-prescription medicines either had no or little evidence of efficacy. Pharmacists did and would use evidence to inform product selection if available, but acknowledged that ineffective products were sold, especially when consumers asked for a named product. This was tempered by their attempts to inform the consumer of the products' effectiveness, or lack of, or in the knowledge that it would cause them no harm.

CONCLUSIONS

Pharmacists took a pragmatic approach to product recommendation in light of the lack of clinical evidence to support their efficacy.

The influence of evidence-based medicine training on decision-making in relation to over-the-counter medicines: a qualitative study

Objectives

To explore the role of evidence of effectiveness when making decisions about over-the-counter (OTC) medication and to ascertain whether evidence-based medicine training raised awareness in decision-making. Additionally, this work aimed to complement the findings of a previous study because all participants in this current study had received training in evidence-based medicine (unlike the previous participants).

Methods

Following ethical approval and an e-mailed invitation, face-to-face, semi-structured interviews were conducted with newly registered pharmacists (who had received training in evidence-based medicine as part of their MPharm degree) to discuss the role of evidence of effectiveness with OTC medicines. Interviews were recorded and transcribed verbatim. Following transcription, all data were entered into the NVivo software package (version 8). Data were coded and analysed using a constant comparison approach.

Key findings

Twenty-five pharmacists (7 males and 18 females; registered for less than 4 months) were recruited and all participated in the study. Their primary focus with OTC medicines was safety; sales of products (including those that lack evidence of effectiveness) were justified provided they did no harm. Meeting patient expectation was also an important consideration and often superseded evidence. Despite knowledge of the concept, and an awareness of ethical requirements, an evidence-based approach was not routinely implemented by these pharmacists. Pharmacists did not routinely utilize evidence-based resources when making decisions about OTC medicines and some felt uncomfortable discussing the evidence-base for OTC products with patients.

Conclusions

The evidence-based medicine training that these pharmacists received appeared to have limited influence on OTC decision-making. More work could be conducted to ensure that an evidence-based approach is routinely implemented in practice.

Community pharmacists' adoption of medicines reclassified from prescription-only status: a systematic review of factors associated with decision making

PURPOSE

Subsequent to reclassification of legal status, more than 90 prescription-only medicines have become available in the UK alone without a prescription. Similar changes are taking place internationally. The aim was to systematically review studies reporting factors associated with community pharmacists' decision making around adoption of these reclassified medicines into practice.

METHOD

A systematic review of English language peer-reviewed published literature from 1990 to 2010 was conducted. Literature was identified through MEDLINE, EMBASE, IPA, CINAHL, BSP, Cochrane Library and PsychINFO databases and other sources including key conference abstracts.

RESULTS

A total of 38 studies were included. Twenty-eight factors associated with pharmacists' decision making were identified. Medicine safety was consistently shown to be one of the key factors; however, the importance of evidence base and financial benefits of reclassification were less obvious. A paucity of high-quality studies limits generalisation of findings.

CONCLUSIONS

Patient safety appears to be the key to pharmacists' decision making. However, the study quality limitations indicate the need for further robust research. The 28 factors identified in this systematic review from international literature can aid rigorous research instrument development for future evaluations.

Pharmacists' attitudes towards an evidence-based approach for over-the-counter medication

BACKGROUND

With increasing deregulation of prescription-only medicines and drive for self-care, pharmacists have greater scope to manage more conditions. This brings added responsibility to be competent healthcare professionals who deliver high quality evidence-based patient care.

OBJECTIVE

This study sought to establish pharmacists' attitudes towards an evidence based approach for over-the-counter medication.

SETTING

Pharmacists working in community pharmacies across Northern Ireland.

METHOD

Following ethical approval, a pre-piloted, self-completed questionnaire was distributed to all community pharmacies in Northern Ireland (n = 529) in September 2008. The development of the questionnaire was largely informed by the findings of a previous qualitative study. It consisted of six sections (mainly closed questions) covering factors that influence decisions regarding over-the-counter medication, recently deregulated prescription-only medicines, medications that lack evidence of effectiveness, knowledge of evidence-based practice, evidence-based practice with over-the-counter medication and demographic information. On receipt of questionnaires, responses to the closed questions were imported into SPSS(®) (version 17.0) for analysis which largely took the form of descriptive statistics. Chi-square and the Mann-Whitney U test were used for association between responses and demographic information with an a priori level of less than 0.05 (P < 0.05) set as significant.

MAIN OUTCOME MEASURE

Pharmacists' attitudes and opinions in relation to decision making about over-the-counter medication and evidence of effectiveness were measured.

RESULTS

A 39.5% (209/529) response rate was achieved. Most pharmacists [191/208 (91.8%)] 'strongly agreed' or 'agreed' that safety was the over-riding concern when dealing with over-the-counter medication. While 88.3% (181/205) 'strongly agreed' or 'agreed' that they were familiar with the concept of evidence-based practice, only 38.0% (78/205) 'strongly agreed' or 'agreed' they knew how to critically appraise research papers. Furthermore, less than a quarter [49/205 (23.9%)] appeared to be familiar with the work of the Cochrane Collaboration. Most [188/207 (90.8%)] 'strongly agreed' or 'agreed' that regardless of evidence of effectiveness, cough medicines were an important management option.

CONCLUSION

Safety was the primary concern when making decisions about over-the counter medicines. Pharmacists lacked knowledge of evidence-based practice and considered medicines which lacked evidence of effectiveness to have an important role in self-care. These factors present barriers to the widespread implementation of evidence-based practice.

Public's views on making decisions about over-the-counter medication and their attitudes towards evidence of effectiveness: a cross-sectional questionnaire study

OBJECTIVE

To explore factors which may influence consumers when making decisions in relation to over-the-counter (OTC) medication.

METHODS

Data were collected from members of the public using a face-to-face interviewer-administered structured questionnaire in 10 shopping centres.

RESULTS

1461 people participated (18.8% males, 81.2% females; ages ranged from under 20 to over 60). Perceived effectiveness, familiarity with the name or brand and safety of the medicine influenced decisions when buying an OTC medicine. Almost all respondents reported that knowledge of effectiveness of OTC medicines was based on previous use. If there was no scientific evidence from drug trials to support effectiveness of a product, but it would not cause harm, two-thirds would still try the product. Over 70% 'agreed/strongly agreed' that people should be able to decide for themselves what OTC medicine they want, irrespective of scientific evidence.

CONCLUSION

There was ambivalence regarding need for evidence of effectiveness when choosing an OTC medicine, with individual autonomy and safety taking precedence over evidence.

PRACTICE IMPLICATIONS

Pharmacists should be aware that patients' expectations in relation to OTC medicines may be in conflict with evidence-based practice.

Australian community pharmacists' practice in complementary medicines: a structural equation modeling approach

OBJECTIVE

This survey tested a model of factors influencing pharmacists' practice in relation to complementary medicines (CMs).

METHODS

Self-administered questionnaires were used to collect data from 212 community pharmacists in New South Wales. Structural equation modeling with AMOS version 6.0, was used to model two practices in relation to CMs: an evaluation of appropriateness of CM use and the decision to sell.

RESULTS

Pharmacists' perceptions of their responsibilities in ensuring the safe use of CMs predicted the comprehensiveness of an evaluation for appropriateness of CM use (P=0.002). When level of comprehensiveness of evaluation increased, pharmacists were less likely to sell CMs in situations where the use of the products was not considered appropriate (P=0.021). Pharmacists' confidence in their CM knowledge, attitudes towards CMs, concern about pharmacy income and pharmacists' characteristics did not significantly affect their practice.

CONCLUSION

Pharmacists' acceptance of their counseling responsibility with respect to CMs was the strongest predictor of both comprehensiveness of an evaluation and the decision to sell a CM.

PRACTICE IMPLICATIONS

Pharmacists must be encouraged to recognise and accept their responsibility in ensuring the safe and effective use of CMs.