Adherence to Good Pharmacy Practices by Community Pharmacies in Lebanon and Opportunities for Quality Improvement: It is Time to Act

Purpose

Good pharmacy practice is an important standard that highlight the quality of services in community pharmacies. In 2018, The Order of Pharmacists in Lebanon (OPL) published their own good pharmacy practices (GPP) guidelines. The need exists for investigational studies to assess GPP implementation status and the professional conduct of on-site staff towards these standards.

Methods

Data collection was carried out between February and August 2020 using a questionnaire covering: Socio-demographic variables; Indicator A (Attitude of the Community Pharmacists); Indicator B (Services and Facilities); Indicator C (Dispensing); Indicator D (Storage). Data analysis were performed on SPSS version 25, T-Test and ANOVA were used. A significant p value of <0.001, 95% confidence interval and variables with missing data counting less than 10% were considered.

Results

A total of 211 staffers from pharmacies were enrolled in the study, each representing one community pharmacy. The mean percent of adherence to GPP standards by community pharmacies in the South of Lebanon was below the recommended threshold of 75%. Only 65.09% adhered to all tested indicators (27% to Indicator A, 56.91% to Indicator B, 68.61% to Indicator C, 66.31% to Indicator D). Higher indicators were seen among providers who were aware of OPL standards (OR = 4.021), female (OR= 2.011) and being a licensed pharmacist (OR=3.506). Cronbach alpha of the overall score was 0.615.

Conclusion

Further steps shall be taken to improve the compliance to GPP standards. Steps shall include, identification of the core standards, such as dispensing, provision of adequate information, monitoring of storage conditions, and ensuring the presence of a licensed pharmacist. It is highly recommended that the OPL and the Ministry of Public Health develop a "Self-assessment tool" and an efficient training program to increase community Pharmacists' awareness status. Regular assessment shall be carried to monitor the progress overtime.

Public views of community pharmacy services during the COVID-19 pandemic: a national survey

OBJECTIVE

To assess public opinion about community pharmacy services in Lebanon during the COVID-19 pandemic.

METHOD

A cross-sectional study using an online questionnaire was conducted between April and August of 2021. A link was shared randomly among the Lebanese population using WhatsApp and Facebook. Public perceptions were explored within 3 different indicators: general services (B) dispensing (C), and storage (D). Chi-square, Student's test and ANOVA tests were used. p < 0.05 was considered statistically significant.

RESULTS

Out of 491 responses, only 9.6% scored above the 75th percentile (19.3% for the general services, 2.4% for dispensing indicator and 12.6% for storage indicator). The main concerns focused on lack of medication and reduced opening hours; however, 67.1% of respondents preferred consulting the community pharmacist instead of visiting primary health care centers, doctor's private clinic and hospitals. Higher mean values of indicators B, C and in the overall indicator were significantly found in the presence of a pharmacist compared to the support pharmacy workforce.

CONCLUSION

The overall public perception was inadequate. Significant difference in terms of quality of services was detected in the presence and absence of a community pharmacist during the crisis. It is recommended that the Order of Pharmacist of Lebanon (OPL) and the Ministry of Public Health (MOPH) undergo further steps mainly to enforce the laws concerning dispensing and storage indicators, improve the services in terms of extending the opening hours, ensure the availability of medicines and increase public awareness.

The current trends and challenges towards good community pharmacy practice and the way forward

Background

The practice of pharmacy continues to evolve. Comprehensive research to monitor and assess the development of the practice is needed. Good Pharmacy Practices (GPP) have been adopted by many countries to enhance the quality of services. Little information is available concerning how pharmacy practices are being implemented in developing countries. Lebanon being a developing country is a good example where community pharmacy practice doesn't follow clear guidelines and no evidence of good clinical practice.

Objectives

This study aims to highlight GPP implementation, to identify obstacles impeding implementation, and to suggest how its application could be facilitated in Lebanon.

Methods

The review included studies published in English during the last five years covering aspects of pharmacy practice in relation to GPP standards. The search excluded research related to hospital pharmacy practice and primary health care centers since they have their own quality standards.

Results

The research identified 20 recent studies that covered aspects of community pharmacy practice in Lebanon in relation to GPP standards. Eight of the studies related to research and professional development,5 related to the provision of medicines,4 related to interaction and communication,1 related to trainees,1 related to pharmacotherapy monitoring, and 1 related to documentation systems. An additional 6 studies provided insight into factors that affect the pharmacy practice in general. It is apparent that the pharmacy practice would benefit if pharmacists were better supported with financial incentives and a readjustment of their working conditions as this would have a positive impact on their productivity, job satisfaction, and overall well-being. The review indicated that the standard of research and professional development was the most studied topic and it was recommended that pharmacists develop their research capabilities. It was observed that there is a tendency towards implementing Continuous Education for pharmacists and obstacles primarily included work and family commitments, lack of interest, lack of time, difficulties in commuting, and lack of competence in the use of technology. This standard is aligned with the FIP's developmental goal of continuing professional development strategies. The search also identified only one pilot study to assess GGP compliance among community pharmacies in Lebanon. This pilot study was limited and showed low adherence of community pharmacies in Lebanon to GPP standards.Barriers to implementation are lack of enforcing laws,inadequate dissemination of the standards among the community pharmacists, poor public perception, and the financial and soscioeconomically crisis facing Lebanon.

Conclusion

Collaborated efforts are needed to implement GPP standards in Lebanon.It is recommended to undergo training and awareness sessions to community pharmacists thus enhancing their commitment and motivation. It is also recommended to establish key performance indicators to monitor the implementation. İndicators should include structure indicators for regulating the storage of medications, process indicators for regulating the dispensing, and outcome indicators for reporting patient safety incidents, measuring public satisfaction and the provision and use of medicines.These recommendations can be used by Health authorities and Pharmacy educational institutions in Lebanon and in all similar low-income countries.

Unawareness of health insurance expiration status among women of reproductive age in Northern Ghana: implications for achieving universal health coverage

BACKGROUND

Ghana implemented a national health insurance scheme in 2005 to promote the provision of accessible, affordable, and equitable healthcare by eliminating service user fees. Termed the National Health Insurance Scheme (NHIS), its active enrollment has remained low despite a decade of program implementation. This study assesses factors explaining this problem by examining the correlates of insurance status unawareness among women of reproductive age.

METHODS

In 2015, a random probability cross-sectional survey of 5914 reproductive-aged women was compiled in the Upper East Region, an impoverished and remote region in Northern Ghana. During the survey, two questions related to the NHIS were asked: "Have you ever registered with the NHIS?" and "Do you currently have a valid NHIS card?" If the answer to the second question was yes, the respondents were requested to show their insurance card, thereby enabling interviewers to determine if the NHIS requirement of annual renewal had been met. Results are based on the tabulation of the prevalence of unawareness status, tests of bivariate associations, and multivariate estimation of regression adjusted effects.

RESULTS

Of the 5914 respondents, 3614 (61.1%) who reported that they were actively enrolled in the NHIS could produce their insurance cards upon request. Of these respondents, 1243 (34.4%) had expired cards. Factors that significantly predicted unawareness of card expiration were occupation, district of residence, and socio-economic status. Relative to other occupational categories, farmers were the most likely to be unaware of their card invalidity. Respondents residing in three of the study districts were less aware of their insurance card validity than the other four study districts. Unawareness was observed to increase monotonically with relative poverty.

CONCLUSION

Unawareness of insurance care validity status contributes to low active enrollment in Ghana's NHIS. Educational messages aimed at improving health insurance coverage should include the promotion of annual renewal and also should focus on the information needs of farmers and low socio-economic groups.

An assessment of a performance-based management agreement initiative in Ghana's health service

BACKGROUND

As part of its efforts to improve efficiency, accountability and overall performance, the Ghana Health Service (GHS) introduced annual Performance-based Management Agreements (PMAs) in the year 2013. However, no assessment of this initiative has since been made in order to inform policy and practice. This paper provides an assessment of this policy initiative from the perspective of managers at various levels of service implementation.

METHODS

Mixed methods were employed. Questionnaires were administered to managers through an online survey (using Google forms). Descriptive and inferential statistical methods were used to analyze and present quantitative results while qualitative data was analyzed via thematic analysis.

RESULTS

The content and objectives of the PMAs were observed to be comprehensive and directed at ensuring high performance of directorates. Targets of PMAs were found to be aligned with overall health sector objectives and priorities. The directors felt PMAs were useful for delegating task to subordinates. PMAs were also found to increase commitment and contributed to improving teamwork and prudent use of resources. However, PMAs were found to lack clear implementation strategies and were not backed by incentives and sanctions. Also, budgetary allocations did not reflect demands of PMAs. Furthermore, directors at lower levels were not adequately consulted in setting PMAs targets as such district specific challenges and priorities are not usually factored into the process. Insufficient training of staff and lack of requisite staff were key challenges confronting the implementation of PMAs in most directorates. Weak monitoring and evaluation was also observed to significantly affect the success of PMAs.

CONCLUSION

There is the need to address the weaknesses and improve on the existing strengths identified by this assessment in order to enhance the effectiveness of PMAs utilization in the Ghana health service.

The providers of health services in Lebanon: a survey of physicians

BACKGROUND

Emerging from civil distress carries with it major challenges to reforming a health system. One such challenge is to ensure an adequate supply of competent human resources. The objective of this study was to assess the supply of physicians in Lebanon in 1998, with an assessment of their practice patterns and capacity building.

METHODS

Lists of members of physician's associations were examined to determine the number of physicians in Lebanon and their geographical distribution. A self-administered survey targeted 388 physicians (5%) randomly stratified by the five regions of Lebanon. Some 377 providers reported information on their demographic profile, practice patterns and development. Further, information on continuing education activities was acquired.

RESULTS

In Lebanon, the overall physician-to-population ratio was 248 per 100, 000, characterized by an evident maldistribution at the intracountry regional level. Physicians worked 38 hours per week examining on average 21 patients per day, with an average time of 30 minutes spent per visit. They also reported spending 11% of their time waiting for patients. Respondents reported a very wide range of income, with 90% earning less than USD 2,000 per month. Moreover, the continuing education profile revealed a total of 43.7 hours per year, similar to that required for board certification in many developed countries. Conference attendance was the dominant continuing education activity (95% of respondents) and consumed most of the time allotted for continuing education, reported at 32 hours per year.

DISCUSSION AND CONCLUSION

Various economic indicators point to an oversupply of physicians in Lebanon and a poor allocation of their time for capacity building. Therefore, it is crucial for decision-makers to closely monitor the increasing supply of providers and institute appropriate intervention strategies, taking into consideration appropriate provision of good-quality services and ensuring that continuing education activities are well established, organized and monitored.

Determinants of Radiologists’ Productivity in Private Group Practices in California

PURPOSE

The purpose of this study was to determine factors that would affect radiologists' productivity in private group practices in California.

METHODS

Individual productivity data were collected for 236 private practice radiologists from 6 private radiology groups in California. The data included information on physician characteristics, facility indicators, and group practice factors that were hypothesized to affect providers' productivity. Statistical tests including chi-square testing and multivariate linear regression were used to analyze the effect of the 3 groupings of factors on the productivity of the radiologists.

RESULTS

With increases in age, the number of years in practice, and the number of years in affiliation with the group practice, productivity seemed to decrease. On the other hand, productivity tended to increase if a radiologist was a shareholder, with an increase in the number of facilities served by the radiologist per day, in the proportion of imaging examinations and interventional procedures conducted, and in the proportion of those examinations stored in picture archiving and communication systems.

CONCLUSIONS

To improve radiologists' productivity, group practices must invest in data-reporting infrastructure for tracking productivity, contract with outpatient imaging centers, and review group practice partnership composition and incentive models to ensure higher productivity. Future studies might consider examining the effect of other factors, such as time spent on nonclinical duties and the use of paramedical assistants in the practice.

Anterior ischaemic optic neuropathy after coronary artery bypass graft: the role of anaemia in diabetics

PURPOSE

To ascertain factors associated with anterior ischaemic optic neuropathy (AION) following coronary artery bypass graft (CABG) in a Lebanese population.

METHODS

A retrospective chart review of consecutive CABG performed over a 5-year period (1995-1999) in one medical centre. A comparison of clinical characteristics was carried out between AION cases and subjects free from AION. The variables analysed included history of diabetes as well as preoperative, intraoperative, or postoperative values of haematocrit, blood sugar, oxygen saturation, and arterial blood pressure.

RESULTS

A total of 1,594 persons were included. Three subjects experienced acute visual loss from AION following CABG, all had diabetes mellitus, and two suffered from severe postoperative anaemia. Among diabetics (n=484), the risk of AION was significantly higher in subjects with postoperative haematocrit falling below 22 (28.6%) than the rest (0.21%) (P=0.001). Blood transfusion was given in two subjects with prompt visual recovery.

CONCLUSIONS

Severe anaemia in patients undergoing CABG appears to be a risk factor for AION, especially in diabetics, and needs prompt correction to prevent or reverse the ischaemic ocular events.

Ocular pathology in congenital heart disease

PURPOSE

To describe the ocular findings in subjects with congenital heart disease (CHD).

METHODS

In a prospective study, the same observer examined 240 consecutive patients with CHD admitted to the medical centre. Two independent geneticists performed identification of syndromes.

RESULTS

The commonest anatomic cardiac anomalies were ventricular or atrial septal defects (62), tetralogy of Fallot (39), pulmonary stenosis (25), and transposition of the great arteries (24). The heart lesions were divided physiologically into volume overload (90), cyanotic (87), and obstructive (63). In all, 105 syndromic subjects included the velocardiofacial syndrome (18), Down's syndrome (17), CHARGE association (6), DiGeorge syndrome (5), Williams syndrome (3), Edwards syndrome (3), Noonan syndrome (3), VACTERL association (2), and Patau syndrome (trisomy 13) (2). The paediatric team recognized 51 patients as syndromic. Two independent geneticists recognized additional 54 patients as syndromic. Positive eye findings were present in 55% (132) and included retinal vascular tortuosity (46), optic disc hypoplasia (30), trichomegaly (15), congenital ptosis (12), strabismus (11), retinal haemorrhages (8), prominent eyes (7), and congenital cataract (6). There was a strong correlation between the retinal vascular tortuosity and both a low haematocrit (P=0.000) and a low arterial oxygen saturation (P=0.002).

CONCLUSIONS

Patients with CHD are at a high risk for ocular pathology and need screening for various ocular abnormalities.

Oral hygiene and lifestyle correlates among new undergraduate university students in Lebanon

Little is known about Lebanese college students' oral hygiene and the factors associated with how often they brush their teeth. The authors used a structured questionnaire to investigate these issues in a sample of 954 new students at the American University of Beirut in fall 1998. The results indicated poor flossing habits and unfavorable dietary habits among the group. Moreover, using logistic regression analysis, they found that variables such as gender, father's education, exercise, and dietary habits, were significantly correlated with the how frequently the students brushed their teeth. Appropriate promotional activities to improve flossing and dietary habits associated with better oral hygiene are recommended. In addition, the authors call for further research to elaborate on the deficiencies in oral health practices and explore a wider variety of lifestyle behaviors and their correlation.

Comparative efficacy of conservative medical and chiropractic treatments for carpal tunnel syndrome: a randomized clinical trail

OBJECTIVE

To compare the efficacy of conservative medical care with chiropractic care in the treatment of carpal tunnel syndrome.

DESIGN

Two-group, randomized, single-blind trial with 9 wk of treatment and a 1-month follow-up interview.

SETTING

Wolfe-Harris Center for Clinical Studies at Northwestern College of Chiropractic in Bloomington, Minnesota.

PATIENTS

Ninety-one of 96 eligible subjects who reported symptoms that were confirmed by clinical exam and nerve conduction studies.

INTERVENTIONS

Interventions included ibuprofen (800 mg 3 times a day for 1 wk, 800 mg twice a day for 1 wk and 800 mg as needed to a maximum daily dose of 2400 mg for 7 wk) and nocturnal wrist supports for medical treatment. Chiropractic treatment included manipulation of the soft tissues and bony joints of the upper extremities and spine (three treatments/week for 2 wk, two treatments/week for 3 wk and one treatment/week for 4 wk), ultrasound over the carpal tunnel and nocturnal wrist supports.

MAIN OUTCOME MEASURES

Outcome measures were pre- and postassessments of self-reported physical and mental distress, nerve conduction studies and vibrometry.

RESULTS

There was significant improvement in perceived comfort and function, nerve conduction and finger sensation overall, but no significant differences between groups in the efficacy of either treatment.

CONCLUSIONS

Carpal tunnel syndrome associated with median nerve demyelination but not axonal degeneration may be treated with commonly used components of conservative medical or chiropractic care.

The practice of chiropractic in South Dakota: a survey of chiropractors

OBJECTIVE

To identify the professional and demographic characteristics of the chiropractors in South Dakota.

DESIGN

Mail survey that covered four major areas: 1) demographics of the chiropractors, 2) population served, 3) factors influencing the economic aspects of the practice, and 4) practice characteristics. A reminder was sent 1 month following the first mailing.

SETTING

The state of South Dakota.

SUBJECTS

The questionnaire was mailed to all licensed chiropractors in South Dakota (n = 157).

RESULTS

The response rate was 68%. Chiropractors responding to the survey were mostly (96%) males and the average age was 41.4 yr with an estimated average of 15 yr of experience. The chiropractors surveyed spent just less than 40 hr/wk at work averaging 128 patient visits with the majority (47%) complaining of low back pain. Data regarding income, the sources of payment, type of community of practice, and the diagnostic as well as treatment techniques were also analyzed. Further analysis was also done to compare rural to urban areas.

CONCLUSION

Rural communities have fewer chiropractors than nonrural areas. Future research needs to be directed toward rural area chiropractic care delivery, with special emphasis on factors influencing recruitment and retention of chiropractors in rural areas. The study also showed a need for more involvement with the younger patient groups (18 yr and under). Health services researchers and chiropractic colleges each has an important role in the advancement of pediatric and adolescent health care.