Referrals of dyspeptic self-care patients from pharmacies to physicians, supported by clinical guidelines

Treatment of Heartburn: A Survey of Ontario and Québec Community Pharmacists

The shift of proton pump inhibitors (PPIs) from prescription to nonprescription (nonRx) status in Canada has altered pharmacist treatment options for heartburn. This report examines pharmacist approaches to therapy based on case severity; pharmacist confidence and consult duration were also explored. A 2022 online survey gathered data from Ontario and Québec pharmacists regarding their therapeutic approaches for two hypothetical heartburn cases. A total of 715 pharmacists participated, with most having 1-10 years of experience. In Ontario, common choices for the milder case included a solo histamine-2 receptor antagonist (H2RA) (21.2%), combination H2RA + antacid (29.4%), and nonRx PPI (22.3%). For the more severe case, common choices for Québec were switches to nonRx H2RA (22.1%), combination H2RA + antacid (13.4%), a nonRx PPI (24.9%), or prescription PPI (22.5%). Pharmacists often recommended switching medications or referring patients with recurring symptoms after seven days. The approaches varied significantly between cases and provinces. The Ontario pharmacists favoured a combination H2RA + antacid for the milder case, while the Québec pharmacists preferred a solo H2RA. For the more severe case, both groups often chose nonRx H2RA followed by nonRx PPI. Despite the differences, the pharmacists demonstrated confidence in managing these situations. These findings highlight potential debates regarding optimal therapeutic approaches and the impact of drug scheduling on patient care.

Patient uptake and outcomes following pharmacist-initiated referrals to general practitioners for asthma review

Uptake and outcomes of pharmacist-initiated general practitioner (GP) referrals for patients with poorly controlled asthma were investigated. Pharmacists referred at-risk patients for GP assessment. Patients were categorized as action takers (consulted their GP on pharmacist’s advice) or action avoiders (did not action the referral). Patient clinical data were compared to explore predictors of uptake and association with health outcomes. In total, 58% of patients (n = 148) received a GP referral, of whom 78% (n = 115) were action takers, and 44% (n = 50) reported changes to their asthma therapy. Patient rurality and more frequent pre-trial GP visits were associated with action takers. Action takers were more likely to have an asthma action plan (P = 0.001) at month 12, and had significantly more GP visits during the trial period (P = 0.034). Patient uptake of pharmacist-initiated GP referrals was high and led to GP review and therapy changes in patients with poorly controlled asthma.

Assessing the referral of clients with respiratory symptoms to general physicians: a survey of community pharmacists in Beirut

OBJECTIVES

The main objective of this study was to assess the ability of community pharmacists practicing in Beirut to identify red flag respiratory symptoms, and therefore to adequately refer clients to a general physician when warranted. Secondary objectives included determining whether demographic factors affect the odds of referral, and to qualify degree of agreement of community pharmacists with a panel of expert physicians.

METHODS

In this cross-sectional study, pharmacies were randomly selected and invited to complete a self-administered survey, each containing 10 clinical vignettes that combined different characteristics (age group, gender, presenting symptom, duration of symptoms). Bivariate and multivariate logistic regressions were used to inspect predictors of referral, correct referral and under-referral.

KEY FINDINGS

A total of 214 pharmacies were visited and 141 (65.9%) responded. Pharmacists were more likely to refer female patients (P = 0.035) and patients who presented with a longer duration of symptoms (P < 0.001). Correct referral was higher in pharmacies that were more than 20 min away from the nearest hospital (P = 0.013) and with clients who presented with haemoptysis (P < 0.001), dyspnoea (P < 0.001) or wheezing (P < 0.027), while it was lower with female patients (P < 0.001). Under-referral was higher in pharmacies that served more than 500 clients weekly (P = 0.048) and in patients presenting for dry cough (P < 0.001) or productive cough (P < 0.001).

CONCLUSION

This study has shown that there is a need for further investigation into the practices of community pharmacists of Beirut. An action plan may be advised to alleviate the burden of patients who might currently be under-referred and experience morbidity as a result.

Pharmaceutical Care in Community Pharmacies: Practice and Research in Sweden

Objective:

To describe the organization and delivery of community pharmacy and medical care, as well as pharmaceutical care practice and research, in Sweden.

Findings:

The Swedish retail pharmacy system of 800 community pharmacies and nearly 80 hospital pharmacies is unique in that it is organized into one single, government-owned chain, known as Apoteket AB. The pharmacy staff consists of pharmacists, prescriptionists, and pharmacy technicians. Some activities related to pharmaceutical care have been directed toward specific patient groups during annual theme campaigns. In the past few years, there has been a growing emphasis on the identification, resolution, and documentation of drug-related problems (DRPs) in Swedish pharmacy practice. A classification system for documenting DRPs and pharmacy interventions was developed in 1995 and incorporated into the software of all community pharmacies in 2001. A national DRP database (SWE-DRP) was established in 2004 to collect and analyze DRPs and interventions on a nationwide basis. Recently, a new counseling technique composed of key questions to facilitate the detection of DRPs has been tested successfully. Patient medication profiles are kept in 160 pharmacies, and a new national register of drugs dispensed to patients became available in 2006. Most pharmaceutical care studies in Sweden have focused on DRPs and resulting pharmacy interventions.

Discussion:

Swedish community pharmacy DRP work is in the international forefront but there is a potential for further developing cognitive services, given the beneficial organization of the country's pharmacies into one single pharmacy chain. The introduction of patient medication profiles has been both late and slow and has only had a marginal effect on pharmaceutical care practice so far. The universities do not appear to have any desire to influence the practice of pharmacy and could potentially take on a more active role in preparing pharmacy students for patient-oriented services. Current threats to pharmaceutical care practice and research include organizational changes, budget cuts, and reduced manpower of Apoteket AB.

Conclusions:

The identification, resolution, and documentation of DRPs are central to community pharmacy practice in Sweden, resulting in a number of research studies. A national DRP database, patient medication profiles, and a new national register of drugs dispensed to patients provide opportunities for growth in pharmaceutical care practice and research in the country.

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.

Can we document the practice of dispensing? A systematic review

WHAT IS KNOWN

Documentation is a process indicator utilized to evaluate quality clinical pharmacist services. In this framework, documentation of dispensing, besides supporting patient care, allows evaluation of the impact of counselling.

OBJECTIVE

To identify and assess studies of documentation by pharmacists in the dispensing process.

METHOD

A systematic review was carried out according to the following steps: (i) identification of studies in the following databases: PubMed/Medline, Web of Science, Scopus and Lilacs, using the descriptors 'counselling', 'dispensing', 'community pharmacy services', 'pharmacies' and 'pharmacists' in different combinations; (ii) evaluation of studies, in which the title, abstract and full text of the studies, and the evaluation of the methodological quality of the selected studies were analysed.

RESULTS

In total, 26 articles met the specific criteria. Few studies addressed documentation as part of the dispensing working process (3), and 16 articles reported documentation using non-electronic systems. The main variables documented were patient information, drug therapy problems and clinical interventions. Furthermore, 20 studies showed the effects of documentation in the dispensing process and 23 studies included statistical evidence. Eight articles met between 42% and 75% of the 28 items recommended by the STROBE initiative, and two articles met approximately 60% of the 36 items recommended by the CONSORT initiative.

WHAT IS NEW AND CONCLUSION

Few studies address documentation as part of the dispensing working process. Thus, researchers should be concerned with standardizing documentation and implementing more robust designs and multicenter studies.

Pharmacists' counseling protocols for minor ailments: a structure-based analysis

BACKGROUND

Self-medication is an important component of health care. To optimize pharmacists' over-the-counter counseling, there are several guidelines and protocols used in practice. In a self-care environment, protocols should comprise items related to patients' autonomy. The structure of self-medication protocols, among other elements, should present steps to facilitate patients' participation.

OBJECTIVE

To analyze structural differences between existing community pharmacy minor ailment protocols, including those related to patient autonomy and empowerment in self-medication conditions.

METHODS

The study design followed a cross-sectional descriptive approach. Self-medication protocols were systematically collected from 3 different professional sources (Pharmaceutical Society [OF], National Pharmacies Association [ANF], and Grupo Holon [GH]). A structural-based analysis, by comparison with the general self-medication OF standard protocol, produced outcome measures such as frequencies of flowchart critical steps, active pharmaceutical substances, dosage forms, and posologies. Simple scores were computed to assess protocols' structural quality, as well as differences between protocols, produced by each professional organization.

RESULTS

Forty-four protocols presented on average 8 counseling steps toward 10 different active substances, 7 dosages forms, and 14 posologic schemes. From a maximum of 30 critical items, 1 protocol scored 24, 7 scored 23, and 5 scored less than 15 items. Significant differences were found between protocols' structural components from different sources, particularly between GHs' protocols compared with those produced by OF and ANF.

CONCLUSIONS

In general, all protocols matched the OF standard for ailment characterization but fell short on steps related to medicine information and selection. Steps for patient participation and agreement were absent, as was pharmacists' expected role of outcomes monitoring. It might be appropriate to redesign self-medication protocols, preferably through a consensus process that includes not only professionals' but also patients' preferences, starting from the prevalent conditions in Portuguese pharmacy practice.

Do Pharmacists Know Which Patients with Bowel Symptoms Should Seek Further Medical Advice? A Survey of Pharmacists Practicing in Community Pharmacy in Western Australia

BACKGROUND:

Pharmacists in Australia are routinely asked to advise people with lower bowel symptoms. Clinical, demographic, and working environment parameters may affect whether appropriate referral for advanced care is advised by pharmacists.

OBJECTIVE:

To characterize how selected clinical, demographic, and working environment variables affect the likelihood of a pharmacist providing a referral for patients with lower bowel symptoms to consult a general practitioner, and to investigate factors associated with agreement with an expert panel and colorectal cancer guidelines.

METHODS:

Self-administered questionnaires were distributed to a random sample of 300 pharmacists in Western Australia. Vignettes were constructed around 6 clinical variables and pharmacists were asked to describe a referral pathway. Logistic regression was used to identify factors associated with odds of referral and agreement with an expert panel.

RESULTS:

One hundred sixty-seven completed surveys were returned, giving a response rate of 56%. The odds of referral to a general practitioner were mostly associated with presenting symptoms, although lower odds of referral were observed with increasing volumes of weekly prescriptions. The odds of pharmacists agreeing with the expert panel for an urgent referral were 70% (95% CI 50 to 80) lower for weight loss as the presenting symptom compared to rectal bleeding. The expert panel considered weight loss or rectal bleeding of 4 weeks' duration as meriting an urgent referral, but 63% and 30% of pharmacists, respectively, disagreed. In contrast to cancer guidelines, over 60% of respondents did not consider persistent diarrhea in a 65-year-old patient as a likely symptom of significant bowel pathology.

CONCLUSIONS:

In general, pharmacists' patterns of referral were influenced by clinical symptoms and not by demographic or working environment variables. They over-referred patients with diarrhea but under-referred those with weight loss and rectal bleeding, according to the expert panel. This is a cause for concern because any unexplained rectal bleeding should be referred for further investigation.

Self-Medication of Upper Gastrointestinal Symptoms: A Community Pharmacy Study

Background

Upper gastrointestinal (GI) symptoms are a common reason for self-treatment with over-the-counter (OTC) medication. However, data are scarce on the typology of GI complaints for which individuals seek self-medication and, more importantly, on the prevalence of alarm symptoms in this population.

Objective

To investigate: (1) the nature of GI symptoms that people intend to self-medicate, (2) prevalence of alarm symptoms, (3) adherence to referral advice given by the pharmacist, and (4) self-reported efficacy and frequency of use of OTC medication for minor complaints.

Methods

This descriptive study was performed in 63 community pharmacies. Participants (N = 592, aged 18–82 y) completed a questionnaire to assess symptom characteristics and previous medical consulting. Based on this information, the pharmacist referred subjects to a physician or advised self-treatment. Four weeks later, participants were presented a follow-up questionnaire evaluating their adherence to referral advice or efficacy of self-treatment.

Results

The most frequently reported GI symptoms were burning retrosternal discomfort (49.2%), acid regurgitation (53.2%), and bothersome postprandial fullness (51.2%). At least one alarm symptom was present in 22.4% of the individuals, with difficulty in swallowing being the most prevalent (15.4%). Although 21% of the customers were referred, only 51.7% of these contacted a physician. Almost all (95.1%) of the remaining customers who were advised self-treatment reported symptom relief with the OTC drug obtained.

Conclusions

Mild GI symptoms will mostly resolve with self-treatment. Yet, the value of pharmacist counseling on OTC treatment should be recognized, as community pharmacists can play an important role in distinguishing symptoms that warrant further medical examination.

The quality of self-care counselling by pharmacy practitioners, supported by IT-based clinical guidelines

OBJECTIVE

The primary objective of the study was to assess the quality of self-care counselling from pharmacy practitioners, supported by national clinical guidelines. The research questions addressed (1) the distribution of symptoms among customers in need of self-care counselling, (2) the quality of the self-care advice provided by pharmacy practitioners, (3) the degree of customer compliance with appropriate pharmacy advice versus the extent of symptom relief, (4) and versus a subsequent medical care visit, and (5) which resource the customers would have turned to in the first place for their ailments, had the pharmacy practitioner not been available.

SETTING

Three large community pharmacies with non-prescription self-selection departments in central Sweden.

METHODS

Ten pharmacy practitioners counselled all customers > or = 18 years old, with whom a dialogue was initiated on advice or products for self-care. The counselling was based on national clinical guidelines for self-care advice in the form of a software decision support program. The data collection consisted of documentation of background customer information, independent assessments of the quality of the advice provided and of telephone follow-ups.

RESULTS

Of all documented symptoms (n = 250), the most common were allergy (26.4%), musculoskeletal symptoms (8.4%) and dyspepsia (7.2%). Independent assessments of the documentation by a physician and a pharmacist found that self-care advice was appropriate to give 97.6% of the customers and that the advice provided was correct in 88.4% of the cases. In total, 217 cases (86.8%) were fully approved by both the physician and the pharmacist. Among the 182 customers who claimed that they complied completely with appropriate advice provided, 135 (74.2%) experienced a great improvement in symptoms. Among the 21 who had only partly followed the advice, six (28.6%) reported the same level of improvement (p < 0.001). If the pharmacy practitioner had not been available, 56.8% of the customers would have turned to medical care in the first instance.

CONCLUSIONS

The study demonstrates the high quality of pharmacy practitioners' self-care counselling supported by IT-based national clinical guidelines, including a favourable impact on customers' ailments. Furthermore, it reveals that pharmacy practitioners greatly relieve the pressure on the health-care system, resulting in reduced costs to society.

Beliefs about Medicines among Swedish Pharmacy Employees

OBJECTIVE

The aim of this study was to describe the beliefs about medicines among pharmacy employees. A further aim was to analyse whether these beliefs were associated with any background characteristics, such as age, professional category or medication use.

METHOD

The study subjects were pharmacy employees at 24 community pharmacies in Göteborg, Sweden. The participating pharmacies had a total of 372 employees (pharmacists, dispensing pharmacists, and pharmacy technicians). Data was collected at the weekly pharmacy information meetings with a questionnaire comprising background questions and the Beliefs about Medicines Questionnaire (BMQ). The general part of the BMQ was used. For each statement in the BMQ, respondents marked their degree of agreement on a five-point Likert scale (1=strongly disagree, 2=disagree, 3=uncertain, 4=agree and 5=strongly agree).

MAIN OUTCOME MEASURE

The three subscales of BMQ General: General Harm, General Overuse and General Benefit.

RESULTS

The majority of the 292 respondents were dispensing pharmacists. More than half of the respondents were aged 45 years or older and had worked in a pharmacy for 20 years or more. Compared to the other professional categories, a higher proportion of dispensing pharmacists stated that they currently used traditional medicines. The pharmacy employees had a mean score for General Benefit of 4.31 and a mean score for General Harm of 1.81. Pharmacists and dispensing pharmacists in general regarded medicines as somewhat more beneficial, whereas pharmacy technicians viewed medicines as slightly more harmful. Those who had worked in a pharmacy for 30-34 years regarded medicines as less harmful compared to those who had worked 0-4 years. Compared to non-users, current users of prescription drugs regarded medicines as more beneficial. When controlling for background characteristics, no confounders were detected for any of the three subscales (ANCOVA analyses).

CONCLUSION

Results of the study of 292 Swedish pharmacy employees show that they regard medicines as beneficial rather than harmful and that there are differences in beliefs between the professional categories. However, the reasons for these differences remain unclear. Nevertheless, the positive beliefs among pharmacy employees may have an impact on the communication with clients and, eventually, clients' adherence to medicines.