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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 212-219  

Evaluation of community pharmacists' professional practice and management of patient's respiratory conditions


1 Department of Clinical Pharmacy and Therapeutics, College of Pharmacy, Applied Science Private University, Amman, Jordan
2 Department of Clinical Pharmacy and Practice, College of Pharmacy, QU Health, Qatar University, Doha, Qatar

Date of Submission18-Sep-2020
Date of Decision17-Dec-2020
Date of Acceptance13-Jan-2021
Date of Web Publication26-May-2021

Correspondence Address:
Mohamed Izham Mohamed Ibrahim
Department of Clinical Pharmacy and Practice, College of Pharmacy, QU Health, Qatar University, Doha
Qatar
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpbs.JPBS_534_20

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   Abstract 


Objectives: We assessed the extent of community pharmacists managing respiratory conditions and their ability to make differential diagnoses between the common cold and allergic rhinitis. Methods: A simulated patient technique was used to achieve the study objectives. Thirty community pharmacies were randomized to be visited by a patient with allergic rhinitis symptoms, followed by a patient with common cold symptoms, and vice versa. One simulated patient visited the 15 pharmacies assigned to allergic rhinitis. Then, after 3–4 days, the pharmacies were revisited by a second simulated patient using the same symptoms; likewise, a simulated patient visited the other 15 pharmacies with common cold symptoms. Then, these pharmacies were revisited by the other simulated patient with the common cold symptoms. Descriptive statistics and correlation analyses were carried out using SPSS at alpha 0.05. Results: Fifteen pharmacies were used for the common cold scenario and 15 for the allergic rhinitis scenario (a total of 30 visits per scenario). Pharmacists showed overall poor skills in asking questions for differential diagnosis between the two conditions. No significant difference was found in the overall differential diagnosis score between the two groups (P = 0.744). The overall adherence to the labeling standard score was low, with an average of 2.38 (standard deviation [SD] = 2.50) out of 11, with no significant difference between the two scenarios (P = 0.332). The overall adherence score to the counseling standard was low, with an average of 2.93 (SD = 3.74) out of 15, with no significant difference between the two scenarios (P = 0.586). Conclusion: The simulated patient technique approach revealed a lack of ability of pharmacists in Amman, Jordan, to make differential diagnoses between the common cold and allergic rhinitis. In addition, pharmacists lacked the ability to carry out their role with respect to the management of the common cold and allergic rhinitis, including treatment recommendations, adherence to medicine labeling standards, and adherence to the counseling standard.

Keywords: Allergic rhinitis, common cold, community pharmacists, Jordan, simulated patient


How to cite this article:
Al-Qudah RA, Abu-Farha R, Al-Ali MM, Jaradaneh NS, Mohamed Ibrahim MI. Evaluation of community pharmacists' professional practice and management of patient's respiratory conditions. J Pharm Bioall Sci 2021;13:212-9

How to cite this URL:
Al-Qudah RA, Abu-Farha R, Al-Ali MM, Jaradaneh NS, Mohamed Ibrahim MI. Evaluation of community pharmacists' professional practice and management of patient's respiratory conditions. J Pharm Bioall Sci [serial online] 2021 [cited 2021 Sep 29];13:212-9. Available from: https://www.jpbsonline.org/text.asp?2021/13/2/212/316936




   Introduction Top


The community pharmacists are uniquely situated to provide valuable support and advice to the general public is highly indicated; there is also strong evidence that pharmacists are an important provider of care.[1],[2],[3] The approachability and location of pharmacies allow most patients to have ready access to a pharmacy.[1],[2] In addition, many patients trust and have confidence in community pharmacists' expertise to advise on prescription and nonprescription medicines.[1] Therefore, they are in a position to facilitate patients' care.[1] Given pharmacists' skills and abilities, they can play a valuable role in offering patient screening, patient management, and referring patients to physicians when needed.[2] In addition, they can provide continuing support and management services to patients with acute and/or chronic conditions.[2]

Two of the most common respiratory conditions faced by community pharmacists are the common cold and allergic rhinitis.[4] For instance, the cold is very common; it is estimated that adults experience two to four colds a year on average.[5] Allergic rhinitis currently affects up to 30% of the world's population, and its prevalence is increasing.[6] Studies describe the self-reported seasonal and perennial nasal symptom prevalence in the United States as 30%–38%,[7] in Europe as 19%–20%,[8] in Australia as 19%,[9] and in the United Arab Emirates as 32%.[10],[11] In Jordan, a study by Karadsheh et al. found that the prevalence of allergic rhinitis among adolescent males was 5.8%.[12] Furthermore, both allergic rhinitis and the common cold are associated with an enormous economic burden as assessed by lost productivity and expenditures for treatment if not treated appropriately.[4],[6],[13],[14]

Differential diagnosis of allergic rhinitis from other forms of rhinitis is not straightforward.[6] This makes the management of allergic rhinitis more complicated.[15] However, many patients are still self-medicating using community pharmacies.[16] To optimize the self-selection of allergic rhinitis medication versus other respiratory illnesses such as the common cold, pharmacists should have the ability to differentiate between these conditions in order to provide the most appropriate therapeutic management.[4] Community pharmacists play a vital role in the differentiation, assessment, and treatment of such conditions.[17]

In Amman, there are 1568 pharmacies serving the community.[3] Therefore, with widespread access to pharmacists, it is important to assess the ability of community pharmacists to differentiate between the symptoms of allergic rhinitis and the common cold in order to appropriately suggest the use of medications and to optimize patients' management of respiratory conditions.[3],[14],[18]

This study used a simulated patient (or mystery shopping or simulated client/patient) technique aimed to assess the extent to which community pharmacists are able to make differential diagnoses between the common cold and allergic rhinitis, suggest appropriate therapeutic options, adhere to medicine labeling standards, and adhere to counseling standards. Moreover, using this method has grown intensely in the area of pharmacy practice. For example, a study by Elayeh et al.[19] had assessed inhaler technique demonstration skills of community pharmacists in Jordan through incorporating simulated patient technique. They reported that the approach revealed a lack of ability to demonstrate correct inhaler technique for different types of inhalers by pharmacists.[19] However, studies evaluating the real practice of community pharmacists in low- and middle-income countries are scarce. The paper reports the cross-sectional study using the simulated patient to assess the extent to which community pharmacists in Jordan are carrying out their role with respect to the management of respiratory conditions. The main strength of the simulated patient method is its practicality in instigation information about surface as well as underlying aspects of patient–provider interactions in an unobtrusive way. The outcomes from this study may provide ideas and strategies for the different stakeholders in the pharmaceutical sector to improve the pharmacy practice in the country.


   Methods Top


Simulated patient technique

This study applied a simulated patient method, which is a nontraditional observational design. The simulated patient method was intended to study the actual professional behavior, attitude, and practice of the pharmacists, as opposed to their self-reported professional activities. Each pharmacy was visited twice, which may give an accurate view of the quality of services the pharmacies provide. The simulated patients only interacted with pharmacists who did not know that they would be visited.

Study setting and ethical consideration

The study was carried out from November 2018 to January 2019 in community pharmacy settings in Amman, Jordan. Ethics approval was obtained from the Faculty of Pharmacy, Applied Science Private University Ethics Committee (reference: 2018/2019/2). Informed consent was not taken since there is no risk of harm on participants and wavier of the consent was necessary to produce valid data.

Population and sampling

The target population was community pharmacists in Jordan. The list of registered pharmacies (n = 1568) in Amman (the capital of Jordan) was obtained from the Jordanian Pharmacists Association. Due to logistical issues, the study only focused on community pharmacies within Amman and excluded cities outside Amman. Amman is a densely populated area compared to other cities in Jordan; thus, most of the community pharmacies are located in this city. Thirty community pharmacies were randomly selected and randomized using a computer-generated program, and they were divided into two simulated patients' cases.

Scenarios

  • Scenario 1: Fifteen community pharmacies were selected and visited by simulated patients with common cold symptoms (signs and symptoms: sore throat, slight cough, tiredness, and body aches). Simulated patient “A” visited them, and after 3–4 days, the other simulated patient (B) repeated the visit using the same scenario (a total of 30 visits)
  • Scenario 2: Fifteen different community pharmacies were selected to be visited by simulated patient B with allergic rhinitis symptoms (signs and symptoms: running nV ose or congestion, sneezing, slight sore throat with phlegm, and slight cough when in bed). After 3–4 days, the same pharmacies were visited by simulated patient “A” using the same scenario.


One simulated patient visited 15 pharmacies with AR symptoms. After 3–4 days, the same pharmacies were visited by the other simulated patient using the same scenario. Then, one patient visited 15 different pharmacies with common cold symptoms. After 3–4 days, the same pharmacies were visited by the other simulated patient (a total of 30 visits). This number reflects the maximum number of pharmacies that could be visited in the available time, with the available resources and with only two patient-actors.

Study instrument

The protocol for differential diagnosis and the data collection form were extracted from the Joint FIP/WHO Guidelines on Pharmacy Practice.[20] The tool was pilot tested and validated by Mohamed Ibrahim et al.[13] The two simulated patients (i.e., two pharmacy students in their 5th year of pharmacy, of the same age and gender) were trained for the common cold and allergic rhinitis scenarios using practice demonstrations and role-playing to learn standardized answers. A panel of three experts (two pharmacy faculty members and one practice clinical pharmacist) provided input during the 1.5 h training session; the simulated patients learned about the two scenarios, as well as how to respond to a pharmacist's questions during the process of enacting a particular scenario. The simulated patients were instructed not to try and seek out specific information from the pharmacist. Both simulated patients were fluent in Arabic. To minimize the interrater variability and to standardize responses, only two trained simulated patients conducted all the visits and all visits were conducted in Arabic. Each of the two simulated patients independently visited or called (according to the study group) each of the 30 community pharmacies within 3–4 days of each other.

Data collection process

The form that the simulated patients needed to complete after each visit was adopted from a previous study in Qatar.[13] During the pharmacy visit, simulated patients gathered information such as pharmacist background, suggested alternatives for treating the conditions, advice regarding the use of antibiotics, and medication labeling practices. The simulated patients also observed whether the pharmacist prescribed antibiotics voluntarily or upon request by the simulated patient. The first four visits of both simulated patients served as pilot studies (i.e., test cases to practice the scenario). After each visit, each simulated patient noted the entire conversation and completed the data collection form. To reduce the impact of memory lapse, forgetfulness, or inability to accurately recall the details of the encounter between the simulated patients and the community pharmacists, the simulated patients were advised to record all information immediately after leaving the pharmacies.

Data analysis

Data analyses were performed using Statistical Package of Social Sciences (SPSS) (IBM SPSS Statistics for Windows, Version 22.0. IBM Corp., Armonk, NY, USA). Descriptive statistics including percentages, means, and frequency distributions were calculated for each of the questions. Chi-square tests and Fisher's exact tests were used to determine if there was an association. P < 0.05 represented a significant relationship.


   Results Top


Characteristics of the pharmacists and pharmacies for both scenarios

During the study period, 30 pharmacies were used to compare the common cold and allergic rhinitis scenarios [Table 1]. There was no significant difference between the two scenarios in terms of the type of pharmacies approached (6 independent pharmacies [20%] in each scenario, P = 1.000) or the gender of pharmacists included in the study (males represented 46.7% [n = 14] in the allergic rhinitis scenario versus 36.6% [n = 11] in the common cold scenario, P = 0.432).
Table 1: Characteristics of the recruited pharmacists and pharmacies for both scenarios

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Characteristics of the dispensing practice

For both conditions, the average time spent by the community pharmacists with patients was 1.39 ± 0.48 min. Approximately half (51.2%) of the dispensed medications were antibiotics in the common cold scenario versus 28.5% in allergic rhinitis cases. Paracetamol tablets were prescribed less than antibiotics; they were prescribed in 17.0% of common cold cases versus 22.8% of allergic rhinitis cases [Figure 1].
Figure 1: Percentage of the types of medications dispensed under both conditions

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Differential diagnosis between the common cold and allergic rhinitis

In this study of the differential diagnosis between the allergic rhinitis and common cold scenarios [Table 2], significant differences between the two groups were found in only three questions: the question about the symptoms that the patient has, the history of presenting the same complaint, and prior medicines they have used for these symptoms (P < 0.05 for all). Pharmacists showed overall poor skills in asking questions for differential diagnosis between the two conditions, with an average value of 2.05 (standard deviation [SD] = 1.95) out of 11 (the total number of questions. No significant difference was found in the overall differential diagnosis score between the two groups (P = 0.744).
Table 2: Questions frequently asked to differentiate between common cold and allergic rhinitis (n=30 for each group)

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Medicine labeling standards

Community pharmacists showed poor adherence to medicine labeling standards in both groups [Table 3], and for most standards, only a small percentage of pharmacists showed adherence to labeling information (range 0% to 66.7%). There was no significant difference between the two scenarios, except for the dose and dosing frequency. Pharmacists managing the common cold scenario showed better adherence to labeling standards compared to pharmacists managing the allergic rhinitis scenario (P < 0.001 for both groups). On the other hand, pharmacists in the allergic rhinitis scenario were more adherent to writing “controlled medicine” on medications than those in the common cold scenario (P = 0.24). The overall adherence score to the labeling standard was low, with an average of 2.38 (SD = 2.50) out of 11, with no significant difference between the two scenarios (P = 0.332).
Table 3: Adherence to the medicine labeling standard by community pharmacists (n=30 for each group)

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Adherence to patients' counseling standard

When comparing community pharmacists' adherence to patients' counseling standards in the two scenarios [Table 4], pharmacists in the two scenario groups showed a difference regarding refusing to dispense antibiotics, providing information about name, indication, dosage, and route of administration of the medication and discussing precautions and contra-indications (P < 0.05 for all). The overall adherence score to counseling standards was low, with an average of 2.93 (SD = 3.74) out of 15, with no significant difference between the two scenarios (P = 0.586).
Table 4: Community pharmacists’ adherence to patients’ counseling standard (n=30 for each group)

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   Discussion Top


This was a novel study conducted in community pharmacies in Jordan that aimed to assess the extent to which community pharmacists are carrying out their role with respect to the management of respiratory conditions. It was necessary to investigate the pharmacists' abilities to make differential diagnoses between the common cold and allergic rhinitis and the medicines prescribed to the patients since health care and pharmacy practice in Jordan have advanced over the years. The evidence indicated that there was an inappropriate assessment to make a differential diagnosis reasonably between the common cold and allergic rhinitis. Pharmacists were also unable to perform their roles with respect to the management of the common cold and allergic rhinitis, including treatment recommendations, adherence to medicine labeling standards, and adherence to the counseling standards.

As it has been confirmed over decades, community pharmacists are the first and most common health-care professionals approached by patients seeking medical advice, including advice about acute or chronic conditions.[14],[17],[21] Hence, pharmacists' skills are highly sought after to provide this important community service.[21],[22] The results of this study highlight the overall poor skills of pharmacists in asking questions for differential diagnosis between the two conditions. The results are similar to those of a study conducted by Mohamed Ibrahim et al.[13] in which community pharmacists were unable to make a differential diagnosis between the common cold and allergic rhinitis. In addition, neither the type of pharmacies approached (independent vs. chain) nor the gender of pharmacists included in the study affected the results of either scenario.

The ability to differentiate between different medical conditions is vital in the community pharmacy setting and highlights the importance of a pharmacist's role.[14] In the current study, the findings indicate that symptoms of the common cold and allergic rhinitis are often similar and confuse pharmacists.[14] Using the differential diagnosis assessment tool, a significant difference between the allergic rhinitis and common cold scenarios was found in only three questions; these questions are about the symptoms that the patient has, the history of presenting the same compliant, and what medicines the patient has used prior for these symptoms. However, no significant difference was found in the overall differential diagnosis score between the two groups. A similar finding was found in Qatar by Mohamed Ibrahim et al.[13] in which pharmacists were unable to differentiate between the common cold and allergic rhinitis. Pharmacists should have the ability to recognize and assess the symptoms of the common cold versus allergic rhinitis.[13],[14] Moreover, it is well documented that patients usually and suboptimally self-select treatment for their conditions, especially allergic rhinitis;[6] as a result, this may affect their quality of life (QoL). Properly assessing the symptoms by pharmacists will help in determining whether the patients should be treated using over-the-counter medications or referred to their physicians.[1],[6],[14]

Community pharmacists showed poor adherence to medicine labeling standards in both groups, and for most standards, only a small percentage of pharmacists showed adherence to labeling standards. There was no significant difference in adherence to labeling standards between the two scenarios, except for the dose and dosing frequency. In this case, pharmacists who managed the common cold scenario showed better adherence to labeling standards compared to pharmacists who managed the allergic rhinitis scenario. Interestingly, a study conducted in Qatar[13] found that only the “dose” and “dosing frequency” of medications on the medication labels were mentioned by pharmacists. A similar finding using the simulated patient method was found in a study conducted in Malaysia,[23] where the majority of the dispensed medications were inadequately labeled in comparison with the current Malaysian regulations.

Conversely, pharmacists in the allergic rhinitis scenario were more adherent to writing “controlled medicine” than those in the common cold scenario. The overall adherence score to labeling standards was low, with no significant difference between the two scenarios. As a result of not complying with the labeling standards established by the World Health Organization[24] to ensure good dispensing practice, patient safety will be at risk due to medication errors. Hence, it is important that the labeling system should be applied and labels should have all required information about the drugs, including the appropriate use and dose frequency.[13],[24] Another suggestion is that there is a need for educational workshops. In addition, regulatory bodies should follow-up on enhancing the medication labeling system and have a clear labeling standard in Jordan. This could result in improving patient adherence and patients' QoL.

In Jordan, many studies have proven the important role of pharmacists in patients' counseling as a part of pharmaceutical care services.[25],[26],[27] In the current study, by comparing community pharmacists' adherence to patients' counseling standards in the two scenarios, pharmacists in the two scenario groups showed a difference in their practice regarding refusing to dispense antibiotics, providing information about name, indication, dosage, and route of administration of the medication and discussing precautions and contra-indications. The overall adherence score to the counseling standard was low, with no significant difference between the two scenarios. A study conducted in Germany[28] reported that 98% of the study subjects offered advice to patients using the pseudo customer method. However, in 36% of the cases, pharmacist advice was only given upon request. Furthermore, more than 50% of the pharmacists did not check the patients' medical condition, especially when a product was requested by a patient upon self-diagnosis.[28] Hence, more pharmacist training and interventional sessions on medication counseling are recommended; similarly, more restricted standards could be applied to make counseling necessary in applicable patient interactions.

The recommended length of counseling by pharmacists was found in the literature to be a minimum of 3 min per patient.[29] In our study, for both conditions, the average time spent by the community pharmacists with patients was 1.39 ± 0.48 min. The average time spent by pharmacists with patients in our study was lower than what is recommended by the literature. Comparatively, a study conducted by Mohamad et al.[13] reported that the median duration of a visit for the common cold was 7.5 versus 6.5 min for allergic rhinitis. In a study conducted by Berger et al.,[28] the time spent in counseling by simulated patients was varied from 30 s to 15 min. Time spent with patients by pharmacists is highly important for patient care and should be emphasized.[13] It is necessary to ensure that the length of counseling time with patients is adequate to allow pharmacists to gather relevant information from the patient, to assess the appropriateness of the medicine chosen, to provide relevant counseling points, to assess the patient's understanding about their medications, and to identify further treatment-related problems, if applicable.[30]

In spite of Jordan's laws, which clearly prohibit the supply of any antibiotic without a prescription, this study found that antibiotics were provided without a prescription for inappropriate use for viral infections such as the common cold. Similarly, a study conducted in Pakistan[31] found that the management of allergic rhinitis was not generally satisfactory at community pharmacies. Ineffective treatment was prescribed by pharmacists with little or no patient counseling.[31] A study by Zawahir et al. found similar results wherein 25% of pharmacists dispensed an antibiotic as the main medication to pseudopatients who had viral infections.[21] Based on simulated patient symptoms, antibiotics would not be appropriate for either condition. Moreover, Vitamin C, herbal syrup, and mucolytic agents would be neutral for both conditions. Paracetamol is appropriate for the common cold, and antihistamines would be more appropriate for allergic rhinitis but could be appropriate for both conditions. It is clear that the management of respiratory conditions, such as the common cold and allergic rhinitis, needs to be addressed with community pharmacists through educational sessions and workshops for better outcomes.

A patient simulation method was used in this study. This method is commonly used worldwide, including in the United Kingdom,[22] Germany,[28] the Slovak Republic,[17] Sri Lanka,[21] Qatar,[13] Malaysia,[23] and Jordan.[18] The simulated patient is a technique involving simulation using “patient-actors.”[30] The simulated patients are well-trained to enact predetermined scenarios; hence, the pharmacist subjected to this approach may or may not be aware of the identity of the simulated patients and their purpose.[30],[32] This method was approved by Madden et al., such that it could minimize observation bias, reduce recall bias, and standardize the cases and potential scenarios to obtain comprehensive information.[33] This approach can be a robust methodological tool for pharmacy practice research, especially if the findings can lead to social and behavioral change.[21]

Study limitations

The study has several limitations. First, the sample size of this study is relatively small. This may limit the conclusions based on these observations; the results of this study can only provide a glimpse of the practices in Jordan pharmacies using the selected scenarios. However, due to the nature of the study design, this sample size is adequate to study the actual behavior and practice of the pharmacists. Thus, to enhance the study's generalizability, a larger sample size is needed that is in line with comparative controlled study designs in order to obtain a better assessment of current practices. Second, the measurement of the outcome is based on a standardized tool that was used by the simulated patient. It would be better if the study used multiple ratings, i.e., multiple patients with the same condition, so that ratings could be averaged.

Study recommendations

This study offers several recommendations, including the need for improvements in the overall management process of the common cold and allergic rhinitis by pharmacists. The Jordanian Pharmacist Association should take the lead in conducting workshops to educate pharmacists from all cities in Jordan. In addition, the results of this study are important and call onto the authorities and policy makers in the country to improve continuous education and support its incorporation into the pharmacists' day-to-day practice. Future studies with different study designs, e.g., pre–post experimental design or quasi-experimental design, are needed to be able to investigate the magnitude of improvements and subsequent practice changes made after educational workshops. Improvements in the overall management process of both conditions are needed.


   Conclusions Top


The results of this study highlight the overall poor skills of pharmacists in asking questions for differential diagnosis between the common cold versus allergic rhinitis. Pharmacists' performances in both appropriate counseling and the labeling of medications were at a suboptimal level. Educational programs focusing on the evidence for managing respiratory conditions, such as the common cold and allergic rhinitis, may help ensure community pharmacists meet appropriate standards for better patient outcomes.

Acknowledgment

The language was edited by the American Journal of Experts and sponsored under the Qatar University Student Grant (Number: QUST-1-CPH-2020-18).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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