Abstract
Background: In Germany, non-pharmacists (pharmacy technicians and pharmaceutical technical assistants) are permitted to advise on and sell medications in addition to pharmacists. The aim of this study was to determine if pharmacists and non-pharmacists referred patients to a medical consultation for a scenario in which consulting a doctor was mandatory ('appropriate outcome') and what the quality of questioning and - if a medication was dispensed - the quality of information provided were in this context. The study also aimed to determine which factors predicted a necessary referral to a doctor. Methods: A cross-sectional, covert simulated patient study was conducted in a random sample of community pharmacies stratified by location in the German state of Mecklenburg-Vorpommern. Each pharmacy was visited once by one of four trained investigators. They simulated a symptom-based request involving a grandmother with acute diarrhoea. A multivariate binary logistic regression analysis using potential variables from bivariate analysis was carried out to determine the predictors for a referral to a doctor. Results: All 199 planned visits were conducted. A necessary referral to a doctor was recommended in 59.8% (n=119) of all visits. The most commonly asked question was 'for whom is the medication?' (75.4%, n=150), while 'clarification by a doctor' was asked the least (17.6%, n=35). In 87.9% (n=175) of all visits a medication was dispensed. Multivariate analysis revealed that, unlike pharmacists, non-pharmacists have a 2.446 times higher likelihood of recommending a referral to a doctor (p = 0.044; 95% CI = 1.025-5.835). Conclusions: In almost half of the visits a necessary referral to a doctor was not recommended. Furthermore, the quality of questioning and the quality of information were below expectations. Moreover, involvement of non‑pharmacists was surprisingly identified as a relevant factor influencing the appropriate outcome.
Highlights
Acute diarrhoea is one of the most common diseases worldwide[1], including in Germany[2]
According to the guidelines of the German Society of General Medicine and Family Medicine, acute diarrhoea is an imbalance between secretion and absorption in the bowels, whereby the symptoms last fewer than 14 days and are associated with an increased frequency (≥ three loose stools in a day) or an increased water content (≥ 75%) or an increased stool weight (≥ 250 g)[4]
Design A cross-sectional study design was chosen in accordance with the ‘STROBE Statement – Checklist of items that should be included in reports of cross-sectional studies’[28] and, to determine the quality of advice provided in the community pharmacies (CP) investigated, based on the highly recommended[29] SP method that is often used internationally[23,30,31,32,33] as a form of participatory observation[34]
Summary
Acute diarrhoea is one of the most common diseases worldwide[1], including in Germany[2]. Worldwide about 1 billion people develop acute diarrhoea each year[2], causing about 2 billion cases of acute diarrhoea[3], and about 30% of the German population suffer from acute diarrhoea episodes each year[2] Because those affected report becoming ill on average 1.7 times per year[2], this means that about 42 million cases of acute diarrhoea can be expected in Germany. The aim of this study was to determine if pharmacists and non-pharmacists referred patients to a medical consultation for a scenario in which consulting a doctor was mandatory (‘appropriate outcome’) and what the quality of questioning and – if a medication was dispensed – the quality of information provided were in this context. Each pharmacy was visited once by one of four trained investigators They simulated a symptom-based request involving a grandmother with acute diarrhoea. Involvement of non‐pharmacists was surprisingly identified as a relevant factor influencing the appropriate outcome
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