Development and content validation of an instrument to document the dispensing of prescribed medicines.

WHAT IS KNOWN AND OBJECTIVE: Qualified dispensing is fundamental for the promotion of the rational use of medicines. Documentation is an indicator of quality and one of the essential steps in the care process. However, in Brazil, there are no models of clinical documentation applicable to dispensing practices. Thus, the objective of this study was to develop and validate an instrument to document the dispensing process of prescribed medicines. METHODS: A methodological development study was carried out from February 2017 to October 2017 in two stages, which were (i) the development of the instrument and (ii) content validation of the proposed instrument. The development phase comprised three stages, which were (i) the elaboration of the prototype based on a previously performed systematic review, (ii) academic brainstorming and (iii) a pre-Delphi consensus. The content validation process was performed using the Delphi technique. The instrument was sent to 40 experts with experience in dispensing, and the consensus among them was calculated using the content validity index (CVI). The study was approved by the Ethics Committee, and all participants signed an informed consent document detailing the terms of the study. RESULTS: In the development stage, three versions of the instrument were generated, which were the prototype, version 1 (changed after academic brainstorming) and version 2 (changed after the pre-Delphi). In the content validation process of version 2 of the instrument, 23 experts returned their evaluation in the first round of the Delphi process and 17 in the second. All the items obtained a CVI >0.83, which resulted in the validation of the instrument. The final instrument comprised the following sections: general information, the identification of technical and legal problems of prescriptions, the conduct for the resolution of the technical and legal problems of prescriptions, medication dispensed, suspected drug-related problems, verbal guidance, written guidance, referral and the referral result. WHAT IS NEW AND CONCLUSION: The developed and validated instrument presents the main variables that should be documented during the dispensing process.

Establishment, Implementation, and Consolidation of Clinical Pharmacy Services in Community Pharmacies: Perceptions of a Group of Pharmacists.

When pharmacists incorporate clinical practice into their routine, barriers and facilitators influence the implementation of patient care services. Three focus groups were conducted with 11 pharmacists who were working for the Farmácia Popular do Brasil program on the establishment, implementation, and consolidation of clinical pharmacy services. The perception of the pharmacists in Brazil about the program was that it facilitated access to health care and medication. The distance between neighboring cities made it difficult for patients to return for services. Lack of staff training created a lack of communication skills and knowledge. The pharmacists wanted to have increased technical support, skill development opportunities, and monitoring of researchers who assessed progress of the service. Pharmacists overcame many of their insecurities and felt more proactive and committed to quality service. Positive experiences in service implementations have shown that it is possible to develop a model of clinical services in community pharmacies.

Quality analysis of research on the use of benzodiazepines by elderly patients in the emergency room: a systematic review.

PURPOSE: To analyze the quality of research on the use of benzodiazepines (BZDs) in the emergency room by the elderly population through the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiative. METHODS: A systematic review was carried out according to the following steps: (1) identification of studies, in which studies were selected from different combinations of the descriptors "elderly-aged," "benzodiazepines," and "emergency room" in the EMBASE-MEDLINE, SciELO, Scopus, and Web of Science databases; (2) evaluation of studies, in which the title, abstract, and full text of the studies were assessed; (3) evaluation of the methodological quality of the studies. The criteria used were those included in the STROBE recommendations. RESULTS: At the end of the selection process, only six articles were identified which met the specific criteria. The sample sizes in these studies varied from 118 to 1,611 patients. More than half (4) of the studies did not describe the type of design used, whereas all collected demographic data and analyzed details on the use of BZDs, such as type administered and/or its relationship to the symptoms, were shown. No article fully complied with the STROBE criteria. CONCLUSIONS: This review shows a lack of methodological quality in the studies performed to date that have evaluated the use of BZDs in elderly patients in emergency rooms. These findings should guide future research in this subject area, providing a more complete approach on aspects related to the use of medications by this specific population.

Pharmaceutical care program for elderly patients with uncontrolled hypertension.

OBJECTIVE: To evaluate the effect of a pilot pharmaceutical care program developed for elderly patients with uncontrolled hypertension. METHODS: Nonrandomized single intervention pre/posttest blood pressure study in a community pharmacy in Aracaju, Brazil. This study enrolled elderly patients diagnosed with essential hypertension and uncontrolled blood pressure. Monthly visits were scheduled during a 10-month period. Pharmaceutical interventions were focused on health education and monitoring of drug-related problems. Primary outcomes included target blood pressure control, reduction in blood pressure, pulse pressure, medication adherence, and reduction of anthropometric indices. RESULTS: 35 of 51 patients completed the study. After 10 months of intervention, 57.2% of elderly patients achieved blood pressure control (P = 0.000) and the mean reduction was 26.6 mm Hg (P < 0.0001) for systolic blood pressure, 10.4 mm Hg (P < 0.0001) for diastolic blood pressure, and 15.7 mm Hg (P < 0.0001) for pulse pressure. Medication adherence also improved (P = 0.0000); however, anthropometric indices remained unchanged. CONCLUSION: The pharmaceutical care program improved outcomes by reducing and controlling blood pressure and improving medication adherence among elderly patients with uncontrolled hypertension.

Communication skills in Brazilian pharmaceutical education: a documentary analysis.

OBJECTIVE: To characterize the inclusion of the teaching of communication skills in the curriculum of Pharmacy Schools of Federal Institutions of Higher Education. METHODS: An exploratory study of documental analysis of curriculum of Pharmacy Schools was carried out. A convenience sample was selected from undergraduate pharmacy courses of Federal Institutions of Higher Education (IFES). The variables collected were related to the identification of the course, its nature (elective or mandatory), workload, semester, and program content. RESULTS: Among the 49 undergraduate pharmacy courses of IFES, 35 (71.4%) had their curriculum available online. The teaching of communication in health was identified in 26 (74.3%) curriculum. In this study, three courses (7.2%) specifically aimed at teaching communication skills, while 39 (92.9%) had content related to this subject. Most courses (22; 52.4%) belonged to the field of Social, Behavioral, and Administrative Sciences. As for the course period, there was a concentration in the third (19%) and fourth (28.6%) years. The main content present in the curriculum was related to the principles and techniques of health communication (42.8%). CONCLUSIONS: Data obtained enabled the identification of gaps in the curricula of undergraduate courses in pharmacy concerning the inclusion of the teaching of communication skills. These results can be used to reflect the current models adopted in Brazil for the teaching of this skills, especially after the recent publication of the new curricular guidelines for undergraduate pharmacy courses.

Pharmacist-physician collaborative care model for patients with uncontrolled type 2 diabetes in Brazil: results from a randomized controlled trial.

RATIONALE, AIMS AND OBJECTIVES: This study aimed to evaluate the effect of a pharmacist-physician collaborative care model on clinical outcomes in patients with uncontrolled type 2 diabetes and determine characteristics that influence this effect. METHODS: A randomized controlled trial was conducted in a secondary care clinic for 80 patients with type 2 diabetes, aged 40-79 years and glycosylated haemoglobin (A1C) level ≥ 7.0%. The intervention group received individual, face-to-face pharmaceutical consultations and remote telephone support after a routine visit. The main measures were clinical outcomes (A1C, blood pressure, LDL cholesterol) and process indicators (medication adherence, medication regimen complexity, use of medicines). Multiple regression models were used to determine the variables that could explain the reduction and individualized control of A1C. RESULTS: From the initial sample of 80 patients, 73 completed this study. Compared with usual care, patients in the intervention group showed greater reduction in A1C (-0.79 vs. -0.16; P = 0.010); and an increase in the percentage of patients achieving the individualized goal of A1C (25.0% vs. 5.4%; P = 0.020). In addition, there was an increase in the percentage of adherent patients and in the average scores of medication adherence. Participation in the intervention group, higher baseline A1C levels and greater change in medication adherence were all significant predictors of improvement in A1C levels. CONCLUSIONS: The results suggest that the collaborative care model proposed is feasible and more effective than the usual care in the reduction and individualized control of A1C levels in patients with uncontrolled type 2 diabetes.

Evaluation of students' attitudes towards pharmacist-physician collaboration in Brazil.

OBJECTIVE: To measure undergraduate pharmacy and medical students' collaborative attitudes regarding Pharmacist-Physician collaboration. METHODS: A cross-sectional descriptive study was conducted from September 2016 to February 2017 in Northeast Brazil. Pharmacy and medical students from the first and the last year of courses were invited to complete Portuguese version of Scale of Attitudes Toward Pharmacist-Physician Collaboration (SATP2C). Descriptive and comparative analyses were performed using IBM SPSS (22 version). Differences were considered significant when p<0.05. RESULTS: Three hundred seventy students completed the SATP2C. Overall, the students had positive attitudes towards physician-pharmacist collaboration. There was no significant correlation between age and score (p=0.79). Women showed a more positive collaborative attitude than men (53.1, SD=6.8 vs. 55.1, SD=6.3). Pharmacy students had a higher score than medical students (57.5, SD=4.7, vs. 51.1, SD=6.4). The first-year medical students had a higher score than last-year medical students (52.3, SD=6.0 vs. 49.5, SD=6.6; p<0.007). There was no significant difference in the attitudes between the first and last year pharmacy students (p<0.007). CONCLUSIONS: Pharmacy and medical students showed positive attitudes towards physician-pharmacist collaboration. However, pharmacy students presented more collaborative attitudes than medical ones. Additionally, the first-year medical students had more collaborative attitudes than last-year medical students. Studies should be conducted to provide recommendations to improve interprofessional education efforts to further enhance the positive attitudes toward physician-pharmacist collaboration.

Influence of Pharmaceutical Care intervention and communication skills on the improvement of pharmacotherapeutic outcomes with elderly Brazilian outpatients.

OBJECTIVE: The goal of this study was to evaluate the influence of Pharmaceutical Care intervention on the results obtained with a group of elderly outpatients and to analyze the communication skills used by healthcare professionals (research pharmacists, dispensing pharmacists, and physicians) during counseling about healthcare and drug therapy. METHODS: The instruments were applied to 30 elderly outpatients assisted at the pharmacy of a primary healthcare unit in Ribeirão Preto (SP), Brazil. The group of patients received follow-up for a period of 12 months. RESULTS: It was observed that Pharmaceutical Care intervention and humanized communication, of an educational nature, optimized the use of medication, reduced symptoms caused by drug therapy, and improved the health conditions of the patients. CONCLUSION: Pharmaceutical Care intervention was essential for the establishment of therapeutic relationships and influenced the care given to elderly people as well as the achievement of positive health outcomes. PRACTICE IMPLICATIONS: After this study, Pharmaceutical Care programs were implemented in different PHCU's of Ribeirão Preto and pharmacists are following-up 300 elderly patients.

Cross-cultural adaptation and validation to Brazil of the scale of attitudes toward physician-pharmacists collaboration.

BACKGROUND: Despite the increasing complexity of medication therapies and the expansion of pharmaceutical clinical services to optimize patient care working in collaboration with physicians. In this sense, interdisciplinary education has been encouraged. However, no instrument is available to measure attitudes toward collaborative relationships. OBJECTIVE: To translate, cross-cultural adaptation and validation an instrument to measure collaboration attitudes toward students of medicine/pharmacy and physicians/pharmacists. METHODS: The process of cross-cultural adaptation was carried out using international recommendations and was performed from January 2014 to April 2015. The instrument under consideration was translated and re-translated. A panel of experts compared the generated documents and the translation was evaluated for 20 undergraduate students of Pharmacy, 20 undergraduate students of Medicine and professionals (20 pharmacists and 20 physicians). RESULTS: The process of cross-cultural translation and validation result in the Portuguese version. Modifications to the grammatical structures were made in order to establish a cross-cultural similarity between the English and Portuguese versions. Regarding the evaluation of the expert panel, six questions required modifications. CONCLUSIONS: Psychometric evaluation demonstrated and confirmed the validity of the Brazilian-Portuguese version to assess collaborative attitudes among pharmacists and physicians. Moreover, the scale can be used to evaluate undergraduates and postgraduates and foster the development of teaching methods that promote comprehensive attitudes in patient care.

Development of a decision support system for the practice of responsible self-medication.

BACKGROUND: Responsible self-medication is an integral part of the health system that consists of community pharmacists counseling patients on treating minor illness using non-prescription medications. Systems for properly managing information can assist disease identification and clinical decision-making. OBJECTIVE: To develop a software program to assist community pharmacists in clinical decision-making regarding selfmedication. SETTING: The study was conducted in northeastern Brazil. METHODS: The study was conducted from February 2012 to January 2014. System development included identifying minor illnesses commonly treated by community pharmacists and creating simulations of community pharmacies using a simulated patient methodology. Clinical pharmacists, production engineering students, professors, and a pharmacist researcher comprised the development group. Five meetings were held to develop the software, and the system was completed in December 2013. MAIN OUTCOME MEASURE: Minor illnesses commonly treated by community pharmacists, and simulated patient methodology. RESULTS: In the first meeting the final list of topics for inclusion in the algorithm indicated the exact questions to be addressed by the community pharmacist to properly manage the complaint. In the second meeting, the discussions in the focus group indicated consensus among pharmacists as to the medications on the list of Groups and Specified Therapeutic Indications of Brazilian Legislation. In the third meeting were defined the parameters to refer patients to the doctor. In the fourth meeting the algorithm was tested using a simulated patient, to observe whether the question order ensures an effective, efficient, and safe decision process for the patient. In the fifth meeting, the algorithm was tested again using a simulated patient with the flu, and all group members agreed upon its final incarnation after refinements to the situations that determined referral to the doctor. CONCLUSION: The software may contribute to identifying health risk situations (potentially unsafe medications based on clinical history, clinical hazards, and past adverse events) requiring medical treatment.

Assessment of Community Pharmacists' Counseling Practices With Simulated Patients Who Have Minor Illness: A Pilot Study.

STATEMENT: A community pharmacist (CP) must provide counseling to consumers of nonprescription medicines and promote responsible self-medication. Previous studies indicate no available statistics on the proportion of pharmacies that provide cognitive services in Brazil. Furthermore, few studies have explored CPs' performance regarding patient-centred cognitive services in community pharmacies. Thus, quality improvement initiatives are needed for the responsible provision of self-medication to fully integrate Brazilian CPs into patient-centred cognitive services. Consequently, the present study's aim was to assess CPs' performance in the management of cases with minor symptoms using nonprescription medicines.

The use of pictograms in the health care: a literature review.

BACKGROUND: The ability of patients to understand pharmacotherapy information is critical to the successful use of medications. One of the risk factors that may predispose the patient to non-adherence is the low retention of verbal information. Thereby, one way to facilitate the understanding of patients regarding prescribed pharmacotherapy is to incorporate pictograms to transmit information in a clear, expeditious, and simple manner. OBJECTIVE: To evaluate literature on the use of pictograms for health professionals and assess their impact on helping patients increase the understanding of and compliance with medical instructions. METHODS: Searches were conducted from February to March 2012. We searched articles in databases, using the keywords: "pictograms," "health," "health care professionals," "medication" and "pictorial representation." After this step, we performed a manual sorting, evaluating titles and abstracts. The articles were carefully examined according to the following variables: (1) geographic location and setting of the studies; (2) study design; (3) number of pictograms used; (4) education; (5) sample size; (6) age of participants; (7) function of pictograms; (8) limitations described in the literature evaluated. RESULTS: The research identified 136 published studies. After the exclusion process, 24 studies met inclusion criteria and from those, 50% were conducted in Africa, and 51.4% were considered effective. In the evaluation of the function of the pictograms, to verify their utility, 23 studies used to educate patients on the use of medications. The translation and cultural adaptation of pictograms was performed in five studies, and one study considered this process as validation. CONCLUSION: In this review, the literature contained only a few studies employing pictograms by health professionals, and most of these were meant for the use of medications. Moreover, the specific results reinforce the need for more studies in this area to provide a more complete approach about pictograms in the heath care.

Improving post-discharge medication adherence in patients with CVD: a pilot randomized trial.

BACKGROUND: Effective interventions to improve medication adherence are usually complex and expensive. OBJECTIVE: To assess the impact of a low-cost intervention designed to improve medication adherence and clinical outcomes in post-discharge patients with CVD. METHOD: A pilot RCT was conducted at a teaching hospital. Intervention was based on the four-item Morisky Medication Adherence Scale (MMAS-4). The primary outcome measure was medication adherence assessed using the eight-item MMAS at baseline, at 1 month post hospital discharge and re-assessed 1 year after hospital discharge. Other outcomes included readmission and mortality rates. RESULTS: 61 patients were randomized to intervention (n = 30) and control (n = 31) groups. The mean age of the patients was 61 years (SD 12.73), 52.5% were males, and 57.4% were married or living with a partner. Mean number of prescribed medications per patient was 4.5 (SD 3.3). Medication adherence was correlated to intervention (p = 0.04) and after 1 month, 48.4% of patients in the control group and 83.3% in the intervention group were considered adherent. However, this difference decreased after 1 year, when adherence was 34.8% and 60.9%, respectively. Readmission and mortality rates were related to low adherence in both groups. CONCLUSION: The intervention based on a validated patient self-report instrument for assessing adherence is a potentially effective method to improve adherent behavior and can be successfully used as a tool to guide adherence counseling in the clinical visit. However, a larger study is required to assess the real impact of intervention on these outcomes.

Assessment of community pharmacists' counselling skills on headache management by using the simulated patient approach: a pilot study.

BACKGROUND: Headache, or cephalalgia, is one of the 20 most disabling diseases in the world and affects a large portion of the world's population. People generally use over-the-counter medications to treat headaches and other minor symptoms. A pharmacist should help patients choose the most effective, safe, and convenient pharmacotherapeutic option. OBJECTIVE: To assess the counselling skills of community pharmacists for headache management by using the simulated patient approach. METHODS: A cross-sectional study was conducted from March 2010 to July 2010. Data were obtained from a convenience sample consisting of one pharmacist from each of the 24 participating community pharmacies. In order to evaluate the pharmacists' counselling skills, a simulated patient role played a standardized headache case requesting self-medication. The interactions of the simulated patient with the pharmacists were audiovisually recorded using a hidden micro camera, and these recordings were analysed using a validated questionnaire. RESULTS: Of the 24 evaluated pharmacists, 19 (79.1%) were women. Information was spontaneously provided by 15 (62.5%) pharmacists. At least one question was asked by the pharmacist to assess the signs and symptoms. Most pharmacists (n=17, 70.8%) recommended sodium dipyrone, either alone or in combination with other drugs. The most discussed items in the simulation visits were contraindications (n=17, 70.8%), indications (n=10, 41.6%), and drug administration times (n=8, 33.3%). None of the pharmacists recommended any non-pharmacological therapeutic alternatives. The overall impressions of the pharmacists' professional counselling skills ranged from poor to fair. CONCLUSIONS: This study showed that the pharmacists' counselling skills and the guidance provided by the pharmacists to the simulated patient were insufficient for the satisfactory management of headache.

Pharmaceutical care in hypertensive patients: a systematic literature review.

BACKGROUND: Since the conception of pharmaceutical care in 1990, many studies have been published purported to implement and/or evaluate interventions under this aegis; however, most have been criticized in methodological approach. As such, there is a need to assess the scientific rigor of the published studies and examine the biases that may compromise the hardiness of their findings. OBJECTIVES: The aim of this review is to describe and appraise published research on the management of patients diagnosed with essential hypertension under the guise of pharmaceutical care. METHODS: MEDLINE, EMBASE, Scopus, and LILACS databases from January 1990 to July 2011 were searched using the keywords "pharmaceutical care," "hypertension," and "blood pressure." Included were clinical trials assessing the impact of pharmaceutical care on outcomes for hypertensive patients. Two independent reviewers abstracted data on descriptive characteristics, research design and outcomes, and study limitations. RESULTS: The literature search identified 917 articles, of which 16 satisfied the inclusion criteria. The studies were conducted primarily in North America (8) and in ambulatory settings (9). Sample sizes ranged from 24 to 235 patients, with most studies reporting a 6-month patient follow-up period. Many studies (9) were randomized clinical trials but generally had a low-quality methods score according to the Jadad scale. Blood pressure (BP) (15), medication adherence (11), and quality of life (9) were the most common outcome measures. As expected, systolic BP was the outcome most positively impacted by the pharmaceutical intervention. CONCLUSIONS: This database search revealed that most of the included studies evaluated the impact of pharmaceutical care on clinical and humanistic outcomes and few studies showed statistically significant improvement in BP. However, a lack of hardiness and many important limitations were common in the studies analyzed. As such, recommendations are made to improve in research design and to demonstrate the effectiveness of the intervention.

Virtual patients in pharmacy education.

A review of the literature relating to the use of virtual patients in teaching pharmaceutical care to pharmacy students was conducted. Only 7 articles met the inclusion criteria for the review and 4 of the studies were conducted in North America. Few articles identified by the review used virtual patient technology that was true-to-life and/or validated.

Developing communication skills in pharmacy: a systematic review of the use of simulated patient methods.

OBJECTIVE: To review the literature relating to the use of simulated patient methods to enhance communication skills of pharmacists. METHODOLOGY: We searched Embase, Lilacs, Medline, Scielo, and Scopus databases between 1980 and 2008, using "communication skills", "patient counseling" and "pharmacist" as keywords. This search was then further refined by using "simulated patients", "pseudo-customer", "standardized patients", and "mystery shoppers" as additional keywords. RESULTS: The initial search identified 241 published studies. Once further refined, 15 studies met inclusion criteria. CONCLUSION: The majority of studies had an assessment focus aimed at documenting counseling behavior of practicing pharmacists, rather than an educational focus aimed at equipping pharmacists with effective communication skills. In instances where simulated patient methods were used for educational purposes, little regard was given to the role of performance and corrective feedback in shaping communication behavior of pharmacists. The majority of studies failed to describe the competencies and skills being investigated in relation to communication in the practice of pharmacy. PRACTICE IMPLICATIONS: Simulated patient methods provide pharmacy educators with a tool for implementing communication skills in the practice of pharmacy and will serve as a basis for implementing communication skills development programs at the College of Pharmacy of the Federal University of Sergipe in Brazil.