Are pharmacies overselling?

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New research investigated how Brisbane pharmacies manage two health issues

The study, by researchers from QUT’s Business School and Faculty of Health School of Clinical Sciences (Pharmacy) and published in JAMA, set out to examine whether therapeutic guidelines are effective mechanisms for ensuring compliance in the provision of OTC medicines for symptom-based requests and product-based requests in Australian pharmacies.

The health issues in question were emergency hormonal contraception and conjunctivitis.

Using standardised patients (SPs) in scenarios of requests for assistance with these issues, 57.6% of pharmacies followed dispensing behaviour compliant with the protocol, while 31.3% involved some form of overtreatment or overselling of medication.

“There was also evidence of an interaction between sex of the standardized patient and pharmacist,” the researchers wrote.

The study was undertaken in 205 pharmacies in the wider Brisbane area, with two standardised patient scenarios developed to evaluate noncompliant behaviour.

The outcomes were the observed likelihood of non-compliant treatments and overtreatments.

“In scenario 1, nine trained female SPs visited 89 pharmacies to request emergency hormonal contraception from pharmacy staff,” the researchers wrote.

“In 45 cases, SPs reported having unprotected intercourse within the last 24 hours (case 1A), and in 44 cases, SPs reported having unprotected intercourse more than 72 hours ago (case 1B), which is past the efficacy threshold of over-the-counter emergency hormonal contraception.

“In scenario 2, 11 SPs (5 male and 6 female) visited 150 pharmacies (154 visits in total) to request treatment for family members or a partner with symptoms indicating bacterial conjunctivitis (case 2A; n = 73) or viral conjunctivitis (case 2B; n = 81).

“In scenario 1—dispensing emergency hormonal contraception when physician referral is recommended—21 of 44 pharmacists (47.7%) in case 1B violated the recommendation by selling the over-the-counter medication.

“With the inclusion of both no physician referral and emergency hormonal contraception sold, this rate increased to 79.5% (35 of 44 pharmacists).

“In scenario 2—1 case each of bacterial and viral conjunctivitis—overtreatment occurred in 55 of 154 cases (35.7%).

“In both scenarios, 140 of 243 pharmacies (57.6%) followed dispensing behavior compliant with the protocol, while 76 of 243 pharmacies (31.3%) involved some form of overtreatment or overselling of medication. Some evidence of an association between sex of SP and pharmacist was also found.”

“The frequency in which both the overuse and underuse of drugs occurs is problematic worldwide and has significant flow-on effects for public health policy across the globe,” said Professor Uwe Dulleck from QUT’s School of Economics and Finance.

“A defining feature of modern health care policy is the push for more autonomy in self-treatment and management.”

Professor Greg Kyle, from QUT’s School of Clinical Sciences, said pharmacies now played a crucial role in the consumer health mix, prompting the Pharmaceutical Society of Australia in 2016 to argue pharmacists should play a larger part in reducing the burden of increasing health costs across the sector.

“This is an excellent concept but it has also highlighted the importance of understanding the interplay of the myriad factors relevant in diagnosis and treatment provision in such a setting to ensure effective and efficient outcomes for all parties,” he said.

“In other words, consumers should be given the appropriate advice for over-the-counter medications in such transactions.

“It seems that is not always the case. Financial considerations may play a role but oversupply could also be due to pharmacists trying to deliberately reduce risk of adverse outcomes – ­ for example, when the patient’s GP is not available late at night or on a weekend.

“We can only observe that the supply decisions are not in line with the recommendations of the therapeutic guidelines.”

Professor Dulleck said the study was of interest for researchers in health as well as those in economics.

“Pharmacists are experts in advising their customers on the right over-the-counter-medication,” he said.

“Economists refer to goods and services of this kind as ‘credence goods’. Understanding the behaviours of experts in such situation is of relevance to many parts of the economy including financial advice, home repairs, legal services and education.

“When consumers have to rely on an expert for advice, especially in health-related matters, the level of trust in relation to their credential is elevated.”

CEO of the PSA, Dr Shane Jackson, responded to the study by saying that it shows the value in community pharmacy as a network to facilitate access to Pharmacist Only Medicines such as emergency hormonal contraception and products to treat bacterial conjunctivitis

“The study suggests consumers receive focussed and cautious care from pharmacists in response to the simulated case studies,” he said.

 “While the sample size is relatively small, the results suggest consumers would benefit from a remuneration structure which supported longer patient-pharmacist interactions, particularly in more complex cases.

“This would allow pharmacists more time with patients and provide more targeted treatments tailored to each consumer’s specific health needs. 

 “As a signatory to the 7th Community Pharmacy Agreement, PSA will work to preserve the accessibility of community pharmacy for the delivery of healthcare services such as vaccinations, medication management and minor illness care. We will also ensure that the 7CPA utilises pharmacists to their full scope of practice and has pharmacists delivering services tailored to community needs.

“PSA provides support to pharmacists in supplying Pharmacist Only Medicines in line with best-practice evidence through the Professional Practice Standards and guidance documents for the supply of Pharmacists Only Medicines, including those mystery-shopped in this study.

“We encourage pharmacists to use these documents to self-reflect on their practice as part of their ongoing Continual Professional Development in staying up-to-date with best-practice in the supply of these medicines.”

Read the study here.

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  1. Tony Lee

    I question if the standardized shoppers had consulted a doctor, that the % diagnosis and treatment would have been better.
    But again would they send standardized shoppers clandestinely to a doctor?

  2. Michael Khoo

    It does my head in when I am expected to supply a treatment for conjunctivitis for a patient that I have not seen.

    “Why …no…little Johnny is at home playing X-Box, I didnt bother to bring him in , because you are just a chemist, and one of the mums on facebook said to just walk in and buy some.”

    Or my personal favorite “Just sell me the drops,or I cant drop the kid off at childcare..”

    It seems that the consumer’s ability to demand chloramphenicol drops has outstripped consumer’s education on the appropriate use of those drops. There really is a desperate need for someone to bring back propamidine drops, or something similar.

    I suspect that eventually chloramphenicol will be little better than placebo, my guess is within the next decade.

  3. Krysti-Lee Rigby

    “SPs reported having unprotected intercourse more than 72 hours ago (case 1B), which is past the efficacy threshold of over-the-counter emergency hormonal contraception./’
    This is true if using levon orgestrel – However Ulipristal is available OTC and is effective up to 120 hours….

  4. Harriet Wright

    I am very interested to know if a similar study is being performed in doctors’ surgeries to check what percentage of them are following guidelines appropriately? Particularly in light of the fact that pharmacies don’t receive government funding for the sale of the drugs listed (both in Schedule 3) whereas GPs do in fact get paid by the government to perform their consultations.

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