Acta Poloniae Pharmaceutica ñ Drug Research, Vol. 74 No. 3 pp. 1011ñ1019, 2017 ISSN 0001-6837Polish Pharmaceutical Society

The concept of pharmaceutical care (PC) hasstarted its active development, probably after thekey publication of Hepler and Strand in 1990 (1). Inour opinion, it continues to evolve further.Nowadays, there exist quite a few interpretations ofthis term, which frequently differ a lot from oneanother (2). Due to the activity organized byPharmaceutical Care Network Europe (PCNE) theconsensus interpretation of PC as ìthe pharmacistíscontribution to the care of individuals in order tooptimize medicines use and improve health out-comesî appeared in 2013 (3). In such a way, undercontemporary conditions PC is considered not onlyas a theory but also as the philosophy of practicewhere the main beneficiary of pharmacistís actionsis a patient (3, 4). Certainly, it is possible to ensuresuch contribution only under estimation of healthcondition and patientís need identification which areultimately provided by the good pharmacy practice(5). Although, with the availability of the appropri-ate theoretical base, the success of the defined con-

cept, in our opinion, correlates with its implementa-tion into the practice of health care, which definedthe aim, strategy, and design of our research.

The aim of the research was the study of thereal pharmaceutical practice in relation to thepatientís needs identification in community pharma-cies of Lviv (Ukraine) in comparison with theresults of the same research received in communitypharmacies of Lublin (Poland) and the establish-ment of the interconnection between this pharma-cistís activity and PC.

EXPERIMENTAL

Methods and materials

The second stage of already conductedresearch in 129 community pharmacies of Lublin(Poland) from February till March 2009 (6) wasundertaken in 139 randomly selected communitypharmacies of Lviv (Ukraine) from November tillDecember 2014 (Fig. 1).

QUALITY OF PHARMACEUTICAL CARE AT THE STAGE OF PATIENTSíNEEDS IDENTIFICATION UNDER CONDITIONS OF COMMUNITY

PHARMACIES AS A TRANSBORDER PROBLEM

ANDRIY ZIMENKOVSKY1, YULIYA NASTYUKHA1*, OLGA BORETSKA1*, MARIOLA DROZD2

and OLEG DEVINYAK3

1Clinical Pharmacy, Pharmacotherapy and Medical Standardization Department, Danylo Halytsky National Medical University, 69 Pekarska Street, 79010 Lviv, Ukraine

2Department of Applied Pharmacy, Medical University of Lublin, Lublin, Poland 3Pharmaceutical Disciplines Department of State Higher Educational Institution

ìUzhhorod National Universityî, Uzhhorod, Ukraine

Abstract: The results of the study of the real pharmaceutical practice in relation to the patientís needs identifi-cation defined that the problem of not always high pharmaceutical care quality at this stage is equally up-to-date for the community pharmacies of Lviv (Ukraine) and Lublin (Poland). It was found that the quantity andamount of questions set by a pharmacist are not related to the conversation duration with a pharmacy visitor,and the communication duration does not have the statistically confirmed dependence on the queue availabili-ty, therefore in the context of pharmaceutical care quality, these criteria are of no high importance. Instead,drug-related problems (n = 209) verified by the authors of this article, that have been distributed into the groupsaccording to the criterion of the information amount received by a pharmacist studying the needs of the patient(visitor of a pharmacy), were determined as a quantitative indicator of potential pharmaceutical care qualityincrease.

Keywords: patientsí needs identification, drug-related problems (DRP), pharmaceutical care

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* Corresponding author: e-mail: y.nastyukha@gmail.com; e-mail: o.boretska@gmail.com

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Figure 1. The structure of the conducted research

Quality of pharmaceutical care at the stage of patients' needs... 1013

The interviewer (whose role was performed bya researcher) referred to the pharmacists of commu-nity pharmacy according to the model of the ìdis-guised visitorî. 150 appeals were conducted to 139community pharmacies of Lviv (Ukraine) and thesame number of appeals was conducted to 129 com-munity pharmacies of Lublin (Poland). According tothe conditions of the research, a visitor (interviewer)asked: ìto advise something against coughingî. Theinterviewer answered a question of pharmacistsaccording to the modeled clinical situation.According to its conditions, dry cough, which lastedfor 3 weeks, disturbs a 2-years-old child. Beforethat, the child has not been observed to have similarsymptoms, the bodyís temperature is normal, theappetite is bad. A cough will not disappear despitethe use of the Althaea syrup.

The documentation of the interviewerís visitsto a community pharmacy, in particular questionsset by a pharmacist, has been done with the help ofspecially developed for this protocol form, whichfirst has been approbated and applied in communitypharmacies of Lublin, and eventually adapted (i.e.,translated from Polish into Ukrainian) and used forthe research in the community pharmacies of Lviv.

The duration of the pharmaceutical care wasmeasured by the interviewer (researcher) during thevisits to the community pharmacies with a help ofstopwatch and was written down to the protocol inseconds.

We used the modified by Eichenberger et al.PCNE V 5.01 classification system, the amendment

with a technical DRP category, which adapted by usto Ukrainian pharmaceutical practice (7).

Applied methods: system approach, modeling,interviewing (the method of ìdisguised visitorî),analytical-comparative, clinical-pharmaceutical,standardization and mathematical-statistical. Theprocessing of the received results has been conduct-ed in the environment for statistical computing R3.1.1. The chi-squared test with the Yatesís correc-tion for continuity has been applied for the researchof the statistical significance of the differences bytheir nominal features, the Studentís t-test in theWelchís modification has been applied in the case ofrelative features. The Pearson double productmoment correlation coefficient has been calculatedin order to detect the strength and significance ofrelations between two relative magnitudes.

The significant discrepancies among theemployees of Lviv and Lublin community pharma-cies under the research on age (according to theinterviewerís estimation) and gender distributionhave not been revealed (Table 1).

The identification of the education level hasbeen conducted regarding the information onbadges, although 63.4% and 57.3% of employeesfrom community pharmacies in Lviv and Lublinhave not indicated this data. Among the otheremployees with badges, a part of individuals with amasterís degree in Lviv, has turned out to be small-er (23.3%) than in pharmacies in Lublin (36.0%),and pharmacists with undergraduate degree in Lviv(13.3%), correspondingly, bigger than in Lublin

Table 1. Characteristics of the pharmacies employees engaged into the research

Characteristics of the Lviv Lublin Statistical

pharmacies employees(Ukraine) (Poland) significance of the

Abs. % Abs. % difference, ρρ

Total 150 100.0 150 100.0 -

Gender

Female 143 95.3 142 94.7 1.0

Male 7 4.7 8 5.3

Age

< 30 years-old 44 29.3 37 24.7 0.39

30-50 years-old 85 56.7 84 56.0

> 50 years-old 21 14.0 29 19.3

Level of education

Master degree 35 23.3 54 36.0 0.017

Undergraduate degree 20 13.3 10 6.7

Not indicated 95 63.4 86 57.3 -

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(6.7%). The discrepancy of the samples of pharma-cists under the research by the education levelreaches statistical significance by the chi-squaredtest, χ2 = 5.69, = 0.017.

RESULTS AND DISCUSSION

The health state estimation and patientís needsidentification belong to the tasks which emerge infront of a community pharmacy employee when thevisitor appeals (5). The appropriate fulfillment ofthese tasks includes finding out: who has got a prob-lem, when malaise appeared, for how long it lasts,what measures have been taken before asking forhelp and what drugs have been used for the staterelief (8). These questions also allow revealingthreatening symptoms. According to the modeledclinical case, with which the visitor (interviewer)came to the community pharmacies, the three-weekslasting cough was a threatening symptom. Thus,according to the appropriate algorithm of actions,the pharmacist had to ask the visitor on how long thecough had lasted, and once he receives the informa-tion ñ immediately refer him to a physician (5, 8).However, the question about a cough was set bypharmacists of community pharmacies in Lviv andLublin not frequently enough, only in 12.0% and12.7% of the cases correspondingly (p = 1).

The general information about the age of apatient (adult or child) has been asked by a lot many

pharmacists. In Lviv this question has been men-tioned statistically significantly more often (73.3%),than in Lublin (30.0%), p-magnitude ρ = 1.42 ◊ 10-13.However, the possibility of the appropriate PC pro-vision toward a specific over the counter drug usewas available only for pharmacists who havelearned the accurate age of a child, because con-traindication, one-time dose, frequency of drugs useby children of different ages differ. Therefore, if toconsider that setting the accurate age of a child bypharmacy employees is an obligatory condition,then it is possible to discuss patientís needs detec-tion in Lviv not in 73.3%, but only in 56.0% of thecases. It decreases the difference among the resultsreceived in community pharmacies of Lviv andLublin, but the disparities are still preserved ñ56.0% vs. 30.0% (ρ = 9.36 ◊ 10-6). However, despitethe better indications in community pharmacies ofLviv regarding this aspect, in our opinion, the situa-tion according to this criterion should be estimatedas unsatisfactory. In more than 1/3 of appeals toLviv pharmacies and 2/3 appeals to Lublin commu-nity pharmacies there existed a potential hazard ofthe limitations ignorance of drugs use among thechildren by a pharmacy employee due to disregardof this question.

The question about the measures taken beforeasking for the help has almost not been raised, onlyin relation to the drugs used for the health state reliefin 18.7% of community pharmacies in Lviv and

Figure 2. The distribution of questions asked by pharmacy employees on complaints about a cough (in both Lviv and Lublin)

Quality of pharmaceutical care at the stage of patients' needs... 1015

2.0% of community pharmacies in Lublin (althoughthe difference is statistically significant, ρ = 5.31 ◊10-6).

The availability of patientís additional symp-toms, such as fever, sore throat, difficult breathing,running nose, was paid insufficient attention.Moreover, this question was asked less frequently(6.7%) in community pharmacies of Lviv than incommunity pharmacies of Lublin (17.3%) (the cor-responding magnitude is ρ = 0.0077) while thisquestion allows a pharmacist to find out the reasonof coughing. The pharmacy employees of the com-munity pharmacy in Lublin asked a visitor in moredetails about an earlier infection, allergy etc.(14.0%), while in Lviv these questions almost hadnot been asked (1.3%), the difference reaches thestatistical significance (χ2 = 15.3, ρ = 9.39 ◊ 10-5).

In community pharmacies of both Lviv (86.0%)and Lublin (87.3%), the most frequently asked ques-tion was about the type of coughing (dry or wet). The

questions whether similar symptoms have beenobserved earlier and whether a patient uses somedrugs now have not been asked neither in Lviv (0.7%and 0.7%) nor in Lublin (1.3% and 0%). The distri-bution of questions set by pharmacies employees ona visitorís (interviewer) request ìto advise somethingagainst coughingî is shown in Figure 2.

Except for already mentioned, the questionabout the form of medication chosen by the patient(syrup, drops, tablets, lozenges etc.) in our opinionhas appeared to be reasonable and widespread inLviv community pharmacies (34.7%). The otherquestions asked by pharmacy employees have notbeen so frequently asked and have not influencedthe general picture of the research: the choice of amedication of synthetic or herbal origin; whether apatient is allergic, in particular to medications;whether there is blood-tinged sputum, which is athreatening symptom; whether the use of theAlthaea syrup has helped a child etc.

Figure 3. The distribution of drugs, recommended by pharmacy employees in Lviv, for the symptomatic cough pharmacotherapy

1016 ANDRIY ZIMENKOVSKY et al.

The usage of non-medication approaches, suchas consuming a lot of liquid, foodstuff rich in vita-min C, putting a warming patch on chest and backareas, has been recommended only in 3 cases (2.0%)in Lviv community pharmacies. Among theemployees of Lublin community pharmacies, suchrecommendations have not been widely spread aswell, although, have been provided more often(8.7%) with statistical significance ρ = 0.021.

Regarding the recommendations about theproper use of drugs, they have been provided by99.3% of pharmacy employees in Lviv, and inLublin this part accounted for 91.3%, the differencehas reached statistical significance (ρ = 0.0026). Thelist of recommended drugs has been quite wide incommunity pharmacies of Lviv (Fig. 3), consideringthat all recommendations were regarding the sameclinical case, eventually, as in community pharma-cies of Lublin (6). Medications with incompleteinformation have been referred to the categoryìOtherî, for example, Herbion syrup without men-tioning its basis ñ Iceland moss, Primula, Hederahelix or Folium Plantaginis lanceolate, since it hasbeen recommended not as the basic medicine, but asan alternative.

Overall, in our opinion, the discrepancies in theresults of the quantitative estimation of recommen-dations provided regarding the drugs use among thecommunity pharmacies of Lviv and Lublin are con-sidered to be less essential, than the results of thequalitative estimation which turned out to be differ-ent. Pharmacy employees in Lviv chose drugs ofherbal origin based on Hedera most frequently,while homeopathic medications were recommendedin Lublin community pharmacies (6). Thus, uponthe availability of the comparative situation in rela-tion to patientís needs study performed by the phar-

macists, there exist differences in the choice of cri-teria of certain medicine in Lviv and Lublin thatrequire further research.

In our opinion, it should be mentioned thatthere is a tendency to recommend a number of drugswhich can be pharmaceutically equivalent or therepresentatives of various pharmacotherapeuticgroups. We believe that this situation creates certainproblems for a pharmacy visitor, for whom it is dif-ficult to make a justified and rational choice of amedication without correspondent professional edu-cation. It is reasonable that a pharmacist should esti-mate a situation, take a decision and offer a choiceof 1-2 drugs among analogues to a pharmacy visitor.Nowadays, in the philosophy of PC the managementof drug-related problems (DRP) (9, 10) is consid-ered to be a key issue. Correctly provided PC isbased on the deep understanding of the DRP natureand the process related to their identification, find-ing a solution, and most crucially, prevention (9).That is why, protocols filled out by an interviewer,in particular, recommendations on the use of drugs,have been used by us as an object of the research forthe identification of the DRP. Thus, DRP (n = 209)verified by us have been distributed into the groupsaccording to the criterion of the information amountreceived by the pharmacist during the study of thepatientís (visitor of a pharmacy) needs (Fig. 4).

It turned out that the causes of more than 25%of identified DRP (n = 53; category I) were relatedto the interviews, which were inappropriately con-ducted with a community pharmacy visitor. Forinstance, a pharmacist did not specify the age of apatient and recommended a contraindicated by agemedication. In another case, a patient who hadalready used Althaea syrup was recommended amedication based on the same medicinal herbs,

Figure 4. Categories of the identified DRP

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without ensuring whether the patient used anydrugs. In such a way, all these DRP could have beenprevented under the condition of the proper patientísneeds study with the help of the interview. Thus,since PC is continuous, systematic and professionalcare provided with the aim of not an only correction,but also DRP prevention (9, 10), and the properstudy of patientís needs allows preventing DRP, thelatest is considered by us to be a stage of PC.

Almost 75% of DRP (n = 156; category II) dis-covered by us emerged despite the sufficient amountof information of a pharmacy employee aboutpatientís needs and their health condition. For exam-ple, a pharmacist found out the age of a child,although still recommended to use drugs contraindi-cated in this age, or asked a patient about the previ-ous usage of the medication based on Althaea, how-ever, recommended pharmaceutically equivalentdrugs. In our opinion, causes for these DRP belongto another area of research and are not related topatientís needs identification.

In our opinion, the verified DRP are reasonableto be considered as a quantitative indicator of poten-tial PC quality increase, in particular under the con-ditions of the community pharmacies at the stage ofpatientís needs identification.

Having raised the question of quality we havedecided to study the influence of the queue availabil-ity on the average duration of the PC provision in acommunity pharmacy using the Student t-test, whichtook place in 48.0% of the cases as a result of theresearch conducted in Lviv. Thus, with the queueavailability the average time of conversation with avisitor accounted for 58.7 ± 44.5 s, and under condi-tions of its absence the conversation duration waseven a bit less ñ 49.3 ± 23.5 s. In such a way, the dura-tion of provided PC does not depend on the queueavailability in the community pharmacy, althoughthis difference is not statistically significant (ρ =0.12). It turned out that undergraduate degree phar-macists provided consultations only 6.5 ± 8.6 s short-er on average than masterís degree pharmacists inpharmacy, this discrepancy is not statistically signifi-cant as well (ρ = 46). The statistically confirmed dif-ferences have been discovered only during the studyof the dependence of PC duration on the age of apharmacist. It has been found out that older employ-ees provide PC a bit longer, than their younger col-leagues, moreover, the basic increase of duration isrelevant for the employees of the age over 50 (thePearson correlation coefficient between the age andtime of conversation accounts for r = 0.19 with the

Figure 5. The increase of the referral probability to a physician with the consultation duration of a community pharmacy visitor

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statistical significance ρ = 0.017). However, there areno reasons to claim that this quantitative indicator hasthe influence on the quality of the provided PC.

The detection of cases which require physi-cianís consultation and the referral of a communitypharmacy visitor to this medical specialist belongsto the duties of a pharmacist (5), although in 93.3%of the cases such recommendations were not provid-ed in Lviv. Sometimes in Lviv community pharma-cies a patient was asked whether he had previouslyvisited a physician (8.0%), though receiving thenegative response, only 2.0% of pharmacy employ-ees insisted on the visit, in 6.0% of the cases theanswer was left without any comments. Probably itis partially related to inappropriately conductedinterview with a visitor. The pharmacy employeewas not aware of the whole situation, therefore,underestimated the complexity of the modeled case.Although, despite the problem of not always a prop-er study of patientís needs for community pharma-cies in Lviv and Lublin, in Lublin only 5.0% ofpharmacy visitors did not receive the referral to aphysician. In such a way, we consider this problemto be specific for Lviv community pharmacies. It isnecessary to mention that on average the conversa-tion with a visitor lasted for less than 1 minute (53.8± 35.3 s), that is evidently insufficient, in compari-son, such conversation in community pharmacies ofLublin lasted 3 minutes (6). The hypothesis aboutthe fact the longer the conversation duration of apharmacy employee with a visitor is, the higher isthe probability of patientís referral to a physician,has been checked with the help of the constructionof the logistic regression model. As a result, it hasbeen discovered that in spite of the low base proba-bility of such occasion, every 50 s of conversationincrease the chance of the referral to a physician by2.1 times, and the hypothesis is confirmed with ρ =0.019. In particular, 1/2 of all recommendations torefer to a doctor belongs to the period from 50 till100 s of conversation in Lviv community pharma-cies (Fig. 5). Guided by the research findings on theimportance of longer time interval of PC provisionin a community pharmacy, we consider the furtherstudy of this issue to be efficient and up-to-date.

In our opinion, the findings testify to the factthat the prescription of standards of the good phar-macy practice, in particular, the requirement of thestandard operational procedure approval for thereferral to a physician (5, 8), does not provide thesolution to the problem. The issue of the inappropri-ate fulfillment of professional duties by pharmacistsrequires the search for additional ways of its resolu-tion, in particular, training.

CONCLUSIONS

1. According to the received results, the appropri-ate interview with a community pharmacy visi-tor would allow preventing 25% of all DRPidentified in community pharmacies of Lviv (n= 53). Since pharmaceutical care is a continu-ous, systematic and professional care providedwith the aim of prevention or correction of DRPwe consider the study of the patientís needswith the help of interview to be a certain stageof pharmaceutical care.

2. The findings of the conducted research testify tothe fact that the quantity and scope of questionsasked by a pharmacist are not related to the con-versation duration with a pharmacy visitor, andthe communication duration does not have thestatistically confirmed dependence on the queueavailability. Therefore, in the context of phar-maceutical care quality, these criteria are of nohigh importance. However, in our opinion, it isefficient to consider the verified DRP as a quan-titative indicator of the potential pharmaceuticalcare quality increase.

3. The findings of the conducted international trans-border comparative research testify to the factthat the defined problem of not always high phar-maceutical care quality, in particular at the stageof patientís needs identification, is equally up-to-date for the community pharmacies of Lviv(Ukraine) and Lublin (Poland), despite some sta-tistical discrepancies in the obtained results.

Funding. The research was not conducted accord-ing to an order of any physical or juridical persons.The conflict of interests is absent in the process ofthe research realization.

Ethical Board Approval. Danylo Halytsky LvivNational Medical University. Protocol 7, 22. 09. 2014.

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Received: 4. 04. 2016