Medication dispensing, additional therapeutic recommendations, and pricing practices for acute diarrhoea by community pharmacies in Germany: a simulated patient study

Main Article Content

Keywords

Diarrhea, Loperamide, Self Medication, Professional Practice, Pharmacies, Pharmaceutical Services, Pharmacists, Quality of Health Care, Costs and Cost Analysis, Patient Simulation, Germany

Abstract

Background: In Germany over-the-counter medications (OTC) – which since 2004 are no longer subject to binding prices – can only be purchased in pharmacies. Pharmacy owners and their staff therefore have a special responsibility when dispensing, advising on and setting the prices of medications.


Objective: The aim of this study was to assess medication dispensing, additional therapeutic recommendations and pricing practices for acute diarrhoea in adults and to evaluate the role of the patient’s approach (symptom-based versus medication-based request) in determining the outcome of these aspects.


Methods: A cross-sectional study was conducted from 1 May to 31 July 2017 in all 21 community pharmacies in a medium-sized German city. Symptom-based and medication-based scenarios related to self-medication of acute diarrhoea were developed and used by five simulated patients (SPs) in all of the pharmacies (a total of 84 visits). Differentiating between the different test scenarios in terms of the commercial and active ingredient names and also the prices of the medications dispensed, the SPs recorded on collection forms whether the scenario involved generic products or original preparations as well as whether recommendations were made during the test purchases regarding an additional intake of fluids.


Results: In each of the 84 test purchases one preparation was dispensed. However, a preparation for oral rehydration was not sold in a single test purchase. On the other hand, in 74/84 (88%) of test purchases, medications with the active ingredient loperamide were dispensed. In only 35/84 (42%) of test purchases, the patient was also recommended to ensure an ‘adequate intake of fluids’ in addition to being dispensed a medication. In symptom-based scenarios significantly more expensive medications were dispensed compared to the medication-based scenarios (Wilcoxon signed rank test: z = -4.784, p < 0.001, r = 0.738). Also within the different scenarios there were enormous price differences identified – for example, in the medication-based scenarios, even for comparable loperamide generics the cheapest preparation cost EUR 1.99 and the most expensive preparation cost EUR 4.53.


Conclusions: Oral rehydration was not dispensed and only occasionally was an adequate intake of fluids recommended. There were also enormous price differences both between and within the scenarios investigated.

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References

1. GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1789-1858. https://doi.org/10.1016/S0140-6736(18)32279-7
2. Lankisch PG, Mahlke R, Lübbers H, Lembcke B, Rösch W. Zertifizierte medizinische Fortbildung: Leitsymptom Diarrhö. Dtsch Arztebl Ausg A. 2006;103(5):A261-A269.
3. Statistisches Bundesamt. Pressemitteilung Nr. 029 vom 25.01.2019. 2019. Available at: https://www.destatis.de/DE/PresseService/Presse/Pressemitteilungen/2019/01/PD19_029_12411.html (accessed Feb 8, 2019).
4. Hagel S, Epple H-J, Feurle GE, Kern WV, Lynen Jansen P, Malfertheiner P, Marth T, Meyer E, Mielke M, Moos V, von Müller L, Nattermann J, Nothacker M, Pox C, Reisinger E, Salzberger B, Salzer HJF, Weber M, Weinke T, Suerbaum S, Lohse AW, Stallmach A. S2k-Leitlinie Gastrointestinale Infektionen und Morbus Whipple. Available at: https://www.awmf.org/uploads/tx_szleitlinien/021-024l_S2k_Infekti%C3%B6se_Gastritis_2015-02-verlaengert.pdf (accessed Aug 10, 2019).
5. Borsch J. Oft ein Fall für die Selbstmedikation. Deutsche Apotheker Zeitung (DAZ): Unabhängige pharmazeutische Zeitschrift für Wissenschaft und Praxis. 2013;23:38. Available at: https://www.deutsche-apotheker-zeitung.de/daz-az/2013/daz-23-2013/oft-ein-fall-fuer-die-selbstmedikation (accessed Sep 6, 2018).
6. Tröbitscher N. Warnhinweise: Medice bleibt gelassen. Available at: https://www.apotheke-adhoc.de/nachrichten/detail/pharmazie/warnhinweise-medice-bleibt-gelassen-perenterol-saccharomyces-boulardii/ (accessed Aug 12, 2019).
7. Arzneimittelgesetz in der Fassung der Bekanntmachung vom 12. Dezember 2005 (BGBl. I S. 3394), das zuletzt durch Artikel 2 des Gesetzes vom 9. August 2019 (BGBl. I S. 1202) geändert worden ist. Available at: https://www.gesetze-im-internet.de/amg_1976/AMG.pdf (accessed Aug 22, 2019).
8. BAK – Bundesapothekerkammer. Arbeitshilfe der Bundesapothekerkammer zur Qualitätssicherung, Information und Beratung im Rahmen der Selbstmedikation am Beispiel der Eigendiagnose Durchfall – Anwendungsbeispiel zu den Leitlinien, Stand der Revision: 13.11.2013. Berlin: BAK, 2013. Available at: https://www.abda.de/fileadmin/assets/Praktische_Hilfen/Leitlinien/Selbstmedikation/AWB_SM_Durchfall.pdf (accessed Sep 4, 2018).
9. Bennadi D. Self-medication: A current challenge. J Basic Clin Pharm. 2013;5(1):19-23. https://doi.org/10.4103/0976-0105.128253
10. Barr W, Smith A. Acute diarrhea in adults. Am Fam Physician. 2014;89(3):180-189.
11. Porteous T, Ryan M, Bond C, Watson M, Watson V. Managing minor ailments; the public's preferences for attributes of community pharmacies. a discrete choice experiment. PLoS One. 2016;11(3):e0152257. https://doi.org/10.1371/journal.pone.0152257
12. Deutscher Bundestag. Achtzehntes Hauptgutachten der Monopolkommission 2008/2009. Drucksache 17/2600. 2010. Available at: http://www.monopolkommission.de/images/PDF/HG/HG18/1702600.pdf (accessed Feb 12, 2019).
13. Merks P, Kaźmierczak J, Olszewska AE, Kołtowska-Häggström M. Comparison of factors influencing patient choice of community pharmacy in Poland and in the UK, and identification of components of pharmaceutical care. Patient Prefer Adherence. 2014;8:715-26. https://doi.org/10.2147/PPA.S53829
14. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm. 1990;47(3):533-543.
15. Sancar M, Tezcan E, Okuyan B, Izzettin FV. Assessment of the attitude of community pharmacists and pharmacy technicians towards diarrhea: a simulated patient study in Turkey. Trop J Pharm Res. 2015;14(8):1509-1515. http://doi.org/10.4314/tjpr.v14i8.26
16. Ibrahim IR, Palaian S, Ibrahim MI. Assessment of diarrhea treatment and counseling in community pharmacies in Baghdad, Iraq: A simulated patient study. Pharm Pract (Granada). 2018;16(4):1313. https://doi.org/10.18549/PharmPract.2018.04.1313
17. Ibrahim MI, Palaian S, Al-Sulaiti F, El-Shami S. Evaluating community pharmacy practice in Qatar using simulated patient method:acute gastroenteritis management. Pharm Pract (Granada). 2016;14(4):800. https://doi.org/10.18549/PharmPract.2016.04.800
18. Khan A, Iqbal Q, Haider S, Khalid A, Hassali MA, Saleem F. Acute diarrheal management in adults: a simulated client study at community pharmacies of Quetta City, Pakistan. J Pharm Pract Community Med. 2019;5(1):13-17. http://doi.org/10.5530/jppcm.2019.1.3
19. Langer B, Bull E, Burgsthaler T, Glawe J, Schwobeda M, Simon K. [Using the simulated patient methodology to assess counselling for acute diarrhoea - evidence from Germany]. Z Evid Fortbild Qual Gesundhwes. 2016;112:19-26. https://doi.org/10.1016/j.zefq.2016.02.001
20. Langer B, Bull E, Burgsthaler T, Glawe J, Schwobeda M, Simon K. Assessment of counselling for acute diarrhoea in German pharmacies: a simulated patient study. Int J Pharm Pract. 2018;26(4):310-317. https://doi.org/10.1111/ijpp.12405
21. Langer B, Kieper M, Laube S, Schramm J, Weber S, Werwath A. Assessment of counselling for acute diarrhoea in North-Eastern German pharmacies – A follow-up study using the simulated patient methodology. Pharmacol Pharm. 2018;9(7):257-269. https://doi.org/10.4236/pp.2018.97020
22. STROBE Statement – Checklist of items that should be included in reports of cross-sectional studies. Available at: https://www.strobe-statement.org/fileadmin/Strobe/uploads/checklists/STROBE_checklist_v4_cross-sectional.pdf (accessed Feb 8, 2019).
23. Bruhn M. Qualitätsmanagement für Dienstleistungen – Handbuch für ein erfolgreiches Qualitätsmanagement. Grundlagen – Konzepte – Methoden, 10th ed. Berlin: Springer; 2016. https://doi.org/10.1007/978-3-662-50360-7
24. Bardage C, Westerlund T, Barzi S, Bernstern C. Nonprescription medicines for pain and fever–A comparison of recommendations and counseling from staff in pharmacy and general sales stores. Health Policy. 2013;110(1):76-83. https://doi.org/10.1016/j.healthpol.2012.12.006
25. Caamaño F, Ruano A, Figueiras A, Gestal-Otero JJ. Data collection methods for analyzing the quality of the dispensing in pharmacies. Pharm World Sci. 2002 Dec;24(6):217-223. https://doi.org/10.1023/A:1021808923928
26. Mesquita AR, Lyra DP Jr., Brito GC, Balisa-Rocha BJ, Aguiar PM, de Almeida Neto AC. Developing communication skills in pharmacy: A systematic review of the use of simulated patient methods. Patient Educ Couns. 2010 Feb;78(2):143-148. https://doi.org/10.1016/j.pec.2009.07.012
27. Xu T, de Almeida Neto AC, Moles RJ. A systematic review of simulated-patient methods used in community pharmacy to assessthe provision of non-prescription medicines. Int J Pharm Pract. 2012;20(5):307-319. https://doi.org/10.1111/j.2042-7174.2012.00201.x
28. Stadt Neubrandenburg. Bevölkerungsstand (amtliche Zahlen): Bevölkerung mit Hauptwohnsitz am 31.12. des Jahres. Available at: https://www.neubrandenburg.de/output/download.php?file=%2Fmedia%2Fcustom%2F2751_1770_1.PDF%3F1493972180&fn=Bev%F6lkerung (accessed Feb 3, 2019).
29. Apotheken Umschau. Apothekenfinder: Ergebnisse – Neubrandenburg. Available at: https://www.apotheken-umschau.de/News--Wissen/Suchergebnisse-Apothekensuche-3139.html?apoSearchId=&pharmacysearch.query=Neubrandenburg&btnSearch=Suchen (accessed May 1, 2017).
30. McCambridge J, Witton J, Elbourne DR. Systematic review of the Hawthorne effect: new concepts are needed to study research participation effects. J Clin Epidemiol. 2014;67(3):267-277. https://doi.org/10.1016/j.jclinepi.2013.08.015
31. Saba M, Diep J, Bittoun R, Saini B. Provision of smoking cessation services in Australian community pharmacies: a simulated patient study. Int J Clin Pharm. 2014;36(3):604-614. https://doi.org/10.1007/s11096-014-9944-7
32. Paravattil B, Kheir N, Yousif A. Utilization of simulated patients to assess diabetes and asthma counseling practices among community pharmacists in Qatar. Int J Clin Pharm. 2017;39(4):759-768. https://doi.org/10.1007/s11096-017-0469-8
33. Byrne GA, Wood PJ, Spark MJ. Non-prescription supply of combination analgesics containing codeine in community pharmacy: A simulated patient study. Res Social Adm Pharm. 2018;14(1):96-105. https://doi.org/10.1016/j.sapharm.2017.01.005
34. Cohen J. Statistical power for the behavioral sciences. 2nd ed. Hillsdale NJ: Erlbaum; 1988.
35. BVM – Berufsverband Deutscher Markt- und Sozialforscher e.V. Richtlinie für den Einsatz von Mystery Research in der Markt- und Sozialforschung. 2006. Available at: https://bvm.org/fileadmin/pdf/Recht_Berufskodizes/Richtlinien/RL_2006_Mystery.pdf (accessed Sep 4, 2018).
36. Farthing M, Salam MA, Lindberg G, Dite P, Khalif I, Salazar-Lindo E, Ramakrishna BS, Goh KL, Thomson A, Khan AG, Krabshuis J, Lemair A, WGO. Acute diarrhea in adults and children: a global perspective. J Clin Gastroenterol. 2013;47(1):12-20. https://doi.org/10.1097/MCG.0b013e31826df662
37. Karim R, Ramdahin P, Boodoo JR, Kochhar A, Pinto Pereira LM. Community pharmacists’ knowledge and dispensing recommendations for the treatment of acute diarrhea in Trinidad, West Indies. Int J Clin Pract. 2004;58(3):264-267. https://doi.org/10.1111/j.1368-5031.2004.0095.x
38. Gokcekus L, Toklu HZ, Demirdamar R, Gumusel B. Dispensing practice in the community pharmacies in the Turkish Republic of Northern Cyprus. Int J Clin Pharm. 2012;34(2):312-324. https://doi.org/10.1007/s11096-011-9605-z
39. Ogbo PU, Aina BA, Aderemi-Williams RI. Management of acute diarrhea in children by community pharmacists in Lagos, Nigeria. Pharm Pract (Granada). 2014;12(1):376. https://doi.org/10.4321/s1886-36552014000100002
40. Brata C, Marjadi B, Schneider CR, Murray K, Clifford RM. Information-gathering for self-medication via Eastern Indonesian community pharmacies: a cross-sectional study. BMC Health Serv Res. 2015;15:8. https://doi.org/10.1186/s12913-014-0670-6
41. Surur AS, Getachew E, Teressa E, Hailemeskel B, Getaw NS, Erku DA. Self-reported and actual involvement of community pharmacists in patient counseling: a cross-sectional and simulated patient study in Gondar, Ethiopia. Pharm Pract (Granada). 2017;15(1):890. https://doi.org/10.18549/PharmPract.2017.01.890
42. Horvat N, Koder M, Kos M. Using the simulated patient methodology to assess paracetamol-related counselling for headache. PLoS One. 2012;7(12):e52510. https://doi.org/10.1371/journal.pone.0052510
43. Seston EM, Nicolson M, Hassell K, Cantrill JA, Noyce PR. Community pharmacy management of acute diarrhoea in adults. Int J Pharm Pract. 2001;9(1):1-8. https://doi.org/10.1111/j.2042-7174.2001.tb01022.x
44. Colgan S, Faasse K, Martin LR, Stephens MH, Grey A, Petrie KJ. Perceptions of generic medication in the general population, doctors and pharmacists: a systematic review. BMJ Open. 2015;5(12):e008915. https://doi.org/10.1136/bmjopen-2015-008915
45. Toverud EL, Hartmann K, Håkonsen H. A Systematic Review of Physicians' and Pharmacists' Perspectives on Generic Drug Use: What are the Global Challenges? Appl Health Econ Health Policy. 2015;13(Suppl 1):S35-S45. https://doi.org/10.1007/s40258-014-0145-2
46. Sharif SI, Chaar RJ, Albadrani ZZ, Shahwan JS, Badreddin MN, Charbaji MAK. Evaluation of the knowledge and perceptions of patients towards generic medicines in UAE. Pharmacol Pharm. 2016;7:369-378. https://doi.org/10.4236/pp.2016.79045
47. Alabid AH, Ibrahim MI, Hassali MA. Antibiotics Dispensing for URTIs by community pharmacists (cps) and general medical practitioners in Penang, Malaysia: a comparative study using simulated patients (SPs). J Clin Diagn Res. 2014;8(1):119-123. https://doi.org/10.7860/JCDR/2014/6199.3923
48. Food & Drug Administration. Facts about Generic Drugs. Available at: https://www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/genericdrugs/ucm167991.htm (accessed Sep 4, 2018).
49. Shafie AA, Hassali MA. Price comparison between innovator and generic medicines sold by community pharmacies in the state of Penang, Malaysia. J Gen Med. 2008;6(1):35-42. https://doi.org/10.1057/jgm.2008.25
50. Ongarora D, Karumbi J, Minnaard W, Abuga K, Okungu V, Kibwage I. Medicine Prices, Availability, and Affordability in Private Health Facilities in Low-Income Settlements in Nairobi County, Kenya. Pharmacy (Basel). 2019;7(2):40. https://doi.org/10.3390%2Fpharmacy7020040
51. Mössner J. Magen-Darm-Mittel und Laxantien. In: Schwabe U, Paffrath D editors. Arzneiverordnungs-Report 2018, Aktuelle Daten, Kosten, Trends und Kommentare, Berlin: Springer; 2018. https://doi.org/10.1007/978-3-662-57386-0_33
52. Arznei-telegramm®. Durchfallmittel Racecadotril (Tiorfan, Vaprino). Available at: https://www.arzneitelegramm.de/html/htmlcontainer.php3?produktid=042_01&artikel=1404042_01k (accessed Oct 6, 2018).
53. Mehra A, Sarkar S, Basu D. Lomotil (diphenoxylate) dependence in India. Indian J Psychol Med. 2013;35(3):248-250. https://doi.org/10.4103/0253-7176.119474
54. Bin Abdulhak AA, Altannir MA, Almansor MA, Almohaya MS, Onazi AS, Marei MA, Aldossary OF, Obeidat SA, Obeidat MA, Riaz MS, Tleyjeh IM. Non prescribed sale of antibiotics in Riyadh, Saudi Arabia: a cross sectional study. BMC Public Health. 2011;11:538. https://doi.org/10.1186/1471-2458-11-538
55. Almaaytah A, Mukattash TL, Hajaj J. Dispensing of non-prescribed antibiotics in Jordan. Patient Prefer Adherence. 2015;9:1389-1395. https://doi.org/10.2147/PPA.S91649
56. Hauptman PJ, Goff ZD, Vidic A, Chibnall JT, Bleske BE. Variability in retail pricing of generic drugs for heart failure. JAMA Intern Med. 2017;177(1):126-128. https://doi.org/10.1001/jamainternmed.2016.6955
57. Mishra K, Bukavina L, Mahran A, Bobrow A, Buzzy CA, Jain N, Gnessin E, Loeb A, Ponsky LE. Variability in prices for erectile dysfunction medications-are all pharmacies the same? J Sex Med. 2018;15(12):1785-1791. https://doi.org/10.1016/j.jsxm.2018.10.011
58. Theisen KM, Park SY, Jeong K, Macleod LC, Bandari J, Ayyash O, Odisho AY, Jacobs BL, Davies BJ. Extreme price variation for generic benign prostatic hyperplasia medications. Urology. 2019;124:223-228. https://doi.org/10.1016/j.urology.2018.10.020
59. Xu PJ, Barnes JM, Choe EM, Syed JR, Siddiqui SA. Variability of retail pricing of generic urologic medications in a major US metropolitan area. Urology. 2019;125:29-33. https://doi.org/10.1016/j.urology.2018.07.045
60. Babar ZU, Grover P, Butler R, Bye L, Sheridan J. A qualitative evaluation of general practitioners' perceptions regarding access to medicines in New Zealand. BMJ Open. 2012;2(2):e000518. https://doi.org/10.1136/bmjopen-2011-000518
61. Bigdeli M, Jacobs B, Tomson G, Laing R, Ghaffar A, Dujardin B, Van Damme W. Access to medicines from a health system perspective. Health Policy Plan. 2013;28(7):692-704. https://doi.org/10.1093/heapol/czs108
62. Vogler S, Österle A, Mayer S. Inequalities in medicine use in Central Eastern Europe: an empirical investigation of socioeconomic determinants in eight countries. Int J Equity Health. 2015;14:124. https://doi.org/10.1186/s12939-015-0261-0
63. Kasonde L, Tordrup D, Naheed A, Zeng W, Ahmed S, Babar ZU. Evaluating medicine prices, availability and affordability in Bangladesh using World Health Organisation and Health Action International methodology. BMC Health Serv Res. 2019;19(1):383. https://doi.org/10.1186/s12913-019-4221-z
64. Mehrotra A, Dean KM, Sinaiko AD, Sood N. Americans Support Price Shopping For Health Care, But Few Actually Seek Out Price Information. Health Aff (Millwood). 2017;36(8):1392-1400. https://doi.org/10.1377/hlthaff.2016.1471
65. Bundesministerium der Justiz und für Verbraucherschutz. Preisangabenverordnung. Available at: https://www.gesetze-im-internet.de/pangv/ (accessed Sep 22 2018).
66. Keller ML. Angabe von Grundpreisen: In welchen Fällen sind Grundpreise entbehrlich? News vom 18.03.2013. Available at: https://www.it-recht-kanzlei.de/keine-angabe-grundpreise-erforderlich.html (accessed Sep 22 2018).
67. Deutscher Bundestag. Petition 72823. Arzneimittelpreise - Preisauszeichnungspflicht für Apotheken vom 26.07.2017. Available at: https://epetitionen.bundestag.de/epet/petition/pdfdownload?petition=72823 (accessed Sep 22, 2018).
68. Take part GmbH & Co. KG. Unser Konzept. Available at: http://apo-take.de/unser-konzept/ (accessed Sep 22, 2018).
69. Besser gesund OHG ipunkt apotheke. Über uns. Available at: http://bessergesund.de/uber-uns/i-punkt-apotheke/ (accessed Sep 22, 2018).

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