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

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.

The Quality of Counselling for Oral Emergency Contraceptive Pills—A Simulated Patient Study in German Community Pharmacies

“…According to the “Guideline for the use of mystery research in market and social research” [ 71 ], the data collected were anonymised and recorded in such a way that the pharmacies or the personnel involved could not be identified. To avoid a possible Hawthorne effect [ 72 ] and also a possible selection bias [ 73 ], the test purchases were carried out covertly—that is, without informing the pharmacies in advance—analogous to some other national [ 48 , 49 , 50 , 51 ] and international studies [ 21 , 33 , 38 ] and therefore pharmacies were not asked for consent to participate in advance. The lack of informed consent in advance was—analogous to the international literature [ 40 , 74 , 75 ]—resolved in that all pharmacies were informed about the procedure and the background of the study upon completion of the study.…”

“…Unlike the many studies conducted in other countries [ 21 , 23 , 30 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ], in Germany, there have not been any investigations to date on the counselling and dispensing of an emergency contraceptive pill using an SPM approach because the few scientific SP studies available for Germany on the counselling quality in pharmacies are always based on indications other than emergency contraception. Clear deficits in the quality of counselling have been identified in these studies [ 46 , 47 , 48 , 49 , 50 , 51 ].…”

A Nationwide Mystery Caller Evaluation of Oral Emergency Contraception Practices from German Community Pharmacies: An Observational Study Protocol

“…The planned study is to be based on a cross-sectional design, conducted with the help of the SPM in the form of covert mystery calls and reported in accordance with the 'STROBE Statement-Checklist of items that should be included in reports of cross-sectional studies' [62]. Against the background of a nationwide study, calls are to be preferred to visits-which have already been used in German CPs [15,60,63,64], but only in relation to one city or one federal state-as the implementation of calls without the requirement of a physical presence in the CP is less costly and thus more feasible. Following the international literature [59,[65][66][67], the SPM in the form of covert mystery calls is a covert participant observation by a person (mystery caller (MC)), -who contacts a CP, -with the help of a call, -to simulate a lifelike conversation situation based on a predefined scenario.…”

“…The actual prices for oral EC of the individual CPs are not available online, raising the question of what prices are actually charged by individual CPs. This lack of price transparency is one of the main reasons for price differences [14], especially as the prices are also usually only disclosed on-site at the CP at the end of the dispensing process [15].…”

Use of secret simulated patient followed by workshop based education to assess and improve inhaler counseling in community pharmacy in Jordan

“…Moreover, secret simulated patient (SSP) method is used in pharmacy research world to assess practice in different settings including the community setting 16,21,22. It relies on capturing a realistic description of the practice using a trained individual (a single simulated patient) or individuals (numerous simulated patients) who conduct a covert visit to a pharmacy enacting a scenario to test staff members without being aware of the SSP’s identity 23,24. Secret simulated patient approach is being used increasingly as a mean of reinforcing and supporting practice improvements by guiding focused and tailored education 15,20,22,25.…”