Quality of assessment and counselling offered by community pharmacists and medication
sale without prescription to patients presenting with acute cardiac symptoms: A simulatedclient study
Tarek Seifaw Kashour1*, Abdulaziz Joury1, Abdullah M. Alotaibi2, Mahmoud Althagafi1, Aws S.
Almufleh1, Ahmed Hersi1, Lukman Thalib3
1
Department of Cardiac Sciences, College Of Medicine, King Saud University, Riyadh, Saudi
Arabia.
2
Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.
3
Department of Health Sciences, CAS, Qatar University, Doha, Qatar.
*Corresponding Author:
Tarek Seifaw Kashour, MBChB, FRCP(C)
Professor, Cardiac Sciences
King Khalid University Hospital
College of Medicine, King Saud University
P.O. Box 7805, Riyadh 11472, Saudi Arabia
E-mail: tkashour@ksu.edu.sa
Tel: +9661 467-1161, Fax: +9661 467-1581
Supplementary Document
Methods:
Scenario description
Two scenarios were prepared: one represents a case of acute coronary syndrome (ACS); the
other represents a case of acute heart failure (AHF) (table 1 supplement). Two simulated clients
visited each pharmacy; during the visit, one of the simulated clients would approach the
pharmacist and begin a conversation by saying that his father has chest pain or shortness of
breath (according to the type of scenario) and would then follow the predetermined protocol
(table 1 supplement). The other simulated client would count the number of clients in the
pharmacy and observe the conversation between the first client and the pharmacist. The actors
were medical students who wore non-medical attire, concealed their identity and the study
objective from the pharmacists, and behaved as though they were not related to each other.
Levels of demand
Three levels of demand were developed depending on whether the pharmacist dispensed
medication voluntarily or at the request of the actor. If the pharmacist voluntarily dispensed any
medication to the first simulated client after finishing the conversation, this was coded as
‘without demand’; if the pharmacist refused to dispense medication, the client would then
attempt to convince the pharmacist to dispense medication by saying: ‘My father is really sick,
do you have something that might help?’ If the pharmacist dispensed medication in response to
that request, this was coded as ‘level 1 demand’. If the pharmacist refused to dispense
medication, the actor would progress to ‘level 2 demand’ by saying ‘The truth is that my father
does not want to go to hospital, please give him something to alleviate his symptoms’. If the
pharmacist did not dispense medication, in response to this request, he would be asked why he
refused; the reason was coded ‘administrative’ if it was legal, or ‘health related’ if it was
medical.
Data collection
Immediately after leaving the pharmacy, both investigators completed a standardized data
collection form that included the city and location of the pharmacy (Eastern, Western, Northern,
Southern, or Central), time and day of the visit, whether the pharmacist advised the actor to seek
medical advice or not, and whether the pharmacist asked about the age of the patient, other
symptoms, comorbidities, current medications, or allergies.
Instructions provided about the dispensed medication’s dose, frequency and duration of use were
recorded. If the pharmacist dispensed any medication, the type of medication and level of
demand were also documented. If medication was not dispensed, the reason for refusal was
documented.
Participants, training, and pilot study
We recruited and trained senior medical students to act as simulated clients. All team members
attended two training and standardization sessions. All participants rehearsed both scenarios to
the senior investigators using the same complaints (terminology and statements). Rehearsal was
repeated to ensure the simulated scenario’s reliability. Lay language was used; no medical terms
were allowed at all. A pilot study (n = 20 pharmacies) was conducted initially for training
purposes and to ensure the project’s feasibility. The results of the pilot study were not included
in the data analysis.
Table 1 supplement: Scenario description
Scenario 1 (ACS scenario):
A simulated client enters the pharmacy and asks the pharmacist for a medication that could
relieve ‘chest pain’ in the client’s father. The pharmacist is provided with the following
information only upon questioning, as follows:
What is the age of your father? He is 65 years old.
Does he have any other symptoms? Yes, he has sweating, nausea, vomiting, and shortness of
breath.
Does your father have any chronic condition? Yes, he has had diabetes and hypertension for
years.
Does your father take any medication? Yes, he is taking anti-diabetic and anti-hypertensive
medications.
Does your father have any drug allergies? Yes, he is allergic to nitroglycerine.
Scenario 2 (HF scenario):
A simulated client enters the pharmacy and asks the pharmacist for a medication that could
relieve ‘shortness of breath’ in the client’s father. The pharmacist is provided with the following
information only upon questioning, as follows:
What is the age of your father? He is 65 years old.
Does he have any other symptoms? Yes, he has fatigue, swelling of both legs, and a cough.
Does your father have any chronic condition? Yes, he has had diabetes and hypertension for
years.
Does your father take any medication? Yes, he is taking anti-diabetic and anti-hypertensive
medications.
Does your father have any drug allergies? Yes, he is allergic to nitroglycerine.
Table 2 supplement: Summary of number of dispended medications per patient, number
and type of questions asked, and quality of counselling provided by pharmacists.
Variable
Number of dispensed
medications per patient
No medication dispensed
One medication
Two medications
More than two medications
Number of questions asked by
pharmacists
No questions were asked
One question
Two questions
Three questions
Four questions
Five questions
Type of question asked by
pharmacist
Age
Comorbidity
Other symptoms
Medication
Allergies
Counselling of patients about
dispensed medications (n = 379)
Dosage and frequency
Duration of treatment
Both of the above
Total number =
600
n (%)
221 (36.8%)
355 (59.2%)
24 (4%)
0 (0.0%)
143 (23.8%)
169 (28.2%)
144 (24%)
85 (14.2%)
47 (7.8%)
12 (2%)
187 (31.2%)
251 (41.8%)
325 (54.8%)
169 (28.2%)
28 (4.7%)
184 (58.5%)
82 (21.6%)
74 (19.5%)