Goel P K, Ross-Degnan D, McLaughlin T J, Soumerai S B
Department of Ambulatory Care and Prevention, Harvard Medical School, Boston, MA, USA.
Int J Qual Health Care. 1996 Dec;8(6):519-26. doi: 10.1093/intqhc/8.6.519.
Retail pharmacies are important sources of advice on pharmaceuticals in developing countries, where many purchasing decisions are unmediated by medical professionals. For childhood diarrhea, choice of drug sales in pharmacies has been found to be consistently poor, whether with or without prescription, as evidenced by a low use of effective oral rehydration salts (ORS) and high use of marginally effective or ineffective products such as antimotility agents, adsorbents, and antimicrobials. Little information is available about factors influencing prescribing by pharmacy personnel in these settings. This paper reports results of an analysis which examined the influence of rural versus urban location, neighborhood socio-economic status (SES), and clinical knowledge of pharmacy assistants on quality of prescribing in retail pharmacies in Kenya.
Using WHO treatment guidelines, we measured quality of prescribing in childhood diarrhea as: (1) the proportion of client encounters in which ORS is prescribed (indicating higher quality practice); and (2) the proportion of visits in which an antidiarrheal product is prescribed (lower quality practice). We obtained data on prescribing in a simple case of childhood diarrhea using surrogate patient visits to 91 pharmacies located in the major urban area of Kenya (Nairobi) and four rural towns. Multivariate logistic regression was used to examine the association between pharmacy predictor variables and the quality of prescribing.
No consistent relationship was found between the clinical knowledge of pharmacy assistants and quality of prescribing. Controlling for number of products prescribed, gender of the assessor, and level of knowledge, multivariate analyses indicated that in comparison to rural pharmacies, the odds of prescribing ORS were significantly higher in pharmacies located in high SES (OR = 4.7; 95% CI = 1.4,16.1) or middle SES (OR = 4.5; CI = 1.9,10.6) urban neighborhoods; the odds in low SES urban pharmacies were similar to those in rural areas (OR = 2.0; CI = 0.6,6.2). The odds of prescribing antidiarrheal products did not differ significantly in any geographic area.
Location of a retail pharmacy in a rural area or in a low-income urban neighborhood was associated with suboptimal quality of prescribing as evidenced by lower use of ORS. No relationship between clinical knowledge and quality of practice was detected. Future research is needed to examine such factors as the influence of intra-pharmacy authority structure, perceived efficacy of pharmaceuticals, local patterns of physician practice, and economic incentives on the quality of prescribing.
在发展中国家，零售药店是药品咨询的重要来源，在这些国家，许多购买决策并非由医学专业人员介导。对于儿童腹泻，无论是有处方还是无处方，药店销售的药品选择一直很差，有效口服补液盐（ORS）的使用率低，而诸如止泻剂、吸附剂和抗菌药物等疗效甚微或无效的产品使用率高，这一点就得到了证明。关于影响这些环境中药房工作人员开药的因素，几乎没有相关信息。本文报告了一项分析结果，该分析研究了肯尼亚农村与城市地区、社区社会经济地位（SES）以及药房助理的临床知识对零售药店开药质量的影响。
我们使用世界卫生组织的治疗指南，将儿童腹泻的开药质量衡量为：（1）开具ORS的客户就诊比例（表明更高质量的做法）；以及（2）开具止泻产品的就诊比例（较低质量的做法）。我们通过替代患者访问肯尼亚主要城市地区（内罗毕）和四个农村城镇的91家药店，获取了简单儿童腹泻病例的开药数据。多变量逻辑回归用于检验药房预测变量与开药质量之间的关联。
未发现药房助理的临床知识与开药质量之间存在一致关系。在控制所开药品数量、评估者性别和知识水平后，多变量分析表明，与农村药店相比，位于高SES（OR = 4.7；95% CI = 1.4,16.1）或中等SES（OR = 4.5；CI = 1.9,10.6）城市社区的药店开具ORS的几率显著更高；低SES城市药店的几率与农村地区相似（OR = 2.0；CI = 0.6,6.2）。在任何地理区域，开具止泻产品的几率均无显著差异。
零售药店位于农村地区或低收入城市社区与次优开药质量相关，这表现为ORS的使用率较低。未检测到临床知识与实践质量之间的关系。未来需要进行研究，以考察诸如药店内部权力结构的影响、药品的感知疗效、当地医生的执业模式以及经济激励措施对开药质量的影响等因素。
