BMJ Open: first published as 10.1136/bmjopen-2017-019237 on 2 February 2018. Downloaded from
PEER REVIEW HISTORY
BMJ Open publishes all reviews undertaken for accepted manuscripts. Reviewers are asked to complete a checklist review form (http://bmjopen.bmj.com/site/about/resources/checklist.pdf) and are provided with free text boxes to elaborate on their assessment. These free text comments are reproduced below.
ARTICLE DETAILS
TITLE (PROVISIONAL) Perceptions, experiences, and expectations of physicians regarding the role of pharmacists in developing countries: the case of Tehran hospital settings AUTHORS Alipour, Fatemeh; Peiravian, Farzad; Mehralian, Gholamhossein
VERSION 1 – REVIEW
REVIEWER Maher Rateb Khdour Al-Quds University REVIEW RETURNED 27-Sep-2017
GENERAL COMMENTS Perceptions, experiences, and expectations of physicians regarding the role of pharmacists in Tehran hospital settings. Thank you for the opportunity to review this interesting paper aiming to explore the attittudes of physicians regarding the pharmacists’ role in hospital settings. This is a good well design and written study, as we need to more collaboration between pharmacist and physicians regarding the expand role of pharmacist. Some comments which may make this http://bmjopen.bmj.com/ paper more powerful and suitable for publication
Abstract Please in the result section in the abstract more results with p-values needed to reflect good work in the text Introduction Is too long Method section Lines 16-20 in page 9 (Within this phase, 50 physicians who were on September 25, 2021 by guest. Protected copyright. practicing in governmental hospitals were invited, and the results of analysis indicated that the survey questionnaire was appropriate enough for the next step. ) should move to line 50 in page 8
Result section The majority of physicians were female (54.7%) …..This is NOT majority Please Tables numbers in the tables SHOUD ADD [CI 95% interval] or SD
Discussion It is likely that less favourable reported experiences of physicians with pharmacists are due to their limited expectations of pharmacists or simply due to the fact that physicians may not be aware of some pharmacist-led services such as patient counselling. Its worth to add some recommendations to increase the expectations of physicians and practice with the pharmacists BMJ Open: first published as 10.1136/bmjopen-2017-019237 on 2 February 2018. Downloaded from
REVIEWER Conxita Mestres School of Health Sciences Blanquerna. University Ramon Llull. Spain REVIEW RETURNED 10-Oct-2017
GENERAL COMMENTS This manuscript address a very interesting and important issue as is to have more knowledge about the perception and expectative of physicians towards the work of hospital pharmacists. Moreover, as the authors say, the location of the work in a country where the pharmaceutical care is not full developed, adds more interest.
However, I have some issues to comment about the manuscript. -Page 5, references 12, 16, the authors refer to them as recent studies; however they are not so recent as they were published on 2007 and 2004. There are more recent publication deal with the improvement on patient care derived from pharmaceutical care. In the same page, line: 48, the authors refer to "appropriate consumption of medications", but I think that it will be more suitable to say, "appropriate medications use".
-Page 6, I found I little confounding the differences in the studies of Pharmacy regarding Pharm- D and PhD programs. I would propose to rewrite this paragraph in order to make it more understandable the differences. In line 47, there is a typo mistake in PhD
-Page 7 The sentence that begins at the end of line 21 and finishes in line 28 is too long, and confusing, to what the authors refer when they say that the pharmacist increase the outcome of Physicians´ interventions? Also in this page when explaining that there are two types of pharmacists in hospitals, I miss a brief explanation of how the Pharmacy Services in the hospitals are organized. http://bmjopen.bmj.com/ -Page 9 end of line 25, "true percentage" maybe it would be better to say a "suitable percentage" At the end of this page it should be better explained how the questionnaires were filled, Regarding the work charge exposed by the physicians not willing to fill the questionnaire, there are some mistakes as "so busy"
-Page 12, Results section. I think that I would be more coherent to on September 25, 2021 by guest. Protected copyright. explain first the actual experience of the physicians and after the expectations.
-Page 13. This section should be shorter, and for instance, I do not see necessary the first paragraph, whose contents have already, be addressed in the introduction.
-Page 14, Line 28, when the authors refer to "repeating medication" are they referring to “prescription"?
-Page 16 the authors point out the need of improving the pharmacy education in order that the pharmacist feel more confident towards physicians. This is true, but maybe that can suggest some solutions? The solutions that they state at the end of the paragraph about increasing the interaction with physicians is not the solution if the pharmacist has not a solid background
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REVIEWER Iftikhar Ali Department of Pharmacy ,University of Swabi ,Pakistan Department of Pharmacy Services ,Northwest General Hospital & Research center,Peshawar, Pakistan REVIEW RETURNED 23-Oct-2017
GENERAL COMMENTS Thank you for the invitation to review the article “Perceptions, experiences, and expectations of physicians regarding the role of pharmacists in Tehran hospital settings". The paper itself is well written, although somewhat descriptive.
Comments: in sequential order
Title: 1. in the title there is small degree of overlap with existing articles
2. Whether these hospitals were teaching /tertiary level hospitals? I would suggest inclusion of government hospitals settings in title
Abstract: Objective Line 16: Suggestions: change Physician-pharmacist to inter- professional Line 18-23: 'Consider Revising for proper language usage
Design: Rewrite Methods: Line 32-42: Suggestion, Replace with: data were collected using a questionnaire consisting of four sections Line 52-56: reword for clarity http://bmjopen.bmj.com/ Conclusion: How it can be concluded on basis of results that their views were positive on clinical role? Key words: expectation, experience (Use mesh terms)
Strengths and limitations of this study First para: make it setting specific
Last para: needs language editing on September 25, 2021 by guest. Protected copyright.
Introduction: Page 4 Line 25-26: change “healthcare system” to increasing cost of therapy Line 46: change “Primary mission of pharmacist” to prime responsibility of Pharmacist Page 5 Line 4: “as patient counselor” is pharmacist only perceive to the role of patient counselor, quite specific make it more generalized Line 8: add reference Page 7 Page 4: Is this statement linked to the only possible reference? Line 50: Hospital pharmacist or Doctor of Pharmacy graduates Methods Line 15: Governmental hospital: describe the level of care i: e (tertiary or teaching) Page 9
BMJ Open: first published as 10.1136/bmjopen-2017-019237 on 2 February 2018. Downloaded from
Line 10: delete “there were not any open ended questions within the questionnaire” Line 32: add reference Page 10 Whether the likert scale items were treated as nominal variables? Line 35: delete “chi –square test was used Page 11 Line 13: Differentiate between drug substitution and drug alternative Line 35, 55: “dermatologist” makes it area of practice rather than designation Page 13
Discussion I would suggest writing the general description of Pharmacy practice before jumping to hospital and clinical pharmacy Line 39: “conduct scarce” –please clarify Page 16 Line 3: change “product “to drug and “pharmaceutical care “to pharmacy services Line 21: deficiency in the clinical contents: Is this only because of the lack of clinical contents in curricula? Conclusion: Line 14: “were eager to develop” I would suggest changing
References
See reference number 3,21,24,35 and correct as per the journal format Tables 1 Write the age like: Age (in years) Under the area of practice see the percentage of ear, nose and throat
General http://bmjopen.bmj.com/ Significant association should be marked with asterisk It is recommended that a native English speaker conduct a minor revision.
VERSION 1 – AUTHOR RESPONSE
Reviewer #1 Comments Actions Taken on September 25, 2021 by guest. Protected copyright. Please in the result section in the abstract more results with p-values needed to reflect good work in the text Thank you very much for positive feedback. I considered your comment regarding p-value. Introduction: Is too long Although the introduction may be too long, we made our great attempt to reduce the size of it. If you have any particular suggestion to do so, please let us know.
Method section Lines 16-20 in page 9 (Within this phase, 50 physicians who were practicing in governmental hospitals were invited, and the results of analysis indicated that the survey questionnaire was appropriate enough for the next step. ) should move to line 50 in page 8
Response: Thanks a lot for your good comment. I considered your comments in the main text.
The majority of physicians were female (54.7%) …..This is NOT majority I changed the phrase to “around half”
BMJ Open: first published as 10.1136/bmjopen-2017-019237 on 2 February 2018. Downloaded from
Comment: Please Tables numbers in the tables SHOUD ADD [CI 95% interval] or SD
Response: Thanks a lot. In our table, the exact number and valid percent have been reported. There is no report showing the average of numbers that we need to report SD.
Discussion It is likely that less favorable reported experiences of physicians with pharmacists are due to their limited expectations of pharmacists or simply due to the fact that physicians may not be aware of some pharmacist-led services such as patient counselling. Its worth to add some recommendations to increase the expectations of physicians and practice with the pharmacists
Response: We have already the following section in our paper, if you think it is not good enough, we can extent it. “Greater efforts are required to increase the awareness of physicians with regard to the importance of collaboration among healthcare professionals in general and what benefits can be gained from this on patients’ quality of life and healthcare cost in particular. It is also important to incorporate direct patient care during clinical rotations with physicians in the pharmacy educational program. Taking rare contact among health professionals into account, collaborative learning between pharmacists and physicians is highly recommended for consideration within undergraduate and postgraduate educational programs. This will promote the improved understanding of clinical pharmacists’ roles by physicians and support interprofessional collaboration in identifying the shared goal of improving care for patients.”
Reviewer #2 Comments Actions Taken Page 5, references 12, 16, the authors refer to them as recent studies; however they are not so recent as they were published on 2007 and 2004. There are more recent publication deal with the improvement on patient care derived from pharmaceutical care. http://bmjopen.bmj.com/ Response: Thank you very much for positive feedback.
I corrected the sentence.
Comment: In the same page, line: 48, the authors refer to "appropriate consumption of medications", but I think that it will be more suitable to say, "appropriate medications use".
on September 25, 2021 by guest. Protected copyright. Response: It was very nice point. Thank you
Comment: Page 6, I found I little confounding the differences in the studies of Pharmacy regarding Pharm- D and PhD programs. I would propose to rewrite this paragraph in order to make it more understandable the differences. In line 47, there is a typo mistake in PhD
Response: As other reviewers have recommended to reduce the size of introduction, I added a very short clarification. “Within the former program, the students mostly are trained to provide pharmaceutical care for societies, while in the latter program the students are expected to be research-oriented”
-Page 7 The sentence that begins at the end of line 21 and finishes in line 28 is too long, and confusing, to what the authors refer when they say that the pharmacist increase the outcome of Physicians´ interventions?
BMJ Open: first published as 10.1136/bmjopen-2017-019237 on 2 February 2018. Downloaded from
Responsel In our country, some pharmacists are called “hospital pharmacist”. They are expected to provide physicians with more information regarding physicians’ prescriptions in the hospital wards. As result, their help would increase the quality of physicians interventions.
- Also in this page when explaining that there are two types of pharmacists in hospitals, I miss a brief explanation of how the Pharmacy Services in the hospitals are organized.
Response: Our hospitals are now lacking clinical pharmacists and those hospitals that do not have clinical pharmacists try to fill this gap through hiring hospital pharmacists. In the hospitals with two types of pharmacist, the hospital pharmacist mostly focus on supply and preparation of pharmaceutical products rather than giving consultation to physicians.
- Page 9 end of line 25, "true percentage" maybe it would be better to say a "suitable percentage"
Response: Thank you very much. I did.
- At the end of this page it should be better explained how the questionnaires were filled, Regarding the work charge exposed by the physicians not willing to fill the questionnaire, there are some mistakes as "so busy"
Response: This is our body: “The questionnaires were distributed by two pharmacy students in a face-to-face manner and were collected by them. In some cases, those pharmacists had to refer physicians later, and in other cases the physicians were not keen on participating in the study mainly because they were so busy.” The number of those physicians who was not interested in filling out the survey is too limited, and in this case, we had to invite another physician.
- Page 12, Results section. I think that I would be more coherent to explain first the actual experience of the physicians and after the expectations. http://bmjopen.bmj.com/ Response: It was a very nice comment. I replaced them.
Page 13. This section should be shorter, and for instance, I do not see necessary the first paragraph, whose contents have already, be addressed in the introduction. I reduced this paragraph as much as possible.
Response: Thanks a lot on September 25, 2021 by guest. Protected copyright.
Page 14, Line 28, when the authors refer to "repeating medication" are they referring to “prescription"?
Response: I changed “repeating” to refilling.
Page 16 the authors point out the need of improving the pharmacy education in order that the pharmacist feel more confident towards physicians. This is true, but maybe that can suggest some solutions? The solutions that they state at the end of the paragraph about increasing the interaction with physicians is not the solution if the pharmacist has not a solid background .
Response: As mentioned in the main body of the paper, the knowledge of pharmacists regarding pharmaceutical is good, thanks to our recent reform in pharmacy curriculum, but they do not use their knowledge in practice. So, the first and outmost thing is that they would be able apply their knowledge in real world. BMJ Open: first published as 10.1136/bmjopen-2017-019237 on 2 February 2018. Downloaded from
Reviewer #3 Comments Actions Taken In the title there is small degree of overlap with existing articles Many thanks for your great comment and positive feedback. I changed the title to the following one: Perceptions, experiences, and expectations of physicians regarding the role of pharmacists in developing countries: the case of Tehran hospital settings. I am not interested in adding “government” in the title, if you agree.
Line 16: Suggestions: change Physician-pharmacist to inter-professional
Response: I considered your comment. Line 18-23: 'Consider Revising for proper language usage I clarified the sentence.
Design: Rewrite
Response: I changed slightly the design section.
Line 32-42: Suggestion, Replace with: data were collected using a questionnaire consisting of four sections
Response: I considered your comment.
Line 52-56: reword for clarity
Response: I changed to the following sentence:
Comment: Almost half of the physicians (51.6%) agreed that they were usually informed by pharmacists regarding clinical problems in prescriptions. How it can be concluded on basis of results that their views were positive on clinical role?
Response: There are some sentences like those written in the first section of results of the abstract http://bmjopen.bmj.com/ imply that physicians have positive view regarding this issue.
Key words: expectation, experience (Use mesh terms) I used the following link, but did not find any Mesh term.
Response: We will be pleased if you have any suggestions.
https://meshb.nlm.nih.gov on September 25, 2021 by guest. Protected copyright.
First para: make it setting specific Last para: needs language editing
Response: I clarified the sentence.
Line 25-26: change “healthcare system” to increasing cost of therapy
Line 46: change “Primary mission of pharmacist” to prime responsibility of Pharmacist
Response: I considered your comment.
Line 4: “as patient counselor” is pharmacist only perceive to the role of patient counselor, quite specific make it more generalized
Line 8: add reference BMJ Open: first published as 10.1136/bmjopen-2017-019237 on 2 February 2018. Downloaded from
Response: The concept of sentence was corrected
The required reference was added.
Page 7: Is this statement linked to the only possible reference?
Line 50: Hospital pharmacist or Doctor of Pharmacy graduates
Response: This reference will cover our concept.
Hospital pharmacists have been our concern in this study not pharmacy graduates
Line 15: Governmental hospital: describe the level of care i: e (tertiary or teaching)
Response: These sort of hospitals are tertiary.
Line 10: delete “there were not any open ended questions within the questionnaire”
Line 32: add reference
Response: The extra sentence was omitted.
The following reference was added: Chap L. Study designs. In: Chap L, ed. Introductory Biostatistics, 1st edn. Hoboken,NJ:JohnWiley&Sons,2003: 445–570. Whether the likert scale items were treated as nominal variables?
Line 35: delete “chi –square test was used The Likert scale items were treated as ordinal variables.
Response: The extra sentence was omitted. http://bmjopen.bmj.com/
Line 13: Differentiate between drug substitution and drug alternative
Line 35, 55: “dermatologist” makes it area of practice rather than designation Many thanks for your great comment. As we used substitution in other sector of the paper, I replaced alternative with substitution.
on September 25, 2021 by guest. Protected copyright. Response: There is a kind of specialty in our country called” dermatologist” who care skin disorders. If you have other suggestions, please let me know and use.
Comment: I would suggest writing the general description of Pharmacy practice before jumping to hospital and clinical pharmacy
Line 39: “conduct scarce” –please clarify
Response: This concern was entirely explained in the “pharmacy practice in Iran and in the introduction. As other reviewer asked me to reduce the size of the first paragraph of the discussion, please allow me not adding new things in this part.
The sentence was improved. Thanks a lot for your contributions
BMJ Open: first published as 10.1136/bmjopen-2017-019237 on 2 February 2018. Downloaded from
Line 3: change “product “to drug and “pharmaceutical care “to pharmacy services
Line 21: deficiency in the clinical contents: Is this only because of the lack of clinical contents in curricula?
Response: As mentioned in the main body of the paper, the knowledge of pharmacists regarding pharmaceutical is good, thanks to our recent reform in pharmacy curriculum, but they do not use their knowledge in practice. So, the first and outmost thing is that they would be able to apply their knowledge in real world.
Line 14: “were eager to develop” I would suggest changing
Response: The concept pf sentence was corrected
Comment: See reference number 3,21,24,35 and correct as per the journal format They are revised. Write the age like: Age (in years) Significant association should be marked with asterisk
It is recommended that a native English speaker conduct a minor revision. It was done.
Response: The paper were edited professionally.
VERSION 2 – REVIEW
REVIEWER Conxita Mestres School of Health Sciences Blanquerna. University Ramon Llull. Spain
REVIEW RETURNED 27-Nov-2017 http://bmjopen.bmj.com/
GENERAL COMMENTS The authors have addressed the main questions that I pointed out in my revision. They have made the corresponding changes in the manuscript.
REVIEWER Iftikhar Ali Department of Pharmacy ,University of Swabi,Pakistan on September 25, 2021 by guest. Protected copyright. REVIEW RETURNED 27-Nov-2017
GENERAL COMMENTS Paper has been improved. However I would encourage the inclusion of additional details as outlined in the comments below.
General Significant association should be marked with asterisk Improve the English of the article, It is recommended that a native English speaker should conduct a revision
Abstract: Objective: This study aimed to elicit the perceptions and expectations of physicians toward the role of pharmacists in hospitals and clarify the level of interaction between physicians and pharmacists in hospital setting change :role of pharmacists in hospital to clarify the level
BMJ Open: first published as 10.1136/bmjopen-2017-019237 on 2 February 2018. Downloaded from
In Results: Almost half of the physicians (51.6%) agreed that they were usually informed by pharmacists regarding clinical problems in prescriptions. Both senior and junior residents had the view that pharmacists informed them if any clinical problems with their prescriptions were discovered (p = 0.04). Suggestion :Use potential problems instead of clinical problem
In Conclusion: This study demonstrated that physicians had positive view on a clinical role for pharmacists and also accepted pharmacists as a valuable source of general drug information Suggestion: Use important instead of clinical and change accordingly in rest of the paper Tables 1 Under the area of practice see the percentage of ear, nose and throat
VERSION 2 – AUTHOR RESPONSE
Actions to Reviewer 3 Thank you so much for your very positive and valuable comments for improving the quality of the paper. My co-author and I strongly believe that your comments can greatly improve our paper from different points of view. All of the mentioned comments were meticulously considered. As for Table 1, I must mention that there is a kind of specialty called 'ear, nose, and throat'. In other words, these three areas are not separate; rather, one physician covers all the mentioned areas.
http://bmjopen.bmj.com/ on September 25, 2021 by guest. Protected copyright.