THREE LEVELS MODEL FOR DIFFERENTIATED PHARMACIST

ARTIGO ORIGINAL
THREE LEVELS MODEL FOR DIFFERENTIATED
PHARMACIST CLINICAL ACTIVITIES
IN THE COMMUNITY PHARMACY – THE PRACTICAL
APPLICATION
Mónica Condinho
ACF – Acompanhamento Farmacoterapêutico, Lda., Pavia, Portugal
Margarida Cavaco
ACF – Acompanhamento Farmacoterapêutico, Lda., Pavia, Portugal
Fernando Miranda
Motta pharmacy, Évora, Portugal. ACF – Acompanhamento Farmacoterapêutico, Lda., Pavia, Portugal
Carlos Sinogas
ACF – Acompanhamento Farmacoterapêutico, Lda., Pavia, Portugal. Universidade de Évora, Portugal
Abstract
Introduction: In order to contribute for the real implementation of cognitive pharmaceutical services in
Portugal, a three levels model of pharmacist clinical intervention in the community pharmacy, based on the
differentiated patient´s health needs, was proposed by the authors («Three Levels Model for Differentiated
Pharmacist Clinical Activities in the Community Pharmacy – The Proposal», accompanying paper).
Objective: To test the practical application of the proposed three levels model for differentiated pharmacist
clinical activities in the community pharmacy.
Methods: The three levels model was implemented in several community pharmacies. The philosophy
of the model, to change the focus of community pharmacies from the product to the patient, was introduced under the supervision of a specialized pharmacist, responsible for the pharmacotherapeutic followup program. All the pharmacy professionals were instructed to ask the customer about the control of his
health problem, whenever applicable. When no non-controlled health problem was detected, dispensing
the product fulfils the customer needs and is considered the level 1 service. If a non-controlled health
problem was detected, the pharmacist considers the clinical situation and delivers the appropriate counseling,
either immediately or delayed for a pharmaceutical consultation, configuring the level 2 service. When, at
level 2, emerges the perception that simple and immediate actions would not control the health problem,
the patient was invited to integrate the pharmacotherapeutic follow-up program, corresponding to the
level 3 service.
Results: The implementation of pharmacotherapeutic follow-up consultations (level 3) started in 2008
and paved the way for the development of this model. Until September 2013, one specialized pharmacist
followed 430 patients with recurrent non-controlled health problems, performing around 3200 pharmaceutical consultations in 20 community pharmacies. The results available for one pharmacy (46 patients)
show mean reductions of 26.4±7.68 mg/dL on total cholesterol (n=28; p=2.510x10-3), 1.9±0.73 % on glycated
haemoglobin (n=29; p=0.022) and 26.2±3.79 mmHg on systolic blood pressure (n=23; p=6.197x10-7).
Level 2 consultations started in May 2012. During the first 16 months of implementation in 5 pharmacies,
346 patients were enrolled. A total of 371 consultations were performed and mean reductions of 53.3±9.27 mg/
dL in total cholesterol (n= 19; p=1.913x10-5), 18.3±2.26 mmHg in systolic blood pressure (n=42; p=4.657x10-10)
and 0.2% in glycated haemoglobin (n=2) have been registered.
Conclusion: The three levels model for differentiated pharmacist intervention, based on the pharmacy
customer´s health needs, seem to be a suitable model for the routine implementation of cognitive pharmaceutical services in Portuguese community pharmacies. Based on this model, the pharmacy can answer to all
their customer´s health needs and contributes for significant improvements on patient´s health condition.
Keywords: Cognitive pharmaceutical services, model of pharmacist clinical intervention, pharmacotherapeutic follow-up consultations.
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Resumo
14
Introdução: Considerando a limitada implementação de serviços farmacêuticos cognitivos em Portugal, em
particular no que à consulta farmacêutica diz respeito, propôs-se um modelo de intervenção farmacêutica
diferenciada, por forma a responder às diferentes necessidades de saúde dos utentes da farmácia, otimizando
recursos e valorizando a intervenção clínica do farmacêutico («Three Levels Model for Differentiated Pharmacist Clinical Activities in the Community Pharmacy – The Proposal», artigo também publicado nesta edição).
Objetivo: Testar a aplicabilidade prática do modelo proposto para intervenção farmacêutica diferenciada
em três níveis de atuação na farmácia comunitária.
Metodologia: Implementação do modelo proposto em várias farmácias comunitárias. A filosofia de trabalho subjacente foi apresentada à equipa de cada uma das farmácias pelo farmacêutico especializado em
acompanhamento farmacoterapêutico, que supervisionou a sua implementação. A primeira etapa consistiu
na mudança de foco da intervenção dos diferentes profissionais de saúde da equipa da farmácia, do produto
e da sua venda para o doente e suas necessidades de saúde. Para tal, toda a equipa foi instruída no sentido de,
em cada atendimento, questionar, sempre que aplicável, o utente acerca do seu problema de saúde. Perante
a ausência de problema de saúde, ou nas situações em que este estava controlado, o profissional satisfez
as necessidades do utente pela dispensa solicitada (nível 1). Nos casos em que um ou mais problemas de
saúde foram percecionados como não controlados, o colaborador avaliou, em primeiro lugar, a recetividade
do doente para o aconselhamento. Em caso afirmativo, um farmacêutico analisou a situação e decidiu a intervenção a tomar: um aconselhamento imediato ou um convite com marcação de consulta farmacêutica de
nível 2. De imediato ou no âmbito da consulta farmacêutica de nível 2, nas situações mais complexas, com
problemas de saúde recorrentemente não controlados, o doente foi encaminhado para a consulta de nível
3, o acompanhamento farmacoterapêutico. O doente manteve-se nesta consulta até ao controlo do problema de saúde ou até que nenhuma outra intervenção fosse possível ou desejável. Terminado o programa de
acompanhamento farmacoterapêutico, o doente retornou ao nível 2, onde o seu estado de saúde continuou
a ser monitorizado pelo farmacêutico residente.
A prestação de cada um dos níveis foi acompanhada da devida formação da equipa da farmácia e do farmacêutico indicado para realizar as consultas de nível 2.
De uma maneira geral, o nível 1 (nível básico de serviço) necessitou apenas de ser consolidado e aperfeiçoado
com introdução de alguns procedimentos técnicos e clínicos e protocolos de intervenção em transtornos
minor. A implementação do nível 2, executado pelo farmacêutico residente, focou-se sobretudo na consulta
farmacêutica, com ensino metodológico e em exercício. Trabalhou-se o guião para recolha de informação,
as intervenções a prestar e a forma de comunicar com o doente. Todas as consultas e intervenções foram
supervisionadas pelo farmacêutico responsável pelo nível 3. Os resultados clínicos, bem como as intervenções efetuadas, foram registados no processo clínico do doente. Sempre que o problema de saúde não era
suscetível de controlo a este nível, o doente era encaminhado para o nível 3 ou, em situações particulares
de urgência, para o médico. No que ao nível 3 diz respeito, o serviço era prestado por farmacêutico externo
especializado e inteiramente dedicado à prática de acompanhamento farmacoterapêutico.
Fluxogramas de intervenção acerca do modelo e da técnica de recrutamento de doentes foram criados e
implementados para auxiliar a equipa.
Resultados e Discussão: A implementação das consultas de acompanhamento farmacoterapêutico, no nível 3 de serviço, iniciou-se em 2008 e induziu o desenvolvimento do modelo proposto, devido à perceção
(adquirida na prática) de que muitos doentes poderiam controlar o seu problema de saúde mediante «simples» intervenções, sem necessidade de estudo específico. Até setembro de 2013 foram acompanhados, por
um farmacêutico especializado em acompanhamento farmacoterapêutico, 430 doentes com problemas de
saúde recorrentemente não controlados em 20 farmácias comunitárias. Cerca de 3200 consultas farmacêuticas foram efetuadas. Os problemas de saúde mais prevalentes foram a dislipidemia, a diabetes e a hipertensão arterial. Em virtude da intervenção farmacêutica a este nível, os resultados clínicos disponíveis, para
uma farmácia (46 doentes), mostram reduções médias de 26,4±7,68 mg/dL nos níveis séricos de colesterol
total (n=28; p=2,510x10-3), 26,2±3,79 mmHg na pressão arterial sistólica (n=23; p=6,197x10-7) e 1,9±0,73% na
hemoglobina glicada (n=29; p=0,022).
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O acompanhamento farmacoterapêutico desenvolvido por farmacêutico externo à equipa da farmácia já deu provas da sua aplicabilidade prática e de significativa mais-valia para a saúde do doente. Por isso, este artigo foca-se
mais na consulta farmacêutica de nível 2, no enquadramento da aplicação do modelo de três níveis proposto.
A consulta farmacêutica de nível 2 iniciou-se em maio de 2012. Nos últimos 16 meses de implementação deste
serviço em cinco farmácias comunitárias, 346 doentes foram incluídos. De um total de 516 consultas marcadas,
efetuaram-se 371 pelos farmacêuticos residentes das farmácias envolvidas, traduzindo uma taxa de desistência de,
aproximadamente, 28 por cento. Diabetes, hipertensão e dislipidemia foram as patologias mais prevalentes. Como
resultado das intervenções farmacêuticas direcionadas a estas patologias, os dados disponíveis para 65 doentes
revelam reduções médias de 53,3±9,27 mg/dL nos níveis séricos de colesterol total (n=19; p=1,913x10-5), de 18,3±2,26
mmHg na pressão arterial sistólica (n=42; p=4,657x10-10) e de 0,2 por cento na hemoglobina glicada (n=2).
Considerando o curto período de implementação da consulta de nível 2 em comparação com a consulta de nível 3,
o número relativamente maior de doentes envolvidos no nível 2 apoia um dos pressupostos do modelo: a maioria
dos doentes pode controlar o seu estado de saúde mediante intervenções farmacêuticas «simples» (adesão à terapêutica, toma correta, melhoria de hábitos de vida, etc.), sem exigir um estudo pormenorizado como aquele que
é feito ao nível 3. Acresce que a altura em que a consulta de acompanhamento farmacoterapêutico começou a ser
implementada corresponde a um período em que a cultura de serviço farmacêutico orientado para o doente ainda
não estava ao nível que hoje se regista.
Conclusão: O modelo de intervenção farmacêutica diferenciada em três níveis de atuação, baseado nas diferentes
necessidades de saúde dos doentes, parece adequado à implementação da prática de serviços farmacêuticos cognitivos na rotina diária da farmácia comunitária. Adicionalmente, através deste modelo, a farmácia responde às
diferentes necessidades de saúde dos seus utentes e contribui, de forma significativa, para a melhoria do estado de
saúde dos seus doentes.
Palavras-chave: Serviços farmacêuticos cognitivos, modelo de intervenção farmacêutica, consultas de acompanhamento farmacoterapêutico.
Introduction
In order to contribute for the real implementation
of pharmaceutical care services in Portugal, a three
levels model of pharmacist clinical intervention in
the community pharmacy, based on the differentiated patient´s health needs, was proposed by the
authors. This model is a result of several years delivering pharmacotherapeutic follow-up consultations
in Portuguese community pharmacies. In the practical experience, the authors perceived that the majority of patients with non-controlled health problems
could be controlled through “simple” interventions as
medication adherence, medicines’ intake according
with the indications or healthy lifestyle habits change,
not requiring the specific and personalized study
applied by pharmacotherapeutic follow-up. Simultaneously, several barriers1 has prevented the implementation of more clinical oriented pharmaceutical
services by the community pharmacy.
In theory, through the three levels model the pharmacy answer to all their customer´s health needs,
from the “simple” non-controlled health problem
(with level 2 pharmaceutical consultation) to a more
complicated and recurrent non-controlled clinical
situation (with level 3 consultation, the pharmacotherapeutic follow-up program).
Objective
To test the practical application of the proposed
three levels model for differentiated pharmacist clinical activities in the community pharmacy.
Methodology
Implementation and development of the three levels
model in several community pharmacies, structuring
the pharmacist interventions and optimizing human
resources, according to patient´s health needs.
A specialized pharmacist in pharmacotherapeutic
follow-up, responsible for the level 3 pharmaceutical
consultations, introduced the philosophy of the three
levels model, in each pharmacy team, supervising its
implementation.
The first change induced was the pharmacist activity
focus, changing from the product and its selling to the
patient and his health needs. All the pharmacy professionals were instructed to ask the customer about the
health problem control (when applicable) and to get
the perception of “what the customer needs and what
he wants”. This procedure, common to all attendance,
was essential for the success of the model implementation. Two situations can be anticipated (Figure 1):
- Absence of non-controlled health problem or
specific counseling. Dispensing the requested
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product completes the attendance. This is the level 1
service offered by all the pharmacy professionals.
- Presence of non-controlled health problem or request for specific counseling. The pharmacy professional should consider the receptivity of the patient to
the pharmacist intervention and decide accordingly.
If the patient is not receptive this is registered in the
informatics patient record. When receptive, the pharmacist evaluates the clinical situation and provides
immediate counseling or schedules a pharmaceutical
consultation (level 2, in general) to take in account
other aspects of the medication or the pathology.
In general, at least in Portugal, the concept of pharmaceutical consultations is not common. The patient
should first understand his non-controlled health
problem and the contribution that the pharmacist
could provide to control it. The meeting with the
pharmacist is scheduled during the period reserved
for the level 2 pharmaceutical consultations. The
patient is invited to bring all his medicines, within
respective boxes, and the last clinical laboratory test
results. The resident pharmacist applies the guidance
formulary for level 2 first consultation (see accompanying paper).
When the health problem cannot be controlled by “simple” interventions as medication adherence, medicine´s
intake according to the indication or lifestyle habits
changes, the patient was invited to integrate the level 3
consultations, for more detailed study.
Pharmacotherapeutic follow-up was provided in
a patient-centered approach using a logical and
methodological reasoning (adapted from Dáder’s
method2) to detect, prevent and solve negative clinical outcomes. When all the health problems were
solved or no additional interventions were foreseen,
the patient was returned for level 2 pharmacist with
a detailed written report.
To implement the model in the adherent community pharmacies, specific formation was offered to
the pharmacy team. In general the importance of
the concept for changing the focus in the Community Pharmacy from the product to the patient was
the starting point. Teaching of procedures for some
health parameters measurements, as blood pressure,
respiratory parameters or capillary blood testing and
protocols for minor diseases were performed for all
the pharmacy professionals to provide level 1 service.
For level 2 service, in particular for the delivering of
pharmaceutical consultations, the resident pharmacist appointed was the target for specific education
on communication with the patient, methodology,
including specific formularies, and clinical interventions to be applied. Weekly there was a personal
contact between the resident pharmacist, responsible for level 2 pharmaceutical consultations and the
specialized pharmacist, responsible for the pharmacotherapeutic follow-up, usually via “Skype”, to discuss specific clinical and methodological aspects.
Level 3 service was provided by the Community Pharmacy through an external specialized pharmacist on
pharmacotherapeutic follow-up offering pharmaceutical consultations according with clinical needs and
therapeutic objectives of the
patients enrolled.
Figure 1 – Flowchart suggested for the professional behavior intervention
during first attendance in the Community Pharmacy
Customer health problem
Absent or controlled
No additional service need (level 1)
Non-controlled
Receptivity evaluation
Not receptive
Add information on the
informatics customer record
Not accepted
Receptive
To induce the need
of the service
Pharmaceutical
consultation
invitation
Accepted
Pharmaceutical
consultation
appointment
(level 2, in general)
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Need for Differentiated
Services
In order to evaluate the
percentage of pharmacy
customers requiring pharmacist intervention to improve
health condition, a brief survey was conducted in 2011.
During six random selected
days all the attendance events
(customers older than 18
years) were analyzed. Based
on a specific flowchart each
attendance was classified in
one of the three service levels,
according with the perceived
patient´s health needs. At the
end of the study, two pharma-
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cists validated all the level classifications independently. Questionnaires with divergent evaluation by
both pharmacists were excluded from the study.
The clinical data presented here was treated using
Microsoft Excel™, with t-student tests and significance levels of p=0.05.
Results
Level 2 Pharmacist Consultations
From May 2012, the beginning of implementation of
the model, to September 2013, about 346 patients was
enrolled in the level 2 pharmaceutical consultations.
Results from 5 community pharmacies show that
during 16 months, 513 pharmaceutical consultations were scheduled, corresponding to an average of
6.4 consultations per month per pharmacy. A drop
out rate of about 28 % was registered. From the
scheduled consultations only 371 were really performed by 5 pharmacists, corresponding to an average of 4.6 consultations per month per pharmacy.
Following the first consultation, 76 patients were appointed for a second level 2 consultation, 39 patients
were referred to pharmacotherapeutic follow-up (level 3) and 21 to other services offered by the pharmacies. The remaining 211 patients controlled immediately the health problem, sometimes with additional
recommendations outside formal consultations.
Diabetes (33.5 %), hypertension (36.1 %), dyslipidaemia (18.7 %) were the most prevalent pathologies
registered at the level 2 service. A total of 963 pharmacist
interventions were performed and registered. About
75 % of these interventions were considered as non-pharmacological (721), with a predominance of lifestyle modification recommendations, especially healthy
eating habits (474 interventions). More than 25 % of
the pharmacist interventions were considered pharmacological (242), with a predominance of recommendations for therapeutic adherence (156 interventions).
The clinical outcomes achieved by level 2 pharmacist
interventions were considered by comparison with
the starting point inducing the invitation to the consultations. Data on hypertension, diabetes and cholesterol levels changes are available for 65 patients.
For 42 patients with non-controlled hypertension,
pharmacist intervention induced a mean reduction of 18.3±2.26 mmHg on systolic blood pressure
(from 153.2 mmHg to 134.9 mmHg; p=4.657x10-10)
and 8.1±1.50 mmHg on diastolic blood pressure (from
80.8 mmHg to 72.7 mmHg; p=2.975x10-6). It was possible to control 24 patients. Nineteen patients were
identified with hypercholesterolemia diagnosed and
non-controlled. After pharmacist interventions, total
cholesterol levels registered a mean reduction of
53.3±9.27 mg/dL (from 236.8mg/dL to 183.5 mg/dL;
p=1.913x10-5), achieving guideline therapeutic goals
for 10 patients.
The pharmacist interventions on 20 diabetic patients
induced mean reductions of 0.2 % in glycated haemoglobin (n=2), 29.9±26.30 mg/dL (from 151.7 mg/dL to
121.8 mg/dL; p=0.285) in fasting glucose (n=10) and
74.2±20.48 mg/dL (from 237.2 mg/dL to 163.0 mg/dL;
p=3.511x10-3) in post-prandial blood glucose (n=13).
Pharmacotherapeutic Follow-up – Level 3 Service
Since September 2008 to September 2013, a total of 430 patients with recurrent non-controlled health problems were
involved with the specialized pharmacist and more than
3200 pharmaceutical consultations were provided to these
patients. The most prevalent diseases registered were dyslipidemia, diabetes and hypertension. Mean reductions of
26.4±7.68mg/dL on total cholesterol (n=28; p=2.51x10-3),
1.9±0.73 % on glycated haemoglobin (n=29; p=0.022)
and 26.2±3.79 mmHg on systolic blood pressure
(n=23; p=6.197x10-7) are attributed to the pharmacotherapeutic follow-up, corresponding to significant
improvements on patient’s health condition [“A new
approach for the implementation of pharmaceutical
care”, paper in preparation].
The Quantitative Needs for Differentiated
Services
During the period of the survey, 405 attendances were
registered, 392 (96.8 %) of them were considered validated by convergent opinions of the two pharmacists.
The results shown that the majority of the consumers (320) would not require clinical services provided
by the pharmacist. Around 81.6 % of attendances, unrelated with non-controlled health problems, would
be satisfied by level 1 service. Forty-four attendees
(around 11.2 %) were evaluated as requiring level
2 service by rapid and simple pharmacist interventions for controlling respective health problems. The
remaining 28 attendances (around 7.1 %) were considered as requiring specialized intervention of the
pharmacist through pharmacotherapeutic follow-up
at level 3 service.
Discussion
The practice of pharmacotherapeutic follow-up, initiated in 2008, paved the way for the development of
the integrated model presented due to the perception
(acquired in the practice) that many patients could
control their health problem through “simple” interventions, without specific study. The added value of
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pharmacotherapeutic follow-up program implemented
through an external specialized pharmacist for patient’s health condition is known and documented3.
In the same way, international literature abundantly
documents the practice of this service and the positive outcomes for the patient´s health condition4,5.
According to the first results of conSIGUE study, the
practice of pharmacotherapeutic follow-up applied
to elderly polimedicated patients induced a reduction of 58 % of patient’s health problems, 30 % of
emergency visits and 50 % of hospitalizations6.
The new proposal and development of the three
levels model and its practical applicability should
document the value of the level 2 pharmaceutical
consultations in addition to the pharmaceutical care
activities, already known. This justifies the main focus of this paper on the results of level 2 consultations.
Most of the non-controlled health problems improved
by correcting the errors on medication process use,
being the poor adherence the most relevant. The level
2 consultations delivered by the resident pharmacist
revealed to be appropriate and sufficient for controlling these health problems. Interventions at this level
are not time consuming and do not require dedicated
study due to the supervision and constant support
provided by the specialized pharmacist responsible
for the level 3 consultations. These level 2 consultations can easily be added to the routine activities of
the resident pharmacist.
For refractory patients, with recurrent non-controlled health problems, more specialized and timeconsuming pharmacist consultations are need, the
pharmacotherapeutic follow-up should be applied.
On practice the relative small number of patients
involved in level 3 consultations (430 patients, 5
years) compared with the data from level 2 consultations (346 patients, 1.3 years), support one of the
premises of this model: the majority of patient´s health
problems could be controlled through “simple” interventions (medication adherence, medicines intake
according the indication, healthy lifestyle habits,
between others), at level 2. The number of patients
requiring specialized service at level 3 is lower.
Regarding the clinical outcomes from level 2 consultations, with a relative small number of patients
with data available, the added value of this consultation for patients is clear. Significative reductions
in total cholesterol and systolic blood pressure were
achieved. For diabetic patients, mean reductions
were also registered in glycaemia, but only in post-prandial the values are statistical significant, due to
Rev Port Farmacoter | 2014;6:89-95
the small number of patients with data available for
fasting glycaemia and glycated haemoglobin.
Considering that the concept of level 2 pharmaceutical consultations is new, the comparison with other
results from pharmacist interventions in the literature is difficult. Nevertheless, a systematic review and
meta-analysis of 30 randomized trials conducted in
2011, in order to determine the impact of pharmacist
care on the management cardiovascular diseases risk
factors, concluded that, in spite of some heterogeneity, the majority of the studies points for a positive
impact of the pharmacist intervention. This review
shows that the pharmacist’s care induces a mean reduction of 8.1 mmHg on systolic blood pressure and
17.4 mg/dL on total cholesterol7. The discrepancies
with the three levels model here proposed could be
due to different number of patients, studies’ design
and the type of pharmacist interventions. In type 2
diabetes, the results of a controlled trial conducted in
Brazil showed mean reductions in fasting glycaemia
with similar amplitude: 20.1 mg/dL5.
Other different studies have been reported8-10, all of
them showing positive clinical outcomes with different objective improvements due to the pharmacist intervention to manage non-controlled health problems.
This model, to provide differentiated services to the
community pharmacy customers, according with their
health needs, proved to be viable in practice, presenting global positive results for the health parameters
studied either on the level 2 or level 3 environment. Different outcomes from both consultations are the result
of pharmacist interventions with different target patients. At level 2 the patients have non-controlled situations due to “simple” causes, while at the level 3 consultations the patients are recurrently non-controlled
or having complex pharmacotherapeutic profiles.
The level 2 consultations implemented in the community pharmacies, where the three levels model
was experimented, were previously scheduled for
half-a-day per week, while the level 3 consultations
were previously scheduled half-a-day every two
weeks. These frequencies proved to be adequate for
the needs registered and agrees with the brief survey
performed, where most of the pharmacy customers
did not need clinical interventions, evaluated to be
more than 80 %. From the remaining customers that
would benefice from pharmacist clinical intervention, only around 7 % would require the specialized
pharmacotherapeutic follow-up.
Data reported in this paper would require longer
implementation of the model for more consolidated
results, especially in what concerns the level 2 con-
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sultations. There is a perception that this three levels
model improves loyalty of customers, but additional
studies are required to demonstrate this added value for
the community pharmacy implementing the model.
Conclusion
The three levels model for differentiated pharmacist intervention, based on the pharmacy customer´s
health needs, seem to be a suitable model for the
routine implementation of pharmaceutical care and
other cognitive pharmaceutical services in Portuguese community pharmacies. Based on this model,
the Community Pharmacy can answer to all their
customer´s health needs and contributes for significant improvements on patient´s health condition,
which rewards them and the pharmacist.
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Acknowledgments
The authors would like to thank the community
pharmacies, where data reported was acquired:
Farmácia Central, Mora, Portugal; Farmácia
Paula Santos, Pêra, Portugal; Farmácia Helena, Faro,
Portugal; Farmácia Motta, Évora, Portugal; Farmácia
Ribeiro Soares, Santa Iria de Azóia, Portugal.
Funding
No funding was received for this work.
Conflicts of Interest
No conflicts of interest to declare.
Rev Port Farmacoter | 2014;6:89-95
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