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Table 1 Overview of identified studies

From: Is there potential for the future provision of triage services in community pharmacy?

Author (year) country [reference] Key aims Study design Measurements Participants Proportion referred (%[n]) Summary of results Characteristics of community pharmacy services that match the working definition of triage
Contact between community pharmacy and the patient or caregiver/proxy Questions are asked to determine the diagnosis Urgency and level of care decided Advice given Decision made to treat or refer
Alkhatib et al. (2015) Australia [44] To evaluate pharmacists’ management of eye infections following the reclassification of ophthalmic chloramphenicol. Cross-sectional postal survey to a randomized sample of community pharmacies. Agreement or specific information by the pharmacist on: 1. Provision of ophthalmic chloramphenicol 2. Protocol and training 3. Pharmacist views 4 Demographics from recall 119 responses from pharmacist managers/ proprietors Not recorded Pharmacists’ capability to treat acute bacterial conjunctivitis was improved and pharmacists felt that there was better utilisation of their professional skills. There was improved access to treatment options for patients. More education and training was signalled by some and use of protocol differed by age group. More sold OTC in larger pharmacies in metropolitan areas, no change in number of prescriptions for chloramphenicol. No evaluation of service.
Baqir et al. (2011) UK [6] To assess what action patients using MAS would have taken if the MAS had not been in place and to approximate the net cost impact. A cost minimization analysis of submitted claims data. One item questionnaire for consumer. Patients were asked what action they would have taken if the MAS was not in place. The calculated net cost impact of the MAS using standard health-care reference costs. 396 patient claims were recorded Not recorded Savings of NHS resources over 1 month equated to £6739.01. Estimation of which resources would be used if not in place identified GPs and EDs as the next port of call.
Berger et al. (2005) Germany [37] To assess the quality of patient counselling in community pharmacy and evaluate a new method of feedback. Observational study using pseudo-customer methodology All aspects of the interview, recommendation and advice. 49 community pharmacies 90 % [27] of cases that warranted referral More assessment was conducted when patient presented with symptoms than a product request. Some appropriate self-medication advice provided in 74 % of visits, usually not sufficient. One of the two cases the optimal decision was referral, whereas the other case medication and advice was sufficient. 90 % of cases that warranted referral were referred but only 30 % with necessary urgency.
Bilkhu et al. (2013) UK [34] To determine and quantify questioning and management of a patient with presumed allergic conjunctivitis. Observational study using pseudo-customer methodology All aspects of the interview, recommendation and advice. The type of pharmacy staff who was involved in the consult 100 community pharmacies 14 % [13] Average questions asked 3.5 ± 2.6. Differential diagnosis questioning and management of allergic conjunctivitis by community pharmacies in this study was lacking. Referral to optometrist comprised 2 % of the 100 pharmacies. 91 % advised on treatment.
Blenkinsopp et al. (1991) UK [50] The aims of the study reported evaluation of pharmacist used referral cards Questionnaires completed by both pharmacist and GP 1. Usefulness and acceptability of the notification card 2. The use of the card in the reporting of suspected adverse drug reactions from the community pharmacist to the GP 3. Acceptability and value of such a card Six pharmacies, 15 general practices in two towns Not recorded % [120] 71 % of patients who were referred to their GP by the pharmacist did so. Overall, 12 % of cards issued were for a suspected adverse drug reactions. Their was a positive perception of the cards by all parties - patients, doctors and pharmacists. Of the referrals GPs felt 88 % of cases were referred appropriately.
Bojke et al. (2004) UK [7] To investigate the effects of an intervention to provide easier access to pharmacists for patients with minor ailments. Analysis of consultation numbers and types. Patient minor ailment type and influencing factors. 1. Effects of the intervention on the total number of consultations by GPs and on the mix of patients seen by the GP 2. Factors affecting patients’ choices between GP and pharmacist consultations for minor ailments 1521 consultations of which 575 patients took the pharmacy option to treat minor ailment Not recorded The total number of GP consultations was unaffected but the intervention led to the number of minor ailments consultations decreasing. The main reason behind patient choice in consulting the GP/pharmacist was the type of minor ailment. Distance did not alter patient choice.
Chui et al. (2005) Singapore [53] To identify pharmacist’s approach in providing advice and consumers’ behaviour in self-treatment and their perception of the community pharmacist’s role in advice. Two structured questionnaires The pharmacists and consumers were surveyed independently using two structured questionnaires. 44 pharmacists and 181 patients 15.5 % [28] said that pharmacists had referred them to a GP. The majority of pharmacists gave advice on self-medication to at least 10 patients per day. The majority of patients (90.9 %) were at least somewhat satisfied with advice provided.
Coelho et al. (2014) Portugal [24] To determine the prevalence of self-medication and to evaluate the clinical impact of pharmaceutical counselling. Cross- sectional observational study All aspects of the interview were recorded including the recommendation advice and when referred 298 patients 9.1 % [27] 51.3 % presented asking for advice, 48.7 % asking for a specific product. 9.1 % referred to GP. Follow up - After 1 week of pharmaceutical intervention, 86.8 % had a positive impact, half of referred patients made GP visit, 80 % of counselled patients had improved symptoms.
Chapman et al. (2010) Australia [23] To understand the nature and impact of primary health care that is provided by community pharmacies Cross- sectional observational study Consultations between customersand staff in community pharmacies. Interview with each customer post consultation and a follow-up phone call. 24 community pharmacies; 280 customers (telephone contact made with 252) 4.2 % (5.6 %) [12 direct (16 conditional)], in addition 3 % (8.3 %) [4 (11 conditional)] from proxy consultations Most elements of consultation only took place when a customer sought advice versus a product. Most did not take the advice of referral from the community pharmacy.
Driesen et al. (2009) Belgium [35] To assess management of acute diarrhoea in an 8-month-old baby using a simulated patient scenario in a community pharmacy Observational study using pseudo-customer methodology This outcome was assessed against the three WWHAM questions that were defined as the most essential topics to be able to evaluate the situation 101 community pharmacies 31 % [not recorded] The majority of pharmacists asked too few questions to adequately analyse the situation. Advice was given but insufficient counselling on medicines. 31 % referral including conditional, good counselling on dehydration. Authors reported too few questions asked to adequately assess the scenario.
Erni et al. (2016) Switzerland [48] To evaluate the impact of this new service as well as the added value for the health care system. Cross- sectional study Ailment, procedure of the consultation, treatment, patient information and outcomes of the follow-up call on a standardized form submitted to the study centre. Pharmacists from 162 pharmacies performed 4118 triages. 7 % [288] (17 % required second opinion of medical practitioner) 4118 triages were completed by 162 pharmacists In 17 % of the cases the option to have a backup consultation was utilised. In follow-up calls, 84 % of the patients who were seen only by pharmacists reported complete relief or symptom reduction. Significant or complete remission was seen in 84 % of the patients triaged by the pharmacist. 9 % required another medical consultation, 7 % of patients needed further pharmacy treatment.
Evans et al. (2005) UK [41] To find out whether community pharmacy was offering appropriate advice to patients seeking advice on management of a persistent ulcer on the tongue. Observational study using pseudo-customer methodology The interviewer then recorded the advice given and noted whether the source was a pharmacist or a pharmacy assistant 40 pharmacists and 40 pharmacy assistants Pharmacist: 81 % [33] Pharmacy assistant: 35 % [14] The most appropriate outcome would be referral. Most pharmacists gave the correct advice of referral. Pharmacy assistants gave inadequate advice in most cases.
Hafejee et al. (2006) UK [45] To elucidate the range of skin problems currently encountered and knowledge to deal with these Questionnaire survey Pharmacists’ dermatology education, patient resources available, and the nature of the skin problems for which patients consulted them and the follow-up arrangements. 20 community pharmacists and 735 dermatological presentations 84 % if symptoms did not resolve [not recorded] There is high number of presentations for dermatological advice, and the presentations are varied. There is a need for more focused dermatology topic teaching for pharmacists both at undergraduate and postgraduate levels. 84 % of pharmacists told patients to consult their GP if symptoms did not resolve.
Hassell et al. (1997) UK [11] Patients qualitative views on pharmacy services and roles Ethnographic-style research study Staff and patient interviews and non-participant observations of medicine and health interactions Ten pharmacies, over 1000 patients interviewed and 44 telephone interviews 6 % [not recorded] Patients used pharmacy instead of GP due to: costs, convenience, and illness seen as minor, to see if pharmacist thought they should see GP. Pharmacists play a major role in keeping minor ailments out of the GPs, and act as a referral mechanism if necessary. Follow up on a sample of the patients seen to check relief of symptoms/ resolution of problem, but outcome not recorded.
Hassell et al. (2001) UK [51] To assess the extent to which patients would visit a community pharmacy instead of a GP for management. Intervention study Transfer rates and reductions in general practice consultations for the 12 conditions. Prescribing outcomes and re-consultation rates. Eight community pharmacies, 1522 patients 3.6 % [21] 37.8 % of eligible patients accepted offer of transfer to community pharmacy for consult and treatment. 3.6 % referred back to GP, 5.7 % re-consultation within 14 days. Pharmacy treatment acceptable and feasible
Jiwa et al. (2010) Australia [46] To characterize factors affect pharmacists providing a referral for patients with lower bowel symptoms to consult a general practitioner Questionnaire Vignettes were constructed around 6clinical variables and pharmacists were asked to describe a referral pathway. 167 community pharmacists and 1503 vignettes 69 % [1040] Cases presented to pharmacists as vignettes. Pharmacist triage was in agreement with expert panel in 70 % of cases. Diarrhoea over referred and weight loss and rectal bleeding under referred.     
Jiwa et al. (2012) Australia [49] To develop a tool to assist community pharmacists to triage patients presenting with cough Assessment tool development and pilot of tool Leicester Cough Questionnaire; Pharmacy Cough Assessment Tool including referral and follow up Four pharmacies and ninety-nine subjects 37 % [37] (however 18 more qualified for referral) The tool identifies patients with cough who might benefit from medical advice and may feasibly be used as an initial screening tool in the community pharmacy setting. 7/37 participants who were referred to their GP could be confirmed to have done so. Two were prescribed antibiotics; one was referred for a chest X-ray and one to a specialist.
Kippist et al. (2011) Australia [39] To investigate how community pharmacists respond to complaints of acute insomnia from people who seek self-treatment and determine the factors affecting this response. Observational study using pseudo-customer methodology Supply/non supply of a sleep aid and scores for pharmacists for skills in eliciting information prior to supply of medication 100 community pharmacies 4 % [4] (24 % of cases overall made some type of referral incl to revisit if no resolution) Many pharmacists are responding appropriately. The most appropriate outcome would be non-supply of medicine A product was supplied in 96 % of visits; conventional medicines in 65 % of cases, and herbal/ homeopathic medicines 31 %.
Krishnan et al. (2000) Germany [33] To determine whether patients with dyspepsia had improved outcomes in quality of life scores comparing an intervention sand a control pharmacy Observational and questionnaire Quality of life scores before and after self-medication. Quantitative and qualitative evaluation of pharmacist advice 36 pharmacies 198 patients 10.8 % [21] and 68.7 % conditional referrals Overall counselling in trained pharmacies was better than non-trained pharmacies. In general patients were asked comprehensive questions and provided with advice. Longer consults were associated with more satisfied reports. However, some pharmacists did not provide sufficient warning for those who were at risk. Drug related problems were not addressed sufficiently.
Mansell et al. (2015) Canada [22] To determine whether patients prescribed such treatment by a pharmacist symptomatically improve within a set time frame. Online questionnaire for patients Demographics, condition, pathway to encounter, outcome including satisfaction and further consultation needed. Ninety pharmacies and125 participants. Not recorded Trust in pharmacists and convenience was the most common reasons for choosing a pharmacist. 27.2 % would have chosen a physician or ED otherwise. Satisfaction with the pharmacist and service was strong; only 5.6 % felt a physician would have been more thorough. The condition significantly/completely improved in 80.8 %; 4 % experienced side effects.
Marklund et al. (2003) [32] Sweden To assess whether pharmacists make appropriate choices with patients with dyspepsia. Assessment of referral cards Demographics, reason for referral, assessment of referral 132 patients Not recorded [132] Of all of the patients who were referred, the assessors agreed that 90 % of the patients should have been referred to their GP.
Martin-Morales et al. (2013) Europe [Greece and Spain] [28] To assess pharmacists’ ability to detect erectile dysfunction and encourage patients to seek medical evaluation. Cross-sectional observational study in two countries Proportion of men with a SHIM score ≤ 21 and, of those, the proportion who visited a physician and credited the pharmacist for their visit. 451 patients 77 % [348] First health care professional approached - 50 % pharmacist, 18 % GP. Follow up phone call to verify the quality of the patient education provided and whether they visited GP. Less than 1/3 referred to GP had visited
Maunder et al. (2005) UK [63] To assess the advice given by pharmacists on oral health and the role of pharmacists in oral healthcare services Questionnaire Pharmacy characteristics, products available, knowledge of pharmacists and promotional activities 17 pharmacies 94.1 % of cases to see the dentist and, 23.5 % to see the GP [not recorded] Most common presentations during data collection was for ulcers and toothache/pain. Advice was given to see a dentist/Dr. Albeit pharmacists had little knowledge of the dentists in the area or emergency arrangements. Pharmacists were interested in having protocols for management of oral health care.
Mehuys et al. (2009) Belgium [30] The role of the pharmacist in triage related to upper gastrointestinal presentations Questionnaire-based referral tool 1. Nature of GI symptoms that people intend to self-medicate 2. Prevalence of alarm symptoms 3. Adherence to referral advice 4. Self-reported efficacy 592 patient consultations 21 % [124] Only 51.7 % of the customers, who were referred, adhered to that advice. Overall 48.7 % of people reported symptom relief and of those given OTC treatment 95.1 % reported relief of symptoms.
Parmentier et al. (2004) UK [52] To evaluate a scheme offering pharmacy referrals for minor ailments in a refugee community. Intervention study The presenting minor ailment and corresponding medication as recorded by the pharmacist. 2 community pharmacies, 184 refugees 1.1 % [2] 200 vouchers were distributed to 184 refugees. Of all the referrals, there were two clients who were referred to the GP and two advised to see the GP if symptoms persisted.
Phillips et al. (2001) UK [27] Use of community pharmacy versus general practice was acceptable as the first point of call for head lice. Before and after training study and questionnaires to health professional and patient Before and after training where pharmacists were asked to record head lice consults 571 patient consultations Not recorded Patients treated for head lice by pharmacist rather than GP. Estimated savings during study period of up to £52000.
Ralph et al. (2001) UK [47] To assess the ability of pharmacists to appropriately manage a range of genital symptoms Questionnaire on case-based scenarios Pharmacist perceptions on their ability to manage a range of genital symptoms and their knowledge of genitourinary services 28 community pharmacies 4–100 % dependant on the condition, some with OTC products Range of symptoms/conditions surveyed. Focus on pharmacist knowledge of genitourinary services nearby - low. Showed that many pharmacists know when to refer STDs, but more education on services to refer to needed.     
Rutter et al. (2004) UK [36] To determine whether an appropriate course of action was taken by UK community pharmacists for cases of headache and abdominal pain Observational study using pseudo-customer methodology All aspects of the interview, recommendation and advice 28 community pharmacies 53.6 % [15] Referral was expected outcome - advised in 53.6 % of cases. Most questions asked were relevant (66 %) but inadequate histories taken.
Schneider et al. (2011) Australia [38] Evaluation of pharmacist assessment and triage when appropriate for chronic cough. Observational study using pseudo-customer methodology Demographic details, assessment questions, and advice provided. 155 community pharmacies 38 % [59] (36 % of these provided OTC supply also) Referral was ideal outcome based on symptoms; only 38 % of cases were referred. Adequate assessment increased likelihood of referral. Consultations conducted by pharmacists were more likely to lead to appropriate outcome.
Scully et al. (1989) UK [43] To assess the advice offered by pharmacy staff with a potential oral carcinoma Observational study using pseudo-customer methodology Advice and recommendation. 57 community pharmacies 8.8 % [5] Referral was the ideal outcome based on the symptoms; only 8.8 % of consultations were advised to see a doctor (n = 4) or a dentist (n = 1), after medication advice.
Symonds et al. (2011) Europe [UK, Germany, Czech Republic and Spain] [29] To determine if community pharmacists could appropriately recommend suitability for supply of sildenafil 50 mg for the treatment of erectile dysyfunction Cross-sectional observational study of natural patients Concordance rate between pharmacist and physician recommendations. 53 pharmacists, 13 physicians and 346 participants Not recorded Agreement between pharmacist, GP and specialist recommendations assessed. 90 % of cases specialist agreed pharmacist gave an acceptable recommendation.
Varela-Centelles et al. (2012) Spain [42] To assess whether pharmacies and herbalist’s shops were offering appropriate advice for patients seeking guidance on a potentially malignant oral lesion Observational study using pseudo-customer methodology Individual interaction with the interviewee according to a previously prepared script and details were recorded 306 community pharmacies and 154 herbalist shops 27.5 % [84] referrals and 36.3 % [111] referrals in addition to OTC sale The most appropriate outcome was referral. Community pharmacies referred more than herabalists. Pharmacy assistants were more likely to recommend OTC remedies (55.6 % vs. 13 %) and significantly less likely to refer than were pharmacists.
Vella et al. (2009) Malta [26] To design two protocols to help pharmacists care for consumers seeking treatment for headache and back pain and assess pharmacists’ management of these conditions Observational study using pseudo-customer methodology Data for each case and divergence from protocol 10 pharmacies and 212 patient interventions Not recorded Compliance higher when pharmacists responded to symptoms than when product asked for by name - less advice given when product requested.
Watson et al. (2015) UK [64] To compare health-related and cost-related outcomes of consultations for symptoms suggestive of minor ailments in EDs, GPs and community pharmacies. Cross-sectional study 1. Whether health-related and cost-related outcomes differ between settings. 2. Whether satisfaction with index consultation is associated with health-related outcomes. 3. What factors (triggers) influence patients’ choice of care setting. 377 patients participated, recruited from EDs (81), general practices (162) and community pharmacies (134). Not recorded Symptom resolution was similar across all three settings: ED (37.3 %), GP (35.7 %) and pharmacy (44.3 %). Mean overall costs per consultation were significantly lower for pharmacy
Watson et al. (2016) UK To assess what factors predicted whether the supply of a guideline compliance for the supply/non-supply of non-prescription medicines. Observational study using pseudo-customer methodology The questions asked during the consultation and the outcome of the consultation 351 patient visits (but some missing data) Not recorded WWHAM questioning was associated with appropriate outcome. After adjusting for WWHAM scoring the outcome was twice as likely to have an appropriate outcome than other consultations. The likelihood of an appropriate outcome increased if the consultation was conducted by the pharmacist
Westerlund et al. (2003) Sweden [31] To measure the outcomes of a counselling model for dyspepsia Observational study using pseudo-customer methodology All aspects of the interview, recommendation and advice and a follow up interview by research staff 33 pharmacy staff and 319 patients 12 % [39] A counselling model to discover and resolve problems related to symptoms and drug use appeared to have a favourable impact on outcomes. Patient outcome: Only 1/5 customers referred contacted GP. 2/3 reported feeling better following self- care advice.
Westerlund et al. (2007) Sweden [25] To assess the quality of self-care from pharmacist using IT clinical guidelines Cross-sectional study, where outcomes were reviewed by a doctor and follow-up with the patient occurred Questions asked and information given Follow-up with the patient 10 pharmacists and 250 customers Not recorded Self-care counselling when supported by IT-based clinical guidelines is high. Independent assessment found a 97.6 % of the consultations were appropriate. Follow-up found that there was a favourable feedback from patients. Referrals were not included in this study