An evaluation of written materials for supporting hypertensive patient education and counselling when performing a new medicine service in Poland.

BACKGROUND: The New Medicine Service (NMS) was developed in England more than ten years ago, as a three-stage consultation led by community pharmacists to support patients taking new medication for a chronic disease. In Poland, the scheme was officially introduced in January 2023. However, its implementation into common practice has been presented with various obstacles, including the need to develop relationships with general practitioners, resolve the payment structure, and provide training with adequate supporting materials. Hence, written materials have been designed for use as an optional tool for counselling patients receiving an NMS in community pharmacies. METHODS: The present study evaluates the ability of these materials to inform patients about the need to adhere to anti-hypertensive medication. A group of 401 randomly-selected adult visitors to pharmacies and/or healthcare centres were surveyed; one third had hypertension in their history. RESULTS: The structure, grammar and readability of the text achieved the required threshold of 40% according to the Plain Language Index. The designed materials effectively informed the patients about anti-hypertensive medication, reflected in an increased score in a knowledge test, and were rated positively regarding information level, comprehensibility and presentation. CONCLUSION: The proposed material may serve as an additional, "patient-friendly" educational tool for use as part of an NMS.

Evaluation of medication safety assessment tools for pharmacist-led medication reviews: the Eastern European pilot project.

Background: Pharmacist-led medication reviews (MR) are one of the key methods to support medication safety in polypharmacy patients. The aims of this study were to pilot MRs in Eastern European community pharmacies, describe medication use in polypharmacy patients, and evaluate the usability of medication safety assessment tools. Methods: The MR pilot was undertaken in Estonia, Latvia, Poland, Hungary, Romania, and Bulgaria. Patients who used at least five medicines were directed to the service by their GPs. Data on drug-related problems (DRPs) and adherence were collected by pharmacists through structured patient interviews. Databases for identification of potential drug-drug interactions (pDDIs) and adverse drug reactions (ADRs) named Inxbase/Riskbase, as well as an integrated tool comprising potentially inappropriate medicines (PIMs) lists EU(7)-PIM and EURO-FORTA, were applied retroactively to the MR pilot data to investigate possibilities for their use and to describe medication use and potential risks in the study population. Results: A total of 318 patients were included in the study, 250 of them elderly (≥65 years). One hundred and eighty (56.6%) participants had a total of 504 pDDIs based on Inxbase analysis. On average, there were 1.6 pDDIs per participant. Twenty-five (5.0%) of the 504 pDDIs were in a high-risk category. A total of 279 (87.7%) participants had a potential ADR in at least one of 10 Riskbase categories. One hundred and fifty-four (20.8%) of the potential ADRs were in a high-risk category. Twenty-seven pDDIs and 68 ADRs documented as DRPs during the service were not included in the databases. Using the integrated EU(7)-PIM/EURO-FORTA PIM list, a total of 816 PIMs were found in 240 (96%) of the 250 elderly participants (on average 3.4 PIMs per elderly participant). Seventy-one (29.6%) of the participants were using high-risk PIMs. Twenty-one percent of high-risk PIMs and 13.8% of medium-risk PIMs were documented as DRPs by the pharmacists during the pilot. Conclusion: Medication safety assessment tools can be useful in guiding decision-making during MRs; however, these tools cannot replace patient interviews and monitoring. Tools that include a thorough explanation of the potential risks and are easy to use are more beneficial for MRs.

Exploring the feasibility of using the ICER Evidence Rating Matrix for Comparative Clinical Effectiveness in assessing treatment benefit and certainty in the clinical evidence on orphan therapies for paediatric indications.

BACKGROUND: The evaluation of clinical evidence takes account of health benefit (efficacy and safety) and the degree of certainty in the estimate of benefit. In orphan indications practical and ethical challenges in conducting clinical trials, particularly in paediatric patients, often limit the available evidence, rendering structured evaluation challenging. While acknowledging the paucity of evidence, regulators and reimbursement authorities compare the efficacy and safety of alternative treatments for a given indication, often in the context of the benefits of other treatments for similar or different conditions. This study explores the feasibility of using the Institute for Clinical and Economic Review (ICER) Evidence Rating Matrix for Comparative Clinical Effectiveness in structured assessment of both the magnitude of clinical benefit (net health benefit, NHB) and the certainty of the effect estimate in a sample of orphan therapies for paediatric indications. RESULTS: Eleven systemic therapies with European Medicines Agency (EMA) orphan medicinal product designation, licensed for 16 paediatric indications between January 2017 and March 2020 were identified using OrphaNet and EMA databases and were selected for evaluation with the ICER Evidence Rating Matrix: burosumab; cannabidiol; cerliponase alfa; chenodeoxycholic acid (CDCA); dinutuximab beta; glibenclamide; metreleptin; nusinersen; tisagenlecleucel; velmanase alfa; and vestronidase alfa. EMA European Public Assessment Reports, PubMed, EMBASE, the Cochrane Library, Clinical Key, and conference presentations from January 2016 to April 2021 were searched for evidence on efficacy and safety. Two of the identified therapies were graded as "substantial" NHB: dinutuximab beta (neuroblastoma maintenance) and nusinersen (Type I SMA), and one as "comparable" NHB (CDCA). The NHB grade of the remaining therapies fell between "comparable" and "substantial". No therapies were graded as having negative NHB. The certainty of the estimate ranged from "high" (dinutuximab beta in neuroblastoma maintenance) to "low" (CDCA, metreleptin and vestronidase alfa). The certainty of the other therapies was graded between "low" and "high". The ICER Evidence Rating Matrix overall rating "A" (the highest) was given to two therapies, "B+" to 6 therapies, "C+" to five therapies, and "I" (the lowest) to three therapies. The scores varied between rating authors with mean agreement over all indications of 71.9% for NHB, 56.3% for certainty and 68.8% for the overall rating. CONCLUSIONS: Using the ICER Matrix to grade orphan therapies according to their treatment benefit and certainty is feasible. However, the assessment involves subjective judgements based on heterogenous evidence. Tools such as the ICER Matrix might aid decision makers to evaluate treatment benefit and its certainty when comparing therapies across indications.

Donor Safety, Discrepancies Between Practice and Theory: Analysis of the Polish Supreme Audit Office's Report.

The introduction and development of genetic testing has caused the emergence of numerous dilemmas, which pertain to the performed tests, their results, and the influence they have on an individual person. To minimize potential doubts, it is crucial to ensure compliance with established procedures and to fulfill all test-associated formalities. In 2018, a report of the Polish Supreme Audit's Office (a governmental control agency) on the quality of genetic tests revealed that there is much to be done in the field of laboratory diagnostics in Poland. The inspection of six selected laboratories performing genetic tests identified shortcomings in terms of formalities accompanying the process of performing laboratory tests, keeping patient documentation and personal data protection. Although the observed shortcomings pertained to legal aspects of genetic tests, and not the quality of the tests themselves, the aforementioned may be detrimental to the individual person and the society (eg, lack of consent undermines the concept of biological material ownership), may cause legal liability to the laboratory personnel and even undermine public trust in genetic testing.

Diet Quality and Level of Nutrition Knowledge among Young People with Orthorexic Tendencies.

The aim of the study was to determine the level of nutrition knowledge and diet quality, understood in terms of healthy and unhealthy eating habits, among young people with orthorexic tendencies. The participants were school students, university students, and those employed in the Lublin region (N = 473). The data were collected by means of a questionnaire. The participants were asked to provide socio-demographic data through filling in the ORTO-15 questionnaire and the Dietary Habits and Nutrition Beliefs Questionnaire (KomPAN). The participants obtained results ranging from 9.3 to 100 (M = 31.15; SD = 11.81) in the non-healthy diet index, from 0.4 to 78.6 in the pro-healthy diet index (M = 21.79; SD = 11.08), and from 0 to 23 in the domain of nutrition knowledge (M = 13; SD = 4.23). A variance analysis showed no significant differences between the pro-healthy diet index and the level of nutrition knowledge. The group with orthorexia obtained statistically higher results in the pro-healthy diet index. Those with a tendency toward orthorexia obtained statistically higher results in the non-healthy diet index. The variance analysis showed that the level of nutrition knowledge of those not focused on healthy foods was significantly lower than in the other groups. The results of the ORTO-15 questionnaire correlated negatively with the pro-healthy diet index and the level of nutrition knowledge, and positively with the non-healthy diet index. We concluded that: 1. the orthorexic group and the group with a tendency toward orthorexia could be characterized with a moderate intensity of a healthy diet and a low intensity of a non-healthy diet; and 2. the level of nutrition knowledge in the orthorexic group did not significantly differ from that of the other groups.

Orthorexic tendencies and the structure of achievement motivation in young people in Poland.

OBJECTIVES: Studies on the psychological aspects of orthorexia nervosa are scarce. What has been studied to date is the correlation between orthorexia nervosa and self-esteem, perfectionism, and personality. The aim of this study is to verify whether patients suffering from orthorexia or those who have a tendency for orthorexia differ in terms of achievement motivation from a healthy control group. METHODS: The study was conducted in the group of 252 medical students. The study relied on the ORTO-15 questionnaire, Eating Attitudes Test-26, and Inventory of Achievement Motivation (Leistungsmotivationsinventar). RESULTS: Patients with a tendency for orthorexia showed higher results in terms of preference of challenging tasks, belief in success, motivation to learn, goal orientation, compensatory effort, care for prestige, achievement satisfaction, and general achievement motivation, as well as self-confidence and ambition. CONCLUSIONS: Patients who suffer from orthorexia differ from those in the control group in terms of achievement motivation. In some respect, their results are parallel to those obtained from girls with anorexia readiness syndrome, which can lead to the conclusion that both orthorexia and anorexia belong to the spectrum of eating disorders.

Interdisciplinary Cooperation between Pharmacists and Nurses-Experiences and Expectations.

BACKGROUND: Getting to know the experience gained so far between professions such as pharmacists and nurses allows for introducing changes aimed at better cooperation, and that can improve the quality of patient care. The aim was to obtain the nurses' opinions on the ongoing cooperation with pharmacists and to analyze the possibilities of cooperation between these groups. METHODS: The survey was conducted from January to March 2021 among 124 nurses in Poland. The link to the electronic questionnaire was sent by e-mails sourced from online social groups for nurses. Before completing the questionnaire, each participant was informed about the anonymous research and the purpose of the data obtained. RESULTS: In total, 80.6% of the respondents confirmed that the pharmacist is a reliable advisor in the field of general information about a drug and 60.9% in the field of clinical information about the drug, and 54.8% of the nurses agreed that a pharmacist should carry out such practices as measuring blood pressure or glucose in a community pharmacy, with 70.1% agreeing that a pharmacist should provide pharmaceutical care in a community pharmacy in the future and the most convinced of this were people with a master's degree. Of the respondents, 74.1% indicated that pharmacist advice should be fully reimbursed by the National Health Fund or another insurance institution. CONCLUSIONS: The study showed that the nursing community appreciates the role of pharmacists and has a positive attitude towards cooperation with this professional group. What is more is that it indicates willingness for interdisciplinary cooperation.

Prescriptions as quality indicators of pharmaceutical services in Polish community pharmacies.

BACKGROUND: Assessment of community pharmacies' quality of service is a very difficult task, resulting from the multiplicity and variety of provided services as well as patient-related factors (i.e. their health condition, expectations, education level or cultural and social background). Although proceedings of pharmaceutical professionals are to a great extend legally determined and described in various acts and regulations, work diligence should be one of the most characteristic traits of a professional pharmacy employee. Many publications addressing the quality of services provided by pharmaceutical employees focus on patient satisfaction, here the authors focused on more objective methods i.e. prescription analysis. OBJECTIVE: The main aim of the study was to assess whether post-inspection National Health Fund reports would constitute a reliable source of quality assessment of pharmaceutical services provided by community pharmacies. METHODS: The study is an in-depth quality and quantity analysis of 28 post-inspection quarterly reports conducted by the National Health Fund between 2013 and 2019. RESULTS: Vast majority of inspections ended in stating a variety of irregularities. CONCLUSIONS: The analysis of irregularities contained in the National Health Fund's post-inspection reports does not seem an appropriate indicator of assessing the quality of pharmaceutical services provided in community pharmacies, because of its targeted character. Inappropriate performance of professional duties by staff members is the main source of irregularities in the implementation of prescriptions for reimbursable medications. There is a need to improve staffs' professional competence and ultimately the quality of pharmaceutical services.

Factors Facilitating and Hindering Development of a Medication Use Review Service in Eastern Europe and Iran-Cross-Sectional Exploratory Study.

Polypharmacy is a common issue in patients with chronic diseases. Eastern-European countries and Iran are exploring possibilities for implementing the Medication Use Review (MUR) as a measure for optimizing medication use and ensuring medication safety in polypharmacy patients. The aim of this study was to gain insights into the development of the community pharmacy sector and map facilitators and barriers of MUR in Eastern Europe and Iran. The representatives of the framework countries received a questionnaire on community pharmacy sector indicators, current and future developments of pharmacies, and factors encouraging and hindering MUR. To answer the questionnaire, all representatives performed document analysis, literature review, and qualitative interviews with key stakeholders. The socio-ecological model was used for inductive thematic analysis of the identified factors. Current community pharmacist competencies in framework countries were more related to traditional pharmacy services. Main facilitators of MUR were increase in polypharmacy and pharmaceutical waste, and access to patients' electronic list of medications by pharmacists. Main barriers included the service being unfamiliar, lack of funding and private consultation areas. Pharmacists in the framework countries are well-placed to provide MUR, however, the service needs more introduction and barriers mostly on organizational and public policy levels must be addressed.

Safety of Medical Devices in Poland - Analysis of Withdrawn and Suspended Certificates of Compliance.

INTRODUCTION: In the European Union, the process of controlling currently used medical devices is carried out and determined by legal provisions. The law stipulates that each entity responsible for using medical equipment must confirm its safety with an appropriate certificate issued by a notifying body. In Poland, the entity responsible for keeping records as to the withdrawn and suspended certificates, is the Office for Registration of Medicinal Products, Medical Devices, and Biocidal Products (URPL). Certification is required for all medical devices prior to their introduction onto the market and during their use. PURPOSE: The article presents data concerning the number of medical devices that failed to meet the certification criteria. METHODS: The research method is an analysis of available subject literature and a report on withdrawn and suspended certificates of medical devices in Poland. RESULTS: In the years 2014-2020, the notified bodies withdrew and suspended 13,354 certificates for medical devices, of which 9792 certificates were withdrawn, 2852 suspended and one falsified. CONCLUSION: The suspension or withdrawal of a certificate for medical devices due to the inefficiency, obsolescence, imprecision, or safety of the devices is an action that improves the safety of patients. Such action reduces the number of medical damages and the obligation to pay compensation to those injured.

Prevalence and Characteristics of Orthorectic Disorders in Adolescence and Young People: Polish Preliminary Studies.

The aim of this work was to assess orthorectic behaviors among young people and to evaluate their attitudes towards caring for their health. The study was conducted in 2019 on a group of 538 respondents aged 16-35. After analysis, 65 questionnaires were eliminated from further research, and the assessment of orthorectic disorders was performed using a method based on the modified ORTO-15 questionnaire on a group of 473 respondents. A large percentage of them exhibited an increased risk of orthorectic behaviors (32.8), which was higher among women than men (34.7% and 28.2%, respectively). People with higher risks of orthorectic disorders significantly more often reduced their consumption of foods high in fats and sugars. Attitudes of people with orthorectic disorders towards health care proved neutral, with a tendency to be positive. Nutritional behaviors observed in the studied group show some irregularities, which indicates the need for preventive and educational measures aimed at increasing awareness of the role of proper nutrition among young people. The obtained results may be the basis for further research on ON symptoms. One of the major areas of future research would be to create a reliable diagnostic tool which would allow for distinguishing between orthorexia and overdiagnosis.

Flu Vaccinations in Pharmacies-A Review of Pharmacists Fighting Pandemics and Infectious Diseases.

The phenomenon of population ageing observed over recent years involves growing healthcare needs and the limited staffing and financing of healthcare systems, and as such demands some functional changes in the healthcare model in many countries. This situation is particularly significant in the face of a pandemic, e.g., flu, and currently COVID-19.As well as social education, preventive vaccinations are the most effective method of fighting the infectious diseases posing a special threat to seniors. Despite this, the vaccination coverage level in most European countries is relatively low. This is largely due to patients having limited access to vaccinations. In some countries, implementing vaccinations in pharmacies and by authorized pharmacists has significantly improved vaccination coverage rates and herd immunity, while lowering the cost of treating infections and the resulting complications, as well as minimizing the phenomenon of inappropriate antibiotic therapies. This article presents the role of pharmacists in the prevention of infectious diseases, pointing out the measurable effects of engaging pharmacists in conducting preventive vaccinations, as well as analyzing the models of implementing and conducting vaccinations in pharmacies in selected countries, and depicting recommendations regarding vaccinations developed by international organizations. The presented data is used to suggest requirements for the implementation of preventive vaccinations in community pharmacies.

Self-reported perinatal depressive symptoms and postnatal symptom severity after treatment with antidepressants in pregnancy: a cross-sectional study across 12 European countries using the Edinburgh Postnatal Depression Scale.

PURPOSE: This study aimed at exploring the prevalence of self-reported antenatal and postnatal depressive symptoms by severity across multiple countries and the association between antidepressant treatment in pregnancy and postnatal symptom severity. MATERIALS AND METHODS: This was a multinational web-based study conducted across 12 European countries (n=8069). Uniform data collection was ensured via an electronic questionnaire. Pregnant women at any gestational week and mothers of children with <1 year of age could participate. We used the Edinburgh Postnatal Depression Scale (EPDS) to measure the prevalence of antenatal and postnatal depressive symptoms according to severity, which were corrected by survey weight adjustment (descriptive analysis). Within mothers with a psychiatric disorder (n=173), we estimated the association between antidepressant treatment in pregnancy and postnatal depressive symptom severity, as standardized EPDS mean scores, via the inverse probability of treatment weight (association analysis). RESULTS: In the descriptive analysis (n=8069), the period prevalence of moderate-to-very severe depressive symptoms was higher in the western and eastern regions relative to the northern region, both in the antenatal period (6.8%-7.5% vs 4.3%) and in the postnatal period (7.6% vs 4.7%). One in two mothers with psychiatric disorders used an antidepressant in pregnancy (86 of 173). In the association analysis, women medicated at any time during pregnancy (adjusted ß=-0.34, 95% confidence interval [CI] =-0.66, -0.02) had a significant postnatal symptom severity reduction compared with the nonmedicated counterpart. This effect was larger (ß=-0.74, 95% CI =-1.24, -0.24) when the analysis was restricted to mothers within 6 months after childbirth. CONCLUSION: The prevalence of self-reported antenatal and postnatal depressive symptoms differs across European countries. Among women with psychiatric disorders, those who had been on treatment with antidepressants during pregnancy were less likely to report postnatal depressive symptoms, particularly within the 6-month period after childbirth, compared with the nonmedicated counterpart.

The European Falsified Medicines Directive in Poland: background, implementation and potential recommendations for pharmacists.

By February 2019, the Polish pharmaceutical industry, community and hospital pharmacies, wholesalers and parallel traders must all comply with the EU-wide Falsified Medicines Directive (FMD) legislation (2011/62/EU), to ensure that no medicinal product is dispensed to a patient without proper tracking and authentication. Here we describe how Poland is complying with the new EU regulations, the actions that have been taken to incorporate the FMD into Polish Pharmaceutical Law and whether or not these actions are sufficient. We found that Poland is only partially compliant with the FMD and further actions need to be undertaken to fully meet the Delegated Act (DA) requirements. Moreover, there is lack of awareness in Poland about the prevalence of falsified medication and the time scale required for implementation of the DA. Based on our findings, we suggest that a public awareness campaign should be started to raise awareness of the increased number of falsified medicines in the legal supply chain and that drug authorisation systems are implemented by Polish pharmacies to support the FMD.

What does the Cantril Ladder measure in adolescence?

INTRODUCTION: The Cantril Scale (CS) is a simple visual scale which makes it possible to assess general life satisfaction. The result may depend on the health, living, and studying conditions, and quality of social relations. The objective of this study is to identify key factors influencing the CS score in Polish adolescents. MATERIAL AND METHODS: The survey comprised 1,423 parent-child pairs (54% girls; age range: 10-17; 67.3% urban inhabitants; 89.4% of parents were mothers). Linear and logistic models were estimated; the latter used alternative divisions into "satisfied" and "dissatisfied" with life. In addition to age and gender, child-reported KIDSCREEN-52 quality of life indexes were taken into account, along with some information provided by parents - child physical (CSHCN) and mental (SDQ) health, and family socio-economic conditions. RESULTS: According to the linear model, nine independent predictors, including six dimensions of KIDSCREEN-52, explain 47.2% of the variability of life satisfaction on the Cantril Scale. Self-perception was found to have a dominating influence (ΔR2 = 0.301, p < 0.001). Important CS predictors also included Psychological Well-being (ΔR2 = 0.088, p < 0.001) and Parent Relations (ΔR2 = 0.041, p < 0.001). The impact of socioeconomic factors was more visible in boys and in older adolescents. According to logistic models, the key factors enhancing the chance of higher life satisfaction are Moods and Emotions (cut-off point CS > 5) and School Environment (CS > 8 points). None of the models indicated a relationship between the CS and physical health. CONCLUSIONS: The Cantril Scale can be considered a useful measurement tool in a broad approach to psychosocial adolescent health.

Care of cancer patients with liver and bone metastases - the place of pharmaceutical care in a balanced plan, focused on the patient's needs and goals.

Metastatic cancer, especially in the growing population of geriatric patients, presents a big challenge to these patients, as well as to treatment teams and the entire health care system. This article describes some common medical problems faced by patients with metastases to liver and bone, and presents a diagnostic approach, and therapeutic management of various symptoms, relevant to advanced stages of the malignant disease. The article highlights the importance of patient education on various aspects of metastatic cancer, and underscores the unique position of pharmacists practicing pharmaceutical care, which is particularly beneficial in this group of patients with advanced malignancy. Also, this paper emphasizes that achieving a proper balance between managing the malignant disease and maintaining the patients' quality of life, especially in the elderly population, should involve coordinated efforts of the oncology treatment team, primary care physicians, pharmacists, therapists and nurses, as well as patients, their families and caregivers.

Hospital Audit as a Useful Tool in the Process of Introducing Falsified Medicines Directive (FMD) into Hospital Pharmacy Settings-A Pilot Study.

BACKGROUND: Recently, the European Union has introduced the Falsified Medicines Directive (FMD). Additionally, in early 2016, a Delegated Act (DA) related to the FMD was published. The main objective of this study was to evaluate the usefulness of external audits in the context of implementing new regulations provided by the FMD in the secondary care environment. METHODS: The external, in-person workflow audits were performed by an authentication company in three Polish hospital pharmacies. Each audit consisted of a combination of supervision (non-participant observation), secondary data analysis, and expert interviews with the use of an independently designed authorial Diagnostic Questionnaire. The questionnaire included information about hospital drug distribution procedures, data concerning drug usage, IT systems, medication order systems, the processes of medication dispensing, and the preparation and administration of hazardous drugs. Data analysis included a thorough examination of hospital documentation in regard to drug management. All data were subjected to qualitative analysis, with the aim of generating meaningful information through inductive inference. RESULTS: Only one dispensing location in the Polish hospitals studied has the potential to be a primary authentication area. In the audited hospitals, an Automated Drug Dispensing System and unit dose were not identified during the study. Hospital wards contained an enclosed place within the department dedicated to drug storage under the direct supervision of senior nursing staff. An electronic order system was not available. In the largest center, unused medications are re-dispensed to different hospital departments, or may be sold to various institutions. Additionally, in one hospital pharmacy, pharmacists prepared parenteral nutrition and chemotherapeutic drugs for patients admitted to the hospital. CONCLUSIONS: External audits might prove beneficial in the course of introducing new regulations into everyday settings. However, such action should be provided before the final implementation of authentication services. To sum up, FMD can impact several hospital departments.

QUALITY OF PHARMACEUTICAL CARE AT THE STAGE OF PATIENTS' NEEDS IDENTIFICATION UNDER CONDITIONS OF COMMUNITY PHARMACIES AS A TRANSBORDER PROBLEM.

The results of the study of the real pharmaceutical practice in relation to the patient's needs identification defined that the problem of not always high pharmaceutical care quality at this stage is equally up-to-date for the community pharmacies of Lviv (Ukraine) and Lublin (Poland). It was found that the quantity and amount of questions set by a pharmacist are not related to the conversation duration with a pharmacy visitor, and the communication duration does not have the statistically confirmed dependence on the queue availability, therefore in the context of pharmaceutical care quality, these criteria are of no high importance. Instead, drug-related problems (n = 209) verified by the authors of this article,tthat have been distributed into the groups according to the criterion of the information amount received by a pharmacist studying the needs of the patient (visitor of a pharmacy), were determined as a quantitative indicator of potential pharmaceutical care quality increase.