Developing a quality framework for community pharmacy: a systematic review of international literature

Objective To identify the defining features of the quality of community pharmacy (CP) services and synthesise these into an evidence-based quality framework. Design Systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data sources International research evidence (2005 onwards) identified from six electronic databases (Embase, PubMed, Scopus, CINAHL, Web of Science and PsycINFO) was reviewed systematically from October 2022 to January 2023. Search terms related to ‘community pharmacy’ and ‘quality’. Eligibility criteria for selecting studies Titles and abstracts were screened against inclusion or exclusion criteria, followed by full-text screening by at least two authors. Qualitative, quantitative and mixed-method studies relevant to quality in CP were included. Data extraction and synthesis A narrative synthesis was undertaken. Following narrative synthesis, a patient and public involvement event was held to further refine the quality framework. Results Following the title and abstract screening of 11 493 papers, a total of 81 studies (qualitative and quantitative) were included. Of the 81 included studies, 43 investigated quality dimensions and/or factors influencing CP service quality; 21 studies assessed patient satisfaction with and/or preferences for CP, and 17 studies reported the development and assessment of quality indicators, standards and guidelines for CPs, which can help define quality. The quality framework emerging from the global literature consisted of six dimensions: person-centred care, access, environment, safety, competence and integration within local healthcare systems. Quality was defined as having timely and physical access to personalised care in a suitable environment that is safe and effective, with staff competent in the dispensing process and pharmacy professionals possessing clinical knowledge and diagnostic skills to assess and advise patients relative to pharmacists’ increasingly clinical roles. Conclusion The emerging framework could be used to measure and improve the quality of CP services. Further research and feasibility testing are needed to validate the framework according to the local healthcare context.

The systematic review is reported using the PRISMA checklist but it is not ref erenced in the manuscript.A statement should be added to the Methods to conf irm that the review complies with and is reported using the PRISMA checklist.
The included studies were not critically appraised.Critical appraisal of the included studies should be undertaken and reported and the results reviewed to determine whether their interpretation is altered as a result of the critical appraisal process.Whilst a several methods were reported across the included studies, many used similar methods e.g.cross-sectional design, and as such critical appraisal should be possible and derive meaningf ul outputs.
More inf ormation should be included regarding the patient and public participants -who were they, how recruited, and so on.What were the actual methods used to present the review results to these individuals and what methods (f ormal or inf ormal) were employed to explore and document their opinions?
The results should be presented to ref lect the order presented in the sentence on page 10 line 27-29 or the sentence could be re-ordered (f or ease).
How are the studies ordered in the Table that describes their method/results?It appears that it might be chronological -oldest to most recent.The authors should consider whether the tabulated results could be re-ordered/grouped to provide additional learning i.e. grouped by country or design, or f ocus etc? A statement should be made in the accompanying text re how the studies are ordered or grouped in the table.Supplementary File 4 -add key to def ine "type" ie.S, P.
Consider removal of terms such as "on the other hand".

REVIEWER
Beverley Glass James Cook University, Pharmacy REVIEW RETURNED 07-Nov-2023

GENERAL COMMENTS
This is an excellent paper -a pleasure to read.Thank you A minor correction -page 7 line 27 Data -------were I am surprised that PPI does not require Ethics as I am not sure this would be the case in Australia.But accept your explanation.
My main concern f or this review is the lack of quality appraisal f or the papers -as per page 4 (Quality of the papers was not critically appraised) and then the inclusion in the limitations of "due to considerably varying methodologies and f indings".This is although in the inclusion criteria, the publication type specif ied.In the systematic reviews in BMJ all I have considered present a quality assessment of papers -using f or example the ROBINS-I f or Quantitative papers and the JB Critical Appraisal f or Qualitative Research.So either including a quality audit or changing the review to a scoping review should be considered.This is very important work and i really look f orward to see how this f ramework progresses and is validated.

Comments: Response
This is an excellent paper -a pleasure to read.Thank you Many thanks.Really glad you enjoyed reading the manuscript.
A minor correction -page 7 line 27 Data -------were We have now implemented this minor correction.
My main concern f or this review is the lack of quality appraisal f or the papers -as per page 4 (Quality of the papers was not critically appraised) and then the inclusion in the limitations of "due to considerably varying methodologies and f indings".This is although in the inclusion criteria, the We strongly agree with this suggestion and have now conducted a critical appraisal.To accommodate f or the varying methodologies, we used multiple checklists f or dif ferent study types.We did not provide cut-of f s as authors of the checklist advised publication type specif ied.In the systematic reviews in BMJ all I have considered present a quality assessment of papers -using f or example the ROBINS-I f or Quantitative papers and the JB Critical Appraisal f or Qualitative Research.So either including a quality audit or changing the review to a scoping review should be considered.This is very important work and i really look f orward to see how this f ramework progresses and is validated.
against this.Furthermore, many of the studies were descriptive in nature.Nevertheless, we included an overall quality statement in the results section along with supplementary file 3, ensuring that all studies and their respective scores are accessible: (methods: page 7): Whilst the methods used for all studies were appropriate, only three 103 105 120 of out the nine Delphi studies fully described the stages of the Delphi process, including a preparatory phase, the actual 'Delphi rounds', interim steps of data processing and analysis, and concluding steps.Furthermore, two of the four mixed methods studies excelled in only one aspect of the mixed methods design.For example, Snyder et al.75achieved high quality in the qualitative elements but demonstrated limitations in the quantitative domain.In contrast, Dadfar et al. 51scored high in the quantitative aspect but lacked in the qualitative dimension."