The study is notable not only for the size of the improvement but also for the methodological machinery behind it. Rather than relying on vague notions of good practice, the team built on an indicator system developed in earlier methodological work using the Delphi method, a structured consensus technique in which panels of experts iteratively rate and refine candidate quality measures until stable agreement is reached. The indicators were then weighted using the Analytic Hierarchy Process, a mathematical framework that converts expert judgments into consistent numerical priorities. This combination produced a set of twenty indicators spanning three categories: structural indicators, which measure whether the resources, protocols, and personnel needed for good pharmaceutical care are in place; process indicators, which measure whether recommended actions such as pain assessment and medication counseling are actually performed; and outcome indicators, which measure whether patients achieve adequate pain control in the end.

To turn those indicators into a single, interpretable score, the researchers employed TOPSIS, the Technique for Order Preference by Similarity to Ideal Solution. TOPSIS is a multi-criteria decision analysis method that positions each evaluated case in a multidimensional space defined by the indicator values, then calculates how close that case sits to an ideal solution, in which every indicator reaches its best possible value, and how far it sits from the worst possible solution. The resulting closeness coefficient, denoted C(i), ranges from zero to one and serves as a composite measure of pharmaceutical care quality. The team pre-specified a threshold of C(i) of at least 0.6 as the definition of overall adherence, giving the study an objective and reproducible yardstick rather than a subjective judgment call.

The evaluation took the form of a single-center before-and-after study with a historical control. First, the researchers retrospectively assessed a pre-intervention cohort of 100 patients who underwent elective orthopedic surgery between November 2024 and January 2025, establishing the baseline reference for pharmaceutical care quality. They then designed and introduced targeted interventions aimed at the weaknesses revealed by the indicator analysis. Finally, they prospectively evaluated a post-intervention cohort of 100 patients treated between April and June 2025. Each group comprised 200 patients in total across the study, and the two cohorts were compared on overall adherence and on the full-score attainment rates of the individual quality indicators, with a Bonferroni correction applied to guard against false positives arising from multiple statistical comparisons.

The headline result was striking. Overall adherence to pharmaceutical care standards, defined as a TOPSIS closeness coefficient of at least 0.6, increased from 41 percent in the pre-intervention cohort to 91 percent in the post-intervention cohort. That corresponds to a risk difference of 50 percentage points, with a 95 percent confidence interval of 37.83 to 60.05 and a P value below 0.001. The median difference in the composite score itself was 0.32, with a 95 percent confidence interval of 0.26 to 0.38. In practical terms, roughly nine out of ten surgical patients after the intervention received pharmaceutical care that met the expert-defined standard, compared with fewer than half before.

Because before-and-after studies with historical controls are vulnerable to bias, particularly when some documentation is missing from the earlier records, the team performed a sensitivity analysis to test how robust their conclusion was. The concern is straightforward: if documentation quality improved over time for reasons unrelated to actual care, some of the apparent improvement might be an artifact. The researchers therefore recalculated the comparison under the most optimistic assumption for the missing pre-intervention data, that is, the assumption most favorable to the baseline group. Even under that scenario, the post-intervention group remained significantly higher, at 91 percent versus 55 percent, with P below 0.001. The finding, in other words, survived a deliberately conservative stress test.

Dissecting the results by indicator type revealed a nuanced pattern. The four structural indicators showed descriptive improvements, with absolute increases ranging from 34 to 60 percentage points, suggesting that the intervention strengthened the underlying infrastructure of pharmaceutical care, such as the availability of standardized protocols and dedicated pharmacist involvement. Among the remaining sixteen indicators, multimodal analgesia, the practice of combining several analgesic mechanisms to achieve better pain relief with lower opioid doses, showed no statistically significant difference, sitting at 96 percent versus 99 percent. This ceiling effect is itself informative: the baseline performance was already near maximal, leaving little room for improvement on that particular measure.

The process and outcome indicators told a more varied story. Of the fifteen indicators in these categories other than multimodal analgesia, thirteen remained statistically significant after the stringent Bonferroni correction, which set the significance threshold at an adjusted alpha of 0.0031. Their risk differences ranged from 14 to 33 percentage points, indicating substantial and reliable gains in the day-to-day execution of pharmaceutical care and in intermediate clinical results. Two outcome indicators, however, did not clear the adjusted threshold: achievement of target resting pain control improved by 17 percentage points, and the combined indicator covering breakthrough pain incidence and its management improved by 10 percentage points, but neither reached the corrected level of significance. This suggests that while the machinery of care, the assessments, the documentation, and the medication management processes, improved dramatically, the ultimate clinical endpoints moved more modestly and require further work to confirm.

The authors are candid about the limitations of their design. A historical control cannot exclude secular trends, such as parallel improvements in staffing, awareness, or documentation practices that occurred between the two study windows. The reliance on a composite TOPSIS measure, while mathematically elegant, means that the headline adherence figure aggregates many distinct aspects of care, and the single-center setting raises questions about whether the same gains could be replicated in hospitals with different resources, case mixes, and pharmacy services. The two-month post-intervention window also leaves open the question of whether the improvements can be sustained over the long term, a common challenge for quality improvement programs of all kinds.

Even with those caveats, the study delivers something the perioperative pain field has lacked: empirical evidence that a rigorously constructed quality indicator system, combining Delphi consensus, hierarchical weighting, and TOPSIS scoring, can be implemented in routine clinical practice and can drive measurable, robust improvements in pharmaceutical care. The work provides a practical reference for hospitals seeking to formalize the pharmacist’s role in orthopedic pain management, and it demonstrates that quality in pharmaceutical care need not remain an abstraction. If the approach generalizes, the humble checklist of well-weighted indicators may prove to be one of the most effective tools yet for ensuring that patients waking up from orthopedic surgery receive the pain care that guidelines have long promised them.

Subject of Research: Quality indicators for pharmaceutical care in orthopedic perioperative pain management

Article Title: Application and evaluation of a quality indicator system for pharmaceutical care in orthopedic perioperative pain management

Article References: Zhu, Q., Feng, P., Chen, X., Huang, J., & Chen, Y. (2026). Application and evaluation of a quality indicator system for pharmaceutical care in orthopedic perioperative pain management. PLOS One, 21(10), e0360057. https://doi.org/10.1371/journal.pone.0360057

Image Credits: AI Generated

DOI: 10.1371/journal.pone.0360057

Keywords: pharmaceutical care, perioperative pain management, orthopedic surgery, quality indicators, TOPSIS, Delphi method, Analytic Hierarchy Process, multimodal analgesia, patient safety, clinical pharmacy, quality improvement, pain control

The study, led by Larissa Couto-Rosa and colleagues at the Federal University of Espírito Santo, set out to fill a conspicuous gap. International research had repeatedly suggested that pharmacists in many countries hold unsatisfactory knowledge about ASD, which can interfere with the quality of care they deliver. Yet until now, no nationwide study had ever assessed the knowledge of Brazilian pharmacists about the disorder. Given that Brazil has one of the largest pharmacy workforces in the world and a universal health system that relies heavily on pharmaceutical services, the absence of such data was a genuine blind spot in health services research.

To close that gap, the team conducted a cross-sectional survey running from June 2021 to August 2022. Pharmacists from all five regions of Brazil were selected by convenience sampling and answered an online questionnaire, open from June 2021 to February 2022, that collected sociodemographic information and measured both knowledge and stigma related to ASD. The instrument at the heart of the study was the Brazilian version of the Autism Stigma and Knowledge Questionnaire, known as the ASK-Q, a validated tool that breaks understanding of autism into distinct domains: diagnosis, etiology, and treatment, alongside items probing stigmatizing attitudes.

The technical thresholds of the ASK-Q are worth understanding, because they set a demanding bar. To be classified as having adequate knowledge, respondents needed to score at least 92.3 percent on the diagnosis domain, 88.7 percent on etiology, and 92.9 percent on treatment. On the stigma scale, the expectation is even stricter: respondents should not endorse stigma at all, with the cut-off set at 99.01 percent. These are not lenient benchmarks. They require near-complete mastery of facts about how autism is identified, what causes it, and how it is treated, as well as the complete absence of misconceptions that have historically surrounded the condition.

Against those demanding standards, the 413 participating pharmacists performed remarkably well. Almost all respondents demonstrated adequate knowledge in every clinical domain: 99.0 percent reached the threshold for etiology, 99.0 percent for diagnosis, and 98.8 percent for treatment. Perhaps most striking of all, every single participant, 100.0 percent, declined to endorse stigma toward people with autism. In a field where international studies have often painted a more troubling picture of gaps and misconceptions among frontline health workers, the Brazilian results stand out as an unusually strong foundational understanding of the disorder.

The survey also revealed a clear pattern in where that knowledge came from. Pharmacists who had a family member with ASD achieved the highest rates of correct answers in the diagnosis domain, a difference that was statistically significant with a p-value below 0.001. Similarly, pharmacists who had direct contact with a person with autism scored highest on the etiology and diagnosis domains, with p-values of 0.004 and 0.002 respectively. In other words, personal exposure to autism, whether through family ties or professional and social contact, was the strongest predictor of deeper understanding. Knowledge, it seems, travels through lived experience more powerfully than through formal training alone.

The demographic profile of the sample adds important context. The majority of participants, 81.1 percent, were women, which mirrors the composition of the pharmacy profession in Brazil and much of the world. The researchers emphasize that the sample was comprehensive, spanning different age groups and socioeconomic backgrounds across the country’s five regions, which strengthens the generalizability of the findings. At the same time, they are candid about a key limitation: because convenience sampling was used, individuals with greater awareness of or interest in autism may have been more likely to agree to participate. That means the true national average could plausibly be lower than the near-perfect scores reported, a caveat that any interpretation of the results must carry.

The study was conducted with rigorous ethical oversight. It was approved by the Human Research Ethics Committee under registration CAAE 39222520.6.0000.8151, carried out in accordance with the Declaration of Helsinki, and all participants provided informed consent and agreed to confidentiality and privacy statements. The statistical analysis was appropriately matched to the data: descriptive statistics summarized the sample, the Mann-Whitney test compared unpaired samples, and the chi-square test assessed associations with categorical variables. The research received no external financial support and was conducted by a team affiliated with the Federal University of Espírito Santo and the Federal University of Catalão.

Why does pharmacist knowledge about autism matter so much in practice? Pharmacists occupy a unique position in the medication-use system. They counsel families starting new therapies, monitor for adverse effects and drug interactions, and increasingly participate in pharmaceutical care programs within Brazil’s unified health system, the SUS. For autistic patients, who may take psychotropic medications or manage co-occurring conditions, a pharmacist who understands the disorder can communicate more effectively, adapt counseling to sensory and communication needs, and flag inappropriate prescriptions. Conversely, a pharmacist who misunderstands autism may reinforce myths, dismiss family concerns, or fail to recognize when a referral is needed. The near-universal absence of stigmatizing attitudes found in this survey is particularly encouraging, because stigma is often the hardest barrier to dismantle.

The authors argue that their findings should feed directly into policy and education. The results, they write, may contribute to strategies to improve knowledge about ASD, such as continuing education programs, integrating autism training into pharmacy curricula, and public health campaigns. They may also influence public policies, clinical practices, and future research in pharmacy and autism care. Given the strong baseline documented here, the priority shifts from remediation to refinement: embedding structured ASD content into professional education so that understanding does not depend on personal contact with an autistic person. For a profession that sees millions of Brazilians every day, even incremental gains in knowledge could translate into earlier recognition of developmental concerns and better support for autistic individuals and their families, long before they reach a specialist’s office.

Subject of Research: Pharmacists' knowledge and stigma regarding autism spectrum disorder in Brazil

Article Title: Pharmacists’ knowledge about Autism Spectrum Disorder – a national survey

Article References: Couto-Rosa, L., Schultz, P. V., Brambila-Manso, B., Rocha, K. S., Ayres, L., Araújo, D. C., & Santos-Júnior, G. A. D. (2026). Pharmacists’ knowledge about Autism Spectrum Disorder – a national survey. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15564-1

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15564-1

Keywords: autism spectrum disorder, pharmacists, Brazil, national survey, health services research, ASK-Q questionnaire, stigma, pharmaceutical care, continuing education, cross-sectional study, public health, diagnosis knowledge