Do community pharmacies unnecessarily recommend oral emergency contraception? A nationwide mystery caller investigation in Germany

Background: Since 2015, oral emergency contraceptives (ECs) have been available in German community pharmacies without prescription as over-the-counter medicines. Given the financial burden, unnecessary hormonal exposure and associated side effects, systematic information gathering is crucial to prevent unnecessary recommendations. This study aimed to determine whether pharmacy staff ask the checklist questions recommended by the German Federal Chamber of Pharmacists (BAK) guideline and provide correct recommendations when oral EC is not indicated (appropriate outcome), and to examine associated factors. Methods: A nationwide study using the simulated patient methodology – considered the “gold standard” – was conducted with a stratified random sample of 376 community pharmacies across Germany. Eight trained female mystery callers aged 21–24 simulated a scenario in which a combined oral contraceptive was forgotten once after sexual intercourse. However, the pill could still be taken within the 12-hour window, making oral EC unnecessary according to the BAK guideline. To ensure quality, each call was monitored by a second observer. Results: Of 376 mystery calls conducted, 322 were included in the primary analysis. An appropriate outcome was achieved in 44.4% (143/322), while oral EC was unnecessarily recommended in 49.1% (158/322). The median questioning score was 2.0 of 4.0 points. A multivariable logistic regression model showed that a higher questioning score and mystery caller identity were significantly associated with the appropriate outcome. Qualitative findings indicated both positive counseling practices and notable deficiencies among pharmacy staff. Conclusion: The results show deficits in information gathering and appropriate recommendations. To improve counseling, the consistent use of the BAK checklist during telephone consultations should be explicitly recommended in the relevant guideline. Targeted training for pharmacy staff may help address professional and communication deficits. Surprisingly, some mystery callers were significantly associated with the appropriate outcome, highlighting the need for further research on the influence of vocal characteristics and last names in telephone consultations.