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      Pharmacist services for non-hospitalised patients

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          Abstract

          This review focuses on non‐dispensing services from pharmacists, i.e. pharmacists in community, primary or ambulatory‐care settings, to non‐hospitalised patients, and is an update of a previously‐published Cochrane Review. To examine the effect of pharmacists' non‐dispensing services on non‐hospitalised patient outcomes. We searched CENTRAL, MEDLINE, Embase, two other databases and two trial registers in March 2015, together with reference checking and contact with study authors to identify additional studies. We included non‐English language publications. We ran top‐up searches in January 2018 and have added potentially eligible studies to 'Studies awaiting classification'. Randomised trials of pharmacist services compared with the delivery of usual care or equivalent/similar services with the same objective delivered by other health professionals. We used standard methodological procedures of Cochrane and the Effective Practice and Organisation of Care Group. Two review authors independently checked studies for inclusion, extracted data and assessed risks of bias. We evaluated the overall certainty of evidence using GRADE. We included 116 trials comprising 111 trials (39,729 participants) comparing pharmacist interventions with usual care and five trials (2122 participants) comparing pharmacist services with services from other healthcare professionals. Of the 116 trials, 76 were included in meta‐analyses. The 40 remaining trials were not included in the meta‐analyses because they each reported unique outcome measures which could not be combined. Most trials targeted chronic conditions and were conducted in a range of settings, mostly community pharmacies and hospital outpatient clinics, and were mainly but not exclusively conducted in high‐income countries. Most trials had a low risk of reporting bias and about 25%‐30% were at high risk of bias for performance, detection, and attrition. Selection bias was unclear for about half of the included studies. Compared with usual care, we are uncertain whether pharmacist services reduce the percentage of patients outside the glycated haemoglobin target range (5 trials, N = 558, odds ratio (OR) 0.29, 95% confidence interval (CI) 0.04 to 2.22; very low‐certainty evidence). Pharmacist services may reduce the percentage of patients whose blood pressure is outside the target range (18 trials, N = 4107, OR 0.40, 95% CI 0.29 to 0.55; low‐certainty evidence) and probably lead to little or no difference in hospital attendance or admissions (14 trials, N = 3631, OR 0.85, 95% CI 0.65 to 1.11; moderate‐certainty evidence). Pharmacist services may make little or no difference to adverse drug effects (3 trials, N = 590, OR 1.65, 95% CI 0.84 to 3.24) and may slightly improve physical functioning (7 trials, N = 1329, mean difference (MD) 5.84, 95% CI 1.21 to 10.48; low‐certainty evidence). Pharmacist services may make little or no difference to mortality (9 trials, N = 1980, OR 0.79, 95% CI 0.56 to 1.12, low‐certaintly evidence). Of the five studies that compared services delivered by pharmacists with other health professionals, no studies evaluated the impact of the intervention on the percentage of patients outside blood pressure or glycated haemoglobin target range, hospital attendance and admission, adverse drug effects, or physical functioning. The results demonstrate that pharmacist services have varying effects on patient outcomes compared with usual care. We found no studies comparing services delivered by pharmacists with other healthcare professionals that evaluated the impact of the intervention on the six main outcome measures. The results need to be interpreted cautiously because there was major heterogeneity in study populations, types of interventions delivered and reported outcomes.There was considerable heterogeneity within many of the meta‐analyses, as well as considerable variation in the risks of bias. What is the aim of this review? To test whether services provided by pharmacists improve patient health. We identified 116 studies to answer this question. Key messages Some services provided by pharmacists can have positive effects on patient health, including improved management of blood pressure and physical function. The pharmacist services did not reduce hospital visits or admissions. Services delivered by pharmacists produced similar effects on patient health compared with services delivered by other healthcare professionals. What was studied in the review? Pharmacists deliver a wide range of services to patients. We need to know which pharmacist services are effective in helping patients to improve their health. This review included studies of pharmacist services for a wide range of conditions including high blood pressure and diabetes. The review measured the effect of these services on benefits (improved health outcomes) as well as harms (unplanned hospital admissions, adverse drug effects). What are the main results of the review? We found 116 relevant studies which involved 41,851 participants. Studies were conducted in 25 countries with the USA, UK, Canada and Australia contributing most studies. Many were conducted in community pharmacies (chemist shops) and hospital outpatient clinics. The studies compared services delivered by pharmacists with either usual care or with care delivered by other health professionals. The studies were of overall high quality, although some had problems because they did not include all the relevant information needed to assess quality. Of the 111 studies that compared pharmacist services with usual care, 47 studies reported the most important outcomes. Compared with usual care, pharmacist services may reduce the percentage of patients whose blood pressure is outside the target range. It is uncertain whether services delivered by pharmacists reduce the number of patients with glycated haemoglobin levels outside the target range, because the certainty of the evidence is very low. Pharmacist services may make little or no difference to hospital attendance or admissions or to adverse drug effects or to death rates. Pharmacist services may slightly improve physical functioning. We found no studies comparing services delivered by pharmacists with other healthcare professionals that evaluated the impact of the intervention on the six main outcome measures. How up‐to‐date is this review? We searched for studies that had been published up to March 2015. We ran top‐up searches in January 2018 and have added potentially eligible studies to 'Studies awaiting classification'.

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          Most cited references160

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          Interventions used to improve control of blood pressure in patients with hypertension.

          Patients with high blood pressure (hypertension) in the community frequently fail to meet treatment goals - a condition labelled as "uncontrolled" hypertension. The optimal way to organize and deliver care to hypertensive patients has not been clearly identified. To determine the effectiveness of interventions to improve control of blood pressure in patients with hypertension. To evaluate the effectiveness of reminders on improving the follow-up of patients with hypertension. All-language search of all articles (any year) in the Cochrane Controlled Trials Register (CCTR) and Medline; and Embase from January 1980. Randomized controlled trials (RCTs) of patients with hypertension that evaluated the following interventions: (1) self-monitoring (2) educational interventions directed to the patient (3) educational interventions directed to the health professional (4) health professional (nurse or pharmacist) led care (5) organisational interventions that aimed to improve the delivery of care (6) appointment reminder systemsOutcomes assessed were: (1) mean systolic and diastolic blood pressure (2) control of blood pressure (3) proportion of patients followed up at clinic Two authors extracted data independently and in duplicate and assessed each study according to the criteria outlined by the Cochrane Handbook. 72 RCTs met our inclusion criteria. The methodological quality of included studies varied. An organized system of regular review allied to vigorous antihypertensive drug therapy was shown to reduce systolic blood pressure (weighted mean difference (WMD) -8.0 mmHg, 95% CI: -8.8 to -7.2 mmHg) and diastolic blood pressure (WMD -4.3 mmHg, 95% CI: -4.7 to -3.9 mmHg) for three strata of entry blood pressure, and all-cause mortality at five years follow-up (6.4% versus 7.8%, difference 1.4%) in a single large RCT- the Hypertension Detection and Follow-Up study. Other interventions had variable effects. Self-monitoring was associated with moderate net reduction in systolic blood pressure (WMD -2.5 mmHg, 95% CI: -3.7 to -1.3 mmHg) and diastolic blood pressure (WMD -1.8 mmHg, 95% CI: -2.4 to -1.2 mmHg). RCTs of educational interventions directed at patients or health professionals were heterogeneous but appeared unlikely to be associated with large net reductions in blood pressure by themselves. Nurse or pharmacist led care may be a promising way forward, with the majority of RCTs being associated with improved blood pressure control and mean SBP and DBP but these interventions require further evaluation. Appointment reminder systems also require further evaluation due to heterogeneity and small trial numbers, but the majority of trials increased the proportion of individuals who attended for follow-up (odds ratio 0.41, 95% CI 0.32 to 0.51) and in two small trials also led to improved blood pressure control, odds ratio favouring intervention 0.54 (95% CI 0.41 to 0.73). Family practices and community-based clinics need to have an organized system of regular follow-up and review of their hypertensive patients. Antihypertensive drug therapy should be implemented by means of a vigorous stepped care approach when patients do not reach target blood pressure levels. Self-monitoring and appointment reminders may be useful adjuncts to the above strategies to improve blood pressure control but require further evaluation.
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            Pharmacist care of patients with heart failure: a systematic review of randomized trials.

            While the role of multidisciplinary teams in the treatment of patients with heart failure (HF) is well established, there is less evidence to characterize the role of individual team members. To clarify the role of pharmacists in the care of patients with HF, we performed a systematic review evaluating the effect of pharmacist care on patient outcomes in HF. We searched PubMed, MEDLINE, EMBASE, International Pharmaceutical Abstracts, Web of Science, Scopus, Dissertation Abstracts, CINAHL, Pascal, and Cochrane Central Register of Controlled Trials for controlled studies from database inception to August 2007. We included randomized controlled trials that evaluated the impact of pharmacist care activities on patients with HF (in both inpatient and outpatient settings). Summary odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random-effects model for rates of all-cause hospitalization, HF hospitalization, and mortality. A total of 12 randomized controlled trials (2060 patients) were identified. Extent of pharmacist involvement varied among studies, and each study intervention was categorized as pharmacist-directed care or pharmacist collaborative care using a priori definitions and feedback from primary study authors. Pharmacist care was associated with significant reductions in the rate of all-cause hospitalizations (11 studies [2026 patients]) (OR, 0.71; 95% CI, 0.54-0.94) and HF hospitalizations (11 studies [1977 patients]) (OR, 0.69; 95% CI, 0.51-0.94),and a nonsignificant reduction in mortality (12 studies [2060 patients])(OR, 0.84; 95% CI, 0.61-1.15). Pharmacist collaborative care led to greater reductions in the rate of HF hospitalizations (OR, 0.42; 95%CI, 0.24-0.74) than pharmacist-directed care (OR, 0.89; 95% CI, 0.68-1.17). Pharmacist care in the treatment of patients with HF greatly reduces the risk of all-cause and HF hospitalizations. Since hospitalizations associated with HF are a major public health problem, the incorporation of pharmacists into HF care teams should be strongly considered.
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              Multifaceted intervention to improve medication adherence and secondary prevention measures after acute coronary syndrome hospital discharge: a randomized clinical trial.

              Adherence to cardioprotective medication regimens in the year after hospitalization for acute coronary syndrome (ACS) is poor. To test a multifaceted intervention to improve adherence to cardiac medications. In this randomized clinical trial, 253 patients from 4 Department of Veterans Affairs medical centers located in Denver (Colorado), Seattle (Washington); Durham (North Carolina), and Little Rock (Arkansas) admitted with ACS were randomized to the multifaceted intervention (INT) or usual care (UC) prior to discharge. The INT lasted for 1 year following discharge and comprised (1) pharmacist-led medication reconciliation and tailoring; (2) patient education; (3) collaborative care between pharmacist and a patient's primary care clinician and/or cardiologist; and (4) 2 types of voice messaging (educational and medication refill reminder calls). The primary outcome of interest was proportion of patients adherent to medication regimens based on a mean proportion of days covered (PDC) greater than 0.80 in the year after hospital discharge using pharmacy refill data for 4 cardioprotective medications (clopidogrel, β-blockers, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors [statins], and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers [ACEI/ARB]). Secondary outcomes included achievement of blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) level targets. RESULTS Of 253 patients, 241 (95.3%) completed the study (122 in INT and 119 in UC). In the INT group, 89.3% of patients were adherent compared with 73.9% in the UC group (P = .003). Mean PDC was higher in the INT group (0.94 vs 0.87; P< .001). A greater proportion of intervention patients were adherent to clopidogrel (86.8% vs 70.7%; P = .03), statins (93.2% vs 71.3%; P < .001), and ACEI/ARB (93.1% vs 81.7%; P = .03) but not β-blockers (88.1% vs 84.8%; P = .59). There were no statistically significant differences in the proportion of patients who achieved BP and LDL-C level goals. A multifaceted intervention comprising pharmacist-led medication reconciliation and tailoring, patient education, collaborative care between pharmacist and patients' primary care clinician and/or cardiologist, and voice messaging increased adherence to medication regimens in the year after ACS hospital discharge without improving BP and LDL-C levels. Understanding the impact of such improvement in adherence on clinical outcomes is needed prior to broader dissemination of the program. clinicaltrials.gov Identifier: NCT00903032.
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                Author and article information

                Journal
                Cochrane Database of Systematic Reviews
                Wiley
                14651858
                September 04 2018
                Affiliations
                [1 ]University of Aberdeen; Institute of Applied Health Sciences; Aberdeen UK
                [2 ]NHS Education for Scotland; Scottish Dental Clinical Effectiveness Programme; Dundee Dental Education Centre Small's Wynd Dundee UK DD1 4HN
                [3 ]University of Aberdeen; Medical Statistics Team; Polwarth Building Foresterhill Aberdeen Scotland UK AB 25 2 ZD
                [4 ]University of California; Clinical Pharmacy; 155 North Fresno Street, Suite 224 San Francisco California USA 93701
                [5 ]University of Aberdeen; Division of Applied Health Sciences; Polwarth Building Foresterhill Aberdeen UK AB25 2ZD
                [6 ]Robert Gordon University; Pharmacy; Garthdee Campus Aberdeen Scotland UK AB10 7QB
                [7 ]Nottingham Trent University; School of Psychology; Nottingham England UK
                [8 ]University of Bath; Department of Pharmacy and Pharmacology; 5w 3.33 Claverton Down Bath UK BA2 7AY
                Article
                10.1002/14651858.CD013102
                6513292
                30178872
                efe94934-c708-4352-ad5b-27e8a293e9c9
                © 2018
                History

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