The Kaiser Permanente/USC Patient Consultation Study: change in use and cost of health care services

Pharmacist services for non-hospitalised patients

BACKGROUND

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.

OBJECTIVES

To examine the effect of pharmacists' non-dispensing services on non-hospitalised patient outcomes.

SEARCH METHODS

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'.

SELECTION CRITERIA

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.

DATA COLLECTION AND ANALYSIS

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.

MAIN RESULTS

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.

AUTHORS' CONCLUSIONS

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.

The Effect of Medication Reviews in a Rural Community Pharmacy Assistance Program: The Cenla Medication Access Program

The purpose of this article is to determine the effect of mediing equations were used to assess change in PURPOSE, USE,cation reviews on patient understanding of and compliance COMPLIANCE, INTERACTION, and REACTION over time. to medications for participants in the Cenla Medication Ac All effects were adjusted for differences in age, race, gender, cess Program (CMAP). A sample of 844 individuals with a to the number of years of education, total number of medicatal of 2013 reviews over a period of 6 months to 1 year protions per patient, and the patient’s primary diagnosis. Signifiduced 5 outcome variables: the percentage of the total cant increases were observed for PURPOSE, USE, and number of drugs the patient understands the purpose of COMPLIANCE. A significant decrease was observed for (PURPOSE), understands the proper use of (USE), and is INTERACTION. No significant difference in REACTION was compliant with (COMPLIANCE) and the percentage of paobserved over time. CMAP has seen increases in patient untients that experienced any drug-drug or drug-disease interderstanding and compliance, as well as a decrease in drug-actions (INTERACTION) or any adverse reactions drug and drug-disease interactions through the first year of (REACTION). Mixed-effects models and generalized estimat medication reviews.

Comply With Us: Improving Medication Adherence

Medication noncompliance is a pervasive problem resulting in significant morbidity and mortality. There are many terms used to describe medication-taking behavior including compliance, adherence, intelligent compliance, and drug forgiveness. More recently, clinicians have focused on the need for a collaborative partnership with patients to attain medication adherence. Problems identified include the patient’s failing to initiate therapy, under using or overusing a drug, stopping a drug too soon, and mistiming or skipping doses. Adherence to medications is a complex health behavior. There are many risk factors associated with decreased compliance, and many strategies have been shown to improve drug-taking behavior and patient outcomes. By careful assessment, the pharmacist can identify the high-risk patient, recommend an individualized care plan, and provide the follow-up necessary to successfully change patient behavior. Pharmacists should focus on improving their own application of behavior modification principles and patient communication skills. Improved medication compliance results in improved humanistic, clinical, and economic outcomes.

Counseling provided by the pharmacist in Romanian community pharmacies: the patients' perspective

BACKGROUND AND AIMS

Patient education is a critical task that may be carried out by the pharmacists, especially in the context of contemporary pharmacists' roles, which tend to be closer to patients and their needs. This study aimed to evaluate the counseling provided by the pharmacist in the community pharmacy, from the patient's perspective.

PATIENTS AND METHODS

We conducted a prospective, non-interventional study in 520 pharmacies from 10 Romanian counties across the country. The first 10 visitors of the pharmacy on a given day were asked to complete a questionnaire regarding the counseling provided by the pharmacist during the visit.

RESULTS

More than 90% of patients received advice from the pharmacist on the route of administration, use in relation to meals, dosage and length of treatment. More than 80% of the patients were counseled on the medicine contraindications and precautions, interactions with other medicines and food, side effects, additional changes in lifestyle and diet appropriate to the condition and the necessity to immediately consult a doctor/pharmacist in case of adverse drug reactions. Lower percentages were registered for advising the patient on the obligation to return to pharmacy the unused psychotropic drugs (38.04%) and the ability of the drug to modify the laboratory results (47.66).

CONCLUSIONS

The results of the present study showed that the counseling activity in the community pharmacy is carried out by the pharmacists in a high proportion, according to the patients' feedback.

Counseling provided by the pharmacist in Romanian community pharmacies: the patients' perspective

BACKGROUND AND AIMS

Patient education is a critical task that may be carried out by the pharmacists, especially in the context of contemporary pharmacists' roles, which tend to be closer to patients and their needs. This study aimed to evaluate the counseling provided by the pharmacist in the community pharmacy, from the patient's perspective.

PATIENTS AND METHODS

We conducted a prospective, non-interventional study in 520 pharmacies from 10 Romanian counties across the country. The first 10 visitors of the pharmacy on a given day were asked to complete a questionnaire regarding the counseling provided by the pharmacist during the visit.

RESULTS

More than 90% of patients received advice from the pharmacist on the route of administration, use in relation to meals, dosage and length of treatment. More than 80% of the patients were counseled on the medicine contraindications and precautions, interactions with other medicines and food, side effects, additional changes in lifestyle and diet appropriate to the condition and the necessity to immediately consult a doctor/pharmacist in case of adverse drug reactions. Lower percentages were registered for advising the patient on the obligation to return to pharmacy the unused psychotropic drugs (38.04%) and the ability of the drug to modify the laboratory results (47.66).

CONCLUSIONS

The results of the present study showed that the counseling activity in the community pharmacy is carried out by the pharmacists in a high proportion, according to the patients' feedback.

Inappropriate prescribing: a systematic overview of published assessment tools

BACKGROUND

Criteria to assess the appropriateness of prescriptions might serve as a helpful guideline during professional training and in daily practice, with the aim to improve a patient's pharmacotherapy.

OBJECTIVE

To create a comprehensive and structured overview of existing tools to assess inappropriate prescribing.

METHOD

Systematic literature search in Pubmed (1991-2013). The following properties of the tools were extracted and mapped in a structured way: approach (explicit, implicit), development method (consensus technique, expert panel, literature based), focused patient group, health care setting, and covered aspects of inappropriate prescribing.

RESULTS

The literature search resulted in 46 tools to assess inappropriate prescribing.Twenty-eight (61%) of 46 tools were explicit, 8 (17%) were implicit and 10 (22%) used a mixed approach. Thirty-six (78%) tools named older people as target patients and 10 (22%) tools did not specify the target age group. Four (8.5%) tools were designed to detect inappropriate prescribing in hospitalised patients, 9 (19.5%) focused on patients in ambulatory care and 6 (13%) were developed for use in long-term care. Twenty-seven (59%) tools did not specify the health care setting. Consensus methods were applied in the development of 19 tools (41%), the others were based on either simple expert panels (13; 28%) or on a literature search (11; 24%). For three tools (7%) the development method was not described.

CONCLUSION

This overview reveals the characteristics of 46 assessment tools and can serve as a summary to assist readers in choosing a tool, either for research purposes or for daily practice use.

Pharmaceutical Consultation in UAE Community Pharmacies

In recent years, the focus of pharmacists as traditional drug dispensers has shifted to more active and participative role in risk assessment, risk management, and other medication related consultation activities. Pharmacy profession is evolving steadily in the United Arab Emirates (UAE). Pharmacists in UAE are so much occupied in their administrative and managerial duties that dispensing is mostly attended to by pharmacy technicians. Pharmacist-led patient counseling is limited to the dosage and frequency of medications and rarely adverse reactions and drug interactions with other medications. Therefore we decided to perform quantitative questionnaires study to explore the role of pharmacist in patient counseling in UAE, the evaluation of pharmacist's opinion on patient counseling and the potential determinants of personal consultation. Results show the frequency and nature of inquiries received by pharmacist. Five to twenty inquires per month are received from patient, most of them related to drug prescription and dose recommendation. Thirty nine percent of pharmacists received inquiries from doctors, most of them related to the dose and mode of action. Ninty two percent of the pharmacists agreed that patient counseling is their professional responsibility. About 82% of pharmacists agreed that counseling will increase their sales and enhance the reputation of their pharmacies. Seventy percent of pharmacists mentioned that they need to undergo training for effective counseling while 46% of pharmacists felt that more staff in the pharmacies would have a positive influence on patient compliance to medication therapies and patient safety. The potential determinants of personal consultation show that 52% of participants trusted pharmacist and 55% considered the pharmacist as a friend. Forty eight percent of participants visited the pharmacy for medical recommendation while 30% for drug compounding, 72% agreed that pharmacist conducts full instruction while 31% agreed about full investigation. In conclusion, reorganization of the pharmacist's activities may improve pharmaceutical consultations. Pharmacists must be exposed to recent trends in drug therapy, dosage forms, dosage, adverse effects and interaction. This will go a long way in providing rational use of drugs to the patients and improve their quality of life.

Effect of outpatient pharmacists' non-dispensing roles on patient outcomes and prescribing patterns

BACKGROUND

The roles of pharmacists in patient care have expanded from the traditional tasks of dispensing medications and providing basic medication counseling to working with other health professionals and the public. Multiple reviews have evaluated the impact of pharmacist-provided patient care on health-related outcomes. Prior reviews have primarily focused on in-patient settings. This systematic review focuses on services provided by outpatient pharmacists in community or ambulatory care settings. This is an update of the Cochrane review published in 2000.

OBJECTIVES

To examine the effect of outpatient pharmacists' non-dispensing roles on patient and health professional outcomes.

SEARCH STRATEGY

This review has been split into two phases. For Phase I, we searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (January 1966 through March 2007). For Phase II, we searched MEDLINE/EMBASE (January 1966 through March 2008). The Phase I results are reported in this review; Phase II will be summarized in the next update.

SELECTION CRITERIA

Randomized controlled trials comparing 1. Pharmacist services targeted at patients versus services delivered by other health professionals; 2. Pharmacist services targeted at patients versus the delivery of no comparable service; 3. Pharmacist services targeted at health professionals versus services delivered by other health professionals; 4. Pharmacist services targeted at health professionals versus the delivery of no comparable service.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed studies for inclusion, extracted data, and assessed risk of bias of included studies.

MAIN RESULTS

Forty-three studies were included; 36 studies were pharmacist interventions targeting patients and seven studies were pharmacist interventions targeting health professionals. For comparison 1, the only included study showed a significant improvement in systolic blood pressure for patients receiving medication management from a pharmacist compared to usual care from a physician. For comparison 2, in the five studies evaluating process of care outcomes, pharmacist services reduced the incidence of therapeutic duplication and decreased the total number of medications prescribed. Twenty-nine of 36 studies reported clinical and humanistic outcomes. Pharmacist interventions resulted in improvement in most clinical outcomes, although these improvements were not always statistically significant. Eight studies reported patient quality of life outcomes; three studies showed improvement in at least three subdomains. For comparison 3, no studies were identified meeting the inclusion criteria. For comparison 4, two of seven studies demonstrated a clear statistically significant improvement in prescribing patterns.

AUTHORS' CONCLUSIONS

Only one included study compared pharmacist services with other health professional services, hence we are unable to draw conclusions regarding comparisons 1 and 3. Most included studies supported the role of pharmacists in medication/therapeutic management, patient counseling, and providing health professional education with the goal of improving patient process of care and clinical outcomes, and of educational outreach visits on physician prescribing patterns. There was great heterogeneity in the types of outcomes measured across all studies. Therefore a standardized approach to measure and report clinical, humanistic, and process outcomes for future randomized controlled studies evaluating the impact of outpatient pharmacists is needed. Heterogeneity in study comparison groups, outcomes, and measures makes it challenging to make generalised statements regarding the impact of pharmacists in specific settings, disease states, and patient populations.

The effect of patient satisfaction with pharmacist consultation on medication adherence: an instrumental variable approach

There are limited studies on quantifying the impact of patient satisfaction with pharmacist consultation on patient medication adherence.

OBJECTIVES

The objective of this study is to evaluate the effect of patient satisfaction with pharmacist consultation services on medication adherence in a large managed care organization.

METHODS

We analyzed data from a patient satisfaction survey of 6,916 patients who had used pharmacist consultation services in Kaiser Permanente Southern California from 1993 to 1996. We compared treating patient satisfaction as exogenous, in a single-equation probit model, with a bivariate probit model where patient satisfaction was treated as endogenous. Different sets of instrumental variables were employed, including measures of patients' emotional well-being and patients' propensity to fill their prescriptions at a non-Kaiser Permanente (KP) pharmacy. The Smith-Blundell test was used to test whether patient satisfaction was endogenous. Over-identification tests were used to test the validity of the instrumental variables. The Staiger-Stock weak instrument test was used to evaluate the explanatory power of the instrumental variables.

RESULTS

All tests indicated that the instrumental variables method was valid and the instrumental variables used have significant explanatory power. The single equation probit model indicated that the effect of patient satisfaction with pharmacist consultation was significant (p<0.010). However, the bivariate probit models revealed that the marginal effect of pharmacist consultation on medication adherence was significantly greater than the single equation probit. The effect increased from 7% to 30% (p<0.010) after controlling for endogeneity bias.

CONCLUSION

After appropriate adjustment for endogeneity bias, patients satisfied with their pharmacy services are substantially more likely to adhere to their medication. The results have important policy implications given the increasing focus on the roles of pharmacists and regulatory changes in professional scope of practice.

The Journey to the DNP Program and Beyond: What Can We Learn From Pharmacy?

Advanced practice nursing has been elevated to a new level with the introduction of the DNP (Doctorate of Nursing Practice). One of the justifications for its implementation is the promotion of parity between nurses and other health care providers who require a practice doctorate. Concerns surrounding parity, the ability of DNP-prepared nurses to affect health care outcomes, equitable salary issues, and the DNP program's effect on the academic PhD (Doctorate of Philosophy) program have been expressed. The purpose of this analysis is to explore these issues using pharmacy as an example for implementing a practice doctorate. Similarities and differences between the professions are examined, and lessons that nursing can learn from pharmacy are discussed.

Interventions in primary care to reduce medication related adverse events and hospital admissions: systematic review and meta-analysis

OBJECTIVE

To identify and evaluate studies of interventions in primary care aimed at reducing medication related adverse events that result in morbidity, hospital admission, and/or mortality.

METHODS

Fourteen electronic databases were systematically searched for published and unpublished data. Bibliographies of retrieved papers were searched and experts and first authors contacted in an attempt to locate additional studies. There were no restrictions on language of publication. All interventions applied in primary care settings which aimed to improve patient safety by reducing adverse events resulting from medication overuse or misuse were considered. Randomised controlled trials, controlled trials, controlled before and after studies, and interrupted time series studies were eligible for inclusion. Study quality assessment and data extraction were undertaken using the Cochrane Effective Practice and Organisation of Care data collection checklist and template. Meta-analysis was performed using a random effects model.

RESULTS

159 studies were initially identified, of which 38 satisfied our inclusion criteria. These were categorised as follows: 17 pharmacist-led interventions (of which 15 reported hospital admissions as an outcome); eight interventions led by other primary healthcare professionals that reported preventable drug related morbidity as an outcome; and 13 complex interventions that included a component of medication review aimed at reducing falls in the elderly (the outcome being falls). Meta-analysis found that pharmacist-led interventions are effective at reducing hospital admissions (OR 0.64 (95% CI 0.43 to 0.96)), but restricting analysis to the randomised controlled trials failed to demonstrate significant benefit (OR 0.92 (95% CI 0.81 to 1.05)). Pooling the results of studies in the other categories did not demonstrate any significant effect.

CONCLUSIONS

There is relatively weak evidence to indicate that pharmacist-led medication reviews are effective in reducing hospital admissions. There is currently no evidence for the effectiveness of other interventions which aim at reducing admissions or preventable drug related morbidity. More randomised controlled trials of primary care based pharmacist-led interventions are needed to decide whether or not this intervention is effective in reducing hospital admissions.

Can pharmacy data improve prediction of hospital outcomes? Comparisons with a diagnosis-based comorbidity measure

OBJECTIVES

The performance of comorbidity measures derived from the hospital discharge abstract, the outpatient pharmacy record, and from both sources combined, were compared in predicting all-cause and unplanned hospital readmission and length of stay.

MATERIALS AND METHODS

Automated hospital and pharmacy data came from Kaiser-Permanente and included 6721 acute hospitalizations in Southern California from April 1993 to February 1995. The Deyo adaptation of Charlson's 17 comorbidities was derived from hospital discharge data and the 29 Chronic Disease Score (CDS) comorbidity markers were derived from outpatient pharmacy claims data. Logistic and OLS regression models were used to compare the performance of each measure in baseline models and to evaluate whether the CDS contributed additional explanatory power in a combined model.

RESULTS

The CDS was a significant predictor of unplanned readmission (C = 0.68) and LOS (Adjusted R(2) = 0.26) in multivariable models adjusted for baseline patient demographic and hospitalization characteristics. The Deyo measure was a significant predictor of all-cause readmission (C = 0.63), unplanned readmission (C = 0.68), and LOS (Adjusted R(2) = 0.26). When pharmacy-based disease markers were added to the Deyo baseline model, modest, statistically significant improvements in predictive power were noted in the unplanned readmission and LOS models.

CONCLUSIONS

The finding that both measures of comorbid disease demonstrated similar predictive power is noteworthy, because secondary diagnosis data document relevant illness in hospital patients and pharmacy claims data were never intended for that purpose. The results suggest that small improvements in model performance may come from combining both sources of data in models to predict hospital readmission and LOS.

[What doctors expect of a pharmacist's work--how a pharmacist is evaluated by doctors]

In recent years, a pharmacists' work has changed in terms of therapeutic management and counseling of patients. Generally, a pharmacist has to provide pharmaceutical care in cooperation with a doctor. In the present study, a questionnaire survey on what a doctor expects of a pharmacist was conducted, and directors of hospital were interviewed on what they expect of a pharmacist. Eighty-two doctors participated in the survey. As results, doctors consider that a pharmacist's work is dispensing of drugs (41%), and highly evaluated the works of a pharmacist in advising doctors regarding pharmacotherapy (29%), checking the prescription (28%), providing patient compliance instructions (27%) and providing drug information (26%). Five directors of hospital expect the pharmacists to carry out risk managements and prescription checks, provide drug information, and consultation on drug costs. In addition, doctors want pharmacists to have more knowledge on pharmacotherapy. These results clearly show what doctors expect of a pharmacist's work.

The Asheville Project: factors associated with outcomes of a community pharmacy diabetes care program

OBJECTIVE

To assess the importance of environment, patient characteristics, and health behavior in explaining differences in clinical, economic, and humanistic outcomes of pharmaceutical care services (PCS) for patients with diabetes.

DESIGN

Quasi-experimental, pre-post cohort-with-comparison group study using multivariate logistic regression.

SETTING

Twelve community pharmacies in Asheville, N.C.

PATIENTS AND OTHER PARTICIPANTS

Eighty-five patients with diabetes who were employees, dependents, or retirees from two self-insured employers; community pharmacists who completed a diabetes certificate program and received reimbursement for PCS.

INTERVENTIONS

Scheduled consultations with pharmacists involving education and training, assessment, monitoring, follow-up, and referral.

MAIN OUTCOME MEASURES

Change in glycosylated hemoglobin (A1c) value, diabetes diagnosis and all-diagnosis utilization and cost of medical care, quality of life, and satisfaction with pharmacy services.

RESULTS

The strongest predictors of improvement in A1c following PCS were the patient characteristics baseline glycemic control and type 1 diabetes. All patients with type 1 diabetes had reduced their A1c concentrations at follow-up. Patients in one employer group (an environmental characteristic) were significantly more likely to have a 10% reduction in diabetes diagnosis costs, compared with employees in the other group. They were also more likely to report improved satisfaction with pharmacy services. No other statistically significant relationships were found.

CONCLUSION

The greatest improvement in A1c occurred among patients with type 1 diabetes and/or higher baseline A1c concentrations. When controlling for other factors, PCS did not emerge as a significant factor in lowering A1c, but it was imprecisely measured, and our proxy measure did not capture the full complement of PCS provided to patients. Success in terms of cost savings and patient satisfaction differed by employer group.

Evidence of the economic benefit of clinical pharmacy services: 1996-2000

We sought to summarize and assess original evaluations of the economic impact of clinical pharmacy services published from 1996-2000, and to provide recommendations and methodologic considerations for future research. A systematic literature search was conducted to identify articles that were then blinded and randomly assigned to reviewers who confirmed inclusion and abstracted key information. Results were compared with those of a similar review of literature published from 1988-1995. In the 59 included articles, the studies were conducted across a variety of practice sites that consisted of hospitals (52%), community pharmacies and clinics (41%), health maintenance organizations (3%), and long-term or intermediate care facilities (3%). They focused on a broad range of clinical pharmacy services such as general pharmacotherapeutic monitoring (47%), target drug programs (20%), disease management programs (10%), and patient education or cognitive services (10%). Compared with the studies of the previous review, a greater proportion of evaluations were conducted in community pharmacies or clinics, and the types of services evaluated tended to be more comprehensive rather than specialized. Articles were categorized by type of evaluation: 36% were considered outcome analyses, 24% full economic analyses, 17% outcome descriptions, 15% cost and outcome descriptions, and 8% cost analyses. Compared with the studies of the previous review, a greater proportion of studies in the current review used more rigorous study designs. Most studies reported positive financial benefits of the clinical pharmacy service evaluated. In 16 studies, a benefit:cost ratio was reported by the authors or was able to be calculated by the reviewers (these ranged from 1.7:1-17.0:1, median 4.68:1). The body of literature from this 5-year period provides continued evidence of the economic benefit of clinical pharmacy services. Although the quality of study design has improved, whenever possible, future evaluations of this type should incorporate methodologies that will further enhance the strength of evidence of this literature and the conclusions that may be drawn from it.

Impact of pharmacists providing a prescription review and monitoring service in ambulatory care or community practice

OBJECTIVE

To systematically review the impact, on patient outcomes and costs to the healthcare system, of pharmacists reviewing and monitoring prescribing in ambulatory care or community practice.

DATA SOURCES

We conducted a systematic search of published literature, up to and including 1998, on outcomes of prescription monitoring and review by pharmacists. Thirteen electronic databases were reviewed, along with a hand search of 11 journals known to publish pharmacy practice research. Fifty-five articles describing 50 comparative studies were identified.

DATA EXTRACTION

Data were extracted including study design, clinical site, and results. A qualitative synthesis of the findings was conducted and methodological quality was appraised.

DATA SYNTHESIS

Pharmacist-run services may be accompanied by improvements in clinical outcomes. Inconsistent definitions used in the research evaluated meant that an overall interpretation of a change in the incidence of compliance and adverse drug reactions was impossible. Other outcomes such as knowledge and satisfaction showed equivocal results overall. There was little or no change in quality of life where this was assessed. Savings in drug acquisition costs may have accrued, but it was impossible to calculate the magnitude. Pharmacist involvement produced a positive impact on cost-benefit and cost-effectiveness.

CONCLUSIONS

The heterogeneity of the studies found and the variety in quality of much of the research design prevent the rigorous assessment of the direction and magnitude of any changes reviewed. Further studies are required, which must be rigorously designed, with blind and independent assessment of clearly defined outcomes. In particular, there is a need to investigate the effect of such services on the incidence of adverse drug reactions and quality of life and to conduct robust cost-benefit analyses.

Expanding the roles of outpatient pharmacists: effects on health services utilisation, costs, and patient outcomes

BACKGROUND

In recent years pharmacists' roles have expanded from simply packaging and dispensing medications to working with other health care professionals and the public.

OBJECTIVES

To assess the effects of expanding outpatient pharmacists' roles on health services utilisation, the costs of health services, and patient outcomes.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, MEDLINE, EMBASE, Pharmline, International Pharmaceutical Abstracts and reference lists of articles up to December 1995. We also searched the published abstracts of three meetings and hand searched five journals and two bibliographies.

SELECTION CRITERIA

Randomised trials, controlled clinical trials, controlled before-and-after studies and interrupted time series analyses of interventions comparing 1. Pharmacist services targeted at patients versus services delivered by other health professionals; 2. Pharmacist services targeted at patients versus no intervention; 3. Pharmacist services targeted at health professionals versus services delivered by other health professionals; and 4. Pharmacist services targeted at health professionals versus no intervention.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Fourteen studies were included involving more than 1991 patients. In the one study identified for comparison 1 the relative changes in professional outcome measures ranged from a 24% increase in clinic visits to a 16% decrease in hospital admissions. Relative differences in patient outcome measures were not statistically significant. Seven studies were identified for comparison 2. Four measured process of care and demonstrated decreases in health services utilisation from -67% for hospital admissions to -564% for total ambulatory care visits, as well as decreases in the numbers and costs of drugs compared to control patients. Five measured patient outcomes and consistently reported improvements in the targeted patient condition. In the one study identified for comparison 3 the intervention delivered by the pharmacist was less successful than that delivered by physician counsellors in decreasing inappropriate antibiotic prescribing. All six studies identified for comparison 4 demonstrated that the pharmacist intervention produced the intended effect on physician prescribing practices. These studies did not measure patient outcomes.

REVIEWER'S CONCLUSIONS

The limited number of studies analysed support the expanded roles of pharmacists in patient counselling and physician education. However, doubts about the generalisability of the studies, the poorly defined nature of the interventions tested, and the lack of studies including cost assessments and patient outcome data indicate that more rigorous research is needed to document the effects of outpatient pharmacist interventions.

The impact of pharmaceutical services in community and ambulatory care settings: evidence and recommendations for future research

OBJECTIVE

To review and evaluate research on pharmaceutical services in community and ambulatory care pharmacy settings, specifically study designs and patient outcome measures, and to provide recommendations to improve future research on pharmaceutical services in community and ambulatory care pharmacy settings.

DATA SOURCE

English-language articles were identified by searching MEDLINE (1966-December 1998) and International Pharmaceutical Abstracts (1970-December 1998), using a combination of search terms: pharmacist services, pharmacist interventions, community pharmacy, ambulatory care, primary care, and patient outcomes. Relevant studies were selected based on article abstracts.

DATA EXTRACTION

From each relevant study, we extracted the study objectives, sample size, study period, study design, major tasks performed by pharmacists, and economic, clinical, and humanistic outcomes (ECHO). Results were tabulated separately for research on community pharmacy and ambulatory care pharmacy settings.

RESULTS

We identified 95 relevant studies. Of these, 21 studies were conducted in community pharmacy settings and 74 in ambulatory care settings. Ten community pharmacy studies used prospective, single group, pretest/posttest, or posttest only designs; seven used prospective two or more group comparison designs; and four used randomized, controlled designs. Nine studies on community pharmacies measured clinical outcomes, two measured humanistic outcomes, and five measured economic outcomes. Four studies measured both clinical and humanistic outcomes and one measured humanistic and economic outcomes. No study measured all three ECHO variables. Twenty-three studies in ambulatory care settings used prospective or retrospective, single group, pretest/posttest or posttest only designs; 21 used prospective or retrospective two-or-more group comparison designs; and 30 used randomized, controlled designs. Thirty-six measured clinical outcomes, five measured humanistic outcomes, and 15 measured economic outcomes. Fifteen studies measured clinical and economic outcomes and three measured clinical and humanistic outcomes.

CONCLUSIONS

Only 21 of 95 selected studies were conducted in community pharmacy settings and measured the impact of pharmaceutical services on patient outcomes. Few studies employed adequate research designs to control threats to internal and external validity. In order to obtain a comprehensive and accurate picture of the impact of pharmaceutical services on patient outcomes, an attempt must be made to measure all three ECHO variables while employing adequate research design.