CRD summary

This review found that pharmacist-provided direct patient care had favourable effects across various patient outcomes, health care settings and disease states. These conclusions were supported by the evidence, but should be interpreted with some caution given the limitations of the included studies and are applicable only to USA as studies conducted in other countries were excluded.

Authors' objectives

To examine the effects of pharmacist-provided direct patient care on therapeutic, safety and humanistic outcomes.

Searching

Eleven databases were searched from inception to January 2009. The search included ongoing studies and grey literature. Full details of the search strategies were available online. Reference lists of relevant reviews were screened. The review was restricted to published studies.

Study selection

Studies that assessed pharmacist involvement in direct patient care, included a comparison a group and reported patient-related therapeutic, safety or humanistic outcomes were eligible for inclusion. Only studies conducted in USA were included.

Most studies were in outpatient/ambulatory/retail/community settings; other studies were in in-patient/institutional settings, emergency departments, at home and in other settings. Most studies were in adults; only a small proportion of studies included children. The most frequently reported conditions were hypertension, dyslipidaemia, diabetes, anticoagulation, asthma/chronic obstructive pulmonary disease, infection and psychiatric conditions. Pharmacist interventions were classed as behavioural, educational, technical and combination/multimodal. Reported publication dates ranged from 1977 to 2008.

Two independent teams of reviewers selected studies for inclusion.

Assessment of study quality

Randomised controlled trials (RCTs) were assessed using a modified Jadad score; details of the modifications were not reported. Studies were assigned a summary score out of 5. Study quality for designs other than RCTS was not assessed formally.

The authors did not state how many reviewers performed the quality assessment.

Data extraction

Studies were classified as favourable where there was a statistically significant (p<0.05) improvement associated with pharmacist-provided care, no effect where there was no difference between treatment groups and not favourable where there was a statistically significant benefit in favour of control groups. Studies were classed as mixed where a statistically significant effect was found for some outcomes and not for others. Studies were classed as unclear where it was not possible to determine the outcome based on the results presented. Data for RCTs were extracted to calculate the mean difference (MD) or standardised mean difference (SMD) for continuous outcomes and odds ratios (ORs) for dichotomous data, together with 95% confidence intervals (CIs).

Two or three reviewers independently extracted data. Disagreements were resolved through discussion.

Methods of synthesis

Studies were grouped according to type of outcome (therapeutic, safety and humanistic). Where at least four studies assessed one particular outcome, summary odds ratios, mean differences or standardised mean differences, together with 95% CIs, were estimated using random-effects models weighted on sample size. Heterogeneity was assessed using the Q statistic. Heterogeneity was investigated by removal of studies one at a time from the meta-analysis. Jadad scores and summary effect sizes were correlated to determine whether bias may have affected the findings. Publication bias was assessed using funnel plots, Kendall's Τ and fail safe N.

Results of the review

Two hundred and ninety-eight studies (number of patients not reported) were included in the review. There were 81 RCTs. Twelve RCTs scored less than 3 out of 5 on the modified Jadad scale.

Therapeutic outcomes (224 studies): Favourable results were found in 51% (18 of 25 studies assessing hospitalisation/readmission) to 100% (all seven studies reported eye examinations) of studies for the various therapeutic outcomes assessed. All outcomes selected for meta-analysis showed a statistically significant beneficial effect of pharmacist interventions: Haemoglobin A1c (MD -1.8%, 95% CI -2.7 to -0.9; six RCTs), low density lipoprotein cholesterol (MD -6.3, 95% CI -6.5 to -6.0; eight RCTs), systolic blood pressure (-7.8mmHg, 95% CI -9.7 to -5.8; 14 RCTs) and diastolic blood pressure (MD -2.9mmHG, 95% CI -3.8 to -2.0; 13 RCTs). There was significant heterogeneity (p<0.05) for all analyses. Exclusion of single studies did not remove the heterogeneity. There was no evidence of publication bias.

Safety outcomes (73 studies): Favourable results were found in 60% (nine of 15 studies reported adverse drug reactions) to 82% (nine of 11 studies reported medication errors) of studies that reported various safety outcomes. Five studies reported a significant reduction in the odds of adverse drug reactions associated with pharmacist provided care (OR 0.53, 95% CI 0.33 to 0.83; five RCTs). There was no evidence of heterogeneity (p<0.14) or publication bias.

Humanistic outcomes (120 studies): Favourable results were reported in 13% (four of 31 studies that reported quality of life) to 57% (20 of 35 studies that reported patient knowledge) of studies for the various humanistic outcomes assessed. Six outcomes were selected for meta-analysis, three of which showed statistically significant beneficial effects of pharmacist interventions: medication adherence (SMD -0.58, 95% CI -0.88 to -0.28; 14 RCTs), patient knowledge (SMD -1.14, -1.79 to -0.48; six RCTs) and quality of life (QoL) general health (SMD -0.13, 95% CI -0.22 to -0.05; five RCTs). There was no significant effect on patient satisfaction, QoL-physical functioning and QoL-mental health. There was significant heterogeneity for medication adjuerence and patient knoweldge, but not for the other meta-analysis. Exclusion of single studies did not remove heterogeneity. There was no evidence of publication bias.

Study quality was not associated with any of the outcomes assessed.

Authors' conclusions

Pharmacist-provided direct patient care had favourable effects across various patient outcomes, health care settings and disease states.

CRD commentary

This review addressed a broad question supported by defined inclusion criteria. An extensive literature search included attempts to locate grey literature, but the review was restricted to published studies. Publication bias was assessed in the review and no evidence of it found. Appropriate steps were taken to minimise bias and errors during study selection and data extraction; it was unclear whether such steps were taken for study quality. Study quality was assessed using a modified version of the Jadad scale, but individual items assessed were not reported and results were only presented as summary quality scores. Therefore, it was difficult to determine the risk of bias in the included studies. Appropriate methods were used to synthesise studies and included an appropriate focus on results from RCTs. Only few studies contributed to each meta-analysis. The number of patients in the included studies was unclear. There was evidence of heterogeneity for some of the outcomes and this was not adequately investigated.

The authors' conclusions were supported by the data. The results were applicable to USA only as studies conducted in other countries were excluded. The small number of studies that assessed each outcome and limitations in the quality assessment mean that the conclusions should be interpreted with some caution.

Implications of the review for practice and research

Practice: The authors stated that incorporating pharmacists as health care team members in direct patient care was a viable solution to help improve USA health care.

Research: The authors stated that future studies on the effects of pharmacist provided direct patient care should comprehensively integrate assessment of long-term level 1 outcomes such as morbidity and mortality. Future studies should identify and replicate the most effective interventions. Economic assessments were required.

Funding

American Society of Health-System Pharmacists (ASHP) Foundation.

Bibliographic details

Chisholm-Burns MA, Kim Lee J, Spivey CA, Slack M, Herrier RN, Hall-Lipsy E, Graff Zivin J, Abraham I, Palmer J, Martin JR, Kramer SS, Wunz T. US pharmacists' effect as team members on patient care: systematic review and meta-analyses. Medical Care 2010; 48(10): 923-933. [PubMed: 20720510]

Original Paper URL

http://journals.lww.com/lww-medicalcare/toc/2010/10000

Indexing Status

Subject indexing assigned by NLM

MeSH

Community Pharmacy Services /organization & administration /statistics & numerical data; Health Knowledge, Attitudes, Practice; Humans; Medication Adherence /statistics & numerical data; Patient Care Team /organization & administration /statistics & numerical data; Patient Education as Topic /statistics & numerical data; Patient-Centered Care /organization & administration; Pharmacists /organization & administration /statistics & numerical data; Professional Role; Professional-Patient Relations; United States

AccessionNumber

12010007167

Database entry date

10/08/2011

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.