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 pharmacist-provided non-dispensing services on patient outcomes, health service utilisation and costs in low- and middle-income countries.

BACKGROUND: The role of pharmacists has expanded beyond dispensing and packaging over the past two decades, and now includes ensuring rational use of drugs, improving clinical outcomes and promoting health status by working with the public and other healthcare professionals. OBJECTIVES: To examine the effect of pharmacist-provided non-dispensing services on patient outcomes, health service utilisation and costs in low- and middle-income countries. SEARCH METHODS: Studies were identified by electronically searching the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (February 2010), MEDLINE (1949 to February 2010), Scopus (1960 to March 2010) and International Pharmaceutical Abstracts (1970 to January 2010) databases. An update of this review is currently ongoing. The search was re-run September 2012 and the potentially relevant studies are awaiting classification. SELECTION CRITERIA: Randomised controlled trials, non-randomised controlled trials, controlled before-after studies and interrupted time series analyses comparing 1. pharmacist-provided non-dispensing services targeted at patients versus (a) the same services provided by other healthcare professionals, (b) the same services provided by untrained health workers, and (c) usual care; and 2. pharmacist-provided non-dispensing services targeted at healthcare professionals versus (a) the same services provided by other healthcare professionals, (b) the same services provided by untrained health workers, and (c) usual care in low- and middle-income countries. The research sites must have been located in low or middle income countries according to World Bank Group 2009 at the time of the study, regardless of the location or the origin of the researchers. DATA COLLECTION AND ANALYSIS: Two authors independently reviewed studies for inclusion in the review. Two review authors independently extracted data for each study. Risk of bias of the included studies was also assessed independently by two authors. MAIN RESULTS: Twelve studies comparing pharmacist-provided services versus usual care were included in this review. Of the 12 studies, seven were from lower middle income countries and five were from upper middle income countries. Eleven studies examined pharmacist-provided services targeted at patients and one study evaluated pharmacist interventions targeted at healthcare professionals. Pharmacist-provided services targeting patients resulted in a small improvement of clinical outcomes such as blood pressure (-25 mm Hg/-6 mm Hg and -4.56 mm Hg/-2.45 mm Hg), blood glucose (-39.84 mg/dl and -16.16 mg/dl), blood cholesterol (-25.7 mg/dl)/ triglyceride levels (-80.1 mg/dl) and asthma outcomes (peak expiratory flow rate 1.76 l/min). Moreover, there was a small improvement in the quality of life, although four studies did not report the effect size explicitly. Health service utilisation, such as rate of hospitalisation and general practice and emergency room visits, was also found to be reduced by the patient targeted pharmacist-provided services. A single study examined the effect of patient targeted pharmacist interventions on medical expenses and the cost was found to be reduced. A single study that examined pharmacist services that targeted healthcare professionals demonstrated a very small impact on asthma symptom scores. No studies assessing the impact of pharmacist-provided non-dispensing services that targeted healthcare professionals reported health service utilisation and cost outcomes. Overall, five studies did not adequately report the numerical data for outcomes but instead reported qualitative statements about results, which prevented an estimation of the effect size.Studies for the comparison of patient targeted services provided by pharmacists versus the same services provided by other healthcare professionals or untrained healthcare workers were not found. Similarly, studies for the comparison of healthcare professional targeted services provided by pharmacists versus the same services provided by other healthcare professionals or untrained healthcare workers were not found. AUTHORS' CONCLUSIONS: Pharmacist-provided services that target patients may improve clinical outcomes such as management of high glucose levels among diabetic patients, management of blood pressure and cholesterol levels and may improve the quality of life of patients with chronic conditions such as diabetes, hypertension and asthma. Pharmacist services may reduce health service utilisation such as visits to general practitioners and hospitalisation rates. We are uncertain about the effect of educational sessions by pharmacists for healthcare professionals due to the imprecision of a single study included in this review. Similarly, conclusions could not be drawn for health service utilisation and costs due to lack of evidence on interventions delivered by pharmacists to healthcare professionals. These results were heterogenous in the types of outcomes measured, clinical conditions and approaches to measurement of outcomes, and require cautious interpretation. All eligible studies were from middle income countries and the results may not be applicable to low income countries.

Diversity characteristics of the 2008-2009 pharmacy college application service applicant pool.

OBJECTIVE: To characterize the 2008-2009 Pharmacy College Application Service (PharmCAS) applicant pool in terms of diversity-related variables compared with admissions-related variables. METHODS: The relationships between the diversity variables of ethnicity, gender, parental education, and prepharmacy education, and the admissions-related variables of grade point average (GPA), pharmacy college admission test (PCAT) score, and acceptance rates were evaluated. RESULTS: There were 16,246 applicants to PharmCAS during the 2008-2009 pharmacy college and school admission cycle. Female applicants and non-underrepresented minorities (non-URMs) achieved higher mean GPAs, and male applicants and non-URMs had higher mean PCAT scores. Higher parental education was associated with higher mean GPA and PCAT scores. Mean PCAT score and GPA increased as prepharmacy education increased, with the exception of a bachelor's degree, which was associated with a lower GPA. Acceptance rates were higher among female applicants, non-URMs, and applicants with higher prepharmacy education and parental education. CONCLUSIONS: Female applicants, non-URMs, applicants with higher than a bachelor's degree, and applicants whose parents attained a doctoral degree were associated with higher mean GPAs and PCAT scores and were accepted to a higher proportion of the colleges and schools to which they applied. Colleges and schools of pharmacy can use these data as a benchmark when evaluating admissions processes.

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.

Medication therapy management: why it no longer should be considered optional.

Medications are the primary therapeutic intervention in many health care settings. As prescription drug use continues to grow, and medication therapies become more complex, our health care systems have become more prone to medication errors and adverse drug events. Medication Therapy Management services provided by pharmacists have been shown to help reduce medication errors, adverse drug events, and costs. Such services need to be integrated into the health care system and not be regarded as optional. This article is intended to provide pharmacists, pharmacy leaders, and health care policymakers the information needed to broach this topic at the health care policy level.

Randomized trials assessing calcium supplementation in healthy children: relationship between industry sponsorship and study outcomes.

OBJECTIVE: To explore the relationship between industry sponsorship of Ca supplementation studies in healthy children and study outcomes. DESIGN: An electronic search for published randomized controlled trials (RCT) was conducted. We collected data on study design features aimed at reducing bias, statistical significance of results, authors' conclusions and financial sponsorship of study. We used Fischer's exact test to examine associations between sponsorship and study results and conclusions. SUBJECTS: Healthy children between the ages of 9 and 18 years. RESULTS: Nineteen trials met our inclusion criteria. Seventeen out of nineteen studies reported a statistically significant improvement of supplementation on bone mineral density. Subjects in eight of the seventeen studies had a baseline daily Ca intake of 800-1300 mg. There was no significant association between study design features and the results or conclusions of the studies. Three studies received government funding, two of which (66.7%) concluded in favour of additional supplementation. Sixteen studies were either industry-funded or had mixed industry funding, thirteen (81.3%) of which had a conclusion supporting Ca supplementation in children. There was no significant association between study sponsorship and authors' conclusions. CONCLUSIONS: The majority of RCT assessing the effects of Ca supplementation in healthy children are industry-funded and support Ca supplementation. The clinical significance of the outcomes measured in Ca supplementation studies should be considered when examining associations between study design and results. Further non-industry funded research is needed to thoroughly assess the impact of funding on authors' conclusions in nutrition research.

Synthesis and evaluation of ligands for D2-like receptors: the role of common pharmacophoric groups.

Arylcycloalkylamines, such as phenyl piperidines and piperazines and their arylalkyl substituents, constitute pharmacophoric groups exemplified in several antipsychotic agents. A review of previous reports indicates that arylalkyl substituents can improve the potency and selectivity of the binding affinity at D(2)-like receptors. In this paper, we explored the contributions of two key pharmacophoric groups, that is, 4'-fluorobutyrophenones and 3-methyl-7-azaindoles, to the potency and selectivity of synthesized agents at D(2)-like receptors. Preliminary observation of binding affinities indicates that there is little predictability of specific effects of the arylalkyl moieties but the composite structure is responsible for selectivity and potency at these receptors.

Fostering and managing diversity in schools of pharmacy.

Organizational benefits of diversity in the workplace have been well documented. In health professions, however, diversity-related research traditionally has focused on the effect of diversity on health care disparities. Few tools exist describing the benefits of diversity from an organizational standpoint to guide pharmacy administrators and faculty members in nurturing and developing a culture of diversity. Given the scarcity of pharmacy specific data, experience from other academic areas and national/international diversity reports were incorporated into this manuscript to supplement the available pharmacy evidence base. This review summarizes the benefits of diversity from an academic organizational standpoint, discusses the issues administrators and faculty members must consider when developing programs, and provides guidance on best practices in fostering and managing diversity.

Poor health literacy as a barrier to patient care.

Only 12% of adults have proficient health literacy, according to the National Assessment of Adult Literacy. In other words, nearly 9 out of 10 adults may lack the skills needed to manage their health and prevent disease. The elderly patient is at especially high risk for having low health literacy. To provide optimal care for patients, pharmacists and other health care practitioners must understand the problems of health literacy and incorporate strategies and tools to improve the effectiveness of their communication with patients.

Clinical outcomes of patients with diabetes mellitus receiving medication management by pharmacists in an urban private physician practice.

PURPOSE: The clinical outcomes of patients with diabetes mellitus in an urban environment receiving pharmacist medication management in collaboration with private-practice physicians were assessed. METHODS: Patients older than 18 years with type 1 or 2 diabetes mellitus who were receiving oral and insulin therapy and who were referred to a pharmacy clinic within a private physician practice for medication management between March 1, 2002, and August 31, 2003, were eligible for study inclusion. Data were collected at three junctures: six months before the first visit with the pharmacist (preperiod measure), on the date of clinic entry (index measure), and six months after the first clinic visit (postperiod measure). Primary outcomes analyzed were glycosylated hemoglobin (HbA(1c)), weight, and blood pressure (goal, <130/80 mm Hg). Secondary outcomes analyzed were smoking cessation and initiation of aspirin, angiotensin-converting-enzyme inhibitor, or angiotensin receptor blocker therapy. RESULTS: A significant reduction in HbA(1c) from the index measure to the postperiod measure was observed (p < 0.001). No significant change was noted in weight or number of patients at goal blood pressure among the preperiod, index, and postperiod measures. No change was observed in the secondary outcomes during the study time intervals. CONCLUSION: Integrating a pharmacist into a private physician practice significantly improved patient glycemic control and maintained patients' weight and the number of patients at blood pressure goal. Clinic adherence with the American Diabetes Association recommendations was sustained.