Effectiveness of clinical pharmacy services: an overview of systematic reviews (2000–2010)

Yemeni Physicians' Attitudes and Perceived Barriers Toward Ward-Based Clinical Pharmacist in Hospital Settings

Background

Clinical pharmacy services (CPSs) are still in their infancy in Yemen. Furthermore, pharmacists are not members of a multidisciplinary healthcare team, so their responsibilities are limited to drug dispensing and marketing. This study examines physicians' attitudes and perceived obstacles regarding the inclusion of clinical pharmacists in hospital medical wards.

Methods

A descriptive observational study was carried out using a validated, self-administered bilingual questionnaire. The study's questionnaire was conducted among physicians in three leading hospitals. Those hospitals were at the forefront of establishing clinical pharmacy units and embracing clinical pharmacy services. Data were analyzed using descriptive statistics.

Results

Sixty-five responses were included. Our data results indicated that physicians believed the most important contributions for clinical pharmacists to improve patient care were "attending medical rounds", followed by "order review". About 75% of physicians showed positive attitudes toward the clinical pharmacist role. However, more than 70% of physicians believed that clinical pharmacists should leave patient care to other healthcare professionals and focus on drug products. Not enough clinical pharmacist staff working in the health center was considered the top perceived barrier (83.1%), followed by "clinical pharmacist responsibilities were not clearly defined" and "clinical pharmacist recommendations are not properly documented".

Conclusion

Strategies to expand clinical pharmacy services in Yemen should focus on several key areas. Protocols must be established to clearly outline the collaboration between clinical pharmacists and physicians. Additionally, fostering inter-professional relationships is crucial to overcoming resistance and increasing awareness and understanding of CPS adoption among healthcare team members.

Key performance indicators for pharmaceutical services: A systematic review

Background

Key performance indicators (KPIs) are a set of indicators that improve the quality of services provided by pharmacists. They enable the monitoring and evaluation of result progress and optimize decision-making for stakeholders. Currently, there is no systematic review regarding KPIs for pharmaceutical services.

Objectives

To identify and assess the quality of KPIs developed for pharmaceutical services.

Methods

A systematic review was conducted in PubMed, Scopus, EMBASE, and LILACS from the inception of the database until February 5th, 2024. Studies that developed a set of KPIs for pharmaceutical services were included. The indicators were evaluated using the Appraisal of Indicators through Research and Evaluation (AIRE) instrument. Two independent reviewers performed the study selection, data extraction, and quality assessment.

Results

Fifteen studies were included. The studies were conducted in different regions, most of which were developed for clinical services in hospitals or ambulatory settings, and used similar domains for the development of KPIs such as medication review, patient safety, and patient counseling. Literature review combined with the Delphi technique was the method most used by the studies, with content validity by inter-rater agreement. Regarding methodological quality, most studies described information on the purpose, definition, and stakeholders' involvement in the set of KPIs. However, little information was observed on the strategy for risk adjustment, instructions for presenting and interpreting the indicator results, the detailed description of the numerator and denominator, evidence scientific, and the feasibility of the set of KPIs. Only one study achieved a high methodological quality in all domains of the AIRE tool.

Conclusion

Our findings showed the potential of KPIs to monitor and assess pharmacy practice quality. Future studies should expand KPIs for other settings, explore validity evidence of the existing KPIs, provide detailed descriptions of evidence, formulation, and usage, and test their feasibility in daily practice.

Impact of a DSS-supported medication review on the safety of drug therapy and quality of life in patients with antithrombotic therapy

Polypharmacy is common among patients with antithrombotic medication, giving rise to concerns about Drug-Related Problems (DRPs). Therefore, these patients would benefit from a Medication Review (MR) along with pharmacist counselling to reduce the risks accompanying polymedication. This prospective study presents a concept for MRs that are applicable in German community pharmacies and can efficiently support pharmacist counselling and improve the safety of drug therapy. As this is a major challenge in everyday pharmacy practice, we used a Decision Support System (DSS) to evaluate its ability to support the process of pharmacist-led MRs. The primary endpoint was the impact of a community pharmacist on the reduction of DRPs. We investigated the impact of the interventions resulting from MRs on patients taking at least one antithrombotic drug as part of their polymedication regimen. Secondary endpoints were the reduction in the number of patients with bleeding risks and the improvement of patients' Quality of Life (QoL) and therapy adherence. Furthermore, the DSS used in the study was controlled for correct data assessment and plausibility of data. We selected adult patients who were taking no less than three different medications for long-term treatment, at least one of which had to be an antithrombotic drug, and who were customers in one of eight selected pharmacies over a period of 6 months. Data from 87 patients were analyzed with DSS-support. A total of 234 DRPs were identified by the pharmacist (2.7 DRPs per patient). MR reduced DRPs by 43.2% which, resulting to a reduction of 1.2 DRPs per patient. The intervention also led to a significant improvement in the patients' QoL (assessed via EQ-5D-5L questionnaire; p < 0.001) and enhanced therapy adherence (assessed via A14 questionnaire; p < 0.001). The control of correct data assessment (with 93.8% concordance) and plausibility of data (with 91.7% concordance) of the DSS software were conducted by an external auditor. No significant effect was found for overall bleeding risk. The results of this study indicate that DSS-supported and structured MR conducted by pharmacists can contribute to a reduction in DRPs and significantly improve patient's QoL and adherence to treatment.

Disadvantaged groups have greater spatial access to pharmacies in New York state

BACKGROUND

The accessibility of pharmacies has been associated with overall health and wellbeing. Past studies have suggested that low income and racial minority communities are underserved by pharmacies. However, the literature is inconsistent in finding links between area-level income or racial and ethnic composition and access to pharmacies. Here we aim to assess area-level spatial access to pharmacies across New York State (NYS), hypothesizing that Census Tracts with higher poverty rates and higher percentages of Black and Hispanic residents would have lower spatial access.

METHODS

The population weighted mean shortest road network distance (PWMSD) to a pharmacy in 2018 was calculated for each Census Tract in NYS. This statistic was calculated from the shortest road network distance to a pharmacy from the centroid of each Census block within a tract, with the mean across census blocks weighted by the population of the census block. Cross-sectional analyses were conducted to assess links between Tract-level socio demographic characteristics and Tract-level PWMSD to a pharmacy.

RESULTS

Overall the mean PWMSD to a pharmacy across Census tracts in NYS was 2.07 Km (SD = 3.35, median 0.85 Km). Shorter PWMSD to a pharmacy were associated with higher Tract-level % poverty, % Black/African American (AA) residents, and % Hispanic/Latino residents and with lower Tract-level % of residents with a college degree. Compared to tracts in the lowest quartile of % Black/AA residents, tracts in the highest quartile had a 70.7% (95% CI 68.3-72.9%) shorter PWMSD to a pharmacy. Similarly, tracts in the highest quartile of % poverty had a 61.3% (95% CI 58.0-64.4%) shorter PWMSD to a pharmacy than tracts in the lowest quartile.

CONCLUSION

The analyses show that tracts in NYS with higher racial and ethnic minority populations and higher poverty rates have higher spatial access to pharmacies.

Multifaceted pharmacist-led interventions in secondary care settings between countries of various income levels: a scoping review protocol

INTRODUCTION

Clinical pharmacy services often involve multifaceted pharmacist-led interventions. However, current pharmacy practice models vary across different countries. Despite the documented benefits of clinical pharmacy services, the characteristics of pharmacist-led interventions in different countries have not yet been adequately explored and described. Therefore, this protocol outlines the methodology for a proposed scoping review aiming to investigate various types of multifaceted pharmacist-led interventions and the outcomes used to evaluate their effectiveness within secondary care settings. Additionally, the scoping review will map the current evidence surrounding the characteristics of interventions and outcomes reported across various countries of socioeconomic status.

METHODS AND ANALYSIS

The scoping review will be conducted according to the JBI Methodology for Scoping Reviews and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Extension for Scoping Reviews. We will systematically search the following electronic databases: MEDLINE (Ovid), CINAHL (EbscoHost), Embase (embase.com), Scopus (scopus.com), Cochrane Library (cochranelibrary.com) and APA PsycInfo (Ovid). Additionally, the reference lists of identified reviews and included full texts will be searched for relevant papers. Grey literature sources, such as International Pharmaceutical Abstracts and the International Pharmaceutical Federation (FIP) website, will be searched. We will include primary studies published in the English language from January 2013 to December 2023, involving secondary care multifaceted pharmacist-led interventions. Two independent reviewers will screen studies against eligibility criteria and use a piloted data extraction form to extract relevant information. We will extract relevant data, complete a tabular summary from each included publication and analyse it.

ETHICS AND DISSEMINATION

Ethical approval is not required as we will be using data from publicly available literature sources. Findings will be disseminated in publications and presentations with relevant stakeholders. We aim to map available evidence across the breadth of studies that have reported multifaceted pharmacist-led interventions and their outcomes.

Development and partial validation of Be-CLIPSS: a classification system for hospital clinical pharmacy activities

BACKGROUND

Documentation of drug related problems (DRPs) and pharmaceutical interventions (PIs) is essential for an objective evaluation of the pharmacist's contribution to pharmacotherapy. However, in Belgium, a nationally used classification system is not available, prohibiting structured and uniform documentation of DRPs and PIs.

AIM

To develop and validate a national classification system for in-hospital clinical pharmacy activities, based on literature and field experience, specifically intended for routine registration.

METHOD

Based on a literature review, a survey among Belgian hospital pharmacists and a stakeholder focus group, a first version of Be-CLIPSS (Belgian CLInical Pharmacy claSsification System) was developed. Inter-rater reliability of the DRPs and PIs was assessed. Additionally, its usability was reviewed. The system was further refined, followed by a second validation.

RESULTS

Both the survey and focus group discussion revealed little use of validated DRP and PI classification systems in Belgium, although these were considered highly desirable if practical and minimally time-consuming. The final classification system encompassed seven clinical pharmacy activities, grouped into four activity classes. The inter-rater reliability for the second activity class was substantial for the DRPs (κ = 0.737) and almost perfect for the PIs (κ = 0.872). The interpretability (86.4%), user-friendliness (61.4%), user satisfaction (84.1%), interest for use in daily practice (68.2%) and difficulty in correctly classifying the DRP and PI (31.8%) were assessed.

CONCLUSION

Be-CLIPSS, a newly developed and partially validated classification system for DRPs and PIs, was found to be user-friendly, with a good interpretability and user satisfaction, resulting in a high interest for use in daily practice.

Scope, content and quality of clinical pharmacy practice guidelines: a systematic review

BACKGROUND

Guidelines for pharmacy practitioners regarding various clinical pharmacy activities have been published in a number of countries. There is a need to review the guidelines and identify the scope of activities covered as a prelude to developing internationally acceptable common guidelines.

AIM

To review the scope of clinical pharmacy guidelines and assess the extent to which these guidelines conform to quality standards as per the AGREE II instrument.

METHOD

Medline, Embase, Guideline Central, International Pharmaceutical Abstracts, Google Scholar and Google (for grey literature) were searched for the period 2010 to January 2023. Guidelines which focused on any health care setting and any clinical pharmacy activity were included. Data were extracted and quality assessed independently by two reviewers using the English version of the AGREE II instrument.

RESULTS

Thirty-eight guidelines were included, mostly originating from Australia (n = 10), Ireland (n = 8), UK (n = 7) and USA (n = 5). Areas covered included medication reconciliation, medicines optimisation, medication management and transition of care. As per the AGREE II assessment, the highest score was obtained for the scope and purpose domain and the lowest score for rigour of development, mainly due to non-consideration of literature/evidence to inform guideline development.

CONCLUSION

Clinical pharmacy guidelines development processes need to focus on all quality domains and should take a systematic approach to guideline development. Guidelines need to further emphasise person-centred care and clinical communication. There is a scope to harmonise the guidelines internationally considering the diverse practices, standards and legislations across different geographies.

Patient preferences and cost-benefit of hypertension and hyperlipidemia collaborative management model between pharmacies and primary care in Portugal: A discrete choice experiment alongside a trial (USFarmácia®)

BACKGROUND

Little is known about patient preferences and the value of pharmacy-collaborative disease management with primary care using technology-driven interprofessional communication under real-world conditions. Discrete Choice Experiments (DCEs) are useful for quantifying preferences for non-market services.

OBJECTIVES

1) To explore variation in patient preferences and estimate willingness-to-accept annual cost to the National Health Service (NHS) for attributes of a collaborative intervention trial between pharmacies and primary care using a trial exit DCE interview; 2) to incorporate a DCE into an economic evaluation using cost-benefit analysis (CBA).

METHODS

We performed a DCE telephone interview with a sample of hypertension and hyperlipidemia trial patients 12 months after trial onset. We used five attributes (levels): waiting time to get urgent/not urgent medical appointment (7 days/45 days; 48 hrs./30 days; same day/15 days), model of pharmacy intervention (5-min. counter basic check; 15-min. office every 3 months for BP and medication review of selected medicines; 30-min. office every 6 months for comprehensive measurements and medication review of all medicines), integration with primary care (weak; partial; full), chance of having a stroke in 5 years (same; slightly lower; much lower), and annual cost to the NHS (0€; 30€; 51€; 76€). We used an experimental orthogonal fractional factorial design. Data were analyzed using conditional logit. We subtracted the estimated annual incremental trial costs from the mean WTA (Net Benefit) for CBA.

RESULTS

A total of 122 patients completed the survey. Waiting time to get medical appointment-on the same day (urgent) and within 15 days (non-urgent)-was the most important attribute, followed by 30-minute pharmacy intervention in private office every 6 months for point-of-care measurements and medication review of all medicines, and full integration with primary care. The cost attribute was not significant. Intervention patients were willing to accept the NHS annual cost of €877 for their preferred scenario. The annual net benefit per patient is €788.20 and represents the monetary value of patients' welfare surplus for this model.

CONCLUSIONS

This study is the first conducted in Portugal alongside a pharmacy collaborative trial, incorporating DCE into CBA. The findings can be used to guide the design of pharmacy collaborative interventions with primary care with the potential for reimbursement for uncontrolled or at-risk chronic disease patients informed by patient preferences. Future DCE studies conducted in community pharmacy may provide additional contributions.

TRIAL REGISTRATION

Current Controlled Trials (ISRCTN): ISRCTN13410498, retrospectively registered on 12 December 2018.

Real-World Effectiveness in Hypertension and Hyperlipidemia Collaborative Management between Pharmacies and Primary Care in Portugal: A Multicenter Pragmatic Controlled Trial (USFarmácia®)

There is evidence of the efficacy of collaborative health interventions with pharmacies and primary care providers but little of its real-world effectiveness. We aimed to assess the effectiveness and discuss the design and challenges of hypertension and hyperlipidemia management between pharmacies and primary care providers using real-world data exchange between providers and experimental bundled payment. This was a pragmatic, quasi-experimental controlled trial. We collected patient-level data from primary care prescription claims and Electronic Medical Record databases, a pharmacy claims database, and patient telephone surveys at several time points. The primary outcomes were changes in blood pressure and total cholesterol. We used matched controls with difference-in-differences estimators in a Generalized Linear Model (GLM) and controlled interrupted time series (CITS). We collected additional data for economic and qualitative studies. A total of 6 Primary Care Units, 20 pharmacies, and 203 patients entered the study. We were not able to observe significant differences in the effect of intervention vs. control. We experienced challenges that required creative strategies. This real-world trial was not able to show effectiveness, likely due to limitations in the primary care technology which affected the sample size. It offers, however, valuable lessons on methods, strategies, and data sources, paving the way for more real-world effectiveness trials to advance value-based healthcare.

Clinical pharmacy services for tuberculosis management: a systematic review

Objective: This study aims to systematically review the content and potential effects of clinical pharmacy services in tuberculosis (TB) care management. Methods: Searches were performed in PubMed, Embase, Cochrane, Scopus, and Web of Science databases following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Study characteristics and outcomes were extracted, and clinical pharmacy service components were characterized using the Descriptive Elements of Pharmacist Intervention Characterization Tool. Results: Twenty articles were included for full-text assessment, of which 10 fulfilled inclusion criteria, comprising 1,168 patients (N = 39 to 258 per study). These articles included five prospective cohort studies, two case-control studies, two quasi-experimental studies, and one cross-sectional study. Intervention foci within clinical pharmacy services were medication adherence (50%), medication safety (40%), education to patients/caregivers regarding needs/beliefs (30%), optimizing medication/therapy effectiveness (30%), emphasizing HRQoL (10%), and drug selections (10%). The three most frequently applied interventions were drug information/patient counseling (80%), adverse drug reaction monitoring (50%), and drug use evaluation (20%). Based on the World Health Organization (WHO) outcome classification, treatment success ranged from 72% to 93%, with higher cure outcomes (53%-86%) than treatment completion (7%-19%). Other outcomes, including isoniazid metabolites, medication counts, sputum conversion, adherence/compliance, knowledge, and quality of life, were better in the intervention group than those in comparator groups, and/or they improved over time. Risk of bias analysis indicated that the included studies were not comparable to a randomized clinical trial. Conclusion: Clinical pharmacy services as single or composite interventions potentially improve TB outcomes, but its evidence is still inconsistent and limited due to the lack of randomized controlled studies using the WHO outcome classification. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=199028, identifier CRD42020199028.

Perceptions and expectations of health professionals regarding hospital pharmacy services and the roles of hospital pharmacists: A qualitative systematic review and meta-synthesis

Background

Pharmacists have become increasingly integrated within the interprofessional hospital team as their scope of practice expanded in recent decades. However, limited research has explored how the roles of hospital pharmacists are perceived by other health professionals.

Aim/Objectives

To identify what is known about the perceptions of hospital pharmacists' roles and hospital pharmacy services held by non-pharmacist health professionals.

Methods

A systematic literature search was conducted in August 2022 in MEDLINE, Embase, and CINAHL to identify peer-reviewed articles published between 2011 and 2022. Title/abstract and full-text screening, by two independent reviewers, identified eligible articles. Inclusion criteria included qualitative studies in hospital settings that reported perceptions regarding the roles of hospital pharmacists held by non-pharmacist health professionals. Data were extracted using a standardised extraction tool. Collated qualitative data underwent inductive thematic analysis by two independent investigators to identify codes, which were reconciled and merged into over-arching themes through a consensus process. Findings were assessed to measure confidence using the GRADE-CERQual criteria.

Results

The search resulted in 14,718 hits. After removing duplicates, 10,551 studies underwent title/abstract screening. Of these, 515 underwent full-text review, and 36 were included for analysis. Most studies included perceptions held by medical or nursing staff. Hospital pharmacists were perceived as valuable, competent and supportive. At an organisational level, the roles of hospital pharmacists were perceived to benefit hospital workflow and improve patient safety. Roles contributing to all four domains of the World Health Organization's Strategic Framework of the Global Patient Safety Challenge were recognised. Highly-valued roles include medication reviews, provision of drug information, and education for health professionals.

Conclusion

This review describes the roles hospital pharmacists performed within the interprofessional team, as reported by non-pharmacist health professionals internationally. Multidisciplinary perceptions and expectations of these roles may guide the prioritisation and optimisation of hospital pharmacy services.

Role of community pharmacy and pharmacists in self-care in Brazil

Global healthcare systems, including the National Health System in Brazil - one of the largest public models in the world -, continue to evolve, as well as populations' health needs, currently shaped on individuals feeling a greater desire to manage their own health. Self-care practices are part of several public policies and clinical guidelines in Brazil including the National Policy on Complementary and Integrative Practices, the National AIDS Control Program, the National Policy for Women's Health, and the Guidelines for Care of People with Chronic Diseases. There are over 100,700 community pharmacies, in the country (89.2% privately owned) employing 234,300 pharmacists, representing an important delivery point for self-care, as they are the first point of access to care for most patients. Self-medication is a common practice in Brazil (prevalence rates of self-medication ranging from 16.1% to 35.0%), especially with non-prescription/over-the-counter medicinal products (65.0%). In fact, these products represent over 25% of volume marketed of medicines, summing revenues of USD 1.9 billion per year. Studies demonstrated a positive budget impact as important savings for the National Health System due to reductions of unnecessary medical appointments and loss of working days. In addition to minor ailments management, other self-care services provided by community pharmacies that are frequently sought by Brazilian citizens (20-25% of cases) are smoking cessation and weight management (costs per service ranging from around USD 5.00-12.00). However, pharmacy services are not yet as fully integrated in Brazil to the same extent as in other countries. Barriers such as standardization of processes (from services' design, implementation, and evaluation in practice), pharmacist remuneration for the provision of services and the amount to be charged for the service are still a matter of controversy. For more rapid and sustainable advances in these practices, communication among various stakeholders, professional practice and healthcare regulations, standardization of services and financing of self-care (both publicly and privately) are urgently needed. This paper provides an overview of some self-care services provided by community pharmacies in Brazil and call attention to the ongoing challenges to move the National Health system forward.

Impact of selected clinical pharmacy services on medication safety and prescription cost of patients attending a selected primary healthcare setting: a translational experience from a resource-limited country

PURPOSE OF THE STUDY

The impact of clinical pharmacy (CP) services on primary healthcare (PH) is less well studied in resource-limited countries. We aimed to evaluate the effect of selected CP services on medication safety and prescription cost at a PH setting in Sri Lanka.

STUDY DESIGN

Patients attending a PH medical clinic with medications prescribed at the same visit were selected using systematic random sampling. A medication history was obtained and medications were reconciled and reviewed using four standard references. Drug-related problems (DRPs) were identified and categorised, and severities were assessed using the National Coordinating Council Medication Error Reporting and Prevention Index. Acceptance of DRPs by prescribers was assessed. Prescription cost reduction due to CP interventions was assessed using Wilcoxon signed-rank test at 5% significance.

RESULTS

Among 150 patients approached, 51 were recruited. Nearly half (58.8%) reported financial difficulties in purchasing medications. DRPs identified were 86. Of them, 13.9% (12 of 86) DRPs were identified when taking a medication history (administration errors (7 of 12); self-prescribing errors (5 of 12)), 2.3% (2 of 86) during reconciliation, and 83.7% (72 of 86) during medication reviewing (wrong indication (18 of 72), wrong strength (14 of 72), wrong frequency (19 of 72), wrong route of administration (2 of 72), duplication (3 of 72), other (16 of 72)). Most DRPs (55.8%) reached the patient, but did not cause harm. Prescribers accepted 65.8% (56 of 86) DRPs identified by researchers. The individual prescription cost reduced significantly due to CP interventions (p<0.001).

CONCLUSIONS

Implementing CP services could potentially improve medication safety at a PH level even in resource-limited settings. Prescription cost could be significantly reduced for patients with financial difficulties in consultation with prescribers.

The CombiConsultation for patients with diabetes, COPD and cardiovascular diseases: Evaluation of interventions and personal health-related goals

BACKGROUND

The CombiConsultation is a consultation with the community pharmacist for patients with diabetes, COPD and/or cardiovascular disease (CVD), aligned with the annual or quarterly consultation with the practice nurse (PN) or general practitioner (GP). The consultation is focused on the personal health-related goals of the patient.

OBJECTIVES

To assess the number and types of personal health-related goals, drug-related problems (DRPs) and interventions identified by pharmacists during a CombiConsultation and to investigate which patients can benefit most from such consultation.

METHOD

Twenty-one Dutch community pharmacies and associated GP practices were included in the CombiConsultation study. CombiConsultations were performed, involving patients with diabetes, COPD and/or (at risk of) CVD. The pharmacists set health-related goals together with the patients and identified DRPs. The number and types of personal health-related goals, DRPs and interventions were analysed. Associations between patient characteristics and the identification of at least one DRP were analysed by multivariate regression analysis.

RESULTS

In 834 patients (49% men, mean age: 70 years), 939 DRPs were identified, mostly (potential) side effects (33%), undertreatment (18%) and overtreatment (14%). In 71% of the patients, one or more DRPs were found, with a median of one DRP per patient. Pharmacists proposed 935 recommendations, of which 72% were implemented. DRPs were found more often in patients using a higher number of drugs for chronic conditions. A total of 425 personal health-related goals were set, of which 53% were (partially) attained.

CONCLUSION

The CombiConsultation can be used as a compact health service contributing to safe and effective use of medication for patients with diabetes, COPD and/or (at risk of) CVD, also in patients under 65 or with less than 5 medications in use. The output of the CombiConsultation reflects its characteristics.

Development, implementation and evaluation of a seven-day clinical pharmacy service in a tertiary referral teaching hospital during surge-2 of the COVID-19 pandemic

BACKGROUND

Seven-day clinical pharmacy services in the acute sector of the National Health Service are limited. There is a paucity of evidential patient benefit. This limits investment and infrastructure, despite United Kingdom wide calls.

AIM

To optimise medicines seven-days a week during surge-2 of the COVID-19 pandemic through implementation of a seven-day clinical pharmacy service. This paper describes service development, evaluation and sustainability.

SETTING

A tertiary-referral teaching hospital, London, United Kingdom.

DEVELOPMENT

The seven-day clinical pharmacy service was developed to critical care, acute and general medical patients. Clinical leads developed the service specification and defined priorities, targeting complex patients and transfer of care. Contributing staff were briefed and training materials developed.

IMPLEMENTATION

The service was implemented in January 2021 for 11 weeks. Multidisciplinary team communication brought challenges; strategies were employed to overcome these.

EVALUATION

A prospective observational study was conducted in intervention wards over two weekends in February 2021. 1584 beds were occupied and 602 patients included. 346 interventions were reported and rated; 85.6% had high or moderate impact; 56.7% were time-critical. The proportion of medicines reconciliation within 24-h of admission was analysed across the hospital between November 2020 and May 2021. During implementation, patients admitted Friday-Sunday were more likely to receive medicines reconciliation within 24-h (RR 1.41 (95% CI 1.34-1.47), p < 0.001). Rostered services were delivered sustainably in terms of shift-fill rate and medicines reconciliation outcome.

CONCLUSION

Seven-day clinical pharmacy services benefit patient outcome through early medicines reconciliation and intervention. Investment to permanently embed the service was sustained.

Willingness to Pay for Clinical Pharmacy Services Among People With Diabetes in Nigerian Community Pharmacies

OBJECTIVES

This study aimed to assess willingness to pay (WTP) for clinical pharmacy services among people with diabetes and to determine the factors affecting WTP for these services.

METHODS

This was a cross-sectional exit survey of 450 people with diabetes visiting 15 community pharmacies in Uyo metropolis, Akwa Ibom State, Nigeria, between August and September 2021. Self-reported questionnaires were administered to eligible patients just before leaving the community pharmacy. Data were analyzed using SPSS (version 25.0). Statistical significance was set at P < .05.

RESULTS

Response rate was 87.3%. Two hundred respondents (50.9%) were willing to pay an average amount of US$2.83 (minimum-maximum, US$0.12-US$24.27) for clinical pharmacy services. The two most often cited reasons for those who were unwilling to pay were their inability to pay and their opposition to paying for any healthcare services. Employment status (P < .001), personal monthly income (P < .001), satisfaction with income (P < .001), household monthly income (P < .001), health insurance coverage (P < .001), insulin use (P < .001), perception of the pharmacist's relevance in healthcare (P = .013) and in diabetes care (P < .001), and satisfaction with the pharmacist's services (P < .001) significantly affected WTP choices. None of the patient characteristics predicted the maximum amounts patients were willing to pay.

CONCLUSIONS

Many of the people with diabetes assessed were willing to pay for clinical services at a reasonable price. Although most patient variables affected their WTP choices, none of the variables predicted the maximum amount they were willing to pay. For possible remuneration for clinical services, community pharmacists should continue to grow their practices and stay current with patient care.

Comprehensive Medication Management Services with a Holistic Point of View, a Scoping Review

Implementing Comprehensive Medication Management (CMM) services uncovered the importance of the totality of the patient's perspective in this process. The holistic approach takes into account the physical, mental and emotional well-being of individuals, as well as their socioeconomic circumstances. The aim of this study was to characterize the scientific evidence associated with CMM services that included this holistic approach. A scoping review was conducted based on Arksey and O'Malley's method. Searches were performed in Google Scholar for papers published between 2010 and 2020 in English, Spanish and Portuguese. Study design, health contexts, sample of patients, results obtained, barriers and facilitators, and the integration of a holistic approach were determined. Two hundred and eighteen papers were evaluated, most of which focused on the implementation of this service through prospective observational studies. A minority of studies reported on a holistic approach, a smaller number examined the effect of social determinants of health, the patient's medication experiences and the pharmacotherapy outcomes from the patient's perspective. Despite the progress achieved, most of the referents do not yet reflect a broader view of the patient's life situation and its relationship to pharmacotherapy and the ways in which the pharmacist implements holistic elements to solve or prevent drug-related problems.

Design and Development of Tools for Risk Evaluation of Diabetes and Cardiovascular Disease in Community Pharmacy

There is an increasing motivation to implement pharmacist-led screening services in community pharmacies. This study aims to develop tools to support the pharmacist in the context of a diabetes and cardiovascular disease risk assessment service. Our development involved a multistep process using a user-centred approach, including a need assessment phase (14 patients, 17 pharmacists) and a creative design phase, followed by the evaluation of the materials (10 patients, 16 pharmacists). Three following themes covering educational needs emerged from stakeholders' discussions: "content", "layout", and "form", with three additional themes regarding the practical organisation: "software", "awareness", and "referral". Based on the need assessment, tools for patient education purposes and awareness campaigns were created. During the development, special attention was paid to the writing style and structure with less text and more graphical colourful elements to suit patients with different health literacy and educational levels. The evaluation phase allowed researchers to observe participants engaging with the materials. Overall, participants were satisfied with the tools. The contents were considered valuable and relevant. However, adaptations were necessary to ensure their understanding and long-term usability. Finally, future research is required to evaluate the materials' impact on patients' behaviour towards their identified risk factors and ensure their effectiveness.

Cost-effectiveness and cost-utility of hypertension and hyperlipidemia collaborative management between pharmacies and primary care in portugal alongside a trial compared with usual care (USFarmácia®)

Background: There is little experience in the economic evaluation of pharmacy/primary care collaborative health interventions using interprofessional technology-driven communication under real-world conditions. This study aimed to conduct cost-effectiveness and cost-utility analyses of a collaborative care intervention in hypertension and hyperlipidemia management between pharmacies and primary care versus usual (fragmented) care alongside a trial.

Methods: An economic evaluation was conducted alongside a 6-month pragmatic quasi-experimental controlled trial. Data sources included primary care clinical software; pharmacy dispensing software; patient telephone surveys; and published literature. The target population was adult patients on hypertension and/or lipid-lowering medication. The perspective was societal. We collected patient-level data on resource use to estimate trial costs. Effect outcomes included blood pressure (BP) and quality-adjusted life years (QALYs). Bootstrapping was used to estimate uncertainty around the incremental cost-effectiveness and cost-utility ratios. Cost-effectiveness planes and acceptability curves were estimated.

Results: The intervention was not shown to have reasonable levels of cost-effectiveness or cost-utility when compared to usual care as denoted by the levels of uncertainty expressed in wide confidence intervals. The probability of the intervention being cost-effective is 28% at the threshold of €20,000 per QALY gained and 57% at the threshold of €500 per mmHg systolic BP decrease.

Conclusion: Considering the limitations of the trial which affected effectiveness and economic outcomes, our results are not generalizable for community pharmacy and primary care in Portugal. This research offers, however, valuable lessons on methods and strategies that can be used in future economic evaluations of collaborative public health interventions with the potential for reimbursement.

Clinical trial registration:https://www.isrctn.com/ISRCTN13410498, identifier ISRCTN13410498

"It is the future. Clinical pharmaceutical care simply has to be a matter of course." - Community pharmacy clinical service providers' and service developers' views on complex implementation factors

BACKGROUND

While there is a lot of documented evidence about the clinical and cost effectiveness of pharmacists' role extensions there is an inherent gap between service development and implementation.

OBJECTIVE(S)

This study aims to better understand the complex factors that influence the implementation of clinical pharmacy services from both the perspective of the community pharmacy service providers and service developers.

METHODS

A prospective qualitative interview study using purposive sampling of twelve service developers and twelve community pharmacy service providers from across all nine Federal States of Austria. The validated and piloted interview guide contained questions and prompts on role perceptions, attitudes, experience, implementation barriers, training needs and measures identified to strengthen clinical pharmacy provision in community pharmacy. Verbatim quotes were independently mapped to the Framework for the Implementation of Services in Pharmacy (FISpH) by two researchers.

RESULTS

24 Interviews were carried out. Data saturation was achieved. There is a great deal of enthusiasm to develop the remit of clinical pharmacy services. It is seen as important to ensure the future survival of the profession. Service developers are more positive and confident in the implementation success and pharmacists' skills than providers. Clear mandates for politics, academia and individual pharmacists have been discussed to affect change.

CONCLUSIONS

Austrian pharmacists are facing the same well documented challenges as many other healthcare systems only with more urgency. The development of a clinical pharmacy service framework; education accreditation standard and a well-supported continuous professional development system are considered key to bring about the necessary culture shift.

Development and assessment of PharmaCheck: an electronic screening tool for the prevention of twenty major adverse drug events

Background

Adverse drug events (ADEs) can be prevented by deploying clinical decision support systems (CDSS) that directly assist physicians, via computerized order entry systems, and clinical pharmacists performing medication reviews as part of medical rounds. However, physicians using CDSS are known to be exposed to the alert-fatigue phenomenon. Our study aimed to assess the performance of PharmaCheck—a CDSS to help clinical pharmacists detect high-risk situations with the potential to lead to ADEs—and its impact on clinical pharmacists’ activities.

Methods

Twenty clinical rules, divided into four risk classes, were set for the daily screening of high-risk situations in the electronic health records of patients admitted to our General Internal Medicine Department. Alerts to clinical pharmacists encouraged them to telephone prescribers and suggest any necessary treatment adjustments. PharmaCheck’s performance was assessed using the intervention’s positive predictive value (PPV), which characterizes the proportion of interventions for each alert triggered. PharmaCheck’s impact was assessed by considering clinical pharmacists as a filter for ruling out futile alerts and by comparing the final clinical PPV with a pharmacist (the proportion of interventions that led to a change in the medical regimen) to the final clinical PPV without a pharmacist.

Results

Over 132 days, 447 alerts were triggered for 383 patients, leading to 90 interventions (overall intervention PPV = 20.1%). By risk class, intervention PPVs made up 26.9% (n = 65/242) of abnormal laboratory value alerts, 3.1% (4/127) of alerts for contraindicated medications or medications to be used with caution, 28.2% (20/71) of drug–drug interaction alerts, and 14.3% (1/7) of inadequate mode of administration alerts. Clinical PPVs reached 71.0% (64/90) when pharmacists filtered alerts and 14% (64/242) if they were not doing it.

Conclusion

PharmaCheck enabled clinical pharmacists to improve their traditional processes and broaden their coverage by focusing on 20 high-risk situations. Alert management by pharmacists seemed to be a more effective way of preventing risky situations and alert-fatigue than a model addressing alerts to physicians exclusively. Some fine-tuning could enhance PharmaCheck's performance by considering the information quality of triggers, the variability of clinical settings, and the fact that some prescription processes are already highly secured.

Adopting AMSTAR 2 critical appraisal tool for systematic reviews: speed of the tool uptake and barriers for its adoption

Background

In 2007, AMSTAR (A MeaSurement Tool to Assess systematic Reviews), a critical appraisal tool for systematic reviews (SRs), was published, and it has since become one of the most widely used instruments for SR appraisal. In September 2017, AMSTAR 2 was published as an updated version of the tool. This mixed-methods study aimed to analyze the extent of the AMSTAR 2 uptake and explore potential barriers to its uptake.

Methods

We analyzed the frequency of AMSTAR or AMSTAR 2 use in articles published in 2018, 2019 and 2020. We surveyed authors who have used AMSTAR but not AMSTAR 2 in the analyzed time frame to identify their reasons and barriers. The inclusion criterion for those authors was that the month of manuscript submission was after September 2017, i.e. after AMSTAR 2 was published.

Results

We included 871 studies. The majority (N = 451; 52%) used AMSTAR 2, while 44% (N = 382) used AMSTAR, 4% (N = 31) used R-AMSTAR and others used a combination of tools. In 2018, 81% of the analyzed studies used AMSTAR, while 16% used AMSTAR 2. In 2019, 52% used AMSTAR, while 44% used AMSTAR 2. Among articles published in 2020, 28% used AMSTAR, while AMSTAR 2 was used by 69%.

An author survey indicated that the authors did not use AMSTAR 2 mostly because they were not aware of it, their protocol was already established, or data collection completed at the time when the new tool was published. Barriers towards AMSTAR 2 use were lack of quantitative assessment, insufficient awareness, length, difficulties with a specific item.

Conclusion

In articles published in 2018-2020, that were submitted to a journal after AMSTAR 2 tool was published, almost half of the authors (44%) still used AMSTAR, the old version of the tool. However, the use of AMSTAR has been declining in each subsequent year. Our survey indicated that editors and peer-reviewers did not ask the authors to use the new version of the tool. Few barriers towards using AMSTAR 2 were identified, and thus it is anticipated that the use of the old version of AMSTAR will continue to decline.

Traduction franco-canadienne de l’Assessment of Systematic Reviews Revised (AMSTAR 2) : validation transculturelle et fidélité interjuges

Objective: Produce a French-Canadian translation of AMSTAR 2, affirm its content validity, and examine interrater reliability. Methods: Based on Vallerand's methodological approach, we conducted forward and parallel inverse-translations. Subsequently, an expert panel evaluated the translations to create a preliminary experimental French-Canadian version. A second expert panel examined this version and proposed additional modifications. Twenty future health professionals then rated the second experimental version for ambiguity on a scale (from 1 to 7). The principal co-investigators then reviewed the problematic elements and proposed a pre-official version. To ascertain content validity, a final back-translation was conducted resulting in the official version. Four judges evaluated 13 systematic reviews using the official French-Canadian version of AMSTAR 2. The Kappa coefficient was used to evaluate interrater reliability. Results: This rigorous adaptation enabled the development of a Franco-Canadian version of AMSTAR 2. Its application demonstrated low ambiguity (mean 1.15; SD 0.26) as well as good overall interrater reliability (total κ > 0.64) across all items. Conclusion: The French-Canadian version of AMSTAR 2 can now support francophone clinicians, educators, and managers in Canada as they undertake evidence-based practice.

The CombiConsultation: a new concept of sequential consultation with the pharmacist and practice nurse/general practitioner for patients with a chronic condition

The primary health care system is generally well organized for dealing with chronic diseases, but comprehensive medication management is still a challenge. Studies suggest that pharmacists can contribute to effective and safe drug therapy by providing services like a clinical medication review (CMR). However, several factors limit the potential impact of a CMR. Therefore, we propose a new pharmaceutical care service for patients with a chronic condition: the CombiConsultation. The CombiConsultation is a medication evaluation service conducted by the (community) pharmacist and either the practice nurse or general practitioner. It consists of 3 steps: medication check, implementation and follow-up. The pharmacist primarily focusses on setting treatment goals for 1 or 2 drug-related problems in relation to a specific chronic condition. In this manuscript we describe the process and characteristics of the CombiConsultation. We compare the CombiConsultation with the CMR and explain the choices made and the implications for implementation.

Impact of Clinical Pharmacist-led Interventions in Turkey

Detecting drug-related problems (DRPs) is important in pharmaceutical care in for better therapeutic outcomes. Clinical pharmacists-led comprehensive medication management plays a crucial role in the rational use of drugs by preventing, identifying, and resolving DRPs. In this review, we aimed to determine the effect of interventions on patient outcomes performed by clinical pharmacists in Turkey. A systematic literature search was performed on PubMed, Google Scholar, EMBASE, Cochrane Library, and Turkish databases (ULAKBIM, Dergipark). The main categories were "clinical pharmacist", "intervention", and "Turkey". Two reviewers reviewed each article independently. Two independent reviewers screened all records and extracted data; disagreements were resolved through a consensus. Randomized controlled studies, pre- to post-intervention comparison studies, and cross-sectional studies including pharmacist-led interventions were included in the review. This review included 15 articles evaluating clinical pharmacist interventions. Ten studies (66.7%) focused on DRPs and pharmacist interventions to these problems, while the remaining 5 (33.3%) studies focused on patient education and adherence issues. Studies were conducted in oncology (33.3%), geriatrics (20.0%), chest diseases (13.3%), psychiatry (6.7%), cardiology (6.7%), and infectious diseases (6.7%) clinics. When results of studies are reviewed, most of the interventions were made at the prescriber level followed by the drug level and patient level. Problems were solved in 54.2-93.2% of DRPs, and adherence, patient knowledge, or skills were improved in most of the studies. Most of the studies were carried out within the scope of a postgraduate or doctorate thesis and yet various positive outcomes such as the prevention of side effects, increased quality of life, and decreased duration of hospital stay were observed with high positive rates of interventions, which indicate that other healthcare workers are ready to collaborate with the clinical pharmacists in Turkey.

Clinical pharmacists' interventions across German hospitals: results from a repetitive cross-sectional study

Background Pharmacists’ interventions (PI) are suitable to improve medication safety and optimise patient outcome. However, in Germany, clinical pharmacy services are not yet available nationwide. Aim To gain prospective data on the extent and the composition of routine PI with special focus on intervention rates among German hospital pharmacists during two intervention weeks. Methods Within a repetitive cross-sectional study, clinical pharmacists documented all PIs on five days during a one-month period (intervention week) in 2017 and 2019 using the validated online-database ADKA-DokuPIK. Additionally, data regarding the supply structure/level of medical care, the extent of clinical pharmacy services and their professional experience were collected. All data were anonymised before analysis. Results In total, 2,282 PI from 62 pharmacists (2017) and 2578 PI from 52 pharmacists (2019) were entered. Intervention rate increased from 27.5 PI/100 patient days in 2017 to 38.5 PI/100 patient days in 2019 (p = 0.0097). Frequency of clinical pharmacy services on a daily basis significantly increased from 60% (2017) to 83% (2019). Reasons for PIs from the categories “drugs” (e.g. indication, choice, documentation/transcription) and “dose” were most common in both intervention weeks. The vast majority of underlying medication errors in both intervention weeks were categorised as “error, no harm” (80.3 vs. 78.6%), while the proportion of errors which did not reach the patient, doubled to 39.8% in IW-2019. Conclusion Regular and daily clinical pharmacy services become more established in Germany and clinical pharmacists are increasingly involved in solving drug related problems proactively and early during the medication management process.

Development of a primary care pharmacy outcomes framework: An umbrella literature review

BACKGROUND

An aging population and rising multi-morbidity has shifted healthcare provision from secondary to primary care. Pharmacy-led services have been introduced to support this. The development of an outcomes framework for these services would facilitate conclusions to be drawn on their effectiveness.

OBJECTIVES

To identify outcomes used to evaluate pharmacy-led medication therapy and disease management services within primary care settings to develop an outcomes framework for future studies.

METHODS

An umbrella literature review was conducted. MEDLINE, EMBASE, The Cochrane Library and PsycINFO were searched in June 2020 to identify relevant articles. Eligible reviews were those including studies published from 2010 onwards which reported on the outcomes of pharmacy-led medication therapy and disease management services within primary care, excluding community pharmacy settings. Data were extracted and a content analysis, guided by the ECHO model, stratified the outcomes into four areas: economic, clinical, humanistic and service.

RESULTS

Twenty-four reviews covering 52 unique studies were identified. Pharmacy-led services included: medication reviews (n=24, 46.2%), disease and therapy management (n=17, 32.7%), educational services (n=6, 11.5%), medicines reconciliation (n=3, 5.8%), and medication compliance support (n=1, 1.9%). Services were commonly targeted towards endocrine (n=23, 44.2%) or cardiovascular diseases (n=20, 38.5%). Outcomes most commonly explored were clinical (n=38, 73.1%) and service outcomes (n=37, 71.2%), followed by humanistic (n=23, 44.2%) and economic outcomes (n=13, 25.0%). Overall, 17 sub-categories of outcomes were identified; common sub-categories were: disease indicators [clinical]; medication use and healthcare utilisation [service]; adherence to medicines [humanistic]; and healthcare costs [economic].

CONCLUSIONS

The findings informed the development of an outcomes framework to guide the evaluation of medication therapy and disease management services, and facilitate international standardised outcome measures within primary care pharmacy to be developed. This could help offer vital evidence on the effectiveness of these services to ensure the pharmacy workforce is working optimally to support primary care.

Defining clinical pharmacy and support activities indicators for hospital practice using a combined nominal and focus group technique

Background Although clinical pharmacy is a crucial part of hospital pharmacist’s day-to-day activity, its performance is not usually subject to a holistic assessment. Objective To define a set of relevant and measurable clinical pharmacy and support activities key performance indicators (cpKPI and saKPI, respectively). Setting Portuguese Hospital Pharmacies. Method After a comprehensive literature review focusing on the metrics already in use in other countries, several meetings with directors of hospital pharmacies were conducted to obtain their perspectives on hospital pharmacy practices and existing metrics. Finally, five rounds with a panel of 8 experts were performed to define the final set of KPIs, where experts were asked to score each indicator’ relevance and measurability, and encouraged to suggest new metrics. Main outcome measure The first Portuguese list of KPIs to assess pharmacists’ clinical and support activities performance and quality in hospital pharmacies. Results A total of 136 KPIs were assessed during this study, of which 57 were included in the original list and 79 were later added by the expert panel. By the end of the study, a total of 85 indicators were included in the final list, of which 40 are considered to be saKPI, 39 cpKPI and 6 neither. Conclusion A set of measurable KPIs was established to allow for benchmarking within and between Portuguese hospital Pharmacies and to elevate professional accountability and transparency. Future perspectives include the use of both cpKPIs and saKPIs on a national scale to identify the most efficient performances and areas of possible improvement.

Methodological standards for conducting and reporting meta-analyses: Ensuring the replicability of meta-analyses of pharmacist-led medication review

BACKGROUND

Meta-analyses of clinical pharmacy services are frequently criticized for restricted data transparency and reproducibility.

OBJECTIVES

To describe the methodological characteristics of meta-analyses of pharmacist-led medication reviews, to identify the elements that limit their replicability and robustness, and to propose recommendations for an appropriate conduction and reporting.

METHODS

A meta-research study was conducted. Systematic searches of the PubMed, Scopus, and Web of Science databases were performed to identify meta-analyses of pharmacist services. Meta-analyses assessing the effect of pharmacist-led medication reviews were selected for data extraction, analysis and replication. Two replication exercises were performed for the two most common outcomes: (i) considering the data provided by authors to construct the meta-analysis and (ii) considering the raw data available in the primary studies included. Prediction intervals (PI), fragility index (FI), and number needed to treat (NNT) were also calculated for each replicated meta-analysis.

RESULTS

Nine studies reporting meta-analyses about pharmacist-led medication review were found comprising 30 different outcomes. Eleven meta-analyses, including six for hospital admission and five for mortality, were replicated. In five meta-analyses, the pooled effect sizes of the replicated meta-analyses differed from the original ones. Only four meta-analyses mentioned the statistical method used. Other meta-analytic parameters (e.g., q-value, tau2) were omitted in all studies. In nine meta-analyses, the data from primary studies had been incorrectly extracted for at least one variable. The PI demonstrated that the uncertainty intervals of the effect sizes were always underestimated by the authors. NNTs showed wide intervals, ranging from benefit to harm, in almost all meta-analyses. Nine recommendations to facilitate the replication of a meta-analysis were proposed: providing all original data needed to build the analysis; informing about the imputed data or data obtained from different sources; performing sensitivity analyses for imputed or unpublished data; inform about all the statistical methods used; providing all statistical results; and reporting the PI, FI and NNT.

CONCLUSION

Errors in data extraction and poor reporting of meta-analytic parameters are common in the pharmacy literature. We proposed nine recommendations to enhance data reproducibility and interpretability. Journal editors and peer reviewers should ensure that authors strictly comply with minimum standards for conduction and reporting of meta-analyses.

Meta-research in pharmacy: Time for a look in the mirror

The volume of the biomedical literature continues to expand at a substantial rate. The research literature surrounding pharmaceutical services is no different. Due in part to events in the recent past, researchers, consumers, funders, and policymakers have raised concerns about the credibility, transparency, and potential waste in the global research enterprise. Meta-research, or research on research, provides a way to examine the efficiency, quality, and potential bias in the overall research ecosystem. The field of meta-research is a relatively new but rapidly growing field that has seen many applications in biomedical research. Applications in pharmacy research, however, are still developing. The goals of this commentary are to introduce pharmacy researchers to the concept of meta-research, discuss several examples of meta-research in pharmacy, and motivate the importance of sustained meta-research efforts in pharmacy.

The role of pharmacy in the management of cardiometabolic risk, metabolic syndrome and related diseases in severe mental illness: a mixed-methods systematic literature review

BACKGROUND

Individuals with severe mental illness, e.g. schizophrenia have up to a 20% shortened life expectancy compared to the general population. Cardiovascular disease, due to cardiometabolic risk and metabolic syndrome, accounts for most of this excess mortality. A scoping search revealed that there has not been a review of published studies on the role of pharmacy in relation to cardiometabolic risk, metabolic syndrome and related diseases (e.g. type 2 diabetes) in individuals with severe mental illness.

METHODS

A mixed-methods systematic review was performed. Eleven databases were searched using a comprehensive search strategy to identify English-language studies where pharmacy was involved in an intervention for cardiometabolic risk, metabolic syndrome or related diseases in severe mental illness in any study setting from any country of origin. First, a mapping review was conducted. Then, implementation strategies used to implement the study intervention were classified using the Cochrane Effective Practice and Organisation of Care Taxonomy. Impact of the study intervention on the process (e.g. rate of diagnosis of metabolic syndrome) and clinical (e.g. diabetic control) outcomes were analysed where possible (statistical tests of significance obtained for quantitative outcome parameters reported). Quality assessment was undertaken using a modified Mixed Methods Appraisal Tool.

RESULTS

A total of 33 studies were identified. Studies were heterogeneous for all characteristics. A total of 20 studies reported quantitative outcome data that allowed for detailed analysis of the impact of the study intervention. The relationship between the total number of implementation strategies used and impact on outcomes measured is unclear. Inclusion of face-to-face interaction in implementation of interventions appears to be important in having a statistically significantly positive impact on measured outcomes even when used on its own. Few studies included pharmacy staff in community or general practitioner practices (n = 2), clinical outcomes, follow up of individuals after implementation of interventions (n = 3). No studies included synthesis of qualitative data.

CONCLUSIONS

Our findings indicate that implementation strategies involving face-to-face interaction of pharmacists with other members of the multidisciplinary team can improve process outcomes when used as the sole strategy. Further work is needed on clinical outcomes (e.g. cardiovascular risk reduction), role of community pharmacy and qualitative studies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018086411.

Effect of the ExactCare medication care management model on adherence, health care utilization, and costs

BACKGROUND: Multimorbidity and polypharmacy are common in the United States and are associated with greater risk of disease-related complications and higher health care costs. ExactCare has implemented a high-touch approach that includes home visits, comprehensive ongoing medication reviews, patient education, medication reconciliation, medication compliance packaging, and electronic reminders and trackers. OBJECTIVE: To test whether the ExactCare program improves medication adherence and reduces health care utilization and costs. METHODS: Using a national database from a large U.S. insurer, we identified Medicare Advantage plan members in 8 states from 2007 to 2018 who had both medical and prescription drug coverage. The index year for an ExactCare patient was identified using the date of the first prescription filled by ExactCare, with the previous year being the baseline. All patients without a prescription from an ExactCare pharmacy were considered potential comparison patients. To propensity match ExactCare and comparison patients, the probability of ExactCare participation was modeled using a logistic regression based on demographics, state, year, urban status, Medicaid eligibility, low-income subsidies, comorbidities, and baseline utilization and costs. Multivariate regression analysis was conducted to generate a difference-in-differences estimate of program effect for the matched pairs as well as patient-level fixed effects, while adjusting for additional time-varying characteristics. Adherence outcomes included the proportion of days covered for oral diabetic medications, antihypertensives, and hydroxymethylglutaryl-coenzyme A reductase inhibitors (statins). Utilization outcomes included emergency department (ED) visits, hospitalizations, and skilled nursing facility (SNF) admissions, hospitalization days, and SNF days. Cost outcomes included total cost of care, prescription drug cost, hospital inpatient cost, and SNF cost. RESULTS: ExactCare patients (N = 701) were propensity-matched to comparison patients (N = 1,395) using the nearest 1:2 match approach, with an average follow-up period of 6.6 and 5.4 years for ExactCare and comparison patients, respectively. One year of ExactCare participation was associated with statistically significant increases in adherence to statins (8.4 percentage points; P < 0.001) and antihypertensive drugs (4.9 percentage points; P < 0.001), but the increase in adherence for diabetes drugs was not statistically significant. ExactCare participation was associated with statistically significant decreases in SNF admission rates (-67 SNF stays per 1,000 member-years; P = 0.011), inpatient days (-857 days per 1,000 member-years; P = 0.022), and SNF days (-1,801 days per 1,000 member-years; P = 0.002), but not with the rates of ED visits or hospital admissions. Each year of ExactCare participation was associated with increases in prescription drug costs ($30 per-member per month [PMPM]; P = 0.006) and decreases in total costs (-$196 PMPM; P = 0.023) and medical costs (-$226 PMPM; P = 0.008), largely attributable to decreases in hospital inpatient costs (-$119 PMPM; P = 0.001) and SNF costs (-$30 PMPM; P = 0.007). CONCLUSIONS: ExactCare's medication care management model was associated with improved medication adherence and an approximately $2,400 per member per year reduction in total cost of care, representing a 5% reduction in average costs. DISCLOSURES: This study was funded by ExactCare Pharmacy under a contract with RAND that grants the study authors sole responsibility for data management, study design, data analysis, manuscript drafting, and the decision to publish. The sponsor had no role in the study design and manuscript drafting. All data analysis was conducted by the study authors. A draft manuscript was reviewed by the sponsor, but the study authors made final decisions regarding the content and study conclusions. Shetty, Chen, and Liu are employed by RAND. Rose has nothing to disclose.

Experiences of the Medication Use Process by People with Intellectual Disabilities. What a Pharmacist Should Know!

There is a scarcity of information about the experience of people with intellectual disabilities in the medication use process. Six people with intellectual disabilities consented to be interviewed by a pharmacist to determine their knowledge and views of medication use. Data from semi-structured interviews were analysed using a grounded theory approach. Self-determination and risk to the quality of the medication use process were identified as theories. Literature review provided two explanations—vulnerabilities of people with intellectual disabilities in healthcare and pharmacists have a role to play in ensuring a quality medication use process for people with intellectual disabilities. People with intellectual disabilities may be ‘expert patients’ and can provide valuable insights into their experience of medication use. They may be ‘high risk’ patients but may not be recognized as such by pharmacists.

Methodological quality and risk of bias of meta-analyses of pharmacy services: A systematic review

BACKGROUND

A suboptimal meta-analysis with misleading conclusions, frequently published in the healthcare journals, can compromise decision making in clinical practice.

OBJECTIVE

To evaluate the reporting quality, methodological quality, and risk of bias of meta-analyses of pharmacy services.

METHODS

Systematic searches to identify all the meta-analyses reporting the effect of pharmacy services were performed in PubMed, Scopus, and Web of Science. The reporting quality, the methodological quality, and the risk of bias of the included meta-analyses were evaluated using PRISMA checklist, R-AMSTAR, and ROBIS, respectively.

RESULTS

A total of 109 meta-analyses were eligible for the study. The heterogeneity, the quality of evidence, and the quality analyses were poorly reported on authors' conclusions (14.3%, 14.7%, and 17.4%, respectively). The median scores of PRISMA and R-AMSTAR tolls were 24 (IQR 21.75-25), and 30 (IQR 27-32.5), respectively. Additionally, most of the studies were considered as high risk of bias (n = 83, 76.1%). No association between the date of publication and guideline compliance exists. PRISMA score was higher in studies published in high impact factor journals (rho = 0.313; p = 0.002), in articles that reported the quality of evidence obtained (p = 0.018), and in those that stated the need for future studies in their conclusions (p = 0.011). R-AMSTAR score was higher in studies published in high impact factor journals (rho = 0.338; p = 0.001), in those which reported the quality of evidence (p = 0.002), and in articles that described the quality analyses in their conclusions (p = 0.046). An association between the risk of bias and the recognition of the need for further studies in their conclusions (p = 0.041) was also found.

CONCLUSION

The rapid increase of the meta-analyses of pharmacy services was not associated with higher quality. Mechanistic meta-analyses with poor conclusions are commonly published. Quality of the analyses, strength of evidence, heterogeneity, and absence of confrontation with current guidelines are rarely considered when synthetizing evidence and making recommendations.

Using network analysis to explore factors moderating the implementation of a medication review service in community pharmacy

BACKGROUND

Implementation factors are hypothesised to moderate the implementation of innovations. Although individual barriers and facilitators have been identified for the implementation of different evidence-based services in pharmacy, relationships between implementation factors are usually not considered.

OBJECTIVES

To examine how a network of implementation factors and the position of each factor within this network structure influences the implementation of a medication review service in community pharmacy.

METHODS

A mixed methods approach was used. Medication review with follow-up service was the innovation to be implemented over 12 months in community pharmacies. A network analysis to model relationships between implementation factors was undertaken. Two networks were created.

RESULTS

Implementation factors hindering the service implementation with the highest centrality measures were time, motivation, recruitment, individual identification with the organization and personal characteristics of the pharmacists. Three hundred and sixty-nine different interrelationships between implementation factors were identified. Important causal relationships between implementation factors included: workflow-time; characteristics of the pharmacy-time; personal characteristics of the pharmacists-motivation. Implementation factors facilitating the implementation of the service with highest centrality scores were motivation, individual identification with the organization, beliefs, adaptability, recruitment, external support and leadership. Four hundred and fifty-six different interrelationships were identified. The important causal relationships included: motivation-external support; structure-characteristics of the pharmacy; demographics-location of the pharmacy.

CONCLUSION

Network analysis has proven to be a useful technique to explore networks of factors moderating the implementation of a pharmacy service. Relationships were complex with most implementation factors being interrelated. Motivation and individual identification with the organisation seemed critical factors in both hindering and facilitating the service implementation. The results can inform the design of implementation programs and tailored strategies to promote faster implementation of innovations in pharmacy.

Evaluating an implementation programme for medication review with follow-up in community pharmacy using a hybrid effectiveness study design: translating evidence into practice

OBJECTIVES

To evaluate an implementation programme of a community pharmacy medication review with follow-up (MRF) service using a hybrid effectiveness-implementation study design, and to compare the clinical and humanistic outcomes with those in a previously conducted cluster randomised controlled trial (cRCT).

SETTING

Community pharmacies in Spain.

PARTICIPANTS

135 community pharmacies and 222 pharmacists providing MRF to polymedicated patients aged 65 or over.

INTERVENTION

The intervention was an implementation programme for the MRF service. A national level group was established, mirrored with a provincial level group. A series of interventions were defined (1) to engage pharmacy owners with the implementation model and (2) to provide training to pharmacists consisting of clinical case studies, process of MRF, communication skills and data collection methods and (3) practice change facilitators.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcomes for the implementation programme were progress, reach, fidelity and integration. The secondary outcomes were number of medications, non-controlled health problems, emergency visits, hospitalisations and health-related quality of life, which were compared with a previous 6-month cluster RCT.

RESULTS

55% of pharmacies reached the implementation phase and 35.6% remained in the testing phase at 12 months. A reach of 89.3% (n=844) was achieved. Fidelity average score was 8.45 (min: 6.2, max: 9.3) out of 10. The integration mean score was 3.39 (SD: 0.72) out of 5. MRF service outcomes were similar to the cluster RCT study; however, the magnitude of the outcomes was delayed.

CONCLUSIONS

The implementation of pharmacy services is a complex multifactorial process, conditioned by numerous implementation factors. In the absence of remuneration, the implementation of the MRF service is a slow process, taking at least 12 months to complete.

TRIAL REGISTRATION NUMBER

CGFTRA-2017-01.

The medication discrepancy detection service: A cost-effective multidisciplinary clinical approach

OBJECTIVE

To estimate the effectiveness of a Medication Discrepancy Detection Service (MDDS), a collaborative service between the community pharmacy and Primary Care.

DESIGN

Non-controlled before-and-after study.

SETTING

Bidasoa Integrated Healthcare Organisation, Gipuzkoa, Spain.

PARTICIPANTS

The service was provided by a multidisciplinary group of community pharmacists (CPs), general practitioners (GPs), and primary care pharmacists, to patients with discrepancies between their active medical charts and medicines that they were actually taking.

OUTCOMES

The primary outcomes were the number of medicines, the type of discrepancy, and GPs' decisions. Secondary outcomes were time spent by CPs, emergency department (ED) visits, hospital admissions, and costs.

RESULTS

The MDDS was provided to 143 patients, and GPs resolved discrepancies for 126 patients. CPs identified 259 discrepancies, among which the main one was patients not taking medicines listed on their active medical charts (66.7%, n=152). The main GPs' decision was to withdraw the treatment (54.8%, n=125), which meant that the number of medicines per patient was reduced by 0.92 (9.12±3.82 vs. 8.20±3.81; p<.0001). The number of ED visits and hospital admissions per patient were reduced by 0.10 (0.61±.13 vs 0.52±0.91; p=.405 and 0.17 (0.33±0.66 vs. 0.16±0.42; p=.007), respectively. The cost per patient was reduced by €444.9 (€1003.3±2165.3 vs. €558.4±1273.0; p=.018).

CONCLUSION

The MDDS resulted in a reduction in the number of medicines per patients and number of hospital admissions, and the service was associated with affordable, cost-effective ratios.

Three opportunities for standardization: A literature review of the variation among pharmacists' patient care services terminology

BACKGROUND

Variation describing pharmacists' patient care services exist, and this variation contributes to the prevalent misunderstanding of pharmacists' roles. In contrast, standard phraseology is a critical practice among highly reliable organizations and a way to reduce variation and confusion.

OBJECTIVE

This work aims to identify and define pharmacists' patient care service terms to identify redundancies and opportunities for standardization.

METHODS

Between May to August 2018, terms and definitions were searched via PubMed, Google Scholar and statements/policies of professional pharmacy organizations. Two references per term were sought to provide an "early definition" and a "contemporary definition." Only literature published in English was included, and data gathered from each citation included the date published, the term's definition, and characterization of the reference's source as either a regulatory or professional body. A five-person expert panel used an iterative technique to revise and verify the list of included terms and subsequent literature review results. Terms were then searched in the National Library of Medicine's Medical Subject Heading Database (MeSH) in July, 2019.

RESULTS

There are fifteen commonly misunderstood terms that refer to the patient care services provided by pharmacists. The appearance of these terms in the literature spanned nearly five decades. Nearly half of terms appeared first in regulatory, law or policy documents; of these, two terms had contemporary definitions appearing in the professional literature that differed from their early regulatory definition. Three opportunities to improve standardization include: (1) Implementation of standardized phraseology systems similar to nursing's Clinical Care Classification System; (2) Academics' adherence to standardized MeSH terms; and (3) Clarification of pharmacy education accreditation standards.

CONCLUSION

Numerous terms are used to describe pharmacists' patient care services, with many definitions of terms overlapping in several key components. The profession has made concerted efforts to consolidate and standardize terminology in the past, but more opportunities exist.

Mapping the characteristics of meta-analyses of pharmacy services: a systematic review

BACKGROUND

Suboptimal meta-analyses with misleading conclusions are frequently published in the health areas, and they can compromise decision making in clinical practice.

AIM OF THE REVIEW

This systematic review aimed to map the characteristics of published meta-analyses of pharmacy services and their association with the study conclusions.

METHOD

We searched electronic databases (PubMed, Scopus, and Web of Science) to identify published meta-analyses of pharmacy services up to January 2019. Components of meta-analyses were extracted (i.e. studies' metadata; methods used in the systematic review; description of the statistical model used for the meta-analysis; main results; conflict of interest and funding source). The methodological quality was evaluated using the R-AMSTAR tool.

RESULTS

A total of 85 meta-analyses were included, with 2016 as the median publication year. Overall, the methodological quality of meta-analyses of pharmacy services was considered suboptimal. Only one-third of authors registered a protocol; complete search strategy and raw data were provided by 55.3% and 9.4% of studies, respectively. Evidence strength (GRADE) was evaluated in only 19.2% of studies. PRISMA and Cochrane recommendations were stated to be followed in 60% and 27.4% of articles, respectively. Around half of studies performed sensitivity analysis, however, the prediction interval was presented by only one meta-analysis. Studies that favoured the pharmacists' interventions poorly discussed the methodological quality and heterogeneity of primary trials.

CONCLUSION

Poor conduction and reporting were observed in meta-analyses of pharmacy services, especially in those that favoured the pharmacist's interventions. Reproducibility and transparency should be rigorously ensured by journal editors and peer-reviewers.

Health consumer engagement in developing novel preventive health community pharmacy roles in cardiovascular disease in Saudi Arabia: A qualitative analysis

Introduction

Cardiovascular diseases (CVD) are one of key leading causes of mortality worldwide. Both modifiable and non-modifiable risk factors contribute to the development of CVD. Modifiable risk factors such as smoking, unhealthy diets and lack of exercise are increasing in prevalence in Saudi Arabia but may be mitigated using pharmacological and non-pharmacological approaches. Thus, identifying, assessing and managing these modifiable risks at an early stage is essential. Pharmacists are highly accessible primary health professionals and can play a crucial role in screening and managing these risk factors in collaboration with primary care physicians. There is currently no research in Saudi Arabia exploring the views of health consumers with CVD risk factors regarding their preferences for or willingness to engage with community pharmacy CVD preventive health services.

Objectives

To explore the perceptions of health consumers about current and feasible future services by pharmacists with a specific focus on CVD risk screening and management in Saudi Arabia.

Methods

Semi-structured interviews were conducted with consumers with at least one modifiable CVD risk factor. The interviews were audio-recorded, transcribed verbatim, translated into English and then thematically analysed.

Results

A total of 25 individuals, most of whom were Saudi (88%) and women (65%), participated in face to face interviews. Five main themes emerged from the analysis of consumers’ responses. 1. Perception of pharmacists’ role, the pharmacists’ main role was perceived as medication supply. 2. Trust and satisfaction with current service, most participants appeared to have low trust in pharmacists. 3. Preferences for future pharmacy services, most participants were willing to engage in future pharmacy delivered CVD preventive health services, provided there was stringent regulation and oversight of the quality of such services. 4. Viability of new pharmacy services was raised with promotion of such services to the public, collaboration with other health professionals, financial incentivization and motivational rewards thought of as essential ingredient to ensure service feasibility. 5. Health beliefs and help seeking behaviours of consumers were diverse and low health literacy was evident; it was thought that pharmacists can help in these matters by educating and advocating for such consumers. Overall, the data suggested that clinical, communication and professional skills need to be enhanced among Saudi pharmacists to enable them to provide optimal patient cantered services.

Conclusion

Health consumers participants were willing to participate and utilise CVD risk screening and management pharmacy-based services, when offered, provided their concerns are addressed. Therefore, in light of the burden of CVD disease in the country, development, implementation and evaluation of pharmacist provided CVD risk screening and management should be undertaken.

Perceptions and Attitudes Towards Clinical Pharmacy Services and Their Impact on The Management of Cancer in Taif, Saudi Arabia

Aim:

To assess the perception and attitude of HCPs and health-related science colleges’ students regarding the clinical pharmacists’ roles and responsibilities in providing better pharmaceutical care to patients in Taif, Saudi Arabia and to detect its impact on management of cancer.

Methods:

This study was conducted in four randomly selected hospitals in Taif and three health-related science colleges in Taif University. A questionnaire was distributed to HCPs and another questionnaire to students of health-related science colleges.

Results:

Three quarters of students perceived that the clinical pharmacist is an important part of the healthcare team. Two-thirds of HCPs expressed confidence in the ability of clinical pharmacists to minimize medication errors. Although two-thirds of HCPs reported that they did not have clinical pharmacists in their institutions, there was substantial willingness among HCPs to cooperate with the clinical pharmacists. Most HCPs expressed the view that the clinical pharmacist is an important integral part of the healthcare team and has a positive impact on cancer management.

Conclusion:

HCPs and students of health-related science colleges valued the role of clinical pharmacists in healthcare delivery and management of cancer. However, new developments in clinical pharmacy services in Taif hospitals are recommended to improve perception and attitudes towards the clinical pharmacy services. Also, well-organized programs should be conducted to students of health-related science colleges to improve their perceptions and attitudes towards the clinical pharmacy services which may have a positive impact on cancer management.

Characteristics of studies of pharmacist services registered in ClinicalTrials.gov

OBJECTIVE

To examine the characteristics of studies of pharmacist services registered in ClinicalTrials.gov.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

ClinicalTrials.gov and MEDLINE databases were searched to identify studies of pharmacist services. Registration information was obtained from the Aggregate Analysis of ClinicalTrials.gov (AACT) database. Studies were excluded if the ClinicalTrials.gov submission date was after December 31, 2018; there were no U.S. study sites; pharmacist services were not mentioned; or pharmacist involvement was limited to medication dispensing, randomization, or measuring study outcomes.

OUTCOME MEASURES

Characteristics of registered studies from ClinicalTrials.gov and AACT data, categories of pharmacist services, changes in registration and focus of pharmacist services over time, and relationships between funding source and result availability and between the focus of pharmacist services and types of outcomes and types of pharmacist interventions.

RESULTS

Overall 401 studies were identified for initial review, with 151 included for detailed review. Pharmacist services were the only intervention in 68 studies (45.0%), a separate intervention in 14 (9.3%), and part of a combined intervention in 40 (26.5%). In 29 studies (19.2%), pharmacist services were not the focus. Registered studies primarily were interventional, randomized, and open-label; included behavioral or "other" interventions; were conducted in the outpatient setting; and were sponsored by "other" sources. The most common health conditions were hypertension and diabetes. Only 29 of the 104 completed studies (27.9%) posted results. Clinical outcomes were the most common primary (80; 53.0%) and secondary outcomes (66; 58.9%). Medication management (69; 45.7%) and patient education or counseling (88; 58.3%) were the most common types of pharmacist interventions.

CONCLUSION

This analysis of ClinicalTrials.gov identified 151 studies of pharmacist services in the United States registered through the end of 2018. Given the breadth of the pharmacy services literature, there is room for improvement in the registration of these types of studies.

Impact of Pharmacist-led Discharge Counseling on Hospital Readmission and Emergency Department Visits: A Systematic Review and Meta-analysis

BACKGROUND

Transitions of care can contribute to medication errors and other adverse drug events.

PURPOSE

The aim of this study was to evaluate the impact of pharmacist-led discharge counseling on hospital readmission and emergency department visits through a systematic review and meta-analysis.

EDATA SOURCES

Lectronic searches were performed in PubMed, Scopus, and DOAJ (Directory of Open Access Journals), along with a manual search (July 2017). PROSPERO registration no. CRD42017068444.

STUDY SELECTION

Two independent reviewers performed all the steps of the systematic review process (screening of titles and abstracts, full-text appraisal, data extraction, and quality assessment), with contributions from a third researcher. We included randomized controlled trials (RCTs) reporting data on pharmacist-led discharge counseling.

DATA EXTRACTION

Primary extracted outcomes were emergency department visits and hospital readmission rates.

DATA SYNTHESIS

Meta-analyses of intervention versus usual care for hospital readmission and emergency department visit rates were performed using the inverse variance method. Results are reported as risk ratios (RRs) with 95% confidence intervals (CIs). Prediction intervals (PIs) were also calculated. Sensitivity and subgroup analyses were performed. A total of 21 RCTs were included in the qualitative synthesis and 18 in the meta-analyses (n = 7,244 patients). The original meta-analysis revealed a significant difference in the impact between pharmacist-led discharge counseling and usual care on overall hospital readmission (RR = 0.864 [95% CI 0.763-0.997], P = .020) and emergency department (RR = 0.697 [95% CI 0.535-0.907], P = .007) visits. However, the small number of included studies, the high heterogeneity among trials (I2 between 40% and 60%), and the wide PIs (hospital readmission: PI 0.542-1.186; emergency department visits: PI 0.027-1.367) prevented drawing further conclusions.

CONCLUSIONS

Insufficient evidence exists regarding the effect of pharmacist-led discharge counseling on hospital readmission and emergency department visits. Further well-designed clinical trials with defined core outcome sets are needed.

An overview of systematic reviews of economic evaluations of pharmacy-based public health interventions: addressing methodological challenges

BACKGROUND

Pharmacy interventions are a subset of public health interventions and its research is usually performed within the scope of a trial. The economic evaluation of pharmacy interventions requires certain considerations which have some similarities to those of public health interventions and to economic evaluations alongside trials. The objective of this research is to perform an overview of systematic reviews of economic evaluations of pharmacy services and triangulate results with recommendations for economic evaluations of both public health interventions and alongside trials.

METHODS

(1) Exploratory review of recommendations on the economic evaluation of public health interventions, (2) exploratory review of recommendations for conducting economic evaluations alongside trials, (3) overview of systematic reviews of economic evaluations of pharmacy interventions (protocol registered with PROSPERO 2016 outlining information sources, inclusion criteria, appraisal of reviews and synthesis methods).

RESULTS

Fourteen systematic reviews containing 75 index publications were included. Reviews reported favorable economic findings for 71% of studies with full economic evaluations. The types of economic analysis are diverse. Two critical quality domains are absent from most reviews. Key findings include the following: certain types of risk of bias, wider scope of study designs, and most economic quality criteria met but some issues unresolved or unclear. Triangulation revealed additional gaps. Limitations include choice of critical quality domains and potential biases in the overview process.

CONCLUSIONS

Economic evaluations of pharmacy-based public health interventions seem to follow most economic quality criteria, but there are still some issues in certain key areas to improve. These findings may assist in improving the design of pilot trials of economic evaluations in pharmacy, leading to robust evidence for payers. Based on the findings, we propose a methodological approach for the economic evaluation of pharmacy-based public health interventions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016032768.