Efficacy of a Bariatric Surgery Clinic-Based Pharmacist

Interventions and impact of pharmacist-delivered services in perioperative setting on clinically important outcomes: a systematic review and meta-analysis

Background

The perioperative arena is a unique and challenging environment that requires coordination of the complex processes and involvement of the entire care team. Pharmacists' scope of practice has been evolving to be patient-centered and to expand to variety of settings including perioperative settings.

Objectives

To critically appraise, synthesize, and present the available evidence of the characteristics and impact of pharmacist-led interventions on clinically important outcomes in the perioperative settings.

Design

A systematic review and meta-analysis.

Methods

We searched PubMed, Embase, and CINAHL from index inception to September 2023. Included studies compared the effectiveness of pharmacist-led interventions on clinically important outcomes (e.g. length of stay, readmission) compared to usual care in perioperative settings. Two independent reviewers extracted the data using the DEPICT-2 (Descriptive Elements of Pharmacist Intervention Characterization Tool) and undertook quality assessment using the Crowe Critical Appraisal (CCAT). A random-effect model was used to estimate the overall effect [odds ratio (OR) for dichotomous and standard mean difference (SMD) for continuous data] with 95% confidence intervals (CIs).

Results

Twenty-five studies were eligible, 20 (80%) had uncontrolled study design. Most interventions were multicomponent and continuous over the perioperative period. The intervention components included clinical pharmacy services (e.g. medication management/optimization, medication reconciliation, discharge counseling) and education of healthcare professionals. While some studies provided a minor description in regards to the intervention development and processes, only one study reported a theoretical underpinning to intervention development. Pooled analyses showed a significant impact of pharmacist care compared to usual care on length of stay (11 studies; SMD -0.09; 95% CI -0.49 to -0.15) and all-cause readmissions (8 studies; OR 0.60; 95% CI 0.39-0.91). The majority of included studies (n = 21; 84%) were of moderate quality.

Conclusion

Pharmacist-led interventions are effective at improving clinically important outcomes in the perioperative setting; however, most studies were of moderate quality. Studies lacked the utilization of theory to develop interventions; therefore, it is not clear whether theory-derived interventions are more effective than those without a theoretical element. Future research should prioritize the development and evaluation of multifaceted theory-informed pharmacist interventions that target the whole surgical care pathway.

Collaborative Prescribing Practice in Managing Patients Post-Bariatric Surgery in a Tertiary Centre in Singapore

Background: A collaborative prescribing (CP) practice model, established by the endocrinologists, pharmacists, and advanced practice nurses, aims to provide for the postoperative monitoring and medical and nutritional management of stable patients after bariatric surgery. Method: Under the CP agreement, endocrinologists refer patients who have undergone bariatric surgery with stable medical conditions to CP practitioners, comprising senior pharmacists and advanced practice nurses. CP practitioners review the patient's weight loss progress, blood test results and vitals, the sufficiency of micronutrient repletion, adherence to supplements and medications, and chronic disease control. CP practitioners can prescribe and adjust the medications and supplements, in accordance with a clinical evaluation and standard guidance. Patients who require immediate attention due to complications or red flags are referred to the primary endocrinologist for further management. Results: From 5 May 2020 to 30 September 2023, CP practitioners provided 672 consultations. At least 68% and 80% of patients achieved appropriate weight loss post-surgery during the acute and maintenance phases, respectively. Less than 10% of the patients presented with anaemia and iron deficiency, and vitamin B12, folate and vitamin D deficiency. More than 80% of patients achieved a HbA1c of less than 7%. Conclusions: The CP practice framework provides a sustainable and viable model to facilitate optimal outcomes after bariatric surgery.

Can Consultation by a Clinical Pharmacist Prevent Morbidity and Mortality in Patients Undergoing Bariatric Surgery?

The purpose of this work was to investigate the effect of clinical pharmacist consultation on the long-term morbidity and mortality outcomes among patients undergoing bariatric surgery. In this retrospective cohort study, 165 bariatric patients at Herzliya Medical Center who were identified as complex cases and were consulted by a clinical pharmacist (2013-2019) were compared with a wider group of bariatric patients with chronic diseases who were recorded in the Israeli General Bariatric Registry during the same years. The primary outcomes were rates of surgical complications, re-hospitalizations, and death up to one year after surgery. The secondary outcome was the rate of re-hospitalizations in different time periods. The twelve (12)-month rate of re-hospitalization in the intervention group was 10.9% vs. 19.5% in the comparison group (p = 0.005); the rate of documented postoperative complications was 2.7% vs. 3.9% (p = 0.462), and mortality was null vs. 0.16%, respectively. As for the secondary outcomes, the rates of re-hospitalizations in the periods of 0-30, 31-90, 91-180, and 181-365 days after surgery were 1.8% vs. 5.3% (p = 0.046), 2.4% vs. 4.1% (p = 0.278), 3.6% vs. 4.8% (p = 0.476), and 7.3% vs. 9.9% (p = 0.256) in the intervention vs. comparison cohorts, respectively. In conclusion, this study demonstrates the importance and benefit of referring to a specialized clinical pharmacist around bariatric surgery for improving patient safety, especially in complex patients. This is the first study to look at the long-term effects of clinical pharmacist consultation on re-hospitalization and mortality among bariatric patients, and our encouraging outcomes should hopefully stimulate more studies to show the invaluable role of specialized clinical pharmacists.