Systematic Review of Economic Evaluations of Services Provided by Community Pharmacists

BACKGROUND

Community pharmacists' scope of practice has been evolving from a traditional dispensing role to providing patient-centered services. Given the constraints in healthcare budget and a need for efficient use of finite resources, decision makers may require convincing evidence of value to recommend these services for public funding. Several economic evaluations have aimed to demonstrate the value of services provided by community pharmacists.

OBJECTIVE

The objective of this study was to systematically review the reporting and methodological quality of full economic evaluations of services provided by community pharmacists.

METHODS

A literature search was conducted in the bibliographic databases MEDLINE, EMBASE, and the NHS Economic Evaluations Database since their inception to February 2019. Two independent reviewers performed title, abstract, full text screening, and data abstraction and assessed the quality of reporting and methodological approaches using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) and Quality of Health Economic Studies (QHES) checklists.

RESULTS

Twenty full economic evaluations were included in the review. Most of these studies were conducted in the UK (40%), followed by the USA (35%), Canada (10%), the Netherlands (5%), Thailand (5%), and Australia (5%). The efficacy or effectiveness data were drawn from individual level or cluster randomized trials, or observational studies. About half of these studies (45%) adopted the perspective of the public healthcare system. Four studies used decision analytic modeling. We identified issues in these studies with selection of study population, efficacy or effectiveness data, time horizon, outcomes measured, measurement or resources used and cost estimation, analytical approaches, and handling of uncertainty with study parameters. The quality of reporting and methodological considerations was variable across these studies, with none of the studies adequately fulfilling all 24 items of CHEERS or 16 questions of QHES checklists.

CONCLUSIONS

Our findings suggest there are various issues related to the quality of conduct and reporting of economic evaluations of services provided by community pharmacists. Interpretation of these studies should be treated with caution to facilitate decision making in the local context. In an era of scarce resources and demand for evidence-informed decision making, there may be a need for guidance on methodological approaches to assess the value of these services.

Pharmacist-Delivered Smoking Cessation Program in Community Pharmacy (The FINE Program) in Japan-The Development of a Training Course and a Feasibility Study

AIM

Although smoking cessation support has been recommended as a routine component of pharmacists'duties, there is limited evidence of smoking cessation being achieved successfully in community pharmacy. The aim of this study was to develop a new smoking cessation program for use in the community pharmacy setting and investigate its feasibility.

METHODS

A feasibility study (the Family pharmacist's Intervention for Nicotine Elimination [FINE] program) was conducted using 8 pharmacists at 2 community pharmacies in Japan. The pharmacists recruited as subjects smokers 20 or more years of age who were taking medications such as antidiabetes drugs. The patients completed questionnaires assessing their smoking status, and the pharmacists provided them with smoking cessation support services. Participating patients met with the pharmacists or talked to them on the phone 5 times at 2- to 4-week intervals and received personalized and structured brief smoking cessation advice. The primary outcome was continuous abstinence determined by Micro Smokerlyzer carbon monoxide monitor at 3 months.

RESULTS

Of 5306 patients, 2296 patients were screened and the rate of smoking was found to be 12.7%. Five smoking patients received the FINE program from pharmacists who had received training. One of the 5 succeeded in quitting smoking after 3 months.

CONCLUSIONS

This is the first study to target Japanese smoking patients in community pharmacies with a brief structured intervention. The results tentatively support the feasibility of the FINE program. Further research including a randomized controlled trial is required to confirm the effectiveness of the FINE program.

Community pharmacy personnel interventions for smoking cessation

BACKGROUND

Community pharmacists could provide effective smoking cessation treatment because they offer easy access to members of the community. They are well placed to provide both advice on the correct use of smoking cessation products and behavioural support to aid smoking cessation.

OBJECTIVES

To assess the effectiveness of interventions delivered by community pharmacy personnel to assist people to stop smoking, with or without concurrent use of pharmacotherapy.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, along with clinicaltrials.gov and the ICTRP, for smoking cessation studies conducted in a community pharmacy setting, using the search terms pharmacist* or pharmacy or pharmacies. Date of the most recent search: January 2019.

SELECTION CRITERIA

Randomised controlled trials of interventions delivered by community pharmacy personnel to promote smoking cessation amongst their clients who were smokers, compared with usual pharmacy support or any less intensive programme. The main outcome measure was smoking cessation rates at six months or more after the start of the intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane for study screening, data extraction and management. We conducted a meta-analysis using a Mantel-Haenszel random-effects model to generate risk ratios (RRs) and 95% confidence intervals (CIs).

MAIN RESULTS

We identified seven studies including 1774 participants. We judged three studies to be at high risk of bias and four to be at unclear risk. Each study provided face-to-face behavioural support delivered by pharmacy staff, and required pharmacy personnel training. Typically such programmes comprised support starting before quit day and continuing with weekly appointments for several weeks afterwards. Comparators were either minimal or less intensive behavioural support for smoking cessation, typically comprising a few minutes of one-off advice on how to quit. Participants in both intervention and control arms received equivalent smoking cessation pharmacotherapy in all but one study. All studies took place in high-income countries, and recruited participants visiting pharmacies. We pooled six studies of 1614 participants and detected a benefit of more intensive behavioural smoking cessation interventions delivered by community pharmacy personnel compared with less intensive cessation interventions at longest follow-up (RR 2.30, 95% CI 1.33 to 3.97; I² = 54%; low-certainty evidence).

AUTHORS' CONCLUSIONS

Community pharmacists can provide effective behavioural support to people trying to stop smoking. However, this conclusion is based on low-certainty evidence, limited by risk of bias and imprecision. Further research could change this conclusion.

What works for whom in pharmacist-led smoking cessation support: realist review

BACKGROUND

New models of primary care are needed to address funding and staffing pressures. We addressed the research question "what works for whom in what circumstances in relation to the role of community pharmacies in providing lifestyle interventions to support smoking cessation?"

METHODS

This is a realist review conducted according to RAMESES standards. We began with a sample of 103 papers included in a quantitative review of community pharmacy intervention trials identified through systematic searching of seven databases. We supplemented this with additional papers: studies that had been excluded from the quantitative review but which provided rigorous and relevant additional data for realist theorising; citation chaining (pursuing reference lists and Google Scholar forward tracking of key papers); the 'search similar citations' function on PubMed. After mapping what research questions had been addressed by these studies and how, we undertook a realist analysis to identify and refine candidate theories about context-mechanism-outcome configurations.

RESULTS

Our final sample consisted of 66 papers describing 74 studies (12 systematic reviews, 6 narrative reviews, 18 RCTs, 1 process detail of a RCT, 1 cost-effectiveness study, 12 evaluations of training, 10 surveys, 8 qualitative studies, 2 case studies, 2 business models, 1 development of complex intervention). Most studies had been undertaken in the field of pharmacy practice (pharmacists studying what pharmacists do) and demonstrated the success of pharmacist training in improving confidence, knowledge and (in many but not all studies) patient outcomes. Whilst a few empirical studies had applied psychological theories to account for behaviour change in pharmacists or people attempting to quit, we found no studies that had either developed or tested specific theoretical models to explore how pharmacists' behaviour may be affected by organisational context. Because of the nature of the empirical data, only a provisional realist analysis was possible, consisting of five mechanisms (pharmacist identity, pharmacist capability, pharmacist motivation and clinician confidence and public trust). We offer hypotheses about how these mechanisms might play out differently in different contexts to account for the success, failure or partial success of pharmacy-based smoking cessation efforts.

CONCLUSION

Smoking cessation support from community pharmacists and their staff has been extensively studied, but few policy-relevant conclusions are possible. We recommend that further research should avoid duplicating existing literature on individual behaviour change; seek to study the organisational and system context and how this may shape, enable and constrain pharmacists' extended role; and develop and test theory.

On the Front Line of Smoking Cessation: Education Needs of Community Pharmacists

Background:

Nicotine replacement therapy (NRT) is now available without prescription, and pharmacists have an opportunity to be the primary health care professionals advising patients who want to try this smoking cessation aid. Undergraduate pharmacy education in Canada incorporates some tobacco-related training, and continuing education opportunities are available. However, there are no published reports of the self-reported educational needs of a broad sample of practising Canadian community pharmacists with regard to smoking cessation.

Methods:

Practising community pharmacists in four Canadian provinces were surveyed about their tobacco-related education and knowledge, practice environment, practices related to helping people quit smoking, needs for further information and training, and methods by which this information might be delivered.

Results:

A corrected response rate of 72% was obtained, giving a weighted n of 960 responses. Most Canadian community pharmacists reported that they would find it helpful to receive additional information or training on a wide range of smoking cessation topics, such as behavioural counselling techniques and motivating patients to quit. Pharmacists who reported that they were familiar with aids such as Helping Your Patients Quit Smoking: A Cessation Guide for Pharmacists (Canadian Pharmacists Association) and who reported that the guide had led them to make changes in their practice were more likely to report that additional information or training would be helpful. Pharmacists who perceived their tobacco-related clinical and non-clinical roles to be important were more likely to report that additional training would be helpful than were those who perceived these roles as less important.

Conclusions:

Although most Canadian community pharmacists would find it helpful to receive additional smoking-related information and training, those who perceive this to be an important activity and who are already using available materials showed the most interest. The challenge to Canadian pharmacy educators is to encourage the enthusiasm of those already interested in helping their patients to quit smoking, while raising the level of interest and motivation among all community pharmacists.

Community pharmacy interventions for public health priorities: a systematic review of community pharmacy-delivered smoking, alcohol and weight management interventions

Background

The Department of Health has identified interventions to manage alcohol misuse, smoking and overweight, delivered by community pharmacists, as public health priorities.

Objectives

To systematically review the effectiveness of community pharmacy interventions to manage alcohol misuse, smoking cessation and weight loss; to explore if and how age, sex, ethnicity and socioeconomic status moderate effectiveness; and to describe how the interventions have been organised, implemented and delivered.

Data sources

Ten electronic databases were searched: Applied Social Sciences Index and Abstracts; Cumulative Index to Nursing and Allied Health Literature; EMBASE; International Bibliography of the Social Sciences; MEDLINE; NHS Economic Evaluation Database; PsycINFO; Social Science Citation Index; Scopus; and the Sociological Abstracts from inception to May 2014. There was no restriction on language or country. Supplementary searches included website, grey literature, study registers, bibliographies and contacting experts.

Review methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Any type of intervention of any duration based in any country and in people of any age was included. The review included interventions set in a community pharmacy and delivered by the pharmacist or the wider pharmacy team. Randomised controlled trials, non-randomised controlled trials, controlled before-and-after studies and interrupted time series studies were included. Data extraction and quality assessment were conducted independently for each study by two reviewers. Meta-analysis and narrative synthesis were also conducted.

Results

The searches identified over 14,000 records, of which 24 studies were included. There were two alcohol, 12 smoking cessation, five weight loss and five multicomponent interventions that included pharmacotherapy and lifestyle changes in participants with diabetes mellitus, dyslipidaemia or hypertension. Nine of the studies were UK based; seven of the studies were rated ‘strong’ for quality. All studies were of adults. Pharmacy-based smoking cessation interventions including behavioural support and/or nicotine replacement therapy are effective and cost-effective in helping adults to stop smoking, particularly when compared with usual care. The pooled odds ratio of the intervention effects for smoking cessation was 1.85 (95% confidence interval 1.25 to 2.75). It is currently unknown which specific types of smoking cessation interventions are the most effective. There was insufficient evidence for the effectiveness of community pharmacy-based brief alcohol interventions. Evidence suggests that pharmacy-based weight-loss interventions are as effective as similar interventions in other primary care settings, but not as effective or cost-effective as commercially provided weight management services based in community settings. None of the five multicomponent studies demonstrated an improvement compared with control for anthropometric outcomes in participants with comorbidities, but they did show improvement in measures associated with the comorbidities. Very few studies explored if and how sociodemographic or socioeconomic variables moderated the effect of interventions. In two studies based in areas of high deprivation, where participants chose the intervention, the sociodemographic characteristics of participants differed between intervention settings. There were also differences in recruitment, attendance and retention of participants by type of setting. The evidence suggests that a distinct group of people might access pharmacies compared with other settings for alcohol management, smoking cessation and weight loss. There is insufficient evidence to examine the relationship between behaviour change strategies and effectiveness; or evidence of consistent implementation factors or training components that underpin effective interventions.

Limitations

The information reported in the publications of included studies did not allow us to assess in detail if and how age, sex, ethnicity and socioeconomic status moderate effectiveness, or to describe how the interventions had been organised, implemented and delivered.

Conclusions

Community pharmacy interventions are effective for smoking cessation. Evaluations of interventions to manage alcohol misuse and obesity, set within the community pharmacy, are needed. The effect of community pharmacy interventions on health inequalities is unclear. Future research in this area is warranted, and trials should include the assessment of age, sex, ethnicity, socioeconomic status and contextual factors, and present analysis of how these factors moderate effectiveness.

Study registration

This study is registered as PROSPERO CRD42013005943.

Funding

The National Institute for Health Research Public Health Research programme.

Cost-effectiveness analysis of clinical smoking cessation interventions in Thailand

AIMS

Clinical smoking cessation interventions have been found typically to be highly cost-effective in many high-income countries. There is a need to extend this to low- and middle-income countries and undertake comparative analyses. This study aimed to estimate the incremental cost-effectiveness ratio of a range of clinical smoking cessation interventions available in Thailand.

METHODS

Using a Markov model, cost-effectiveness, in terms of cost per quality-adjusted life years (QALY) gained, from a range of interventions was estimated from a societal perspective for males and females aged 40 years who smoke at least 10 cigarettes per day. Interventions considered were: counselling in hospital, phone counselling (Quitline) and counselling plus nicotine gum, nicotine patch, bupropion, nortriptyline or varenicline. An annual discounting rate of 3% was used. Probabilistic sensitivity analyses were conducted and a cost-effectiveness acceptability curve (CEAC) plotted. Comparisons between interventions were conducted involving application of a 'decision rule' process.

RESULTS

Counselling with varenicline and counselling with nortriptyline were found to be cost-effective. Hospital counselling only, nicotine patch and bupropion were dominated by Quitline, nortriptyline and varenicline, respectively, according to the decision rule. When compared with unassisted cessation, probabilistic sensitivity analysis revealed that all interventions have very high probabilities (95%) of being cost-saving except for nicotine replacement therapy (NRT) patch (74%).

CONCLUSION

In middle-income countries such as Thailand, nortriptyline and varenicline appear to provide cost-effective clinical options for supporting smokers to quit.

Stages of change of the readiness to quit smoking among a random sample of minority Arab male smokers in Israel

BACKGROUND

Despite advanced smoking prevention and cessation policies in many countries, the prevalence of cigarette smoking among indigenous and some ethnic minorities continues to be high. This study examined the stages of change (SOC) of the readiness to quit smoking among Arab men in Israel shortly after new regulations of free-of-charge smoking cessation workshops and subsidized medications were introduced through primary health care clinics.

METHODS

We conducted a countrywide study in Israel between 2012-2013. Participants, 735 current smokers; 18-64 years old; were recruited from a stratified random sample and interviewed face-to-face using a structured questionnaire in Arabic. We used ordered regression to examine the contribution of socio-economic position (SEP), health status, psychosocial attributes, smoking-related factors, and physician advice to the SOC of the readiness to quit smoking (pre-contemplation, contemplation and preparation).

RESULTS

Of the current smokers, 61.8% were at the pre-contemplation stage, 23.8% were at the contemplation stage, and only 14.4% were at the preparation stage. In the multinomial analysis, factors significantly (P < 0.05) contributing to contemplation stage compared to pre-contemplation stage included [odds ratio (OR), 95% confidence interval (CI)]: chronic morbidity [0.52, (0.31-0.88)], social support [1.35, (1.07-1.70)], duration of smoking for 11-21 years [1.94, (1.07-3.50)], three or more previous attempts to quit [2.27, (1.26-4.01)], knowledge about smoking hazards [1.75, (1.29-2.35)], positive attitudes toward smoking prevention [1.44, (1.14-1.82)], and physician advice to quit smoking [1.88, (1.19-2.97)]. The factors significantly (P < 0.05) contributing to preparation stage compared to pre-contemplation stage were [OR, (95 % CI)]: chronic morbidity [0.36, (0.20-0.67)], anxiety [1.07, (1.01-1.13)], social support [1.34, (1.01-1.78)], duration of smoking 5 years or less [2.93, (1.14-7.52)], three or more previous attempts to quit [3.16, (1.60-6.26)], knowledge about smoking hazards [1.57, (1.10-2.21)], and positive attitudes toward smoking prevention [1.34, (1.00-1.82)].

CONCLUSIONS

Most Arab men who currently smoke are in the pre-contemplation stage, indicating low readiness to quit smoking. New policies of free-of-charge smoking-cessation group sessions and subsidized medications introduced through primary health care clinics in Israel may be less effective among Arab men. For these policies to promote cessation more successfully, tailored interventions and campaigns may be needed to increase the readiness to quit smoking in this population, especially for those at the pre-contemplation stage.

Assessing the effectiveness of a pharmacist-delivered smoking cessation program in the State of Qatar: study protocol for a randomized controlled trial

BACKGROUND

It had been reported that up to 37% of the adult male population smokes cigarettes in Qatar. The Global Youth Tobacco Survey also stated that 13.4% of male school students aged 13 to 15 years in Qatar smoke cigarettes. Smoking cessation is key to reducing smoking-related diseases and deaths. Healthcare providers are in an ideal position to encourage smoking cessation. Pharmacists are the most accessible healthcare providers and are uniquely situated to initiate behavior change among patients. Many studies have shown that pharmacists can be successful in helping patients quit smoking. Studies demonstrating the effectiveness of pharmacist-delivered smoking cessation programs are lacking in Qatar. This proposal aims to test the effect of a structured smoking cessation program delivered by trained ambulatory pharmacists in Qatar.

METHODS/DESIGN

A prospective, randomized, controlled trial is conducted at eight ambulatory pharmacies in Qatar. Participants are randomly assigned to receive an at least four-session face-to-face structured patient-specific smoking cessation program conducted by the pharmacist or 5 to 10 min of unstructured brief smoking cessation advice (emulating current practice) given by the pharmacist. Both groups are offered nicotine replacement therapy if feasible. The primary outcome of smoking cessation will be confirmed by an exhaled carbon monoxide test at 12 months. Secondary outcomes constitute quality-of-life adjustment as well as cost analysis of program resources consumed, including per case and patient outcome.

DISCUSSION

If proven to be effective, this smoking cessation program will be considered as a model that Qatar and the region can apply to decrease the smoking burden.

TRIAL REGISTRATION

Clinical Trials NCT02123329 .

Smoking cessation in community pharmacy practice-a clinical information needs analysis

Background

With the emerging role of pharmacists in implementing smoking cessation services and the recent evidence about smoking cessation pharmacotherapies, a needs analysis to assess baseline knowledge about current smoking cessation practice is needed; hence, training and development in this area can target possible ‘gaps’.

Objective

This study aimed at exploring pharmacy students’ knowledge about and attitudes toward smoking cessation, as compared to practicing community pharmacists and smoking cessation educators. The overall objective was to uncover underlying ‘gaps’ in pharmacy-based smoking cessation practice, particularly clinical gaps.

Setting

Final-year pharmacy students at the University of Sydney, practicing community pharmacists and smoking cessation educators in Australia.

Method

As no previous standard pharmacist-focused smoking cessation knowledge questionnaires exist, a review of the literature informed the development of such a questionnaire. The questionnaire was administered to a cohort of fourth-year pharmacy students at the University of Sydney, practicing pharmacists and smoking cessation educators. Data analysis was performed using Predictive Analytics SoftWare (PASW® Statistics 18). Mean total scores, independent t-tests, analysis of variances and exploratory factor analysis were performed.

Main outcome measure

To determine areas of major clinical deficits about current evidence related to smoking cessation interventions at the pharmacy level.

Results

Responses from 250 students, 51 pharmacists and 20 educators were obtained. Smoking educators scored significantly higher than pharmacists and students (P < .05), while score differences in the latter two groups were not statistically significant (P > .05). All groups scored high on ‘general’ knowledge questions as compared to specialised pharmacologic and pharmacotherapeutic questions. All respondents demonstrated positive attitudes toward the implications of smoking cessation. Factor analysis of the 24-item knowledge section extracted 12 items loading on 5 factors accounting for 53% of the total variance.

Conclusions

The results provide a valid indication of ‘gaps’ in the practice of up-to-date smoking cessation services among Australian pharmacy professionals, particularly in clinical expertise areas involving assessment of nicotine dependence and indications, dosages, adverse effects, contraindications, drug interactions and combinations of available pharmacotherapies. These gaps should be addressed, and the results should inform the design, implementation and evaluation of a pharmacy-based educational training program targeting current clinical issues in smoking cessation.

Discrete choice experiments in pharmacy: a review of the literature

Objective

Discrete choice experiments (DCEs) have been widely used to elicit patient preferences for various healthcare services and interventions. The aim of our study was to conduct an in-depth scoping review of the literature and provide a current overview of the progressive application of DCEs within the field of pharmacy.

Methods

Electronic databases (MEDLINE, EMBASE, SCOPUS, ECONLIT) were searched (January 1990–August 2011) to identify published English language studies using DCEs within the pharmacy context. Data were abstracted with respect to DCE methodology and application to pharmacy.

Key findings

Our search identified 12 studies. The DCE methodology was utilised to elicit preferences for different aspects of pharmacy products, therapy or services. Preferences were elicited from either patients or pharmacists, with just two studies incorporating the views of both. Most reviewed studies examined preferences for process-related or provider-related aspects with a lesser focus on health outcomes. Monetary attributes were considered to be important by most patients and pharmacists in the studies reviewed. Logit, probit or multinomial logit models were most commonly employed for estimation.

Conclusion

Our study showed that the pharmacy profession has adopted the DCE methodology consistent with the general health DCEs although the number of studies is quite limited. Future studies need to examine preferences of both patients and providers for particular products or disease-state management services. Incorporation of health outcome attributes in the design, testing for external validity and the incorporation of DCE results in economic evaluation framework to inform pharmacy policy remain important areas for future research.

Smoking cessation counseling in Qatar: community pharmacists' attitudes, role perceptions and practices

BACKGROUND

Smoking is a major public health problem in Qatar. The potential for community pharmacists to offer smoking cessation counseling in this country can be high.

OBJECTIVES

To determine the current smoking cessation practices of community pharmacists in Qatar, to examine their attitudes about tobacco use and smoking cessation, to evaluate their perceptions about performing professional roles with respect to smoking cessation and to assess their perceived barriers for smoking cessation counseling in the pharmacy setting in Qatar.

SETTING

Community pharmacies in Qatar.

METHODS

The objectives were addressed in a cross sectional survey of community pharmacists in Qatar from June 2010 to October 2010. A phone call was made to all community pharmacists in Qatar (318 pharmacists) inviting them to participate. Consenting pharmacists anonymously completed the survey either online or as paper using fax. Data was analyzed using Statistical Package of Social Sciences (SPSS®) Version 18.

MAIN OUTCOME MEASURES

Qatar community pharmacists' smoking cessation practices, their attitudes toward tobacco use, smoking cessation and smoking cessation counseling and their perceived barriers for smoking cessation counseling.

RESULTS

Over 5 months, we collected 127 surveys (40 % response rate). Only 21 % of respondents reported that they always or most of the time asked their patients if they smoke. When the patients' smoking status was identified, advising quitting and assessing readiness to quit were always or most of the time performed by 66 and 52 % of respondents respectively. Only 15 % always or most of the time arranged follow-up with smokers and 22 % always or most of the time made smoking cessation referrals. Most respondents (>80 %) agreed that smoking could cause adverse health effects and that smoking cessation could decrease the risk of these effects. In addition, the majority (>80 %) believed that smoking cessation counseling was an important activity and was an efficient use of their time. The top two perceived barriers for smoking cessation counseling were lack of time (65 % of respondents) and lack of patients' interest in smoking cessation (54 %).

CONCLUSIONS

Qatar community pharmacists have positive attitudes toward smoking cessation counseling. These attitudes need to be translated into action. Interventions should be implemented to overcome perceived barriers and to improve smoking cessation activities among pharmacists.

Review of services provided by pharmacies that promote healthy living

BACKGROUND

The recognition that community pharmacies have the potential to make a greater contribution to promoting public health has led to a new concept, called the Healthy Living Pharmacy (HLP). These are designed to meet public health needs through a tiered commissioning framework delivering health and well being services through community pharmacy, tailored to local requirements for tackling health inequalities.

AIM

To search the literature for quality evidence to support the inclusion of services in the HLP portfolio and suggest areas where more evidence is required.

METHOD

A systematic review of the research literature covering the period January 1990-August 2011 inclusive, using MEDLINE, EMBASE, Pharmline, NHS Evidence and the Cochrane databases. On-line searching of the grey literature (e.g. conference proceedings) was also carried out. Standard methods of assessing quality were employed.

RESULTS

A total of 377 papers were included. Over time, there was a marked increase in frequency of publications reflecting a growing pharmacy interest in the public healthcare agenda; over a third (35 %) of papers appeared in the last three-year study period. The body of research had a wide geographical basis; contributions were as follows: UK (51.5 %), US (20.4 %), Australia/New Zealand (9.8 %), Europe (7.7 %) and Canada (7.2 %). The topics of contraception, cardiovascular disease prevention, diabetes and smoking cessation accounted for 40 % of included papers. The literature supports the introduction of specific community pharmacy services, targeted at customer groups, both with and without pre-existing diseases. Good evidence exists for smoking cessation, cardiovascular disease prevention, hypertension and diabetes. Some good evidence exists for interventions on asthma and heart failure. The evidence supporting weight management, sexual health, osteoporosis detection, substance abuse and chronic obstructive pulmonary disease is weak and needs development.

CONCLUSION

There is strong evidence for the role of community pharmacy in a range of services, not only aimed at improving general health, but also maintaining the health of those with existing disease. In other areas, the evidence is less strong and further research is required to justify their inclusion in a HLP portfolio.

Stage-based interventions for smoking cessation

BACKGROUND

The transtheoretical model is the most widely known of several stage-based theories of behaviour. It proposes that smokers move through a discrete series of motivational stages before they quit successfully. These are precontemplation (no thoughts of quitting), contemplation (thinking about quitting), preparation (planning to quit in the next 30 days), action (quitting successfully for up to six months), and maintenance (no smoking for more than six months). According to this influential model, interventions which help people to stop smoking should be tailored to their stage of readiness to quit, and are designed to move them forward through subsequent stages to eventual success. People in the preparation and action stages of quitting would require different types of support from those in precontemplation or contemplation.

OBJECTIVES

Our primary objective was to test the effectiveness of stage-based interventions in helping smokers to quit.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group's specialised register for trials, using the terms ('stage* of change', 'transtheoretical model*', 'trans-theoretical model*, 'precaution adoption model*', 'health action model', 'processes of change questionnaire*', 'readiness to change', 'tailor*') and 'smoking' in the title or abstract, or as keywords. The latest search was in August 2010.

SELECTION CRITERIA

We included randomized controlled trials, which compared stage-based interventions with non-stage-based controls, with 'usual care' or with assessment only. We excluded trials which did not report a minimum follow-up period of six months from start of treatment, and those which measured stage of change but did not modify their intervention in the light of it.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the participants, the dose and duration of intervention, the outcome measures, the randomization procedure, concealment of allocation, and completeness of follow up.The main outcome was abstinence from smoking for at least six months. We used the most rigorous definition of abstinence, and preferred biochemically validated rates where reported. Where appropriate we performed meta-analysis to estimate a pooled risk ratio, using the Mantel-Haenszel fixed-effect model.

MAIN RESULTS

We found 41 trials (>33,000 participants) which met our inclusion criteria. Four trials, which directly compared the same intervention in stage-based and standard versions, found no clear advantage for the staging component. Stage-based versus standard self-help materials (two trials) gave a relative risk (RR) of 0.93 (95% CI 0.62 to 1.39). Stage-based versus standard counselling (two trials) gave a relative risk of 1.00 (95% CI 0.82 to 1.22). Six trials of stage-based self-help systems versus any standard self-help support demonstrated a benefit for the staged groups, with an RR of 1.27 (95% CI 1.01 to 1.59). Twelve trials comparing stage-based self help with 'usual care' or assessment-only gave an RR of 1.32 (95% CI 1.17 to 1.48). Thirteen trials of stage-based individual counselling versus any control condition gave an RR of 1.24 (95% CI 1.08 to 1.42). These findings are consistent with the proven effectiveness of these interventions in their non-stage-based versions. The evidence was unclear for telephone counselling, interactive computer programmes or training of doctors or lay supporters. This uncertainty may be due in part to smaller numbers of trials.

AUTHORS' CONCLUSIONS

Based on four trials using direct comparisons, stage-based self-help interventions (expert systems and/or tailored materials) and individual counselling were neither more nor less effective than their non-stage-based equivalents. Thirty-one trials of stage-based self help or counselling interventions versus any control condition demonstrated levels of effectiveness which were comparable with their non-stage-based counterparts. Providing these forms of practical support to those trying to quit appears to be more productive than not intervening. However, the additional value of adapting the intervention to the smoker's stage of change is uncertain. The evidence is not clear for other types of staged intervention, including telephone counselling, interactive computer programmes and training of physicians or lay supporters. The evidence does not support the restriction of quitting advice and encouragement only to those smokers perceived to be in the preparation and action stages.

An evaluation of a rural community pharmacy-based smoking-cessation counselling and nicotine replacement therapy initiative

Objective

To evaluate the efficiency and the effectiveness of a rural community pharmacy-based smoking-cessation counselling and nicotine replacement therapy (NRT) initiative.

Setting

Community pharmacies in NHS Highland in the north of Scotland.

Key findings

Most clients (77%) smoked cigarettes for an average of 34 pack-years ranging from 1 to 174 pack-years. Almost three-quarters (73%) of the NRT prescribed was in the form of patches. Most respondents (91%) claimed pharmacists' advice was useful, and most (65%) thought that the pharmacist was their preferred healthcare professional for smoking-cessation advice because of ease of access. At the end of week four, 45% of clients reported that they had stopped smoking, this fell to 35% at the end of week 12, and at 44 weeks the point prevalent abstinence rate was 15.8%. Of those that did not stop, 19% reduced their smoking level. This initiative cost £525 for each quitter. Thirteen quality criteria were defined in the assessment framework of which six were achieved.

Conclusions

There are no established criteria for evaluating community pharmacy-based smoking-cessation initiatives currently available, neither are reductions in smoking levels reported. Enhancing the role of the community pharmacist to include health improvement improves the interface between healthcare and the consumer, and helps to meet the national recommendations. Community pharmacy-based smoking-cessation initiatives impact on smoking-cessation targets, allow for the variety of services relevant to the needs of the population and are part of the key to making a difference.

Methods

A review of the literature on community pharmacy-based smoking-cessation initiatives informed a performance assessment framework. Data for evaluation were collected through client records, questionnaires and semi-structured interviews of the stakeholders, and a cost-effectiveness analysis was undertaken.

Implementation of inpatient and outpatient tobacco-cessation programs

PURPOSE

Two programs in which pharmacists have an active role in the provision of tobacco-cessation education are described.

SUMMARY

An algorithm for tobacco- cessation education was created for use in an inpatient tobacco-cessation program. Patient education handouts were created, and the content of each handout varied by the patient's level of readiness to make a quit attempt. Doctor of pharmacy students who were assigned to the general internal medicine clerkship rotation at the hospital provided tobacco-cessation education to patients. During monthly rotations, these students assess the smoking status of each patient, gauge the patient's readiness to quit, and provide brief tobacco-cessation education to those who smoke. Patients who are willing to quit smoking are asked if they can be contacted by a representative of the health system's tobacco-cessation program. This program includes a series of three group classes focusing on behavior modification and pharmacotherapy provided at a discounted price. An outpatient tobacco-cessation clinic was initiated to provide all patients of the network an opportunity to participate and have access to tobacco-cessation services. The clinic consists of group and individual classes using the principles and interventions highlighted in national clinical practice guidelines. All referred patients must attend an initial one-on-one visit with the clinical pharmacist before enrollment into the group class. During this visit, general medical information is collected, and the patient's stage of change and willingness to set a quit date are determined. A medication review for drug-smoking interactions is conducted, individual goals are discussed, and a care plan is created.

CONCLUSION

Tobacco-cessation services were implemented by pharmacists working in inpatient and outpatient settings.

Cost-effectiveness of interventions to support self-care: A systematic review

Objectives: Interventions to support patient self-care of their condition aim to improve patient health and reduce health service costs. Consequently, they have attracted considerable policy interest. There is some evidence of clinical effectiveness but less attention has been paid to whether these interventions are cost-effective. This study examines the quality and quantity of existing evidence of the cost-effectiveness.

Methods: A systematic review was carried out to assess the extent and quality of economic evaluations of self-care support interventions. Thirty-nine economic evaluations were assessed against a quality checklist developed to reflect the special features of these interventions.

Results: The majority of the studies claimed that self-care support interventions were cost-effective or cost saving. The overall quality of economic evaluations was poor because of flaws in study designs, especially a narrow definition of relevant costs and short follow-up periods.

Conclusions: The current evidence base does not support any general conclusion that self-care support interventions are cost-effective, but ongoing trials may provide clearer evidence.

Knowledge and attitudes about smoking cessation among pharmacy technicians

OBJECTIVE

To evaluate the knowledge and attitudes of pharmacy technicians before and after attending a continuing education program about smoking cessation.

DESIGN

A pre/post survey of a single group.

SETTING

Two statewide meetings of the Iowa Pharmacy Association.

PARTICIPANTS

Pharmacy technicians.

INTERVENTION

One 2-hour continuing education (CE) course about smoking cessation for pharmacy technicians.

MAIN OUTCOME MEASURES

Changes in scores before and after the CE sessions among three domains (knowledge, efficacy, and outcome) of a validated survey instrument.

RESULTS

Fifty-one technicians completed both the presession and postsession questionnaire. For the three survey domains, technicians' knowledge (P = .034), efficacy (P < .001), and outcome (P < .001) showed significant improvement between the presession and postsession surveys (Wilcoxon signed rank test).

CONCLUSION

Pharmacy technicians who attended a CE program on smoking cessation improved their knowledge, attitudes, and self-confidence in helping smokers quit. Additional research should be conducted to test the role of pharmacy technicians in smoking cessation promotion.

Community pharmacy personnel interventions for smoking cessation

BACKGROUND

Smoking cessation is a potentially appropriate role for community pharmacists because they are encouraged to advise on the correct use of nicotine replacement therapy (NRT) products and to provide behavioural support to aid smoking cessation.

OBJECTIVES

This review assessed the effectiveness of interventions by community pharmacy personnel to assist clients to stop smoking.

SEARCH STRATEGY

A search was made of the Cochrane Tobacco Addiction Group database for smoking cessation studies conducted in the community pharmacy setting, using the search terms pharmacist* or pharmacy or pharmacies. Date of the most recent search: March 2003.

SELECTION CRITERIA

Randomized trials which compared interventions by community pharmacy personnel to promote smoking cessation amongst their clients who were smokers compared to usual pharmacy support or any less intensive programme. The main outcome measure was smoking cessation rates at six months or more after the start of the intervention.

DATA COLLECTION AND ANALYSIS

Data were extracted by one author and checked by the second, noting: the country of the trial, details of participant community pharmacies, method of subject recruitment, smoking behaviour and characteristics of participants on recruitment, method of randomization, description of the intervention and of any pharmacy personnel training, and the outcome measures. Methodological quality was assessed according to the extent to which the allocation to intervention or control was concealed. Because of the potentially important cluster effects, we also rated trials according to whether they checked for or adjusted for these but, in the absence of consensus on how to pool cluster level data, we adopted a narrative approach to synthesizing the data, rather than a formal meta-analysis.

MAIN RESULTS

We identified two trials which met our selection criteria. They included a total of 976 smokers. Both trials were set in the UK and involved a training intervention which included the Stages of Change Model; they then compared a support programme involving counselling and record keeping against a control receiving usual pharmacy support. In both studies a high proportion of intervention and control participants began using NRT. Both studies reported smoking cessation outcomes at three time points. However, the follow-up points were not identical (three, six and 12 months in one, and one, four and nine months in the other), and the trend in abstinence over time was not linear in either study, so the data could not be combined. One study showed a significant difference in self-reported cessation rates at 12 months: 14.3% versus 2.7% (p < 0.001); the other study showed a positive trend at each follow-up with 12.0% versus 7.4% (p = 0.09) at nine months.

REVIEWER'S CONCLUSIONS

The limited number of studies to date suggests that trained community pharmacists, providing a counselling and record keeping support programme for their customers, may have a positive effect on smoking cessation rates. The strength of evidence is limited because only one of the trials showed a statistically significant effect.