Systematic Review and Meta-Analysis of Medication Reviews Conducted by Pharmacists on Cardiovascular Diseases Risk Factors in Ambulatory Care

Association between pharmacist-led telehealth services and improvements in cardiovascular outcomes among patients with cardiovascular risk factors: A scoping review

Background

Cardiovascular disease is the leading cause of death globally. Despite the effectiveness of lifestyle changes and recommended therapeutics, access to primary care and treatments to improve cardiovascular risk-factors (CRFs) remains challenging. Pharmacists and telehealth services have been proposed as potential solutions to overcome these barriers.

Methods

PubMed, OVID, and CINAHL databases were searched from January 2006 to March 2023. The primary outcomes were changes from baseline in systolic/diastolic blood pressure, glycated hemoglobin (A1c), cholesterol levels, and adherence to any patient counseling. Only studies conducted in the United States and Canada were included in the review.

Results

Of 110 screened bibliographic records, 14 studies were included in the review. The pharmacist-led telehealth interventions included medication therapy management, medication reviews, and counseling on lifestyle changes. Nine studies reported significant improvements with intervention, 7 studies on CRFs and 2 studies on medication adherence at the 12-month follow-up, when pharmacist-led telehealth services were compared to usual care or historical data (p < 0.05).

Conclusion

This scoping review provides evidence for continued support to the development and implementation of pharmacist-led telehealth services in primary cardiovascular care. The findings suggest that pharmacist-led telehealth interventions can improve cardiovascular outcomes and adherence to drug and non-drug therapy among patients with CRFs. However, because of lack of published randomized clinical studies on patients with CRFs residing in underserved communities, future directions in research should focus on exploring the implementation of pharmacist-led telehealth services in rural or underserved communities, utilizing various payment models to enhance accessibility and feasibility.

Remodeling arteries: studying the mechanical properties of 3D-bioprinted hybrid photoresponsive materials

3D-printed cell models are currently in the spotlight of medical research. Whilst significant advances have been made, there are still aspects that require attention to achieve more realistic models which faithfully represent the in vivo environment. In this work we describe the production of an artery model with cyclic expansive properties, capable of mimicking the different physical forces and stress factors that cells experience in physiological conditions. The artery wall components are reproduced using 3D printing of thermoresponsive polymers with inorganic nanoparticles (NPs) representing the outer tunica adventitia, smooth muscle cells embedded in extracellular matrix representing the tunica media, and finally a monolayer of endothelial cells as the tunica intima. Cyclic expansion can be induced thanks to the inclusion of photo-responsive plasmonic NPs embedded within the thermoresponsive ink composition, resulting in changes in the thermoresponsive polymer hydration state and hence volume, in a stimulated on-off manner. By changing the thermoresponsive polymer composition, the transition temperature and pulsatility can be efficiently tuned. We show the direct effect of cyclic expansion and contraction on the overlying cell layers by analyzing transcriptional changes in mechanoresponsive mesenchymal genes associated with such microenvironmental physical cues. The technique described herein involving stimuli-responsive 3D printed tissue constructs, also described as four- dimensional (4D) printing, offers a novel approach for the production of dynamic biomodels.

The Importance of Clinical Pharmacists in Improving Blood Glucose and Lipid Levels in Patients with Diabetes and Myocardial Infarction

Purpose

The aim of this study was to evaluate whether intervention by clinical pharmacists can improve blood glucose and lipid levels in diabetic patients with complex medical conditions.

Methods

The retrospective database included 138 patients with diabetes who had presented with acute myocardial infarction (AMI) between January 2019 and October 2021. Blood glucose and lipid levels were measured within 12 weeks and 78 weeks of follow-up. Propensity score matching (PSM) was used to balance the confounding effects of patients' characteristics.

Results

A total of 138 eligible patients were assigned to either the intervention group (n = 47) or the usual care group (n = 91). After the intervention, there were significant improvements in blood glucose (glycosylated hemoglobin-HbA1C % from 9.0 to 8.3; fasting blood glucose-FBG mmol/L from 11.3 to 7.1; postprandial blood glucose-PBG mmol/L from 17.0 to 12.1; p < 0.001) and lipid levels (total cholesterol-TC from 4.9 to 3.5, low-density lipoprotein cholesterol-LDL-C from 3.0 to 1.8, p < 0.001, mmol/L) in both follow-up periods. The blood glucose effects were most pronounced in the PBG control rate (76.9% vs 54.0%) before PSM, while HbA1C% and PBG control rate after PSM were significantly higher in the intervention group (HbA1C% rate: 65.6% vs 38.5%; PBG rate: 79.2% vs 45.8%; p < 0.05, intervention vs non-intervention). Subgroup analysis further confirmed the improvement of blood glucose and lipid mainly in patients with higher baseline FBG (≧10mmol/L) and moderate follow-up duration (4-12 weeks).

Conclusion

The intervention of clinical pharmacists in multidisciplinary team can significantly improve blood glucose and lipid levels in complex type 2 diabetic patients, especially those with high baseline FBG and moderate follow-up durations.

Hypertension management and drug-related problems. A case report of the 23-year history of Mr. Jonas

Arterial hypertension is a lifelong disease, which management is recognized as the most effective way to reduce cardiovascular mortality. Even though there is extensive evidence on the benefits of lifestyle modification and antihypertensive treatment, many patients with hypertension do not reach blood pressure targets. This paper aims to review the history of antihypertensive treatment of one patient and identify the drug related problems that occurred over the study period. In this case report, the patient's health record was studied, guidelines checked and a semi-structured interview conducted. Drug related problems were identified and possible pharmacist interventions were introduced. Drug related problems that could have contributed to the lack of hypertension control were adherence, side effects and disease-drug interaction. Identified pharmacists' interventions ranged from managing self-medication, to collaboration with general practitioner to change prescribing, and counselling the patient on medication use, including adherence. Even though the drug related problems were not that serious in the studied case, the patient could have valued from pharmacist intervention.

Evaluation of Internet-based pharmaceutical care effect on young and middle-aged patients with hypertension by the principal component analysis and the Markov cohort during COVID-19 pandemic

BACKGROUND

Pharmaceutical care has the potential to improve hypertension control rates in young and middle-aged patients. Due the COVID-19 epidemic, standard intervention methods may not be applicable. We propose establishing an internet-based pharmaceutical care (IPC) route to improve blood pressure control in young and middle-aged patients with hypertension. An evaluation method based on Principal Component Analysis (PCA) and Orthogonal Partial Least-Discriminant Analysis (OPLS-DA) was established to evaluate the effect of the IPC method.

METHODS

1) Internet-based Pharmaceutical care (IPC) was provided by pharmacists mainly using Wechat software for one year after enrollment; 2) PCA and OPLS-DA were applied to analyze questionnaire reliability and data variability; 3) Markov cohort was used to evaluate the IPC effect.

RESULTS

Ninety-seven young and middle-aged patients were enrolled. 96 patients received the IPC. 1) The blood pressure control rate increased to 71.88% after IPC in 96 patients. 2) After conducting PCA and OPLS-DA analysis, 10 questions in the questionnaire were significantly improved after the IPC. 3) Markov cohort results showed that patient survival after 28 cycles was 18.62 years and the quality-adjusted life year (QALY) was extended by 5.40 years. The cumulative cost-effectiveness ratio was ¥87.10 per QALY.

CONCLUSIONS

The IPC method could significantly improve the blood pressure control rate of patients. The questionnaire analysis method based on PCA and OPLS-DA is an effective method to evaluate the effect of the IPC method. The Markov cohort showed that the IPC had an effect on blood pressure control rate changes. Patients had a strong willingness to pay for IPC.

BC Clinical impact of medication reviews with follow-up in cardiovascular older patients in primary care: A cluster-randomized controlled trial

AIMS

Cardiovascular diseases (CVD) are the primary cause of death in Chile. Pharmacist-led medication review with follow-up (MRF) has improved CVD risk factors control in Europe and North America. However, their healthcare systems differ from Chile's, precluding generalizability. This trial aimed to determine the effect of MRF on CVD risk factor control among older patients with polypharmacy attending public primary care centres in Chile.

METHODS

A cluster-randomized controlled trial was conducted in 24 centres. Patients older than 65 years with moderate-to-high CVD risk, five or more medications, hypertension, type 2 diabetes or dyslipidaemia, received MRF in addition to usual care or usual care alone for 12 months. Primary outcome measures were clinical goal achievement for hypertension, type 2 diabetes and dyslipidaemia, as well as medication adherence, medication number and CVD risk score. Adjusted generalized estimating equations were used, with odds ratios (ORs) for binary measures and mean differences for continuous measures.

RESULTS

In total, 324 patients from 12 centres (174 MRF group, 150 usual care group, six centres each) received four pharmacist visits. Significant improvements were found for goal achievement in hypertension (OR 4.37, 95% confidence interval [CI] 2.54 to 7.51, P = .001), LDL cholesterol (OR 3.67, 95% CI 2.13 to 6.33, P = .001), type 2 diabetes (OR 6.97, 95% CI 3.69 to 13.2, P = .001), medication adherence (OR 6.60, 95% CI 1.36 to 31.9, P = .022), medications number (-0.86, 95% CI -1.14 to -0.58, P < .001) and CVD risk score (-2.27, 95% CI -2.84 to -1.69, P < .001).

CONCLUSION

Pharmacist-led medication review with follow-up improved cardiovascular disease risk factor control and medication adherence. This study supports pharmacists' inclusion in primary care teams.

Clinical pharmacy services are reimbursed in Germany: challenges of real world implementation remain

Over the last two decades, community pharmacy has experienced major changes as the role of pharmacists is evolving from a product to a service and a patient focus. As part of this change, new and innovative clinical pharmacy services aimed at improving medicines use and patient outcomes have been designed, both nationally and internationally. Since June 2022, five services are reimbursed by all statutory health insurance funds and private insurance companies in Germany: medication review for patients with polymedication; blood pressure control in hypertension; assuring proper inhalation techniques for patients receiving a new device or a device change; medication review including a follow-up for patients taking oral anticancer drugs or immunosuppressants post-transplantation. Beyond reimbursement, the upscaling and sustainable provision of these professional services are now the main challenges. Implementation research will provide important information for the further development of pharmaceutical care programs.

Community pharmacists perception and role in the prevention and management of cardiovascular disease conditions: Evidence from Ghana

BACKGROUND

Globally, Cardiovascular Diseases (CVDs) are the leading non-communicable diseases with a high mortality if not detected and managed early. The study assessed community pharmacists' perception and determined their role in CVDs prevention and management.

METHOD

A cross-sectional study was conducted among 103 registered community pharmacists in the Ahafo, Bono and Bono East regions of Ghana. Data was collected using validated questionnaires through an online and in-person surveys. The data was analysed using Microsoft Excel and STATA 14.1.

RESULTS

Community Pharmacists had knowledge on the concept of pharmaceutical care (n = 93, 92.2%). The roles that Pharmacists played in CVD management and control included educating clients on their conditions and drug therapy, checking for possible drug interactions and screening for risk factors. The barriers to CV health promotion were increase of the pharmacist's workload (n = 96, 93.2%), lack of time (n = 91, 88.4%) and lack of CVD educational materials and clinical tools (n = 56, 54.4%).

CONCLUSION

Community pharmacists have a positive perception of their role in CVDs and performed various activities to reduce the burden of CVDs. However, cardiovascular health promotion in community pharmacies is hindered by increase of the pharmacist's workload, lack of time and lack of CVD educational materials.

Pharmacist Interventions for Medication Adherence: Community Guide Economic Reviews for Cardiovascular Disease

INTRODUCTION

Adherence to medications for cardiovascular disease and its risk factors is less than optimal, although greater adherence to medication has been shown to reduce the risk factors for cardiovascular disease. This paper examines the economics of tailored pharmacy interventions to improve medication adherence for cardiovascular disease prevention and management.

METHODS

Literature from inception of databases to May 2019 was searched, yielding 29 studies for cardiovascular disease prevention and 9 studies for cardiovascular disease management. Analyses were done from June 2019 through May 2020. All monetary values are in 2019 U.S. dollars.

RESULTS

The median intervention cost per patient per year was $246 for cardiovascular disease prevention and $292 for cardiovascular disease management. The median change in healthcare cost per person per year due to the intervention was -$355 for cardiovascular disease prevention and -$2,430 for cardiovascular disease management. The median total cost per person per year was -$89 for cardiovascular disease prevention, with a median return on investment of 0.01. The median total cost per person per year for cardiovascular disease management was -$1,080, with a median return on investment of 7.52, and 6 of 7 estimates indicating reduced healthcare cost averted exceeded intervention cost. For cardiovascular disease prevention, the median cost per quality-adjusted life year gained was $11,298. There were no cost effectiveness studies for cardiovascular disease management.

DISCUSSION

The evidence shows that tailored pharmacy-based interventions to improve medication adherence are cost effective for cardiovascular disease prevention. For cardiovascular disease management, healthcare cost averted exceeds the cost of implementation for a favorable return on investment from a healthcare systems perspective.

Effects of Pharmacist Interventions on Cardiovascular Risk Factors and Outcomes: An Umbrella Review of Meta-analysis of Randomized Controlled Trials

AIM

To grade the evidence from published meta-analyses of randomized controlled trials (RCTs) that assessed effects of pharmacist intervention on cardiovascular risk factors and cardiovascular outcomes.

METHODS

MEDLINE, Embase, and the Cochrane Library were searched from database inception to July 2021. Meta-analyses of RCTs were eligible. Quality of evidence were assessed by GRADE approach.

RESULTS

From 9,308 publications, 149 full-text articles were evaluated for eligibility, and 24 studies with 85 unique meta-analyses that assessed effects of pharmacist intervention on cardiovascular risk factors and cardiovascular outcomes. Overall, 71.7% (61/85) of unique meta-analyses showed significant impacts of pharmacist intervention. For the quality of evidence, 63.4% of meta-analyses had large heterogeneity (I² > 50%) while 1.2%, 16.5%, 32.9% and 49.4% of meta-analyses were graded as high, moderate, low and very low quality based on GRADE approach, respectively. Among meta-analyses with moderate quality, pharmacist interventions significantly mitigated risk factors (including 6/3 mmHg reduction of blood pressure, increased the rate of lipid control, glucose control and smoking cessation (pooled OR 1.91 (1.55, 2.35), 3.11 (2.3, 4.3), and 2.3 (1.33, 3.97), respectively)) and improved medication adherence (pooled OR 1.67 (1.38, 2.02)). Furthermore, pharmacist interventions significantly reduced all-cause mortality (pooled OR 0.72 (0.58, 0.89)) and improved quality of life in patients suffering from chronic heart failure.

CONCLUSION

This umbrella review found convincing evidence that pharmacist intervention can provide a wide range of benefits in cardiovascular disease management, ranging from risk factor control, improvement in medication adherence and in some setting, reduction in morbidity and mortality.

Cost-utility analysis of medication review with follow-up for cardiovascular outcomes: A microsimulation model

BACKGROUND

Cardiovascular diseases are the leading cause of death. Pharmacist-led medication review with follow-up might be cost-effective preventing cardiovascular diseases.

OBJECTIVE

To undertake a cost-utility analysis of the addition of pharmacist-led medication review with follow-up to usual care compared to usual care alone for cardiovascular outpatients.

MATERIALS AND METHODS

A state-transition microsimulation model was built to project outcomes over a lifetime time horizon. Inputs from a cluster randomized controlled trial conducted in primary health care centers in Chile with full-time pharmacists were used. Probabilities were estimated using patient-level data. Utilities and costs associated with each health state were obtained from the literature, whereas the intervention costs were retrieved from the trial. The public third-party payer perspective was used. Uncertainty was evaluated through one-way and probabilistic sensitivity analyses.

RESULTS

For the base case analysis, an incremental cost-effectiveness ratio of $963 per quality-adjusted life-year was observed which was considered cost-effective. The results were robust to sensitivity analyses and were driven by decreased cardiovascular events resulting in lower mortality.

CONCLUSIONS

Medication review with follow-up was deemed a cost-effective addition to usual care with low uncertainty.

Effects of a pharmaceutical care intervention on clinical outcomes and patient adherence in coronary heart disease: the MIMeRiC randomized controlled trial

Background

In the treatment of coronary heart disease, secondary prevention goals are still often unmet and poor adherence to prescribed drugs has been suggested as one of the reasons. We aimed to investigate whether pharmaceutical care by a pharmacist at the cardiology clinic trained in motivational interviewing improves clinical outcomes and patient adherence.

Methods

This was a prospective, randomized, controlled, outcomes-blinded trial designed to compare pharmaceutical care follow-up with standard care. After standard follow-up at the cardiology clinic, patients in the intervention group were seen by a clinical pharmacist two to five times as required over seven months. Pharmacists were trained to use motivational interviewing in the consultations and they tailored their support to each patient’s clinical needs and beliefs about medicines. The primary study end-point was the proportion of patients who reached the treatment goal for low-density lipoprotein cholesterol by 12 months after discharge. The key secondary outcome was patient adherence to lipid-lowering therapy at 15 months after discharge, and other secondary outcomes were the effects on patient adherence to other preventive drugs, systolic blood pressure, disease-specific quality of life, and healthcare use.

Results

316 patients were included. The proportion of patients who reached the target for low-density lipoprotein cholesterol were 37.0% in the intervention group and 44.2% in the control group (P = .263). More intervention than control patients were adherent to cholesterol-lowering drugs (88 vs 77%; P = .033) and aspirin (97 vs 91%; P = .036) but not to beta-blocking agents or renin–angiotensin–aldosterone system inhibitors.

Conclusions

Our intervention had no positive effects on risk factors for CHD, but it increased patient adherence. Further investigation of the intervention process is needed to explore the difference in results between patient adherence and medication effects. Longer follow-up of healthcare use and mortality will determine if the increased adherence per se eventually will have a meaningful effect on patient health.

Trial registration: ClinicalTrials.gov NCT02102503, 03/04/2014 retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02178-0.

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.

Medication incident recovery and prevention utilising an Australian community pharmacy incident reporting system: the QUMwatch study

PURPOSE

To identify factors in community pharmacy that facilitate error recovery from medication incidents (MIs) and explore medication safety prevention strategies from the pharmacist perspective.

METHODS

Thirty community pharmacies in Sydney, Australia, participated in a 30-month prospective incident reporting program of MIs classified in the Advanced Incident Management System (AIMS) and the analysis triangulated with case studies. The main outcome measures were the relative frequencies and patterns in MI detection, minimisation, restorative actions and prevention recommendations of community pharmacists.

RESULTS

Participants reported 1013 incidents with 831 recovered near misses and 165 purported patient harm. MIs were mainly initiated at the prescribing (68.2%) and dispensing (22.6%) stages, and most were resolved at the pharmacy (76.9%). Detection was efficient within the first 24 h in 54.6% of MIs, but 26.1% required one month or longer; 37.2% occurred after the patient consumed the medicine. The combination of specific actions/attributes (85.5%), appropriate interventions (81.6%) and effective communication (77.7%) minimised MIs. An array of remedial actions were conducted by participants including notification, referral, advice, modification of medication regimen, risk management and documentation corrections. Recommended prevention strategies involved espousal of medication safety culture (97.8%), better application of policies/procedures (84.6%) and improvements in healthcare providers' education (79.9%).

CONCLUSION

Incident reporting provided insights on the human and organisational factors involved in the recovery of MIs in community pharmacy. Optimising existing safeguards and redesigning certain structures and processes may enhance the resilience of the medication use system in primary care.

Pharmacist-led cardiovascular risk prevention in Western Canada: a qualitative study

OBJECTIVES

Preventing cardiovascular diseases (CVD) is a public health and policy priority, including for employers. A novel CVD risk management programme that included medication management was delivered by pharmacists to employees of a Canadian university. This qualitative study describes the experiences and perceptions of participants who received individual health consultations in this programme.

METHODS

A qualitative study design using free-text responses was adopted. Data (5658 words) came from evaluation surveys completed by 119 programme participants were iteratively coded and thematically analysed.

KEY FINDINGS

We identified four themes characterising participant experiences of pharmacist-led CVD prevention. Theme one was labelled self-efficacy because personalised health information and advice on CVD risk factor management empowered participants to make improvements for their health. Participants expressed a range of positive responses about the longer consultations, supportive communication and safe setting of their pharmacist-led encounters; hence, Theme two is labelled pharmacists' interpersonal skills. The wider context of the programme included a number of enabling factors (Theme three) that either supported or limited participant engagement in the programme. A number of changes to behaviour and health measures were identified and participant suggestions to expand and continue the programme further contributed to perceptions of positive programme impact (Theme four).

CONCLUSIONS

This study raises questions about how external resources and broader determinants might enable, or hinder, future programme success and sustainability. It also highlights the need for greater understanding and communication of the importance of primary prevention and the role of pharmacists in CVD risk reduction and workplace health promotion.

Medication review with follow-up for cardiovascular outcomes: a trial based cost-utility analysis

Aim: To assess the trial-based cost-effectiveness of medication review with follow-up compared with usual care in primary care. Materials & methods: A cluster randomized controlled trial included patients if they were independent older adults, receiving five or more prescriptions, with moderate or high cardiovascular risk. Costs were estimated from the public healthcare sector perspective, and health benefits were measured as quality-adjusted life years. Both of which were used to calculate the incremental cost-effectiveness ratio. Results: Twelve centers completed the study, six (146 patients) in the intervention group and six (145 patients) in the control group. The base-case analysis showed an incremental cost-effectiveness ratio of US$ (2019) 434.4/quality-adjusted life year (95% CI 64.20-996.03). Conclusion: The intervention was cost-effective in the public primary care setting.

Clinical pharmacy services in Brazil, particularly cardiometabolic diseases: a systematic scoping review and meta-analyses

OBJECTIVE

To map the clinical pharmacy services conducted in Brazil, their characteristics, outcomes, and process measures in general population, as well as the assessment of the clinical impact on people with cardiometabolic diseases (cardiovascular diseases and metabolic diseases).

METHODS

A systematic scoping review and meta-analysis were conducted. The electronic searches were re-run in March 2020. To the clinical impact assessment, meta-analyses of cardiometabolic outcomes (i.e., change of systolic (SBP) and diastolic blood pressure (DBP), triglycerides, total cholesterol, glycated hemoglobin (HbA1c), fasting glycemia, LDL-, and HDL-cholesterol) were led. The risk of bias was assessed with the Cochrane Collaboration tools.

RESULTS

71 studies were identified (7,402 patients), being the majority quasi-experimental studies (n=41) and published by research groups of Southeast Brazil (n=33). Medication therapy management (n=62) was the most frequent clinical pharmacy service, performed on outpatient setting (n=45), with adults or elderly people (n=58) with hypertension (n=18) or diabetes (n=10). Process measures (n=58) (e.g. resolution of drug related-problem) were widely used as indicator, followed by clinical (n=44) (e.g. change in SBP), humanistic (n=12) (e.g. change in quality-of-life score assessed by Short-Form 36 Health Survey Questionnaire), and economic outcomes (n=3) (incremental cost-effectiveness ratio for reduction in HbA1c). Regarding the assessment of clinical impact of the services, 20 studies were included in meta-analyses, showing improvement in most cardiometabolic outcomes when considered individual studies. However, the evidence presents high risk of bias, high heterogeneity (median 67-90%) and imprecision, contributing to wide prediction intervals and low reliability.

CONCLUSIONS

A predominance of studies on cardiometabolic diseases, process measures, and clinical outcomes were identified. Considering the assessment of the clinical impact of clinical pharmacy services in cardiometabolic diseases, an improvement in most cardiometabolic outcomes was showed, however, with low confidence and wide prediction interval. Therefore, development of larger studies with low risk of bias and major homogeneity is necessary for a better comprehension of clinical pharmacy service characteristics, benefits, and the population groups most benefited.

Primary health care pharmacists and vision for community pharmacy and pharmacists in Chile

The Chilean healthcare system is composed of public and private sectors, with most of the higher-income population being covered privately. Primary healthcare in the public system is provided in more than 2,500 public primary care centers of different sizes with assigned populations within territories. Private insurance companies have their own healthcare networks or buy services from individual health providers. Patients from the public system receive most medications free of charge in primary care pharmacies embedded in each care center. Private patients must purchase their medicines from community pharmacies. Some government policies subsidize part of the cost of medications, but original medicines remain as the most expensive of Latin America. Three chain pharmacies have more than 90% of the market share, and these pharmacies have negative public perception because of price collusion court sentences. A non-profit, municipal pharmacy model was developed but has limited implementation. Most privately owned independent and chain community pharmacies do not provide pharmaceutical services as there is no remuneration or cover by insurers. The limited number of publicly owned Municipal pharmacies could implement pharmaceutical services in community settings as they are non-profit establishments and have full-time pharmacists but are not resourced for these services. A limited number of pharmaceutical services are almost exclusively provided in public primary care, including medication reviews, pharmaceutical education, home visits and pharmacovigilance services, but several barriers to their implementation remain. A risk-based multimorbidity care model was implemented in 2020 for public primary care with additional employment of part-time pharmacists to provide services. We believe that this model will help pharmacists to optimize their time by prioritizing the much-needed clinical tasks. We propose within this multimorbidity care model that the more time-consuming services are provided to higher risk patients. Pharmacy prescribing i.e. amending or approving changes in medications in primary care for chronic conditions could also be useful for the health system, but pharmacists would require additional training. The landscape for pharmaceutical services for primary care in Chile is promising, but the integration with community pharmacies will not be possible until they are funded by public and private insurance, and the public perception of these establishments is improved.

Partnering With Pharmacists to Reduce Cardiovascular Risk in Outpatient Settings

See Article Martınez-Mardones et al.

Systematic Review and Meta-Analysis of Medication Reviews Conducted by Pharmacists on Cardiovascular Diseases Risk Factors in Ambulatory Care

Background

Pharmacists‐led medication reviews (MRs) are claimed to be effective for the control of cardiovascular diseases; however, the evidence in the literature is conflicting. The main objective of this meta‐analysis was to analyze the impact of pharmacist‐led MRs on cardiovascular disease risk factors overall and in different ambulatory settings while exploring the effects of different components of MRs.

Methods and Results

Searches were conducted in PubMed, Web of Science, Embase, the Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library Central Register of Controlled Trials database. Randomized and cluster randomized controlled trials of pharmacist‐led MRs compared with usual care were included. Settings were community pharmacies and ambulatory clinics. The classification used for MRs was the Pharmaceutical Care Network Europe as basic (type 1), intermediate (type 2), and advanced (type 3). Meta‐analyses in therapeutic goals used odds ratios to standardize the effect of each study, and for continuous data (eg, systolic blood pressure) raw differences were calculated using baseline and final values, with 95% CIs. Prediction intervals were calculated to account for heterogeneity. Sensitivity analyses were conducted to test the robustness of results. Meta‐analyses included 69 studies with a total of 11 644 patients. Sample demographic characteristics were similar between studies. MRs increased control of hypertension (odds ratio, 2.73; 95% prediction interval, 1.05–7.08), type 2 diabetes mellitus (odds ratio, 3.11; 95% prediction interval, 1.17–5.88), and high cholesterol (odds ratio, 1.91; 95% prediction interval, 1.05–3.46). In ambulatory clinics, MRs produced significant effects in control of diabetes mellitus and cholesterol. For community pharmacies, systolic blood pressure and low‐density lipoprotein values decreased significantly. Advanced MRs had larger effects than intermediate MRs in diabetes mellitus and dyslipidemia outcomes. Most intervention components had no significant effect on clinical outcomes and were often poorly described. CIs were significant in all analyses but prediction intervals were not in continuous clinical outcomes, with high heterogeneity present.

Conclusions

Intermediate and advanced MRs provided by pharmacists may improve control of blood pressure, cholesterol, and type 2 diabetes mellitus, as statistically significant prediction intervals were found. However, most continuous clinical outcomes failed to achieve statistical significance, with high heterogeneity present, although positive trends and effect sizes were found. Studies should use a standardized method for MRs to diminish sources of these heterogeneities.