Improving the well-being of elderly patients via community pharmacy-based provision of pharmaceutical care: a multicentre study in seven European countries

Stakeholders' perspectives about challenges, strategies and outcomes of importance associated with adherence to appropriate polypharmacy in older patients - A qualitative study

Background

Older patients experience challenges when taking polypharmacy. Studies have applied different interventions to improve adherence to polypharmacy. However, inconsistencies in outcomes have impeded the synthesis of evidence. To generate high-quality studies and selectively report outcomes, a Core Outcome Set (COS) is advocated.

Objectives

This study explored stakeholders' perspectives about the challenges older patients face when taking polypharmacy, strategies to overcome each challenge, and outcomes of importance that may contribute to COS development.

Methods

Semi-structured interviews were undertaken with academics, healthcare professionals, and public participants. A series of open-ended questions investigated challenges with adherence to polypharmacy in older patients and strategies to overcome these challenges. A list of outcomes (n = 7) compiled from previous studies associated with adherence to polypharmacy was presented to participants for their views. Content analysis was conducted to identify key themes and outcomes proposed by participants.

Results

Participants suggested 11 multidimensional healthcare system-related, medication-related, patient-related, and socioeconomic-related challenges and 16 educational and behavioural strategies associated with adherence to polypharmacy in older patients. Participants agreed with the importance of the seven outcomes presented and suggested a further six outcomes they deemed to be important for use in trials aimed at improving adherence to appropriate polypharmacy in older patients.

Conclusions

Adherence to polypharmacy was deemed challenging, requiring supportive interventions. A list of 13 outcomes in the context of adherence to appropriate polypharmacy in older patients was identified to inform a future study that will develop a COS for clinical trials targeting interventions to improve adherence to appropriate polypharmacy in older patients.

Exploring the heterogeneity in community pharmacist-led medication review studies - A systematic review

BACKGROUND

Findings on the effectiveness of medication reviews led by community pharmacists (CPs) are often inconclusive. It has been hypothesized that studies are not sufficiently standardized, and thus, it is difficult to draw conclusions.

OBJECTIVE(S)

To examine differences in the way CP-led medication review studies are set up. This was accomplished by investigating (1) patient selection criteria, (2) components of the medication review interventions, (3) types of outcomes, and (4) measurement instruments used.

METHODS

A systematic literature search of randomized controlled trials of CP-led medication reviews was carried out in PubMed and Cochrane Library. Information on patient selection, intervention components, and outcome measurements was extracted, and frequencies were analyzed. Where possible, outcomes were mapped to the Core Outcome Set (COS) for medication review studies. Finally, a network analysis was conducted to explore the influence of individual factors on outcome effects.

RESULTS

In total, 30 articles (26 studies) were included. Most articles had a drug class-specific or disease-specific patient selection criterion (n = 19). Half of the articles included patients aged ≥60 years (n = 15), and in 40% (n = 12/30) patients taking 4 drugs or more. In 24 of 30 articles, a medication review was comprised with additional interventions, such as distribution of educational material and training or follow-up visits. About 40 different outcomes were extracted. Within specific outcomes, the measurement instruments varied, and COS was rarely represented.

CONCLUSION

The revealed differences in patient selection, intervention delivery, and outcome assessment highlight the need for more standardization in research on CP-led medication reviews. While intervention delivery should be more precisely described to capture potential differences between interventions, outcome assessment should be standardized in terms of outcome selection by application of the COS, and with regard to the selected core outcome measurement instruments to enable comparison of the results.

Strategies to Improve Therapeutic Adherence in Polymedicated Patients over 65 Years: A Systematic Review and Meta-Analysis

BACKGROUND

Part of the population over 65 years of age suffer from several pathologies and are therefore polymedicated. In this systematic review and metanalysis, we aimed to determine the efficacy of several strategies developed to improve adherence to pharmacological treatment in polymedicated elderly people.

DESIGN

Web Of Science, PubMed and the Cochrane Library were searched until 2 January 2024. In total, 17 of the 1508 articles found evaluated the efficacy of interventions to improve adherence to medication in polymedicated elderly patients. Methodological quality and the risk of bias were rated using the Cochrane risk of bias tool. Open Meta Analyst® software was used to create forest plots of the meta-analysis.

RESULTS

In 11 of the 17 studies, an improvement in adherence was observed through the use of different measurement tools and sometimes in combination. The most frequently used strategy was using instructions and counselling, always in combination, in a single strategy used to improve adherence; one involved the use of medication packs and the other patient follow-up. In both cases, the results in improving adherence were positive. Five studies using follow-up interventions via visits and phone calls showed improved adherence on the Morisky Green scale compared to those where usual care was received [OR = 1.900; 95% CI = 1.104-3.270] (p = 0.021).

DISCUSSION

There is a high degree of heterogeneity in the studies analyzed, both in the interventions used and in the measurement tools for improving adherence to treatment. Therefore, we cannot make conclusions about the most efficacious strategy to improve medication adherence in polymedicated elderly patients until more evidence of single-intervention strategies is available.

The Effect of Pharmacist-Initiated Deprescribing Interventions in Older People: A Narrative Review of Randomized Controlled Trials

Background Polypharmacy is common among older people and may be associated with adverse drug events (ADEs) and poor health outcomes. Pharmacists are well-positioned to reduce polypharmacy and potentially inappropriate medications. Objective The objective of this narrative review was to summarize the results from randomized-controlled trials that evaluated pharmacist-led interventions with the goal or effect to deprescribe medications in older individuals. Data Sources We searched Medline, Embase, CINAHL Complete, APA PsycInfo, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials. Data Synthesis Of the 25 studies included, the interventions were conducted in nursing facilities (n = 8), outpatient/community dwellings (n = 8), or community pharmacies (n = 9). Interventions were categorized as comprehensive medication reviews (n = 10), comprehensive medication reviews with pharmacist follow-up (n = 11), and educational interventions provided to patients and/or providers (n = 4). Pharmacist-led interventions had a beneficial effect on 22 out of 32 total medication-related outcomes (eg, number of medications, potentially inappropriate medications, or discontinuation). Most (n = 18) studies reported no evidence of an effect for other outcomes such as health care use, mortality, patient-centered outcomes (falls, cognition, function, quality of life), and ADEs. Discussion Interventions led to improvement in 69% of the medication-related outcomes examined across study settings. Five studies measured ADEs with none accounting for adverse drug-withdrawal events. Large well-designed studies that are powered to find an effect on patient-centered outcomes are needed. Conclusion Pharmacist-led interventions had a significant beneficial effect on medication-related outcomes. There was little evidence of benefit on other outcomes.

A rapid review of interventions to improve medicine self-management for older people living at home

BACKGROUND

As people age, they are more likely to develop multiple long-term conditions that require complicated medicine regimens. Safely self-managing multiple medicines at home is challenging and how older people can be better supported to do so has not been fully explored.

AIM

This study aimed to identify interventions to improve medicine self-management for older people living at home and the aspects of medicine self-management that they address.

DESIGN

A rapid review was undertaken of publications up to April 2022. Eight databases were searched. Inclusion criteria were as follows: interventions aimed at people 65 years of age or older and their informal carers, living at home. Interventions needed to include at least one component of medicine self-management. Study protocols, conference papers, literature reviews and articles not in the English language were not included. The results from the review were reported through narrative synthesis, underpinned by the Resilient Healthcare theory.

RESULTS

Database searches returned 14,353 results. One hundred and sixty-seven articles were individually appraised (full-text screening) and 33 were included in the review. The majority of interventions identified were educational. In most cases, they aimed to improve older people's adherence and increase their knowledge of medicines. Only very few interventions addressed potential issues with medicine supply. Only a minority of interventions specifically targeted older people with either polypharmacy, multimorbidities or frailty.

CONCLUSION

To date, the emphasis in supporting older people to manage their medicines has been on the ability to adhere to medicine regimens. Most interventions identify and target deficiencies within the patient, rather than preparing patients for problems inherent in the medicine management system. Medicine self-management requires a much wider range of skills than taking medicines as prescribed. Interventions supporting older people to anticipate and respond to problems with their medicines may reduce the risk of harm associated with polypharmacy and may contribute to increased resilience in the system.

PATIENT OR PUBLIC CONTRIBUTION

A patient with lived experience of medicine self-management in older age contributed towards shaping the research question as well as the inclusion and exclusion criteria for this review. She is also the coauthor of this article. A patient advisory group oversaw the study.

The effectiveness and cost of integrating pharmacists within general practice to optimize prescribing and health outcomes in primary care patients with polypharmacy: a systematic review

BACKGROUND

Polypharmacy and associated potentially inappropriate prescribing (PIP) place a considerable burden on patients and represent a challenge for general practitioners (GPs). Integration of pharmacists within general practice (herein 'pharmacist integration') may improve medications management and patient outcomes. This systematic review assessed the effectiveness and costs of pharmacist integration.

METHODS

A systematic search of ten databases from inception to January 2021 was conducted. Studies that evaluated the effectiveness or cost of pharmacist integration were included. Eligible interventions were those that targeted medications optimization compared to usual GP care without pharmacist integration (herein 'usual care'). Primary outcomes were PIP (as measured by PIP screening tools) and number of prescribed medications. Secondary outcomes included health-related quality of life, health service utilization, clinical outcomes, and costs. Randomised controlled trials (RCTs), non-RCTs, interrupted-time-series, controlled before-after trials and health-economic studies were included. Screening and risk of bias using Cochrane EPOC criteria were conducted by two reviewers independently. A narrative synthesis and meta-analysis of outcomes where possible, were conducted; the certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation approach.

RESULTS

In total, 23 studies (28 full text articles) met the inclusion criteria. In ten of 11 studies, pharmacist integration probably reduced PIP in comparison to usual care (moderate certainty evidence). A meta-analysis of number of medications in seven studies reported a mean difference of -0.80 [-1.17, -0.43], which indicated pharmacist integration probably reduced number of medicines (moderate certainty evidence). It was uncertain whether pharmacist integration improved health-related quality of life because the certainty of evidence was very low. Twelve health-economic studies were included; three investigated cost effectiveness. The outcome measured differed across studies limiting comparisons and making it difficult to make conclusions on cost effectiveness.

CONCLUSIONS

Pharmacist integration probably reduced PIP and number of medications however, there was no clear effect on other patient outcomes; and while interventions in a small number of studies appeared to be cost-effective, further robust, well-designed cluster RCTs with economic evaluations are required to determine cost-effectiveness of pharmacist integration.

TRIAL REGISTRATION

CRD42019139679.

Opportunities for extended community pharmacy services in United Arab Emirates: perception, practice, perceived barriers and willingness among community pharmacists

Background

Community pharmacies are widely distributed in the United Arab Emirates where community pharmacists’ (CPs’) perspectives on provision of extended community pharmacy services (ECPS) is not known. This study assessed CPs perception, practices, perceived barriers and willingness to provide ECPS.

Methods

A descriptive cross-sectional survey using a self-administered Likert-type questionnaire (Cronbach alpha = 0.976) was conducted among 195 community CPs in Northern emirates, selected through multistage sampling technique. The filled questionnaires were assessed for CPs’ perception, practice, perceived barriers and willingness to perform ECPS. Mann–Whitney and Kruskal–Wallis tests examined the association between demography and outcome variables (alpha value of 0.05) with further analysis using Dunn’ post hoc test.

Results

Of the respondents, 71.8% (n = 140) ‘strongly agreed’ that every CP must provide ECPs and 39% (n = 76) ‘strongly agreed’ in supporting ECPS with another 44.1% (n = 86) ‘agreed’ on the same. The major barriers felt by CPs in practicing ECPS were lack of incentive for employee pharmacists [3 (2–3)], lack of documentation [3 (2–3)], insufficient time [3 (2–3)] and lack of patients’ demand [(2–3)]; maximum score (5–5). CPs also responded ‘completely’ willing to provide services such as blood pressure measurement, pregnancy testing and BMI measurement. Pharmacy location influenced practice score (p = 0.008) and access to the internet had a significant effect on barriers score (p = 0.000). Availability of drug information sources impacted perception (p = 0.038), practice (p = 0.000) and willingness scores (p = 0.011).

Conclusions

CPs’ perception on providing ECPS was positive and they are currently offering ECPS within their available resources and facilities. Less demand from patients and lack of time were reportedly the major barriers in offering ECPS. Proper utilization of CPs in providing ECPS can complement the healthcare system with additional cost and time savings for the patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40545-022-00418-y.

Theoretical model and measurement of shared decision making in web-based pharmaceutical care consultation

Objectives

We aimed to construct a theoretical model and an observer-based measurement of shared decision making (SDM) in web-based pharmaceutical care consultation.

Methods

We first constructed a theoretical model through analysis of SDM models and interviews with 24 key informants. Then, the initial measurement was formulated, and the content was evaluated by 16 key informants alone. A cross-sectional study was executed, where 300 provider-patient encounters were collected at the online platform ‘Good Doctor Website’, for reliability and validity assessment. Content validity was evaluated by appropriateness score, that is the median of 7–9 and without disagreement. Interrater reliability was evaluated by Spearman correlation coefficient using 30 out of 300 samples. Single indicator validity was tested by Pearson correlation analysis, and convergent validity was evaluated by the Multiple Indicators Multiple Causes (MIMIC) model using 300 samples.

Results

Theoretical model constructed included four elements: ‘comprehensive understanding of the patient's condition’, ‘exchanging ideas on medication options’, ‘achieving a medication plan’, and ‘providing decision support’. Measurement constructed included four dimensions and 19 items, and four dimensions were in accordance with four elements of the theoretical model. We found median scores of these dimensions and items were 7–9 and without disagreement, indicating good content validity. Spearman correlation coefficients of 19 items were greater than 0.750, suggesting good interrater reliability. Pearson coefficients between 19 items and their external variables were significant (p < 0.001), and MIMIC model results showed that the R² values of dimensions 1–4 were over 0.5, indicating good single indicator validity and convergent validity.

Conclusions

Characteristics of web-based pharmaceutical care consultation, highlighting the importance of medication history, medication regimen, and detailed medication plan, were observed in the theoretical model. Measurement constructed had good reliability and validity and may be used by health policymakers to improve the quality of pharmaceutical care consultation online.

Impact of pharmacist-led interventions on patient care in ambulatory care settings: A systematic review

BACKGROUND

In an era of rapid evolution in healthcare delivery, major changes have occurred within the profession of pharmacist. Because the impact of pharmacist-led interventions in the hospital setting has been well-studied and showed mixed findings on drug-related readmissions, all-cause emergency department visits and mortality, this systematic review focused on services provided by pharmacists in the community or ambulatory care setting without being limited to a specific intervention or outcome.

OBJECTIVE

To investigate the impact of pharmacist-led interventions, categorised into clinical medication review (CMR), adherence review (AR), and prescription review (PR) on various aspects of patient care (clinical, behavioural, economic and humanistic outcomes in ambulatory care setting) and understand which particular intervention makes the greatest contribution.

METHODS

A literature search was conducted using MEDLINE, Embase and the Cochrane Library for publications from 2000 onwards.

FINDINGS AND INTERPRETATION

A total of 31 relevant publications corresponding to 27 controlled trials (CTs) and 4 observational studies were selected. CMR was the most studied pharmacist-led intervention (n = 19, 61.29%), followed by AR (n = 6, 19.3%). CMR demonstrated a favourable effect on different clinical outcomes mainly the management of drug-related problems and adverse events, and it also contributed the most to the reduction of healthcare costs. AR was the most effective intervention to improve patient's adherence. CMR alone or combined with AR both raised equally the patient's satisfaction.

CONCLUSION

Our results showed that CMR can play a major role in the management of drug-related problems and economic issues. AR can significantly improve patient compliance. Larger, standardised and rigorously designed intervention studies are needed to help decision-makers to select appropriate interventions leading to meaningful improvements in patient care.

Evaluation of a community pharmacy-based medication therapy management programme: A study protocol of a pilot randomized controlled trial with an embedded qualitative study

Objectives

The main objectives are: to evaluate the feasibility and effectiveness of a community-pharmacy based medication therapy management programme; to explore patients’ experiences and views towards medication therapy management service delivered by community pharmacists.

Research design and methods

A mixed-methods research design consisting of a pilot randomized controlled trial embedded with qualitative study will be used in this study. The study consists of two phases: a 6-month follow-up pilot randomized control trial (quantitative approach) to assess the feasibility and effectiveness of a community pharmacy-based medication therapy management programme. The primary outcome is HbA1C and secondary outcomes include: clinical and health services utilization and process measures, medication adherence, diabetes distress as well as satisfaction with care. Phase two consists of an embedded qualitative study using semi-structured interviews to explore patients’ experiences and views with the medication therapy management programme. Study data collection will be collected between April 2021 and December 2021.

Ethics consideration

The study has been approved by institutional review boards from Princess Nourah bent Abdulrahman University (Approval # 20–0240), King Fahad Medical City (Approval # 20-388E) and Birmingham University (Approval # ERN_20-0768).

Pharmacist-led interventions to improve medication adherence in older adults: A meta-analysis

BACKGROUND/OBJECTIVE

As pharmacists work to ensure reimbursement for chronic disease management services on the national level, evidence of their impact on important health metrics, such as medication adherence, is needed. However, summative evidence is lacking on the effectiveness of pharmacists to improve medication adherence in older adults. The objective was to assess the effectiveness of pharmacist-led interventions on medication adherence in older adults (65+ years).

DESIGN/SETTING/PARTICIPANTS

Using a systematic review and meta-analytic approach, a comprehensive search of publications in PubMed, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar was conducted through April 2, 2020 for randomized clinical trials of pharmacist-led interventions to improve medication adherence in older adults. A standardized mean difference effect size (Cohen's d) was calculated for medication adherence in each study. Study effect sizes were pooled using a random-effects model, with effect sizes weighted by inverse of its total variance.

MEASUREMENTS

Medication adherence using any method of measurement.

RESULTS

Among 40 unique randomized trials of pharmacist-led interventions with data from 8822 unique patients (mean age, range: 65-85 years), the mean effect size was 0.57 (k = 40; 95% Confidence Interval [CI]: 0.38-0.76). When two outlier studies were excluded from the analysis, the mean effect size reduced to 0.41 (k = 38; 95% CI: 0.27-0.54). A sensitivity analysis of medication adherence outcome by time point resulted in a mean effect size of 0.64 at 3 months (k = 12; 95% CI: 0.32-0.97), 0.30 at 6 months (k = 13; 95% CI: 0.11-0.48), 0.22 at 12 months (k = 12; 95% CI: 0.08-0.37), and 0.36 for outcome time points beyond 12 months (k = 5; 95% CI: 0.02-0.70).

CONCLUSION

This meta-analysis found a significant improvement in medication adherence among older adults receiving pharmacist-led interventions. Implementation of pharmacist-led interventions supported by Medicare reimbursement could ensure older adults' access to effective medication adherence support.

Impact of Medication Reviews Delivered by Community Pharmacist to Elderly Patients on Polypharmacy: A Meta-analysis of Randomized Controlled Trials

OBJECTIVE

The aim of the study was to assess the impact of medication reviews delivered by community pharmacists to elderly patients on polypharmacy.

METHODS

A systematic literature search was performed in four bibliographic databases/search engine (PubMed, Embase, CENTRAL, and IPA) and three gray literature sources (OpenGrey, ClinicalTrials.gov, and Digital Access to Research Theses - Europe) from inception to January 2018. Randomized controlled trials were selected if they met the following criteria: (a) studied in patients 65 years or older who were taking four or more prescribed medications; (b) the "test" interventions were delivered by community pharmacists; and (c) measured one of these following outcomes: hospitalization, emergency department (ED) visit, quality of life, or adherence. Quality of the included studies was assessed using the Cochrane Effective Practice and Organization of Care Group risk of bias tool. Random-effects model meta-analyses were performed.

RESULTS

Of the 3634 articles screened, four studies with a total of 4633 participants were included. The intervention provided in all included studies was clinical medication review. Three studies were at low risk of bias, and the remaining study had unclear risk of bias. When compared with usual care, medication reviews provided by community pharmacist significantly reduced risk of ED visits (risk ratio = 0.68; 95% confidence interval = 0.48-0.96). There was also a tendency that pharmacist interventions decreased risk of hospitalizations (risk ratio = 0.88; 95% CI = 0.78-1.00), although no statistical significant.

CONCLUSIONS

The current evidence demonstrates that clinical medication reviews for older people with polypharmacy reduces the risk of ED visits. Medication reviews can be considered as another area where community pharmacists can contribute to improve patient safety.

Impact of community-pharmacist-led medication review programmes on patient outcomes: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

The role of pharmacists has evolved over the past few decades from being product-oriented to being service-oriented. Community-pharmacist-led medication review programmes have been commissioned in different countries under different names. The services provided by general pharmacists can have a positive impact on patient health, but the impact of the services offered by community pharmacists is relatively unknown.

OBJECTIVE

To evaluate the effectiveness of community-pharmacist-based medication review programmes among patients with long-term conditions.

METHODS

The electronic databases Cochrane Library, MEDLINE and Embase were searched from their inception until January 2020 for randomised controlled trials (RCTs) published in the English language assessing the effectiveness of community-pharmacist-led medication review programmes on patients' clinical and healthcare utilisation outcomes. Random-effects meta-analysis was used to pool data statistically, where applicable. The study protocol was published in PROSPERO (ID: CRD42020165693).

RESULTS

Forty-two reports of 40 RCTs were included in the systematic review, and 12 RCTs were included in the meta-analysis. Compared to the control, a significant improvement was noted in the community-pharmacist-based medication review group for the following outcomes: blood pressure (BP) in patients with diabetes (mean difference [MD] in systolic blood pressure [SBP]: 6.82 [95% CI -11.33, -2.32]; MD in diastolic blood pressure [DBP]: 2.13 [95% CI -3.35, -0.92]) and in the hypertension patients (MD in SBP: 6.21 [95% CI -13.26, 0.85]; MD in DBP: 2.11 [95% CI -6.47, 2.26]), HbA1c in patients with diabetes (MD -0.61; 95% CI -0.96, -0.25), and total cholesterol (TC) in patients with hyperlipidaemia (MD -0.18; 95% CI -0.32, -0.05).

CONCLUSION

Community-pharmacist-led medication review can improve certain clinical and healthcare utilisation outcomes in patients with long-term conditions.

Association of pharmacist counseling with adherence, 30-day readmission, and mortality: A systematic review and meta-analysis of randomized trials

OBJECTIVE(S)

To determine the association of pharmacist medication counseling with medication adherence, 30-day hospital readmission, and mortality.

METHODS

The initial search identified 21,590 citations. After applying the inclusion and exclusion criteria, 62 randomized controlled trials (RCTs) (49 for the meta-analysis) were included in the final analysis. Data were pooled using a random-effects model.

RESULTS

The participants in most of the studies were older patients with chronic diseases who, therefore, were taking many drugs. The overall methodologic quality of evidence ranged from low to very low. Pharmacist medication counseling versus no such counseling was associated with a statistically significant 30% increase in relative risk (RR) for medication adherence, a 24% RR reduction in 30-day hospital readmission (number needed to treat = 4.2), and a 30% RR reduction in emergency department visits. RR reductions for primary care visits and mortality were not statistically significant.

CONCLUSION

The evidence supports pharmacist medication counseling to increase medication adherence and to reduce 30-day hospital readmissions and emergency department visits. However, higher-quality RCT studies are needed to confirm or refute these findings.

Integration of and visions for community pharmacy in primary health care in Denmark

In 2014, the Danish government launched a plan for health entitled: "Healthier lives for everyone - national goals for the health of Danes within the next 10 years". The overall objective is to prolong healthy years of life and to reduce inequality in health. In Denmark, the responsibility for health and social care is shared between the central government, the regions and the municipalities. National and local strategies seek to enhance public health through national and local initiatives initiated by different stakeholders. The Danish community pharmacies also contribute to promoting public health through distribution of and counselling on medication in the entire country and through offering several pharmacy services, six of which are fully or partly remunerated on a national level. Because of greater demands from patients, health care professionals and society and a lack of general practitioners, the Danish community pharmacies now have the opportunity to suggest several new functions and services or to extend existing services. The Danish pharmacy law changed in 2015 with the objective to maintain and develop community pharmacies and to achieve increased patient accessibility. The change in the law made it possible for every community pharmacy owner to open a maximum of seven pharmacy branches (apart from the main pharmacy) in a range of 75 km. This change also increased the competition between community pharmacies and consequently the pharmacies are now under financial pressure. On the other hand, each pharmacy may have been given an incentive to develop their specific pharmacy and become the best pharmacy for the patients. Community pharmacies are working to be seen as partners in the health care system. This role is in Denmark increasingly being supported by the government through the remunerated pharmacy services and through contract with municipalities. Concurrent with the extended tasks for the Danish community pharmacies and utilisation of their excellent competencies in medication the community pharmacies need to focus on their main tasks of supplying medicines and implementing services. This requires efficient management, an increased use of technology for distribution and communication and continuing education and training.

Impact of a global leader on pharmaceutical practice and policy around the world

This commentary describes the contributions of a Dutch pharmacist who contributed in a unique manner to the development of community pharmacy practice in Europe, to the evolution of practice-based research and to its publication. With an interest in pharmaceutical care and in clinical pharmacy, Dr. van Mil changed practice and policy in Europe over the last decades in a very visible way, here documented through a summary of some of his main written contributions. We write this to honour his memory and contribute to the preservation of his legacy.

[Barriers and enablers to pharmacist-led medication review in community pharmacy: A prospective study in Grand Est, France]

Since 2018, French community pharmacists are involved in pharmaceutical care program performing medication review (MR). Near graduated pharmacy students from two faculties of pharmacy were assigned to implement and perform 3 MR in order to identify enablers and barriers of the implementation of MR by community pharmacists. Among 179 MR performed by 117 pharmacists during 5 months, they reported 3 main barriers: the time spending to initiate and perform all steps in MR (lack of time), patients recruiting, and compensation by health care system. Communications initiatives to patients and health professionals in primary care could facilitate patient MR adhesion. Simplification of administrative approach and optimization of software will be welcome and useful in order to reinforced MR implementation and leading.

Deprescribing for Community-Dwelling Older Adults: a Systematic Review and Meta-analysis

BACKGROUND

Polypharmacy and use of inappropriate medications have been linked to increased risk of falls, hospitalizations, cognitive impairment, and death. The primary objective of this review was to evaluate the effectiveness, comparative effectiveness, and harms of deprescribing interventions among community-dwelling older adults.

METHODS

We searched OVID MEDLINE Embase, CINAHL, and the Cochrane Library from 1990 through February 2019 for controlled clinical trials comparing any deprescribing intervention to usual care or another intervention. Primary outcomes were all-cause mortality, hospitalizations, health-related quality of life, and falls. The secondary outcome was use of potentially inappropriate medications (PIMs). Interventions were categorized as comprehensive medication review, educational initiatives, and computerized decision support. Data abstracted by one investigator were verified by another. We used the Cochrane criteria to rate risk of bias for each study and the GRADE system to determine certainty of evidence (COE) for primary outcomes.

RESULTS

Thirty-eight low and medium risk of bias clinical trials were included. Comprehensive medication review may have reduced all-cause mortality (OR 0.74, 95% CI: 0.58 to 0.95, I2 = 0, k = 12, low COE) but probably had little to no effect on falls, health-related quality of life, or hospitalizations (low to moderate COE). Nine of thirteen trials reported fewer PIMs in the intervention group. Educational interventions probably had little to no effect on all-cause mortality, hospitalizations, or health-related quality of life (low to moderate COE). The effect on falls was uncertain (very low COE). All 11 education trials that included PIMs reported fewer in the intervention than in the control groups. Two of 4 computerized decision support trials reported fewer PIMs in the intervention arms; none included any primary outcomes.

DISCUSSION

In community-dwelling people aged 65 years and older, medication deprescribing interventions may provide small reductions in mortality and use of potentially inappropriate medications.

REGISTRY INFORMATION

PROSPERO - CRD42019132420.

For which patient subgroups are there positive outcomes from a medication review? A systematic review

Background:

A medication review is a possibility to assess and optimise a patient’s medicine. A model that includes a medication review and a follow-up seem to provide the best results. However, it is not known whether specific subgroups of patients benefit more from a medication review than others.

Objective:

This literature review summarises the evidence that is available on which patient subgroups exist positive outcomes from a medication review carried out in a primary care setting.

Methods:

We performed a PICO analysis to identify keywords for setting, medication review and effect. We then conducted a search using the PubMed database (2004 to 2019) to identify studies relevant for our investigation. A screening process was carried out based on either title or abstract, and any study that matched the aim and inclusion criteria was included. All matching studies were obtained and read, and were included if they met predefined criteria such as study design, medication review and primary care. The studies were divided into subgroups. First, each subgroup was divided according to the studies’ own definition. Secondly, each subgroup was allocated as either risk patients if the subgroup described a specific patient subgroup or risk medication, if the subgroup was defined as using a specific type of medication. This was done after discussion in the author group.

Results:

28 studies from a total of 935 studies were included. Identified studies were divided into either risk patients; frail, recently discharged or multimorbid patients, or risk medication; heart medication, antithrombotic medication, blood pressure lowering medication, antidiabetic medication, anti-Parkinson medication or medication increasing the risk of falls. The subgroups identified from a medication review in primary care were defined as being frail, recently discharged from hospital or multimorbid (risk patients), or defined as patients using anticoagulant or blood pressure lowering medication (risk medication). Most of the medication reviews in the studies that showed an economic effect included at least one follow-up and were delivered by a pharmacist.

Conclusions:

The literature review demonstrates that medication reviews delivered by pharmacists to specific subgroups of patients are a way of optimising the economic effect of medication reviews in primary care. This is obtained by reducing health-related costs or the number of contacts with primary or secondary health care services.

Sustainable Business Models in Hybrids: A Conceptual Framework for Community Pharmacies’ Business Owners

Community pharmacies have recently been asked to contribute to sustainable healthcare systems through active participation in an integrated model of care and by playing a major educational role for environmental conservation. Therefore, dramatic changes in their institutional context have led to increasing competition in the drugs retail sector and a shift toward a service-oriented business. These factors urge rethinking of the business model of these hybrid organizations, which combine a profit-oriented, social, and more recently addressed, environmental identity. This paper aims at discussing a sustainable business model (SBM) that could allow community pharmacies to contribute to public health through pharmacists’ current role and development of that role. The effects of the COVID-19 pandemic suggest that human health should be at the center of the sustainable development agenda; the pandemic raises questions about the traditional role of community pharmacies, such as extending patient-oriented services. The SBM for community pharmacies represents an opportunity to enhance their role among the healthcare workforce, especially in a time of global pandemics. In addition, the SBM can support community pharmacies to integrate sustainability in day-to-day pharmacy practice, although it should be customized based on the contextual characteristics of the business and on differences between countries, such as health policies and regulations.

Bridging the gap between physical and mental illness in community pharmacy (PharMIbridge): protocol for an Australian cluster randomised controlled trial

INTRODUCTION

There is a significant life expectancy gap attributable to physical comorbidities for people living with severe and persistent mental illness (SPMI) compared with the general population. Medications are a major treatment for SPMI management and physical illnesses, hence pharmacists are well positioned to support mental healthcare and comorbidities. The randomised controlled trial (RCT) aim is to evaluate effectiveness of an individualised, pharmacist led, support service for people experiencing SPMI focusing on medication adherence and physical comorbidity management, compared with standard care (a medication-management service; MedsCheck). METHODS AND ANALYSIS: PharMIbridge is a cluster RCT, whereby community pharmacies in four Australian regions will be randomised (1:1 ratio), to either Intervention Group (IG) or Comparator Group (CG). All IG and CG pharmacy staff will receive Blended-Mental Health First Aid training. Additionally, IG pharmacists will receive further training on medication adherence, goal setting, motivational interviewing, managing physical health concerns and complex issues relating to psychotropic medication. CG pharmacists will not receive additional training, and will provide standard care (MedsCheck). The primary outcome will be change in participants medication adherence for psychotropic medication over 6-months. Using mixed-effects logistic regression model and a cluster size of 48 pharmacies, a total of 190 participants will need to be recruited to each arm to find a statistically significant difference in medication adherence. Secondary outcomes will be changes in factors associated with cardiometabolic risk and quality of life, emphasising physical and psychological well-being; medication-related problems; adherence to other prescribed medication; pharmacists knowledge, confidence and ability to support people experiencing SPMI; and effects on healthcare utilisation. A within RCT-based economic evaluation comparing the intervention with standard care will be undertaken.

ETHICS AND DISSEMINATION

The protocol and pharmacist training programme received Griffith University Human Research Ethics Committee approval (HREC/2019/473 and HREC/2019/493 respectively). Results will be published in peer-reviewed journals and available at the Sixth Community Pharmacy Agreement website (http://6cpa.com.au/about-6cpa/).

TRIAL REGISTRATION NUMBER

ANZCTR12620000577910.

Interventions for improving medication-taking ability and adherence in older adults prescribed multiple medications

BACKGROUND

Older people taking multiple medications represent a large and growing proportion of the population. Managing multiple medications can be challenging, and this is especially the case for older people, who have higher rates of comorbidity and physical and cognitive impairment than younger adults. Good medication-taking ability and medication adherence are necessary to ensure safe and effective use of medications.

OBJECTIVES

To evaluate the effectiveness of interventions designed to improve medication-taking ability and/or medication adherence in older community-dwelling adults prescribed multiple long-term medications.

SEARCH METHODS

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, CINAHL Plus, and International Pharmaceutical Abstracts from inception until June 2019. We also searched grey literature, online trial registries, and reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs. Eligible studies tested interventions aimed at improving medication-taking ability and/or medication adherence among people aged ≥ 65 years (or of mean/median age > 65 years), living in the community or being discharged from hospital back into the community, and taking four or more regular prescription medications (or with group mean/median of more than four medications). Interventions targeting carers of older people who met these criteria were also included.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data, and assessed risk of bias of included studies. We conducted meta-analyses when possible and used a random-effects model to yield summary estimates of effect, risk ratios (RRs) for dichotomous outcomes, and mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, along with 95% confidence intervals (CIs). Narrative synthesis was performed when meta-analysis was not possible. We assessed overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were medication-taking ability and medication adherence. Secondary outcomes included health-related quality of life (HRQoL), emergency department (ED)/hospital admissions, and mortality.

MAIN RESULTS

We identified 50 studies (14,269 participants) comprising 40 RCTs, six cluster-RCTs, and four quasi-RCTs. All included studies evaluated interventions versus usual care; six studies also reported a comparison between two interventions as part of a three-arm RCT design. Interventions were grouped on the basis of their educational and/or behavioural components: 14 involved educational components only, 7 used behavioural strategies only, and 29 provided mixed educational and behavioural interventions. Overall, our confidence in results regarding the effectiveness of interventions was low to very low due to a high degree of heterogeneity of included studies and high or unclear risk of bias across multiple domains in most studies. Five studies evaluated interventions for improving medication-taking ability, and 48 evaluated interventions for improving medication adherence (three studies evaluated both outcomes). No studies involved educational or behavioural interventions alone for improving medication-taking ability. Low-quality evidence from five studies, each using a different measure of medication-taking ability, meant that we were unable to determine the effects of mixed interventions on medication-taking ability. Low-quality evidence suggests that behavioural only interventions (RR 1.22, 95% CI 1.07 to 1.38; 4 studies) and mixed interventions (RR 1.22, 95% CI 1.08 to 1.37; 12 studies) may increase the proportions of people who are adherent compared with usual care. We could not include in the meta-analysis results from two studies involving mixed interventions: one had a positive effect on adherence, and the other had little or no effect. Very low-quality evidence means that we are uncertain of the effects of educational only interventions (5 studies) on the proportions of people who are adherent. Low-quality evidence suggests that educational only interventions (SMD 0.16, 95% CI -0.12 to 0.43; 5 studies) and mixed interventions (SMD 0.47, 95% CI -0.08 to 1.02; 7 studies) may have little or no impact on medication adherence assessed through continuous measures of adherence. We excluded 10 studies (4 educational only and 6 mixed interventions) from the meta-analysis including four studies with unclear or no available results. Very low-quality evidence means that we are uncertain of the effects of behavioural only interventions (3 studies) on medication adherence when assessed through continuous outcomes. Low-quality evidence suggests that mixed interventions may reduce the number of ED/hospital admissions (RR 0.67, 95% CI 0.50 to 0.90; 11 studies) compared with usual care, although results from six further studies that we were unable to include in meta-analyses indicate that the intervention may have a smaller, or even no, effect on these outcomes. Similarly, low-quality evidence suggests that mixed interventions may lead to little or no change in HRQoL (7 studies), and very low-quality evidence means that we are uncertain of the effects on mortality (RR 0.93, 95% CI 0.67 to 1.30; 7 studies). Moderate-quality evidence shows that educational interventions alone probably have little or no effect on HRQoL (6 studies) or on ED/hospital admissions (4 studies) when compared with usual care. Very low-quality evidence means that we are uncertain of the effects of behavioural interventions on HRQoL (1 study) or on ED/hospital admissions (2 studies). We identified no studies evaluating effects of educational or behavioural interventions alone on mortality. Six studies reported a comparison between two interventions; however due to the limited number of studies assessing the same types of interventions and comparisons, we are unable to draw firm conclusions for any outcomes.

AUTHORS' CONCLUSIONS

Behavioural only or mixed educational and behavioural interventions may improve the proportion of people who satisfactorily adhere to their prescribed medications, but we are uncertain of the effects of educational only interventions. No type of intervention was found to improve adherence when it was measured as a continuous variable, with educational only and mixed interventions having little or no impact and evidence of insufficient quality to determine the effects of behavioural only interventions. We were unable to determine the impact of interventions on medication-taking ability. The quality of evidence for these findings is low due to heterogeneity and methodological limitations of studies included in the review. Further well-designed RCTs are needed to investigate the effects of interventions for improving medication-taking ability and medication adherence in older adults prescribed multiple medications.

Pharmaceutical care services available in Danish community pharmacies

In recent years, increased longevity of the Danish population has resulted in a growing segment with age-related and chronic health conditions. This, together with a general increase in the demand on the services of doctors, has augmented the role of pharmacies in the provision of healthcare services. In Denmark, a variety of pharmacy services has been developed, evaluated and implemented since the introduction of pharmaceutical care. The services are aimed at the person responsible for administering the medicine e.g. the patient themselves or care workers, thereby supporting medication safety. The services available have been developed, evaluated and implemented in collaboration between community pharmacies, the Danish Association of Pharmacies, the Danish College of Pharmacy Practice and international collaborators. In this commentary we present an overview of the available pharmacy service, the contents of each service, remuneration and the scientific evidence behind each service. The commentary covers: Inhaler Technique Assessment Service; New Medicines Service; Medication Review; and Medication Safety in Residential Facilities.

Community pharmacy interventions for health promotion: effects on professional practice and health outcomes

BACKGROUND

Community pharmacies are an easily accessible and cost-effective platform for delivering health care worldwide, and the range of services provided has undergone rapid expansion in recent years. Thus, in addition to dispensing medication, pharmacy workers within community pharmacies now give advice on a range of health-promoting behaviours that aim to improve health and to optimise the management of long-term conditions. However, it remains uncertain whether these health-promotion interventions can change the professional practice of pharmacy workers, improve health behaviours and outcomes for pharmacy users and have the potential to address health inequalities.

OBJECTIVES

To assess the effectiveness and safety of health-promotion interventions to change community pharmacy workers' professional practice and improve outcomes for users of community pharmacies.

SEARCH METHODS

We searched MEDLINE, Embase, CENTRAL, six other databases and two trials registers to 6 February 2018. We also conducted reference checking, citation searches and contacted study authors to identify any additional studies.

SELECTION CRITERIA

We included randomised trials of health-promotion interventions in community pharmacies targeted at, or delivered by, pharmacy workers that aimed to improve the health-related behaviour of people attending the pharmacy compared to no treatment, or usual treatment received in the community pharmacy. We excluded interventions where there was no interaction between pharmacy workers and pharmacy users, and those that focused on medication use only.

DATA COLLECTION AND ANALYSIS

We used standard procedures recommended by Cochrane and the Effective Practice and Organisation of Care review group for both data collection and analysis. We compared intervention to no intervention or to usual treatment using standardised mean differences (SMD) and 95% confidence intervals (95% CI) (higher scores represent better outcomes for pharmacy user health-related behaviour and quality of life, and lower scores represent better outcomes for clinical outcomes, costs and adverse events). Interpretation of effect sizes (SMD) was in line with Cochrane recommendations.

MAIN RESULTS

We included 57 randomised trials with 16,220 participants, described in 83 reports. Forty-nine studies were conducted in high-income countries, and eight in middle-income countries. We found no studies that had been conducted in low-income countries. Most interventions were educational, or incorporated skills training. Interventions were directed at pharmacy workers (n = 8), pharmacy users (n = 13), or both (n = 36). The clinical areas most frequently studied were diabetes, hypertension, asthma, and modification of cardiovascular risk. Duration of follow-up of interventions was often unclear. Only five studies gave details about the theoretical basis for the intervention, and studies did not provide sufficient data to comment on health inequalities. The most common sources of bias were lack of protection against contamination - mainly in individually randomised studies - and inadequate blinding of participants. The certainty of the evidence for all outcomes was moderate. We downgraded the certainty because of the heterogeneity across studies and evidence of potential publication bias. Professional practice outcomes We conducted a narrative analysis for pharmacy worker behaviour due to high heterogeneity in the results. Health-promotion interventions probably improve pharmacy workers' behaviour (2944 participants; 9 studies; moderate-certainty evidence) when compared to no intervention. These studies typically assessed behaviour using a simulated patient (mystery shopper) methodology. Pharmacy user outcomes Health-promotion interventions probably lead to a slight improvement in health-related behaviours of pharmacy users when compared to usual treatment (SMD 0.43, 95% CI 0.14 to 0.72; I² = 89%; 10 trials; 2138 participants; moderate-certainty evidence). These interventions probably also lead to a slight improvement in intermediate clinical outcomes, such as levels of cholesterol or glycated haemoglobin, for pharmacy users (SMD -0.43, 95% CI -0.65 to -0.21; I² = 90%; 20 trials; 3971 participants; moderate-certainty evidence). We identified no studies that evaluated the impact of health-promotion interventions on event-based clinical outcomes, such as stroke or myocardial infarction, or the psychological well-being of pharmacy users. Health-promotion interventions probably lead to a slight improvement in quality of life for pharmacy users (SMD 0.29, 95% CI 0.08 to 0.50; I²= 82%; 10 trials, 2687 participants; moderate-certainty evidence). Adverse events No studies reported adverse events for either pharmacy workers or pharmacy users. Costs We found that health-promotion interventions are likely to be cost-effective, based on moderate-certainty evidence from five of seven studies that reported an economic evaluation.

AUTHORS' CONCLUSIONS

Health-promotion interventions in the community pharmacy context probably improve pharmacy workers' behaviour and probably have a slight beneficial effect on health-related behaviour, intermediate clinical outcomes, and quality of life for pharmacy users. Such interventions are likely to be cost-effective and the effects are seen across a range of clinical conditions and health-related behaviours. Nevertheless the magnitude of the effects varies between conditions, and more effective interventions might be developed if greater consideration were given to the theoretical basis of the intervention and mechanisms for effecting behaviour change.

Pharmacist services in nursing homes: A systematic review and meta-analysis

AIMS

Pharmacists have been contributing to the care of residents in nursing homes and play a significant role in ensuring quality use of medicine. However, the changing role of pharmacist in nursing homes and their impact on residents is relatively unknown.

METHODS

Six electronic databases were searched from inception until November 2018 for articles published in English examining the services offered by pharmacists in nursing homes. Studies were included if it examined the impact of interventions by pharmacists to improve the quality use of medicine in nursing homes.

RESULTS

Fifty-two studies (30 376 residents) were included in the current review. Thirteen studies were randomised controlled studies, while the remainder were either pre-post, retrospective or case-control studies where pharmacists provided services such as clinical medication review in collaboration with other healthcare professionals as well as staff education. Pooled analysis found that pharmacist-led services reduced the mean number of falls (-0.50; 95% confidence interval: -0.79 to -0.21) among residents in nursing homes. Mixed results were noted on the impact of pharmacists' services on mortality, hospitalisation and admission rates among residents. The potential financial savings of such services have not been formally evaluated by any studies thus far. The strength of evidence was moderate for the outcomes of mortality and number of fallers.

CONCLUSION

Pharmacists contribute substantially to patient care in nursing homes, ensuring quality use of medication, resulting in reduced fall rates. Further studies with rigorous design are needed to measure the impact of pharmacist services on the economic benefits and other patient health outcomes.

Clinical outcomes of community pharmacy services: A systematic review and meta-analysis

Community pharmacy services (CPS) have been shown to be positive in many disease management and patient care programs, but clinical outcomes were followed by process indicators and methodological flaws in previous researches made it difficult to prove the effectiveness of clinical outcomes of CPS. Therefore, this study attempted to review the clinical outcomes of CPS. Interventions included are provision of medication review, patient education, adherence assessment, health/lifestyle advice, physical assessment, monitoring, prescribing, or adjusting and administering therapy from community pharmacists. By searching for key words like community pharmacists, pharmaceutical services, clinical outcomes in MEDLINE and EMBASE and manually searching (up to June 2017), 1910 studies investigating the clinical outcomes of CPS were obtained. After screening the titles, abstracts and full texts for relevancy, 52 researches with controlled groups were included and assessed for methodological quality. Finally, 25 studies were selected for the meta-analysis based on their common endpoints: systolic blood pressure, diastolic blood pressure and glycosylated haemoglobin. The Cochrane tool was used to assess the risk of bias. Chi-square and I-square tests were performed to assess heterogeneity, and the weighted mean differences were estimated using random effect models. Of the 52 articles, 47 studies demonstrated that CPS had positive clinical outcomes, 3 studies showed mixed outcomes and 2 studies revealed no effects. In the meta-analysis, intervention groups displayed greater reductions in systolic BP (95% CI: -8.198-2.356), diastolic BP (95% CI: -3.648-0.645) and HbA1c (95% CI: -0.905-0.224) than usual care groups. CPS have positive clinical outcomes, particularly significant reductions in systolic BP, diastolic BP and HbA1c. It was difficult to find out which intervention(s) of CPS directly led to certain changes and influence of CPS might be underestimated for only three common surrogate endpoints. More researches should be conducted with sufficient data.

Identifying treatment related problems and associated factors among hospitalized post-stroke patients through medication management review: A multi-center study

Background

Stroke is a major cause of disability and one of the leading causes of death among the elderly. Treatment related problems can lead to undesirable consequences. The Medication Management Review (MMR) service is aimed at identifying, resolving and preventing TRPs, subsiding the undesirable outcomes associated with TRPs.

Objectives

To explore the types, frequencies and severity of TRPs amongst post-stroke patients recruited through hospitals via conducting the MMR service by clinical pharmacists in Jordan. Associations between patient factors and the identified TRPs were explored.

Methods

This cross-sectional descriptive study was conducted over three months in 2017 in different geographical areas throughout Jordan. Randomly recruited patients were interviewed at the hospitals to collect their demographic data and clinical characteristics. Types/frequencies/severity of TRPs for each stroke patient were identified by a clinical pharmacist. Associations between the identified TRPs and patient's factors were explored through multiple regression analysis.Key findings:Out of 198 stroke patients (mean age: 56.6 ± 14.2) who completed the study, 110 (55.6%) were males. Many of the patients (82 (41.6%)) were smokers and 61 (69.2%) had hypertension and/or diabetes. The mean number of TRPs per patient was 2.5 ± 1.1. The most common TRP categories involved efficacy issues (198 (40.6%)), inappropriate drug adherence (136 (27.9%)) and inappropriate patient knowledge (114 (23.4%)). More than 70.0% (342/487) of the identified TRPs were of major severity. Higher number of TRPs was found to be associated with being a male, having a lower educational level, being a current smoker, having a higher number of drugs and a poorer quality of life.

Conclusion

Lack of drug efficacy, inappropriate drug adherence and patient knowledge were the major TRPs identified via delivering the MMR service to post-stroke patients. The identified TRPs highlights the importance of the MMR service, and supports planning future strategies aimed at decreasing the incidence of strokes.

Pharmacist services for non-hospitalised patients

BACKGROUND

This review focuses on non-dispensing services from pharmacists, i.e. pharmacists in community, primary or ambulatory-care settings, to non-hospitalised patients, and is an update of a previously-published Cochrane Review.

OBJECTIVES

To examine the effect of pharmacists' non-dispensing services on non-hospitalised patient outcomes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, two other databases and two trial registers in March 2015, together with reference checking and contact with study authors to identify additional studies. We included non-English language publications. We ran top-up searches in January 2018 and have added potentially eligible studies to 'Studies awaiting classification'.

SELECTION CRITERIA

Randomised trials of pharmacist services compared with the delivery of usual care or equivalent/similar services with the same objective delivered by other health professionals.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures of Cochrane and the Effective Practice and Organisation of Care Group. Two review authors independently checked studies for inclusion, extracted data and assessed risks of bias. We evaluated the overall certainty of evidence using GRADE.

MAIN RESULTS

We included 116 trials comprising 111 trials (39,729 participants) comparing pharmacist interventions with usual care and five trials (2122 participants) comparing pharmacist services with services from other healthcare professionals. Of the 116 trials, 76 were included in meta-analyses. The 40 remaining trials were not included in the meta-analyses because they each reported unique outcome measures which could not be combined. Most trials targeted chronic conditions and were conducted in a range of settings, mostly community pharmacies and hospital outpatient clinics, and were mainly but not exclusively conducted in high-income countries. Most trials had a low risk of reporting bias and about 25%-30% were at high risk of bias for performance, detection, and attrition. Selection bias was unclear for about half of the included studies.Compared with usual care, we are uncertain whether pharmacist services reduce the percentage of patients outside the glycated haemoglobin target range (5 trials, N = 558, odds ratio (OR) 0.29, 95% confidence interval (CI) 0.04 to 2.22; very low-certainty evidence). Pharmacist services may reduce the percentage of patients whose blood pressure is outside the target range (18 trials, N = 4107, OR 0.40, 95% CI 0.29 to 0.55; low-certainty evidence) and probably lead to little or no difference in hospital attendance or admissions (14 trials, N = 3631, OR 0.85, 95% CI 0.65 to 1.11; moderate-certainty evidence). Pharmacist services may make little or no difference to adverse drug effects (3 trials, N = 590, OR 1.65, 95% CI 0.84 to 3.24) and may slightly improve physical functioning (7 trials, N = 1329, mean difference (MD) 5.84, 95% CI 1.21 to 10.48; low-certainty evidence). Pharmacist services may make little or no difference to mortality (9 trials, N = 1980, OR 0.79, 95% CI 0.56 to 1.12, low-certaintly evidence).Of the five studies that compared services delivered by pharmacists with other health professionals, no studies evaluated the impact of the intervention on the percentage of patients outside blood pressure or glycated haemoglobin target range, hospital attendance and admission, adverse drug effects, or physical functioning.

AUTHORS' CONCLUSIONS

The results demonstrate that pharmacist services have varying effects on patient outcomes compared with usual care. We found no studies comparing services delivered by pharmacists with other healthcare professionals that evaluated the impact of the intervention on the six main outcome measures. The results need to be interpreted cautiously because there was major heterogeneity in study populations, types of interventions delivered and reported outcomes.There was considerable heterogeneity within many of the meta-analyses, as well as considerable variation in the risks of bias.

'Has she seen me?': a multiple methods study of the pharmaceutical care needs of older people with sensory impairment in Scotland

OBJECTIVES

To explore the pharmaceutical care needs of, and service provision to, older people with sensory impairment (visual, hearing and dual impairment) on prescribed polypharmacy (≥4 medicines) in Scotland.

DESIGN

Interviews were conducted with older people with sensory impairment and community pharmacy personnel, which informed the content of a subsequent national cross-sectional survey of community pharmacists.

SETTING

Scotland, 2015-2016.

PARTICIPANTS

Older people with sensory impairment and community pharmacy personnel.

RESULTS

Interviews were completed with 23 older people with sensory impairment (dual impairment n=13, visual or hearing impairment n=5 of each) and 30 community pharmacy personnel from eight of 14 Scottish Health Boards. A total of 171 survey responses were received.Older people reported that they did not always disclose their sensory impairment to pharmacy personnel. They also reported that medicines were difficult to identify particularly when their name, shape or colour changed. Pharmacy personnel relied on visible cues such as white canes or guide dogs to identify visual impairment and suggested that hearing loss was less visible and more difficult to identify. Many assistive aids in support of medicine management, such as dosette boxes, seemed inadequate for complex medication regimens. Few community pharmacy personnel reported receiving training in the care of people with sensory impairment.

CONCLUSIONS

This is the first comprehensive, multistakeholder, in-depth exploration of the pharmaceutical care needs of older people with sensory impairment. Strategies are needed to enable people with sensory impairment to disclose their impairment to pharmacy personnel (and other healthcare providers). Community pharmacy personnel require training to deliver person-centred pharmaceutical care for older people with sensory impairment particularly regarding communication with individuals in this vulnerable population.

Cost analysis and cost-benefit analysis of a medication review with follow-up service in aged polypharmacy patients

BACKGROUND

Drug related problems have a significant clinical and economic burden on patients and the healthcare system. Medication review with follow-up (MRF) is a professional pharmacy service aimed at improving patient's health outcomes through an optimization of the medication.

OBJECTIVE

To ascertain the economic impact of the MRF service provided in community pharmacies to aged polypharmacy patients comparing MRF with usual care, by undertaking a cost analysis and a cost-benefit analysis.

METHODS

The economic evaluation was based on a cluster randomized controlled trial. Patients in the intervention group (IG) received the MRF service and the comparison group (CG) received usual care. The analysis was conducted from the national health system (NHS) perspective over 6 months. Direct medical costs were included and expressed in euros at 2014 prices. Health benefits were estimated by assigning a monetary value to the quality-adjusted life years. One-way deterministic sensitivity analysis was undertaken in order to analyse the uncertainty.

RESULTS

The analysis included 1403 patients (IG: n = 688 vs CG: n = 715). The cost analysis showed that the MRF saved 97 € per patient in 6 months. Extrapolating data to 1 year and assuming a fee for service of 22 € per patient-month, the estimated savings were 273 € per patient-year. The cost-benefit ratio revealed that for every 1 € invested in MRF, a benefit of 3.3 € to 6.2 € was obtained.

CONCLUSION

The MRF provided health benefits to patients and substantial cost savings to the NHS. Investment in this service would represent an efficient use of healthcare resources.

Clinical impact of an interdisciplinary patient safety program for managing drug-related problems in a long-term care hospital

Background Medication reviews intended to identify drug-related problems (DRPs) have been researched in primary care, acute care and nursing homes rather than in long-term care hospitals (LTCHs). Objectives To assess the clinical impact of an interdisciplinary pharmacotherapy quality improvement and patient safety program in elderly patients with polypharmacy admitted to an LTCH. Setting An interventional, longitudinal, prospective study was conducted in a Spanish LTCH Method A total of 162 elderly (≥ 70 years) patients with polypharmacy (≥ 5 medications) were included. Pharmacist conducted the pharmacotherapy follow-up of patients (reconciliation, pharmacotherapeutic optimization, educational interviews) from admission to discharge. Demographic, clinical and treatment-related variables were recorded. Main outcome measured Clinical impact of the program by DRP-based effectiveness and drug-related morbidity (DRM)-based safety indicators. Results 895 DRPs (median of 5 (1-23)) were identified in 153 (94.4%) patients. The most common DRPs were unnecessary drug (25.3%), dosage too high (24.9%) and a need for additional drug (24.8%). The most frequent pharmacotherapy recommendations were individualizing the dosage regimen (29.6%) and stopping (27.3%) or starting (21.9%) a drug. The mean implementation rate of pharmacotherapy recommendations was 90.9%. The effectiveness indicator revealed a 94.9% of prevented or resolved DRPs. The safety indicator showed an 89.3% of prevented or resolved DRM. Therefore, the program prevented or resolved 92.5% of adverse effects and 91.7% of suboptimal responses or therapeutic failures. Conclusion This interdisciplinary patient safety program seems to be a valuable approach to identify, prevent and resolve the high number of DRPs and potential DRM that elderly patients with polypharmacy admitted to an LTCH present.

Professional, structural and organisational interventions in primary care for reducing medication errors

BACKGROUND

Medication-related adverse events in primary care represent an important cause of hospital admissions and mortality. Adverse events could result from people experiencing adverse drug reactions (not usually preventable) or could be due to medication errors (usually preventable).

OBJECTIVES

To determine the effectiveness of professional, organisational and structural interventions compared to standard care to reduce preventable medication errors by primary healthcare professionals that lead to hospital admissions, emergency department visits, and mortality in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases, and two trial registries on 4 October 2016, together with reference checking, citation searching and contact with study authors to identify additional studies. We also searched several sources of grey literature.

SELECTION CRITERIA

We included randomised trials in which healthcare professionals provided community-based medical services. We also included interventions in outpatient clinics attached to a hospital where people are seen by healthcare professionals but are not admitted to hospital. We only included interventions that aimed to reduce medication errors leading to hospital admissions, emergency department visits, or mortality. We included all participants, irrespective of age, who were prescribed medication by a primary healthcare professional.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted data. Each of the outcomes (hospital admissions, emergency department visits, and mortality), are reported in natural units (i.e. number of participants with an event per total number of participants at follow-up). We presented all outcomes as risk ratios (RRs) with 95% confidence intervals (CIs). We used the GRADE tool to assess the certainty of evidence.

MAIN RESULTS

We included 30 studies (169,969 participants) in the review addressing various interventions to prevent medication errors; four studies addressed professional interventions (8266 participants) and 26 studies described organisational interventions (161,703 participants). We did not find any studies addressing structural interventions. Professional interventions included the use of health information technology to identify people at risk of medication problems, computer-generated care suggested and actioned by a physician, electronic notification systems about dose changes, drug interventions and follow-up, and educational interventions on drug use aimed at physicians to improve drug prescriptions. Organisational interventions included medication reviews by pharmacists, nurses or physicians, clinician-led clinics, and home visits by clinicians.There is a great deal of diversity in types of professionals involved and where the studies occurred. However, most (61%) of the interventions were conducted by pharmacists or a combination of pharmacists and medical doctors. The studies took place in many different countries; 65% took place in either the USA or the UK. They all ranged from three months to 4.7 years of follow-up, they all took place in primary care settings such as general practice, outpatients' clinics, patients' homes and aged-care facilities. The participants in the studies were adults taking medications and the interventions were undertaken by healthcare professionals including pharmacists, nurses or physicians. There was also evidence of potential bias in some studies, with only 18 studies reporting adequate concealment of allocation and only 12 studies reporting appropriate protection from contamination, both of which may have influenced the overall effect estimate and the overall pooled estimate. Professional interventionsProfessional interventions probably make little or no difference to the number of hospital admissions (risk ratio (RR) 1.24, 95% confidence interval (CI) 0.79 to 1.96; 2 studies, 3889 participants; moderate-certainty evidence). Professional interventions make little or no difference to the number of participants admitted to hospital (adjusted RR 0.99, 95% CI 0.92 to 1.06; 1 study, 3661 participants; high-certainty evidence). Professional interventions may make little or no difference to the number of emergency department visits (adjusted RR 0.71, 95% CI 0.50 to 1.02; 2 studies, 1067 participants; low-certainty evidence). Professional interventions probably make little or no difference to mortality in the study population (adjusted RR 0.98, 95% CI 0.82 to 1.17; 1 study, 3538 participants; moderate-certainty evidence). Organisational interventionsOverall, it is uncertain whether organisational interventions reduce the number of hospital admissions (adjusted RR 0.85, 95% CI 0.71 to 1.03; 11 studies, 6203 participants; very low-certainty evidence). Overall, organisational interventions may make little difference to the total number of people admitted to hospital in favour of the intervention group compared with the control group (adjusted RR 0.92, 95% CI 0.86 to 0.99; 13 studies, 152,237 participants; low-certainty evidence. Overall, it is uncertain whether organisational interventions reduce the number of emergency department visits in favour of the intervention group compared with the control group (adjusted RR 0.75, 95% CI 0.49 to 1.15; 5 studies, 1819 participants; very low-certainty evidence. Overall, it is uncertain whether organisational interventions reduce mortality in favour of the intervention group (adjusted RR 0.94, 95% CI 0.85 to 1.03; 12 studies, 154,962 participants; very low-certainty evidence.

AUTHORS' CONCLUSIONS

Based on moderate- and low-certainty evidence, interventions in primary care for reducing preventable medication errors probably make little or no difference to the number of people admitted to hospital or the number of hospitalisations, emergency department visits, or mortality. The variation in heterogeneity in the pooled estimates means that our results should be treated cautiously as the interventions may not have worked consistently across all studies due to differences in how the interventions were provided, background practice, and culture or delivery of the interventions. Larger studies addressing both professional and organisational interventions are needed before evidence-based recommendations can be made. We did not identify any structural interventions and only four studies used professional interventions, and so more work needs to be done with these types of interventions. There is a need for high-quality studies describing the interventions in more detail and testing patient-related outcomes.

Geographical accessibility to community pharmacies by the elderly in metropolitan Lisbon

BACKGROUND

In ageing societies, community pharmacies play an important role in delivering medicines, responsible advising, and other targeted services. Elderly people are among their main consumers, as they use more prescription drugs, need more specific health care, and experience more mobility issues than other age groups. This makes geographical accessibility a relevant concern for them.

OBJECTIVES

To measure geographical pedestrian accessibility to community pharmacies by elderly people in the Lisbon Metropolitan Area (LMA).

METHODS

The number of elderly people living within a 10- and 15-min walk was estimated based on the exploitation of population census data, the address-based location of 801 community pharmacies, and a Google Maps Application Programming Interface (API) method for calculating distances between pharmacies and the centroids of census statistical subsections. Results were compared to figures attained via traditional methods.

RESULTS

In the LMA, 61.2% of the elderly live less than a 10 min walk from the nearest pharmacy and 76.9% live less than 15 min away. This opposes the common view that pharmacies are highly accessible in urban areas. In addition, results show a high spatial variability of proximity to pharmacies.

CONCLUSIONS

Despite the illusion of good coverage suggested at the metropolitan scale, accessibility measures demonstrate the existence of pharmaceutical deprivation areas for the elderly. The findings indicate the need for more accuracy in both access measurements and redistribution policies. Measurement methods and population targets should be reconsidered.

Pharmaceutical Care in Community Pharmacies: Practice and Research in Sweden

Objective:

To describe the organization and delivery of community pharmacy and medical care, as well as pharmaceutical care practice and research, in Sweden.

Findings:

The Swedish retail pharmacy system of 800 community pharmacies and nearly 80 hospital pharmacies is unique in that it is organized into one single, government-owned chain, known as Apoteket AB. The pharmacy staff consists of pharmacists, prescriptionists, and pharmacy technicians. Some activities related to pharmaceutical care have been directed toward specific patient groups during annual theme campaigns. In the past few years, there has been a growing emphasis on the identification, resolution, and documentation of drug-related problems (DRPs) in Swedish pharmacy practice. A classification system for documenting DRPs and pharmacy interventions was developed in 1995 and incorporated into the software of all community pharmacies in 2001. A national DRP database (SWE-DRP) was established in 2004 to collect and analyze DRPs and interventions on a nationwide basis. Recently, a new counseling technique composed of key questions to facilitate the detection of DRPs has been tested successfully. Patient medication profiles are kept in 160 pharmacies, and a new national register of drugs dispensed to patients became available in 2006. Most pharmaceutical care studies in Sweden have focused on DRPs and resulting pharmacy interventions.

Discussion:

Swedish community pharmacy DRP work is in the international forefront but there is a potential for further developing cognitive services, given the beneficial organization of the country's pharmacies into one single pharmacy chain. The introduction of patient medication profiles has been both late and slow and has only had a marginal effect on pharmaceutical care practice so far. The universities do not appear to have any desire to influence the practice of pharmacy and could potentially take on a more active role in preparing pharmacy students for patient-oriented services. Current threats to pharmaceutical care practice and research include organizational changes, budget cuts, and reduced manpower of Apoteket AB.

Conclusions:

The identification, resolution, and documentation of DRPs are central to community pharmacy practice in Sweden, resulting in a number of research studies. A national DRP database, patient medication profiles, and a new national register of drugs dispensed to patients provide opportunities for growth in pharmaceutical care practice and research in the country.

Community Pharmacy Services in Portugal

Objective:

To describe the status and outline the trends of community pharmacy services in the Portuguese healthcare system.

Findings:

The legal framework for Portuguese pharmacies includes geographic and demographic criteria for opening pharmacies and restricting ownership to pharmacists. Since 1975, pharmacy owners have been organized under one association, the Portuguese National Pharmacy Association, which has dealt with pharmacy development over the past 20 years. Securing the economic sustainability of pharmacies was the first milestone. Investing in information software and communication technologies and modernizing the architecture of pharmacies was the next step. Then, professional services such as point-of-care measurements, drug waste management, and needle exchange services were developed. The methadone substitution program was introduced at a later date. Finally, major comprehensive services, including disease management/pharmaceutical care programs, were implemented.

Discussion:

All Portuguese pharmacies are independent, which means that the decision to provide different services and the extent to which they are attained vary from pharmacy to pharmacy. Recent political changes seem to reinforce the need to pursue the strategies already defined—to expand the traditional scope of pharmacy business to a wider range of health services.

Conclusions:

Achievements that have been accomplished and strategies that are in place reflect a high level of organization and unity among Portuguese pharmacies. From a global perspective, pharmacies are reorganizing to be able to compete against other possible agents and are preparing to expand their scope of intervention.

Pharmaceutical Care in Community Pharmacies: Practice and Research in Germany

Objective:

To discuss the provision of pharmaceutical care in community pharmacies in Germany including community pharmacy, organization and delivery of health services, pharmacy education, community pharmacy services, research in community pharmacy, and future plans for community pharmacy services.

Findings:

In Germany, cognitive pharmaceutical services have been developed for more than 12 years. Several studies and programs have shown that pharmaceutical care and other pharmaceutical services are feasible in community pharmacy practice and that patients benefit from these services. In 2003, a nationwide contract was established between representatives of the community pharmacy owners and the largest German health insurance fund. In this so-called family pharmacy contract, remuneration of pharmacists for provision of pharmaceutical care services was successfully negotiated for the first time. In 2004, a trilateral integrated care contract was signed that additionally included general practitioners, combining the family pharmacy with the family physician. Within a few months, the vast majority (>17 000) of community pharmacies have registered to participate in this program.

Conclusions:

German community pharmacies are moving from the image of mainly supplying drugs toward the provision of cognitive pharmaceutical services.

Humanistic and economic outcomes of pharmacist-provided medication review in the community-dwelling elderly: A systematic review and meta-analysis

WHAT IS KNOWN AND OBJECTIVE

Recent reviews have shown that pharmacist-provided medication review in the elderly can improve clinical outcomes and reduce medication discrepancies compared with usual care. However, none determined whether these translate to improved humanistic and economic outcomes. This review sought to evaluate the effects of medication review on health-related quality of life (HRQoL) and healthcare costs in the elderly.

METHODS

A systematic search of MEDLINE, EMBASE, CINAHL, Web of Science and the Cochrane library for studies published in English from inception to 31 August 2015 was conducted. The review included studies lasting at least 3 months that randomly assigned community-dwelling participants aged at least 65 years to receive either pharmacist-provided medication review or usual care. Studies set in nursing homes were excluded.

RESULTS AND DISCUSSION

The review identified 25 studies that included 15 341 participants and lasted between 3 and 36 months. Twenty and 13 studies reported HRQoL and economic outcomes, respectively. Overall, there was no significant difference in HRQoL and healthcare costs between pharmacist-provided medication review and usual care. Meta-analysis of studies that reported the 36-item Short-Form Health Survey found significant differences in favour of usual care in the body pain (mean difference: 2·94, 95% CI: 0·54-5·34, P = 0·02) and general health perception (mean difference: 1·83, 95% CI: 0·16-3·50, P = 0·03) domains, whereas there were no significant differences in other domains. Meta-analysis of the EuroQol-5D utility (mean difference: -0·01, 95% CI: -0·02-0·01, P = 0·57) and visual analogue scale (mean difference: 0·01, 95% CI: -3·24-3·26, P = 1·00) found no significant differences. Costs of hospitalization, medication and other healthcare resources consumed were similar between groups.

WHAT IS NEW AND CONCLUSION

Humanistic and economic outcomes of pharmacist-provided medication review were largely similar to those of usual care. Further research using more robust methodology is needed to determine whether improved medication management can improve HRQoL and reduce healthcare costs. Careful thought should be given to capturing relevant outcomes that reflect the potential benefits of this intervention.

Adherence to Glaucoma Medications Over 12 Months in Two US Community Pharmacy Chains

This study determined the degree of adherence to medications for glaucoma among patients refilling prescriptions in community pharmacies. Methods: Data abstracted from the dispensing records for 3615 adult patients (18 years or older, predominantly over 45) receiving glaucoma medications from two retail pharmacy chains (64 stores in total) were analyzed. From a 24-month historic data capture period, the 12-month levels of adherence were determined using standard metrics, the proportion of days covered (PDC) and the medication possession ratio (MPR). The overall 12-month mean PDC was only 57%, and the mean MPR was 71%. Using a criterion by which 80% coverage was considered satisfactory adherence, only 30% had satisfactory overall 12-month PDC coverage, and only 37% had satisfactory overall 12-month MPR coverage. Refill adherence increased with age and was highest in the 65-and-older age group (p < 0.001). Differential adherence was found across medication classes, with the highest satisfactory coverage seen for those taking alpha2-adrenergic agonists (PDC = 36.0%; MPR = 47.6%) down to those taking direct cholinergic agonists (PDC = 25.0%; MPR = 31.2%) and combination products (PDC = 22.7%; MPR = 31.0%). Adherence to glaucoma medications in the community setting, as measured by pharmacy refill data, is very poor and represents a critical target for intervention. Community pharmacists are well positioned to monitor and reinforce adherence in this population.

Evaluation of the types and frequency of drug-related problems and the association with gender in patients with chronic diseases attending a primary health care center in Jordan

BACKGROUND

Drug-related problems (DRPs) can be defined as any event that is drug related that results in harm or in providing less than optimum medical care to patients. The aim of this study is to determine the types and frequency of each type of DRP in selected outpatient settings in Jordan, with emphasis on gender as a grouping variable.

METHODS

This study was a non-randomized controlled trial, carried out over 3 days, at Alsarih Medical Health Center in the north of Jordan. Clinical pharmacists conducting the research interviewed a randomly selected population, assessed their DRPs, proposed appropriate clinical interventions to physicians and provided appropriate patient counseling.

RESULTS

The study included a total of 258 patients (mean age 54.4±12.1; male ratio 37.6%). The most frequently encountered DRPs in our study were patients' need for counseling and education (83.8%), and life style modifications (80%). This study also revealed that 71.8% of patients required additional and/or more frequent monitoring, and 53% of patients had untreated conditions that required pharmacological and/or non-pharmacological interventions. Gender did not affect the frequency of DRPs among patients.

CONCLUSION

Certain types of DRPs are the most common among outpatient settings. Therefore, measures should be taken to specifically tackle these types of DRPs.

Cardiovascular medication adherence among patients with cardiac disease: a systematic review

AIMS

The aim of this study was to critically appraise and synthesize the best available evidence on the effectiveness of interventions suitable for delivery by nurses, designed to enhance cardiac patients' adherence to their prescribed medications.

BACKGROUND

Cardiac medications have statistically significant health benefits for patients with heart disease, but patients' adherence to prescribed medications remains suboptimal.

DESIGN

A systematic quantitative review of intervention effects.

DATA SOURCES

We conducted systematic searches for English-language, peer-reviewed randomized controlled trial publications via Medline, EMBASE, CINAHL, the Cochrane Library, ProQuest, Web of Science and Google Scholar published between January 2004-December 2014.

REVIEW METHODS

According to pre-determined inclusion and exclusion criteria, eligible studies were identified and data extracted using a predefined form. Of 1962 identified papers; 14 studies met the study inclusion criteria, were assessed for risk of bias using the Cochrane Collaboration tool; and included in the review.

RESULTS

Study findings were presented descriptively; due to the heterogeneity of studies meta-analysis was not possible. Included papers described interventions categorized as: (1) multifaceted; and (2) behavioural and educational, comprising: (a) text message and mail message; (b) telephone calls; (c) motivational interviewing and (d) nurse-led counselling and education.

CONCLUSIONS

Substantial heterogeneity limited the robustness of conclusions, but this review indicated that motivational interviewing, education and phone or text messaging appeared promising as means to enhance cardiac medication adherence. Future research should integrate multifaceted interventions that target individual behaviour change to enhance adherence to cardiovascular medications, to build on the beneficial outcomes indicated by this review.

Impact of strategies to reduce polypharmacy on clinically relevant endpoints: a systematic review and meta-analysis

AIM

The aim of the present study was to explore the impact of strategies to reduce polypharmacy on mortality, hospitalization and change in number of drugs.

METHODS

Systematic review and meta-analysis: a systematic literature search targeting patients ≥65 years with polypharmacy (≥4 drugs), focusing on patient-relevant outcome measures, was conducted. We included controlled studies aiming to reduce polypharmacy. Two reviewers independently assessed studies for eligibility, extracted data and evaluated study quality.

RESULTS

Twenty-five studies, including 10 980 participants, were included, comprising 21 randomized controlled trials and four nonrandomized controlled trials. The majority of the included studies aimed at improving quality or the appropriateness of prescribing by eliminating inappropriate and non-evidence-based drugs. These strategies to reduce polypharmacy had no effect on all-cause mortality (odds ratio 1.02; 95% confidence interval 0.84, 1.23). Only single studies found improvements, in terms of reducing the number of hospital admissions, in favour of the intervention group. At baseline, patients were taking, on average, 7.4 drugs in both the intervention and the control groups. At follow-up, the weighted mean number of drugs was reduced (-0.2) in the intervention group but increased (+0.2) in controls.

CONCLUSIONS

There is no convincing evidence that the strategies assessed in the present review are effective in reducing polypharmacy or have an impact on clinically relevant endpoints. Interventions are complex; it is still unclear how best to organize and implement them to achieve a reduction in inappropriate polypharmacy. There is therefore a need to develop more effective strategies to reduce inappropriate polypharmacy and to test them in large, pragmatic randomized controlled trials on effectiveness and feasibility.

Development of a pharmacy practice intervention: lessons from the literature

The development of health interventions is receiving increasing attention within the scientific literature. In the past, interventions were often based on the ISLAGIATT principle: that is, 'It seemed like a good idea at the time'. However, such interventions were frequently ineffective because they were either delivered in part or not at all, demonstrating a lack of fidelity, or because little attention had been paid to their development, content, and mode of delivery. This commentary seeks to highlight the latest methodological advances in the field of intervention development, drawing on health psychology literature, together with guidance from key organisations and research consortia which are setting standards for development and reporting. Those working within pharmacy practice research can learn from the more systematic approach being advocated, and apply these methods to help generate evidence to support new services and professional roles.

Impact of tooth replacement on the nutritional status of partially dentate elders

OBJECTIVES

The aim of this study was to compare the impact of two different tooth replacement strategies on the nutritional status of partially dentate older patients. Nutritional status was measured using the full version of the Mini Nutritional Assessment (MNA) and the short form of the Mini Nutritional Assessment (MNA-SF).

MATERIALS AND METHODS

A randomised controlled clinical trial was conducted (Trial Registration no. ISRCTN26302774). Partially dentate patients aged 65 years and older were recruited and randomly allocated to the two different treatment groups: the removable partial dentures (RPD) group and the shortened dental arch (SDA) group. Nutritional status was measured using the MNA and MNA-SF administered at baseline and 1, 6 and 12 months after treatment intervention by a research nurse blinded to the treatment group allocation of all participants.

RESULTS

Data collected using the full version of the MNA showed significant improvements in mean MNA scores over the length of the study (p < 0.05). For the entire patient group, there was a mean increase of 0.15 points at 6 months and a further increase of 0.19 points at 12 months. These increases were similar within the treatment groups (p > 0.05). For MNA-SF, the analysis showed that there were no significant differences recorded over the data collection points after treatment intervention (p < 0.05).

CONCLUSION

Tooth replacement using conventional and functionally orientated treatment for the partially dentate elderly showed significant improvements in MNA score 12 months after intervention.

CLINICAL RELEVANCE

Prosthodontic rehabilitation may play an important role in the nutritional status of partially dentate elders.

Pharmaceutical care model to assess the medication-related risks of travel

BACKGROUND

People are at greater risk of health problems when travelling and a significant number of travel-related health problems are associated with the effects of travel on pre-existing chronic diseases. Medications play a key role in the management of these conditions. However, there is a notable lack of research evaluating the potential medication-related risks associated with travel.

OBJECTIVE

To apply a systematic pharmaceutical care model developed to evaluate potential pharmaceutical risks (PPRs) and pharmaceutical care issues (PCIs) in travellers.

SETTING

Adult travellers leaving Cairns International Airport, Australia, for an international destination.

METHOD

A cross-sectional survey using semi-structured interviews, including a systematic medication history, followed by the application of a pharmaceutical care model to evaluate each participant for PPRs and PCIs.

MAIN OUTCOME MEASURE

Evaluation of standard clinical and travel-related PPRs and PCIs.

RESULTS

Medications for chronic diseases were being taken by 47.7% of the 218 travellers interviewed. Although 75.2% of participants presented with no PPRs, a total of 274 PCIs were identified across 61.5% of the participants, with an average of 2.04 PCIs per participant. The most prevalent PCIs related to the inadequate precautions taken by some travellers visiting malaria-endemic regions. Although 91 participants recognised that they were travelling to malaria-endemic regions, 65.9% of these participants were not using malarial chemoprophylaxis, and only 16.5% were using chemoprophylaxis that fully complied with standard recommendations. The second most prevalent PCI was the need for 18.8% of participants to be educated about their medications. Other PCIs identified have the potential to increase the risk of acute, travel-related conditions, and complicate the care of travellers, if they inadvertently became unwell while overseas.

CONCLUSION

PPRs and PCIs were not identified in all participants. However, the impact of many of the identified medication-related issues could be substantial to the traveller. This study represents the novel application of a pharmaceutical care model to identify potential PPRs and PCIs in travellers that may not be identified by other pre-travel risk assessment methods.

The economics of medicines optimization: policy developments, remaining challenges and research priorities

BACKGROUND

This review scopes the evidence on the effectiveness and cost-effectiveness of interventions to improve suboptimal use of medicines in order to determine the evidence gaps and help inform research priorities.

SOURCES OF DATA

Systematic searches of the National Health Service (NHS) Economic Evaluation Database, the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects.

AREAS OF AGREEMENT

The majority of the studies evaluated interventions to improve adherence, inappropriate prescribing and prescribing errors.

AREAS OF CONTROVERSY

Interventions tend to be specific to a particular stage of the pathway and/or to a particular disease and have mostly been evaluated for their effect on intermediate or process outcomes.

GROWING POINTS

Medicines optimization offers an opportunity to improve health outcomes and efficiency of healthcare.

AREAS TIMELY FOR DEVELOPING RESEARCH

The available evidence is insufficient to assess the effectiveness and cost-effectiveness of interventions to address suboptimal medicine use in the UK NHS. Decision modelling, evidence synthesis and elicitation have the potential to address the evidence gaps and help prioritize research.

Investigation of knowledge of asthma and inhaler devices in pharmacy workers

OBJECTIVE

Effective management of asthma requires the development of a partnership between the patient and his or her health care professionals. In a number of countries, including Turkey, pharmacy workers are the last link in the asthma therapy chain and usually give information to their patients about the use of these drugs and asthma. As a result, we investigated knowledge of asthma and the use of inhaler devices in pharmacy workers in Istanbul pharmacies.

METHODS

The study was performed with 266 pharmacists and 261 pharmacist assistants selected from 4221 pharmacies in Istanbul by random sampling, with a 90% confidence interval. Each patient was asked to fill out a questionnaire that measured their knowledge of asthma. They were also asked to demonstrate how to use the inhaler devices.

RESULTS

The high number of incorrect answers to the 11th question, that ''the majority of upper respiratory tract infections triggering asthma are viral'', may be a contributor to the unnecessary use of antibiotics in Turkey (incorrect answers from 41.2% of pharmacists and 34.5% of pharmacist assistants). Scores for inhalation device techniques for the pharmacists were as follows: metered-dose inhaler (MDI), 4.9 ± 3.9; discus, 4.4 ± 3.7; aerolizer, 4 ± 3.1; and turbuhaler, 3.8 ± 2.9.

CONCLUSIONS

Istanbul pharmacy workers have limited knowledge about asthma and inhaler devices and need further education, which may contribute to improved asthma control in Turkey.