Healthy Skepticism Library item: 2242

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Publication type: news

Roughead L, Semple S, Vitry A.
The Value of Pharmacist Professional Services in the Community: A systematic review of the literature 1990-2002
2000

Full text:

Executive Summary

This review of the value of professional pharmacist services was commissioned by the Pharmacy Guild of Australia to inform ongoing research and strategic planning for the development of professional pharmacist services in the community setting both within Australia and internationally.

This review encompasses the research effort published in the English language since 1990 supporting professional pharmacy practice in the community setting and evaluates the strength of the evidence for the effectiveness of professional pharmacist services, in terms of consumer outcomes, and where possible, the economic benefit. In reaching conclusions about the value of professional pharmacist services, we utilised the best available evidence, (i.e. studies that had employed rigorous research design) and the best available outcomes, (i.e. studies that had monitored changes in health outcomes).

It was encouraging to find a large number of trials meeting this level of methodological rigour and utilising changes in health outcomes as study endpoints. This review encompasses over 70 randomised controlled trials evaluating professional pharmacist services that have monitored patient outcomes as the end-point for the study. These studies were conducted in the community, outpatient and extended-care settings.

There is clear evidence across a number of different settings for the effectiveness of pharmaceutical care services, continuity of care services post-hospital discharge, pharmacist education services to consumers and pharmacist education services to health practitioners for improving patient outcomes or medication use.

There is more limited evidence, often limited to one or two countries, but still positive evidence for the effectiveness of pharmacist managed clinics, pharmacist review of repeat prescribing and pharmacist participation in therapeutic decision making in improving patient outcomes.

New professional services that have not yet been adequately evaluated include pharmacist administration of vaccines, pharmacist involvement in pre-admission clinics and pharmacist participation in hospital in the home services.

There were some areas of established pharmacy professional practice for which rigorous controlled studies were either not located or only a small number were located with equivocal results. More research is still required to establish best practice for medication review in aged-care facilities and medication review in the outpatient setting, as well as pharmacist participation in pharmacist-only and pharmacy-only medicines use. In addition, more research is required concerning pharmacist involvement in smoking cessation services and screening services.

Economic evaluation of the value of pharmacist professional services is limited. Nine studies meeting the review criteria assessed the impact of pharmacist professional services on drug costs, of which six showed a significant. Eight studies were descriptive economic studies and included comparisons of various health care resources between the intervention and control groups, however, only 2 studies showed a reduction in health care costs. Only two full economic evaluation were located. The clinical relevance of the cost/effectiveness ratio used in one study was unclear, while the second cost-effectiveness study related to smoking cessation services in a pilot study in only 2 community services, which means the results cannot be reasonably extrapolated.

Given the scarcity of economic studies for most types of clinical pharmacist services, it is difficult to comment on their impact on drug costs, health care resource costs or cost-effectiveness. Most of the evidence comes from pharmaceutical care studies and medication review studies. There is some evidence that these interventions can reduce drug costs. Further studies would be needed to establish for how long these savings are maintained and how frequently these interventions should take place.

Common methodological limitations observed in a number of studies included the open allocation of subjects to intervention or control groups and the assessment of outcomes by reviewers who were aware of the group allocation of subjects. Methodological rigour would be improved if the pharmacists providing the intervention were unaware of the group allocation of subjects, or alternatively, if the pharmacy was used as the unit of allocation, if steps were taken to avoid cross contamination between pharmacies and subjects were unaware of pharmacy allocation. In addition, independent reviewers blinded to subject group allocation, should be utilised to monitor outcomes. One further methodological consideration is the type of end-point monitored. The variability in end-points used in the studies considered in this review often made it difficult to synthesise findings.

In addition, health related quality of life measures were commonly utilised, often demonstrating no effect, which raises questions of whether this is due to the lack of effect of the service, or the lack of sensitivity of the measure. By comparison, adverse drug events were seldom utilised as an outcome measure, even where the aim of the study was to reduce medication misadventure. Where adverse drug events were monitored as an endpoint, variable methods were used and explicit criteria for assessing adverse drug events often omitted, despite their existence. Given that the focus of professional pharmacist services is to improve medication use and reduce medication misadventure adverse drug events are likely to be a more sensitive endpoint for assessing the effect than health-related quality of life measures. It would seem appropriate to give further consideration to incorporating adverse drug events, assessed by independent panels utilising explicit criteria, more commonly as an outcome measure of the services.

Overall, this review demonstrates that there is considerable high quality evidence to support the value of professional pharmacy services in the community setting. Studies evaluating the majority of professional services currently provided by community pharmacists were located and, importantly, demonstrated improvements in outcomes for patients. Improvement in economic analyses is still required. Where the evidence is sound, consideration now needs to be given to implementing these services more broadly within a country’s health system.