E-drug: Review of Community Pharmacy Services
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Dear e-druggers,
Last year I sent a note requesting information on trials assessing the
efficacy and cost-effectiveness of community pharmacy services for a
systematic review we were undertaking on behalf of the Pharmacy
Guild of Australia.
Thank you to all of those who responded. The report is now finished
and is on the Pharmacy Guild of Australia's website at:
http://www.guild.org.au/public/researchdocs/reportvalueservices.pdf
The report, which reviews over 70 randomised controlled trials,
covers the following topics:
- Pharmaceutical care services;
- Continuity of Care Services;
- Pharmacist Clinic Services;
- Medication review for repeat prescriptions;
- Medication review in Aged-care facilities;
- Pharmacist education to consumers;
- Education services for health care professionals;
- Drug Information services;
- Pharmacist participation in therapeutic decision making;
- Pharmacist involvement in non-prescription medicine use;
- Smoking cessation services;
- Pharmacist immunisation services.
I have attached the executive summary below.
Kind regards,
Libby Roughead
School of Pharmaceutical, Molecular and Biomedical Sciences,
University of South Australia
GPO Box 2471
Adelaide, 5001
South Australia
Phone +61 8 8302 2179
Fax +61 8 8302 2389
E-mail: libby.roughead@unisa.edu.au
The Value of Pharmacist Professional Services in the Community
Setting: A systematic review of the literature 1990-2002
Dr Libby Roughead, Dr Susan Semple, Dr Agnes Vitry
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.
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